STD testing and at home STD test options

Sexually transmitted diseases (STDs) also referred to as sexually transmitted infections (STIs) or 'venereal diseases', are more common than most realise. In fact, the World Health Organisation estimates that more than 1 million infections are acquired daily across the globe¹.

With this rate of infection, one may be inclined to think that regular STD testing would be part of normal healthcare screening protocols, however, this is not always practical. As such, the focus for screening is usually placed on high risk groups in many parts of the world. This means that in order to be proactive about your sexual health (even if you've only had one partner) or if you're worried about having potentially been exposed to an STD, it is often necessary to request an STD test at a health clinic or during a medical consultation or, if you prefer to ensure 100% anonymity, to order a home STD test online.

Most people think that they would know if they had a sexually transmitted disease, however, this is not always the case largely due to the fact that not all STDs show signs or symptoms immediately. While some, like genital herpes may develop symptoms within days, others can take weeks, months or even years to become evident.

In addition, some symptoms may be mild and not immediately associated with an STD. By the time symptoms are evident, cause complications and are diagnosed, the disease in question may have been spread to any sexual partner/s an infected person has had, without anyone being the wiser.

STD testing may be ordered if symptoms of a sexually transmitted disease/infection develop, if a person fears that he/she may have come into contact with an STD via sexual intercourse with an infected person, or as part of routine screening in certain high risk population groups.

Common STDs

The most commonly contracted STDs include:

• Human Papillomavirus (HPV): This highly contagious infection is easily transmitted through skin-to-skin and sexual contact. Certain strains are considered high risk (HPV 16 and 18) as these cause 70% of cervical cancers and those that are considered lower risk strains (like HVP 6 and 11) cause approximately 90% of genital warts (although these don't appear in everyone with the virus)² . Genital warts can usually be diagnosed upon examination, but additional testing may be helpful in some instances and may include a biopsy (a procedure in which a sample of tissue is taken) or colposcopy (a procedure to examine a woman's vagina, vulva and cervix for signs of disease).
• Hepatitis B & Hepatitis C: Hepatitis B and C are viral infections. Hepatitis B (HBV) is transmitted through contact with infected blood and in semen during sexual intercourse. Hepatitis C is usually spread through blood or skin exposure (for example when sharing needles during drug abuse or coming into contact with an open wound of an infected person). In rare instances, Hepatitis C may be sexually transmitted.
• Gonorrhea (also spelled Gonorrhoea and referred to as 'the clap' or 'the drip') and Chlamydia: These common STDs are transmitted through all forms of sexual contact with an infected person. A mother may also pass these infections to a child during childbirth as it passes through the birth canal. The two are usually screened for simultaneously. Testing is useful as the bacteria that cause these infections doesn't always result in symptoms.
• Syphilis: This bacterial infection is transmitted through sexual (oral, genital or anal) contact with an infected person. The initial stages of a syphilis infection are characterised by infectious, painless sores, known as chancres which can occur in, on or around the genitals, anus and mouth. Pregnant women can also transmit the infection to their unborn child as the infection can cross the placenta into the womb.
• Herpes: The herpes virus occurs in two strains, type 1 herpes is generally associated with cold sores, and type 2 with genital herpes. One may be infected with either strain of the herpes virus and not show symptoms or may experience painful outbreaks of sores around the mouth, genitals or anus. The virus is usually transmitted through contact with the infectious sores, but it is also possible for it to be spread when no symptoms are present. A pregnant woman who has genital herpes present at the time of delivery may infect her child as it passes through the birth canal, resulting in neonatal herpes.
• Trichomoniasis (Trich): This common STD is the result of an infection with a parasite, Trichomonas vaginalis, during sexual intercourse. It is estimated that only 30% of infected people develop symptoms. When symptoms do occur, they usually present as mild to severe inflammation accompanied by itching and irritation of the genitals, burning during urination and/or vaginal or penile discharge.
• HIV/AIDS: HIV is a viral infection that may be transmitted via blood or during sexual intercourse. In pregnant women it can cross the placenta and infect an unborn child or may infect a baby during delivery. Flu-like symptoms (headache and fever) and a rash may occur a few weeks after infection, but often an infected person is asymptomatic until the disease progresses to AIDS. This may take 10 years or longer³.

