A Deep Dive into the Dean Street Express Clinic Model for Quick Anonymous STI Self-testing

"The theme of this year's conference is transcending barriers and creating opportunities," said Cornelis (Kees) Rietmeijer, MD, PhD, at the opening plenary session of the Centers for Disease Control and Prevention 2016 STD Prevention Conference on September 20, 2016 in Atlanta, Georgia.

"One of the big barriers, one of the big challenges … is how to integrate high-impact HIV prevention with the delivery of high-quality STD services. … STD programs in clinics play a very important role in HIV prevention. They diagnose a disproportionate number of HIV-infected persons and link them to HIV care, and they identify those who are at highest risk for HIV infection and would benefit from PEP (post-exposure prophylaxis) and PrEP (pre-exposure prophylaxis)," added Dr. Rietmeijer, professor of community and behavioral health at the Colorado School of Public Health Public Health, Aurora.

New prevention and treatment models are needed worldwide, he said, highlighting the Dean Street Express Clinic in London, England, as a successful high-volume mainly self-service STI-testing clinic that has caught international attention, where clients receive their results through text messaging, usually on the same day. He introduced Dr. Sheena McCormack, MBBS, MSc, FRCP, Dip Ven, of the University College London, Chelsea and Westminster Hospital in London, England, who helped develop and works with the clinic and who gave the Ward Cates Memorial Lecture, "PrEPortunity for STD Control."

"We can transcend barriers. There are really big opportunities at the moment and we need to grab them and take advantage of them," said Dr. McCormack, a clinical epidemiologist who has been coordinating HIV prevention trials since 1994 and has been involved in HIV prevention in Europe and Africa. She was the lead scientist on the PROUD PrEP study in the United Kingdom, which found that daily PrEP was very effective in gay and other men who have sex with men (MSM).

"We've been seeing lots of gonorrhea over the last 5 years and lots of other bacterial STIs in MSM as well. Between 2013 and 2014, chlamydia went up by 26%, gonorrhea by 32% and syphilis by 46%, and we're seeing these figures universally. There has been a change in drugs used around sex. … With them, sex can go on for a long time, and that facilitates the transmission of hepatitis C, lymphogranuloma venereum (LGV), as well as all the other infections."

"In Grindr (grindr.com) and other social apps for gay men and others wanting sex—whatever kind of sex you want, there will be an app for you out there somewhere—you find parties that facilitate condomless sex. In South London, about a third of people who attend these parties only use condoms the whole time, so there is very little risk of transmission there; a third of people are exclusively having sex with HIV-positive concordant partners, so there's no risk of transmission of HIV there; but there is risk of other infections."

"As always with sexual behavior, it's diverse, and that's what makes our jobs interesting," she added.

Who is most at risk of HIV? In the PROUD PrEP study conducted in 13 clinics in the UK, Dr. McCormack and her colleagues found a surprisingly high rate—9% per year—of HIV in patients who were not taking PrEP, even though they had PEP, condom promotion, motivational interviewing, and STI diagnosis and treatment.

"PrEP has had a profound effect on a substantive population of men: an 86% reduction rate in HIV," she said.

"Bacterial infection rates were rising before PrEP, but PrEP may have helped accelerate them. Most of this is fueled by changing social norms, particularly for women as they are increasing the number of partners they have," she told Contagion.

The Dean Street Express Clinic (www.deanstreetexpress.nhs.uk) at 34 Dean Street in Soho in central London, sponsored by the City of Westminster and the National Health Service (NIH), opened in September 2014 and it was immediately fully booked.

"The drop-in center has come from two pressures," Dr. McCormack told Contagion. "One, we knew that we had to increase throughput, and two, we had no clear increase in our budget to do this. And we were diagnosing so much HIV in our patients. It's about location, location, location. We were right in the middle of a massive gay scene and we could not cope with the HIV that we were seeing and treating in the clinic along with the asymptomatics. So we had to move what we could from the clinic to another venue."

"Moving out self-screening was the obvious choice. You don't need a doctor to do this. You don't really even need a nurse. People can do this themselves very well. And they really like it," she said.

The providers were also under pressure to make visiting the busy sexual health testing and treatment clinic acceptable, and they created an efficient yet attractive relaxing space. The façade has no signage advertising it as a sexual health clinic. "We want to make the educational facts fun and acceptable, and people love it. It doesn't feel like going to sexual health clinic," Dr. McCormack told Contagion. "One person said, 'I really thought that a waiter was going to come with cocktails and canapés.'"

Dean Street Express offers free confidential routine sexual health screening tests for STI/STD and HIV six days a week to people who without symptoms. Clients reserve a time slot online, provide a cellphone number, receive an SMS text message confirmation, and show that message to a staff member when they arrive at the clinic. They check themselves in on an iPad to avoid transcription errors; and messages, including lab tests, are texted to the phone.

