Rik Koekenbier, Fennema H, Leent van E, Zuilhof W, Veen van E, Davidovich U Online Research and Prevention unit Amsterdam Public Health Service Research department The STI outpatient clinic online: The use and efficacy of a full-scale STI & HIV testing applications online Aids conference 2010

2 Content 1.Introduction: mantotman project and Test Lab 2.Test Lab procedure 3.Research questions 4.Results 5.Conclusion

3  Goal of the website: “one stop shop” for all the information and interventions on sexual health  Main features of the website: 1.MANcyclopedy; online encyclopedia on sexual health 2.Sekswijzer; internet-tailored personal advice on sexual health & safe sex 3.Test Lab: Online application to arrange STI&HIV testing Cooperation of:  Public health services Amsterdam and Rotterdam  Schorer; homosexuality, health and well-being Introduction: Mantotman Project

4 General benefits of the internet 1.It increases the accessibility to services 2.It increases the availability of the service (24/7) 3.It offers user friendly environment & anonymity Why Test Lab? 1.To stimulate MSM to get tested on a regular basis 2.To lower the threshold for STI and HIV testing  No physical examination  No referral needed Introduction: why online STI testing and Test Lab

5 Procedure: Test Lab procedure 1.Participants visit the website for an intake  Referral selection: 1. test locations or 2. STI clinic (symptomatic or partner with STI)  Print referral letter (personal code) 2.Participants visits one of the diagnostic laboratory’s in the city  Collection of urine, blood, (self)-swabs (rectal, throat)  Anonymous and free (registration on personal code and nickname)

6 Procedure: Test Lab locations Amsterdam: 9 test locationsRotterdam: 9 test locations

7 Procedure: Test Lab procedure 1.Participants visit the website for an intake  Selection: Referral to test locations or referral to the STI clinic (symptomatic or partner with STI)  Print referral letter (personal code) 2.Participants visits one of the diagnostic laboratory in the city  Collection of: urine, blood, (self)-swabs ( anal, throat)  Anonymous and free (registration on personal code and Nickname) 3.The lab results are sent to the STI clinic. Diagnosed by the medical doctor and the “diagnoses” are put online. 4.Participants obtain test their personal “diagnoses” online  “Diagnoses” 1) all tests are negative, 2)`your test failed 3) One ore more tests are positive 5.Man who tested positive visit the STI clinic for further examination and treatment.

8 1.Chlamydia: 1. urogenital (urine) 2. rectal (self-swab) NAAT 2.Gonorrhea: 1. urogenital (urine ), 2. rectal (self-swab), 3. throat (swab) NAAT 3.Syphilis: anti-TP + => VDRL and FTA 4.HIV (opting-out): combo Antibody & Antigen test Procedure: Test Packets

9 Procedure: referral letter

10 Procedure: Back office

11 Procedure: Soa*Hiv

12 Procedure: Results online Soa*Hiv

13 Research questions: 1 1.What is the usage of Test Lab and what is the service’s feasibility Usage:  Number of visits, visitors, referred to Test Lab locations or STI clinic, men tested Feasibility:  Diagnoses put online, diagnoses viewed, time between the different steps in the Test Lab procedure and do positive men visit the STI clinic?

14 Research questions: 2 2.What is the efficacy of Test Lab in finding MSM with an STI or HIV infection Efficacy:  % positives in Test Lab compared to % positives at the STI-clinic A’dam (positivity rate)  Data selection:  Test Lab: users from Amsterdam  STI-clinic Amsterdam: asymptomatic, same period, same STI/HIV tests

15 Results Data collection:  11 months, from February 2008 till January 2009 Demographics: (users of test Lab N= 532)  Age –Mean: 36 SD=11  Self reported HIV status –55% I’m HIV Negative (N=259) –9% I’m HIV Positive (N=45) –36% I don’t know my status (N=189)

16 Results: Usage 31% of the men who got tested never visited the STI clinic before Unique visitors Visitors Amsterdam or Rotterdam Intake completed Referred to Test lab locations Tested Results put online Results viewed online Positives visiting STI Clinic % (2121/3555) 66% (1406/2121) 80% (1130/1406) 47% (532/1130) 100% (532/532) 99% (530/532) 99% (83/84)

17 Results: Increase of use

18 Results: feasibility Time in days between the different steps in the procedure Mean (days) Median (days) Online intake => visit test location: 10 (SD = 16) 4 Visit test location => results online: 8 (SD = 5) 7 Results put online => results viewed: 1 (SD = 3) 0

19 Results: Lab results Laboratory results Positive % (/total*) Lues (syphilis) 4% (18/496) Chlamydia urine 3% (16/521) rectal (self-swab) 5% (23/508) Gonorrhea urine 0% (0/508) rectal (self-swab) 4% (17/412) oral 4% (22/512) HIV 0.7% (3/414) * Difference in total due to failed tests or opting out for HIV

20 Results: Online diagnoses Total Amsterdam Rotterdam Number tested All tests are Negative 78% (416/532) 77% (258/334) 79% (158/198) One or more tests failed 6% (32 / 532) 5% (17/334) 8% (15/198) One ore more tests are positive 13% (25/198) Multiple infections: 71 clients - 1 infection 10 clients - 2 infections 3 clients - 3 infections 16% (84/532)18% (59/334)

21 Results: HIV status and online diagnoses One or more tests: failed All tests are: Negative On or more tests are: Positive I’m HIV negative 7,5% (22/295) 78,6% (232/295) I’m HIV positive 2.2% (1/45) 55.6% (25/45) I don't know my status 4.8% (9/189) 82.5% (156/189) 12.7% (24/189) 13.9% (41/295) 42.2% (19/45)

22 Results: Efficacy, Test Lab vs STI clinic STI positivity rate:  Test Lab Amsterdam: 19% (59/317)  STI clinic Amsterdam: 15% (260/1701)

23 Results: Overall test lab Number tested 1883 All tests are Negative ,4% One or more tests failed 67 3,6% One ore more tests are positive % New HIV diagnoses:  1,3% (21/1631) Usability and acceptability of the application  Abstract number: CDC0660 Electronic poster: on conference website

24 Conclusion 1.The online procedure is feasible: 1.High % of referred get tested (49%) 2.99% of results are obtained online 3.99% of positive clients visited the STI clinic 2.The online procedure is efficient in selecting the right population 1.16% one ore more positive test results 2. % of positive higher compared to STI clinic (not significant) 3.The service is used by a high risk HIV+ population 4.And 31% of users never visited the STI clinic before

25 Acknowledgment Funding:  The Aids fonds  The centre of infectious disease control Special thanks:  Martijn van RooijenData management and analyses