Self-sampling strategies (with/without digital innovations) in populations at risk of Chlamydia trachomatis and Neisseria gonorrhoeae: a systematic review and meta-analyses

Abstract

Background: Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) resulted in over 200 million new sexually transmitted infections last year. Self-sampling strategies alone or combined with digital innovations (ie, online, mobile or computing technologies supporting self-sampling) could improve screening methods. Evidence on all outcomes has not yet been synthesised, so we conducted a systematic review and meta-analysis to address this limitation.

Methods: We searched three databases (period: 1 January 2000-6 January 2023) for reports on self-sampling for CT/GC testing. Outcomes considered for inclusion were: accuracy, feasibility, patient-centred and impact (ie, changes in linkage to care, first-time testers, uptake, turnaround time or referrals attributable to self-sampling).We used bivariate regression models to meta-analyse accuracy measures from self-sampled CT/GC tests and obtain pooled sensitivity/specificity estimates. We assessed quality with Cochrane Risk of Bias Tool-2, Newcastle-Ottawa Scale and Quality Assessment of Diagnostic Accuracy Studies-2 tool.

Results: We summarised results from 45 studies reporting self-sampling alone (73.3%; 33 of 45) or combined with digital innovations (26.7%; 12 of 45) conducted in 10 high-income (HICs; n=34) and 8 low/middle-income countries (LMICs; n=11). 95.6% (43 of 45) were observational, while 4.4% (2 of 45) were randomised clinical trials.We noted that pooled sensitivity (n=13) for CT/GC was higher in extragenital self-sampling (>91.6% (86.0%-95.1%)) than in vaginal self-sampling (79.6% (62.1%-90.3%)), while pooled specificity remained high (>99.0% (98.2%-99.5%)).Participants found self-sampling highly acceptable (80.0%-100.0%; n=24), but preference varied (23.1%-83.0%; n=16).Self-sampling reached 51.0%-70.0% (n=3) of first-time testers and resulted in 89.0%-100.0% (n=3) linkages to care. Digital innovations led to 65.0%-92% engagement and 43.8%-57.1% kit return rates (n=3).Quality of studies varied.

Discussion: Self-sampling had mixed sensitivity, reached first-time testers and was accepted with high linkages to care. We recommend self-sampling for CT/GC in HICs but additional evaluations in LMICs. Digital innovations impacted engagement and may reduce disease burden in hard-to-reach populations.

Prospero registration number: CRD42021262950.

Keywords: Chlamydia Infections; DIAGNOSIS; META-ANALYSIS; NEISSERIA GONORRHOEAE; SYSTEMATIC REVIEW.

Figure 1

Preferred Reporting Items for Systematic Reviews and Meta-Analysis flow chart of included studies. CT, Chlamydia trachomatis; GC, Neisseria gonorrhoeae.

Figure 2

Geographical map, demographics and testing types described in included studies (n=45). (A) Heatmap of countries and percentages of (B) populations and (C) self-sampling strategies with or without a digital health component. FSW, female sex worker; MSM, men who have sex with men; PLWHIV, people living with HIV; WSWM, women having sex with women and men.

Figure 3

Summary receiver operating characteristic (SROC) curves for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) (n=13).

Figure 4

Quality assessment of included studies. (A) Cross-sectional studies (n=24) and (B) cohort studies (n=4) were assessed using the Newcastle–Ottawa Scale (NOS); (C) diagnostic accuracy studies (n=16) using the tool for Quality Assessment of Diagnostic Accuracy Studies (QUADAS). N/A, not applicable to a particular study