In an online survey of mail-in self-collection sexually transmitted infection test users during COVID-19, 66.2% of respondents reported a new sex partner. White race in men, women younger than 25 years, and increased condom usage were significantly associated with reporting a new sex partner.
Background
The COVID-19 pandemic has coincided with an explosion of online platforms for sexually transmitted infections (STIs) testing using self-collected, mail-in specimens. Reports on the effect of COVID-19–associated restrictions on sexual behaviors have been mixed, but STI transmissions have continued during the pandemic. We sought to understand the pandemic impact on sexual habits associated with STIs among IWantTheKit users.
Methods
Users of IWantTheKit, a free, online STI testing platform, were invited to complete an anonymous questionnaire. Descriptive statistics were used to describe survey responses. Associations with reports of new sex partnerships were explored as a marker of STI risk. Descriptive statistics, univariate and multivariate logistic regression models were used to analyze individual characteristics and reported behaviors associated with self-reported new sexual partnerships during the first 2 COVID-19 pandemic waves.
Results
Of the 3462 users of the online STI testing platform between June 2020 and February 2021, 1088 (31.4%) completed the online survey; 705 (66.2%) of 1065 reported a new sex partner. One-quarter met their sex partners using apps. Overall, 10% were symptomatic and almost 18% were concerned that their partner had an STI. White race in men (odds ratio, 1.81; 95% confidence interval, 1.04–3.16), women younger than 25 years (odds ratio, 1.85; 95% confidence interval, 1.09–3.14), and increased condom use in both men and women were significantly associated with reports of new sexual partnerships in adjusted analysis.
Conclusions
Despite pandemic restrictions on social gatherings, new sexual partnerships were common in this population, associated with common risk factors, and may help to explain ongoing STI transmission.
The Centers for Disease Control and Prevention (CDC) 2020 data revealed that 2 of the 3 most common notifiable sexually transmitted infections (STIs), gonorrhea, and syphilis, were at an all-time high with increased case numbers of 45%, and 52%, respectively, compared with 2016.1 The coronavirus disease 2019 (COVID-19) pandemic, caused by the severe acute respiratory syndrome coronavirus 2, significantly disrupted access to medical services, including STI testing. This reduction in service limited opportunities for laboratory testing and diagnosis, and collection of epidemiological data likely resulting in an underestimate of the true burden of STIs in 2020.2
In response to the reduction of in-clinic STI testing services, caused by the COVID-19 pandemic, the availability and use of online, mail-in, self-collection services and human immunodeficiency virus (HIV) self-test provision greatly expanded, especially during the early stages of the pandemic.3–6 Online testing services attract a diverse population of individuals, including priority populations, men who have sex with men (MSM) and people of color,7 in part because of perceived benefits, such as increased convenience. During the pandemic, the free, online mail-in self-collection STI testing service, IWantTheKit (IWTK), experienced a significant increase in the number of users. During the first pandemic wave, those who traditionally sought STI testing services and treatment at sexual health clinics in Baltimore City were referred to IWTK because of clinic closures.8
Despite the increased popularity of online testing services, there are limited data on the sexual behaviors, including new partnerships, of individuals seeking online STI testing. In an Australian online survey, 53% of respondents, reported decreases in sexual activity during COVID-19 lockdown in 2020, compared with 2019; this included a decrease in casual sex partners.5 A study of MSM in Baltimore demonstrated decreases in STI risk behaviors, but minimal change in STI positivity during compared with before the pandemic.9 Other studies, including surveys of MSM, found no changes to sexual behaviors during the pandemic.10,11 Data are limited on the impact of sexual behaviors associated with increased risk for STI transmission during pandemic conditions.
Using an anonymous online survey, we sought to understand the impact of the COVID-19 pandemic on sexual behaviors associated with STI/HIV transmission and acquisition, such as condom use and new sexual partnerships, from a sample of individuals requesting online STI/HIV testing services.
