Introducing home‐based STI screening in this low‐income setting in Gugulethu, South Africa resulted in a moderately higher proportion of women screened compared with clinic‐based screening (unadjusted RR 1.3). A similar study conducted in São Paulo, Brazil also found a slightly higher response rate for home‐based than clinic‐based STI screening within 2 weeks of enrolment (80% vs 76%).8
Both studies showed a modest effect, suggesting that home‐based screening is, at a minimum, as acceptable as clinic‐based screening for women in resource‐poor settings, and may result in more women being screened. The moderate difference found in both studies may be due to the high proportion of respondents recruited from clinics, who are probably women predisposed to clinic attendance.
The response rate was higher than expected in both groups, with 42% of the clinic group responding compared with our hypothesised response rate of 20%. Although this finding is encouraging, still less than half (44%) of the women overall were screened for STIs in this high‐prevalence setting. The response rate was much higher in the Brazil study.8
In addition to potential sociocultural differences, the studies targeted different age groups: the Brazil study included women aged 18–40, whereas this study focused on young women 14–25 years old. Young women may have greater barriers to receiving STI screening than older women, as is seen in the present study, with women aged 23–25 nearly three times as likely to respond as women aged 14–17, after adjustment for randomisation group.
- Self‐sampling and self‐testing for diagnosis of sexually transmitted infections (STIs) are feasible and acceptable options for many women in low‐income communities.
- Home‐based STI screening is as acceptable as, if not slightly more acceptable than, clinic‐based screening to young women. However, self‐sampling and self‐testing at home may be more prone to user error than at the clinic.
- Many resource‐limited settings do not currently have STI screening programmes, relying on syndromic management of people with symptoms who seek care at clinics, while asymptomatic infections go undiagnosed and untreated. As in‐house PCR capability increases and rapid diagnostics improve, self‐sampling and self‐testing should be used to provide STI screening services in a wide range of clinical and non‐clinical venues to maximise programme coverage for management of symptomatic and asymptomatic cases.
Self‐testing and self‐sampling were feasible in both clinic and home settings. However, women at home had more difficulties than women in the clinic in terms of performing the rapid test, especially reading the test results. As rapid diagnostics continue to be developed, instructions should be carefully pre‐tested and designs refined for ease of interpretation of results. Women did not report difficulties using the mail and the toll‐free number, suggesting that this type of screening initiative is possible in resource‐poor settings.
This study had limitations. Women preferred the setting in which they had experience; having women try both environments and discuss preferences may be more informative. The choice of interpretation of “partial responders” alters study findings. Nevertheless, the proportion of women who were successfully tested for CT, NG and TV by PCR was equivalent in the two groups, and all women who tested positive were treated in both groups. Data on the number of attempts needed to track positive cases, however, were not systematically recorded; nor were data on the number of women who called with positive rapid TV tests.
Finally, the findings have limited policy implications at present in that the cost of commercial PCR diagnostics for CT and NG remains prohibitively high. However, in countries such as South Africa and Brazil, where infrastructure for laboratory technology is growing, the potential for using cheaper in‐house PCR techniques with self‐acquired samples is becoming a viable reality. In addition, women themselves report being willing to pay a nominal fee (US$2.30), suggesting potential for introducing subsidised home kits into services.
Creative screening programmes for STIs are needed in resource‐poor settings with a heavy disease burden. South Africa does not currently have screening programmes, relying on syndromic management for people with symptoms who seek care at clinics, while asymptomatic infections go undiagnosed and untreated. We have shown that self‐sampling and self‐testing are feasible and acceptable options in low‐income communities such as Gugulethu. As rapid diagnostic tests and laboratory infrastructure improve, these technologies should be used to introduce STI screening services into a wide range of clinical and non‐clinical venues to maximise programme coverage.