As cash-strapped councils have had to cut face-to-face sexual health services, there has been a rise in the use of online sexual health services to deliver STI tests - a trend most likely to impact people in their twenties.
But experts have raised concerns that kits ordered on the internet may not be the best solution for everyone, and may not adequately protect those who are vulnerable.
Figures released this week by the Labour Party show the total number of contacts with sexual and reproductive health services has declined by 245,000 since 2015/16, from just over two million to around 1.7m last year.
The number of people being diagnosed with syphilis has risen 20% since 2017 while gonorrhoea has risen by 22%, Public Health England (PHE) figures showed.
Sexual health is largely a young people’s issue, with twenty-somethings particularly affected.
Those aged 20-24 had the highest rates of all newly-diagnosed STIs in 2017, except syphilis, for which the highest rates were among those aged 25-34, a review of PHE’s most-recent data found.
Yet, despite the move towards digital services, 21-year-old Sheffield student Niru says ordering a sexual health test online to be delivered through the letterbox simply isn’t an option for him.
“My parents are strict and if they find out I’m ordering sexual tests, they’ll probably chuck me out,” he told HuffPost UK.
“If I didn’t have strict parents I’d probably order to my house as it’s more secure than going into uni. When I say secure, you get less people looking at you. It would be definitely an option, but obviously in my case it’s not an option.”
Katie, 22, said she goes into the clinic for her sexual health tests and would never think about paying for an online sexual health kit.
“I’ve seen them. The ones that come up if you’re searching for them are the ones you have to pay for, it’s like £60 to get a chlamydia kit. I’m not paying for it,” she said.
“Sometimes you have to go [to your doctor’s] saying that you’ve got symptoms for them to give you the test because they’ve a limited amount of tests.”
Meanwhile, Endi, 20, said her decision on how to take a sexual health test is all about speed.
“I would do it online if it was quicker that way,” she said. “[But] how long does it take? Where do I send it back? Bit weird.
“Back home [the wait for a check up] was long.”
Clinicians believe regular testing is crucial to tackling STI rates and sexual health organisations say people are increasingly going online to request tests they can take themselves without seeing a nurse or doctor.
There are two types of online services currently available: HIV testing kits, which provide an almost-instant result; and STI screening kits, where samples are sent to a lab for analysis and results come later.
Several different organisations and companies currently supply online postal testing in the UK – some privately, such as Superdrug – while others are commissioned to provide the service by councils, which assumed responsibility for funding many sexual health services in 2013.
Since then, there has been a £55.7 million cut in local councils’ sexual health services budgets, according to figures from the House of Commons Library.
The London Sexual Health Providers Group told an ongoing parliamentary inquiry into sexual health provision, due to report soon, that cuts had led many councils to reduce “the number and capacity of the services they commission”.
One sexual health service in south London said it had reduced opening times by 30% and slashed the number of nurses by a similar percentage as a result of budget cuts.
It is against this backdrop that online testing is increasingly seen as a cost-saving solution, with the screening of those without symptoms delivered through postal kits for a fraction of the cost of a face-to-face appointment.
HOW DO ONLINE SEXUAL HEALTH TESTS WORK?
Sexual health tests ordered online arrive through the letterbox like a paperback from Amazon or a plastic ASOS bag.
But inside the innocuous packaging is a small set of items familiar to anyone who has had a sexual health check-up.
In one STI screening kit received by HuffPost UK, empty sealed vials for blood and urine are presented neatly in separate transparent bags, with clear pictorial instructions showing how to take samples.
Blood is captured via small lancets which neatly direct a pin-prick needle into a person’s fingertip – perhaps an unpleasant prospect for those afraid of needles or blood, or both.
Swabs for chlamydia and gonorrhoea tests, meanwhile, are also packaged separately and with unique instructions.
Once the samples are taken and sealed, people are instructed to pop them into a bright yellow plastic bag already marked up with a freepost address.
Results are received a few days later via text message.
Similar kits exist to test for HIV but these often provide an instant result.
