A US Veterans Health Administration study showed that younger populations were less likely to get guideline-recommended repeat testing for chlamydia/gonorrhea but were more likely to get HIV and syphilis testing performed.
Background
The Centers for Disease Control and Prevention (CDC) recommends testing patients with chlamydia (CT)/gonorrhea (GC) for other sexually transmitted infections (STIs) and repeating CT/GC testing 3 to 12 months later. We assessed repeat CT/GC testing and testing for HIV/syphilis in accordance with CDC guidelines in the US Veterans Health Administration.
Methods
Molecular laboratory testing for CT/GC during January 1, 2013–December 31, 2020 was retrieved from Veterans Health Administration data sources. Patients were evaluated for syphilis, HIV, and repeat CT/GC testing within 1 year after a positive CT/GC test result. Differences of CT/GC-positive patients associated with receiving recommended testing were assessed using χ2/Fisher exact tests.
Results
A total of 41,630 of 1,005,761 CT (4.1%) and 17,649 of 1,013,198 GC (1.7%) results were positive. Median ages of positive CT/GC patients were 29 and 36 years, respectively. Repeat testing rates for CT/GC within 90 to 119 days were 3.9% and 2.9%, and rates within 90 to 365 days were 32.8% and 34.7%, with 8.6% and 15% being positive again, respectively. Guideline-compatible repeat testing in known HIV-positive patients nearly doubled (75.7% for CT and 67.8% for GC). The CDC-recommended HIV testing was performed for 72.4% and 65.5% CT and GC first positives, respectively, whereas syphilis testing was completed for 66.5% and 60.5% CT and GC, respectively. Compared with 25- to 34-year-old patients with CT or GC, those younger than 25 years had higher odds of guideline-discordant repeat testing but had lower odds of not receiving HIV/syphilis testing.
Conclusions
Nearly two-thirds of patients did not receive recommended repeat testing, and nearly one-third were not tested for HIV/syphilis. Veterans Health Administration providers may benefit from additional education on CDC-recommended sexually transmitted infection guidelines and testing recommendations.
Chlamydia (CT) and gonorrhea (GC) infections caused by Chlamydia trachomatis and Neisseria gonorrhoeae, respectively, are among the most common sexually transmitted infections (STIs) in the United States.1 Untreated infections can lead to significant morbidity, particularly in female individuals, leading to pelvic inflammatory disease, ectopic pregnancy, and infertility.1 Therefore, identification and appropriate treatment of symptomatic and asymptomatic infection is important to decrease transmission rates and minimize complications.
For patients with documented CT or GC infections, a test of cure (TOC) at 4 weeks after completing therapy is not recommended unless the patient is pregnant or treated for pharyngeal GC (TOC for pharyngeal GC was not recommended in 2010; in 2015, it was recommended for all with pharyngeal GC treated with an alternative agent, but more recent guidelines in 2021 recommend TOC for all pharyngeal GC infections).1 However, the Centers for Disease Control and Prevention (CDC) recommends repeating CT/GC testing 3 months after infection because of high risk of reinfection.1 If retesting at 3 months is not possible, then retesting whenever the patient next seeks medical care within 12 months after initial treatment is recommended.1 Several studies have shown that, although patients are often treated for CT/GC, they are often not retested for reinfection or screened for other STIs such as human immunodeficiency virus (HIV) and syphilis.2–9 McWhirter et al.2 found that, among 14- to 24-year-old patients from an urban federally qualified health center system, 39.9% of patients were noted to have CT/GC repeat testing within 2 to 6 months after a positive test result. Rose et al.3–5 studied repeat testing at 6 weeks to 6 months after a positive CT/GC test result in patients of all age ranges from New Zealand and found that 25% to 34% were retested and 18% to 21% of those were positive again.
In addition to repeat testing, the CDC also recommends patients with CT/GC be screened for other STIs, including HIV and syphilis.1 Several studies have looked at testing for HIV and syphilis after a diagnosis of another STI and found that testing rates ranged from 15% to 55%.2,6,10–14 McWhirter et al.2 also evaluated HIV and syphilis testing within 6 months of a CT or GC infection and found that approximately 54% and 50% had HIV and syphilis testing performed, respectively.
The Veterans Health Administration (VHA) includes more than 1275 inpatient or outpatient health care facilities nationwide and in US territories and serviced more than 6.81 million Veterans in fiscal year 2021.15 Several studies have evaluated CT/GC in Veterans. These studies evaluated societal factors that increased the risk of STIs in Veteran compared with nonVeteran men, as well as documenting rising rates of STIs in Veterans.16–18 Herein, we evaluated the frequency of repeat testing 3 to 12 months after CT/GC infection, frequency of testing for HIV/syphilis after CT/GC infection, and characteristics associated with guideline-discordant testing in VHA.
