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. 2023 Jun 7:09564624231180641. doi: 10.1177/09564624231180641

STI testing, diagnoses and online chlamydia self-sampling among young people during the first year of the COVID-19 pandemic in England

Tamilore Sonubi 1,✉, Dahir Sheik-Mohamud 1, Natasha Ratna 1, James Bell 1, Alireza Talebi 1, Catherine H Mercer 2,3, Katy Sinka 1, Stephanie J Migchelsen 1, Kate Folkard 1, Hamish Mohammed 1,3
PMCID: PMC10251181  PMID: 37287231

Abstract

Purpose

COVID-19 control measures reduced face-to-face appointments at sexual health services (SHSs). Remote access to SHSs through online self-sampling was increased. This analysis assesses how these changes affected service use and STI testing among 15–24 year olds (‘young people’) in England.

Methods

Data on all chlamydia, gonorrhoea and syphilis tests from 2019-2020, among English-resident young people were obtained from national STI surveillance datasets. We calculated proportional differences in tests and diagnoses for each STI, by demographic characteristics, including socioeconomic deprivation, between 2019–2020. Binary logistic regression was used to determine crude and adjusted odds ratios (OR) between demographic characteristics and being tested for chlamydia by an online service.

Results

Compared to 2019, there were declines in testing (chlamydia-30%; gonorrhoea-26%; syphilis-36%) and diagnoses (chlamydia-31%; gonorrhoea-25%; syphilis-23%) among young people in 2020. Reductions were greater amongst 15-19 year-olds vs. 20-24 year-olds. Amongst people tested for chlamydia, those living in the least deprived areas were more likely to be tested using an online self-sampling kit (males; OR = 1.24 [1.22–1.26], females; OR = 1.28 [1.27–1.30]).

Conclusion

The first year of the COVID-19 pandemic in England saw declines in STI testing and diagnoses in young people and disparities in the use of online chlamydia self-sampling which risk widening existing health inequalities.

Keywords: Young people, COVID-19 pandemic, STIs, Chlamydia, Gonorrhoea, Syphilis, Socioeconomic deprivation, online STI testing, COVID-19 impact, STI service provision

Background

Sexually transmitted infections (STIs) present a public health challenge in England. The burden of STIs is greatest amongst young people aged 16–24 years and they are most likely to access sexual health services (SHSs).1,2,3,4,5,6 Between 2010-12, they had the highest prevalence of chlamydia (3.1% of women and 2.3% of men in this age group). The prevalence of gonorrhoea was highest amongst people 20–24 years of age. 7

The majority of chlamydia and gonorrhoea infections are asymptomatic, particularly amongst women, and may result in poor sexual and reproductive health if left untreated; 8 this includes a higher risk of pelvic inflammatory disease (PID), and ectopic pregnancy, which are preventable with early diagnosis and treatment.9,10 Consequently, opportunistic chlamydia screening has been offered to sexually active 15–24 year olds in England since 2003 through the National Chlamydia Screening Programme (NCSP).

There had been increases in attendances at SHSs between 2016–2020. 3 However, SHS delivery was greatly disrupted in March 2020 after the introduction of public health measures to reduce COVID-19 transmission such as national lockdowns, the requirement to stay at home, and social distancing. Moreover, the introduction of legislation restricting social interaction may have resulted in some people with STI-related symptoms avoiding attending SHSs due to fear of being judged for breaking these rules, creating a false sense of reduced demand for STI testing services. 11 However, to ensure continued provision of STI testing, SHSs across England were rapidly reconfigured to provide more remote care via online consultations. 3

To understand how STI testing, diagnoses and service use among 15–24 year olds in England changed during the first year of the COVID-19 pandemic, we compared the demographic characteristics of young people tested for STIs in 2019 and 2020 then, among all young people tested for chlamydia, determined the correlates of being tested via an online service instead of a face to face appointment.

Methods

Data description

We conducted a retrospective cohort study of 15–24 year olds (hereafter referred to as ‘young people’) residing in England who received an STI test or diagnosis utilising data from the GUMCAD STI Surveillance System and the CTAD Chlamydia Surveillance System. GUMCAD is a pseudonymised and depersonalised dataset of all attendances at SHSs in England and was used to obtain data on chlamydia, gonorrhoea and syphilis tests and diagnoses in young people attending this setting; syphilis diagnoses included primary, secondary and early latent stages.12,13 CTAD is a pseudonymised and depersonalised dataset of all publicly provided chlamydia tests and diagnoses, including those made through the NCSP, and was the source of data for chlamydia tests and diagnoses from community-based settings (those offering non-specialist STI-related care such as general practices and pharmacies [some pharmacies provide a home-based self-sampling kit, which are shipped to the laboratory.]).14,15 All tests and diagnoses are coded by healthcare practitioners in keeping with surveillance reporting specifications. To avoid double counting of tests or diagnoses in each surveillance system, only one test or diagnosis of each STI for each person with a unique person identifier was counted within a 6-week episode. 15 Neither GUMCAD nor CTAD include personal identifiers so individuals cannot be matched between datasets; individuals are identified using a clinic-specific patient identification code in GUMCAD 16 and a unique patient identifier number in CTAD. 14

