Digital sexually transmitted infection and HIV services across prevention and care continuums: evidence and practical resources

Keywords: chlamydia, clinical, digital, e-health, gonorrhoea, HIV, m-health, partner services, social media, STI.

A person can visit a website, complete a brief survey instrument, and then be advised about self-testing or self-sampling for appropriate sexually transmitted infections (STI). Then a mailed self-test kit allows the person to test themselves and interpret the result, all from the comfort of their home. This could then provide the basis for an online automated consultation, collection of antibiotics from a community pharmacy, and refer sex partners into the health system. Although this collection of digital health services may sound like fiction, pilot programs and a growing evidence base support digital STI services.^1,2 For the purposes of this review, we define digital health as ‘the field of knowledge and practice associated with the development and use of digital technologies to improve health’.³ This includes mHealth, eHealth, artificial intelligence, and related big data approaches.³ Online STI services can be standalone or they can operate as an extension of a physical clinic. Digital tools can also be used to make face-to-face services more effective and create new ways of engaging people with testing, wider prevention interventions and clinical care, including facilitating partner notification. In the context of sexual health, this includes STI clinics sending text messages to patients, software and hardware to spur healthy behaviours, remote photographic diagnosis, symptoms checkers, online treatment, and related online STI projects.

Several factors have catalysed this shift. First, self-testing and self-sampling have decentralised diagnostics so that testing can be provided outside of health facilities.⁴ Self-testing refers to a process in which a person collects their own samples (usually swab, urine, or blood), performs the diagnostic test and interprets their result in a place of their choice (e.g. home, clinic, work, or elsewhere). In self-sampling, the person collects their own sample (usually swab, urine, or blood) and sends it to a laboratory for processing.⁵ Second, increased usage of digital technologies in daily life, combined with advances in the technologies themselves such as expanding digital algorithms (e.g. machine learning⁶), technologies (e.g. mobile phone applications⁷) and services (e.g. unstructured supplementary service data (USSD), unstructured supplemental service data), have created possibilities for wholly online care. Alongside these technological trends are more supportive legislation and policies to facilitate digital services.³ Third, digital approaches can reduce STI/HIV stigma,⁸ highlighting the potential for greater population coverage. Fourth, the expansion of HIV pre-exposure prophylaxis (PrEP) has generated increased demand for associated STI testing.⁹ Fifth, conventional STI clinics have been closed or limited in scope during the coronavirus disease 2019 (COVID-19) pandemic, with patients encouraged to use available online services.¹⁰ In many settings, people living with HIV have been encouraged to avoid in-person attendance. In some cases, this has accelerated existing research on digital approaches to optimising STI services as alternatives to face-to-face care.¹¹

Digital STI services have been introduced to meet different aims, including driving demand for essential STI services, reaching individuals who choose not to use in-person facilities, and to increase service efficiency by decreasing uncomplicated visits to in-person services in an attempt to reduce costs. They may also be able to reach individuals who cannot reach in-person facilities, including people in remote rural areas, people with disabilities, and people who do not have access to transportation. At the same time, digital services could exacerbate existing inequities by creating barriers for people with low health literacy or others,¹² underlining the importance of considering these issues when planning and implementing new digital services.

Previous reviews of digital sexual health services have focused exclusively on HIV,¹ pre-dated the COVID-19 pandemic,^2,13,14 focused on specific populations,^15,16 or focused on specific technologies.¹⁷ Within a special issue of Sexual Health, this narrative review examines the evidence and implications of digital STI/HIV services, focused on promoting testing, facilitating testing, clinical management and referrals, partner services, and prevention. Where appropriate, we reference national and professional body guidance and recommendations. We also make recommendations about priority areas for research and remaining challenges ahead in the digital STI service development process.

We used a narrative rather than a scoping or systematic review for the following reasons: there was substantial heterogeneity in the types of interventions and measured outcomes; there were marked differences in operational definitions across studies; and there was limited research for some key populations. We searched PubMed, Google Scholar, CINAHL using search terms ‘digital’, ‘social media’, ‘HIV’, ‘STI’, ‘e-Health’, ‘mHealth’, and ‘STD’. We were substantively interested in reviewing the evidence for STI services, but have included information about HIV services where appropriate. We included low-, middle-, and high-income country settings, but we only searched in the English-language and limited our included articles to English-language studies.

We have structured this review according to a prevention and care continuum because many public sector STI services use similar organisational categories,^18,19 it aligns with WHO and UNAIDS metrics, and is relevant to many STI clinical contexts. Here, we will focus on engagement (including testing promotion), testing, clinical management and referrals, partner services, prevention, and surveillance. Each of these respective sections includes evidence from systematic and scoping reviews, best practice guidelines, and practical open-access resources. We prioritised evidence from systematic reviews and randomised controlled trials over other types of evidence. At the same time, given the sparse literature in many fields, we included single studies where relevant.