MATERIALS AND METHODS
Data for CT/GC molecular laboratory tests during January 1, 2013–December 31, 2020 were retrieved from VHA Corporate Data Warehouse (a national repository of data from clinical and administrative systems) for individuals tested in outpatient or inpatient VHA settings including active-duty personnel seeking care at a federal facility (one that treats both active-duty and Veterans), Veterans, and Tricare (the uniformed services health care program for active duty and retirees as well as their dependents) participants. Repeat tests within 30 days of a positive result were removed to prevent inclusion of patients who were repeatedly tested for the same infection. Nonmolecular testing was excluded because the number of nonmolecular tests was limited. Centers for Disease Control and Prevention guidelines from 2010 to 2021 (which largely stayed the same in regard to follow-up testing, although changed slightly in terms of TOC for pharyngeal GC) were used to determine recommended testing.1 Patients were evaluated for repeat CT/GC testing within 1 year (<90 days, 90–365 days, or no repeat testing) after any positive GC or CT test result. Testing from 90 to 119 days was also evaluated to determine the number of patients being tested during the CDC's preferred time frame. However, testing being performed within 90 to 365 days was considered guideline compatible because if testing at 3 months is not possible, then testing within 12 months is acceptable per CDC guidelines.1 Guideline-discordant testing was considered those either retested at <90 days or not retested within 365 days after a positive CT/GC result. HIV screening and confirmatory tests and serologic syphilis tests were evaluated within 30 days before and within 365 days after a positive CT/GC result. Newly tested syphilis and HIV results were not determined to be previously known to be positive or new. Median days and interquartile range (IQR) from CT/GC diagnosis to HIV/syphilis testing was also evaluated. Those known to be positive for HIV were identified and compared with those who were HIV negative. Patients with any positive HIV screening or confirmatory test result before December 31, 2019, were defined as known HIV positive and evaluated for repeat CT/GC testing and syphilis testing. Sex, age, race/ethnicity, US Health and Human Service (HHS) geographic regions based on patient residence (https://www.hhs.gov/about/agencies/iea/regional-offices/index.html), rurality, and medical complexity of the performing facility were obtained.19 Differences in proportions for characteristics of CT/GC-positive patients associated with receiving recommended testing were analyzed using the χ2 or Fisher exact tests (Open Epi version 3.01, www.openepi.com, Atlanta, GA). Odds ratios (ORs) and confidence intervals (CI) were calculated. Median age and IQR were calculated, and a 2-sided Wilcoxon rank sum test (https://astatsa.com/WilcoxonTest/) was used to compare medians.
This project was approved by the Stanford University Institutional Review Board (Protocol ID 47191), “Public Health Surveillance in the Department of Veterans Affairs,” and written informed consent was waived.
RESULTS
A total of 41,630 of 1,005,761 CT results (4.1%) (36,138 of 585,791 unique patients [6.2%]) and 17,649 of 1,013,198 GC results (1.7%) (14,598 of 589,581 unique patients [2.5%]) were positive. Most patients were male (70.2% in CT and 89.2% in GC), and the median ages (IQR) of positive CT/GC patients were 29 (25–35) and 36 (29–51) years, respectively. Although the largest percentage of cases was in the 25- to 34-year age group, there were 1376 patients in the greater than 65-year age group testing positive with the oldest patient being 88 years old. The majority of CT or GC cases were diagnosed in high complexity medical facilities and in urban areas. Most CT cases were identified as non-Hispanic White and in HHS region 5 Chicago, whereas most GC cases were in non-Hispanic Black or African American (Black) and in HHS region 4 Atlanta (Table 1).
TABLE 1.
Positive Chlamydia (CT) or Gonorrhea (GC) Test Results in VHA, 2013 to 2019
| CT POS (N = 41,630), n (%) | GC POS (N = 17,649), n (%) | |
|---|---|---|
| Sex | ||
| F | 12,400 (29.8) | 1907 (10.8) |
| M | 29,230 (70.2) | 15,742 (89.2) |
| Age, median (IQR), y | 29 (25–35) | 36 (29–51) |
| Age groups, y | ||
| <25 | 9682 (23.3) | 1333 (7.6) |
| 25–34 | 20,917 (50.2) | 6638 (37.6) |
| 35–44 | 6207 (14.9) | 3595 (20.4) |
| 45–54 | 2787 (6.7) | 2797 (15.8) |
| 55–64 | 1538 (3.7) | 2409 (13.6) |
| 65+ | 499 (1.2) | 877 (5.0) |
| Race/Ethnicity | ||
| Non-Hispanic, American Indian, or Alaska Native | 439 (1.1) | 144 (0.8) |
| Non-Hispanic, Asian | 760 (1.8) | 149 (0.8) |
| Non-Hispanic, Black, or African American | 15,716 (37.8) | 9676 (54.8) |
| Hispanic/Latino | 1194 (2.9) | 351 (2.0) |
| Non-Hispanic, >1 race | 809 (1.9) | 386 (2.2) |
| Non-Hispanic, Native Hawaiian, or other Pacific Islander | 600 (1.4) | 145 (0.8) |
| Unknown | 1875 (4.5) | 591 (3.4) |
| Non-Hispanic, White | 20,237 (48.6) | 6207 (35.2) |
| HHS regions | ||
| Region 1: Boston | 1218 (2.9) | 382 (2.1) |
| Region 2: New York | 1469 (3.5) | 682 (3.9) |
| Region 3: Philadelphia | 3242 (7.8) | 1962 (11.1) |
| Region 4: Atlanta | 8772 (21.1) | 4656 (26.4) |
| Region 5: Chicago | 9866 (23.7) | 2449 (13.9) |
| Region 6: Dallas | 6062 (14.6) | 2647 (15.0) |
| Region 7: Kansas City | 1494 (3.8) | 811 (4.6) |
| Region 8: Denver | 1323 (3.2) | 474 (2.7) |
| Region 9: San Francisco | 6296 (15.1) | 2947 (16.7) |
| Region 10: Seattle | 1788 (4.3) | 639 (3.6) |
| Rurality | ||
| Rural | 1146 (2.8) | 454 (2.6) |
| Urban | 40,484 (97.2) | 17,195 (97.4) |
| Medical complexity of facility | ||
| 1: High complexity* | 31,235 (75.0) | 15,495 (87.8) |
| 2: Medium complexity | 2424 (5.8) | 1008 (5.7) |
| 3: Low complexity | 2314 (5.6) | 730 (4.1) |
| Combined federal facility† | 5657 (13.6) | 416 (2.4) |
HHS regions: 1: Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont; 2: New Jersey, New York, Puerto Rico, and the Virgin Islands; 3: Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, and West Virginia; 4: Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee; 5: Illinois, Indiana, Michigan, Minnesota, Ohio, and Wisconsin; 6: Arkansas, Louisiana, New Mexico, Oklahoma, and Texas; 7: Iowa, Kansas, Missouri, and Nebraska; 8: Colorado, Montana, North Dakota, South Dakota, Utah, and Wyoming; 9: Arizona, California, Hawaii, Nevada, American Samoa, Commonwealth of the Northern Mariana Islands, Federated States of Micronesia, Guam, Marshall Islands, and Republic of Palau; 10: Alaska, Idaho, Oregon, and Washington.
