A study of a digital sexually transmitted infection testing service in British Columbia, Canada, found a sustained increase in digital sexually transmitted infection testing resulting from COVID-19–related public health restrictions.
Abstract
Background
Evidence of long-term impacts of COVID-19–related public health restrictions on digital sexually transmitted and blood-borne infection (STBBI) testing utilization is limited. We assessed these impacts on GetCheckedOnline (a digital testing resource for STBBIs) relative to all STBBI tests in British Columbia (BC).
Methods
Interrupted time series analyses were conducted using GetCheckedOnline program data comparing monthly test episodes (STBBI tests per requisition) among BC residents, stratified by BC region, and testers' sociodemographic and sexual risk profiles, for the prepandemic (March 2018–February 2020) and pandemic periods (March 2020–October 2021). Trends in GetCheckedOnline testing per 100 STBBI tests in BC regions with GetCheckedOnline were analyzed. Each outcome was modeled using segmented generalized least squared regression.
Results
Overall, 17,215 and 22,646 test episodes were conducted in the prepandemic and pandemic periods. Monthly GetCheckedOnline test episodes reduced immediately after restrictions. By October 2021 (end of the pandemic period), monthly GetCheckedOnline testing increased by 21.24 test episodes per million BC residents (95% confidence interval, −11.88 to 54.84), and GetCheckedOnline tests per 100 tests in corresponding BC regions increased by 1.10 (95% confidence interval, 0.02 to 2.17) above baseline trends. After initial increases among users at higher STBBI risk (symptomatic testers/testers reporting sexual contacts with STBBIs), testing decreased below baseline trends later in the pandemic, whereas monthly GetCheckedOnline testing increased among people 40 years or older, men who have sex with men, racialized minorities, and first-time testers via GetCheckedOnline.
Conclusions
Sustained increases in utilization of digital STBBI testing during the pandemic suggest fundamental changes in STBBI testing in BC, highlighting the need for accessible and appropriate digital testing, especially for those most affected by STBBIs.
The COVID-19 pandemic and resulting public health restrictions had unintended consequences on access to sexual and reproductive health (SRH) services.1,2 Since the pandemic was declared in March 2020 and public health restrictions enacted, disrupted access to standard SRH services including testing for sexually transmitted and blood-borne infections (STBBI) has been reported.3–7 However, evidence suggests increased utilization of digital STBBI testing during the initial months of the pandemic in response to service gaps created by public health restrictions.6,8–10
During the pandemic, digital STBBI testing interventions facilitated testing among youth; gay, bisexual, and other men who have sex with men (MSM); and other populations disproportionately affected by STBBIs.6,11,12 In the United Kingdom, digital STBBI testing facilitated through postal-based self-sample collection increased during the pandemic, accounting for 44% of all tests between April and June 2020, compared with 20% prepandemic.9 Another postal-based self-sample collection service in the United States showed increased orders immediately after public health restrictions in March 2020.6 In Canada, the current authors demonstrated that users of a digital STBBI testing service offering web-based laboratory test requisition were less likely to report unmet sexual health needs during the pandemic.13
However, evidence is limited regarding long-term utilization digital STBBI testing during the pandemic, especially among health equity seeking and historically disadvantaged populations.9 Current evidence is predominantly cross-sectional, not accounting for prepandemic trends in digital STBBI testing patterns.6,13 The effects of the pandemic and unintended impacts of public health restrictions that disproportionately impacted health equity-seeking populations may be perpetuated in access to STBBI testing during the pandemic,9 considering that these populations are differentially affected by suboptimal internet access and digital health literacy.10,14 Positivity rates of STBBI from early studies were also variable. Some studies demonstrated initially increased positivity for HIV and other STBBIs with return to baseline rates after 3 months of the pandemic,9 whereas others demonstrated no changes.6 Understanding long-term impacts of the pandemic on positivity rates and testers' risk profiles can elucidate access needs being fulfilled by digital STBBI interventions during this period.
To address knowledge gaps, this study used routinely collected program data from a provincial digital STBBI testing service in British Columbia (BC), Canada, called GetCheckedOnline. Testing data were used to assess monthly utilization rates during the COVID-19 pandemic and the relative contribution of GetCheckedOnline tests to all STBBI tests in regions where GetCheckedOnline is available, accounting for prepandemic trends. The study also assessed GetCheckedOnline testing stratified by populations disproportionately affected by STBBI. We hypothesized that COVID-19–related public health restrictions would result in increased utilization of GetCheckedOnline, and increased utilization relative to all STBBI tests in regions of BC GetCheckedOnline is available. We also hypothesized increased utilization of digital STBBI testing among first-time testers and historically disadvantaged populations including gay, bisexual, and other MSM; young people (≤24 years); and racialized minorities.
