What can be done to shift the sexual health paradigm?
First would be widespread implementation of point-of-care STI testing to reduce delays and support same-day treatment, Dr. Hazra said, as well as integrating point-of-care systems into services for populations disproportionately affected by the current STI epidemic and providing more resources to clinics serving these communities. Bringing the testing to the patient is the goal, he said, whether that’s through mobile testing units, community outreach in harm reduction settings, or direct-to-consumer over-the-counter testing.
Much can be learned from the adoption of point-of-care testing for HIV, he said. The discussions happening now about point-of-care STI testing mirror those that occurred several decades ago, when the first point-of-care tests for HIV went on the market—questions like, “‘Where do we implement this? What happens to folks if they do home testing?’
“Point-of-care HIV testing broke a lot of barriers,” he said. For the first time, rapid test results were available outside traditional clinics, at outreach events, in mobile vans, and in the home. “And this was unheard of before the point-of-care model approach,” he said. It normalized HIV screening, expanding access to groups that are marginalized even as it shifted public perception of the testing from something only for those with high risk to a standard part of health care. “It’s a model for STI screening, through same-day results, real-time counseling, and linkage to care, all of which are key pillars of patient-centered prevention for HIV,” but also could be adapted to STI control.
Cost and reimbursement continue to stymie point-of-care STI test implementation. Novel technologies like the Visby direct-to-consumer point-of-care model are out of reach for the groups that are underserved and experiencing high rates of STIs. CLIA-waiver limitations are a barrier to implementation, as are workflow disruptions, staff training, quality assurance needs, and the limited menu of available tests—all of which are beyond the means of physicians to address.
Still, there are meaningful opportunities to integrate point-of-care testing into sexual health workflows. In clinics where walk-in STI screening is available, “being able to put point-of-care STI testing alongside HIV point-of-care [testing] would be transformative,” Dr. Hazra said, with its real-time results. Medical assistant- or RN-led STI screening protocols can help maximize clinic efficiency. STI testing can be brought to community events and mobile clinics, as is done for HIV testing. Leveraging electronic health record alerts can prompt physicians to order a point-of-care STI test they might not otherwise order. And public health partnerships at the city and state levels can help implement point-of-care testing across larger footprints.
Where—and when—should point-of-care testing be implemented?
For syphilis, the most vulnerable population for a primary infection are those who are pregnant, Dr. Hazra said, and thus one of the most effective settings for the Treponema point-of-care syphilis assay would be a prenatal visit. Where Dr. Hazra practices, on the South Side of Chicago, rates of congenital syphilis are high. “So being able to do that point-of-care [test] at any clinical encounter or visit, whether they’re coming to see an OB, whether they’re coming to the ER, is where I would focus,” he said. Important too is that eliminating congenital syphilis has buy-in from stakeholders across different specialties and professions, easing the way for implementation.
In an STI clinic, on the other hand, the point-of-care Treponema test would be less relevant, given that many patients may have had a previous syphilis infection. “However, asking patients about past infection may be a nice screener to see if they would benefit from a point-of-care syphilis test,” he said. It’s a question that should be asked in the field or during mobile outreach, too, so that patients with no prior infection can be tested and linked quickly to treatment if necessary.
For gonorrhea and chlamydia, the best way to use point-of-care testing is to prioritize symptomatic patients, he said. “If we do point-of-care gonorrhea and chlamydia [testing] for everyone who walks in our doors, I don’t think that’s the best use of our resources.” Prioritizing symptomatic patients can affect clinical management and antibiotic choice and potentially interrupt downstream transmission. A major limitation, however, is that none of the point-of-care tests for gonorrhea and chlamydia on the market are validated for rectal specimens. “That’s a limitation for the majority of populations impacted by STIs.”