To assess the feasibility of testing indoor commercial sex workers (CSW) for Chlamydia trachomatis and Neisseria gonorrhoeae in an outreach setting. All CSW seen on outreach over a 6-week period were offered self-taken vulval swabs for chlamydia and gonorrhoea testing. Feasibility was assessed by all the outreach workers on a standardised proforma. Of the 93 women offered the service, 40 accepted, of whom five (12%) had not previously accessed sexual health services. The majority of women declining the service had recently attended a sexual health clinic. Three cases of chlamydia and one of gonorrhoea were diagnosed. The cost per sexually transmitted infection (STI) was £392.50. Most of this group of women were knowledgeable about sexual health and were already having regular check-ups, but a significant minority did not know how to access STI care. Offering STI testing on outreach was feasible and cost effective.
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The prevalence of sexually transmitted infections (STI) among commercial sex workers (CSW) in the UK is reportedly declining,1 although a group of CSW do not attend STI services.2 Outreach targets this group.3 Open Doors is a women’s health project offering a range of services to CSW in East London, including outreach and specialist genitourinary medicine clinics. This study aims to assess the feasibility of testing CSW for Chlamydia trachomatis and Neisseria gonorrhoeae in an outreach setting.
Between 1 June 2007 and 14 July 2007 a dedicated STI outreach testing team offered CSW vulval swabs for chlamydia and gonorrhoea using the Becton Dickinson ProbeTec (Oxford, UK). Written information in a range of languages was provided. Data recorded on a standardised proforma included contact details, STI testing history and outreach environment. CSW diagnosed with STI were advised to attend STI clinics for further testing and treatment. When this was impossible, the outreach team provided treatment under a patient group directive.
The cost of the service was calculated as: hourly salary of outreach team × (number of hours spent providing tests + number of hours providing results and treatment) + (cost of tests).
Guidance was sought from East London and the City Research Ethics Committee who considered this to be an evaluation of a service provision.
Ninety-three women were offered the test, of whom 40 (43%) accepted the service. The reasons why women declined the service are listed in table 1.
Of the 40 tests that were taken, three (8%) were positive or equivocal for C trachomatis and one for gonorrhoea (3%).
Proformas noted the disruptive environment, although seven commented that the communal aspect was on occasion supportive to the CSW. Language issues came up on nearly half the proformas. Some of the researchers were able to communicate in different languages. Leaflets in a range of languages were available on a palm pilot and interpreter services were available over the telephone via Language Line.
Four women mentioned the difficulty of attending a STI clinic because of work schedule. Five of the women had not had a sexual health check-up in this country as they did not know how to access services in the UK. Three other women did not access sexual health services as they had previous bad experiences in healthcare settings.
Contacting the clients with positive STI results required a number of attempts and methods but was achieved in all cases.
A total of 74 staff hours was spent delivering this service, 60 h delivering the tests and 14 h checking and communicating the STI results. The hourly salary of the staff was £15. The cost of the STI tests was £11.50 per test. The cost of diagnosing the four STI was £15 × 74 + 40 × £11.50 = £1570 or £392.50 per STI diagnosed.
Some sex workers do not access sexual health services and testing for STI on outreach may help target this group.
Twelve of 40 women tested on outreach would not have gone to an STI clinic. The main reason for declining testing was having already accessed sexual health services.
Four of 40 women tested had an STI, which was treated by the outreach team.
Testing sex workers for gonorrhoea and chlamydia on outreach was acceptable, feasible and cost effective.
Of 93 women seen, 46 were identified as having ongoing sexual health needs not met by existing services, of whom 40 accepted STI testing. Three cases of chlamydia and one of gonorrhoea were diagnosed. The cost per STI diagnosed was £392.50.
This is the first UK-based study investigating the feasibility of testing CSW for STI in an outreach setting. Studies in non-UK settings have found the uptake of outreach chlamydia screening among CSW to be 66%4 and the STI prevalence to be 7.4%.5 This is comparable with this study, which had an uptake of 43% and a STI prevalence of 10%.
A lack of appropriate tools to communicate with women who speak no English was demonstrated. Further work aims at improving communication with women who do not understand English.
Four out of 40 tests (10%) yielded an STI. This prevalence was slightly lower than the 11–15% seen in audits of CSW at specific clinics in East London (unpublished data). Two decades of harm reduction outreach projects may have contributed to these low rates. These data seem at odds with other data published about CSW in East London, which show an extremely high prevalence of STI among CSW.6 7 However, those studies focused on street CSW, whereas this new work focuses on indoor workers, who may be more likely to have been screened for infection.8 We were unable to provide this service directly to street sex workers, although nocturnal outreach to street sex workers does direct them to a drop-in service the following day where sexual health screening is provided.
The cost per STI diagnosed was £392.50, which should be interpreted in the light of the finding that selective chlamydia screening has been estimated to save £538 per case identified.9
This study did not look at STI other than chlamydia and gonorrhoea and cannot comment on the prevalence of STI among CSW. It was a feasibility study and did not address the issue of acceptability. Over half the women declined STI screening, mainly because they had recently had a sexual health check-up or were booked to have one soon. Of the 40 women accepting the service, five (12%) were not accessing services for a variety of reasons. Offering this service led on to further discussions about sexual health.
This study demonstrates that it is feasible and cost effective to provide sexual health services on outreach. Future work will include testing for chlamydia, gonorrhoea, trichomonas, HIV and syphilis and hepatitis B vaccination on outreach.
Competing interests: None.
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