What is an STD test?

An STD test, as the name implies, is a laboratory test that determines the presence of a sexually transmitted disease/infection.

These tests may require a sample of urine, blood and/or anal and genital secretions, depending on the STD being tested for.

STD testing goals

Untreated sexually transmitted diseases may cause a variety of complications, particularly in women, which, depending on the particular disease/infection present, may include^4,5:

• Chronic pelvic pain
• Upper genital tract infections
• Genital neoplasms (tumours in the genital regions)
• Pelvic inflammatory disease (PID)
• Infertility
• Sterility
• Pregnancy complications
• Mother-to-child transmission of the STD (resulting in stillbirth, neonatal death, prematurity, low birth-weight, sepsis, pneumonia, neonatal conjunctivitis and congenital deformities)
• Conjunctivitis (Inflammation of the conjunctiva of the eye/s)
• Arthritis
• Heart disease
• Certain cancers (Human papillomavirus (HPV) associated cervical and rectal cancers as well as penile cancer in men)
• Increased risk of HIV transmission

The early treatment of STIs/STDs can prevent these types of complications. As such the goals of STD testing are twofold:

1. To identify and treat those with infections before complications arise.
2. To identify, test and treat any of the infected person's sexual partner/s in order to prevent transmission of the disease and reinfections.

When to get an STD test

It may seem like the most efficient way to test for STDs is to just 'test for everything'. While this is possible, it is best to consult with a doctor about one's specific risks and lifestyle factors that may lead to an infection as there are some downsides to testing for everything, namely:

• Tests can be expensive
• Some tests, especially blood tests when screening for herpes, can give false positives which may cause unnecessary anxiety and relationship issues.

There is no specific rule for how often one should have an STD test. If an STD test is requested, a doctor will generally determine when a re-evaluation is required based on the individual's lifestyle and risk factors. In those who test positive for an STD, more frequent testing will be required, while in those with previously negative tests, changes in lifestyle factors (such as moving from a monogamous, long-term relationship to being single and sexually active) may prompt more regular screening.

STD testing is advisable if one:

• Has symptoms: If any signs or symptoms of an STD are noted, this should be discussed with a healthcare practitioner who will then recommend the appropriate test/s. While this may seem like an embarrassing issue to discuss, let alone be physically examined for, medical professionals see many STD cases on a regular basis (remember, millions of people suffer from them) and are trained to deal with them. Avoiding momentary embarrassment by putting off a consultation is not worth suffering potentially damaging long-term health complications.
• Has had an STD before: Those who are sexually active and have previously been diagnosed with an STD/STI should be screened approximately 3 months after treatment has ceased.
• Is sexually active: Anyone who is sexually active should undergo STD screening (even if only one has only had a single partner and uses protection). HIV should be done as a standard test and women may wish to be tested for gonorrhoea and chlamydia as, unlike in men, these infections may be present without the development of symptoms.
• Is entering into a new sexual relationship: Even when engaging in protected sex, accidental condom breakage may lead to STD exposure. As such, prior to commencing a new sexual relationship it is important for sexual partners to discuss their STD status, and both get tested as a precautionary measure. Again, it is important to remember that those with STDs do not always have symptoms and getting tested is often the only way to know one's status.
• Engages in unprotected sex: If one has or plans to have any type of sexual intercourse (oral, vaginal or anal) with a new partner, it's advisable to be tested for STDs.
• Is involved in a risky relationship: If one's partner has a diagnosed sexually transmitted disease like HIV or hepatitis B or C or if one is in an open relationship or isn't completely sure that one's partner is faithful regular STD screening is advised.
• Is involved in high-risk sexual behaviour: This includes those involved in sex work, men who have sex with men, those who have casual sex with multiple partners, as well as those who are IV drug users. In these instances, one is at greater risk of being exposed to HIV, Hepatitis C, syphilis, chlamydia and gonorrhoea. Testing after high risk contact is often advised.
• Was born between 1945 and 1965⁶: This generation may have been exposed to Hepatitis C either during sexual intercourse or through contaminated blood used in transfusions (before it was recognised as a virus that could be screened for). All people born during this period of time should be screened for Hepatitis C at least once.

