Reimagining STI Clinics for a New Generation

Heather Boerner

September 18, 2019

WASHINGTON, DC — When patients arrive in the heart of London's Soho neighborhood, they could be going to any of the posh restaurants that line the narrow streets. Instead, they enter a storefront with frosted windows and a stylized neon sign that simply reads, Dean Street Express.

Inside the storefront is a white entry room where patients check in on a touch screen and list the tests they're there for. An alert is then sent to their cell phone, assigning them a clinic number. A staff member hands them a container filled with the requisite swabs and vials and they head to a private room down the hall. There, a screen embedded in a mirror walks them through the process of taking a throat swab for gonorrhea, for instance, or a urine sample for gonorrhea or chlamydia.

After they gather the necessary samples and seal them in the container, patients place the container into a pneumatic tube that shoots the samples to the lab. There, the lab technician starts running tests for chlamydia and gonorrhea and routes the others for evaluation.

If patients want an HIV test or another test that requires bloodwork, they head downstairs to a pop-art-painted waiting room with free wi-fi. There, a counselor meets with them and takes their blood sample.

And that's it. Chlamydia and gonorrhea screening results are sent by text to the patient quickly. The rest arrive within 6 hours.

Dean Street Express represents "the dream and the goal" for those providing care, said Chad Hendry, director of sexual and reproductive health at Howard Brown Health in Chicago.

For years, there has been talk of fast-tracking visits for patients who want to be tested for sexually transmitted infections (STIs). But recently, "there's been this push for that care to be separated out from regular clinical services. That's the big difference," Hendry said here at the United States Conference on AIDS 2019.

NACCHO Typical STI Clinic

In the year after the opening of Dean Street Express, which is funded by the National Health Service Foundation Trust, the clinic processed 39,180 more chlamydia and gonorrhea tests than its traditional counterpart down the street. It also cut time to diagnosis notification by 8.68 days, from 8.95 days at the traditional clinic to 0.27 days at the express clinic (Int J STD AIDS. 2018;29:474-482).

The same study estimated that testing and care through the express clinic could result in 196 fewer cases of chlamydia or gonorrhea and save the healthcare system £124,284 (about US$155,521).

It is hoped that results will be similar at the two Howard Brown Health express clinics in Chicago, said Hendry.

Those are two of seven express clinics in the United States that have been selected to participate in the STD Express Data Collaborative, a joint effort between the National Association of County and City Health Officials (NACCHO) and the Division of STD Prevention at the Centers for Disease Control and Prevention. The goal is to evaluate the effectiveness, costs, and outcomes associated with such rapid testing in communities over a 12-month period. It is expected that data collection from the express clinics will end in April 2020.

Express clinics make sense, said Hendry. In many neighborhoods, there are no health clinics.

"What we and a lot of clinics find is that we're reaching the same people" with traditional clinics, he said. "But we're not reaching the people we need to reach."

The Howard Brown express clinics are located in Hyde Park and Oak Park, neighborhoods with HIV rates of 20.6 to 40.3 cases per 100,000 people in 2017, which are among the highest rates in Chicago.

The Howard Brown clinics are not as sleek as Dean Street Express, but they do have several things in common: they exist outside traditional primary care clinics, in storefronts in neighborhoods; and they use an online platform to register patients, order tests, and deliver results.

"We even have the pneumatic tube, just like they do," said Hendry.

The express clinics offer rapid on-site screening for HIV, syphilis, hepatitis C, and pregnancy, along with laboratory-based screening for chlamydia and gonorrhea. Unlike in traditional Howard Brown clinics, where the high volume of testing often means that people only receive their results if they test positive, in the express clinics, "by the time you walk out the door, you'll already have all your rapid laboratory results," he said.

Because the American express clinics do not have the same kind of laboratory equipment as Dean Street Express, nonrapid test results can take up to 3 days.

In the 7 months since the express clinics launched, many of the 210 people served have been from communities that traditional clinics have not reached, said Hendry. Half the clientele is black men, 63% of those clients are men who primarily identify as gay, bisexual, or queer, and 44.3% were referred by family or friends.

"A number have come back a second or third time," he added.

Systems Change for Sexual Health

Community engagement can help clinics provide the services that patients want, said Sarah McKenney, PhD, from the New York City Department of Health and Mental Hygiene.

When McKenney joined the department, it was specifically to come up with a more welcoming name for the city's STI clinics. After focus groups and other forms of community engagement, the city settled on "sexual health clinics."

The city has since created a Sexual Health Advisory Group, which consists of community members who continue to guide clinical services and approaches.

Active curation of the Google listing for their clinics, which provide up-to-date hours of operation and photos, and engagement with reviewers have been used to increase use of the clinics and make them welcoming places for all, said McKenney.

That is easier said than done in much of the country, said one audience member who identified himself as an exhibitor from Seattle. Clinicians might not understand that people often come to their clinics because they have nowhere else to go.

"The fact that you were able to change the name to sexual health clinics is remarkable," he said.

One audience member explained that when she suggested a name change, the health department — concerned that "sexual health clinic" implied a full range of services, such as HIV pre-exposure prophylaxis (PrEP) and postexposure prophylaxis (PEP) — vetoed the idea. She asked McKenney for advice on how to bring the idea up again.

McKenney suggested that she offer New York City as an example, and create a robust list of places where people interested in PrEP, PEP, and other services can get them. She also suggested that engagement with community members could allay fears about the name change.

Ask people in the community how mad they would be if they came to the clinic for PReP and were unable to get it, McKenney said. "You really can't know until you start asking."

When you walk into the clinic, it's like you're walking into a new home.

Like Dean Street Express, the Howard Brown express clinics have no signage indicating that they are STI testing sites. "You wouldn't have any idea what's in the building," said Hendry.

This is not unique to Chicago, said Byron Buck, a PhD candidate at the University of Mississippi Medical Center in Jackson.

He described the Open Arms Healthcare Center in Jackson, which is a traditional clinic with a nontraditional set-up.

"When you walk into the clinic, it's like you're walking into a new home," Buck told Medscape Medical News. "We want that feel," he noted, because "we don't want anyone to know what you're coming in for."

This is a major part of defeating the stigma against STIs and HIV, said Hendry.

Buck said he will take home the concepts of online tools and community engagement that could make Jackson's clinics more patient-centered.

There is an express clinic in Jackson, but it is "on the third floor, so that kind of works against us in retention and recruitment," he pointed out. Having an online presence with accurate information could help people find the clinic.

That and the idea of a sexual health advisory group left Buck inspired to connect with the people they serve in a deeper way. "Sometimes we get busy but we always want to make sure we hear from our community," he said.

Hendry, McKenney, and Buck have disclosed no relevant financial relationships.

United States Conference on AIDS (USCA) 2019. Presented September 7, 2019.

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