“You don’t need a doctor or a nurse, you don’t need to pay for clinic premises, heating, lighting, all of the paraphernalia that goes around a clinical environment,” Paula Baraitser, the clinical director of online sexual testing firm SH:24 told HuffPost UK.
Baraitser said that the ease of the service tends to appeal to people in their twenties who might be living away from the family home. “Once people are in their twenties is really when online services take off,” she added.
“I was recently looking at our contraception figures – we provide online contraception that is delivered to your home – and the majority of people who are ordering contraception from us are in their twenties.”
SH:24, which operates as a community interest company, began on a scheme to accelerate digital disruption within the NHS. In 2013, the firm obtained a grant to explore digital sexual health testing in two south London boroughs, Lambeth and Southwark, which have exceptionally high STI rates.
“We have doubled access since then and reduced the number of people attending clinics for what we call asymptomatic screening [for those without obvious symptoms],” Gillian Holdsworth, SH:24’s managing director, said.
“Before we set up we found 40% of those attending clinics were asymptomatic and coming in for a checkup. We thought these people might want to do the tests at home and manage their sexual health remotely.”
The service uses an online system together with an in-house clinical team available to users over the phone – an important difference, Holdsworth said, to other companies offering similar services.
“There are a number of online service providers that don’t have any safeguarding, which is an enormous concern,” she said.
“There are some online providers with whom you can order a test kit for a 16-year-old who has had 12 partners in the past six months and nobody ever phones you up and they’ll still send you a kit. It’s quite extraordinary really.”
SH:24, which received over 100,000 requests for kits last year, has expanded across the UK and has noticed a difference in its users within and outside the capital.
“When we look in London, I would say 30% of the service users were under the age of 25,” Holdsworth added.
“But when you look outside of London, in some areas, the under 25s use of the service is as high as 80%.”
Among the reasons for the difference could be the large distances between clinics in some counties, such as Staffordshire and Essex, which would require long journeys on public transport.
“Outside London, it is very much a young person’s service. In London, it’s a little bit different,” Holdsworth said.
Marc Thompson, the strategic lead for health improvement at the Terrence Higgins Trust, said online sexual health testing reduces the burden of attending a physical clinic.
“It’s a really great change that we’ve seen,” he said. “It takes a burden off the NHS and off sexual health clinics. But it also puts you in control of your own sexual health.
“You can test as often as you need to – between every sexual partner if you wanted to – so I think it’s a good thing to put that into people’s hands.”
But he cautioned: “One of the downsides could be is that when people go to a clinic and get a positive result for an STI they get treated straight away and are wrapped up into some sort of care or have a conversation with somebody at the clinic about reducing or avoiding their risk in the future.
“When one tests at home, the onus is then on you to follow that up.”
Thompson added that it is particularly important that people in their twenties feel able to talk about sexual health.
“I think it’s really, really important that around this time that younger people of that age bracket have the right information around sexual health, have access to testing, screening, and are able to have conversations about it.”
Thompson also called for more investment in sexual health services. “We are seeing huge cuts to our sexual health services. We need investment. We need that to be rolled back or to be stopped,” he said.
A Department of Health and Social Care spokesperson said: “Sexually transmitted infections continue to fall - and online sexual health services play an important role in further improving access to testing.
“Online providers are held to same quality standards as other services, ensuring safeguards are in place for under-18s.
“Prevention is at the heart of the NHS Long Term Plan, and comes alongside the £3 billion we are giving to councils to fund public health services this year, including sexual health services.”
#TwentiesTakeover
For one day HuffPost UK is joining forces with BBC Radio 5 Live to put people aged 20-29 at the forefront of the news agenda in a Twenties Takeover on Thursday 16 May.
Every 5 Live News programme will be co-presented by some of the most exciting new voices in the UK today, and HuffPost UK journalists will be reporting on issues that cut across the lives of young people – from the precarity of housing and work, to sexual health, the realities of modern dating and the pressure to keep up appearances on social media.