Examining the acceptability of offering STI screening in higher educational settings

Uptake of screening for STIs, such as chlamydia and gonorrhoea, is often inadequate in young people despite provision of open-access sexual health services. Offering STI tests outside medical settings is currently being explored as a way to increase uptake in this group.

In 2017, St George’s University of London ran the ‘Test n Treat’ feasibility trial where free, confidential on-site testing for chlamydia and gonorrhoea was offered to students at six higher-education colleges in South London. We have previously reported on the main results of the trial and the cost estimates of providing such a service .

As part of the trial, the research team wanted to understand the acceptability of this type of service among students as well as the barriers and facilitators to its use. They interviewed a small sample of students, some of whom used the service and some of whom did not, as well teachers and the research team. The results of this qualitative study, which Aquarius Population Health gave advisory support to, were published in August 2020.

The paper reports that students who used the service had a very positive opinion of it. There were a number of barriers to using the service identified, including embarrassment about STI testing and the perceived view that individuals would be viewed negatively by their peers if they had an STI test. On the flip side, peers also acted as facilitators to uptake, for example, if a group of friends encouraged each other to get tested. A lack of understanding of STIs was another major barrier, with many students lacking understanding about the long-term consequences of STIs or having the misconception that only people with symptoms should get tested.  Where a £5 honorarium was given to students using the service, this acted as a legitimate incentive for testing, mitigating the (perceived) social stigma of testing.

The paper concludes that if a similar service were provided in future, uptake could be improved if education about sexual health was offered alongside testing, if small cash incentives were given and if peer influencers were engaged to promote the service.

Fleming, C., Drennan, V.M., Kerry-Barnard, S. et al. Understanding the acceptability, barriers and facilitators for chlamydia and gonorrhoea screening in technical colleges: qualitative process evaluation of the “Test n Treat” trial. BMC Public Health 20, 1212 (2020). https://doi.org/10.1186/s12889-020-09285-1

Cost analysis of near patient chlamydia and gonorrhoea screening and treatment in further education/technical colleges

Aquarius collaborated with St George’s University of London on an NIHR-funded study, ‘Test n Treat’ (TnT). In this cluster randomised feasibility trial, rapid chlamydia (CT) and gonorrhoea (NG) testing and same day on-site chlamydia treatment in six technical colleges in South London was delivered. 

Using process data from the trial (the main results of which were published last year) and NHS cost data, the overall cost of providing the TnT service was calculated, as well as the cost per CT/NG screen and the cost per CT/NG infection diagnosed. These took into account the fixed daily costs, such as staff time and equipment use, and the per screen costs, i.e. the consumables used to collect and test samples, and were dependent on uptake of screening. Since the average cost per screen was higher if uptake was low as per what was observed in the trial, and lower if uptake was high, costs for a range of update scenarios were assessed. If daily capacity for screening was achieved (calculated as 49 screens/day), the cost per screen was £47 (including the £10 incentive given to students to encourage participation). This increased to £91, if uptake was equivalent to the average uptake observed on the trial (19 screens/day). The paper concluded that delivering this type of service is more expensive per person than CT and NG screening in sexual health clinics but could be more comparable in areas of high CT/NG prevalence.


Kerry-Barnard S, Huntington, S, Fleming C, et al. Near patient chlamydia and gonorrhoea screening and treatment in further education/technical colleges: a cost analysis of the ‘Test n Treat’ feasibility trial. BMC Health Services Research. https://doi.org/10.1186/s12913-020-5062-5

Cluster-randomised feasibility trial of a chlamydia test and treat (TnT) service in further education colleges

Aquarius were involved in a recent cluster-randomised feasibility trial looking at whether provision of a same day test and treatment (TnT) service for chlamydia in further education colleges could be used to improve uptake of chlamydia testing in sexually active 16-24 year olds. The trial found that despite a high prevalence of chlamydia among sexually active students at the colleges, uptake of the free confidential TnT service was low. At the three colleges, 13% of students were tested when the service was first offered and 10% when it was offered again three months later. Interviews with students revealed that low uptake was associated with not feeling at risk of a sexually transmitted infection, perceptions of stigma, and lack of knowledge about sexually transmitted infections, while all students interviewed were positive about the TnT service itself.

PublicationOakeshott P, Kerry-Barnard S, Fleming C, et al. “Test n Treat” (TnT): a cluster randomised feasibility trial of on-site rapid Chlamydia trachomatis tests and treatment in ethnically diverse, sexually active teenagers attending technical colleges. Clinical Microbiology and Infection. https://doi.org/10.1016/j.cmi.2018.10.019.