METHODS
Study Setting and Data Sources
Getcheckedonline.com is a digital STBBI testing service launched in September 2014 and currently operating in 8 regions in the Canadian province of BC.15 This service was designed to reduce testing barriers among people disproportionately impacted by STBBIs and facing barriers accessing in-person services.15 Described in detail elsewhere, the digital testing model involves users creating accounts, having tests recommended, online STBBI laboratory requisition (for chlamydia, gonorrhea, syphilis, HIV, and hepatitis C virus [HCV]), and sample collection at a nearby partner laboratory. Results are available online if negative or by follow-up telephone calls from public health nurses if positive.15
Two data sources were used. First, routinely collected data were extracted from GetCheckedOnline's program database. This database contains information from user-filled forms during account creation and each STBBI test requisition including user's self-reported sociodemographic characteristics (age, sex, residence, partners' sex), and sexual behaviors (STBBI symptoms, sexual contacts with STBBIs, and condomless sex with >1 partner in the past 3 months). Second, to assess changes in the relative contribution of GetCheckedOnline to all STBBI tests conducted in BC regions where GetCheckedOnline is available, monthly aggregate-level STBBI testing data were obtained from the BC provincial health laboratory (inclusive of tests conducted via GetCheckedOnline). However, the BC provincial health laboratory data were only available for syphilis, HCV, and HIV tests. Therefore, the analysis of the relative contribution of GetCheckedOnline to all STBBI tests in corresponding BC regions where GetCheckedOnline is available was restricted to these 3 infections, to ensure suitable comparisons. Analyses of GetCheckedOnline program data used all testing data for syphilis, HCV, HIV, chlamydia, and gonorrhea. For each database, monthly data were extracted covering the prepandemic (March 2018–February 2020) and pandemic periods (March 2020–October 2021). Despite its launch in 2014, GetCheckedOnline had relatively slow growth in number of tests until a couple of years after launch when it increased significantly. Therefore, we selected a prepandemic period where the service had relatively stable number of tests and selected all the data available for the pandemic period.
Exposure, Outcome, and Stratifying Variables
The main exposure was defined as widespread implementation of pandemic-related public health orders in BC on March 17, 2020,16 which limited access to nonessential medical services including in-person STBBI testing. Three outcomes were evaluated including (1) number of monthly test episodes completed via GetCheckedOnline, defined as an instance of laboratory requisition for STBBI testing, specimen submission at partner laboratories, and performance of requested tests, irrespective of the tests requested. This outcome was standardized by dividing the monthly number of test episodes by monthly BC population estimates linearly interpolated from quarterly estimates17; (2) proportion of monthly tests completed by GetCheckedOnline among all STBBI tests completed in jurisdictions in BC where GetCheckedOnline is available. The total tests reported were performed either through GetCheckedOnline or other sites; and (3) proportion of monthly GetCheckedOnline test episodes reporting positive results for any STBBIs.
To explore health equity in utilization of GetCheckedOnline, the monthly number of completed test episodes was stratified by age, sex, sexual orientation, race, first time ever testing for STBBI (i.e., number of tests representing first contact with the health systems for STBBI testing), first time using GetCheckedOnline (irrespective of previous in-person tests), users reporting sexual contacts with STBBIs, STBBI symptoms, condomless sexual intercourse with >1 sexual partner within 3 months preceding the test episode, and those with STBBI diagnosis in the preceding 12 months before current episode. All stratified outcomes were reported per 100 test episodes.
Data Analyses
The data were summarized using descriptive statistics for all outcomes presenting the total number of tests prepandemic and during the pandemic. Median monthly tests and interquartile ranges (IQRs) for tests per 1 million BC residents and test episodes positive for any STBBI per 100 tests via GetCheckedOnline were also presented. Interrupted time series analyses were conducted for each monthly outcome of interest, determining the impact of public health restrictions in March 2020 (immediately after restrictions) and change in outcome trends thereafter. This quasi-experimental design is popular in health policy and systems research for its strong evidence of causal effects, controlling for secular trends in study outcomes.18–20 Segmented generalized least squares regression was used for modeling and assessing autocorrelation using the Durbin-Watson test and visual assessments of autocorrelation functions and partial autocorrelation functions.18,21 Where appropriate, polynomial terms were included in models for outcomes following a nonlinear trend (Supplementary Material, http://links.lww.com/OLQ/A951). Estimates of the absolute and relative changes in outcomes immediately after enactment of restrictions and at the end of the study period in October 2021 (19 months after initial public health orders) were generated from each regression model. Corresponding 95% confidence intervals (95% CIs) for these estimates were generated using the delta method. If the 95% CI for absolute and relative changes did not span across “0,” the changes were considered significant.22 Analyses were conducted using R version 3.5.2.23 Ethical approval was granted by the University of British Columbia Behavioral Research Ethics board (ethics number H21-02378).
Sensitivity Analyses
Given the heterogeneity of public health interventions (including restrictions) implemented during the pandemic,16 sensitivity analyses were conducted to assess our first 2 outcomes (test episodes via GetCheckedOnline and proportion of all tests in BC done by GetCheckedOnline) using an impact model with 2 interruptions (March 2020 and June 2021—the beginning of BC's restart plan; Fig. 1).
Figure 1.
Timeline of COVID-19 case counts and public health restrictions, March 2020 to November 2021 (source: BC COVID-19 Dashboard).
RESULTS
The analysis included 17,215 test episodes completed through GetCheckedOnline before the pandemic and 22,646 test episodes during the study pandemic period (Table 1). Median monthly test episodes via GetCheckedOnline increased from 135.5 per million BC residents (IQR, 104.0–166.7) before the pandemic to 226.3 per million BC residents (IQR, 205.4–251.0) during the pandemic. The median monthly number of tests via GetCheckedOnline for every 100 tests conducted in BC jurisdictions where GetCheckedOnline is available increased from 2.7 (IQR, 2.2–3.7) before the pandemic to 5.3 (5.0–6.0) during the pandemic.
