Survey: Access to STI testing is not implemented at health stations in accordance with recommendations

Terveydenhuollon asiakas ja terveydenhoitaja näytteenottotikku kädessään.

In autumn 2022, Hivpoint carried out a survey to find out how access to HIV and other STI (sexually transmitted infections) tests is implemented at public health stations. Hivpoint’s volunteer carried out the survey by calling the appointment booking service of 20 health stations around Finland. He started the call by asking, “I’ve had unprotected sex, what tests do I need?” After this, he waited to see what more detailed questions the employee would ask and how he would be referred for tests for STIs at the health station. The caller had a pre-planned backstory in which he had unprotected intercourse in sex between men and an unprotected oral sex situation during a trip abroad. The caller told the backstory to the employee who answered the call if he was asked for more information about the situation.

According to the Current Care Guidelines for STIs, the possible risk and time of the risk situation must be determined by interviewing the client in order to plan a reliable STI testing (Finnish Medical Society Duodecim, 2018). According to the HIV testing recommendation of the Finnish Institute for Health and Welfare, people in public health care must be able to get tested for HIV on their own initiative, without a doctor’s referral, free of charge and anonymously. In addition, clients should always be offered an HIV test if there is a reason to suspect any STI or if the situation has involved sex between men. (THL 2010.)

In accordance with the recommendations, the person who called the appointment booking service should first have been asked for more information about exposure situations related to unprotected sex, i.e. what kind of sex he has had, and then he should have been referred to at least a chlamydia, gonorrhea, syphilis and HIV tests. Chlamydia and gonorrhea samples should have been taken not only from the urine sample but also from the pharynx and anus. Unfortunately, the correct referral to tests was only done at two health stations.

The assessment of the need for treatment remained the responsibility of the client

The survey revealed that the caller was not able to get all the STI tests he needed at 18 health stations, while the survey included 20 health stations. The most challenging part was getting samples from the mucous membranes of the pharynx or anus, because there was any questions about the possibility of oral sex or anal intercourse. Getting tested for syphilis was also difficult. The test was offered at only four health stations.

Appropriate guidance was not always provided. For example, the caller was instructed to search online for more information. Only one time the caller was advised to use a condom until the caller had received the results of an STI tests. On the phone the workers at the health stations often also pondered the need for STI tests on the basis of the caller’s lack of symptoms, even though all STIs can be transmitted and cause serious health problems to the person, even if they are asymptomatic.

“It was said that only the most common STIs would be tested. Only if there were symptoms, then also HIV.”

“A lot of people asked only about symptoms”

The survey revealed that employees of health stations’ telephone services rarely specified the risks related to sexual situations. It is important that a professional always finds out the client’s sex habits and when the exposure situation occurred at the beginning of each contact. Based on the information, the customer should be told which tests are needed, from which mucous membrane samples are taken and when tests can be taken.  At only 11 health stations the caller was asked how much time had passed from the unprotected sex. There seems to be the most room for improvement in the knowledge and skills of professionals to ask the right questions. 

Access to HIV testing was denied at three health stations

Based on three phone calls, the caller would not have been able to get tested for HIV at all. Getting tested was denied on various grounds. In two calls, the customer was directed to order tests online or directed to contact them again through the electronic Omaolo service. In one call, an employee said it was not worth getting tested if there were no symptoms, but eventually agreed to make a referral for an HIV test after the caller himself raised the issue of unprotected anal intercourse in sex between men.

Especially with HIV test, being asymptomatic should never be a reason not to take a test, because HIV infection can be asymptomatic for years. If left untreated, HIV infection can lead to a life-threatening AIDS stage, so it is very important for the person that the infection is diagnosed as early as possible. It also helps to prevent further infections.

“Anonymous HIV testing is possible”

The survey showed that good counselling was also available and, for example, access to anonymous HIV testing had improved compared to Hivpoint’s previous survey in 2020. It was particularly positive that in a few cases the nurse investigated the implementation of an anonymous HIV test and called back to tell about the possibility. It seemed that the request for an anonymous test was respected. At health stations where an anonymous HIV test was not available, the reason was usually that the employee did not know how to make a laboratory request.

Heterosexual assumption as a barrier to getting tested for STIs

Hivpoint’s survey revealed that the health station employee most often assumed that the caller was a straight man and that unprotected sex in his case would have been vaginal intercourse. The heterosexual assumption was highlighted, for example, by referring to vaginal intercourse as “normal sex”, which is a discrimination. Normative assumptions and discriminatory practices prevent the realisation of equality in health services, because clients are not directed to the right tests and therefore do not always receive the treatment they need.

Sexual health must not be overlooked!

In Finland there are approximately 800 people living with HIV who are unaware of their infection. HIV testing is the only way to find these infections. A significant proportion of new HIV infections, up to 63%, are diagnosed late, i.e. when HIV is already at an advanced stage or even into the AIDS stage. The number of gonorrhea and syphilis infections is also increasing. There is now work to be done in public health care to find new HIV infections and to realise everyone’s right to be tested for HIV.

Health stations need common testing practices and guidelines that are easy for employees to use and always available. The employer, i.e. the parties responsible for health services in the wellbeing services counties, must ensure up-to-date information for the staff through training, updating the workplace’s internal instructions and good orientation. The smoothest way would be for the wellbeing services counties to have uniform policies on testing for HIV and other STIs.