The Internet provides patients, as well as clinicians with immediate, confidential access to information about sexually transmitted diseases (STDs).1,2 Young individuals are avid users of the Internet and usage has been considered to be a risk factor for STDs.3–7 Data indicate that there are 246,402,574 North American Internet users.8
It is logical to link Internet educational sexual health material to self-screening tests for STDs and partner notification.9 We implemented an Internet educational website www.iwantthekit.org, which offered women free collection kits for self-collected vaginal samples with mailing to a laboratory for chlamydia and gonorrhea testing.10 Focus group research guided this program.11 Over 1200 women have now used this program; we report new data and confirm earlier findings about the characteristics of women who used www.iwantthekit.org.
The Internet program was open initially to women in Maryland.10 Washington, DC and West Virginia) were added in 2005 or 2006. The program was Institutional Review Board approved, and was advertised by radio, flyers, and magazines. Since 2005, 97.1% have used the Internet to request kits, and 2.9% used the toll free number. From July 2004 to May 2008, 1203 women mailed self-collected vaginal swabs for testing.
The kit included contact and consent forms, instructions, swab, and questionnaire. Later, new questions were added about education, insurance, and income. Swabs were tested for chlamydia and gonorrhea by commercial nucleic acid amplification tests.10 In 2006, nucleic acid amplification testing for trichomonas was added. Treatment was previously described.10,12
Chi square tests were performed for univariate analysis, and logistic regression was performed using SAS version 9.1 (Cary, NC). P ≤0.05 was considered significant. Variables significant in univariate logistic regression analysis and other variables considered important were entered into a multiple logistic regression model.
Overall, 3774 kits were requested and 32.4% were returned; kits returned for 2008 was 40.1%. Of 1203 participants, 64.0% were black, 28.2% were white, and 7.8% listed “other races,” multiple races, or ethnicities. Median age was 23 years (range, 14–63). Chlamydia prevalence was 9.1%, by age group, 0.8% were age 14 years, all uninfected; 25.8% were 15 to 19 years (15.3% infected), 33.2% were 20 to 24 years (11.1% infected), 18.6% were 25 to 29 years (6.8% infected), and 21.8% were ≥30 years (1.2% infected). Prevalence was 11.1% for black, 9.7% for “Other,” and 3.3% for white race. Prevalence varied: 10.2% for 2004, 6.4% for 2005, 9.5% for 2006, 9.5% for 2007, and 8.7% for 2008 (P = 0.824).
Of participants, 40.9% were from Baltimore, 49.1% were from other Maryland jurisdictions, 3.6% were from Washington, DC, and 4.6% were from West Virginia. Prevalence for Baltimore (10.1%) was higher than Maryland (9.5%), WA (4.7%), and West Virginia (3.7%). Approximately 40% of women called for results, while ∼60% were contacted.
Although 2.1% of women reported no partners in the previous year, 38.7% had 1 partner, whereas 45.2% had 2 to 4 partners, 11.3% reported 5 to 9, 1.8% reported 10 to 15, and 0.9% reported >16 partners. Male partners were reported by 91.7%, female partners by 1.8%, and both sexes by 6.5%. Women reported high risk behavior: 38.6% and 59.2% having new or multiple partners, respectively, in last 90 days; 13.0% used condoms consistently; 79.3% reported oral sex, 31.2% reported anal sex, and 52.1% reported drinking before sex. Nonconsensual sex was reported by 22.5%. Most women (69.6%) reported a pelvic examination within the year; 3.1% reported a history of pelvic inflammatory disease (PID). Previous STDs were common, with 55.0% reporting a STD history and 39.5% having had chlamydia.
Overall, 62.2% reported ≥1 symptom, which was associated with chlamydia (P = 0.02). Discharge (47.8%) was associated with chlamydia (P = 0.02). Also associated with chlamydia was pain during intercourse (15.4%) (P = 0.08) and abnormal vaginal bleeding (6.9%), (P = 0.01). Neither lower abdominal pain (17.2%) (P = 0.73) nor pain during urination (6.1%) (P = 0.13) was chlamydia associated. Of chlamydia infected women, 96.5% were treated; 1.3% of the women were gonorrhea infected; all were treated. Of trichomonas tests for 496 women, 7.5% were positive; all were treated. Questions about socioeconomic status were available for 562 women; 42.7% reported high school education, 62.6% had insurance, and most incomes were $10,000 to 50,000 (Table 1).