The study period was from 1st January 2019 to 31st December 2020 (inclusive), where data from 2019 relates to the pre-COVID period and 2020 relates to the first year of the COVID-19 pandemic. To be considered in the analysis data were restricted to people aged 15–24 years, at the time of the test or diagnosis, residing in England. Residential location was defined using the lower super output area (LSOA), small geographical areas for the reporting of small area statistics with an average size of 1,620 residents. 17 To obtain a measure of area-level socioeconomic deprivation, LSOAs were used to match to quintiles of the 2019 Index of Multiple Deprivation (IMD) dataset. 18 Additionally, the LSOAs were matched to the 2011 census area classification to categorise young people as living either in an urban or rural setting.19,20,21 Ethnicity was categorised using the national Census classification, as follows: Asian (including Bangladeshi, Chinese, Indian, Pakistani and any other Asian background), Black African, Black Caribbean, Other Black ethnicity, Mixed ethnicity (including White and Black Caribbean, White and Black African, White and Asian and any other Mixed or Multiple ethnic background), Other, and White. 22

Statistical analysis

We determined the proportional change in the characteristics of young people tested for STIs between 2019 and 2020. Demographic and clinical characteristics included age group (15–19 or 20–24 years), area of residence (rural or urban), residential area-level deprivation, (as defined by IMD quintile, where quintile 1 is the most deprived and quintile 5 is the least deprived), ethnicity, gender and public health region of residence (categorised as: East Midlands, East of England, London, North-East, North-West, South-East, South-West, West Midlands and Yorkshire and Humber) these characteristics were compared for all three STIs as they can be assessed in both CTAD and GUMCAD surveillance systems. Sexual orientation (including heterosexual males, men who have sex with men [MSM], heterosexual females and women who have sex with women [WSW]), and HIV status (categorised as; HIV diagnosed, HIV undiagnosed or unknown) were compared for gonorrhoea and syphilis as they are only collected in the GUMCAD surveillance system. Testing services (categorised as physical or online services) were compared for chlamydia only, as the CTAD surveillance system comprehensively captures all chlamydia testing from all publicly-commissioned testing services. The Pearson’s chi-square test was used to compare these characteristics across both years.

Subsequently, to assess any inequalities in the access to online self-sampling services for chlamydia testing (hereafter: ‘online chlamydia testing’), we restricted the sample to young people tested for chlamydia then used binary logistic regression to determine the crude and adjusted associations with being tested via an online service (yes vs no); all models were stratified by gender. Bivariate models were created to determine the unadjusted odds ratios (ORs) for being tested online and residential area-level deprivation, as defined by IMD quintile (the primary independent variable), and each potential confounder (year of test, age group, area of residence and region of residence). All associations with a p-value less than 0.05 were considered to be statistically significant and all variables that had significant crude associations were included in the multivariable model. Adjusted odds ratios (aORs) were calculated using hierarchical modelling and covariates were added using a forward building approach. Firstly, Model 1 was constructed with the year of test included a priori due to the scale up of online service provision during 2020. 3 The remaining covariates were added sequentially as follows: Model 2 was based on Model 1 with age group included as a confounder. Model 3 was based on Model 2 with the addition of area of residence. Lastly, Model 4 comprised Model 3 with the inclusion of region of residence. Ethnicity was excluded from the regression analysis due to a high degree of item non-response: 29% of young people tested for chlamydia were reported with an unspecified ethnic group in CTAD. All data analyses were performed using Stata v15 (College Station, TX, USA). 23

Results

Trends in STI tests and diagnoses

There were 26–36% decreases in tests and diagnoses for chlamydia, gonorrhoea and syphilis among young people between 2019 and 2020 (Tables 1-3). However, there were greater proportional decreases among 15–19 compared to 20–24 year olds. By ethnicity, testing and diagnoses of all 3 STIs decreased for all ethnic groups with larger proportional declines among young people of Asian and Black non-African/non-Caribbean ethnicities. The number of chlamydia tests fell across all the different types of services offering testing (physical services - 47%; 1,041,553 to 554,299), with the exception of online services where there was a 33% increase in testing between 2019 (271,684 tests) and 2020 (361,622 tests). Comparisons by sexual orientation could only be done for gonorrhoea and syphilis and, in both cases, testing and diagnoses fell to the largest extent (33–46%) among heterosexual men.

Table 2.

Number of syphilis tests and diagnoses among 15–24 year olds residing in England, by demographic characteristics: 2019–2020.