*1: High complexity facilities include facilities in 1a, 1b, and 1c categories.
†Combined federal facility is not categorized as level 1, 2, or 3 so is broken out separately.
F indicates female; IQR, interquartile range; M, male.
Repeat Testing After Initial CT/GC Positive
Repeat testing at 90 to 119 days from initial CT or GC infection occurred in 3.9% and 2.9%, respectively. Repeat testing within 90 to 365 days from initial CT or GC infection occurred in 32.8% and 34.7%, respectively (Table 2). Of CT/GC positives receiving guideline-compatible repeat testing within 90 to 365 days, 8.6% of CT and 15% of GC were again positive. From 2013 to 2018, the percent receiving guideline-compatible repeat testing for CT and GC at 90 to 365 days, gradually increased annually from 25.6% to 38.3% and 26.6% to 39%, respectively. In 2019, the percent receiving repeat testing at 90 to 365 days (which extended through 2020 and coincided with the COVID-19 pandemic) fell slightly for both CT and GC to 34.4% and 36.4%, respectively. Of those tested <90 days from a CT/GC positive result, 9.6% were positive again for CT and 13.5% for GC. In patients with CT that were retested in <90 days and had a positive result, the median time to repeat positive test result was 28 days (mean, 33.1 days), whereas the median was 51 days (mean, 47.8 days) for GC. Compared with female patients, male patients had lower odds of repeat testing <90 days from a positive result (CT: OR, 0.9 [95% CI, 0.8–0.9]; GC: OR, 0.7 [95% CI, 0.6–0.8]). For CT, male in comparison to female patients had lower odds of not receiving repeat testing within 365 days (OR, 0.8 [95% CI, 0.8–0.9]), but for GC, male patients had higher odds of not receiving repeat testing within 365 days (OR, 1.6 [95% CI, 1.4–1.8]). Compared with 25- to 34-year-old patients, those younger than 25 years had higher odds of guideline-discordant repeat testing for both CT and GC (repeat testing <90 days: ORs, 1.2 [95% CI, 1.1–1.3] and 1.3 [95% CI, 1.1–1.6]; no repeat testing: ORs, 2.3 [95% CI, 2.1–2.4] and 1.2 [1.1–1.4], respectively). Compared with non-Hispanic White CT-positive individuals, non-Hispanic Black, and those of more than one race had lower odds of guideline-discordant repeat testing (repeat testing <90 days: ORs, 0.7 [95% CI, 0.7–0.8] and 0.8 [95% CI, 0.6–0.9]; no repeat testing: ORs, 0.8 [95% CI, 0.8–0.9] and 0.7 [95% CI, 0.6–0.8], respectively). For GC, only more than one race had lower odds of guideline-discordant repeat testing for both testing <90 days from positive result (OR, 0.6 [95% CI, 0.4–0.9]) as well as not receiving repeat testing in 365 days (OR, 0.7 [95% CI, 0.6–0.9]) compared with non-Hispanic White individuals. Compared with urban areas, those in rural areas with GC had higher odds of guideline-discordant testing (repeat testing <90 days: (OR, 1.9 [95% CI, 1.4–2.6]; no repeat testing in 365 days: OR, 2.1 [95% CI, 1.6–2.6]). However, for CT-positive patients in rural areas compared with those in urban areas, there was only an increased odds of not receiving repeat testing in 365 days (OR, 1.2 [95% CI, 1.1–1.4]). Compared with high complexity medical facilities, CT- or GC-positive patients presenting to medium complexity, low complexity, or a combined federal facility had higher odds of guideline-discordant repeat testing in both those with testing <90 days from positive result as well as no repeat testing in 365 days (Table 2).
TABLE 2.