MATERIALS AND METHODS
IWantTheKit was established in 2004 as an online platform to provide free, home-based specimen self-collection and mail-in for STI testing in a reference laboratory.12 To explore changes in sexual behavior of online STI test users during pandemic conditions, we conducted an online survey. An external link to the survey was provided on the IWTK website in June 2020, during the first wave of COVID-19, and was available to residents of Maryland, and Washington, DC (served by IWTK in 2020); it was extended to Alaska residents in September 2020. The Johns Hopkins School of Medicine Institutional Review Board (IRB00248714) and the Alaska Area Institutional Review Board (2020-07-030-2) provided ethical approval.
The survey was anonymous, independent of kit return or STI result, and data collected were deidentified and unlinked to the individual respondent. Each time a user logged onto IWTK to order an STI test kit, they were offered the opportunity to participate in the survey after completing their orders; the survey was optional, and an online consent statement was available for all participants. Multiple responses were possible to some questions, and any question could be omitted per respondent's preference, hence the denominator could be different from the total number of individual respondents. Data on sexual orientation were collected in the survey, but not by IWTK, so comparisons were not possible between those who completed the survey and those who did not. The survey captured data in different domains that are key to understanding sexual health and wellbeing, including demographic, gender, sexual orientation, condom use, and other behavioral data.
STATISTICAL ANALYSES
Descriptive statistics were generated using mean and standard deviations (SD), median and interquartile range for continuous measures, counts and percentage for categorical measures in both the survey population and all IWTK users in the same period. Difference of distribution between the 2 populations and between demographic groups were tested using Student t test if comparing continuous variables, and Fisher's exact test if comparing categorical variables. Univariate and multivariate logistic regression models were used to examine the association between the primary outcome response (ie, “Have you had any new sexual partner since COVID-19 shut down [March 16, 2020]?”) and factors of interest. Variables that were significant at 0.05 level from the univariate regression, eg, sex, race, sexual orientation, and age categories were included in the multivariate regression. Odds ratio (OR) with 95% confidence intervals (CIs) were estimated.
For the purposes of this analysis, COVID-19 waves13 were defined as a rising number of COVID-19 cases with an identifiable peak, followed by a decline.14 For these analyses, the first wave was defined as March to June 2020, and the second wave November 2020 to February 2021. The timeframes chosen mapped closely to other measures of reduced access to sexual health services, such as national chlamydia and gonorrhea screening data, where in early April 2020, there was an overall decrease in testing by 59% for women and 63% for men compared with baseline.2 Other temporal trends, such as periods of reduced reporting of bacterial STIs to the CDC, between March and June 2020, and increased diagnoses of syphilis and gonorrhea in November and December 202015 closely aligned with the timeframes used in these analyses. We hypothesized that there might be less new sex partner meeting during the second wave of COVID-19, when restrictions to movements were greatest, compared with earlier in 2020 when restrictions had been somewhat relaxed. To explore the effect of time, we undertook a sensitivity analysis to determine if there were differences by periods corresponding to different COVID-19 waves. All statistical analyses were performed using Stata I/C 15 (StataCorp. 2017. Stata Statistical Software: Release 15. College Station, TX).
RESULTS
Survey Population
Between June 10, 2020, and February 2, 2021, there were 3462 individual STI testing kit orders through IWTK; of those, 1088 (31.4%) users responded to the survey. Of these, 637 (58.6%) of survey participants were residents in Baltimore City, 326 (30.0%) were Maryland residents outside of Baltimore City, 50 (4.6%) were Alaska residents, and 48 (2.5%) resided in Washington, DC; 27 (2.5%) did not provide a residence response. Of those answering the questions, 69.1% (739 of 1069) reported that they had not tried to access STI testing other than through IWTK during the pandemic and 81.4% (908 of 1115) reported that they would inform “all” of their sex partners of any positive STI results. Overall, 17.0% (180 of 1060) reported no condom use during the pandemic, 15.2% (229 of 1502) sought testing because they were concerned that a partner had an STI, and 14.4% (217 of 1502) were symptomatic.
