Apps May Be 'the Only Way' to Get Rural Patients STI Tests

Heather Boerner

July 23, 2018

AMSTERDAM — The future of testing for HIV and sexually transmitted infection (STI) could lie in a combination of apps and self-testing in areas of the United States where healthcare is sparse and gay men are stigmatized, according to Patrick Sullivan, PhD, from Emory University in Atlanta.

"Mobile apps may be the only way to reach these men, who don't have symptoms and aren't out to their providers," Sullivan told the audience during a preconference session on HIV and STI syndemics here at the International AIDS Conference 2018.

"We may be able to provide a fairly comprehensive package of sexual health services, completely through new media tools, that includes STI testing," Sullivan explained.

Two recent datasets challenge physicians and others to take immediate action to prevent the widening gap in outcomes for black Americans.

Great Need, Great Disparity

First, data from the Centers for Disease Control and Prevention (CDC) showed that the gap between white men and black men receiving pre-exposure prophylaxis (PrEP) is on track to increase, as reported by Medscape Medical News. The CDC emphasized the need to reach out to black communities more generally.

Then, last week, the CDC reported that although black men who have sex with men account for 36% of new HIV diagnoses, they only account for 6% of HIV tests (MMWR Morb Mortal Wkly Rep. 2018;76:778-781).

"For black men who have sex with men in the southern United States, racism, lower education levels, stigma, income inequality, and lack of access to healthcare are barriers to testing, linkage, and retention in HIV prevention and treatment services," the report states. "In addition, some persons living with HIV infection in the rural southeastern United States might have to travel more than 50 miles to receive HIV care."

Sullivan presented a series of tools for physicians and their patients that could help ease these disparities.

Ten active studies — primarily of young men who have sex with men — are underway to assess whether apps and online resources have any effect on the prevention, diagnosis, and treatment of HIV. Some are recruiting participants and others have completed pilot studies and are moving on to randomized controlled trials. All are part of the University of North Carolina/Emory Center for Innovative Technology (iTech) program, which was launched in 2016 as part of the Adolescent Trials Network.

At-home testing that integrates all sexual health conditions — HIV, but also Chlamydia and rectal, oropharyngeal, and penile gonorrhea — is key to the iTech program, said Sullivan.

This is because increased rates of STI are often associated with HIV acquisition and are a marker of condomless sex and HIV risk. Plus, "men have trouble finding providers who will do the STI testing that's recommended," such as rectal swabs for gonorrhea, at least in the Atlanta area, he reported. "Being able to collect these specimens at home is actually welcome."

Testing Tailoring to the Individual

But there is more to the program than self-testing. In some of the iTech studies, men are asked how they want to receive their tests and then are linked to the care they are asking for. This move is the result of several focus groups of black and young men who have sex with men, conducted by Sullivan and his colleagues, which indicate that men are tired of getting rote suggestions about HIV testing that involve a clinical setting and blood draws.

So apps were designed to ask about behaviors and preferred methods of testing: Are you more confident in a blood test and okay with waiting for results? Or are you averse to needles and want results immediately? If a clinic visit is indicated, the app suggests that the user schedule one. If the user is more comfortable collecting a specimen for HIV or STI testing at home, the app arranges for the appropriate tests to be sent.

Should men who are already being tested every 6 months be forced to discuss HIV risk? "Maybe some men just need that counseling once a year," Sullivan told Medscape Medical News.

iTech is looking at ways to scale-up its efforts. A national study and studies in states with the highest number of black and Latino men who have sex with men are being planned.

A pilot study that examined whether black men who have sex with men living in rural areas are interested in PrEP, conducted Aaron Siegler, PhD, also from Emory University, has recently wrapped up. An app arranged for a kit to test HIV and STI status to be sent to interested users. If lab results indicated they were eligible for PrEP, the app scheduled a telemedicine meeting with a provider who could prescribe PrEP.

Results from the pilot study are still being analyzed, but the creators hope to hand off, eventually, the app and administration to local health departments.

There haven't been cost-effectiveness studies yet, but you can imagine it would be cheaper to do this by mail than to try to set up clinics in all these areas in the South.

Siegler's system is "really working," said Sullivan. "There haven't been cost-effectiveness studies yet, but you can imagine it would be cheaper to do this by mail than to try to set up clinics in all these areas in the South."

The process has a long way to go before effectiveness and affordability are proven. But this new way to address the universal problem of poor access to care is intriguing, said Jackie Cassell, BMBCh, from the University of Sussex in Brighton, United Kingdom, who is editor of Sexually Transmitted Diseases.

"One of the things that absolutely resonates in the United Kingdom is accessibility in rural and distant populations," she explained. "For very simple things — like getting an HIV test — it's really good to see some exciting moves forward."

But it might not be specialists who manage such remote care, noted Linda-Gail Bekker, MBChB, who is president of the International AIDS Society.

"This needs to be nurse-driven," at least in Africa, she said. "That's the aspirational goal."

The National Institutes of Health funds the iTech program. Sullivan, Cassell, and Bekker have disclosed no relevant financial relationships.

International AIDS Conference 2018. Presented July 22, 2018.

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