Urine drop-off testing: a self-directed method for STI screening and prevention

Canadian Journal of Human Sexuality, The,  Spring-Summer, 2008  by Patrick O'Byrne,  Rick Dias

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Abstract: Within bathhouses in many urban centres across North America, nurses provide traditional, face-to-face STI testing services for gonorrhea, chlamydia, HIV, hepatitis B, and syphilis. Because these services require the physical presence of a nurse, they are not accessible for men who visit bathhouses during non-designated testing times. In addition, some men resist traditional STI testing services because they find the procedure to be embarrassing. In response to these problems, we piloted the use of self-directed gonorrhea/chlamydia urine testing kits within two bathhouses in a Canadian urban centre. A drop-box placed in a visible but discrete area of each bathhouse allowed participants to provide samples and contact information. Of those tested in this study, (n = 50), 55.8% reported not having previously accessed services at the host testing-site, and 34.6% reported not being regularly tested for STIs. Among the latter, 16 of 19 had never been previously tested; eight subsequently underwent additional serologically based STI/HIV testing for the first time, with four testing positive for infectious syphilis. None of the drop-off participants tested positive for either gonorrhea or chlamydia. The Discussion considers the potential impact of this unique STI service for a small, but previously untested population.

Introduction

Recently, the incidence rates for all sexually transmitted infections (STIs) have increased within the population of men who have sex with men (MSM) (CDC, 2006; PHAC, 2006). It has been reported that STIs make HIV positive individuals more likely to transmit HIV (i.e., STI co-infection increases genital compartment viral loads), and render HIV negative individuals more susceptible to HIV acquisition (due to the increased permeability of the genital membranes associated with a localized infection) (Chan, 2005; Gray et al., 2001; Pourbohloul & Brunham, 2004; Xu, Politch, Tucker, Mayer, Seage & Anderson, 1997). The increase in STI rates among MSM has thus led to a nearly worldwide increase in research on, and sexual health service delivery within, this population. One STI prevention strategy directed to a specific MSM sub-population has been the provision of STI services (counselling, testing, treatment, and vaccination) within bathhouses. Although many MSM have accessed this innovative service, it is known that some individuals resist such public STI testing either actively and intentionally or for other reasons. Some men may visit bathhouses at times other than the designated testing periods and/ or they may feel uncomfortable disclosing intimate details of their sexual histories to sexual health nurses within these environments (Holmes & O'Byrne, 2006; Hogben, Bloom, MacFarlane, St Lawrence, Malotte & GCAP, 2004; Malta, Bastos, Stathdee, Cunningham, Pilotto, & Kerrigan, 2007). In the absence of STI testing, infected individuals may remain undetected, untreated and unknowingly able to continue to spread infection(s). To address the problem of men going undetected because they did not use the current bathhouse STI services, we developed a continuously available self-directed urine drop-off (UDO) testing kit for gonorrhea and chlamydia that did not require a face-to-face interaction with a nurse, and piloted it in two Canadian bathhouses. The present paper presents the findings of this pilot project.

Materials and Methods

Location and duration

This research lasted six months (Feb 22-Aug 21, 2007), and took place within the only two bathhouses located within the pilot city. Unlike bathhouses in larger and more cosmopolitan urban centres, such as those visited by Holmes, O'Byrne, & Gastaldo (2007), which had 22, 114, and 126 rooms with 1800, 12000, and 12000 patrons respectively per month, the two bathhouses in this study had 25 and 27 rooms, and averaged 2000 patrons per month.

UDO drop-box

Four weeks prior to commencing the clinical services component of this project, the drop-boxes (without UDO kits) were mounted in both bathhouses in a visible, but discreet, location. Physically, the drop-box was a Plexiglas[R] structure with a backboard (containing posters with information on gonorrhea/ chlamydia transmission, sites of infection, and treatment), and two side-by-side boxes--one with an open top for the available kits, and the other with a locked top and a one-way deposit slit for the used UDO kits.

UDO kit

Once the four-week introduction period ended, the open side of the drop-box was filled and maintained with eight to ten UDO kits for the duration of the study. Each kit contained a urine specimen container, a BD Urine Preservation Transport (UPT) kit (for more details, see BD, 2007), and a consent/contact form, which, as mandated by Ontario infectious disease legislation (Government of Ontario, 2007), requested a full name, date of birth, and means by which the participant could be contacted, if necessary. In addition, four further questions on sexual orientation, the presence of symptoms, a history of STIs, and STI testing frequency were included on the contact form. See Table 1 for a summary of these questions. To complete a UDO kit, participants had to acquire a kit, complete the forms and provide a urine specimen, deposit the completed kit through the drop-slit into the drop-box, and then wait ten days for results; if these results were negative no follow-up occurred. If follow-up was required, it was undertaken by the associated districts public health department. In addition, all samples were submitted by the pilot city's STI clinic to the Ontario Public Health laboratories.