Potential changes to the patient instructions before clinical implementation. These results suggest that self-administered testing could be substituted for clinician-administered testing, potentially improving detection. But widespread implementation would require a few modifications to the testing instructions based on the trained providers’ observations. Although the evidence is anecdotal, providers noted that several patients had difficulty with the instructions. For example, the placard said to use only the swab with the “blue shaft,” but 5 patients got confused and used the white swab either in addition to or instead of the blue swab. (The additional white swab was intended for use in making wet preps, when women are tested.) Many more patients ultimately used the correct swab, but appeared confused by the presence of the additional swab in the kit.
The confusion in these situations might have been avoided if the instructions had told men to throw one swab away and to use only the “blue swab” or the swab with the “blue handle” to avoid potential confusion over the word “shaft.” Another helpful modification to the instructions would be to alert men to the presence of the preservative liquid in the tubes. Several patients laid the tube horizontally with the cap off and spilled much of the liquid. It was still possible to test these samples, and there were no discrepancies between patient and provider results involving them. But ensuring standardization of the test tube contents should still be a priority in editing the instructions.
Incorporating self-testing into clinical practice. While the results of this study suggest that self-testing could be used with a few modifications to the instructions, how best to incorporate self-testing into the clinical setting still needs to be addressed. It might be possible for patients to simply perform testing after a physical exam; for patients to come in when it is convenient for them and leave a sample in the lab; or even for patients to perform testing at home and bring the swabs back to their clinic at a later time.
We obtained the results in this study when patients performed testing in a clinic with a trained provider in the room. One concern in implementing widespread self-testing would be that a provider’s presence in our study might have made patients more likely to spend the time needed to read instructions thoroughly and to put effort into performing the test correctly. However, it is also possible that knowing a provider will be duplicating the testing could lead to decreased patient effort. It may be that having responsibility for one’s own test results is what ensures adequate performance.
Further studies could explore the impact of a provider in the room, but studies have already examined testing done in private and yielded similar results for concordance, which suggests that any impact of the provider’s presence was relatively minimal. A 2009-2010 study at a London clinic, for example, allowed patients to perform testing privately following instructions from a nurse and identified a 9.8% prevalence of rectal CT infection and a 4.2% prevalence of rectal GC infection. These results are similar to those seen in our study and therefore suggest that patients were appropriately identifying infections without observation.28
Another study published in 2012 demonstrated that GC/CT testing swabs sent through the mail without any accompanying transport medium yielded results equivalent to those for swabs shipped in the liquid medium. This approach would make testing at home significantly easier, as patients would not have to be concerned about appropriate storage of their samples before returning them to a clinic.29
Applicability to female patients. Implementation of self-administered testing should be considered for female patients. In fact, most prior studies on the feasibility of self-testing have focused on women, as detection of their chlamydia and gonorrhea infections is equally critical. CDC guidelines stress the importance of yearly chlamydia screening for all women <25 years and for women >25 years who are at high risk (ie, multiple partners); and yearly gonorrhea screening for women at high risk, given the risk of medical complications including pelvic inflammatory disease and infertility if infections are missed.5
Researchers have found that after women participate in self-testing, they report that they would get STI testing more regularly if they could perform it themselves.19,30 Additionally, in studies similar to ours, women performing testing for gonorrhea and chlamydia using self-collected vaginal swabs have achieved similar sensitivity and specificity results to provider-performed testing.12,15,31