Tests Diagnoses
2019 2020 Percentage difference 2019 2020 Percentage difference
Age
 15 to 19 136,686 78,620 −42% 223 139 −38%
 20 to 24 382,761 255,340 −33% 948 766 −19%
Ethnicity
 Asian 24,157 14,354 −41% 61 40 −34%
 Black African 25,799 17,443 −32% 19 24 26%
 Black Caribbean 19,560 12,608 −36% 29 36 24%
 Other black ethnicity 6,165 3,547 −42% 17 9 −47%
 Mixed ethnicity 31,476 21,445 −32% 72 50 −31%
 White 351,999 211,583 −40% 861 626 −27%
 Other 6,880 4,455 −35% 21 24 14%
 Unknown ethnicity 53,411 48,525 −9% 91 96 5%
Sexual orientation
 Heterosexual males 146,927 78,987 −46% 192 121 −37%
 MSM 44,921 35,974 −20% 693 568 −18%
 Heterosexual females 283,049 185,791 −34% 220 154 −30%
 WSW 2,866 2,767 −3% 3 3 0%
 Unknown sexual orientation 41,684 30,441 −27% 63 59 −6%
Area of residence
 Rural 50,909 30,084 −41% 74 55 −26%
 Urban 459,186 294,991 −36% 1,070 837 −22%
 Unknown area of residence 9,352 8,885 −5% 27 13 −52%
Residential area-level deprivation (deprivation Quintile) a
 1 (most deprived) 114,267 70,837 −38% 357 275 −23%
 2 128,123 84,643 −34% 327 245 −25%
 3 102,827 66,940 −35% 219 168 −23%
 4 87,324 54,707 −37% 149 111 −26%
 5 (least deprived) 77,554 47,948 −38% 92 93 1%
 Unknown deprivation quintile 9,352 8,885 −5% 27 13 −525
Region of residence
 East Midlands 38,033 19,792 −48% 72 43 −40%
 East of England 48,082 28,046 −42% 59 59 0%
 London 142,416 103,316 −27% 382 315 −18%
 North-East 20,684 11,430 −45% 91 78 −14%
 North-West 55,936 30,863 −45% 205 127 −38%
 South-East 82,258 56,890 −31% 137 99 −28%
 South-West 45,034 28,029 −38% 61 63 3%
 West Midlands 42,700 23,298 −45% 76 60 −21%
 Yorkshire and Humber 37,252 24,131 −35% 72 48 −33%
 Unknown region of residence 7,052 8,165 16% 16 13 −19%
HIV status
 HIV Diagnosed 949 618 −35% 58 43 −26%
 HIV Negative or unknown 518,498 333,342 −36% 1,113 862 −23%
 Total 519,447 333,960 −36% 1,171 905 −23%
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aDeprivation quintile is an area-level measure of deprivation and socioeconomic status based on the 2019 Index of Multiple Deprivation (IMD) quintiles.

Table 1.

Number of gonorrhoea tests and diagnoses among 15–24 year olds residing in England, by demographic characteristics: 2019–2020.

Tests Diagnoses
2019 2020 Percentage difference 2019 2020 Percentage difference
Age
 15 to 19 238,554 157,303 −34% 8,278 5,815 −30%
 20 to 24 559,757 433,457 −23% 17,397 13,447 −23%
Ethnicity
 Asian 31,993 20,516 −36% 985 641 −35%
 Black African 35,797 26,257 −27% 1,396 1,259 −10%
 Black Caribbean 29,370 21,071 −28% 1,892 1,345 −29%
 Other black ethnicity 9,130 5,755 −37% 513 353 −31%
 Mixed ethnicity 47,461 35,606 −25% 2,175 1,729 −21%
 White 554,275 382,189 −31% 16,393 11,327 −31%
 Other 9,572 6,292 −34% 409 303 −26%
 Unknown ethnicity 80,713 93,074 15% 1,912 2,305 21%
Sexual orientation
 Heterosexual males 196,172 131,192 −33% 6,557 4,554 −31%
 MSM 47,550 39,356 −17% 6,525 4,782 −27%
 Heterosexual females 465,906 363,502 −22% 11,037 8,419 −24%
 WSW 4,561 5,244 15% 61 78 28%
 Unknown sexual orientation 84,122 51,466 −39% 1,495 1,429 −4%
Area of residence
 Rural 79,697 60,021 −25% 1,590 1,100 −31%
 Urban 704,883 518,388 −26% 23,643 17,773 −25%
 Unknown area of residence 13,731 12,351 −10% 442 389 −12%
Residential area-level deprivation (deprivation Quintile) a
 1 (most deprived) 179,282 130,529 −27% 7,756 5,944 −23%
 2 193,177 144,229 −25% 7,027 5,463 −22%
 3 157,740 118,779 −25% 4,651 3,437 −26%
 4 134,641 98,672 −27% 3,296 2,323 −30%
 5 (least deprived) 119,740 86,200 −28% 2,503 1,706 −32%
 Unknown deprivation quintile 13,731 12,351 −10% 442 389 −12%
Region of residence
 East Midlands 57,710 43,033 −25% 2,102 1,570 −25%
 East of England 74,590 58,536 −22% 1,851 1,535 −17%
 London 204,435 151,651 −26% 8,554 6,676 −22%
 North-East 30,391 19,930 −34% 965 713 −26%
 North-West 88,276 54,658 −38% 3,094 1,915 −38%
 South-East 122,652 86,955 −29% 2,509 1,620 −35%
 South-West 69,963 56,043 −20% 1,314 862 −34%
 West Midlands 80,152 59,789 −25% 2,788 2,341 −16%
 Yorkshire and Humber 59,577 48,957 −18% 2,144 1,676 −22%
 Unknown region of residence 10,565 11,208 6% 354 354 0%
HIV status
 HIV Diagnosed 1,574 969 −38% 316 198 −37%
 HIV Negative or unknown 796,737 589,791 −26% 25,359 19,064 −25%
 Total 798,311 590,760 −26% 25,675 19,262 −25%
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aDeprivation quintile is an area-level measure of deprivation and socioeconomic status based on the 2019 Index of Multiple Deprivation (IMD) quintiles.

