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Infectious disease experts at Johns Hopkins say new research clearly shows that screening teens and young adults for sexually transmitted infections may best be achieved by making free, confidential home-kit testing available over the Internet. From a public health standpoint, the project is a clear winner, the experts say.
Reporting in the February issue of Sexually Transmitted Diseases, the Johns Hopkins team describes the success of the program started in Baltimore in 2004 that lets men and women in their 20s or teens order home-testing kits for the most common STIs over the Internet at www.iwantthekit.org.
The Johns Hopkins group designed the website, accessible now in several states, to track new and recurrent infections by providing private, confidential testing for Chlamydia trachomatis, Neisseria gonorrhoeae and Trichomonas vaginalis. The project also facilitates treatment for those who test positive.
"Our results are repeatedly showing us that we have to go online if we want young people to be screened for sexually transmitted infections, especially young people in harder-to-reach, urban-poor minority groups," says infectious disease specialist Charlotte Gaydos, MS, DrPH, senior study investigator. She says the website now routinely gets 100,000 monthly hits.
As of Jan. 1, some 3,500 young people, half under the age of 23, and many from low-income households, have gotten their test kit for free via the website, some more than once. Initially, kits were also offered at local pharmacies and in public health clinics, but nine of 10 who used the kit ordered it online. "The Internet is by far the most popular means of getting tested among this sexually active group, and at a time when they are most at risk of becoming infected."
The program, which Gaydos says "could readily be introduced to all 50 states and overseas," has grown increasingly popular since its debut, when only test kits for women were offered. Kits for both sexes can be ordered by anyone in Maryland, the District of Columbia, West Virginia and parts of Illinois, and in Denver and Philadelphia.
Gaydos and her team expect an influx of orders after federally funded newspaper and radio ads to promote the website appear in Washington, D.C., throughout Maryland and in Philadelphia during April, national sexually transmitted infections awareness month.
Each home test kit comes with instructions, a unique identification number, and a prepaid return envelope to return self-collected vaginal, penile or rectal swabs in specially sealed test tubes to Gaydos' lab at Johns Hopkins. The kits are mailed in plain, brown paper envelopes and contain a detailed questionnaire that allows researchers to gather important information about who used the kit and why. Within two weeks of sending the test to the lab, people can call a toll-free number, provide their identification number and a secret password chosen when they ordered, and get their test results.
So far, 444 women and girls, some as young as 15, and 192 men and boys, for whom screening started in 2006, have tested positive for one or more bacterial or protozoon infections. All but four women and one man who tested positive sought subsequent treatment. For those who test positive, referrals are offered to nearby public health clinics.
"Using the Web is a very safe, private, secure and practical forum for young people to deal with sexually transmitted infections," says Gaydos, a professor at the Johns Hopkins University School of Medicine. "People can order a kit any time of day, without having to leave school or work, and can get tested with a level of anonymity that minimizes any fear of stigma or self-conscious feelings that may come with talking to a parent, school counselor or health professional about a sex-related health problem."
The latest study results focused on women and showed that 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, which if left untreated can lead to so-called pelvic inflammatory disease and infertility in women, ranged from 3.3 percent to 5.5 percent in local clinics to 4.4 percent to 15.2 percent with the Internet service, statistics that Gaydos says demonstrate the online program's potentially greater reach.
"A lot of these young women are poor with little to no health insurance, and seldom see a physician or undergo a health check-up, so this is a free means of getting them tested and cared for quickly and before they potentially pass the infection on to someone else," says Gaydos, who notes that at least four in five people infected show no symptoms, so the chances of them unknowingly spreading infections are high.
Overall, Gaydos says the program, funded by a grant from the U.S. Centers for Disease Control and Prevention (CDC), is also highly effective in promoting retesting, noting that 17 percent of users feel comfortable enough with the system to use it again and almost half of these people have been screened multiple times, even if they test negative at first.
Gaydos stresses that people who have been infected once are 10 percent more likely to get re-infected. This is why, she says, the CDC recommends that all sexually active women age 25 or younger get screened for chlamydia at least once a year, with women who have tested positive getting retested within three months of their initial infection. Gaydos says 6 percent of repeat kit-users have tested positive before, while her other research has shown a 25 percent chlamydia re-infection rate among young women in the Baltimore area alone.
The need for repeat testing applies equally to sexually active males, says Gaydos, whose team reported in December in Sexually Transmitted Diseases that among 501 tested, some as young as 14, many did not practice safe sex. Only 13 percent used condoms. Even more were at risk of re-infection, with 34 percent having already had an infection and 29 percent having had sex with someone who had previously been infected.
Fortunately, Gaydos adds, 89 percent of males tested said they would use the iwantthekit.org screening program again, citing how easy it was to simply mail in a penile swab.
As part of the April campaign, run under the slogan "GYT," text speak for get yourself tested, Gaydos plans to distribute iwantthekit.org flyers and brochures at shopping malls, recreation centers and libraries - all gathering spots for young people. She also plans to supply handouts to municipal public health departments and family planning clinics throughout the region.
To make kit-ordering easier, the Johns Hopkins team has incorporated product bar coding in its brochures and advertisements that can be read by standard computer apps, which are also free. People can take a picture of the bar code with their cell phone, open the app and be taken, automatically, to the ordering page of the iwantthekit.org website. This is very important for reaching underprivileged youth, says Gaydos, especially many Hispanic and black teens and other young adults who cannot afford a home computer and whose access to the Internet is mainly through their smart phones. Home test kits can also be ordered through the website's Facebook page.
The Johns Hopkins team launched the iwantthekit.org program in Baltimore, Md., in part because of the city's high infection rates.
Baltimore consistently ranks among the top 10 U.S. cities for newly acquired cases of chlamydia. According to previous CDC biannual surveys of risky youth behaviors in the United States, 32 percent of students are sexually active by the ninth grade.