Modelling cost-effectiveness of multipathogen POC tests for sexually transmitted infections

In this BMJ Open article, we report on health economic modelling results that compare three possible strategies for point-of-care (POC) sexually transmitted infection (STI) testing with the current practice of microscopy and lab-based testing.  Results showed that testing for STIs with either a dual, triple or quadruple POC test provided more patient benefit than current practice but may cost more. The quadruple POC test was the least expensive POC strategy relative to standard care – with an incremental cost-effectiveness ratio of £36,585 per quality adjusted life years gained, when taking the clinic’s perspective. When taking the commissioners’ perspective, who pay for the services delivered through tariffs, over £26 million in savings could be achieved using the 4-bug test, mainly because patients were treated appropriately on their first testing visit rather than having to re-attend.


PublicationHuntington SE, Burns RM, Harding-Esch E, et al.  ‘Modelling-based evaluation of the costs, benefits and cost-effectiveness of multipathogen point-of-care tests for sexually transmitted infections in symptomatic genitourinary medicine clinic attendees.’ 

To request a copy of the published article, please email caroline.dombrowski@aquariusph.com.

Test n Treat – rapid STI testing and treatment in colleges: study protocol

Sexually active young people attending London further education (FE) colleges have high rates of chlamydia, but screening rates are low. We describe the study protocol for “Test and Treat” (TnT), an NIHR-funded research study. This is a cluster randomised feasibility trial of frequent, rapid, on-site chlamydia testing using the Cepheid GeneXpert system and same-day treatment in six FE colleges. As part of the study we also conducted qualitative and economic assessments to assess the feasibility of conducting a future large-scale trial to investigate if TnT reduces chlamydia rates. The methods for recruitment, participant data collection, sample collection and testing are described, for baseline and follow-up in the control and intervention groups. The statistical analysis plan for TnT has been published separately.


PublicationKerry-Barnard S, Fleming C, Reid F, et al. ‘Test n Treat (TnT)’- Rapid testing and same-day, on-site treatment to reduce rates of chlamydia in sexually active further education college students: study protocol for a cluster randomised feasibility trial. Trials. 2018 Jun 5;19(1):311. doi: 10.1186/s13063-018-2674-8.

To request a copy of the published article, please email caroline.dombrowski@aquariusph.com.

Rapid testing and treatment for sexually transmitted infections improve patient care and yield public health benefits

With collaborators at Chelsea and Westminster NHS Foundation Trust, we estimated the impact of a rapid testing and result notification service for patients testing for sexually transmitted infections at the Dean Street Express clinic. We found that a rapid testing service for asymptomatic infections resulted in 8 days’ faster time to result notification for CT and/or NG which enables faster treatment, thus reducing infectious periods and leading to fewer transmissions, unnecessary partner attendances and clinic costs, compared with those attending an existing ‘standard’ sexual health clinic.

PublicationWhitlock GG, Gibbons DC, Longford N, et al. Rapid testing and treatment for sexually transmitted infections improve patient care and yield public health benefits
International Journal of STD & AIDS. First Published October 23, 2017


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Evaluating the costs, benefits and cost-effectiveness of multi-pathogen point-of-care tests for sexually transmitted infections

We estimated costs, benefits and cost-effectiveness of three accurate 30-minute NAAT POCT strategies that detect different STI combinations, compared with standard care  (laboratory-based NAAT for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG)).  We found the CT-NG-MG-TV POCT strategy was the cheapest using tariff costing. It offered the most benefits, which in turn may have wider public health impacts through rapid and accurate STI diagnosis and management. Different testing strategies may be more cost-effective in different SHCs and patient groups. Further evidence is needed to capture the diversity of STI prevalence and management of patients across clinical services to better inform economic analyses.

Harding-Esch EM, Huntington SE, Burns RM, et al. Evaluating the costs, benefits and cost-effectiveness of multi-pathogen point-of-care tests for sexually transmitted infections STI & HIV World Congress. 9-12 July 2017. Rio de Janiero, Brazil.


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The cost of pelvic inflammatory disease and potential cost-savings of chlamydia screening

Problem: The POPI trial was a randomised control trial in South London estimating the incidence of pelvic inflammatory disease (PID) and the potential impact of screening for chlamydial infection on preventing PID. The study group wanted to know the costs to the health care system of managing PID, and what cost savings could be made through chlamydia screening.