TABLE 1.
Characteristics of GetCheckedOnline (Digital STBBI) Test Episodes Conducted in Prepandemic (March 2018–February 2020) and Pandemic Periods (March 2020–October 2021), British Columbia, Canada
| Outcome | Prepandemic | During the Pandemic |
|---|---|---|
| March 2018–February 2020 (n = 17,215) | March 2020–October 2021 (n = 22,646) | |
| Monthly test episodes per 1 million residents, median (IQR)* | 135.5 (104.0–166.7) | 226.3 (205.4–251.0) |
| Monthly GetCheckedOnline tests per 100 tests in BC jurisdictions with this testing service, median (IQR)†,‡ | 2.7 (2.2–3.7) | 5.3 (5.0–6.0) |
| GetCheckedOnline test episodes positive for any STBBI, no. (%) | 910 (5.3) | 1180 (5.3) |
| GetCheckedOnline test episodes stratified by user characteristics | ||
| Age, no. (%) | ||
| ≤24 y | 4299 (25.0) | 6326 (27.9) |
| 25–39 y | 9609 (55.8) | 12,829 (56.7) |
| ≥40 y | 3307 (19.2) | 3491 (15.4) |
| Sex, no. (%) | ||
| Female | 6978 (40.5) | 9460 (41.8) |
| Male | 9874 (57.4) | 12,627 (55.8) |
| Nonbinary and others | 363 (2.1) | 559 (2.5) |
| Region, no. (%) | ||
| Metro Vancouver | 10,111 (58.7) | 14,580 (64.4) |
| Vancouver Island | 4808 (27.9) | 5921 (26.1) |
| Interior British Columbia | 2296 (13.3) | 2145 (9.5) |
| Sexual orientation, no. (%) | ||
| MSM (male partners only) | 3152 (18.3) | 4200 (18.5) |
| MSM (male and female partners) | 736 (4.3) | 876 (3.9) |
| WSW (female partners only) | 230 (1.3) | 339 (1.5) |
| WSW (female and male partners) | 1099 (6.4) | 1196 (5.3) |
| MSW exclusively (female partners only) | 5723 (33.2) | 7213 (31.9) |
| WSM exclusively (male partners only) | 5561 (32.3) | 7925 (35.0) |
| Others | 714 (4.1) | 897 (4.0) |
| Race/ethnicity | ||
| White | 9473 (55.0) | 11,612 (51.3) |
| Racialized minority | 4137 (24.0) | 6696 (29.6) |
| Prefer not to say | 3605 (20.9) | 4338 (19.2) |
| Sexual risk and behaviors, no. (%) | ||
| First time ever testing for STBBI | 1446 (8.4) | 2084 (9.2) |
| First time testing for STBBI via GetCheckedOnline | 8766 (50.9) | 12,183 (53.8) |
| Users reporting STBBI symptoms | 3183 (18.5) | 4274 (18.9) |
| Users reporting sexual contact with a diagnosed STBBI | 1558 (9.1) | 2090 (9.2) |
| Users reporting an STBBI diagnosis in the past 12 mo | 2615 (15.2) | 3634 (16.0) |
| Users reporting unprotected sex with >1 partners in the past 3 mo | 8247 (47.9) | 10,740 (47.4) |
*Monthly test episodes per 1 million BC residents calculated by dividing the test episodes per month by monthly interpolated estimates of BC population.
†Tests restricted to HIV, HCV, and syphilis. All other test numbers in the table include tests for chlamydia, gonorrhea, HIV, HCV, and syphilis.
‡Jurisdictions of BC where GetCheckedOnline is available include Vancouver, Victoria, Langford, Duncan, Kamloops, Nelson, Kimberly, and Maple Ridge.
MSW indicates men who have sex with women; WSM, women who have sex with men; WSW, women who have sex with women.
Number of GetCheckedOnline Tests Per Million BC Residents and Number of Test Episodes Positive for Any STBBIs
Immediately after public health restrictions in March 2020, the monthly number of GetCheckedOnline test episodes per million BC residents reduced by −75.99 tests (95% CI, −90.98 to −61.01) representing a −36.91% (95% CI, −36.74% to −37.08%) change (Table 2). By October 2021 (19 months after initial public health restrictions), this number increased by 21.48 tests per million (95% CI, −11.88 to 54.84) relative to expected prepandemic trends, representing a 7.07% (95% CI, 6.90% to 7.24%) change (Fig. 2). The number of test episodes positive for any STBBIs reduced by −0.69 per 100 tests in March 2020, and by October 2021, it had reduced by −3.70 per 100 test episodes (95% CI, −5.58 to −1.83), representing a −43.96% change (95% CI, −56.44% to −31.47%).
TABLE 2.
