Sexually Transmitted Infections

Everlywell Now Has An STI Test Subscription. Is It Worth It?

Everlywell, the HelloFresh of lab tests, debuted an STI subscription service called Current last month.

For $14.99 a month, Everlywell will send you one of five STI tests (usually priced at $49 on their website). The company boasts that you'll get physician-reviewed results within days, a physician from a third-party telehealth network will reach out should you have a positive test, and, on top of that, there's no cancelation fee. But is it something you need?

Current STD testing subscription Credit: everlywell

Current came after sales of Everlywell's STI tests quadrupling during the height of quarantine, which they consider to be March and April of 2020, compared to sales in March and April of 2019.

"When we noticed that people were buying at-home collection STD tests from us in record numbers despite the lockdown, we started thinking about how to deliver testing to these individuals in an accessible, affordable way that wouldn't put them at further risk of exposure to coronavirus," Dr. Frank Ong, Everlywell's Chief Medical and Scientific Officer, told Mashable.

In an Everlywell study of 500 participants, nearly 25 percent of people reported breaking stay-at-home orders in April in order to pursue sexual activity, Ong cited. "Although their decisions were risky, they still needed testing," he said. "We wanted to provide an affordable option to help people stay up-to-date with their sexual health testing, especially in times like this where many individuals are still taking precautions to avoid hospitals and clinics for non-essential reasons and routine services."

Over a thousand people have signed up for Current so far, according to Everlywell. The subscription sounds enticing in theory, especially in pandemic times: An STI test you don't have to leave your house for, all for 15 bucks a month.

But what do other doctors think?

Dr. Kim Langdon, OBGYN for Medzino, put it bluntly: "The websites that offer these tests claim that they do not claim to diagnose or treat any disease — so what is the point?" While Everlywell does state that their tests are, in fact, diagnostic, their website does say that if you test positive for an STI, you should visit a doctor and establish a treatment plan. The test includes a telehealth visit with a doctor if you get a positive result, during which you can get a prescription if necessary. But, depending on your situation, you may still need to seek in-person medical care.

Furthermore, tests are only one component of a diagnosis, said Michael Tahery MD, an OBGYN in Los Angeles with subspecialty training in urogynecology. He told Mashable that a lot of home testing kits are user-dependent. "How well a person is willing to poke their finger and get enough blood [for] the sample...Makes all the difference," said Tahery.

Mashable Trend Report

To that, Ong said that this sampling issue is called "Quantity Not Sufficient" or QNS. Everlywell's QNS rate for their sexual health tests ranges between 4 percent to less than 1 percent, said Ong, depending on the test. "It's slightly higher for specimens using dried blood spot collection (4 percent or less on average) than it is for swab or urine collection (less than 1 percent on average)," he said, "but still quite low across the board."

But even if the patient gathers a perfect sample, there still can be snags. If someone, say, thinks they might have gonorrhea or chlamydia due to discharge and orders that test, the test only tells them whether they have either STI. The test doesn't account for a myriad of other conditions that cause unusual discharge that a doctor can detect during an in-person visit.

"Maybe it's herpes. Maybe it's just a bacterial vaginosis. Maybe it is trichomoniasis," said Tahery. "It could end up not really taking care of the problem they have if [the test] gives them a sense of false reassurance." Indeed, Current's one test a month system won't benefit someone who has a different infection than what they ordered.

On three of their tests — chlamydia/gonorrhea, trichomoniasis, and syphilis — the FAQs say that the test will give you results within greater than 99 percent accuracy. Kecia Gaither, MD, MPH, FACOG, OBGYN and Director of Perinatal Services at NYC Health + Hospitals/Lincoln, said that at-home STI testing has about a 92 percent efficacy as compared to a lab, which has 98 percent efficacy.

"As a physician I think if there is a concern for a sexually transmitted infection, a physicians' visit is recommended," said Gaither. "A history and a physical exam — inclusive of a pelvic will be had — blood, wet prep of vaginal secretions, and cultures will be obtained. Any prescription for antibiotics or anti-viral medications can be prescribed."

Like Tahery, Gaither pointed out that the patient may have an issue going on other than what their Current test detects. She said, "There may be other conditions that are present that may not be appreciated on a home test outside of a physicians' watchful eyes."

"There may be other conditions that are present that may not be appreciated on a home test outside of a physicians' watchful eyes."