Repeat Testing After Positive Chlamydia (CT; N = 41,630) or Positive Gonorrhea (GC) (N = 17,649) Test Results Within 365 Days
| Repeat Testing After Positive CT Test Results (N = 41,630) Within 365 d | Repeat Testing After Positive GC Test Results (N = 17,649) Within 365 d | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Repeat Testing in 90–365 d From CT POS Result (N = 13,649), n (%) | Repeat Testing in <90 d From CT POS Result (N = 6548), n (%) | Odds Ratio (CI) |
No Repeat Testing in 365 d From CT POS Result (N = 21,433), n (%) | Odds Ratio (CI) | Repeat Testing 90–365 d From GC POS Result (N = 6119), n (%) | Repeat Testing <90 d From GC POS Result (N = 2152), n (%) | Odds Ratio (CI) |
No Repeat Testing in 365 d From GC POS Result (N = 9378), n (%) | Odds Ratio (CI) | |
| Sex | ||||||||||
| F | 3759 (30.3) | 1950 (15.7) | Referent | 6691 (54.0) | Referent | 769 (40.3) | 369 (19.4) | Referent | 769 (40.3) | Referent |
| M | 9890 (33.8) | 4598 (15.7) | 0.9 (0.8–0.9) | 14,742 (50.5) | 0.8 (0.8–0.9) | 5350 (34.0) | 1783 (11.3) | 0.7 (0.6–0.8) | 8609 (54.7) | 1.6 (1.4–1.8) |
| Age, median (IQR) | 30 (26–36) | 30 (26–36) | NA | 28 (24–34) | NA | 35 (29–47) | 36 (30–51) | NA | 37 (30–52) | NA |
| Age groups, y | ||||||||||
| <25 | 2099 (21.7) | 1200 (12.4) | 1.2 (1.1–1.3) | 6383 (65.9) | 2.3 (2.1–2.4) | 447 (33.5) | 174 (13.1) | 1.3 (1.1–1.6) | 712 (53.4) | 1.2 (1.1–1.4) |
| 25–34 | 7405 (35.4) | 3499 (16.7) | Referent | 10,013 (47.9) | Referent | 2564 (38.6) | 766 (11.6) | Referent | 3308 (49.8) | Referent |
| 35–44 | 2261 (36.4) | 1091 (17.6) | 1.0 (0.9–1.1) | 2855 (46.0) | 0.9 (0.9–1.0) | 1340 (37.2) | 459 (12.8) | 1.1 (1.0–1.3) | 1796 (50.0) | 1.0 (1.0–1.1) |
| 45–54 | 1083 (38.9) | 438 (15.7) | 0.9 (0.8–1.0) | 1266 (45.4) | 0.9 (0.8–1.0) | 885 (31.6) | 321 (11.5) | 1.2 (1.0–1.4) | 1591 (56.9) | 1.4 (1.3–1.5) |
| 55–64 | 608 (39.5) | 227 (14.8) | 0.8 (0.7–0.9) | 703 (45.7) | 0.9 (0.8–1.0) | 669 (27.8) | 290 (12.0) | 1.5 (1.2–1.7) | 1450 (60.2) | 1.7 (1.5–1.9) |
| 65+ | 193 (38.7) | 93 (18.6) | 1.0 (0.8–1.3) | 213 (42.7) | 0.8 (0.7–1.0) | 214 (24.4) | 142 (16.2) | 2.2 (1.8–2.8) | 521 (59.4) | 1.9 (1.6–2.2) |
| Test result | ||||||||||
| Negative | 12,475 (67.8) | 5922 (32.2) | Referent | NA | NA | 5201 (73.6) | 1861 (26.4) | Referent | NA | NA |
| Positive | 1173 (65.2) | 626 (34.8) | 1.1 (1.0–1.2) | NA | NA | 918 (75.9) | 291 (24.1) | 0.9 (0.8–1.0) | NA | NA |
| Unknown | 1 (100) | 0 (0) | 1.1 (0.04–31.4)‡ | NA | NA | 0 (0) | 0 (0) | 2.8 (0.06–140.9) | NA | NA |
| Race/Ethnicity | ||||||||||
| Non-Hispanic, American Indian, or Alaska Native | 141 (32.1) | 71 (16.2) | 0.9 (0.7–1.2) | 227 (51.7) | 0.9 (0.8–1.2) | 60 (41.7) | 25 (17.3) | 1.1 (0.7–1.7) | 59 (41.0) | 0.6 (0.4–0.9) |
| Non-Hispanic, Asian | 317 (41.7) | 140 (18.4) | 0.8 (0.6–1.0) | 303 (39.9) | 0.6 (0.5–0.7) | 61 (40.9) | 24 (16.1) | 1.0 (0.6–1.6) | 64 (43.0) | 0.6 (0.5–0.9) |
| Non-Hispanic, Black, or African American | 5541 (35.3) | 2183 (13.9) | 0.7 (0.7–0.8) | 7992 (50.8) | 0.8 (0.8–0.9) | 3406 (35.2) | 1106 (11.4) | 0.8 (0.7–0.9) | 5164 (53.4) | 0.9 (0.9–1.0) |
| Hispanic/Latino | 451 (37.8) | 213 (17.8) | 0.9 (0.7–1.0) | 530 (44.4) | 0.7 (0.6–0.8) | 140 (39.9) | 49 (14.0) | 0.9 (0.6–1.3) | 162 (46.1) | 0.7 (0.6–0.9) |
| Non-Hispanic, >1 race | 316 (39.1) | 130 (16.1) | 0.8 (0.6–0.9) | 363 (44.8) | 0.7 (0.6–0.8) | 158 (40.9) | 39 (10.1) | 0.6 (0.4–0.9) | 189 (49.0) | 0.7 (0.6–0.9) |
| Non-Hispanic, Native Hawaiian, or other Pacific Islander | 162 (27.0) | 91 (15.2) | 1.0 (0.8–1.3) | 347 (57.8) | 1.3 (1.0–1.5) | 58 (40.0) | 23 (15.9) | 0.9 (0.6–1.7) | 64 (44.1) | 0.7 (0.5–1.0) |
| Unknown | 498 (26.6) | 322 (17.2) | 1.2 (1.0–1.4) | 1055 (56.2) | 1.2 (1.1–1.4) | 172 (29.1) | 78 (13.2) | 1.2 (0.9–1.5) | 341 (57.7) | 1.2 (1.0–1.5) |
| Non-Hispanic, White | 6223 (30.8) | 3398 (16.8) | Referent | 106,16 (52.4) | Referent | 2064 (33.3) | 808 (13.0) | Referent | 3335 (53.7) | Referent |
| Rurality | ||||||||||
| Rural | 328 (28.6) | 184 (16.1) | 1.2 (1.0–1.4) | 634 (55.3) | 1.2 (1.1–1.4) | 95 (20.9) | 63 (13.9) | 1.9 (1.4–2.6) | 296 (65.2) | 2.1 (1.6–2.6) |
