The Acceptability and Cost of a Home-based Chlamydia Retesting Strategy

Findings From the REACT Randomised Controlled Trial

K. S. Smith; J. M. Kaldor; J. S. Hocking; M. S. Jamil; A. M. McNulty; P. Read; C. S. Bradshaw; M. Y. Chen; C. K. Fairley; H. Wand; K. Worthington; S. Blake; V. Knight; W. Rawlinson; M. Saville; S. N. Tabrizi; S. M. Garland; B. Donovan; R. Guy

Disclosures

BMC Public Health. 2016;16(83) 

In This Article

Results

Acceptability

Survey Respondents. Overall 445/600 (74 %) of participants completed the survey (MSM 165/200 [83 %], women 150/200 [75 %], heterosexual men 130/200 [65 %]). Comparing survey respondents with non-respondents, there were significant differences in risk group and demographics, with a higher proportion of MSM and a lower proportion of heterosexual men (p = 0.001), and a lower proportion aged <30 years (p = 0.015). Overall 236 of 302 (78 %) home-arm participants and 209 of 298 (70 %) clinic arm participants completed the survey. There were no significant differences in baseline characteristics (risk group, demographics, sexual behaviour or STI clinical information) between survey respondents in the home versus the clinic arm (Table 1).

Acceptability of SMS Reminders (All Participants). The majority of survey respondents were comfortable or very comfortable with receiving an SMS reminder about retesting (85 %, n = 378) and were comfortable with the timing and wording of the SMS reminders (90 %, n = 399). Among those who nominated a single choice of their preferred reminder method (n = 401), 75 % had a preference for SMS and 15 % said they would prefer email reminders. Responses were similar between the home and clinic groups.

Reasons for not Retesting (All Participants). Amongst the 28 survey respondents in the home arm who didn't retest, the main reasons were: lack of time (32 %, n = 9), not considering themselves to be at risk (18 %, n = 5), misplacing their kit (14 %, n = 4), not receiving their kit (11 %, n = 3) and not being sure about how to self-collect specimens (7 %, n = 2). Among clinic arm respondents who didn't retest (n = 67), the main reasons were: lack of time (43 %, n = 29), not considering themselves to be at risk (16 %, n = 11), no reminder (7 %, n = 5) and went overseas/changed address (7 %, n = 5).

Acceptability of Home Collection (Home Arm Participants Only). Of the participants from the home arm who completed the survey (n = 236), 141 (60 %) retested at home at any time during the study period (home-based retesters) (52 females, 43 heterosexual males and 46 MSM). The majority of home-based retesters were comfortable or very comfortable having the kit posted to their home (86 %, n = 121); found it easy to follow the instructions and collect the specimens (96 % both, n = 136 and 135 respectively); were confident they had collected the specimens correctly (90 %, n = 127); and reported no problems collecting the specimen (69 %, n = 97) (Table 2). Amongst those who reported problems collecting their specimens (n = 42), the main problems were not knowing how far to insert the swab (60 %, n = 25), urine splashing on the hands (26 %, n = 11), followed by difficulty aiming urine onto the swab (5 %, n = 2).

Preferred Retesting Strategy (Home Arm Participants Only). The majority of home-based retesters (65 %, n = 92) said they would prefer home testing in the future, 21 % had no preference and 14 % preferred clinic retesting (Table 2). Among home-based retesters who said they preferred home testing in the future, the main reasons were that it saves time (70 % n = 64) and was more convenient (57 %, n = 52), followed by more confidential (27 %, n = 25) and less embarrassing (22 %, n = 20). For those who preferred clinic retesting (n = 20), the main reasons were that they were more confident that the tests would be done properly (65 %, n = 13), followed by more confidential (30 %, n = 6), more convenient (20 %, n = 4), and would like to be able to talk to a clinician (10 %, n = 2).

Comparing those with a preference for home testing to those who didn't, there were significant differences in being comfortable having the kit sent to their home (p = 0.045), living with friends/flatmates rather than with their partner, parents or alone (p = 0.034) and not being diagnosed with chlamydia previously (p = 0.030). Of those who preferred home testing, 62 % lived with their friends/flatmates, 16 % alone, 11 % with a partner and 10 % with parents, compared with 37 %, 27 %, 18 % and 12 % respectively among those who preferred clinic retesting or didn't have a preference (Table 2).

Preference for Receiving Kit (Home Arm Participants Only). The majority of home-based retesters (91 %, n = 129) said they would prefer to be sent their kit in the mail and 9 %, (n = 12) said they preferred to collect their kit from the clinic. There were no significant differences in preference for receiving kits by age group (≤25 years or > 25 years), risk group or who they lived with (Table 3).

Cost

Cost of the Clinic Retest Pathway Per Person. The overall cost per person of the clinical pathway from initial testing to result notification, treatment visit and retesting at the clinic was $168.60 (MSM $216.30, heterosexual men $142.50, women $145.30): $80.10 for the initial consultation, $3.70 for result notification and SMS, $14.90 for the treatment visit, and $69.90 for the retest visit (Table 4). Overall costs were greater for MSM due to the additional cost of testing two samples (rectal swab and urine), versus a single sample for heterosexual men (urine) and women (vaginal swab).

Cost of the Home Retesting Strategy Per Person. The home retesting strategy included the costs for the initial testing, result notification and treatment visit at the clinic, plus the cost of retesting at home. The overall cost per person of this strategy was $154.00 (MSM $196.40, heterosexual men $131.50, women $133.00); $80.10 for the initial consultation, $3.70 for result notification and SMS, $14.90 for the treatment visit, and $55.30 for the retesting component (Table 4).

Cost Per Infection. In the home arm, 61 % (n = 184) of participants retested. Of these, all were sent home testing kits, and 73 % (n = 134) self-collected at home and mailed their specimen/s to the laboratory and 27 % (n = 50) retested at the clinic. In total, 31 repeat infections were detected. In the clinic arm, 39 % (n = 117) retested at the clinic and 12 repeat infections were detected. Based on these results, the overall cost per repeat infection detected was estimated to be $1409.20 for the home retesting strategy and $3132.60 for the clinic retesting pathway: a difference of $1723.40 per infection detected (Table 5).

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