Table 3.

Number of chlamydia tests and diagnoses among 15–24 year olds residing in England, by demographic characteristics: 2019–2020.

Tests Diagnoses
2019 2020 Percentage difference 2019 2020 Percentage difference
Age
 15 to 19 418,019 258,419 −38% 48,138 31,140 −35%
 20 to 24 914,914 670,879 −27% 80,288 57,165 −29%
Ethnicity
 Asian 38,185 25,549 −33% 3,077 2,046 −34%
 Black African 41,229 31,450 −24% 5,587 3,977 −29%
 Black Caribbean 35,566 26,380 −26% 5,449 3,653 −33%
 Other black ethnicity 9,914 6,710 −32% 1,408 887 −37%
 Mixed ethnicity 55,686 44,242 −21% 6,479 5,031 −22%
 White 740,482 533,857 −28% 72,369 51,307 −29%
 Other 11,440 7,974 −30% 1,145 794 −31%
 Unknown ethnicity 400,431 253,136 −37% 32,912 20,610 −37%
Gender
 Female 940,083 669,050 −29% 82,920 57,636 −30%
 Male 380,647 252,121 −34% 44,173 29,476 −33%
 Unknown gender 12,203 8,127 −33% 1,333 1,193 −11%
Online vs. Physical services
 Online services 271,684 361,622 33% 22,838 31,726 39%
 Physical services 1,041,553 554,299 −47% 104,343 55,607 −47%
 Unknown testing service 19,696 13,377 −32% 1,245 972 −22%
Area of residence
 Rural 147,884 106,001 −28% 12,899 9,017 −30%
 Urban 1,105,688 774,434 −30% 107,641 74,482 −31%
 Unknown area of residence 79,361 48,863 −38% 7,886 4,806 −39%
Residential area-level deprivation (deprivation Quintile) a
 1 (most deprived) 290,480 202,207 −30% 33,041 22,991 −30%
 2 299,190 209,304 −30% 29,881 20,884 −30%
 3 255,757 180,401 −29% 23,280 16,095 −31%
 4 217,828 154,037 −29% 18,732 12,967 −31%
 5 (least deprived) 190,317 134,486 −29% 15,606 10,562 −32%
 Unknown deprivation quintile 79,361 48,863 −38% 7,886 4,806 −39%
Region of residence
 East Midlands 104,710 77,763 −26% 11,149 7,829 −30%
 East of England 137,273 102,422 −25% 11,886 9,302 −22%
 London 298,401 199,182 −33% 28,481 18,347 −36%
 North-East 61,670 43,572 −29% 5,921 4,818 −19%
 North-West 162,097 102,017 −37% 16,571 10,129 −39%
 South-East 182,138 125,763 −31% 17,257 11,864 −31%
 South-West 134,229 98,483 −27% 11,587 7,833 32%
 West Midlands 111,664 77,602 −31% 11,812 8,373 −29%
 Yorkshire and Humber 140,751 102,494 −27% 13,762 9,810 −29%
 Total 1,332,933 929,298 −30% 128,426 88,305 −31%
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aDeprivation quintile is an area-level measure of deprivation and socioeconomic status based on the 2019 Index of Multiple Deprivation (IMD) quintiles.