| Urban | 13,321 (32.9) | 6364 (15.7) | Referent | 20,799 (51.4) | Referent | 6024 (35.0) | 2089 (12.2) | Referent | 9082 (52.8) | Referent |
| Medical complexity of facility | ||||||||||
| 1: High complexity* | 11,776 (37.7) | 5197 (16.6) | Referent | 14,262 (45.7) | Referent | 5622 (36.3) | 1867 (12.0) | Referent | 8006 (51.7) | Referent |
| 2: Medium complexity | 724 (29.9) | 426 (17.6) | 1.3 (1.2–1.5) | 1274 (52.5) | 1.5 (1.3–1.6) | 249 (24.7) | 122 (12.1) | 1.5 (1.2–1.8) | 637 (63.2) | 1.8 (1.5–2.1) |
| 3: Low complexity | 663 (28.7) | 412 (17.8) | 1.4 (1.2–1.6) | 1239 (53.5) | 1.5 (1.4–1.7) | 182 (24.9) | 106 (14.5) | 1.8 (1.4–2.2) | 442 (60.6) | 1.7 (1.4–2.0) |
| Combined federal facility† | 486 (8.6) | 513 (9.1) | 2.4 (2.1–2.7) | 4658 (82.3) | 7.9 (7.2–8.7) | 64 (15.4) | 59 (14.2) | 2.8 (1.9–4.0) | 293 (70.4) | 3.2 (2.4–4.2) |
*1: High complexity facilities include facilities in 1a, 1b, and 1c categories.
†Combined federal facility is not categorized as level 1, 2, or 3 and so is broken out separately.
‡Fisher exact test used.
Boldface indicates statistical significance.
CI, confidence interval; F indicates female; IQR, interquartile range; M, male.
Testing for Syphilis and HIV in CT/GC-Positive Patients
HIV testing within 1 year was performed for 72.4% and 65.5% CT and GC first positives, respectively, whereas syphilis testing was performed for 66.5% and 60.5% CT and GC, respectively (Table 3). In CT and GC patients tested, HIV tests were positive in 2.1% and 5.9%, and syphilis was positive in 4.1% and 11.3%, respectively, although the results were not determined to be new or known positive. HIV and syphilis testing in CT-positive patients from 2013 to 2019 has increased annually from 68.3% to 76% and 56.7% to 72.3%, respectively. For HIV testing in GC-positive patients, in 2013 it was 66% and dropped to 63.3% in 2014 and then slowly increased to 67.5% in 2019. For syphilis testing in GC-positive patients from 2013 to 2019, the percent being tested has steadily increased from 56.3% to 65.2%. The majority of positive CT cases were also tested for HIV and syphilis on the same day, whereas there was increased time before testing for HIV and syphilis in those positive for GC. Median time (IQR) between HIV or syphilis testing and CT positive test result was 0 days (0–0 days) for both HIV and syphilis testing, whereas for GC it was 0 days (0–31 days for HIV and 0–11 days for syphilis) for HIV and syphilis testing. Male patients tested positive for CT/GC had higher odds (CT: OR, 1.4 [95% CI, 1.3–1.4]; GC: OR, 1.5 [95% CI, 1.3–1.6]) of not receiving HIV testing or syphilis testing (CT: OR, 1.2 [95% CI, 1.2–1.3]; GC: OR, 1.3 [95% CI, 1.1–1.4]) when compared with female patients. Those younger than 25 years in both the CT and GC groups had lower odds of not receiving HIV (CT: OR, 0.5 [95% CI, 0.5–0.6]; GC: OR, 0.3 [95% CI, 0.3–0.4]) or syphilis testing (CT: OR, 0.5 [95% CI, 0.4–0.5]; GC: OR, 0.8 [95% CI, 0.7–0.9]) when compared with the 25- to 34-year-old age group. For both CT and GC patients, non-Hispanic Asian individuals had lower odds of not receiving HIV testing (CT: OR, 0.7 [95% CI, 0.6–0.8]; GC: OR, 0.6 [95% CI, 0.4–0.9]), whereas Hispanic/Latino individuals had lower odds of not receiving syphilis testing for both CT and GC (CT: OR, 0.8 [95% CI, 0.7–0.9]; GC: OR, 0.7 [95% CI, 0.6–0.9]) when compared with non-Hispanic White individuals. Those positive for CT and GC in rural areas had higher odds of not receiving HIV or syphilis testing (HIV: CT, OR of 1.7 [95% CI, 1.5–1.9]; GC, OR of 1.3 [95% CI, 1.1–1.6]; syphilis: CT, OR of 1.9 [95% CI, 1.6–2.1]; GC: OR of 1.4 [95% CI, 1.1–1.7]) compared with patients in urban areas. Those positive for CT and GC who presented to medium medical complexity facilities had higher odds of not receiving HIV testing (CT: OR, 1.4 [95% CI, 1.3–1.6]; GC: OR, 1.4 [95% CI, 1.2–1.4]) or syphilis testing (CT: OR, 1.5 [95% CI, 1.4–1.7]; GC: OR, 1.3 [95% CI, 1.2–1.5]) when compared with high complexity facilities.