Can digital tools engage those at risk for STIs? Engagement refers to a set of bidirectional opportunities for health workers and local community members to communicate.²⁰ Engagement with STI services specifically focuses on education and awareness activities to generate demands for STI services, especially testing services. STI engagement activities could be entirely digital, entirely in-person, or a digital/in-person hybrid.²¹ Engagement strategies use text messages, social networking mobile phone applications, user support groups, and websites to increase awareness of STI services (e.g. preventive and therapeutic services available).

One systematic review found that mobile phone applications increased sexual health knowledge and sexual health service use among adolescents, but found few studies and observed substantial heterogeneity.²² Another systematic review found that crowdsourcing facilitated HIV community engagement in online and in-person settings.²³ Crowdsourcing has a group of people solve all or part of a problem and then share solutions with the public.²⁴ Crowdsourcing approaches include open calls, hackathons, and related participatory events. In the context of HIV engagement, crowdsourcing can provide a formal mechanism for stakeholder consultation, end-user involvement, public judging, and other critical elements.^24,25 A review of digital media interventions for sexual health promotion among youth also found increases in knowledge related to HIV prevention.¹⁵

Several open access resources and guidance documents exist. The United States Centers for Disease Control and Prevention have open access resources and best practice guidelines on social marketing communications.²⁶ The UNAIDS/AVAC Good Participatory Practice Guidelines provides suggestions for enhancing HIV community engagement that are relevant to digital approaches.²⁷ The growing evidence base suggests that digital tools can enhance STI and HIV engagement with STI services, increasing knowledge and promoting awareness of STI testing options.

How can digital STI services be used to enhance access to STI/HIV testing and what is their effectiveness? Digital technologies have been used to expand access to STI testing through self-sampling (e.g. HIV, syphilis, gonorrhoea, chlamydia, human papillomavirus)^28–30 and self-testing (e.g. HIV,^31–33 syphilis,^34–36 and hepatitis C virus³⁷). Digital tools cover a range of functions of varying degrees of complexity and sophistication, including booking appointments at STI clinics, ordering test kits, identifying people who would most benefit from testing (triaging), conducting online sexual health consultations, verifying completion of self-testing kits, referring people to access facility-based services, and provision of STI test results.² In resource-limited settings, USSD has been used to promote self-testing and confirm test uptake.³⁸

There is growing evidence to support the use of digital approaches to increase the uptake of HIV testing. One systematic review found moderate certainty of evidence (two randomised controlled trials, two observational studies) to support digital crowdsourcing methods to develop interventions that increase HIV testing compared to conventional approaches.³⁹ A scoping review of qualitative studies⁴⁰ and a scoping review of quantitative studies³² demonstrates that crowdsourcing approaches can enhance HIV test uptake. A systematic review found moderate certainty of evidence that text messages increased sexual health testing compared to conventional messages (e.g. print messages, clinic education).¹⁷ Two randomised controlled trials found that digital interventions to facilitate online self-testing increased HIV, syphilis, chlamydia, and gonorrhoea test uptake.^33,41 A systematic review found that digital interventions to support HIV self-testing were feasible, acceptable, and often preferred compared to conventional services.⁴²

Several open access resources and best practice documents can help to inform digital STI testing services. The WHO/SESH/SIHI practical guide on crowdsourcing for health and health research provides practical advice on organising crowdsourcing activities,²⁴ and is accompanied by a Special Programme on Training and Research in Infectious Diseases consensus statement⁴³ and systematic review.³⁹ Public Health England created a user guide for e-sexual health services, which also provides practical advice on organising self-sampling through the internet.⁴⁴ The British Association of Sexual Health and HIV released guidance on STI self-sampling packs and processes⁴⁵ and online sexual health provision more broadly.⁴⁶ The American Sexually Transmitted Diseases Association created a position statement on direct-to-consumer STI testing services.⁴⁷ One Welsh report examined the relationship between digital technology and health inequalities.¹² There is strong evidence, policy support, and open access resources outlining how digital tools can facilitate HIV self-testing.⁴⁸ A growing evidence base suggests that syphilis self-testing,³⁵ HCV self-testing, and other STI self-sampling could be useful adjuncts to traditional care in some settings.⁴

