Repeat testing for chlamydia trachomatis, a “safe approach” to unsafe sex? a qualitative exploration among youth in Stockholm

Nielsen et al. BMC Health Services Research (2017) 17:730 DOI 10.1186/s12913-017-2681-6 RESEARCH ARTICLE Open Access Repeat testing for chlamydia trachomatis, a “safe approach” to unsafe sex? a qualitative exploration among youth in Stockholm Anna Nielsen1* , Ayesha De Costa2, Kristina Gemzell Danielsson1 and Mariano Salazar2 Abstract Background: Chlamydia trachomatis testing is offered to youth in Sweden, through a network of Youth Health Clinics, free at the point of care, in an attempt to bring down the prevalence and incidence of the infection. Nevertheless, infections rates have continued to rise during the past two decades and re-testing rates among youth for Chlamydia trachomatis has been reported to be high in Stockholm County. A few literature reports suggest that testing for sexually transmitted infections and the test result itself can have an undesirable impact on the sexual behaviour for the individual, i.e. increase sexual risk-taking. Methods: This qualitative study aimed to explore the motives for repeated testing for Chlamydia trachomatis among youth using the services of the Youth Health Clinics in Stockholm, and how testing affects their subsequent risk-taking. We interviewed 15 repeat testers aging 18–22 years. Results: Our main findings were that the fear of social stigma related to infecting a peer was a major driver of the re-testing process. The repetitive testing process, the test result, and the encounter with personnel did not decrease sexual risk-taking among this group. Conclusions: While testing and treatment services are an important part of Chlamydia trachomatis prevention it must not take the focus away from primary prevention strategies. Testing should be encouraged, but not to the exclusion of risk reduction measures. The testing services must be complemented with stronger emphasis on safe sex, especially for those who attend the clinics repeatedly, otherwise the easy accessible testing services risk counteracting its own purpose. Future research should focus on developing and evaluating youth appropriate interventions to increase condom use, taking into consideration factors which youth perceive as important to drive this behaviour change. Keywords: Chlamydia trachomatis, Youth, Repeat testing, Stigma, Sexual health, Sweden, Sexual behaviour, Health care utilization Background Chlamydia trachomatis (C.trachomatis) is the most commonly reported sexually transmitted infection (STI) in Sweden and worldwide, most commonly affecting young adults [1, 2]. In an attempt to control the epidemic, several countries have introduced population-based screening programs or opportunistic screening programs [1]. * Correspondence: 1 Department of Women′s and Children′s Health K6, Karolinska University Hospital Solna, 17176 Stockholm, Sweden Full list of author information is available at the end of the article In Sweden, an opportunistic screening approach, which began in the 1980s, is available across the country [3]. The most effective way to tackle the epidemic of C.trachomatis is still being debated, and different guidelines on C.trachomatis screening exist in different settings [4]. For example, in the United States re-testing for C.trachomatis 3 months after diagnosis is recommended, [5]. In the United Kingdom, the National C.trachomatis Screening Program aims to test people under the age of 25 once a year [6]. The Swedish opportunistic screening program has been held up as a model program [7]. Approximately © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Nielsen et al. BMC Health Services Research (2017) 17:730 500,000 C.trachomatis tests are performed in the country per year (2011–2015) with an overall positivity rate of six to 7 % [2]. Women account for 57% of all reported cases. The median age for infected individuals is 22 years for women and 24 years for men [2]. Guided by national laws and regulations [8, 9], regional policies control the preventive work in the different County Councils in Sweden [10]. Repeat testing after an infection is not official policy in Stockholm County [10]. Nevertheless, repeated testing for C.trachomatis is relatively common behaviour among youth living in Stockholm County. In a recent study, we found that 42% of youth using the testing services at the Youth Health Clinics (YHC) in Stockholm re-tested for C.trachomatis during a 3 year period [11]. The repeat testers in our study tested between two to 19 times over the study period [11]. Re-testing was associated with being female, a previous positive test and living in a high- or middleincome area of Stockholm. Furthermore, we found high rates of C.trachomatis among repeat testers both at baseline and at repeat tests which suggests the possibility that this group might be continuing to engage in unsafe sexual practices [11]. However, the reasons for repeat C.trachomatis testing on an individual level are still unknown. There is some evidence in the literature which suggests that a positive test result for a STI might affect sexual risk taking promoting a more protective disposition, at least in the short term [12, 13]. A negative STI test result, on the other hand, seems to have no effect on subsequent risk taking [12]. Studies focusing on HIV testing indicate that a negative test result can have an undesirable effect on behavioral changes, i.e. adopting more risky sexual practices [14–17]. Re-testing for C. trachomatis can have positive consequences for people and the society; i.e. positive cases are detected and treated. Thus, comprehensive testing services are therefore important. However, re-testing can also have negative consequences for health systems and individuals. For individuals, repeated testing might be a consequence of continuous risky sexual behaviour that exposes them not only to C.trachomatis infections but to other more serious infections such as gonorrhoea, HPV, syphilis, and HIV. For health systems, repeated testing without long term behavioural change might not reduce C.trachomatis incidence and therefore can result in an inefficient use of resources. In addition, repeated infections and subsequent antibiotic use contributes to increase antibiotic resistance in this population [18]. Evidence from Sweden has shown that C.trachomatis testing services are repeatedly used by a proportion young adults [11], who, in spite of their constant exposure to testing services, continue to ex (...truncated)