TABLE 3.
Human Immunodeficiency Virus (HIV) or Syphilis Testing After 1st Positive Chlamydia (CT) (N = 36,138) or Gonorrhea (GC) (N = 14,598) Test Within 365 Days
| HIV Testing After 1st Positive CT (N = 36,138) or GC (N = 14,598) Test Result Within 365 d | Syphilis Testing After 1st Positive CT (N = 36,138) or GC (N = 14,598) Test Result Within 365 d | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| CT POS Tested for HIV (N = 26,166), n (%) | CT POS Not Tested for HIV (N = 9972), n (%) | Odds Ratio (CI) | GC POS Tested for HIV (N = 9567), n (%) | GC POS Not Tested for HIV (N = 5031), n (%) | Odds Ratio (CI) | CT POS Tested for Syphilis (N = 24,029), n (%) | CT POS Not Tested for Syphilis (N = 12,109), n (%) | Odds Ratio (CI) | GC POS Tested for Syphilis (N = 8828), n (%) | GC POS Not Tested for Syphilis (N = 5770), n (%) | Odds Ratio (CI) | |
| Sex | ||||||||||||
| F | 8604 (76.6) | 2628 (23.4) | Referent | 1268 (72.6) | 479 (27.4) | Referent | 7815 (69.6) | 3417 (30.4) | Referent | 1141 (65.3) | 606 (34.7) | Referent |
| M | 17,562 (70.5) | 7344 (29.5) | 1.4 (1.3–1.4) | 8299 (64.6) | 4552 (35.4) | 1.5 (1.3–1.6) | 16,214 (65.1) | 8692 (34.9) | 1.2 (1.2–1.3) | 7687 (59.8) | 5164 (40.2) | 1.3 (1.1–1.4) |
| Age, median (IQR), y | 28 (24–35) | 30 (26–36) | NA | 35 (29–50) | 37 (30–53) | NA | 28 (24–35) | 30 (26–36) | NA | 35 (29–50) | 37 (30–52) | NA |
| Age groups, y | ||||||||||||
| <25 | 7267 (81.3) | 1675 (18.7) | 0.5 (0.5–0.6) | 876 (72.6) | 330 (27.4) | 0.3 (0.3–0.4) | 6850 (76.6) | 2092 (23.4) | 0.5 (0.4–0.5) | 816 (67.7) | 390 (32.3) | 0.8 (0.7–0.9) |
| 25–34 | 12,280 (69.3) | 5447 (30.7) | Referent | 3637 (67.1) | 1780 (32.9) | Referent | 11,089 (62.6) | 6638 (37.4) | Referent | 3361 (62.0) | 2056 (38.0) | Referent |
| 35–44 | 3680 (69.5) | 1617 (30.5) | 1.0 (0.9–1.1) | 1890 (65.4) | 999 (34.6) | 1.1 (1.0–1.2) | 3375 (63.7) | 1922 (36.3) | 1.0 (0.9–1.0) | 1740 (60.2) | 1149 (39.8) | 1.1 (1.0–1.2) |
| 45–54 | 1696 (70.3) | 717 (29.7) | 1.0 (0.9–1.0) | 1520 (65.0) | 818 (35.0) | 1.1 (1.0–1.2) | 1549 (64.2) | 864 (35.8) | 0.9 (0.9–1.0) | 1391 (59.5) | 947 (40.5) | 1.1 (1.0–1.2) |
| 55–64 | 937 (69.8) | 405 (30.2) | 1.0 (0.9–1.1) | 1207 (60.0) | 803 (40.0) | 1.4 (1.2–1.5) | 879 (65.5) | 463 (34.5) | 0.9 (0.8–1.0) | 1120 (55.7) | 890 (44.3) | 1.3 (1.2–1.4) |
| 65+ | 306 (73.4) | 111 (26.6) | 0.8 (0.7–1.1) | 437 (59.2) | 301 (40.8) | 1.4 (1.2–1.6) | 287 (68.8) | 130 (31.2) | 0.7 (0.6–0.9) | 400 (54.2) | 338 (45.8) | 1.4 (1.2–1.6) |
| Race/Ethnicity | ||||||||||||
| Non-Hispanic, American Indian, or Alaska Native | 274 (71.5) | 109 (28.5) | 1.0 (0.8–1.3) | 79 (68.7) | 36 (31.3) | 0.9 (0.6–1.3) | 256 (66.8) | 127 (33.2) | 0.9 (0.8–1.2) | 74 (64.3) | 41 (35.7) | 0.9 (0.6–1.3) |
| Non-Hispanic, Asian | 505 (78.5) | 138 (21.5) | 0.7 (0.6–0.8) | 104 (76.5) | 32 (23.5) | 0.6 (0.4–0.9) | 443 (68.9) | 200 (31.1) | 0.8 (0.7–1.0) | 100 (73.5) | 36 (26.5) | 0.6 (0.4–0.9) |
| Non-Hispanic, Black, or African American | 9780 (72.8) | 3657 (27.2) | 0.9 (0.9–1.0) | 5007 (64.1) | 2800 (35.9) | 1.1 (1.0–1.2) | 8957 (66.7) | 4480 (33.3) | 0.9 (0.9–1.0) | 4555 (58.3) | 3252 (41.7) | 1.2 (1.1–1.2) |
| Hispanic/Latino | 778 (76.2) | 243 (23.8) | 0.8 (0.7–0.9) | 208 (71.0) | 85 (29.0) | 0.8 (0.6–1.1) | 711 (69.6) | 310 (30.4) | 0.8 (0.7–0.9) | 203 (69.3) | 90 (30.7) | 0.7 (0.6–0.9) |