How have digital STI services been used in STI clinical management and referral pathways and what is their effectiveness? Digital approaches have been used to increase access and adherence to a range of commonly used drugs, ranging from preventive drugs (e.g. pre-exposure prophylaxis, PrEP, among people at risk for HIV infection) to therapeutics (e.g. anti-retroviral therapy among people living with HIV infection). One UK study provided a digital pathway for management of people with chlamydia, which included an online automated consultation and electronic prescribing enabling people to collect antibiotics at a pharmacy without needing to present to conventional clinical facilities.⁴⁹ This research was based on a clinical decision-making algorithm. Mobile phone text message medication reminders can increase adherence to ART.⁵⁰ Digital PrEP systems could allow an individual to determine PrEP eligibility, initiate STI self-testing and self-sampling, and provide clinical consultation related to PrEP initiation. Several pilots have been developed that integrate PrEP initiation and digital technologies.⁵¹

Digital technologies have also been used to facilitate linkage to HIV services following diagnosis. One study from rural South Africa suggested that mobile phone-connected HIV testing and web-based clinical care and prevention pathways have the potential to support access to HIV prevention and care, particularly for young people and men.⁵²

Several systematic reviews have examined digital interventions to enhance ART adherence among people living with HIV. One Cochrane systematic review⁵⁰ and a subsequent systematic review⁵³ found that scheduled short message service (SMS) text messages can increase ART adherence compared to conventional approaches. In contrast, there is much less evidence concerning use of digital interventions within STI treatment.

How can digital interventions enhance partner services and what is the evidence of their effectiveness? Digital interventions can enhance partner services by assisting index patients to notify their partners (either personally or anonymously via text message or email) and facilitating sex partner management.⁵⁴ This could include providing test results notification or providing postal self-testing or self-sampling kits to partners.

Several studies have examined the effectiveness of digital partner service interventions. A narrative review from this special issue provides a summary of evidence on partner services, including digital approaches. One single study showed that prototype mobile phone applications may enhance partner notification and testing.⁵⁵ The US Centers for Disease Control and Prevention provide a toolkit for digital partner services⁵⁶ and National Coalition of Sexually Transmitted Diseases Directors in the United States created guidelines for internet-based partner services.⁵⁷ A modest evidence base suggests that digital tools may enhance HIV partner services, but less research and programs exist for other STIs.⁵⁴ Further research and programs are needed in this area.

How have digital approaches been used to increase uptake of vaccines for the prevention of STIs and what is their effectiveness? Digital methods have been used to increase human papillomavirus and HBV vaccinations. Some of the strategies identified below could be relevant to other STI vaccines, which may be developed in the next decade (e.g. gonorrhoea, chlamydia, syphilis). Vaccine promotion must negotiate the complex digital communication environment, especially misinformation and anti-vaccine sentiment from diverse groups.⁵⁸ There is an extensive literature on how social media has been used to amplify HPV vaccine hesitancy, sew confusion, and decrease HPV uptake.^59,60 One single study found that artificial intelligence can be used to examine social media discussions about HPV vaccines, with this analysis of HPV vaccine-related Twitter discussions demonstrating that social media data can inform public health communication and education programs to improve HPV vaccination rates.⁶¹

There is less evidence about the use of digital tools to support HPV vaccination. One systematic review examined how social media interventions enhance HPV vaccination services using an implementation science framework.⁶² Another systematic review assessed attitudes, beliefs, and knowledge from social media studies on HPV vaccination.⁶³ The World Health Organization created HPV vaccine communication considerations with a strong focus on digital media.⁶⁴ Although some pilots have examined digital tools to increase HBV vaccination,⁶⁴ there is relatively less evidence. For example, a randomised controlled trial of a crowdsourced digital intervention included hepatitis B vaccination as a secondary outcome.⁶⁴

Few studies and programs have used digital tools for STI prevention. The limited data available for HPV suggest that harms associated with social media are substantial and need to be considered when implementing digital HPV interventions.

Is digital sexual health care good value for money? Although online services are often assumed to represent better value for money than more traditional modes of care delivery, there has been very little robust health economic evaluation. Individual components of care pathways may well be cheaper when delivered digitally as they tend to shift tasks from a clinician-led to a self-managed process with accompanying reduction in health care professional time and health system costs. However, it is important to evaluate health system costs in the context of whole care pathways; although it may be cheaper to diagnose asymptomatic infections using self-sampling in place of clinician-obtained samples, if it takes more resources for the service to achieve adequate downstream outcomes, such as index patient treatment or partner notification success, the net costs may be greater than traditional care. Further complexity arises as online services tend to generate new demand for testing and a shift of activity between services. One analysis found that online STI testing increased the number of STI tests, increased the overall cost of testing, and decreased the average cost per diagnosis.⁶⁵ The article by Gibbs et al. in this issue provides more in-depth perspectives on health economic evaluation of digital sexual health services.

