STI Quarterly

Testing program to reach at-risk women

How can your clinic reach more women at risk for chlamydia and gonorrhea? Take a tip from the Sexually Transmitted Disease (STD) Program at the Los Angeles County Department of Public Health, which is expanding its popular "I Know" at-home testing program in a further outreach to the community.

Kicked off in 2009, the Don't Think Know Home Test Kit program provides a simple way for women in Los Angeles County to test for chlamydia and gonorrhea in the privacy of their own home. The free kit includes a swab for taking a test sample from the vagina, a swab collection tube, and an envelope for mailing purposes. The swab is tested at the Los Angeles County Public Health Laboratory. Results are available online or by phone one week after the kit is mailed.

The kits have been available free of charge to females ages 12 to 25 through a designated web site, www.DontThinkKnow.org, or by calling the county's STD telephone hotline, (800) 758-0880. In September 2011, public health officials announced enhancements to the program, with digital tablets and touch-screen kiosks making the kits more widely and immediately available to women.

An individual can order the kit from a kiosk or be provided a kit from an outreach worker using a digital tablet that requisitions the kit, explains Peter Kerndt, MD, MPH, director of the county's STD program. If women are at an outreach event where kits are available, they can take them home, collect their sample, and drop the results in the mailbox.

This point-of-service access might help reach younger women who might hesitate to have a kit mailed to their home, explains Kerndt. Even though the kit arrives via U.S. mail in a white 8 1/2 x 11 inch envelope with no external marks, some women might hesitate in placing an order, he notes. 

Getting more young women tested is a public health priority: Los Angeles County reports the highest number of chlamydia cases and the second-highest number of gonorrhea cases of any county in the nation. More than 30,000 women and girls acquire infections every year, with younger women most heavily affected. In 2010, there were 20,337 chlamydia cases and 2,136 gonorrhea cases reported in females ages 15-24.

Technology is the key

The rise of self-collected nucleic acid amplification testing now available for gonorrhea and chlamydia screening makes such at-home testing possible, says Kerndt.

The Los Angeles program draws from initial work by Charlotte Gaydos, MS, DrPH, and researchers at Johns Hopkins University (JHU), who launched the "I Want The Kit" program in Baltimore in 2004. Recent research published by the JHU research teams shows at-home testing is effective in reaching young women at risk. Over a five-year period in Maryland, the iwantthekit.org screening program detected more cases of chlamydia infection among young females than regular screening programs available at traditional family planning clinics. Infection rates for chlamydia ranged from 3.3% to 5.5% in local clinics to 4.4% to 15.2% with the Internet service.1

While technology has greatly improved STI screening options, the reliability of specimens sent via mail must be verified by local laboratories. Los Angeles public health officials have worked with the Centers for Disease Control and Prevention to ensure that the quality of mailed samples would be sufficient for accurate testing.2

The Los Angeles program is cost-effective, data indicate. An analysis determined each requested kit at $6.50, with test processing cost at $17.75. When considering ongoing costs, saved patient travel, and clinic visit costs, the intervention is potentially cost-saving over clinic-based testing, the analysis suggests.3

In the last two years, the county has received over 3,700 orders; 57% of ordered kits have been returned to the public health lab, with almost all of them testable, says Kerndt. The kits have yielded an approximate 9% positive rate for chlamydia or gonorrhea, and public health officials have been able to confirm treatment on almost all of those patients, says Kerndt.

The system has the capacity to link tested women with health care services; there are about 60 clinical sites that are searchable, based on zip codes, where women can go to obtain treatment, Kerndt notes. Test results are available on the dontthinkknow.org web site or by telephone. Women can use the clinic locator service on the web site to locate a clinic for care. Women can print out their test results and take them with to their clinician. The printed results page explains that a home test was provided by the Department of Public Health and that the person needs treatment.

Extra effort is needed

The expansion of the Los Angeles program is needed to reach at-risk women, said Mark Ridley-Thomas. Thomas is supervisor of the county's Second Supervisorial District, site of the county's highest STD rates. Public health officials are linking with community organizations in the district, including faith-based organizations, to provide enhanced access to the kits, as well as other targeted areas of risk.

"The "I Know" program has a track record of success, so we come together today to encourage women who may be afraid — who likely have no symptoms, but who have made some choices that put them at risk — to take that first step toward getting help and taking a test right in the privacy of their own homes," said Ridley-Thomas in an announcement of the program expansion.

References

  1. Gaydos CA, Barnes M, Aumakhan B, et al. Chlamydia trachomatis age-specific prevalence in women who used an internet-based self-screening program compared to women who were screened in family planning clinics. Sex Transm Dis 2011; 38:74-78.
  2. Papp J. Home-screening tool: self-collected vaginal swabs for detection of Chlamydia trachomatis and Neisseria gonorrhoeae. Presented at the 2010 National STD Prevention Conference. Atlanta; March 2010.
  3. Gift T. Cost effectiveness of the "I Know" home test kit. Presented at the 2010 National STD Prevention Conference. Atlanta; March 2010.