| Non-Hispanic, >1 race | 496 (72.6) | 187 (27.4) | 0.9 (0.8–1.1) | 216 (70.4) | 91 (29.6) | 0.8 (0.6–1.1) | 446 (65.3) | 237 (34.7) | 1.0 (0.9–1.2) | 205 (66.8) | 102 (33.2) | 0.8 (0.6–1.0) |
| Non-Hispanic, Native Hawaiian, or other Pacific Islander | 404 (76.5) | 124 (23.5) | 0.8 (0.6–0.9) | 85 (72.0) | 33 (28.0) | 0.8 (0.5–1.2) | 381 (72.2) | 147 (27.8) | 0.7 (0.6–0.9) | 81 (68.6) | 37 (31.4) | 0.7 (0.5–1.1) |
| Unknown | 1301 (77.4) | 379 (22.6) | 0.7 (0.6–0.8) | 338 (66.0) | 174 (34.0) | 1.0 (0.8–1.2) | 1237 (73.6) | 443 (26.4) | 0.7 (0.6–0.8) | 322 (62.9) | 190 (37.1) | 1.0 (0.8–1.2) |
| Non-Hispanic, White | 12,628 (71.1) | 5135 (28.9) | Referent | 3530 (66.5) | 1780 (33.5) | Referent | 11,598 (65.3) | 6165 (34.7) | Referent | 3288 (61.9) | 2022 (38.1) | Referent |
| Rurality | ||||||||||||
| Rural | 619 (61.0) | 396 (39.0) | 1.7 (1.5–1.9) | 239 (59.5) | 163 (40.5) | 1.3 (1.1–1.6) | 528 (52.0) | 487 (48.0) | 1.9 (1.6–2.1) | 212 (52.7) | 190 (47.3) | 1.4 (1.1–1.7) |
| Urban | 25,547 (72.7) | 9576 (27.3) | Referent | 9328 (65.7) | 4868 (34.3) | Referent | 23,501 (66.9) | 11,622 (33.1) | Referent | 8616 (60.7) | 5580 (39.3) | Referent |
| Medical complexity of facility | ||||||||||||
| 1: High complexity* | 18,566 (70.0) | 7965 (30.0) | Referent | 8300 (65.5) | 4379 (34.5) | Referent | 16,830 (63.4) | 9701 (36.6) | Referent | 7625 (60.1) | 5054 (39.9) | Referent |
| 2: Medium complexity | 1322 (61.9) | 815 (38.1) | 1.4 (1.3–1.6) | 515 (57.6) | 379 (42.4) | 1.4 (1.2–1.6) | 1137 (53.2) | 1000 (46.8) | 1.5 (1.4–1.7) | 475 (53.1) | 419 (46.9) | 1.3 (1.2–1.5) |
| 3: Low complexity | 1331 (65.3) | 706 (34.7) | 1.2 (1.1–1.4) | 393 (62.6) | 235 (37.4) | 1.1 (1.0–1.4) | 1201 (59.0) | 836 (41.0) | 1.2 (1.1–1.3) | 388 (61.8) | 240 (38.2) | 0.9 (0.8–1.1) |
| Combined federal facility† | 4947 (91.1) | 486 (8.9) | 0.2 (0.2–0.3) | 359 (90.4) | 38 (9.6) | 0.2 (0.1–0.3) | 4861 (89.5) | 572 (10.5) | 0.2 (0.2–0.3) | 340 (85.6) | 57 (14.4) | 0.3 (0.2–0.3) |
*1: High complexity facilities include facilities in 1a, 1b, and 1c categories.
†Combined federal facility is not categorized as level 1, 2, or 3 and so is broken out separately.
Boldface indicates statistical significance.
CI, confidence interval; F indicates female; IQR, interquartile range; M, male.
HIV Cohort
A total of 889 of 41,630 (2.1%) and 1907 of 17,649 (10.8%) individuals were identified in the CT- and GC-positive groups, respectively, as having a positive HIV result before December 31, 2019 (Supplementary Digital Content Table 1, results of analysis, http://links.lww.com/OLQ/A911). Guideline-compatible repeat testing values in the HIV cohort were 673 of 889 (75.7%) for CT and 1293 of 1907 (67.8%) for GC (Supplementary Digital Content Table 2, results of analysis, http://links.lww.com/OLQ/A911). For those known to be HIV positive who were also positive for GC, compared with the 25- to 34-year age group, there was higher odds of guideline-discordant testing with repeat testing <90 days from a positive GC result in the 55- to 64-year and 65+-year age groups (OR of 2.1 [95% CI, 1.3–3.6] and OR of 2.7 [95% CI, 1.1–6.1], respectively) as well as no repeat testing in 365 days in the age groups 45–54 and 55–64 years (OR of 1.5 [95% CI, 1.1–2.0] and OR of 1.7 [95% CI, 1.2–2.4], respectively). Compared with high complexity facilities, medium and low complexity facilities tended to have higher odds of guideline-discordant testing (<90 days or no repeat testing in 365 days), although all did not reach significance.