Correlates of being tested for chlamydia via an online service

Amongst all young people tested for chlamydia, those living in the least deprived areas were more likely to be tested online (unadjusted ORs - males: 1.24 [1.22–1.26]; females: 1.28 [1.27–1.30]) compared to young people living in the most deprived areas. This association remained after adjusting for confounders in the final model (aORs - males: 1.29 [1.27–1.32]; females 1.32 [1.30–1.34]) (Table 4). In the final model, there was a greater likelihood of being tested for chlamydia via an online service in 2020 [(males: 2.81 [2.77–2.84]; females: 2.45 [2.44–2.47]) vs. 2019] and a similarly increased likelihood amongst 20–24 year olds [(males: 1.47 [1.45–1.49]; females: 1.63 [1.61–1.64]) vs 15–19 year olds]. Online testing was also more likely among residents of urban areas [(males: 1.17 [1.15–1.20]; females: 1.16 [1.15–1.17]) vs rural] and was generally less likely among all regions of residence compared to London (Appendix B). Further results relating to the demographic characteristics of males and females tested for chlamydia can be found in Appendix A and Appendix C.

Table 4.

Unadjusted and adjusted logistic regression analysis of the association between deprivation quintile a and chlamydia testing via an online service among 15–24 year olds in England: 2019–2020, stratified by gender.

Crude odds ratio (95% CI) Model 1, adjusted odds ratio a (95% CI) Model 2, adjusted odds ratio b (95% CI) Model 3, adjusted odds ratio c (95% CI) Model 4, adjusted odds ratio d (95% CI)
Male Residential area-level deprivation (deprivation quintile)*
1 (most deprived) 1 – – – –
2 1.30 (1.28–1.33) 1.32 (1.29–1.34) 1.30 (1.28–1.32) 1.31 (1.29–1.34) 1.18 (1.16–1.20)
3 1.40 (1.38–1.43) 1.42 (1.40–1.45) 1.41 (1.39–1.43) 1.46 (1.43–1.48) 1.35 (1.32–1.37)
4 1.36 (1.34–1.39) 1.39 (1.36 – 1.41) 1.39 (1.36–1.41) 1.45 (1.42–1.48) 1.37 (1.35–1.40)
5 (least deprived) 1.24 (1.22–1.26) 1.25 (1.23–1.28) 1.26 (1.23–1.28) 1.31 (1.29–1.34) 1.29 (1.27–1.32)
Female Residential area-level deprivation (deprivation quintile)*
1 (most deprived) 1 – – – –
2 1.34 (1.32–1.35) 1.35 (1.34–1.37) 1.34 (1.32–1.35) 1.35 (1.34–1.37) 1.20 (1.19–1.21)
3 1.40 (1.39–1.42) 1.42 (1.40–1.43) 1.40 (1.39–1.42) 1.46 (1.44–1.47) 1.33 (1.32–1.35)
4 1.39 (1.38–1.41) 1.40 (1.39–1.42) 1.40 (1.38–1.41) 1.46 (1.45–1.48) 1.38 (1.36–1.39)
5 (least deprived) 1.28 (1.27–1.30) 1.29 (1.27–1.30) 1.29 (1.28–1.31) 1.35 (1.33–1.37) 1.32 (1.30–1.34)
Open in a new tab

Deprivation quintile is an area-level measure of deprivation and socioeconomic status based on the 2019 Index of Multiple Deprivation (IMD) quintiles.

aModel 1 adjusted for year of test.

bModel 2 adjusted for year of test and age group.

cModel 3 adjusted for year of test, age group and area of residence.

dModel 4 adjusted for year of test, age group, area of residence and region.

Discussion

There was a decrease in STI testing and diagnoses among young people during the first year of the COVID-19 pandemic, with up to 50% larger decreases in teenagers. In keeping with the reconfiguration of SHSs in 2020 to offer more remote consultations, we found a 33% increase in chlamydia testing of young people via online services, but there was evidence of inequalities in access to testing via this modality.

Among young people tested for chlamydia, those living in the least deprived areas were more likely to be tested for chlamydia online, compared to those living in the most deprived areas. Further inequalities in chlamydia online testing were found, with young people living in rural areas or regions outside London and those aged 15-19 being less likely to be tested for chlamydia using an online service. This suggests that there may be socioeconomic or structural barriers to online testing, which may include lack of online access. 15–19 year olds may find it more difficult to be tested for chlamydia using an online service if they are still living with their parents and are unable to discreetly receive the self-sampling kit. The greater likelihood of being tested for chlamydia online for young people living in London reflects the fact that there is a pan-London online sexual health service for all London residents. 24

The reductions in STI testing between 2019 and 2020 are partly due to the extensive public health measures to help reduce the transmission of COVID-19. 25 Moreover, individuals may have delayed their visits to SHSs due to fear of COVID infection 26 and with lockdown restrictions it would have been difficult to meet and interact with new people, reducing the possibility of new sexual encounters. 26 All these factors may have contributed to the decline in STI testing in 2020.