Specific STD Routine Screening Medical Guidelines

In general, medical professionals follow the routine screening guidelines outlined in the table below⁷ . Those who do not fall within these groups may be tested at their request, based on the presence of symptoms or lifestyle and risk factors as well as prevalence of specific STDs at the time.

How long after exposure should one get tested for an STD?

Anyone who has engaged in sexual activity and believes that they may have been at risk of being exposed to an STD should be tested. In general, after exposure it will take some time to obtain a reliable STD test result.

While tests for some STDs like gonorrhoea and chlamydia can be done relatively soon after exposure using a highly sensitive urine test, tests that rely on the presence of antibodies that the body produces in response to the infection, instead of the infection itself for diagnosis can’t be conducted until a few weeks after exposure and it may be a few months before a negative result can be trusted.

Timelines for testing after potential exposure to and STD are as follows:

• Gonnorrhea and chlamydia: 2 weeks after exposure.
• Syphilis: 1 week to 3 months after exposure.
• Hepatitis B and Hepatitis C: 6 weeks to 3 months.
• Herpes virus: 5 to 10 days after contact and repeated after 4 – 6 months.
• Trichomoniasis: 5 to 28 days after exposure.
• HIV: 9-11 days after exposure (an HIV RNA test will be required for early detection). Other tests can only be performed 2 – 3 weeks after exposure.

STD tests, when to get them and which samples are required

Samples for STD tests may be collected by the person undergoing an STD test or by a doctor or lab technician.

In general, the following tests and samples are performed for the STDs mentioned in the table below:

At Home STD test

For those who feel mortified at the thought of seeing a medical professional in person regarding a potential infection with an STD, or who want to 'know their STD status' before discussing this with their regular healthcare provider, new generation methods of testing have given rise to a number of at home STD test kit options which are available for purchase online and in some pharmacies and retail stores.

STD panel tests which, depending on the supplier, can be used to test for up to 14 common STDs and individual STD tests can be purchased.

The provider one chooses will depend on the preferred sample collection and testing method, of which there are three available:

1. STD test kit with self-collected sample and results at home

Some STD test kits require the person conducting the test to self-collect the sample and follow the specific test instructions in order to self-administer the test. Results show up within 10 to 20 minutes (depending on the test).

Pros of rapid results self-test kits

• Convenience – These types of tests are easy to obtain online.
• Anonymity – This method of STD testing ensures anonymity.
• Results are rapid – Waiting times are greatly reduced with results in 10 to 20 minutes compared to the 2 to 5 days necessary with laboratory tests.

Cons of rapid results at home STD test kits

• Margins for user error - This method relies heavily on the user's ability to correctly administer the test and results.
• Not the same quality as lab tests - Rapid results test often do not have the same specificity or sensitivity (i.e. the ability to identify the true negative and true positive rate) as laboratory testing.
• Not always completely accurate - False negatives and false positives may occur. Neither is ideal, as a false negative may put one's mind at ease that an STD is not present, when it is and lead to the further spread of the disease and possible health complications due to the fact that the disease is not treated early on. False positives may cause unnecessary anxiety, depression and relationship issues or breakdown, all of which increase the risk of adverse health and mental health complications and in some cases, suicide.
• No medical supervision, support or treatment – These types of STD tests do not come with the medical supervision, interpretation and potential for treatment via consulting medical healthcare professionals that other self-testing options offer. There is also no post-result counselling or advice. This means that if one does test positive, a follow-up medical consultation will be required, and the test will most likely have to be repeated with the sample submitted to a lab. This will mean an additional cost and a waiting period for results to be confirmed and before treatment can begin.

MY MED MEMO: It is extremely important to be aware of the fact that a positive or negative result obtained from these types of tests is not conclusive and does warrant further testing under medical supervision.

2. Self-collection at home STD test kit with lab submission

Some at-home STD test providers provide a kit which allows for the self-collection of sample/s according to a strict set of instructions accompanying the particular STD home test ordered online. Once the sample is collected, it is mailed back to the provider for laboratory analysis.

