Institute for Global Health


SEQUENCE digital

SEQUENCE digital - Sexual health equity through evidence-based online clinical care (Improving sexual health for all, in a digital NHS)

Project Summary

Multiple factors challenge the control of Sexually Transmitted Infections (STIs), including rises in key STIs, increasing antimicrobial resistance, and large-scale disinvestment in sexual health services.

Online sexual healthcare offers considerable potential for health gains and aligns with NHS digital- and self-managed strategies, but evidence for effectiveness is lacking, particularly related to clinical outcomes, impact on health inequalities, patient experience, and economic parameters. 

SEQUENCE digital addresses these challenges to provide new insights and outputs to advance the development, uptake and delivery of online clinical care within a digital NHS.

We will achieve this by optimising a previously developed innovative eSexual Health Clinic (eSHC), which contained a unique-to-the-NHS online automated clinical consultation and electronic prescribing algorithm for comprehensive management of people with chlamydia and their partners. Exploratory studies have demonstrated that this Online Chlamydia Care Pathway (OCP) was safe and delivery feasible. 

SEQUENCE digital builds on previous work to improve health outcomes for people with STIs and their partners, by developing and evaluating inclusive, comprehensive, evidence-based clinical care pathways fit for a digital NHS.

Through five inter-linking work packages (WPs), we will:

  • Determine patterns of uptake of current online versus physical sexual health services and identifies modifiable factors to increase engagement and reduce health inequalities (WP1).
  • Optimise and test the OCP, in randomised pilot studies, and through preliminary cost-consequence analyses (WP2). 
  • Conduct a RCT to determine the effectiveness of the OCP compared with routine care. We will also integrate a process evaluation to explore how content and context intersect to shape patient and partner outcomes (WP3). 
  • Evaluate the equity, efficiency and cost-effectiveness of the OCP and explore the potential impact on health inequalities (WP4).

This work is underpinned by WP5, which uses stakeholder & patient & public involvement, engagement & co-production to respond rapidly to dynamic environments and support timely translation of findings into health policy and practice.


Estcourt CS, Gibbs J, Sutcliffe LJ, Gkatzidou V, Tickle L, Hone K, Aicken C, Lowndes CM, Harding-Esch EM, Eaton S, Oakeshott P, Szczepura A, Ashcroft RE, Copas A, Nettleship A, Sadiq ST, Sonnenberg P. The eSexual Health Clinic System management, prevention and control of sexually transmitted infections: exploratory studies in people testing for Chlamydia trachomatis, Lancet Public Health 2017.

Gibbs J, Aicken CRH, Sutcliffe LJ, Gkatzidou V, Tickle LJ, Hone K, Sadiq ST, Sonnenberg P, Estcourt CS. Mixed-methods evaluation of a novel online STI results service. Sexually Transmitted Infections 2017.

Aicken CRH, Sutcliffe LJ, Gibbs J, Tickle LJ, Hone K, Harding-Esch E, Mercer CH, Sonnenberg P, Sadiq ST, Estcourt CS, Shahmanesh M. Using the eSexual Health Clinic to access chlamydia treatment and care via the internet: a qualitative interview study. Sexually Transmitted Infections. Published Online First: 07 October 2017. doi: 10.1136/sextrans-2017-053227

Gibbs J, Clifton S, Sonnenberg P, Blandford A, Johnson AM, Estcourt CS. Legislation and regulation in the era of online sexual health: how do we ensure provision of safe, high-quality care? Sexually Transmitted Infections. 94(8):550-551, 2018 12.

Singh A, Gibbs J, Estcourt C, Sonnenberg P, Blandford A. Are HIV Smartphone Apps and Online Interventions Fit for Purpose?  ACM proceedings 7th International conference on Digital Health 2017.  ACM ISBN 978-1-4503-5249-9/17/07.

Eaton S; Biggerstaff D; Petrou S; Osipenko L; Gibbs J; Estcourt CS; Sadiq T; Szczepura A.
Young people's preferences for the use of emerging technologies for asymptomatic regular chlamydia testing and management: a discrete choice experiment in England. BMJ Open. 9(1):e023663, 2019 01 29.

Gibbs J, Sonnenberg P, Estcourt CS. Confidentiality of sexual health patients’ information - what has history taught us and where do we stand? Sex Transm Infect, February 2017 - Volume 93 - 1, doi:10.1136/sextrans-2016-053045. 

Flowers P; Riddell J; Park C; Ahmed B; Young I; Frankis J; Davis M; Gilbert M; Estcourt C; Wallace L; McDaid LM. Preparedness for use of the rapid result HIV self-test by gay men and other men who have sex with men (MSM): a mixed methods exploratory study among MSM and those involved in HIV prevention and care. HIV Medicine. 18(4):245-255, 2017 Apr. UI: 27492141.  

Gibbs J, Gkatzidou V, Tickle L, Manning SR, Tilakkumar T, Hone K, Ashcroft RE, Sonnenberg P, Sadiq ST, Estcourt CS. “Can you recommend any good STI apps?” A review of content, accuracy and comprehensiveness of current mobile medical applications for sexually transmitted infections and related genital infections. Sex Transm Infect 2016, UI 2788495

Gibbs J, Sutcliffe LJ, Gkatzidou V, Hone K, Ashcroft RE, Harding-Esch EM, Lowndes CM, Sadiq ST, Sonnenberg P, Estcourt CS. The eClinical Care Pathway Framework: a novel structure for creation of online complex clinical care pathways and its application in the management of sexually transmitted infections. BMC Medical Informatics and Decision Making 2016 Jul 22;16:98. doi: 10.1186/s12911-016-0338-8.

Aicken CRH, Fuller SS, Sutcliffe LJ, Estcourt CS, Gkatzidou V, Oakeshott P, Hone K, Sadiq ST, Sonnenberg P, Shahmanesh M. Young people’s perceptions of smartphone-enabled self-testing and online care for sexually transmitted infections: qualitative interview study. BMC Public Health. 2016, 16:974. DOI: 10.1186/s12889-016-3648-y.