Taking STI Screening Access to Community-Based Organizations

October 09, 2023 - When Joshua O’Neal, sexual health program director at the Fulton County Board of Health (FCBOH) in Georgia, took on a project to improve patient access to STI testing, he didn’t know he’d be facing a perfect storm of public health crises.

He also didn’t know that confluence of events—tackling growing rates of STIs and the Mpox outbreak disproportionately affecting the LGBTQ+ community—would open doors to building trust and streamlining public health outreach to increase patient access to testing, PrEP, and drug user health.

The project, dubbed Testing My Way, was rolled into FCBOH’s #StopHIVATL program and was designed last year to close the gap in STI testing in the area.

STIs have seen an uptick in recent years. Gonorrhea and syphilis cases have been steadily climbing since 2017, according to the Centers for Disease Control and Prevention (CDC). Chlamydia cases have seen similar growth, save for 2020, when case counts went down, likely due to lower testing rates during the pandemic.

The #StopHIVATL program came in response to those numbers, plus issues in accessing STI testing that FCBOH observed. The program aimed to take new approaches to STI screening that offered different options to users who needed better care access. The program leveraged at-home STI test kits offered by Ash Wellness. Participants could apply to get a home test from the FCBOH Stop HIV ATL webpage.

But what O’Neal, who helped the program’s leader Dr. Milon Davis get the program off the ground, didn’t know was that the test kit rollout would coincide directly with the nation’s Mpox crisis.

Nationally, Mpox spiked in the summer of 2022, reaching a boiling point between July and August. Georgia was among the states with the highest case counts, with CDC data from September putting total case counts at 2,000.

It was a perfect storm of public health crises, O’Neal said, but it also created new opportunities for FCBOH.

“At the same time that we were launching, Mpox was hitting hard, and that was a new thing for us,” O’Neal said in an interview with PatientEngagementHIT. “We had the unprecedented opportunity for literally thousands of metro Atlanta queer and trans individuals, Black and Brown individuals, people who are living with HIV, coming to our doors where initially there was no demand for that.”

Between its relationships with community-based organizations (CBOs) and the unheard-of need for more public health information, O’Neal said FCBOH saw a new opportunity to build trust with a population with whom trust has long faltered.

“We partnered with community-based organizations to get Mpox vaccines into the arms of the people that they serve and center,” he explained. “And in that partnership, people started to see and build a sense of trust, a connection with Fulton County Board of Health and see what it is that we do, who we are, where we're at.”

That set the stage for expanding the #StopHIVATL and Testing My Way programs and creating an integrated experience.

STI Testing Expands Beyond Home Test Kits

Testing My Way was originally slated to help individuals complete STI testing at home, but after cementing itself within the community during the Mpox outbreak, O’Neal said FCBOH decided to expand the program to onsite testing.

Using the test kits, the Board of Health was able to bring screenings to locations without full lab capacities, including its mobile clinics and other community sites.

But it’s not just Mpox and STIs that FCBOH brought on the road. In the wake of the opioid and overdose crisis facing the entire nation, O’Neal said the Board of Health has created an integrated approach to the community’s biggest public health needs.

“In the last year, we have officially created sexual health express services, a screening center, and a drug user health center,” O’Neal outlined. “There, we also provide safer injection supplies like syringes and the works, as well as fentanyl test strips, xylazine test strips, and Narcan. So together, we're providing sexual health, drug user health services, and supplies, which were absolutely launched with the support of these testing kits.”

This has made for a wraparound public health experience, all driven by the success of the home test kits, O’Neal said.

Home test kits fill the gap, but education remains a hurdle

A year following the program launch, O’Neal and his colleagues at FCBOH can celebrate the successes of the home testing kit program. One-year impact data shared via email showed it was effective at closing access gaps. Four in 10 people accessing the tests were folks who hadn’t had an STI screening in the past year, and 20 percent were individuals who hadn’t been tested for HIV in the same period.

Moreover, these test kits helped detect STI cases. Of the 1,673 test kits distributed since June 2022, 18 percent were registered and 15 percent yielded results, meaning patients completed the tests and sent them in. Around a third (34 percent) were cataloged as reactive.

But O’Neal acknowledged that there’s still an uphill battle to be fought. For one thing, sex ed in Georgia is lacking, and the problem doesn’t necessarily affect the healthcare consumer—in some cases, it’s the provider.

“There are very few people having conversations about sex and sexuality down here,” O’Neal said. “And, truthfully, most of them, including people who are in the sexual health realm, the language they use is stigmatizing, the information they use is outdated, they're not fluent in this information. The players never even got good sex ed, so how are they supposed to be the messengers in terms of sex ed?”

While providers might know that STIs are a big problem, they simply don’t have the language to communicate this with patients in a way that is sex-positive and non-stigmatizing. “Because it's so stigmatized, because of the lack of information and conversations about it, because people feel so bad about open sexuality, they feel judged potentially by providers and family and friends in terms of being sexually active and engaged,” O’Neal explained.

Improving public health education among not just laypeople, but healthcare providers as well, will be critical in ameliorating this issue, but that’s a Sisyphean feat, O’Neal indicated. In a state like Georgia, there are cultural norms that often push against FCBOH’s mission.

Fighting an uphill culture battle

Despite its gains, FCBOH still has its setbacks, namely in terms of how to get what many consider a progressive message out in a more conservative part of the country. O’Neal stressed that it’s important to be sex-positive in STI testing messaging, but that’s been met with resistance from some local businesses and even the state Department of Health.

Take, for example, FCBOH’s messaging on drug use, which O’Neal shared is being co-located and coordinated with its STI testing plans for those who need it. In one of FCBOH’s billboards addressing the overdose crisis—CDC reported 106,699 overdose deaths in 2021, 88 percent of which stemmed from synthetic opioids like fentanyl—ad copy reads “do a line, do a strip.” Far from encouraging drug use, O’Neal said the message was intended to address the immediate crisis of drug overdose and synthetic drugs.

“We get resistance from the people who have the businesses we're trying to use for the billboards, from the platforms that we're trying to use to get the message out there, from DPH who is trying to shut it down because they think that we're condoning drug use,” he said. “I know exactly what the message is to get to people who use drugs. And if this message doesn't resonate with some people, then the message wasn't meant for them.”

In terms of its sexual health programming, O’Neal shared that some of the Board of Health’s t-shirts, which it uses as public health messaging, have also been banned. The shirts can be suggestive, he said, but they are also provocative and spark more conversation in his community than his FCBOH Polo shirt can. Plus, FCBOH staff who “earn” a t-shirt have completed extensive sexual health training, meaning they are actually qualified to engage in public conversations, O’Neal noted.

Moving forward

FCBOH intends to continue its partnership with Ash Wellness and keep integrating its sexual health and drug user health programming. On top of that, O’Neal said the Board of Health is considering adding its PrEP follow-ups, as well.

The organization recently revamped its PrEP program, requiring people to complete just an annual follow-up appointment via telehealth and quarterly HIV and STI screenings. Folding this into the testing kit program will make the PrEP program more accessible, O’Neal said.

This is being complemented by new approaches to patient education, particularly regarding how to use the test kits. While O’Neal stressed that the kits aren’t hard to use, there can be roadblocks for people who have never used them before or who are stressed about testing because they are experiencing symptoms or have had an exposure.

“We have found that one of the best ways to really introduce people to the service and the testing components is to walk people through it,” O’Neal concluded. “That way, they feel more confident, and they know how to use it. We know that if we start the kit, they're likely going to send it in and submit it.”