Table 1 describes the characteristics of survey responders and all IWTK users during the same period. Proportionally, more White-identifying individuals responded to the survey than overall White-identifying IWTK users (30.6% vs 21.1%). Less African American/Black-identifying respondents completed the survey than overall African American/Black-identifying IWTK users (53.6% vs 63.0%, respectively). The survey respondents were broadly representative of all IWTK users with respect to age and gender identity.
TABLE 1.
Characteristics of Survey Respondents Compared With All IWTK Users Between June 2020 and February 2021
| Survey Responders | All IWTK Users | |
|---|---|---|
| n | 1088 | 3462 |
| Age (median [IQR]), y | 27 [23, 34] | 27 [23, 33] |
| Age (mean (SD)), y | 29.75 (9.50) | 29.29 (8.86) |
| Age categories, n (%), y | ||
| 17 and younger | 0 (0.0) | 52 (1.5) |
| 18–24 | 358 (32.9) | 1111 (32.1) |
| 25–34 | 445 (40.9) | 1564 (45.2) |
| 35–44 | 163 (15.0) | 508 (14.7) |
| 45–54 | 58 (5.3) | 151 (4.4) |
| 55 and older | 29 (2.7) | 76 (2.2) |
| Race, n (%) | ||
| White | 333 (30.6) | 731 (21.1) |
| African American/Black | 583 (53.6) | 2180 (63.0) |
| Others | 172 (15.8) | 551 (15.9) |
| Gender identity, n (%) | ||
| Male/man | 500 (46.0) | 1687 (48.7) |
| Female/woman | 545 (50.1) | 1706 (49.3) |
| Trans man | 5 (0.5) | 9 (0.3) |
| Trans woman | 4 (0.4) | 7 (0.2) |
| Genderqueer | 23 (2.1) | 49 (1.4) |
| Different identity | 2 (0.2) | 4 (0.1) |
IWTK, IWantTheKit; IQR, interquartile range; SD, standard deviation.
New Sex Partnerships During the COVID-19 Pandemic
Of the 1088 survey respondents, 23 (2.1%) did not answer the question about a new sex partner and were excluded from this analysis. Of 1065 respondents, the majority (66.2%) reported having a new sex partner during the COVID-19 pandemic. Of respondents reporting a new sex partner who answered the question 25.3% (271 of 1073) met their partners using dating Apps (data not shown). Table 2 shows the demographic characteristics of the population stratified by self-reports of new sex partner(s).
TABLE 2.
Differences by New Sex Partner(s) Report During the COVID-19 Pandemic Between June 2020 and February 2021
| Overall | No New Sex Partner | New Sex Partner | P* | |
|---|---|---|---|---|
| n (%) | 1065 (100) | 360 (33.8) | 705 (66.2) | |
| Age (median [IQR]) | 27 [23, 34] | 28 [23, 35] | 27 [23, 33] | 0.062 |
| Age categories (%) | 0.283 | |||
| 18–24 | 354 (33.2) | 108 (30.0) | 246 (34.9) | |
| 25–34 | 434 (40.8) | 145 (40.3) | 289 (41.0) | |
| 35–44 | 161 (15.1) | 61 (16.9) | 100 (14.2) | |
| 45–54 | 58 (5.4) | 26 (7.2) | 32 (4.5) | |
| 55 and older | 28 (2.6) | 9 (2.5) | 19 (2.7) | |
| Missing | 30 (2.8) | 11 (3.1) | 19 (2.7) | |
| Race (%) | <0.001 | |||
| White | 329 (30.9) | 82 (22.8) | 247 (35.0) | |
| African American/Black | 574 (53.9) | 220 (61.1) | 354 (50.2) | |
| Others | 162 (15.2) | 58 (16.1) | 104 (14.8) | |
| Gender identity (%) | 0.001 | |||
| Male/Man | 494 (46.4) | 138 (38.3) | 356 (50.5) | |
| Female/Woman | 534 (50.1) | 211 (58.6) | 323 (45.8) | |
| Trans Man | 5 (0.5) | 0 (0.0) | 5 (0.7) | |
| Trans Woman | 4 (0.4) | 0 (0.0) | 4 (0.6) | |
| Genderqueer | 23 (2.2) | 8 (2.2) | 15 (2.1) | |
| Different Identity | 2 (0.2) | 2 (0.6) | 0 (0.0) | |
| Missing | 3 (0.3) | 1 (0.3) | 2 (0.3) | |
| Sexual orientation (%) | <0.001 | |||
| Heterosexual | 622 (58.4) | 237 (65.8) | 385 (54.6) | |
| Gay/lesbian/MSM | 180 (16.9) | 35 (9.7) | 145 (20.6) | |
