Only Three in Ten: Online STI Self-Sampling Struggles to Win Trust Among Gay and Bisexual Men in Southern China

A large survey of nearly a thousand men who have sex with men in southern China has found that fewer than one in three would be willing to use an online self-sampling service to test themselves for gonorrhea and chlamydia, two of the most common sexually transmitted infections worldwide. The study, conducted in 2024 across four cities in Guangdong Province and published in BMC Public Health, offers one of the most detailed pictures yet of how a technology that public health planners have championed as a way to expand screening is actually perceived by the people it is meant to reach. The result is a sobering counterpoint to the optimism that has surrounded mailed and online specimen collection kits in high-income settings, and it suggests that the barriers in China are less about logistics than about trust.

The research team, led by investigators at the Dermatology Hospital of Southern Medical University in Guangzhou, recruited 984 participants with the help of community-based organizations in Shenzhen, Foshan, Jiangmen and Yunfu. Each respondent answered questions covering sociodemographic characteristics, sexual behavior, and their attitudes toward a hypothetical online self-sampling service in which they would collect their own specimens and receive results remotely. The headline figure was stark: just 30.1 percent said they would be willing to use such a service for gonorrhea and chlamydia screening. In a population that bears a disproportionate share of the global STI burden, and where stigma and clinic access often suppress testing rates, that level of hesitancy represents a substantial missed opportunity.

The technical logic behind self-sampling is straightforward. Gonorrhea and chlamydia are caused by bacteria, Neisseria gonorrhoeae and Chlamydia trachomatis, that infect mucosal surfaces and are frequently asymptomatic, meaning that people who feel well can still transmit the infections unknowingly. Diagnosis depends on nucleic acid amplification tests, which are highly sensitive and can be run on urine specimens or swabs collected from the throat, rectum or urethra. Because these specimens can be collected without a clinician, self-sampling decouples testing from the clinic visit itself. A user orders a kit online, collects the sample at home, mails it to a laboratory, and receives results through a phone or web portal. In theory, this removes the two biggest deterrents to screening: the time and cost of travel, and the fear of being seen in a sexual health clinic.

That theory has performed reasonably well in countries such as the United Kingdom, the United States and Australia, where internet-based testing services have grown steadily and studies have repeatedly shown high acceptability among men who have sex with men. China presents a different landscape. Sexual health services are concentrated in dermatology and venereology hospitals, confidentiality concerns weigh heavily given persistent stigma toward homosexuality, and there is no established national infrastructure for mailing diagnostic specimens. The Guangdong study is among the first to quantify how these conditions shape willingness to adopt self-sampling, and the answer, at 30 percent, is considerably lower than the figures of 60 to 90 percent often reported from Western settings.

Why did so many respondents decline? The researchers asked directly, and the answers clustered around three concerns. Among those unwilling to use online self-sampling, 70.5 percent cited doubts about the accuracy and reliability of the test, 63.8 percent worried about the privacy of their data, and 60.5 percent pointed to cost. Each of these concerns is technically addressable, which is precisely what makes the findings useful. Accuracy worries can be countered with transparent information about the performance of nucleic acid amplification testing on self-collected specimens, which in clinical validation studies performs comparably to clinician-collected samples. Privacy concerns can be met with encrypted result delivery, discreet packaging and clear data governance policies. Cost can be subsidized or folded into public health programs, since treating an asymptomatic infection is far cheaper than managing its complications.

The statistical analysis added a second layer of insight by identifying who was more and less willing to embrace the technology. Using multivariable logistic regression, the team found that men who had previously used HIV pre-exposure prophylaxis, or PrEP, were markedly more open to self-sampling, with an adjusted odds ratio of 3.46, meaning their odds of willingness were roughly three and a half times those of men without PrEP experience. This makes intuitive sense. PrEP users are already engaged with a sexual health service, accustomed to regular screening, and familiar with the idea of preventive medicine delivered proactively rather than reactively. Their experience appears to build a kind of health system literacy that transfers to new testing modalities.

At the opposite end of the spectrum, two behavioral factors predicted lower acceptability. Men who reported more frequent sexual activity were less willing to use online self-sampling, as were men who reported engaging in commercial sex. This pattern is the most concerning finding in the study, because it inverts the public health ideal. The people at highest risk of acquiring and transmitting gonorrhea and chlamydia, and who therefore have the greatest need for frequent screening, are precisely the ones most reluctant to use a tool designed to make screening easier. The authors suggest several possible explanations: highly sexually active men may prefer the immediacy and reassurance of in-person clinical care, may already have established testing routines they trust, or may doubt that a mailed kit can keep pace with their testing needs. Whatever the mechanism, the implication is that a self-sampling program rolled out without attention to this group could widen rather than narrow existing screening gaps.

The cross-sectional design of the study imposes some limits on interpretation. Attitudes were measured at a single point in time, willingness was hypothetical rather than observed, and the sample was recruited through community-based organizations in one province, which may not represent men who are less connected to community networks. The authors are careful to frame their conclusions accordingly. Still, the consistency of the three dominant concerns, accuracy, privacy and cost, across a sample of nearly a thousand respondents gives the findings considerable weight, and the association with PrEP use provides a concrete lever for intervention.

That lever points toward a broader lesson about digital health adoption. Self-sampling is often described as a technology problem, as if mailing kits were the hard part. The Guangdong data suggest otherwise: the hard part is trust. A diagnostic service that asks people to handle their own specimens, share sensitive information online, and wait for results without a clinician in the room asks for a level of confidence in an unfamiliar system that cannot be assumed. The authors argue that improving health awareness, strengthening engagement with existing sexual health services, and enhancing user confidence in online platforms are the keys to raising acceptability. In practice, this could mean introducing self-sampling to PrEP cohorts first, where trust is already established, and using peer educators from community-based organizations to vouch for the service’s accuracy and discretion.

The stakes extend well beyond Guangdong. Gonorrhea and chlamydia continue to climb globally, drug-resistant gonorrhea is an escalating threat, and the World Health Organization has emphasized expanding testing as a cornerstone of control. If self-sampling is to fulfill its promise as a scalable screening strategy, it will need to work not only in London and San Francisco but in the large cities of Asia and Africa where stigma is intense and clinical capacity is stretched thin. The Chinese study is a reminder that the same kit can be a welcome convenience in one context and a source of suspicion in another. Closing that gap will require the unglamorous work of validation studies, transparent communication and community partnership, done before the technology is scaled, so that the people with the most to gain from discreet, accurate home testing are not the last to trust it.

Subject of Research: Acceptability of online self-sampling for gonorrhea and chlamydia testing among men who have sex with men in Southern China

Article Title: Acceptability of online self-sampling for gonorrhea and chlamydia among men who have sex with men in Southern China: a cross-sectional study

Article References: Acceptability of online self-sampling for gonorrhea and chlamydia among men who have sex with men in Southern China: a cross-sectional study. (n.d.). https://doi.org/10.1186/s12889-026-29791-y

Image Credits: AI Generated

DOI: 10.1186/s12889-026-29791-y

Keywords: gonorrhea, chlamydia, online self-sampling, men who have sex with men, sexually transmitted infections, STI screening, China, public health, PrEP, cross-sectional study, test acceptability, Guangdong