Tahery does see some value in these tests. If, for example, someone can't get access to routine medical care, an affordable STI test could help. (They would still have to go to a doctor if the test came out positive, however.) He also gave the example of a young person who doesn't want their parents to know they're sexually active but wants to get tested. (The tests are in discreet packages, though for some people that may not be enough to ensure privacy.)

Then there's the case of someone who doesn't want to visit a doctor over COVID concerns — but again, one test doesn't have all the answers. Moreover, Tahery thinks using Current could lead to over-testing. The National Coalition for Sexual Health recommends getting tested at least once every six months if you have multiple partners.

If someone wants an STI test monthly, Tahery wonders if testing is sufficient. "Shouldn't someone talk to this person and discuss safe sex and birth control?" he asked. "There's so many other things that are missing out of the picture than just doing one test and [leaving] it."

Not everyone in the United States has access to medical care; that's an unfortunate fact. For those who do, visiting a doctor will provide more answers than a monthly STI test delivered to you — as well as advice on how to prevent them in the future. For those who don't, Current may provide some peace of mind, as long as the user is aware of the drawbacks.

UPDATE: Oct. 9, 2020, 2:54 p.M. EDT This article has been updated with clarifications from Everlywell.

STDs Have Been On The Rise. Who Should Pick Up The Tab For Testing?

Inside the glassy waiting room of a Hollywood clinic, a 33-year-old man sat and listened for his number to be called over the beats of a Mariah Carey song.

"It's just really easy. You don't have to make an appointment," said the man, who comes to the AIDS Healthcare Foundation clinic every two or three months to get tested for sexually transmitted diseases.

Nor does he get asked about his health insurance, which has sometimes been a frustration elsewhere. "And I like the discretion," added the man, who declined to give his name. "You don't want people in your business."

For months, the AIDS Healthcare Foundation has been resisting a push from Los Angeles County for such providers to ask people if they have insurance that can cover costs related to STD tests, a step that the Department of Public Health says is needed in order to spare public dollars for more services.

The Public Health Department has long contracted with community organizations to test people for sexually transmitted diseases. In the past, the county shouldered all the costs of processing those tests at a county lab.

County officials said that for several years, their contracts have included a requirement for groups to check if clients have a "third-party payer" that could foot the bill for testing, such as public or private insurance.

Many groups had already started doing so before the county stopped routinely covering the costs of laboratory testing in January, the department said.

If someone has no insurance to cover such testing costs, the organizations can have the county pay for it, although they cannot exceed the overall amount of money allotted to them under their contracts.

Getting insurers to pay for testing has been a strategy for strapped public health departments around the country, seen as a crucial way to offset the costs of providing free care to the uninsured and other needed services as federal funding to combat sexually transmitted diseases has fallen short of the need. L.A. County Public Health said it was hunting for "as many revenue streams as possible" to ramp up STD efforts.

"This type of work cannot just be exclusively publicly funded," said Dr. Rita Singhal, the department's chief medical officer and director of the disease control bureau. "The more revenue for this effort, the better." In the past, the department said it spent between $1.1 million and $2.3 million annually on testing for STDs.

But some local groups focused on sexual health argue that the change undermines their push to make STD testing easy and routine. Across the country, syphilis and gonorrhea have been on the rise — a longtime trend exacerbated by the interruption of preventative services as health agencies grappled with COVID-19. L.A. County has seen a persistent rise in STDs over the last decade, although there are some early signs of progress.

"If you're trying to control a disease that's spiking, you have to take away any deterrents, any obstacles" to routine screening, said Michael Weinstein, president of the AIDS Healthcare Foundation.

Dr. Ward Carpenter, chief health officer for the Los Angeles LGBT Center, said health providers want people to get tested regularly even if they have no symptoms, and "the harder that is, the more barriers that are in place, the less likely people are to do that."

Among the concerns: Young adults who are on the health plans of their parents may not want to hand over insurance information, fearing their tests could show up in paperwork seen by their families. Such privacy concerns could also affect people who are insured through a spouse, Carpenter said. And clients who are "underinsured" may get stuck with a bill later, he said, and decide to stop getting regularly tested.

California lawmakers are considering legislation, Assembly Bill 1645, that would prohibit insurance plans from imposing out-of-pocket costs for recommended screenings for sexually transmitted diseases. L.A. County Public Health said it was backing that bill and "exploring as many models as possible to reduce the impact of health insurance screening," including the use of technology to smooth the process.

