In Singapore, national guidance already recommends annual gonorrhoea and chlamydia screening for everyone who is sexually active. A primary care physician explains why the offer of a test still has to be made differently – and how molecular testing removes friction.
Most of the barriers to preventing sexually transmitted infections (STIs) are not technical. Dr Tan, a primary care physician in Singapore with two decades in men’s health, treats STI screening as part of everyday preventive care. “A very big focus of our work is risk reduction,” he says.
The difficulty, though, is reaching people who don’t think they need testing.
For patients, the hardest part is asking for the test
Before a test can be offered, the subject has to be raised. Perceived stigma can make that conversation very difficult for the patient.
Researchers in Singapore interviewed 35 gay, bisexual and queer men about their testing histories; participants described sexual health clinics as spaces of costly disclosure. Attending a sexual health clinic can feel like an admission, exposing or imposing an identity that a person may not have chosen to declare. Furthermore, the judgement patients anticipate often stems from family, religion, and wider society, rather than from anything a clinician has said.1
While gay, bisexual and queer men may experience more intense stigma than other groups, that feeling of judgement may be familiar to anyone, of any sexuality, who has visited a sexual health clinic. Walking through the clinic door can be a source of intense discomfort.
Patients often misjudge their own risk
The easiest patients to identify arrive worried. They have symptoms, or a partner who has been diagnosed. “These patients are already anxious and want the test done,” Dr Tan says. “The most challenging [to identify] are those who feel well, are at risk, and don’t know it.”
He points to serial monogamy as a common blind spot. A patient moves from one exclusive relationship to the next and reasons that monogamous partners can’t put them at risk. But that judgement about a partner’s fidelity may not be correct—and it assumes everyone earlier in the chain was uninfected too.
For this reason, the Communicable Diseases Agency recommends annual chlamydia and gonorrhoea screening for everyone who is sexually active2,3.
Cases may not be identifiable by symptoms alone
STIs often present without symptoms. In Singapore, chlamydia has the highest incidence of the four notifiable STIs; most throat and rectal chlamydia infections are asymptomatic.2
More than 90% of throat and rectal gonorrhoea infections may also be asymptomatic, as may be more than 50% of cervical infections and around 10% of urethral ones3. As a result, infections may go undetected.
Economies across the Asia-Pacific region face the same challenge. Among 336 sexually active men screened at a counselling and testing centre in Kaohsiung, Taiwan, Hsieh et al. (2026) found that 76.1% of infections were found in the throat or rectum rather than the genital tract. 65.7% produced no symptoms at all.
If testing had only been offered to men reporting symptoms, 72.9% of chlamydia and 50% of gonorrhoea infections would have been missed—even with all three sites sampled4.
A negative result from one site doesn’t mean a person is infection-free
Sampling only the genital site may also miss an infection. Dr. Tan describes a man treated for urethral gonorrhoea who insisted on a single, faithful partner. The partner’s urine test was clear – but her throat swab was positive.
That pattern is replicated at scale. In a multicentre cohort of 1,610 Thai men who have sex with men, Hiransuthikul et al. (2019) found that of 249 gonorrhoea infections, screening the throat alone would have missed 55.7%, the rectum alone 39.6% and the urethra alone 77.4%5.
Molecular testing makes multi-site testing practical
Testing three sites – urine, throat and rectal – can therefore improve detection. But multi-site testing asks more of a patient than testing a single site, so the test needs to be as easy as possible to say yes to. Molecular testing helps to reduce friction in three ways:
- Samples are easy to provide. Singapore’s guidance names urine as the specimen of choice for men, with first-void urine as sensitive as a urethral swab. Self-taken vaginal swabs are accepted;2,3 invasive samples aren’t required.
- The test is accurate. Nucleic acid amplification tests (NAATs) detect an organism’s genetic material directly, with sensitivity usually well above 90% and specificity usually at or above 99%6.
- Results arrive quickly. Across 12 remote and regional primary health services in Australia, molecular point-of-care testing lifted the proportion of patients treated within seven days from 47% to 76%7, because the result arrived while the patient was still in the room.
Reframing the offer in primary care
When a doctor offers an STI test before a patient has to ask, perceived stigma is removed because the patient doesn’t have to raise the subject themselves. Dr Tan explains that STI screening could be offered alongside a cardiovascular risk assessment and routine blood panels, as one part of a longevity-focused health review.
Success is therefore determined by the conversation in the clinic. When doctors offer a test to someone who feels fine, giving the patient no reason to feel accused, we can improve uptake – and improve sexual health outcomes at scale.
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