| Bisexual | 196 (18.4) | 64 (17.8) | 132 (18.7) | |
| Other | 46 (4.3) | 11 (3.1) | 35 (5.0) | |
| Missing | 21 (2.0) | 13 (3.6) | 8 (1.1) | |
| Reason for STI test order (%) | 0.001 | |||
| Symptomatic | 107 (10.0) | 44 (12.2) | 63 (8.9) | |
| Concern that partner might have an STI | 191 (17.9) | 56 (15.6) | 135 (19.1) | |
| HIV check/PrEP | 723 (67.9) | 234 (65.0) | 489 (69.4) | |
| Missing | 44 (4.1) | 26 (7.2) | 18 (2.6) | |
| Sex with a partner(s) that respondent thought might have an STI (%) | 0.021 | |||
| No | 609 (57.2) | 227 (63.1) | 382 (54.2) | |
| Yes | 219 (20.6) | 63 (17.5) | 156 (22.1) | |
| Missing | 237 (22.3) | 70 (19.4) | 167 (23.7) | |
| Condom use since the pandemic (%) | <0.001 | |||
| No use/less often | 299 (28.1) | 132 (36.7) | 167 (23.7) | |
| More often | 212 (19.9) | 46 (12.8) | 166 (23.5) | |
| The same amount | 459 (43.1) | 113 (31.4) | 346 (49.1) | |
| Other | 95 (8.9) | 69 (19.2) | 26 (3.7) |
*P value calculated by Fisher exact test.
Factors Associated With New Sex Partnerships
In the univariate analyses (data not shown), reporting a new partner was significantly associated with being male, White (compared with African American/Black), younger than 25 years (compared to ≥35 years), being gay/lesbian/MSM, ordering an STI test because of concern that a partner may have an STI, and using condoms (compared with prepandemic) the same amount or greater. Table 3 describes adjusted ORs of factors associated with having a new sex partner. In the multivariate analyses those most likely to report a new sex partner(s) during the pandemic were White men compared with African American/Black, women younger than 25 years (compared to ≥35 years), and with increased condom use in both women and men. In men, pandemic-related sexual anxiety was associated with having a new partner during the pandemic.
TABLE 3.
Factors Associated With Reporting New Sexual Partner(s) During the COVID-19 Pandemic Between June 2020 and February 2021
| Male | Female | |||||||
|---|---|---|---|---|---|---|---|---|
| OR | CI | P | OR | CI | P | |||
| Race (ref: African American/Black) | ||||||||
| White | 1.81 | 1.04 | 3.16 | 0.037 | 1.33 | 0.84 | 2.11 | 0.224 |
| Other | 0.84 | 0.46 | 1.54 | 0.570 | 0.86 | 0.50 | 1.50 | 0.601 |
| Age categories (ref: ≥35 y) | ||||||||
| <25 y | 1.49 | 0.83 | 2.67 | 0.186 | 1.85 | 1.09 | 3.14 | 0.023 |
| 25–34 y | 0.99 | 0.59 | 1.66 | 0.973 | 1.64 | 0.97 | 2.76 | 0.063 |
| Male: sexual orientation (ref: heterosexual) | ||||||||
| Gay/MSM | 1.54 | 0.90 | 2.63 | 0.115 | ||||
| Bisexual/other | 0.89 | 0.47 | 1.68 | 0.716 | ||||
| Female*: sexual orientation (ref: heterosexual) | ||||||||
| Nonheterosexual | 1.04 | 0.67 | 1.62 | 0.856 | ||||
| Why order (ref: symptomatic) | ||||||||
| Thought partner had STI | 1.61 | 0.74 | 3.50 | 0.226 | 1.76 | 0.82 | 3.76 | 0.146 |
| To obtain an HIV test | 1.51 | 0.79 | 2.88 | 0.216 | 1.27 | 0.66 | 2.41 | 0.473 |
| Condom use (ref: no use/less often) | ||||||||
| More often | 2.26 | 1.21 | 4.21 | 0.010 | 3.02 | 1.66 | 5.47 | <0.001 |
| Same amount | 1.55 | 0.93 | 2.59 | 0.096 | 2.66 | 1.71 | 4.15 | <0.001 |
| Other | 0.16 | 0.07 | 0.37 | <0.001 | 0.31 | 0.14 | 0.67 | 0.003 |
| COVID-19 effect on sex behavior vs no effect | 1.69 | 1.08 | 2.65 | 0.023 | 1.38 | 0.91 | 2.08 | 0.126 |
*The numbers in the female bisexual or other categories were too small for separate analysis. They were combined into a nonheterosexual category consisting of gay/lesbian/bisexual/other.