Absolute and Relative Changes in STBBI Testing Outcomes in British Columbia Canada Immediately After Public Health Restrictions and 19 Months After Restrictions, Compared With Expected Baseline Trends (Prepandemic Restrictions)
| Outcome* | Immediately After the Public Health Orders (March 2020) | 19 mo After Initial Public Health Orders (October 2021) | ||
|---|---|---|---|---|
| Absolute Change, Per 100 Tests (95% CI) | Relative Change (95% CI), % |
Absolute Change, Per 100 Tests (95% CI) | Relative Change (95% CI), % | |
| Test episodes per 1 million residents | −75.99 (−90.98 to −61.01) | −36.91 (−37.08 to −36.74) | 21.48 (−11.88 to 54.84) | 7.07 (6.90 to 7.24) |
| GetCheckedOnline tests per 100 tests in BC jurisdictions with this testing service†‡ | −1.43 (−1.91 to −0.95) | −30.37 (−40.48 to −20.16) | 1.10 (0.02 to 2.17) | 15.40 (5.37 to 25.42) |
| GetCheckedOnline test episodes positive for any STBBI, per 100 tests | −0.69 (−1.57 to 0.18) | −10.67 (−20.52 to −0.82) | −3.70 (−5.58 to −1.83) | −43.96 (−56.44 to −31.47) |
| GetCheckedOnline test episodes stratified by user characteristics | ||||
| Age | ||||
| ≤24 y | 1.00 (−0.17 to 2.17) | 3.67 (2.93 to 4.41) | −3.45 (−6.08 to −0.83) | −11.15 (−12.44 to −9.86) |
| 25–39 y | 1.00 (0.47 to 1.52) | 1.78 (1.71 to 1.86) | 0.59 (−0.64 to 1.82) | 1.05 (0.86 to 1.24) |
| ≥40 y | −1.92 (−2.45 to −1.39) | −11.34 (−12.21 to −10.47) | 2.42 (1.26 to 3.57) | 18.28 (15.17 to 21.39) |
| Sex | ||||
| Female | −2.42 (−3.94 to −0.90) | −5.55 (−5.93 to −5.17) | −6.18 (−9.43 to −2.93) | −12.77 (−13.43 to −12.12) |
| Male | 3.08 (1.38 to 4.78) | 5.68 (5.41 to 5.96) | 5.74 (2.10 to 9.39) | 11.71 (11.00 to 12.43) |
| Nonbinary and others | −0.65 (−0.98 to −0.32) | −28.50 (−58.11 to 1.12) | 0.49 (−0.21 to 1.19) | 19.35 (−31.99 to 70.69) |
| Region | ||||
| Metro Vancouver | 3.77 (1.36 to 6.17) | 6.22 (5.91 to 6.53) | 0.89 (−4.25 to 6.04) | 1.40 (0.81 to 2.00) |
| Vancouver Island | −2.13 (−4.39 to 0.12) | −8.05 (−9.56 to −6.53) | 3.11 (−1.73 to 7.94) | 12.85 (8.95 to 16.75) |
| Interior British Columbia | −1.63 (−2.94 to −0.32) | −12.62 (−16.32 to −8.93) | −4.00 (−6.80 to −1.20) | −32.83 (−41.73 to −23.93) |
| Sexual orientation | ||||
| MSM (male partners only) | 4.71 (3.54 to 5.87) | 30.85 (28.49 to 33.22) | 7.38 (4.88 to 9.87) | 71.77 (60.63 to 82.90) |
| MSM (male and female partners) | −0.28 (−1.01 to 0.45) | −6.94 (−27.39 to 13.51) | 0.07 (−1.50 to 1.63) | 1.72 (−47.96 to 51.41) |
| WSW (female partners only) | −0.32 (−0.45 to −0.18) | −18.49 (−40.12 to 3.13) | −0.78 (−1.07 to −0.48) | −33.78 (−60.32 to −7.23) |
| WSW (female and male partners) | −0.69 (−0.81 to −0.56) | −12.04 (−13.85 to −10.24) | 0.62 (0.33 to 0.91) | 13.23 (7.08 to 19.37) |
| MSW exclusively (female partners only) | −1.07 (−2.22 to 0.09) | −3.19 (−3.68 to −2.70) | −2.08 (−4.55 to 0.39) | −6.21 (−7.25 to −5.17) |
| WSM exclusively (male partners only) | 0.32 (−1.13 to 1.78) | 0.93 (0.36 to 1.49) | −4.17 (−7.28 to −1.05) | −10.65 (−11.62 to −9.69) |
| Others | −1.83 (−2.81 to −0.84) | −40.22 (−62.74 to −17.69) | −0.36 (−2.47 to 1.75) | −6.94 (−43.71 to 29.82) |
| Race/ethnicity | ||||
| White | −3.09 (−4.69 to −1.48) | −5.69 (−5.95 to −5.44) | −1.80 (−5.24 to 1.64) | −3.40 (−3.98 to −2.82) |
| Racialized minority | 3.74 (2.45 to 5.03) | 15.32 (14.30 to 16.34) | 5.75 (3.00 to 8.50) | 23.01 (20.93 to 25.09) |
| Prefer not to say | −1.16 (−14.79 to 12.47) | −5.43 (−19.56 to 8.69) | −4.30 (−19.09 to 10.48) | −19.93 (−34.89 to −4.96) |
| Sexual risk and behaviors | ||||
| First time ever testing for STBBI | 0.73 (−0.36 to 1.82) | 9.71 (0.61 to 20.88) | 3.79 (1.46 to 6.13) | 62.93 (32.62 to 93.24) |
| First time testing for STBBI via GetCheckedOnline | 10.79 (8.87 to 12.71) | 22.40 (22.01 to 22.79) | 6.05 (1.94 to 10.16) | 13.84 (12.83 to 14.85) |
| Users reporting STBBI symptoms§ | 4.11 (2.80 to 5.42) | 21.18 (19.54 to 22.82) | −2.10 (−4.91 to 0.70) | −10.04 (−13.06 to −7.03) |
| Users reporting sexual contact with a diagnosed STBBI§ | 2.56 (1.44 to 3.68) | 25.43 (20.22 to 30.63) | −3.81 (−6.22 to −1.39) | −32.44 (−40.72 to −24.16) |
| Users reporting an STBBI diagnosis in the past 12 mo§ | 5.68 (4.34 to 7.03) | 35.37 (32.91 to 37.84) | −2.65 (−5.54 to 0.24) | −15.15 (−19.60 to −10.70) |
| Users reporting unprotected sex with >1 partners in the past 3 mo§ | 3.81 (2.45 to 5.18) | 7.79 (7.52 to 8.06) | −0.76 (−3.68 to 2.16) | −1.51 (−2.04 to −0.97) |
*Tests restricted to HIV, HCV, and syphilis. All other test numbers in the table include tests for chlamydia, gonorrhea, HIV, HCV, and syphilis.