Our findings are consistent with international literature highlighting the negative impact the COVID-19 pandemic had on STI testing. A report from the EuroTEST COVID-19 impact assessment consortium found that, among 34 countries in the World Health Organization European Region and in different test settings, 95% of them tested less than half the expected number of people between March and May 2020, this decline continued until August 2020. 27 Research in the USA found a reduction in STI testing and case detection resulting in more than, 27,000 missed cases of chlamydia and 5500 cases of gonorrhoea between March and June 2020. 25 The implications of these missed cases are likely to be increased community transmission due to the asymptomatic nature of these STIs and associated long-term sexual and reproductive health complications. 25 Studies have found that testing via online services is preferred over physical services, particularly amongst young people, 28 but this may not be the case for teenagers who are living at home. The advantages of online services include privacy and the ability to self-sample. 29 Previous research has found that online testing is more likely to be used by women and those between the ages of 20–30 years compared to younger age groups. Consistent with our findings, research conducted amongst online services and SHSs in London found those living in less deprived areas are more likely to use online services when testing for an STI even when adjusting for confounders. 30

Our analysis benefitted from a very large sample from national surveillance datasets which included patient-level data with key demographic factors so we could robustly assess differences in testing patterns within different subgroups. However, our analysis is not without limitations. Urban and rural area classifications were based on the 2011 census (the most up to date dataset at the time of writing) and these may not be accurate for all areas of England in 2020. We were unable to adjust for ethnicity in the regression analysis predicting being tested online for chlamydia due to a high proportion of missing values for ethnicity in the CTAD surveillance system. The regression analysis was restricted to chlamydia because we were only able to reliably identify all sources of online testing for chlamydia by using a combination of CTAD and GUMCAD data at the time of writing. While GUMCAD is a rich source of data on STI testing, it underestimates online testing for gonorrhoea and syphilis as it could only identify online testing by standalone online providers, and not online testing provided as an alternate service by physical SHSs, in 2019 and 2020. Similarly, we did not perform a regression analysis with count data to determine correlates of being tested for chlamydia online versus not being tested-this is because of a lack of underlying population data for all key variables (e.g. age group, gender and residential area-level deprivation). However, as we have comprehensive data on all young people tested for chlamydia, we were able to assess the correlates of being tested online. Whilst we included deprivation quintile in our analyses, this is an area-level, rather than individual-level, measure of deprivation and is subject to the ecologic fallacy. Additionally, the larger proportional drop in STI tests among teenagers may be explained by residual confounding as our analyses could not take risk behaviours such as multiple condomless sex partners into account, and it is unclear how this varied between 15–19 and 20–24 year olds between 2019 and 2020.

Reduced testing, missed infections and late diagnoses may have potential consequences such as an increase in PID and infertility. 31 This will impact the quality of life of young people with STIs and increase costs to the healthcare system with the need for treatments for STI-related complications or sequelae. Additionally, the difference in the means of testing between those in the least and most deprived areas suggests barriers to access to online services, which should not occur, as STI testing is free at the point of delivery in England. Given the increasing shift to online service provision, there remains a need to assess how equitably they are provided and to reduce the risk of differential access widening existing inequalities in sexual health. This will require innovative health promotion strategies and targeted interventions for young people living in the most deprived areas.

Contributors: TS, DSM, NR, JB, SJM and HM planned the analysis. TS, DSM, NR, JB and AT reviewed and analysed the results of the analysis. TS and DSM wrote the first draft of the manuscript. All co-authors reviewed and edited the manuscript.

Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Acknowledgments

The authors thank all laboratories and sexual health services that report CTAD and GUMCAD surveillance data to UKHSA. We also thank colleagues in the CTAD, GUMCAD and NCSP teams at UKHSA. We acknowledge members of the National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Blood Borne and Sexually Transmitted Infections (BBSTI) Steering Committee: Professor Caroline Sabin (HPRU Director), Dr John Saunders (UKHSA Lead), Professor Catherine Mercer, Dr Hamish Mohammed (previously Professor Gwenda Hughes), Professor Greta Rait, Dr Ruth Simmons, Professor William Rosenberg, Dr Tamyo Mbisa, Professor Rosalind Raine, Dr Sema Mandal, Dr Rosamund Yu, Dr Samreen Ijaz, Dr Fabiana Lorencatto, Dr Rachel Hunter, Dr Kirsty Foster and Dr Mamooma Tahir.

Appendix A.

Table A1.

Demographic characteristics of 15–24 year old males tested for chlamydia in England: 2019–2020.