ref, reference group.
Survey Responses During Different Waves of COVID-19
By the completion of the survey (February 2021), the United States had experienced 2 distinct waves of COVID-19. The first occurred in March to June 2020, the second in November 2020 to February 2021.14 We undertook a sensitivity analysis on survey responses to determine if there were differences by wave and found no significant differences in new sex partner meeting during the 2 wave periods (data not shown).
DISCUSSION
In our online survey of online STI test users with over 1000 respondents, the majority reported a new sex partner during the first year of the pandemic, which was considered a proxy for increased STI risk.1,16,17 Early in the pandemic, there was widespread speculation about the effects of COVID-19 on sexual behaviors.18 These data supported both increased isolation and fewer sex partners, and increased sexual activity during pandemic compared with prepandemic. The mechanisms underlying these differences have not been elucidated but could include those mediated by boredom and stress,19 pandemic “fatigue,” and prolonged restrictions, disrupting relationship norms resulting in higher-risk sex.20,21 However, empirical evidence to support or refute such speculation is limited. There was no evidence of significant differences in reported new sex partnerships during different pandemic waves, including periods of more and less stringent social distancing mandates,14 suggesting that more social distancing requirements may not have changed new sex partner seeking behaviors.
Other surveys and studies have provided additional context to sexual behavior during the pandemic. In an online survey of US MSM during COVID-19, the majority of the 518 respondents did not consider it important to reduce the number of sex partners.11 Between February and May 2020, 202 (39%) of participants reported a mean increase of 2.3 sex partners, a mean increase of 2.1 anal sex partners, but a very small increase in partners with whom they reported unprotected anal sex.11 In a Spanish study of 536 respondents to an online survey, the mean number of sexual activities per week was 2.39 (1.80); 72% of respondents reporting sexual activity were female. Data were not presented on behaviors associated with higher risk of STI, such as condom use or sex with a new partner.22 It is important to note that respondents to our survey were actively seeking out STI testing and, therefore, were a priori at potential greater risk of STI. This is supported by the finding that people continued to have sex with partners in whom they suspected STIs. Previous IWTK data demonstrated a positive association between STI positivity and higher self-reported sexual risk scores in women23 and men.24
In our survey respondents who identified as male and White, or who were women younger than 25 years were significantly more likely to report a new sex partner; published data collected during a similar timeframe corroborate our data showing increased sexual activity in respondents who were younger, and male.25 The CDC STI data consistently demonstrate that people younger than 25 years have the highest rates of bacterial STIs.1 Reassuringly, reported condom use did not decrease over the study period; this finding may reflect behavioral compensation in the context of new relationships and suggests that respondents did not represent a homogenous population of individuals with increased vulnerability. There were a substantial proportion who had symptoms or who were concerned that they may have been exposed to an STI, which may explain accessing IWTK during a time when STI testing and treatment services were curtailed.
Conversely, other study findings are at odds with ours, including studies reporting that behaviors shifted toward monogamy during COVID-19 with fewer reports of partners outside of primary relationships.26 None of the published studies examine sexual habits and new sexual relationship status, and were general population surveys or primarily in sexual minority men.
