1.1.4.1. Included studies

No studies were included in this review.

1.1.4.2. Excluded studies

For details of excluded studies and reason for exclusion, see Appendix I.

1.1.7.1. Included studies

No economic evidence was included for this review question.

1.1.7.2. Excluded studies

Details of the studies excluded at full-text screening are given in Appendix I.

1.1.9.1. The outcomes that matter most

The committee agreed that the key outcomes in this area were rates of testing among very high risk groups, and proportion of very high risk groups who undertook testing. They agreed that the re-testing rate was also very important since people who continue to be at very high risk need to test regularly, ideally every 3 months.

1.1.9.2. The quality of the evidence

No evidence was identified for interventions specifically aimed at the groups included in the protocol:

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commercial sex workers

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people with multiple sex partners (>10 partners within 3 months)

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people engaging in so-called chemsex

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gay, bisexual and other men who have sex with men previously diagnosed with a bacterial STI (in the last year)

There were no RCT studies that met the protocol and no suitable uncontrolled studies were found. The committee were disappointed with the lack of evidence but noted that they were aware that research is building in this area. The option of using expert witness testimony was not explored as the committee found it acceptable to proceed using the evidence presented in review C combined with their own experiences of very high risk groups instead.

Given the lack of evidence, the committee did not feel that it was possible to directly extrapolate the data from other groups to the very high-risk groups identified for this review, as people in these groups represent a very small minority with distinct challenges. In spite of that the committee agreed that recommendations made on the basis of more general interventions to increase the uptake and frequency of testing would have some impact on these groups too, despite not sufficiently addressing their circumstances. The committee noted that stigma around sexual behaviour was a common concern found in the qualitative evidence reviewed in RQ2.2, and inferred that this was likely to be a key driver in people from very high-risk groups not accessing services. The committee agreed to make a research recommendation to explore what sexual health services can do to reduce stigma (see appendix J). They note this complemented other research recommendations, for example about delivering sexual health services within other services. They also agreed that outreach was likely to be effective in reaching some of these groups and they noted that they had made a research recommendation about this in review B to investigate how outreach could best be tailored to specific groups.

1.1.9.3. Benefits and harms

The committee agreed that recommendations they had made previously about monitoring uptake of kits and about tailoring interventions to particular communities may help to increase access for people in the groups identified for this review. They noted that many services already have some tailored services, for example for sex-workers or for people who participate in so-called chemsex. They also noted that getting people into services for STI testing also gave an opportunity for HIV testing, partner notification, PrEP (if appropriate) and other services, so it wasn’t simply an STI test.

1.1.9.4. Cost effectiveness and resource use

The committee agreed that the economic modelling undertaken for this guideline shows that cost-effectiveness is dependent on population prevalence of STIs, this means that any intervention that is cost-effective in the general population is likely to be more cost-effective in a very high-risk population where rates of STIs are higher, assuming the costs and relative effectiveness of the interventions ins similar in the high-risk population. They noted that in the absence of evidence, and to avoid disadvantaging high-risk groups, it was appropriate to extrapolate this evidence to these populations. They also noted that for the interventions recommended in the guideline (self-sampling, tailoring interventions and increasing accessibility there was no a priori reason to assume they would be less effective in high-risk populations.

K.1.1. Why this is important

The committee noted themes in the qualitative research that indicated that shame and stigma were powerful barriers to people attending sexual health services, and also to the uptake of treatments like PrEP. They were interested in how services can be less stigmatising, for example by delivering them within other services or by making service changes that helped to reduce stigma.

K.1.2. Rationale for research recommendation

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K.1.3. Modified PICO table

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