Number and proportion tested in online services Number and proportion tested in physical services
Age group (years)
 15–19 37,627 (23.1%) 124,890 (76.8%)
 20–24 152,859 (32.5%) 317,392 (67.5%)
Area of residence
 Rural 20,521 (28.2%) 52,145 (71.8%)
 Urban 165,813 (89.0%) 356,975 (68.3%)
 Unknown area of residence 4,152 (11.1%) 33,162 (88.9%)
Region of residence
 London 58,322 (37.0%) 99,114 (63.0%)
 East Midlands 18,518 (38.5%) 29,578 (61.5%)
 East of England 17,513 (25.2%) 52,085 (74.8%)
 North-East 5,240 (18.9%) 22,510 (81.1%)
 North-West 10,012 (14.6%) 58,466 (85.4%)
 South-East 21,454 (25.7%) 61,869 (74.2)
 South-West 22,052 (34.6%) 41,587 (65.3%)
 West Midlands 14,520 (27.8%) 37,618 (72.1%)
 Yorkshire and Humber 22,855 (36.7%) 39,455 (63.3%)
Year of test
 2019 81,880 (21.5%) 298,767 (78.5%)
 2020 108,606 (43.1%) 143,515 (56.9%)
Residential area-level deprivation (deprivation Quintile) a
 1 (most deprived) 34,679 (26.6%) 95,436 (73.3%)
 2 45,911 (32.1%) 96,871 (67.8)
 3 41,352 (33.8%) 81,030 (66.2%)
 4 35,331 (33.0%) 71,259 (66.8%)
 5 (least deprived) 29,061 (31.3%) 64,524 (68.7%)
 Unknown deprivation quintile 4,152 (11.1%) 33,162 (88.9%)
Total 190,486 442,282
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aDeprivation quintile is an area-level measure of deprivation and socioeconomic status based on the 2019 Index of Multiple Deprivation (IMD) quintiles.

Table A2.

Demographic characteristics of 15–24 year old females tested for chlamydia in England: 2019–2020.

Number and proportion tested in online services Number and proportion tested in physical services
Age group (years)
 15–19 102,232 (20.2%) 404,106 (79.8%)
 20–24 337,692 (30.6%) 765,103 (69.4%)
Area of residence
 Rural 44,744 (24.9%) 135,043 (75.1%)
 Urban 383,826 (28.6%) 957,935 (71.4%)
 Unknown area of residence 11,354 (13.0%) 76,231 (87.0%)
Region of residence
 London 123,797 (36.8%) 212,252 (63.2%)
 East Midlands 43,825 (32.8%) 89,923 (67.2%)
 East of England 38,838 (22.9%) 130,417 (77.0%)
 North-East 11,834 (15.7%) 63,595 (84.3%)
 North-West 29,550 (15.4%) 162,180 (84.6%)
 South-East 52,636 (24.0%) 166,789 (76.0%)
 South-West 50,939 (30.2%) 117,440 (69.7%)
 West Midlands 33,625 (24.9%) 101,346 (75.1%)
 Yorkshire and Humber 54,880 (30.5%) 125,267 (30.5%)
Year of test
 2019 188,169 (20.0%) 751,914 (80.0%)
 2020 251,755 (37.6%) 417,295 (62.4%)
Residential area-level deprivation (deprivation quintile) a
 1 (most deprived) 84,665 (23.6%) 273,626 (76.4)
 2 105,764 (29.3%) 255,330 (70.7)
 3 94,142 (30.3%) 216,725 (69.7%)
 4 79,044 (30.1%) 183,472 (69.9%)
 5 (least deprived) 64,955 (28.4%) 163,825 (71.6%)
 Unknown deprivation quintile 11,354 (13.0%) 76,231 (87.0%)
 Total 439,924 1,169,209
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aDeprivation quintile is an area-level measure of deprivation and socioeconomic status based on the 2019 Index of Multiple Deprivation (IMD) quintiles.

Appendix B.

Table B1.

Adjusted logistic regression analysis of the association between deprivation quintile a and chlamydia testing via an online service among 15–24 year old males in England: 2019–2020.

Adjusted odds ratio (95% CI)
Age group (years)
 15–19 1
 20–24 1.47 (1.45–1.49)
Area
 Rural 1
 Urban 1.17 (1.15–1.20)
Region of residence
 London 1
 East Midlands 1.03 (1.01–1.05)
 East of England 0.49 (0.48–0.50)
 North-East 0.37 (0.35–0.38)
 North-West 0.26 (0.25–0.26)
 South-East 0.56 (0.55–0.58)
 South-West 0.84 (0.82–0.85)
 West Midlands 0.62 (0.60–0.63)
 Yorkshire and Humber 0.93 (0.91–0.95)
Year of test
 2019 1
 2020 2.81 (2.77–2.84)
Residential area-level deprivation (deprivation Quintile) a
 1 (most deprived) 1
 2 1.18 (1.16–1.20)
 3 1.35 (1.32–1.37)
 4 1.37 (1.35–1.40)
 5 (least deprived) 1.29 (1.27–1.32)
Open in a new tab

aDeprivation quintile is an area-level measure of deprivation and socioeconomic status based on the 2019 Index of Multiple Deprivation (IMD) quintiles.

bAll p-values <0.05.

Table B2.

Adjusted logistic regression analysis of the association between deprivation quintile a and chlamydia testing via an online service among 15–24 year old females in England: 2019–2020.