The CDC data consistently show African American/Black persons shouldering a disproportionate burden of STI in the United States1; our study demonstrated that, after controlling for other factors, White men were more likely to report new sex partners. The observed differences between the survey findings and CDC data may be explained by unmeasured factors. For example, White men may have a greater number of new sexual partners than other men but this risk may be mitigated by behavioral compensation, such as increased condom use, or by better access to clinical services.
One-third of men who completed the survey identified as MSM. Prepandemic data demonstrates that sexual minority men had higher numbers of new sex partners than their heterosexual counterparts.17 Other studies of majority White MSM in early COVID-19 showed half had fewer sex partners during pandemic compared with prepandemic.10 None of the other studies described were in predominately African American/Black persons with almost equal spilt between men and women. Observed differences between other studies and ours may, in part, have been mediated by differences in race and sex. Although we cannot directly compare findings because of different enrolment criteria, time lines, information on partner status, and populations surveyed, our data demonstrated that after controlling for other factors, sexual orientation was not associated with reports of new sexual partnerships during the pandemic.
The strengths of this study include a large sample size (>1000), from people ordering an online STI test kit, which suggests that users at least had a perception of increased risk of STI, including almost 30% who were either symptomatic or concerned that they were exposed to an STI. The findings of the current analysis add to other studies where STI testing behaviors were not assessed. The survey ran for 8 months and covered 2 COVID-19 waves in the United States. Approximately a third of male-identified respondents were MSM. The proportion of African American/Black persons who completed the survey was greater than 50%. The anonymous nature of the survey should have reduced social desirability bias.
The study also had limitations. The lack of a comparison group, other than the internal contrast between those who did and did not report a new sex partner, prevents correlation with other populations. The cross-sectional design, prevents analyses of change in individual responses over time or to behavior before the pandemic. The same anonymity that may have encouraged disclosure of sexual behaviors precluded measurement of sexual risk scores, the proportion of respondents who returned their kits, nor allowed assessment of associations between reported behavior and IWTK STI positivity. It is possible that the same individual took the survey more than once if they ordered STI testing multiple times during the survey period. Respondents were people ordering STI tests online, introducing ascertainment bias; response and nonresponse bias are suggested by the observation that proportionately less people of color answered the survey than who used the IWTK platform during the pandemic. These and other unmeasured biases limit the generalizability of these data. Nonetheless, they do reveal that the majority of survey respondents did have a new sexual partner during the pandemic. It is noteworthy that the survey was conducted before the widespread use of COVID-19 vaccination, after which behaviors may have changed.
Social distancing mandates were not observed as demonstrated by reports of sexual activity with new sex partner(s) especially in younger women, and those identifying as White men and may explain ongoing STI transmission. As STI/HIV online testing platform offerings increase, they should be leveraged to highlight the benefits and availability of STI/HIV prevention. Online testing platforms should capitalize on their visibility to priority populations, historically underserved by healthcare institutions, to ensure equity of access to sex-positive safer sex messaging.
Footnotes
Y.C.M. and J.H.M. share senior authorship.
Acknowledgments: Cornelia Jessen, MA, Senior Program Manager, Research Services Department, Alaska Native Tribal Health Consortium for her support.
Conflicts of Interest: None declared.
Source of Funding: National Institute of Biomedical Imaging and Bioengineering (U54EB07958). Dr. Yukari C. Manabe.
Author contributions: All authors contributed to the study conception and design. Data analysis was performed by T.Y. and Y.H.H. The first draft of the article was written by M.M.H. and all authors commented on previous versions of the article. All authors read and approved the final article.
Contributor Information
Tong Yu, Email: tyu29@jhmi.edu.
Gretchen S. Armington, Email: garming2@jhmi.edu.
Yu-Hsiang Hsieh, Email: yhsieh1@jhmi.edu.
Yukari C. Manabe, Email: ymanabe@jhmi.edu.
Johan H. Melendez, Email: jmelend3@jhmi.edu.
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