†Monthly test episodes per 1 million BC residents calculated by dividing the test episodes per month by monthly interpolated estimates of BC population.
‡Jurisdictions of BC where GetCheckedOnline is available include Vancouver, Victoria, Langford, Duncan, Kamloops, Nelson, Kimberly, and Maple Ridge.
§Estimates derived from polynomial segmented generalized least square regression models.
MSW indicates men who have sex with women; WSM, women who have sex with men; WSW, women who have sex with women.
Figure 2.
Time series of monthly GetCheckedOnline tests per million population BC. Footnote: Tests include chlamydia, gonorrhea, HIV, HCV, and syphilis.
Relative Contribution of GetCheckedOnline to All STBBI Tests in Regions of BC Where GetCheckedOnline Is Available
The relative contribution of GetCheckedOnline to all STBBI tests in BC jurisdictions where the service was available changed by −1.43 per 100 tests (95% CI, −1.91 to −0.95) immediately after the public health restrictions, representing a −30.37% change (95% CI, −40.48% to −20.16%). By October 2021, this number had increased by 1.10 tests above expected prepandemic trends (95% CI, 0.02 to 2.17), representing a 15.40% (95% CI, 5.37% to 25.42%) change (Fig. 3).
Figure 3.
Time series of monthly contribution of GetCheckedOnline to all STBBI tests in regions of BC where GetCheckedOnline is available. Footnote: Tests limited to HIV, HCV, and syphilis because of data availability.
Composition of Users Accessing Digital STBBI Testing Via GetCheckedOnline
Immediately after public health restrictions, the largest significant reductions were observed in the number of GetCheckedOnline test episodes per 100 conducted by adults 40 years or older (−1.92 [95% CI, −2.45 to −1.39]), users in interior BC (−1.63 [95% CI, −2.94 to −0.32]), and nonbinary and other users (−0.65 [95% CI, −0.98 to −0.32]), whereas the largest significant increases were observed for male individuals (3.08 [95% CI, 1.38 to 4.78]), MSM (4.71 [95% CI, 3.54 to 5.87]), and racialized minorities (3.74 [95% CI, 2.45 to 5.03]). By October 2021, the largest significant reductions compared with baseline trends were observed in the number of GetCheckedOnline test episodes per 100 conducted by users 24 years or younger (−11.15 [95% CI, −12.73 to −9.56]), users in interior BC (−4.00 [95% CI, −6.80 to −1.20]), and female individuals (−6.18 [95% CI, −9.43 to −2.93]), whereas the largest increases were among first-time ever testers (3.79 [95% CI, 1.46 to 6.13]), racialized minority users (5.75 [95% CI, 3.00 to 8.50]), and MSM (7.38 [95% CI, 4.88 to 9.87]).
Immediately after public health restrictions, the proportion of test episodes by users conducting their first STBBI test via GetCheckedOnline increased by 10.79 per 100 tests (95% CI, 8.87 to 12.71). Similar increases were noted for test episodes by users reporting STBBI symptoms, sexual contacts with STBBIs, and previous STBBI diagnoses within 12 months preceding the test episode. By October 2021, the proportion of test episodes by users reporting sexual contact with diagnosed STBBI symptoms and STBBI diagnoses within 12 months preceding the test episode had changed by −3.81 per 100 tests (95% CI, −6.22 to −1.39) and −2.65 per 100 tests (95% CI, −5.54 to 0.24), respectively.
Sensitivity Analysis
Additional public health restrictions in June 2021 were associated with a level change of −94.69 test episodes per million BC residents (95% CI, −121.4 to −68.14) and −1.47 tests per 100 tests in BC (95% CI, −2.30 to −0.64). However, after the BC restart phase 1, there was a nonsignificant trend change of 11.79 test episodes per million BC residents (95% CI, −0.21 to 23.80) and 0.29 tests per 100 tests in BC (95% CI, −0.09 to 0.67; Supplementary Material, http://links.lww.com/OLQ/A951).