Adjusted odds ratio (95% CI)
Age group (years)
 15–19 1
 20–24 1.63 (1.61–1.64)
Area
 Rural 1
 Urban 1.16 (1.15–1.17)
Region of residence
 London 1
 East Midlands 0.80 (0.79–0.81)
 East of England 0.44 (0.43–0.44)
 North-East 0.31 (0.30–0.31)
 North-West 0.28 (0.27–0.28)
 South-East 0.51 (0.50–0.51)
 South-West 0.68 (0.67–0.69)
 West Midlands 0.53 (0.52–0.54)
 Yorkshire and Humber 0.71 (0.70–0.72)
Year of test
 2019 1
 2020 2.45 (2.44–2.47)
Residential area-level deprivation (deprivation Quintile) a
 1 (most deprived) 1
 2 1.20 (1.19–1.21)
 3 1.33 (1.32–1.35)
 4 1.38 (1.36–1.39)
 5 (least deprived) 1.32 (1.30–1.34)
Open in a new tab

aDeprivation quintile is an area-level measure of deprivation and socioeconomic status based on the 2019 Index of Multiple Deprivation (IMD) quintiles.

bAll p-values <0.05.

Appendix C.

Table C1.

Number and proportion of chlamydia tests by testing service and deprivation quintile a amongst 15–24 year old males in England: 2019–2020.

Deprivation quintile a
Testing service 1 (most deprived) 2 3 4 5 (least deprived)
Physical services Specialist sexual health service 69,860 71,130 57,781 49,387 43,850
(53.7%) (49.8%) (47.2%) (46.3%) (46.9%)
Non-specialist sexual health service 5,721 3,591 2,276 1,612 1,462
(4.4%) (2.5%) (1.9%) (1.5%) (1.6%)
General practice (GP) 9,207 10,366 9,123 7,615 6,358
(7.1%) (7.3%) (7.5%) (7.1%) (6.8%)
Pharmacy 647 978 1,046 915 836
(0.5%) (0.7%) (0.9%) (0.9%) (0.9%)
Termination of pregnancy centres 5 6 5 6 3
(0.0%) (0.0%) (0.0%) (0.0%) (0.0%)
Other b 8,687 9,847 9,968 10,364 11,234
(6.7%) (6.9%) (8.1%) (9.7%) (12.0%)
Online services Online 34,679 45,911 41,352 35,331 29,061
(26.7%) (32.2%) (33.8%) (33.2%) (31.1%)
Total c 130,115 142,782 122,382 106,590 93,585
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aDeprivation quintile is an area-level measure of deprivation and socioeconomic status based on the 2019 Index of Multiple Deprivation (IMD) quintiles.

bIncludes other services providing chlamydia testing, such as outreach settings, prisons, education settings and any other settings.

cTotals include tests from unknown testing services.

Table C2.

Number and proportion of chlamydia tests by testing service and deprivation quintile a amongst 15–24 year old females in England: 2019–2020.

Deprivation quintile a
Testing service 1 (most deprived) 2 3 4 5 (least deprived)
Physical services Specialist sexual health service 138,082 133,456 107,714 89,520 78,302
(38.5%) (37.0%) (34.6%) (34.1%) (34.2%)
Non-specialist sexual health service 16,847 11,184 6,816 4,893 3,792
(4.7%) (3.1%) (2.2%) (1.9%) (1.7%)
General practice (GP) 67,115 64,873 60,091 53,046 49,186
(18.7%) (18.0%) (19.3%) (20.2%) (21.5%)
Pharmacy 1,834 2,653 3,063 2,598 2,561
(0.5%) (0.7%) (1.0%) (1.0%) (1.1%)
Termination of pregnancy centres 8,325 7,248 5,142 3,708 2,971
(2.3%) (2.0%) (1.7%) (1.4%) (1.3%)
Other a 35,464 31,428 29,881 24,528 23,889
(9.9%) (8.7%) (9.6%) (9.3%) (10.4%)
Online services Online 84,665 105,764 94,142 79,044 64,955
(23.6%) (29.3%) (30.3%) (30.1%) (28.4%)
Total b 358,291 361,094 310,867 262,516 228,780
Open in a new tab

Deprivation quintile is an area-level measure of deprivation and socioeconomic status based on the 2019 Index of Multiple Deprivation (IMD) quintiles.

aIncludes other services providing chlamydia testing, such as outreach settings, prisons, education settings and any other settings.

bTotals include tests from unknown testing services.

Footnotes

Author contributions: There was a decrease in STI testing of young people during the first year of the COVID-19 pandemic in England with larger reductions among teenagers. There was an increase in the use of online STI self-sampling services but with inequalities in provision which risk widening existing inequalities in sexual health.

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical approval: This study was undertaken for health protection purposes under the permissions granted to UKHSA to collect and process pseudonymised surveillance data under Regulation 3 of The Health Service (Control of Patient Information) Regulations 2020 and under Section 251 of the NHS Act 2006.

ORCID iD

Tamilore Sonubi https://orcid.org/0000-0001-8099-3580

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