Step into a bathroom inside UNC’s Infectious Diseases Clinic and you are met with a poster detailing the correct way to swab yourself for a sexually transmitted disease or STD.
The ID Clinic inside the NC Memorial Hospital on Carolina’s campus is one of a few clinics in the state giving patients the option to screen themselves for chlamydia and gonorrhea. Self-swabbing is one of a handful of interventions created by a multidisciplinary quality improvement group including the clinic’s nurses, social workers, a certified medical assistant and a provider.
“Sex is normal and healthy,” says Ellen McAngus, LCSWA, a social work practitioner in the ID Clinic. “But we need to give our patients the right tools to protect themselves and their partners.”
UNC ID Clinic providers manage the care for 1,800 people living with HIV. In 2015, clinic nurse Anita Holt, RN, and Associate Clinic Director Amy Heine, FNP, noticed screening rates for syphilis in patients living with HIV were down, despite there being an increase in syphilis cases in North Carolina. In fact, the number of syphilis cases in the state increased by 64 percent between 2014 and 2015, according to the NC Department of Health and Human Services.
Nurses began having frank discussions about sexual health with patients. If they felt the person was at risk for syphilis or hadn’t been screened in a year, the nurse would flag the patient’s chart so the provider knew to order the test. The number of screenings for syphilis increased, prompting Holt and Heine to meet with colleagues about adding chlamydia and gonorrhea testing.
Testing Extragenital Sites
Any clinic that receives funding from the U.S. government’s Health Resources and Services Administration (HRSA), like UNC’s ID Clinic, has to track STD screening rates. Adding screenings for chlamydia and gonorrhea helps the clinic meet this expectation, increases access to treatment, reduces transmission to uninfected partners and educates patients about where these infections can hide.
“People don’t always know you can get STDs in places other than the vagina or penis,” says McAngus.
This revelation prompted Tim Menza, MD, PhD, to introduce self-swabbing to the ID Clinic. He says while syphilis anywhere in the body can be caught through a blood test, chlamydia and gonorrhea can live in extragenital sites like the throat and anus.
“For example, you could screen a woman vaginally, and if the test is negative, it doesn’t necessarily mean she hasn’t had an exposure to chlamydia or gonorrhea. She could have been exposed through condomless oral or anal sex. Many people think oral sex isn’t sex, so they won’t tell their provider. And anal sex, especially for women, is also rarely discussed,” Menza says. “This project really opened the door for us to empower providers and patients to have more sexual health conversations, and to offer patients self-swabbing if we feel they are at risk for an STD exposure. The option to self-swab puts part of a patient’s health care in their hands. And they do just as good of a job as providers as far as getting an adequate sample for testing.”
Discussing Sexual Health
Just like syphilis, gonorrhea and chlamydia are on the rise in North Carolina. Gonorrhea and chlamydia have increased by 14 and nine percent respectively from 2014 to 2015, according to the state Department of Health and Human Services. The department estimates the cost to the society at more than $24 million.
Because STDs can be asymptomatic, regular testing is critical to diagnosing infection and preventing transmission. When a patient comes into the ID Clinic, their first stop is a nurse who checks their vital signs and asks lifestyle questions about smoking, drugs and sexual behavior. Holt says by following this routine, it gets patients used to talking about sex during each visit.
“I tell patients that I ask these questions of everyone who comes in so they know this is not something we are singling them out for,” she says. “We need all the facts to provide them with the best care possible. We will never get STIs under control if we don’t have these conversations.”
Holt and Heine have learned the importance of asking sexual health questions in multiple ways since people define terms differently.
“I asked a patient once if they were sexually active and they said no,” Heine says. “But as we talked further, they told me they had had sex the week before. They just didn’t consider sex a week ago as being sexually active. You have to be very specific.”
Closing the Loop
If the nurse believes the patient could be at risk for chlamydia or gonorrhea, they will offer them the option to self-swab. If the patient declines, the nurse can offer to screen them or flag their chart to prompt the provider to ask about swabbing. The nurse or certified medical assistant will even set up a testing tray in the patient room as a second reminder for providers to screen their patient. But many times, the patients accept the offer to step into the bathroom and swab themselves.
Alyssa Draffin, LCSW, social work lead, says self-swabbing is a more comfortable option for patients who have been sexually assaulted.
“People living with HIV tend to have higher rates of sexual trauma, and for some, being swabbed in the vagina or rectum can trigger anxiety or panic,” Draffin says.
If the patient tests positive for syphilis, chlamydia or gonorrhea, they are given treatment and connected with the clinic’s social workers. The social workers will conduct a five to 10-minute behavioral intervention with the patient and then follow up by phone.
“There is absolutely no judgement during these talks,” McAngus says. “The talk is meant to be educational and reduce their risk for contracting an STI going forward. We don’t want people retreating into the shadows. We want the clinic to be a space that’s safe.”
Social workers share their notes from the behavioral interventions with the patient’s provider. This collaborative approach has increased the number of screenings for chlamydia and gonorrhea in the clinic from 34 percent to 50 percent. And the group continues to tweak their interventions based on patient feedback. Menza is asking patients who chose the option to self-swap to complete an anonymous survey to see how that process can be improved.
“The ID Clinic is a really special place to work because all the cogs in the wheel, from doctors and nurses to social workers and patients, are working together to improve public health,” Draffin says.