Today is the last day of Sexually Transmitted Infections (STI) Awareness Month. It is a good time to recognize the importance of wider testing and expanded access to testing as a way of improving sexual health in our communities. The incidence of sexually transmitted disease (STD) is increasing in the United States per the Centers for Disease Control and Prevention. The terms STI and STD are used interchangeably, although it is possible to have infection without the disease, and it is possible to transmit infection to sexual partners without having the disease.
Recently, a team of experts in infectious diseases (Dr. Arti Barnes who has specific expertise in STIs, and me), population health (Dr. Jasmin Tiro), public health (Dr. Katelyn Jetelina and Ms. Andrea Betts) and data warehouse (Ms. Theresa Mendoza) completed a study on patterns of STD testing in North Texas and published the results in STD journal. After obtaining approval from the Institutional Review Board, we examined de-identified claims data from the Dallas Fort Worth Hospital Council Foundation data warehouse on patients who attended 54 emergency departments in Dallas, Tarrant, Collin and Denton counties on STI tests during a one-year period. We analyzed patterns of three most commonly used tests: 1) combined gonorrhea and chlamydia DNA-based tests; 2) HIV antibody tests; and 3) syphilis serological tests. Because the risk factors for acquiring these infections are the same, deciding to test for one STI might as well be combined with testing for the other STIs so that we do not miss the opportunity to diagnose them.
We found that 4.6% of all patients attending these 54 emergency departments during the year of our study were tested for at least one STD. Ninety-two percent of the patients received only one test although they may have been eligible to receive all three tests. Less than 0.2% of the patients received all three tests. A major limitation of our study is that we did not have the test results or whether these patients were treated or not.
As in the rest of the country, the incidence of STIs in Texas is increasing as well per state surveillance reports. I asked Dr. Ank Nijhawan who is an expert in Infectious Diseases, specifically HIV and STIs to weigh in. She thinks we have a strong case for two things.
1. Need for opt-out bundled testing for STIs and HIV. “For reasons that are not completely clear to me, but likely have to do with funding streams and the way in which the HIV epidemic unfolded in the US, HIV and STIs are treated like separate entities. However, we see many STIs in our HIV clinic and vice versa. When a patient presents for a possible STI, he/she should be tested for all STIs including HIV. When we have these artificial boundaries clinically – STIs managed in STI clinic, HIV in HIV clinic, clinicians may not automatically connect the two. This is why I think a bundled test order set makes sense. We don’t have to worry about remembering to order multiple tests.”
2. We need to promote Sexual Health clinics. “Although it seems minor, changing the name of a sexually transmitted disease clinic to a sexual health clinic is critical. It would be better to make the clinic less about episodic visits and offer the option of ongoing comprehensive sexual health care (e.g., regular STI screening, family planning, pre-exposure prophylaxis for HIV). We as healthcare and public health professionals need to do a better job of not only promoting the name and concept of these clinics, but we also need to let people in our communities know about them.”
The CDC in their press release in 2017 called for an effective national response that includes standardizing, integrating STD testing, and care into routine medical care, especially for pregnancy women. Interventions to increase risk- and symptom-based STI testing are needed to improve early detection and linkage to STI care services. Although we studied emergency departments in our study, it might be expensive to test patients in these locations. Urgent care clinics are better suited for this purpose, although there may not be enough of them. We need a concerted approach from healthcare systems and public health to curb the rise in STIs and promote sexual health in our communities.