A video (https://www.youtube.com/watch?v=q0X9QpWyRkA) shows them how to take a throat, vaginal or anal swab, to urinate into a container, and they send their samples through a pneumatic tube to the lab. Most results are processed in about an hour and most people receive all their results within 6 hours.

A blood test for HIV provides results in 60 seconds and is the one interaction with a trained health care provider who has seen the person's history and can provide information and advice about safe sex and clean needles and provide condoms. Some labs take about six hours to come back and those results are also texted to the cellphone.

"The person receives results for syphilis, hepatitis, gonorrhea, and chlamydia," Dr. McCormack said.

People who would like to receive emergency contraception, a 28-day regimen of PEP to prevent HIV infection after risky sex, or be seen for genital blisters or penile discharge, or if they have had sex with someone with gonorrhea, chlamydia, syphilis, or LGV, can make an appointment to see a health care professional, usually on the same day, at the free sexual health and HIV clinic down the street at 56 Dean Street (www.dean.st).

"At least 92% of people are treated within a week, whereas before the express, only 18% would be treated within a week. This reduces the community infectious time, which is a key goal," Dr. McCormack said.

Public Health England recommends that gay men should have routine tests every three months if they regularly have unprotected sex with new partners; and if they don't, they should be tested for HIV at least once a year.

"There is a high burden of STI's in HIV-positive population," Dr. McCormack said. "For HIV, we see people every six months."

Several websites help Dean Street's clients learn and take action:

• The 56 Dean Street clinic coordinates messages with PrEPster (www.prepster.info), whose mission is to promote PrEP access. "Being at risk for HIV is a period you go through. PrEP is not something you take for life, unlike HIV treatment. And we need to get that message across," Dr. McCormack said.
• They also direct people to I Want PrEP Now (www.iwantprepnow.co.uk ) to buy generic PrEP that the staff monitors for quality from online pharmacies in other countries, which is much less expensive than buying through the National Health Service (£40 vs £400 per month).
• Gay men living in Greater London can receive at-home finger-prick HIV test kits by mail through Dean Street at Home (http://www.deanstreetathome.com/) and receive their results by text or phone call. Men who test positive are referred to 56 Dean Street for help.
• The Dean Street Wellbeing Programme (www.community.dean.st) includes art exhibits, movies, community discussions, performance art and other events, and talk therapy and support groups at 56 Dean Street and other venues.
• The Dean Street Express Clinic uses social media and Facebook (https://www.facebook.com/deanstexpress) to share timely messages about sexual health. "A video of Prince Harry's fingerprick HIV test was viewed by 2.8 million people on Facebook and picked up by The Sun newspaper, which has very high readership," Dr. McCormick noted.

"How do you change your clinic?" Dr. McCormack asked the audience. "You need to create standards for the staff, especially with your business manager. Let them all own the change. Once you have the plan your staff is happy, check with your service users. Are clients happy to receive your services by text? Is it private enough? Harness technology, even if it feels strange."

Send symptomatic patients to the highest level of staff and have the simpler work done by staff who are paid less. Have the users take their own history, which avoids transcription errors.

Always pilot the change. Have a goal and reward your staff for performance. "Every month we award a £20 voucher. And at every Christmas party, we have staff-nominated Golden Swab Awards in ridiculous categories—it's a great honor to receive a Golden Swab Award."

"It's really difficult to shift social norms," Dr. McCormack noted. "Antibiotic resistance is definitely a potential threat but resistance to change is the greater threat."

"What I love about PrEP is that it's an incentive to bring people into the clinic we may not have seen before and an incentive to engage them in regular testing. It's definitely going to stop HIV increasing at the same rate as the other STIs go up, and it's an opportunity that you cannot ignore. It's an opportunity that Ward Cates would not want you to ignore."

The Ward Cates Memorial Lecture was given to honor Dr. Willard (Ward) Cates Jr., MD, MPH, former CDC epidemiologist who became the agency's director of the Division of Sexually Transmitted Diseases. At the time of his death in March 2016, he was the president emeritus of research at Family Health International (now FHI 360).

Lorraine L. Janeczko, MPH, is a medical science writer who creates news, continuing medical education and feature content in a wide range of specialties for clinicians, researchers and other readers. She has completed a Master of Public Health degree through the Department of Epidemiology of the Johns Hopkins Bloomberg School of Public Health and a Dana Postdoctoral Fellowship in Preventive Public Health Ophthalmology from the Wilmer Eye Institute, the Johns Hopkins University School of Medicine and the Bloomberg School.

DISCLOSURES: Gilead supported all the trials by supplying free drug and a grant for diagnostics and start-up costs of the pilot phase of the PROUD study.

SOURCES:

• 2016 CDC STD Prevention Conference p 52 (https://www.cdc.gov/stdconference/2016/STD_Conference_2016_Program_Book.pdf)
• Audio recording, slides from McCormack's talk and in-person interview

Quotes: audio recording and interview