Where would young people using an online STI testing service want to be treated? A survey of young Australians

Introduction

In the context of health service digitalisation, health system constraints and rising STI rates in many high-income countries, there has been a growth of online testing services in the UK, Europe, North America and Australia.^1,2 Online STI testing services typically test for one or more of chlamydia, gonorrhoea, syphilis and/or HIV. Although studies of online testing have shown an increase in test uptake,^3,4 there is no clear evidence on whether online services reduce time until treatment.^5,6 Access to treatment is key to ensuring those who test positive get timely care.

Different STIs require different treatment pathways, depending on whether or not an injection is required. With chlamydia, for example, a prescription for oral antibiotic tablets can be issued by telehealth, by e-prescription or sent through the post, as done by some services (e.g. SH:24 in the UK, https://sh24.org.uk/). In contrast, treatment for gonorrhoea and syphilis usually require administration of intramuscular, antibiotic injections by a health professional, which necessitates in-person attendance at a health provider. Moving from an online to in-person service may present online STI testing users with various barriers to treatment, including time and availability of appointments, cost, and embarrassment.⁷ Expansion of allied health professional roles, including the roles of nurse practitioners in managing treatment and the role of pharmacists in delivering vaccines, present new opportunities for where and by whom STIs can be treated. There is a need to understand users’ preferences for treatment options, as well as to explore the potential of non-clinic alternatives that may reduce barriers, such as time and cost, and ultimately time to treatment.

This study is part of a larger project to implement an online STI testing service (Test-it.org.au) in Victoria, Australia, that is informed by young people. The online STI testing service will be implemented by the Melbourne Sexual Health Centre, and aims to build supportive pathways for online clients to be treated. This survey aims to understand where young people want to be treated for gonorrhoea and syphilis if they test positive using an online service, and investigates sociodemographic factors associated with their preferences, and reasons underlining these preferences.

Methods

We conducted a cross-sectional survey administered online using Qualtrics (September and October 2022) comprised of closed and open-text questions. We recruited young Australians aged 16–29 years via paid Facebook advertisements, University of Melbourne communication channels, and newsletters of sexual health and/or youth-focus networks. Refer to Ludwick et al. (2023) for the full study methods.⁸ In this paper, we report results on preferences for receiving injectable antibiotics as a distinct part of the service pathway that cannot be provided online. Survey questions (Supplementary material file S1) enquired about four service options for receiving injectable antibiotics (based on possible options available in Australia). As health service use is known to be influenced by cost and availability, we included information about likely fees and booking requirements, based on the current service context in Australia. Participants were asked whether they preferred to receive injections at a:

Descriptive statistics were used to present sociodemographic characteristics of respondents and the percentage of overall respondents preferring a particular service option. For the purpose of analysis, respondents’ gender and sexual orientation were coded into a single variable, as follows: cisgender male and heterosexual; cisgender female and heterosexual; women who have sex with women; men who have sex with men; and non-binary, transgender and intersex. Multinomial logistic regression examined associations between respondents’ sociodemographic characteristics and service preferences, generating adjusted relative risk ratios (RRR) and 95% confidence intervals (CI). Variables selected for inclusion in the multivariable model were based on our earlier analysis of the survey, and included age, sexual orientation (cisgender male and heterosexual; cisgender female and heterosexual; women who have sex with women; men who have sex with men; non-binary, transgender, intersex), residential location (rural versus not), ever attended university (yes versus no), and ever tested for an STI (yes versus no).⁸ For the multinomial analysis, we compared the relative risk of preferring an alternative service over the current standard in Australia (e.g. GP-provided treatment). Using content analysis, short, free-text responses were inductively coded in Excel, and are presented using proportion of respondents and illustrative quotes.

Ethical approval was granted by the University of Melbourne (2022–24281).

Results

A total of 905 individuals aged 16–29 years participated in the survey, and of these, 777 (86%) answered the question on treatment preferences and were included in the analysis. Approximately half identified as heterosexual (45.3%; 352/777) and half as sexually or gender diverse (54.7%; 425/777). Approximately one-fifth (19.3%; 148/765) resided rurally, and one-quarter (24.2%; 185/765) were culturally or linguistically diverse. Approximately half (55.6%; 430/773) reported that they had previously tested for an STI (Table 1).

For intramuscular injections, the most common preference was treatment at a sexual health clinic (37.8%; 294/777), followed by a nurse located at a pharmacy (26.8%; 208/777; Table 2).