How do digital sexual healthcare interventions affect health inequalities? Health inequalities are systematic differences in health outcomes for people occupying different positions in society.⁶⁶ STIs and HIV are socially patterned and disproportionately affect those already experiencing health inequalities, especially people marginalised based on race, gender, socio-economic disadvantage, and disability. In parallel, people from these groups may experience barriers accessing health care due to stigma and geographical inaccessibility of existing services.

Digital health interventions could be a useful tool in addressing some of these barriers and have potential to increase access to sexual health care. However, unless they are implemented in an inclusive way,⁶⁷ digital interventions could reinforce existing barriers and inadvertently widen the digital health divide.^12,68 This is because the ability to engage effectively with digital services often requires access to an internet-enabled device, sufficient bandwidth, and digital literacy to navigate self-management pathways.⁶⁹

Within sexual health, there is limited evidence on the impact of digital sexual healthcare interventions and health disparities. Some digital crowdsourcing interventions have been designed to increase participation from women, ethnic minorities, and other under-represented groups.^70–72 At the same time, several studies suggest that socio-economically disadvantaged groups have lower uptake of online STI testing,^73,74 whereas other studies have not reported social gradients in online testing.⁷⁵ Work from the United Kingdom among people with mild learning difficulties highlighted considerable barriers to kit use and sample collection.⁷⁶ These inequalities highlight the need for legal, ethical, and human rights research to better understand the broader context of digital STI interventions.⁷²

Although digital services show considerable promise, gaps in the evidence base make it challenging to determine what types of digital interventions will work for whom and in which circumstances. First, there is a need for usability research that explicitly involves the end-user in the research process. Co-creation and related engagement of end-users has been shown to be effective in the development of many digital health interventions⁷⁷ and is advocated by a Lancet commission on Governing Health Futures.⁷⁸ Second, cost-effectiveness research and costing studies more broadly are needed to determine the circumstances in which digital interventions could be good value for money. Often, digital interventions require substantial resources for development and sometimes digital interventions assume ownership of a smartphone or other device. Research using low-cost platforms for analogue phones are needed to spur innovation focused on low-income users. Third, there is a need for legal and ethical research to consider how digital services impact health disparities. Finally, our data suggest that many digital tools have been developed for HIV and not applied to STI services. For example, although digital HIV self-testing has been widely used and is mentioned in World Health Organization guidelines, far fewer studies and programs have examined digital syphilis/other STI self-testing approaches.

Our review has several limitations. First, we only included guidelines that could be identified through a narrative review according to our specified criteria. A systematic review on the topic would likely identify more guidelines and best practice statements, but would likely encounter difficulties with the volume of disparate literature. This is particularly important for the identification of guidelines created in low- and middle-income country contexts. Second, our review excluded non-English-language studies. Although there is support for this approach from empirical studies,⁷⁹ this also privileges high-income country research. Third, digital tools also contribute to a broader literature on telemedicine and telehealth, which demands a review of its own. Fourth, we acknowledge that there are substantial differences between HIV and other STI digital interventions. For example, digital interventions for people living with HIV (PLHIV) are often about long-term management (e.g. antiretroviral support), whereas STI interventions may be more focused on acute issues; however, a broader discussion of these differences is beyond the scope of this manuscript.

The evidence and open access resources identified have important implications for the public, providers, and health systems. For the public, some of the digital transitions we described present new methods for engagement prior to seeing a healthcare professional in a clinical setting. The public can and must have an important voice in shaping the development of digital STI care pathways and how they relate to in-person services. For providers, digital tools may increase overall public demand and enhance linkage to clinical services. For health systems, digital systems could save resources and create more efficient clinics, but evidence from robust health economic analyses are needed. The studies we identified underline the need for integration of both digital and in-person services so that someone can move seamlessly between digital and in-person pathways based on preferences, medical needs, and resources. People may need assistance (e.g. peer navigators) in order to facilitate these transitions and reap the full potential of digital tools. Evaluation of whole systems are needed to adequately assess their effectiveness.

We relied on public open access databases to find relevant data. All data presented in this paper are available by contacting the corresponding author.

Joseph D. Tucker, Jane Hocking, and Claudia Estcourt are Editors of Sexual Health, but they were blinded from the peer review process for this paper. The authors report no other conflicts of interest.

This study received support from the US National Institutes of Health (UH3HD096929, K24AI143471, R01AI158826 to JDT). JSH is supported by a National Health and Medical Research Council Senior Research Fellowship (1136117).