DISCUSSION
This study found that testing via GetCheckedOnline abruptly declined immediately after public health restrictions in March 2020, but rapidly increased during the pandemic, exceeding prepandemic trends by October 2021. The proportion of test episodes positive for any STBBI reduced below prepandemic trends during the pandemic, but the proportion of tests completed by GetCheckedOnline among all tests completed in jurisdictions in BC where GetCheckedOnline is available initially declined before increasing beyond prepandemic trends. There were significant and sustained changes in GetCheckedOnline testers' characteristics during the pandemic with increased use among MSM, racialized minorities, first-time ever testers, and first-time testers via GetCheckedOnline. However, there was a relatively reduced use of GetCheckedOnline among users in Interior BC and users 24 years or younger. Findings suggest that initial increases among testers at higher risk of STBBIs including symptomatic testers and testers reporting contacts with STBBIs rapidly declined below prepandemic trends by October 2021.
Previous studies demonstrated increased utilization of digital STBBI testing during the first 6 months of the pandemic mostly using “before and after” or cross-sectional designs.6,9,11,12,24 This study extends existing literature by using quasi-experimental methods providing robust evidence that accounts for secular trends and is less influenced by selection bias and confounding.18,19 Such quasi-experimental methods also demonstrate the utility of program-level data in exploring the impact of population-level interventions like the COVID-19–related public health restrictions on the use of digital interventions.18 Our findings add nuance by suggesting that despite initial declines in testing attributed to reduced casual sexual contacts and engagement with health systems, rapid recovery in utilization of digital STBBI testing services was observed during the pandemic.25–28 Moreover, evidence on positivity rates is mixed as some studies described no changes or reductions,6 whereas others described increased positivity12 during the pandemic.26 Our findings corroborate other studies suggesting initial increases in positivity rates among populations with higher risk (symptomatic testers and testers reporting contacts with STBBIs), but these rates decreased as users with lower STBBIs risk increasingly accessed the service.9
Our findings corroborate studies revealing increased contribution of digital STBBI testing services to regional testing during the initial months of the pandemic, adding information about the sustainment of these trends over time.9,12,13,26 The scale-up of these services may explain findings, as greater than 80% of SRH services in Canada provided remote (digital) services during the pandemic, with 20% of them launching first during the period.26 This builds on prior research from our team, which demonstrated increased unmet need for sexual health services in BC during the first 4 months of the pandemic, except among GetCheckedOnline users who had reduced odds of unmet needs.13 Our findings reinforce the role of digital STBBI testing interventions in securing access to STBBI services, especially when there are barriers to clinic-based services. Furthermore, our study examined variations in utilization by age, sex, sexual orientation, and other health equity factors. Although most studies have not explored these variations, our findings of significant increases in utilization of GetCheckedOnline among MSM, racialized minorities, and older adults 40 years or older during the pandemic aligns with wider changes in SRH service utilization patterns in other studies.9 Our study also demonstrated increased first-time testers accessing digital STBBI testing, suggesting users' transition from in-clinic to digital STBBI testing.9
Policy Implications
The pandemic demonstrated digital STBBI testing services' capacity to sustain testing access where traditional clinic-based services are unavailable, highlighting their increasing role in STBBI testing in BC.9,26 Efforts to maintain and improve these digital STBBI testing interventions are necessary as gaps remain. For example, initial reductions in GetCheckedOnline tests at the peak of public health restrictions may be due to lack of home testing options including self-sampling and self-testing. Other jurisdictions with such options observed the share of digital STBBI testing compared with all tests doubled in the 3 months (April–June 2020) after initial restrictions.9 Decision makers may consider integrating these additional digital STBBI testing modalities. Global reductions in sexual activities during the pandemic must be considered when interpreting our findings, as interpersonal relations were curtailed in response to the pandemic.29 Findings from our sensitivity analysis also suggest that GetCheckedOnline's increased contribution to overall STBBI tests coincided with the commencement of BC's restart plan. We anticipate that demand for digital STBBI testing may continue increasing beyond the study period, and additional research is required to assess its overall health systems impact, alongside outcomes including linkage to treatment and partner notification.
Regarding health equity, although some populations experiencing marginalization and higher risk of STBBIs benefited from digital STBBI testing in the pandemic, younger adults (≤24 years) and users in interior BC (mainly rural communities) did not to the same extent as others.9 Findings demonstrate the need for focused design and promotion among populations most at risk for STBBIs and those needing testing alternatives. Findings of increased use among users identifying as racialized minorities, first-time STBBI testers, often with lower sexual risk (as demonstrated by declining positivity rates) may imply that digital STBBI testing may be more mainstream. However, we must ensure accessibility among populations needing digital STBBI testing by designing these services with a focus on equity.14,30 Moreover, further research is needed to characterize reasons for differences in use of GetCheckedOnline, especially among historically disadvantaged populations who can benefit the most from these services. Updated studies exploring use of digital STBBI testing among various populations will further clarify the health equity implications of these interventions as the world settles into a postpandemic era.