Results of the logistic regression model indicated that factors independently associated with being chlamydia positive included age <25 years. (OR: 3.4), black race (OR: 3.4), and new partner (OR: 1.7) (Table 2). Almost 91% preferred to collect a their own specimen and 94.5% thought the swab was safe (Table 3). For sampling, 48.8% preferred vaginal swab, 11.5% preferred swab or urine, and 20.7% preferred pelvic exams. For collection ease, 96.7% rated collection easy/very easy (Table 3), 91.7% stated they would use the Internet program again, and by questionnaire 10.6% had used it previously (Table 3). Many participants found the program by “surfing-the-Internet” (30.1%), while 34.4% heard it by radio (Table 3). Preference for receiving results (N = 1179) included: 35.5%, e-mail; 9.8%, Internet; 32.0%, US mail; 32.7%, an 800 number; and 32.7%, listed phone call (>1 answer possible). Website data indicated from January to May, 2008, there were an average of 499,248 “hits”/month, with “sessions” averaging 3043/month, or ∼100 sessions/d. Educational STD pages have been added to the website, including gonorrhea, trichomonas, human papillomavirus (HPV), herpes simplex-2 virus (HSV2), syphilis, bacterial vaginosis, and HIV.
Similar to our earlier manuscript,10 this report of the expanded Internet program continues to support the concept of an educational STD website that encourages self sampling at home and sending specimens to a laboratory. Prevalence was high for young women: for those <20 years, 15.3% were chlamydia infected. The program attracted young women; 59% were <25 years and >77% were <30 years. Young women often report fear of doctors and pelvic examinations, concerns with privacy, stigma, and embarrassment at attending STD clinics13–15 may not seek care for STDs,16,17 or not know of chlamydia screening recommendations for sexually active young women. Provision of a confidential home collection method, may augment routine clinical care for chlamydia. Almost all women used Internet-linked e-mail to request a kit, supporting a preference for “Internet ordering,” in concert with the comfort of young adults with the Internet. The addition of more website STD educational pages may further enhance knowledge of participants about increasing rates of several STDs.
Self-collected vaginal swabs for the diagnosis of chlamydia are accurate, acceptable, and their use has been sanctioned by policy makers.18–28 Our findings support the premise that self-collected vaginal swabs are acceptable to women. This study found that previously demonstrated risk factors for chlamydia, such as race, age, and new partners, remained significant characteristics of Internet users as well.29–33 More than half of women reported a previous STD, but viral infections (HSV2 and HPV) were reported less frequently. This may be because screening for HSV and HPV is not routinely performed, however research has indicated these viral infections are highly prevalent.34,35 Interestingly, 2.1% reported being HIV-positive.
Since previous chlamydia infection is associated with increased risk of being reinfected,36,37 Centers for Disease Control and Prevention recommends rescreening of previously infected women.12,38 This recommendation could be accomplished by Internet-recruitment of previously infected individuals using automated Internet e-mail reminders. In our data, more than 10% of 348 women reported reuse of this website, supporting this concept, but validation is required.
Income and insurance coverage information may indicate that it is not lack of financial support that motivates women to seek nonclinic testing, but rather issues of privacy and stigma.11,36 Many women indicated that e-mail was a preferred method for receiving results; US mail and phone were commonly listed, thus indicating several methods were acceptable. Funding could allow cost-saving Internet reporting by secure password protection, especially for negative results (majority). Many women learned of the website from a popular radio station, recommended by our focus groups.11 Other ways for finding the website included “surfing the web” (30%), whereas 12% reported being told by a friend, indicating important tools for effective health communications.