Test kits with laboratory analysis often offer free telephonic consultations with a doctor who will interpret and explain the test results and, at their discretion, write a prescription for treatment. Other services offer this at an additional cost.

Pros of at-home STD kits with lab sample analysis

• Ease of accessibility and convenience - These STD test/s can be purchased on line with next day delivery.
• Confidentiality – Privacy and complete confidentiality is assured. Some providers allow for complete anonymity.
• Higher accuracy – With samples being analysed in a laboratory, these tests have higher specificity and sensitivity and therefore a more reliable result.
• Access to medical consultation – As mentioned, many services offer a medical consultation once the result has been obtained to interpret the result and offer advice and/or treatment.

Cons of self-test STD kits with lab sample analysis

• Margin for user error: While these tests come with a specific set of detailed instructions on sample collection for the specific STD being screened for, the results may be influenced by the quality of sample collection. It is therefore of utmost importance to follow instructions correctly.

3. Online STD self-test ordering with laboratory collection

Using this option, one orders the desired test/s online and then locates a nearby testing centre and visits when convenient (remaining anonymous is possible). No appointment is necessary, no questions are asked, no paperwork is filled in, a blood or urine sample is collected in minutes and the process is complete.

Regardless of the submission method selected, results are generally available within a few days (generally 1-5 days depending on the STD test/s ordered) and are emailed to the person undergoing testing. This may be followed up with a complimentary medical consultation via phone or e-mail, or this service may be offered at an additional cost.

Pros of online STD test ordering with laboratory collection and analysis

• Ease of accessibility – These STD test/s can be ordered online.
• Convenience – Labs are stationed in many cities around the world and no appointment is required, no paperwork is necessary, and one simply visits after ordering and paying for the test online.
• Anonymity – Even though one has to physically report to a nearby laboratory for sample collection, the purpose of the sample collection is not known to the staff at the facility, and it is possible to remain completely anonymous.
• Removes the margin for untrained user error – Due to the fact that samples for testing are collected in a clinical environment by trained medical personnel, there is a far lower margin for error and contamination of samples.
• Medical consultation and support – Whether included in the test price or offered as an added service, these tests allow for a consultation with a medical professional who will interpret the results and, at their discretion prescribe treatment. There is no need to go elsewhere if this option is available.

Cons of online STD test ordering with laboratory collection and analysis

• Requires a clinic / testing station visit – While these are conveniently located, the test sample collection is not done at home like some others.

Positive STD test results - what next?

In instances where one tests positive for an STD (i.e. a test indicates that a sexually transmitted disease/infection is present), further testing may be required to confirm the diagnosis, especially given the time frame after exposure.

Once a definite diagnosis is confirmed, a doctor will commence a specific treatment regimen according to the STD present.

You can learn about how each STD is treated by following the links below:

• Hepatitis B and Hepatitis C treatment
• Herpes virus (HSV 2) / genital herpes treatment
• Gonnorrhea treatment
• HIV treatment

The doctor in question will generally provide STD counselling to discuss one's personal risk factors and education on how to prevent further infections in future, living with a sexually transmitted disease that cannot be cured (such as HIV), as well as the necessity to inform one's sexual partner/s about the infection.

Depending on the country in which one resides, the doctor may be required to notify the health authorities of certain new sexually transmitted infections. This is often the case with chlamydia, gonorrhoea, syphilis, hepatitis B and C and HIV. In these notifications, the identity of the infected individual will remain strictly confidential.

Notifying sexual partner/s of possible STD Infection

If one is diagnosed with a sexually transmitted disease / infection, one should immediately notify one's current and previous sexual partner/s so that they can get tested and treated. It is important to follow the treating medical professional's advice on abstaining from sexual intercourse for the recommended time period while treatment is taking place.

In some countries like the United States of America, expedited partner therapy (EPT) is available to those with confirmed chlamydial and gonorrhoeal infections. This allows an infected individual to directly approach their sexual partner/s with medications and prescriptions to be fulfilled which helps to treat current infections and prevent recurring ones. One may enquire as to whether similar systems are in place in one's country of residence.