Strengths and Limitations
This study accounted for preexisting trends and therefore may more accurately estimate the impact of COVID-19–related restrictions on access to digital STBBI testing via GetCheckedOnline. GetCheckedOnline's implementation across multiple jurisdictions in BC, Canada, and our use of provincial STBBI testing data assures us of the generalizability of our findings to BC. However, findings may not be generalizable beyond BC and to other digital STBBI testing models including self-sampling or testing models. Given the heterogeneity and multiplicity of COVID-19–related public health restrictions concurrently implemented, we also cannot determine what specific restrictions may have resulted in observed changes in access to STBBI testing via GetCheckedOnline. The multiplicity of interventions at different time points during the pandemic also limited our ability to model all potential impacts of the varied public health restrictions. However, we are confident about our findings given their consistency when different impact models were evaluated. Our assessment of the relative contribution of GetCheckedOnline to all BC STBBI tests was restricted to HIV, HCV, and syphilis given limitations in the data for chlamydia and gonorrhea tests conducted in BC. However, we posit that trends in the contribution of GetCheckedOnline to chlamydia and gonorrhea tests may be similar to other tests, as the tests are mostly concurrently conducted. Furthermore, we limited our analyses to October 2021 because of data availability. Updated analyses would be required to understand longer-term effects of the pandemic on GetCheckedOnline use.
CONCLUSIONS
The COVID-19 public health restrictions were associated with transient declines in digital STBBI testing via GetCheckedOnline, with rapid increase beyond baseline trends at the end of the study. These trends were consistent for GetCheckedOnline test episodes per million BC population and relative contribution of GetCheckedOnline to tests in BC regions where GetCheckedOnline is available. However, positivity rates declined steadily during the period. After initial increases in testing among users at higher risk of STBBIs, including symptomatic testers and testers reporting contacts with STBBIs, there were subsequent decreases below prepandemic trends. Changes in use of GetCheckedOnline varied by age, sex, sexual orientation, race, and user groups, with MSM, racialized minorities, and first-time testers increasing use beyond prepandemic trends compared with others. These findings suggest that digital STBBI testing became more mainstream during the pandemic, often serving as users' first point of contact with health systems, highlighting the need for equity-focused design and implementation to promote utilization, especially among populations most in need of routine STBBI testing.
Footnotes
This was supported by the Canadian Institute of Health Research (CIHR; Implementation Science Team Grant: FR# CTW-155387; principal investigators: M.G., D.G., C.W. [https://cihr-irsc.gc.ca/e/193.html]). D.G. is supported by a Canada Research Chair in Sexual and Gender Minority Health (https://www.chairs-chaires.gc.ca/home-accueil-eng.aspx). I.I. is supported by the CIHR Frederick Banting and Charles Best Doctoral Award (grant number AWD-018949 CIHR 2021; https://cihr-irsc.gc.ca/e/50513.html) and the University of British Columbia Four Year Doctoral Fellowship (4YF).
Conflict of Interest and Sources of Funding: None declared.
Contributorship Statement: I.I. conceptualized the study; H.P., A.A., and J.W. support the program, curated the data, and facilitated data access. I.I. conducted the data analyses and drafted the initial version of the manuscript. H.C., D.G., C.W., T.G., and J.W. reviewed the initial statistical analysis plans and various versions of the manuscript. A.S., M.K., and M.G. supervised the analyses and report writing. MG supervised the entire study. All authors reviewed and approved the manuscript.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (http://www.stdjournal.com).
Contributor Information
Heather Pedersen, Email: heather.pedersen@bccdc.ca.
Aidan Ablona, Email: Aidan.Ablona@bccdc.ca.
Hsiu-Ju Chang, Email: HsiuJu.Chang@bccdc.ca.
Catherine Worthington, Email: worthing@uvic.ca.
Daniel Grace, Email: daniel.grace@utoronto.ca.
Troy Grennan, Email: Troy.Grennan@bccdc.ca.
Jason Wong, Email: Jason.Wong@bccdc.ca.
Amy Salmon, Email: asalmon@cheos.ubc.ca.
Mieke Koehoorn, Email: mieke.koehoorn@ubc.ca.
Mark Gilbert, Email: Mark.Gilbert@bccdc.ca.
REFERENCES
- 1.Reid D Dema E Boso Perez R, et al. A mixed-method investigation into challenges in accessing sexual and reproductive health (SRH) services in Britain during the COVID-19 pandemic (Natsal-COVID). Sex Transm Infect 2021; 97(Suppl 1):A25–A26. [Google Scholar]
- 2.Willemsma K Barton L Stimpson R, et al. Characterizing female infectious syphilis cases in British Columbia to identify opportunities for optimization of care. Can Commun Dis Rep 2022; 47(2–3):68–75. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Cucinotta D, Vanelli M. WHO declares COVID-19 a pandemic. Acta Biomed 2020; 91:157–160. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Chow EPF Hocking JS Ong JJ, et al. Sexually transmitted infection diagnoses and access to a sexual health service before and after the national lockdown for COVID-19 in Melbourne, Australia. Open Forum Infect Dis 2020; 8:ofaa536. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Nagendra G Carnevale C Neu N, et al. The potential impact and availability of sexual health services during the COVID-19 pandemic. Sex Transm Dis 2020; 47:434–436. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Melendez JH Hamill MM Armington GS, et al. Home-based testing for sexually transmitted infections: Leveraging online resources during the COVID-19 pandemic. Sex Transm Dis 2021; 48:8–10. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Barbee LA Dombrowski JC Hermann S, et al. “Sex in the time of COVID”: Clinical guidelines for sexually transmitted disease management in an era of social distancing. Sex Transm Dis 2020; 47:427–430. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.O'Byrne P Musten A Orser L, et al. At-home HIV self-testing during COVID: Implementing the GetaKit project in Ottawa. Can J Public Health 2021; 112:587–594. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Public Health England . The impact of the COVID-19 pandemic on prevention, testing, diagnosis and care for sexually transmitted infections, HIV and viral hepatitis in England. Provisional data: January to September 2020 [Internet]. England; December 2020. Available at: https://www.gov.uk/government/publications/covid-19-impact-on-stis-hiv-and-viral-hepatitis. Accessed March 3, 2020.