Compared with injections provided by a local GP, individuals with diverse sexual or gender orientation were more likely to prefer treatment at sexual health clinics (MSM versus heterosexual men adjusted relative risk ratio [aRRR] 2.5; 95% CI 1.1–5.7; WSW versus heterosexual men aRRR 2.6, 95% CI 1.1–5.7; transgender/non-binary versus heterosexual men aRRR 2.5, 95% CI 1.0–6.0). Older respondents aged 25–29 years versus respondents aged16–18 years were more likely to prefer all other options to GP clinic-provided treatment (pharmacy aRRR 3.3, 95% CI 1.4–7.4; sexual health clinic aRRR 2.3, 95% CI .1–4.9; community health clinic aRRR 6.8, 95% CI 1.8–26) or have no preference (aRRR 3.7, 95% CI 1.3–10.0). Those who had previously tested versus those who had not tested were less likely to prefer alternatives over general practice (sexual health clinic aRRR 0.6, 95% CI 0.4–1.1; community health clinic aRRR 0.1, 95% CI 0.1–0.3; no preference aRRR 0.4, 95% CI 0.2–0.8; Table 3).

In free-text responses, 529 respondents described the rationale for their preferred treatment location (Table 4). Of those who selected pharmacies, most described factors related to convenience (134/150), such as location, large number of providers, walk-in service rather than appointment-based and general ease of access. In contrast, free service was a key factor raised by those who selected treatment at sexual health clinics (130/238) and community health centres (22/32). Sexual health clinics were also valued for providing a safe space to receive treatment that is free of stigma and judgement, and that is delivered by specialists. Community health clinics were perceived to be less obvious to others as to why they were there. Familiarity with and trust of GPs emerged as key reasons for preferring them as treatment providers (77/109).

Discussion

In our survey of young Australians, we found that young people would prefer to be treated for an STI at a sexual health clinic or by a nurse at a pharmacy, with comparatively fewer preferring a GP clinic. Gender and sexually diverse young people were statistically more likely than other groups to prefer sexual health clinics, whereas older cohorts (aged 25–29 years) were more likely to choose any alternative to GP clinics. These findings parallel other studies, which conclude that high-risk patients generally do not tend to use their GPs for sexual health services,⁹ and that sexual health clinics are increasingly frequented by MSM.^10,11

Common barriers to STI treatment include cost, stigma and access to health providers.^12,13 In our study, sexual health clinics were valued primarily for their specialist and free services that are delivered without stigma. Other studies have similarly highlighted these attributes in other countries, as well as factors related to not being registered with a GP, greater speed and convenience, including availability of same-day, walk-in services.^14,15 In our study, however, benefits associated with convenience, including location and no appointments, were primarily associated with the option of being treated by a nurse at a pharmacy rather than sexual health clinics.

In Victoria, Australia, there is only one dedicated specialist sexual health clinic, and availability for walk-ins and appointments quickly reaches daily capacity. Thus, decentralising treatment to other health providers is important. In some countries, such as Canada and Australia,¹⁶ the role of pharmacies is expanding, opening potential for their role not only in screening for STIs, but also in providing treatment.¹⁷ Although our survey showed a considerable level of interest in being treated at a pharmacy, the role of pharmacists in Australia is currently limited by unclear guidelines, lack of training in intramuscular injections for pharmacists and lack of financial incentives to do so. As an alternative, ‘Supercare Pharmacies’ in Victoria (24-hour pharmacies that have nurses available in the evenings for walk-in clients), could potentially perform this role within pharmacies. However, there are only a handful of these pharmacies in Victoria. Increasing the capacity of the newly established sexual and reproductive health hubs funded by the Victorian Government might be a good alternative that bridges the gap between limited availability at the specialist clinic and lack of interest in going to a GP clinic.

Although our study findings draw from a relatively large sample that captures differences in preferences by sociodemographic characteristics, our study is limited in that it draws on hypothetical scenarios, rather than data on health service usage. Our findings contribute to the literature by demonstrating commonalities among the factors that affect the choice of STI treatment provider in different countries, while also highlighting how the country context, including the structure and organisation of health services organisation (e.g. decentralised genitourinary medicine clinics in UK versus centralised, single specialised sexual health provider in Victoria), affects the attributes associated with different types of providers and user preferences. As online STI testing clinics become the mainstay of service provision in many countries, developing supportive pathways to treatment and means to monitor treatment outcomes will be essential.

Supplementary material

Supplementary material is available online.