Limitations to this study exist. Since all information was self-reported, there is possibility of recall bias and lack of veracity. Submission of samples was self-motivated, and women may have participated because of symptoms, rather than after learning about the asymptomatic nature of chlamydia, and thus, the prevalence may be overestimated. However, the fact that women would submit vaginal swabs via Internet recruitment merits further study. We recommend that Internet recruitment be extended to other areas of the country in order to validate our results. The limitation of having to call or contact approximately 60% of the women with their results and nonreturned kits raises a cost issue. A cost analysis is planned and could point the way for web implementation methods that might be more cost-effective.
Women exhibited high acceptability and high prevalence. Taking advantage of expanding services offered by the Internet with home collection may provide new outreach screening tools. Even home-testing for chlamydia with point-of-care-tests may be within our reach. Focus groups have indicated the need to “normalize” chlamydia testing, favoring home testing.11,13,36 Translational research could identify ways to better implement this type of program into public health practice and into wider geographical areas.
1. Tietz A, Davies SC, Moran JS. Guide to sexually transmitted disease resources on the Internet. Clin Inf Dis 2004; 38:1304–1310.
2. Mitka M. Internet seen as clinical research tool. JAMA 2005; 294:2290–2291.
3. McFarlane M, Bull SS, Rietmeijer CA. The Internet as a newly emerging risk environment for sexually transmitted diseases. JAMA 2000; 284:443–446.
4. McFarlane M, Bull SS, Rietmeijer CA. Young adults on the Internet: Risk behaviors for sexually transmitted diseases and HIV(1). J Adol Health 2002; 31:11–16.
5. McFarlane M, Bull SS, Rietmeijer CA. Women, the Internet, and sexually transmitted infections. J Women’s Health (Larchmt) 2004; 13:689–694.
6. Rietmeijer CA, Bull SS, McFarlane M. Sex and the Internet. AIDS 2001; 15:1433–1434.
9. MacFarlane M, Kachur R, Klausner JD, et al. Internet-based health promotion and disease control in the 8 cities: Successes, barriers, and future plans. Sex Tansmit Dis
. 2005; (suppl):S60–S64.
10. Gaydos CA, Dwyer K, Barnes M, et al. Internet-based screening for Chlamydia trachomatis
to reach non-clinic populations with mailed self-administered vaginal swabs. Sex Tansmit Dis 2006; 33:451–457.
11. Gaydos CA, Rizzo-Price PA, Barnes M, et al. The use of focus groups to design an Internet-based program for Chlamydia screening with self-administered vaginal swabs: What women want? Sex Health 2006; 3:209–215.
12. Centers for Disease Control and Prevention. Sexually transmitted disease treatment guidelines. MMWR 2006; 55(RR-11):1–100. Available at: www.cdc.gov/std/treatment/2006/rr5511.pdf
. Accessed February 28, 2007. CDC 2007.
13. Blake DR, Kearney MH, Oakes JM, et al. Improving Participation in Chlamydia Screening Programs. Arch Pediatr Adolesc Med 2003; 157:523–529.
14. ACOG Committee Opinion. Sexually transmitted diseases in adolescents. Obstet Gynecol 2004; 104:891–889.
15. Millstein SG, Adler NE, Irwin CE Jr. Sources of anxiety about pelvic examinations among adolescent females. J Adolesc Health Care 1984; 5:105–111.
16. Lane MA, McCright J, Garrett K, et al. Features of sexually transmitted diseases services important to African Am adolescents. Arch Pediatr Adolesc Med 1999; 153:829–833.
17. Freed LH, Ellen JM, Irwin CE, et al. Determinants of adolescents’ satisfaction with health care providers and intentions to keep follow-up appointments. J Adol Health 1998; 22:475–479.
18. Rompalo AM, Gaydos CA, Shah N, et al. Evaluation of use of a single intravaginal swab to detect multiple sexually transmitted infections in active-duty military women. Clin Inf Dis 2001; 33:1455–1461.
19. Schachter J, Chernesky MA, Willis DE, et al. Vaginal swabs are the specimens of choice when screening for Chlamydia trachomatis
and Neisseria gonorrhoeae
: Results from a multicenter evaluation of the APTIMA assays for both infections. Sex Transmit Dis 2005; 32:725–728.
20. Gray RH, Wawer MJ, Girdner J, et al. Use of self-collected vaginal swabs for detection of Chlamydia trachomatis
infection. Sex Transm Dis 1998; 25:450.
