ASSIST: Assessing the impact of online self-sampling for STIs and HIV

Sexual health was recognised as a critical component of a healthy society. Despite rising rates of STIs, funding for services had declined, and care particularly when delayed often came at a high cost. As a result, services were under pressure to find innovative, cost-effective ways to deliver care.

Online postal self-sampling (OPSS) emerged as one such innovation. It allowed individuals to order a testing kit online, self-sample at home, and post it to a laboratory for analysis. These services were expected to increase access to testing especially among groups most at risk while reducing costs, stigma, and health inequalities.

ASSIST (Assessing the Impact of Online Self-Sampling for STIs and HIV) was a 39-month study designed to evaluate the effects of OPSS on health inequalities, access to care, and clinical and economic outcomes. It also aimed to identify the factors affecting the implementation and sustainability of OPSS services.

The research focused on three areas: London, Birmingham, and Sheffield to ensure a diverse and inclusive population sample. It involved document reviews, interviews with service users and staff, and analysis of data from national, clinic-based, and online sources. An economic evaluation was conducted alongside this.

By analysing these multiple data sources, researchers were able to understand both the benefits and limitations of OPSS, as well as the organisational and systemic changes required to implement and embed these services into routine sexual health practice.

This large-scale evaluation of the introduction of online postal self-sampling (OPSS) for sexually transmitted infections (STIs), including HIV, within the sexual health economy demonstrated that OPSS led to an overall increase in testing activity even when access to clinic-based services was restricted. The greatest relative increases in testing were observed among populations that already had higher levels of testing activity prior to OPSS implementation.

The study also identified significant challenges in tracking user journeys across hybrid service models that included both online and clinic-based pathways, particularly where an external OPSS provider was involved. This hindered the ability to fully capture key clinical outcomes across all testing activity.

Generally, OPSS services were associated with lower costs but also lower positivity rates. However, the evaluation highlighted hidden costs that must be considered when comparing online services with traditional clinic-based approaches for detecting and treating STIs.

High demand for OPSS was shown to potentially destabilise the broader sexual health system and, in some cases, may have underserved certain groups with unmet sexual health needs, thereby exacerbating existing health inequalities. The findings pointed to a need for rebalancing clinic-based and OPSS services to account for their respective impacts on the wider system and in response to changing contextual factors.

The evaluation provided important insights into how OPSS services influenced testing behaviour, access, and system stability across multiple regions. While OPSS contributed to increased access and lower service delivery costs, these benefits were not uniformly experienced across all populations. The inability to capture comprehensive clinical data through external providers and the potential for increased inequality were significant considerations for future planning.

The project underscored the need for sexual health services to carefully balance innovation with equity ensuring that OPSS models complement rather than displace essential clinic-based care. The findings are expected to inform national policy and local service design in integrating OPSS sustainably within the sexual health landscape.

University College London (UCL)

Chelsea & Westminster Hospital NHS Foundation Trust (Chelwest FT)

NHS Greater Glasgow & Clyde (NHSGGC)

UK Health Security Agency

University Hospitals Birmingham NHS Foundation Trust (UHB)

University of Birmingham

University of Oxford