Dr. Jeffrey Klausner, a USC Keck School of Medicine professor and formerly an STD prevention director in San Francisco, was nonetheless concerned by the county's move, calling it "a penny saved, a pound foolish."

"It's going to come back and bite them," Klausner said. "There will be a decrease in testing ... Particularly among the most vulnerable groups and young people."

So far, L.A. County Public Health said its early data suggest STD testing has not fallen this year compared with last. Nearly 12,000 tests were reported to the county between January and March — a similar volume to the past — and the department believes the total amount of testing by community groups is likely higher because some are not being reported to the county.

The county agency said it was too early to tell whether it is spending less on testing, but it expects insurers to pick up more costs over time.

The move was welcomed by Dr. Tony Mills, chief executive of the Men's Health Foundation, which also contracts with the county. Most people in California are eligible for some kind of health coverage, Mills said, and asking about it provides an opportunity to connect patients to coverage and other care.

If people are uneasy about a test showing up on paperwork for a shared plan, "we can easily get around" that issue by tapping other funds, he said. But L.A. County needs to be "the payer of last resort. ... That's going to save more money for the county to use on other things that are integrally important."

"It's just asking the providers to do a little bit more work," Mills said.

The Public Health Department said that to boost the number of people screened and treated for STDs, it needs to support a range of screening models, including home testing and street medicine teams. Mario Pérez, director of its division of HIV and STD programs, said that to make a dent in the STD crisis, the department wants most community groups to screen 10,000 to 20,000 people each annually.

"If you want to support that level of volume, having multiple revenue streams at your disposal becomes very important," he said.

One survey of more than 4,000 patients at STD clinics found that more than half had some kind of health insurance coverage, and 57% of those who were insured were willing to use it for their visit.

Among those waiting at the AIDS Healthcare Foundation clinic on a recent afternoon was Walter, a 32-year-old who said he liked going to the Hollywood site because his visits usually took less than a half hour.

He used to get routinely tested at an urgent care facility, but stopped when it no longer accepted his insurance. Still, he wasn't fazed by the idea of being asked for insurance information in the future.

"For me, it's not a deterrent or a big deal," he said.

Another patient named Joe sought out the Hollywood clinic after getting results back from a test he had taken in the U.K. Even asking people about insurance will discourage people from STD testing and treatment, said the 26-year-old, who had been worried about obstacles he might face to getting treatment as a foreign tourist. "It will put fear in people, and as soon as you start doing that, people stop doing it," he said.

Federal funding for preventing STDs has barely budged in the last decade, resulting in STD programs losing about 40% of their buying power and forcing them to rely more heavily on other funds, said Stephanie Arnold Pang, senior director of policy and government relations for the National Coalition of STD Directors.

A survey of public health departments found the vast majority were billing Medicaid for STD services and more than two thirds billed private third-party payers. San Francisco City Clinic, a public clinic focused on sexual health, will bill Medi-Cal — the California Medicaid program — if a patient has it, but doesn't bill private insurance or charge patients, according to the San Francisco Department of Public Health.

"It makes a lot of sense that jurisdictions are looking to have folks use insurance because it is another payer source in a system that's very challenged," Pang said.

But doing so has on-the-ground impacts: Carpenter, at the LGBT Center, said the organization had to hire more staff to collect billing information and testing takes longer as a result.

The AIDS Healthcare Foundation advertises free testing without an appointment and wants to get people in and out within an hour, Weinstein said. That speedy, walk-in model "will go out the window" if it has to screen everyone for insurance, he said.

Weinstein, an outspoken figure whose group has clashed with the county and other government agencies in court, said in late August that his group would not ask clients for information about third-party payers.

The Public Health Department, however, said the AHF had indicated to the county that it would begin screening clients for insurance. In response, the AHF said it would screen existing clients — people who are already AHF patients — when they come in for testing, but not "all individuals who walk in to our testing sites."

Under the county contracts, groups can turn to the county to cover lab costs for such testing only after they have checked that patients don't have insurance they could bill instead. The AHF said it expects an increase of at least $1 million annually in lab costs as a result of the county rule.

The Public Health Department said it was continuing to work with the AHF on adjusting to the change, as well as with any other groups "to review and resolve any unintended consequences tied to this approach." It has been hammering out a spending plan for an added $10 million allocated by the county for STD services, including efforts to "cover critical program elements not covered by" other payers.

---