In some countries, health departments undertake to notify an infected person's sexual partners of the possibility of infection on their behalf if required. In these instances, the infected person's name remains highly confidential and is not disclosed to any party.

Tips on notifying a sexual partner of an STD

While it may be extremely uncomfortable to notify a sexual partner that one is infected with an STD, it is important to do so in order for treatment to begin before complications arise. The following tips may be helpful during this type of conversation:

• Remain calm and try not to attribute blame: STDs are common and millions of people have them. An STD is nothing more than a health condition, it does not automatically mean a partner has been unfaithful or that a person is immoral. STD symptoms may not be present or take years to show up, as such, these diseases may have been contracted during a previous committed sexual relationship.
• Know your facts: Learning all one can about the STD one has contracted will help to separate fact from fiction and assist in answering any questions one's partner may have on how it is transmitted and treated and how they can be prevented in future.
• Consider the timing when delivering this information: It is important to inform one's sexual partner of an STD infection as soon as possible. Do so in a private, relaxed atmosphere or, if one is no longer involved with the partner in question, a phone call may be more appropriate. Rehearsing what one will say out loud beforehand is often helpful, as it allows for a calm, confident delivery of this information.
• Be prepared: STDs are a highly sensitive topic for most and hearing the news that one may be infected may illicit an emotional response. Anger and accusations of unfaithfulness may be made. Being prepared for outbursts, remaining calm and explaining the situation as is appropriate to one's personal circumstances is most effective in dealing with these kinds of responses. If one suspects that a partner may react violently to news that he/she may be infected with a sexually transmitted disease, notification via phone, text or e-mail may be a safer and more advisable option.

Rescreening and retesting after an STD

Due to high reinfection rates, those diagnosed with and treated for trichomonas, gonorrhoea and chlamydia should be retested three months after treatment conclusion, or during the first follow-up visit within a year following treatment.

Those with a positive HIV test result will undergo continuous, life-long testing in the ongoing treatment and management of the virus.

References

<sup>1.  Sexually transmitted infections (STIs). Who.int. https://www.who.int/news-room/fact-sheets/detail/sexually-transmitted-infections-(stis). Published 2016. Accessed December 18, 2018.

2. Kari P Braaten M. Human Papillomavirus (HPV), HPV-Related Disease, and the HPV Vaccine. PubMed Central (PMC). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2492590/. Published 2008. Accessed December 18, 2018.

3. The Stages of HIV Infection Understanding HIV/AIDS. AIDSinfo. https://aidsinfo.nih.gov/understanding-hiv-aids/fact-sheets/19/46/the-stages-of-hiv-infection. Published 2018. Accessed December 18, 2018.

4. S G. [Complications of sexually transmitted diseases: clinical course and treatment]. - PubMed - NCBI. Ncbi.nlm.nih.gov. https://www.ncbi.nlm.nih.gov/pubmed/11367920. Published 2000. Accessed December 18, 2018.

5. Low N, Broutet N, Turner R (2017) A Collection on the prevention, diagnosis, and treatment of sexually transmitted infections: Call for research papers. PLoS Med 14(6): e1002333. https://doi.org/10.1371/journal.pmed.1002333

6. Turner B, Taylor B, Hanson J et al. Implementing hospital-based baby boomer hepatitis c virus screening and linkage to care: Strategies, results, and costs. J Hosp Med. 2015;10(8):510-516. doi:10.1002/jhm.2376 

7. California STD screening recommendations 2015. Cdph.ca.gov. https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH%20Document%20Library/CA_STD-Screening-Recs.pdf#search=std%20screening%20recommendations. Published 2015. Accessed December 18, 2018.

8. STD Facts - HPV and Men. Cdc.gov. https://www.cdc.gov/std/hpv/stdfact-hpv-and-men.htm. Published 2017. Accessed December, 2018.

9. Marfatia Y, Dixit R, Bhavsar C. Laboratory diagnosis of human papillomavirus virus infection in female genital tract. Indian J Sex Transm Dis AIDS. 2011;32(1):50. doi:10.4103/0253-7184.81257</sup>