- 10.Gómez-Ramírez O Iyamu I Ablona A, et al. On the imperative of thinking through the ethical, health equity, and social justice possibilities and limits of digital technologies in public health. Can J Public Health 2021; 112:412–416. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Menza TW Garai J Ferrer J, et al. Rapid uptake of home-based HIV self-testing during social distancing for SARS-CoV2 infection in Oregon. AIDS Behav 2021; 25:167–170. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Carnevale C Richards P Cohall R, et al. At-home testing for sexually transmitted infections during the COVID-19 pandemic. Sex Transm Dis 2021; 48:11–14. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Gilbert M Chang HJ Ablona A, et al. Accessing needed sexual health services during the COVID-19 pandemic in British Columbia, Canada: A survey of sexual health service clients. Sex Transm Infect 2022; 98:360–365. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Rodriguez JA, Clark CR, Bates DW. Digital health equity as a necessity in the 21st century cures act era. JAMA 2020; 323:2381–2382. [DOI] [PubMed] [Google Scholar]
- 15.Gilbert M Haag D Hottes TS, et al. Get checked… where? The development of a comprehensive, integrated Internet-based testing program for sexually transmitted and blood-borne infections in British Columbia, Canada. JMIR Res Protoc 2016; 5:e186. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Canadian Institute for Health Information . COVID-19 Intervention Timeline in Canada [Internet]. 2022. Available at: https://www.cihi.ca/en/covid-19-intervention-timeline-in-canada. Accessed March 3, 2022.
- 17.Government of British Columbia . Population estimates [Internet]. 2022. Available at: https://www2.gov.bc.ca/gov/content/data/statistics/people-population-community/population/population-estimates. Accessed May 12, 2022.
- 18.Bernal JL, Cummins S, Gasparrini A. Interrupted time series regression for the evaluation of public health interventions: A tutorial. Int J Epidemiol 2017; 46:348–355. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Bottomley C, Scott JAG, Isham V. Analysing interrupted time series with a control. Epidemiol Methods 2019; 8:20180010. [Google Scholar]
- 20.Penfold RB, Zhang F. Use of interrupted time series analysis in evaluating health care quality improvements. Acad Pediatr 2013; 13:S38–S44. [DOI] [PubMed] [Google Scholar]
- 21.White KJ. The Durbin-Watson test for autocorrelation in nonlinear models. Rev Econ Stat 1992; 74:370. [Google Scholar]
- 22.Zhang F Wagner AK Soumerai SB, et al. Methods for estimating confidence intervals in interrupted time series analyses of health interventions. J Clin Epidemiol 2009; 62:143–148. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.R Core Team . R: A Language and Environment for Statistical Computing [Internet]. Vienna, Austria: R Foundation for Statistical Computing, 2021. Available at: https://www.r-project.org/. Accessed March 29, 2022. [Google Scholar]
- 24.Bell J Canepa S Kreis S, et al. Impact of COVID-19 lockdowns on sexual health care utilization and STD reporting, Maricopa County. Inquiry 2021; 58:469580211055583. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Van Bilsen WPH Zimmermann HML Boyd A, et al. Sexual behavior and its determinants during COVID-19 restrictions among men who have sex with men in Amsterdam. J Acquir Immune Defic Syndr 2021; 86:288–296. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Public Health Agency of Canada . How has COVID-19 impacted the delivery of STBBI-related services, including harm reduction services, in Canada? [Internet]. Infobase Data Blog 2022. Available at: https://health-infobase.canada.ca/datalab/covid-19-impact-stbbi-services.html. Accessed May 14, 2022. [Google Scholar]
- 27.Coombe J Kong FYS Bittleston H, et al. Love during lockdown: Findings from an online survey examining the impact of COVID-19 on the sexual health of people living in Australia. Sex Transm Infect 2021; 97:357–362. [DOI] [PubMed] [Google Scholar]
- 28.Tao J Napoleon SC Maynard MA, et al. Impact of the COVID-19 pandemic on sexually transmitted infection clinic visits. Sex Transm Dis 2021; 48:e5–e7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Li G Tang D Song B, et al. Impact of the COVID-19 pandemic on partner relationships and sexual and reproductive health: Cross-sectional, online survey study. J Med Internet Res 2020; 22:e20961. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Crawford A, Serhal E. Digital health equity and COVID-19: The innovation curve cannot reinforce the social gradient of health. J Med Internet Res 2020; 22:e19361. [DOI] [PMC free article] [PubMed] [Google Scholar]