Readily treatable sexually transmitted infections (STIs) nonetheless pose serious public-health hazards because of their potential sequelae, including sterility and even death. Many STIs are also asymptomatic, adding to the risk posed. Although HIV risk-reduction safer-sex guidelines and education in the 1980s and 1990s emphasised barrier protection to prevent most STIs or reduce the likelihood of infection, non-adherence has always been an issue, more recently exacerbated since the introduction of HIV pre-exposure prophylaxis (PrEP) in 2012. PrEP users are advised to continue using barrier protection during sex but have often demonstrated a belief that the medication regimen protects them from serious harm, putting them at risk of other STIs. With diminished adherence to safer-sex practices for STI prevention, testing and treatment become the next line of protection.
However, a variety of conditions may also impede testing. Sexually active people may mistakenly believe that they can tell if someone is infected or they may take at face value a sexual partner’s declaration of health. They may also be lulled into a false sense of health with the asymptomatic nature of some STIs. Cultural stigma or personal shame about STI infection and testing may inhibit taking the initiative to be tested, which can be further amplified if clinic access is limited or delayed. Clinics find their capacity stretched to the limit, even in countries with a national health service, necessitating turning away some clients.
A streamlined approach of STI testing without physical examination has been demonstrated in previous studies to reduce one barrier and to increase clinic capacity. ‘Express testing’ has been trialled in other Anglophone countries (USA, Australia, UK) but not in Canada. This study, following a feasibility pilot, documents implementation of express STI testing at an Ottawa, Canada, sexual health clinic that had been experiencing increased demand and a precipitously rising number of clients who had to be turned away.
Since the beginning of professional nursing in the 19th century, the role of nurses in public health, including sexual health, has been significant. This well-conducted study tests an innovative intervention in which nurses conducted triage of clinic patients and recommended express testing for some according to established study criteria. Out of nearly 13,000 clients, slightly more than half sought testing; a substantial majority were male, and of those a disproportionate percentage were men who have sex with men. Over half of the express clients were first-time clients. Express testing cut the visit time in half. Although this intervention increased capacity at the clinic, it did not solve the problem entirely. Nonetheless, the study demonstrates the efficacy of a nurse-led intervention.
The authors frankly acknowledge the limitations of the study. Most seriously in terms of health outcomes was the use of a less sensitive test for pharyngeal and rectal samples. Further demographic data (e.g. concerning race, ethnicity, socio-economic status) would have added other dimensions for a more robust analysis of results. It was also not clear the extent to which clients followed-up on positive results with treatment. It would also have been helpful to identify how many (if any) of the clients also were adhering to a PrEP regimen prior to testing.
Nonetheless, the role of advanced-practice nursing in particular is affirmed, and the study deserves replication in other clinical settings.
Biography
Thomas Lawrence Long is Associate Professor in Residence in the University of Connecticut’s School of Nursing and on the core faculty of Women’s, Gender and Sexuality Studies. He is the author of AIDS and American Apocalypticism: The cultural semiotics of an epidemic (SUNY Press, 2005), co-editor of The Meaning Management Challenge: Making sense of health, illness, and disease (Interdisciplinary Press, 2010) and co-author of Writing in Nursing: A brief guide (Oxford University Press, 2017).