Approach: We worked with the study team to define the question based on the data they had already collected during the trial, and then developed a strategy to answer it. This involved extracting data from patient notes and building a simple model in Excel to estimate the costs of care for women with PID. National costs were applied to local data, and we scaled up the results to estimate the potential cost savings, both locally and nationally.

 Impact: This work provided estimates of the cost of managing PID, which are useful to groups exploring the impact of delivering care to these patients and also for those wishing to explore the impact of interventions to avoid PID such as chlamydia screening. The results were published in Sexually Transmitted Infections, and has been cited many times in prestigious journals and authoritative reports and used in two modelling studies.



“Dr Adams is an excellent health economist, very clear thinking and easy to work with. She has original ideas and delivers on time. She designed the cost analysis for our trial, supervised the research assistant who assembled the relevant data and enabled publication in a high ranking journal.”

  • Dr Pippa Oakeshott, Professor of General Medicine, St Georges University


Related publications

publication_iconAghaizu A, Adams EJ, Turner KME, et al. What is the cost of pelvic inflammatory disease and how much could be prevented by screening for Chlamydia trachomatis? Cost analysis of the POPI (prevention of pelvic infection) trial. Sex Transm Infect 2011; 87:312-317.

The benefits and cost-savings of a new point-of-care test for chlamydia and gonorrhoea

Problem: Cepheid’s Xpert® CT/NG test is a high performance point-of-care test for chlamydia and gonorrhoea, and offers a promising advance in the diagnosis and control of two common sexually transmitted infections. When the test was launched in 2013, Cepheid wanted to understand how sexual health clinics in England might use it and to develop evidence comparing its costs and benefits to standard laboratory tests.

Approach: We approached the challenge in two projects. For the first, we defined the current patient pathways for chlamydia and gonorrhoea testing treatment and compared them to what they would be if a rapid POCT was used. We held workshops with staff in four sexual health clinics, asking them to map out the current patient pathways for chlamydia and gonorrhoea diagnosis and treatment. We then helped them brainstorm ways in which their services might include a point-of-care chlamydia and gonorrhoea test, and describe how this would change their patient pathways. Finally, we used Dots, our cloud-based pathway builder tool, build to estimate the costs of the pathways. The work indicated that the pathways could be streamlined with a point-of-care test, and we estimated that this would cost less to deliver than current practice.

For the second project, we developed an economic model to compare the overall costs and benefits of a point-of-care test to standard care. We combined the results of our first project with previous work our team had conducted on chlamydia and gonorrhoea testing and management. The model showed that the test could deliver £10million in cost savings, and give far more effective management of chlamydia and gonorrhoea at a population level. Our results were published in Sexually Transmitted Infections, and have been presented at national and international conferences.

Impact: Our work gave Cepheid the empirical evidence to demonstrate the value and potential impact of adopting their test in clinics. Since our projects, Cepheid has had increasing interest in the test, and several centres have purchased it. This includes a major London sexual health clinic which has introduced a new testing service as a result.



“I started working with Aquarius in 2012. Elisabeth and her team have always delivered great results, including 2 peer-reviewed publications, that add real value and insight, and they come up with creative ways to answer our questions. I enjoy collaborating with them and look forward to continuing our work on a range of disease areas in the future.”

  • Dr. Anne Postulka, Senior Director Medical & Economic Value, Cepheid


Related publications

publication_iconAdams EJ, Ehrlich A, Turner KME, et al. Mapping patient pathways and estimating resource use for point of care versus standard testing and treatment of chlamydia and gonorrhoea in genitourinary medicine clinics in the UK. BMJ Open 2014;4: e005322. doi:10.1136/bmjopen-2014-005322

publication_iconTurner KME, Round J, Horner PJ, et. al. What are the clinical and economic costs and benefits of implementing point of care NAAT tests for Chlamydia trachomatis and Neisseria gonorrhoeae in genitourinary medicine clinics in England? Sex Transm Infect. Published online 22 Nov 2013: doi:10.1136/sextrans-2013-051147

Featured article: Read the Clinical Services Journal about this work.


Benefits of a point of care test for sexual health testing

publication_iconOur recently published studies have highlighted the economic and clinical benefits of incorporating a point-of-care nucleic acid amplification test for chlamydia and gonorrhoeae into sexual health clinics. In this article, some of the papers’ authors highlight the advantages over traditional immunoassay techniques for point-of-care detection.

The Clinical Services Journal. May 2014, p59-61.

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