21. Wiesenfeld HC, Lowry DLB, Heine RP, et al. Self-collection of vaginal swabs for the detection of Chlamydia, gonorrhea, and trichomonas. Sex Transm Dis 2001; 28:321–325.
22. Newman SB, Nelson MB, Gaydos CA, et al. Female prisoners’ preference of collection methods for testing for Chlamydia trachomatis
and Neisseria gonorrhoeae
infection. Sex Transm Dis 2003; 30:306–309.
23. Schachter J, McCormick WM, Chernesky MA, et al. Vaginal swabs are appropriate specimens for diagnosis of genital tract infection with Chalmydia trachomatis
. J Clin Microbiol 2003; 41:3784–3789.
24. Shafer MA, Moncada J, Boyer CB, et al. Comparing first-void urine specimens, self-collected vaginal swabs, and endocervical specimens to detect Chlamydia trachomatis
and Neisseria gonorrhoeae
by a nucleic acid amplification test. J Clin Microbiol
25. Hsieh Y-H, Howell MR, Gaydos JC, et al. Preference among female army recruits for use of self-administered vaginal swabs or urine to screen for Chlamydia trachomatis
genital infections. Sex Transmit Dis 2003; 30:769–773.
26. Richardson E, Sellers JW, Mackinnon S, et al. Prevalence of Chlamydia trachomatis
infections and specimen collection preference among women, using self-collected vaginal swabs in community settings. Sex Transmit Dis 2003; 30:880–885.
27. Chernesky MA, Hook III EW, Martin DH, et al. Women find it easy and prefer to collect their own vaginal swabs to diagnose Chlamydia trachomatis
or Neisseria gonorrhoeae
infections. Sex Transmit Dis 2005; 32:729–733.
28. Hoebe CJPA, Rademaker CW, Brouwers EEHG, et al. Acceptibility of self-taken vaginal swabs and first-catch urine samples for the diagnosis of urogenital Chlamydia trachomatis
and Neisseria gonorrhoeae
with an amplified DNA assay in young women attending a public health sexually transmitted disease clinic. Sex Transmit Dis 2006; 33:491–495.
29. Mosure DJ, Berman S, Kleinbaum D, et al. Predictors of Chlamydia trachomatis
infection among female adolescents: A longitudinal analysis. Am J Epidemiol 1996; 144:997–1003.
30. Gaydos CA, Howell MR, Pare B, et al. Chlamydia trachomatis
infections in female military recruits. N Engl J Med 1998; 339:739–744.
31. Gaydos CA, Howell MR, Quinn JC, et al. Sustained high prevalence of Chlamydia trachomatis
infections in female army recruits. Sex Transm Dis 2003; 30:539–544.
32. Miller WC, Ford CA, Morris M, et al. Prevalence of chlamydial and gonococcal infections among young adults in the United States. JAMA 2004; 291:2229–2236.
33. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance Supplement 2003, Chlamydia Prevalence Monitoring Project. US Department of Health and Human Services, Centers for Disease Control and Prevention, October 2004. 1–17. 2004.
34. Xu F, Sternberg MR, Kottiri BJ, et al. Trends in herpes simplex virus type 1 and type 2 seroprevalence in the United States. JAMA 2006; 296:964–973.
35. Manhart LE, Holmes KK, Koutsky LA, et al. Human papillomavirus infection among sexually active young women in the United States: Implications for developing a vaccination strategy. Sex Tansmit Dis 2008; 33:508.
36. Rose SB, Smith MC, lawton BA. “If everyone does it, it’s not a big deal.” Young people talk about chlamydia testing. N Z Med J. 2008; 121:33–42.
37. Gaydos CA, Wright C, Wood BJ, et al. Chlamydia trachomatis
reinfection rates among female adolescents seeking rescreening in school-based health centers. Sex Tansmit Dis 2008; 35:233–237.
© Copyright 2009 American Sexually Transmitted Diseases Association
38. Centers for Disease Control and Prevention. Screening tests to detect Chlamydia trachomatis
and Neisseria gonorrhoeae
infections–2002. MMWR 2002; 51(RR-15):1–38.