Syphilis testing after the first positive CT or GC result occurred in 507 of 539 (94.1%) for CT and 1135 of 1247 (91%) for GC in the HIV cohort (Supplementary Digital Content Table 3, results of analysis, http://links.lww.com/OLQ/A911). Of those who were known to be HIV positive and tested for syphilis, the result was positive 46.7% for CT and 43.5% for GC, although the results were not determined to be new or previously known to be positive. Known HIV positives who were GC positive at medium complexity facilities had higher odds of not receiving syphilis testing when compared with high complexity facilities (OR, 3.5 [95% CI, 1.4–8.2]).
DISCUSSION
Several studies have evaluated the risk of STIs in US Veterans, but none have evaluated whether VHA follows CDC guidelines regarding repeat CT/GC and syphilis/HIV testing in those who test positive for CT and GC.1,16–18 In our study, only 3% to 4% of patients had repeat testing at 3 months; however, approximately a third of patients had repeat testing during the 3- to 12-month period, consistent with other non-VHA studies.2–5,7–9 Interestingly, in those with known HIV infection, guideline-compliant repeat CT/GC testing nearly doubled to greater than 67%. Although it was not specifically evaluated in this study, it is possible that increased guideline compliance with repeat testing in known HIV-positive patients may be related to specialized care with infectious disease specialists who may be more likely to repeat or do quarterly CT/GC testing, but further evaluation is needed.
In VHA, of those retested within 90 to 365 days, 8.6% of CT and 15% of GC were positive, which is not unexpected because of the increased risk of reinfection.1 Rates of reinfection in VHA were lower than in studies that evaluated patients of all age ranges who live in New Zealand (18%–21%); however, retesting occurred from 6 weeks to 6 months.3–5 A review evaluating reinfection in men found median reinfection rates of 11.3% and 7% for CT and GC, respectively, whereas a separate study evaluating women showed reinfection rates of 19% to 20% and 11.7% for CT and GC, respectively.20,21
Approximately 75% and 43% of those with CT and GC, respectively, who did not receive repeat testing according to guidelines were younger than 35 years, and approximately 65% of male patients with either CT or GC had guideline-discordant testing. The younger male Veteran population typically does not seek VA benefits as much as the older male population in VHA and may be less likely to follow-up regarding repeat testing.22 Although not evaluated in this study, other studies found that those who have primary care providers, are followed by infectious diseases or obstetrics/gynecology, or were diagnosed in outpatient settings as opposed to inpatient or emergency department settings were more likely to have repeat testing performed.6,7,12 Other reasons for low retesting rates may be clinicians not educating patients on the importance of retesting or a lack of systems to standardize follow-up care in those with CT/GC infection. To increase guideline compliance, a potential strategy in VHA could be to have a follow-up appointment automatically setup with the individual's primary care doctor for their repeat testing. Although some studies did not see an improvement in repeat testing after text messages,23,24 other studies demonstrated that text messages, postcards, or electronic chart reminders with active recall were effective in certain populations.5,25–28 Rose et al.5 improved retesting from 25.4% to 47.9% with clinician education, patient education about reinfection risk reduction and retesting, and text reminders at 2 to 3 months after treatment for retesting. The VHA has a robust electronic medical record system and patient portal (My HealtheVet) that could be used for patient clinical reminders to improve repeat testing. Reminders and reflex laboratory orders for repeat testing and other STI testing in patients with positive CT/GC tests could improve follow-up. Individualized health education counseling by a health educator regarding STI prevention (importance of partner notification, consistent condom use, and retesting) may help patients better understand follow-up testing and how to prevent future infections.29
Regarding screening patients positive for CT/GC for other STIs, VHA is screening nearly two-thirds of patients for HIV, syphilis, or both, which is higher than previous publications found.2,6,10–14 An earlier study in VHA from 2001 to 2013 found that 45% were tested for HIV after an STI diagnosis.10 Despite improved HIV and syphilis screening in VHA compared with other studies, approximately a third of VHA patients still are not tested for HIV/syphilis. Many of those positive for CT/GC and not tested for HIV and syphilis were younger than 35 years. Identification of such high-risk individuals and implementing follow-up care with their primary care doctor could potentially improve testing practices.
Several limitations were present in our study including the fact that repeat CT/GC or HIV/syphilis testing performed outside VHA was not available if those services were not ordered and paid for by VHA. This potentially underestimates the total number of CT/GC-positive patients as well as those receiving appropriate HIV/syphilis and repeat testing. Pregnant women and pharyngeal cases of GC (CDC guidelines have changed from 2010 to 2021 with most recent guidelines recommending TOC in all pharyngeal GC infections), where repeat testing at 4 weeks is recommended, were not identified in this study, which could explain some of the repeat CT/GC testing done in the <90-day time frame and overestimate those with guideline-discordant care. The indication (i.e., symptomatic versus asymptomatic) and anatomical site for the repeat testing was not identified, which could contribute to a higher number of positives if patients were returning symptomatic and receiving testing or being screened at other anatomical sites. Treatment of STI was not evaluated in this study, which could account for positivity on repeat testing for CT/GC. Laboratory data were extracted for 2020 to allow for up to a year of repeat testing for those testing positive in 2019; however, because of the COVID-19 pandemic, patients may have had different health-seeking behaviors. Positive HIV and syphilis test results were not determined to be new or previously known. Therefore, this study is unable to determine the number of new HIV or syphilis cases identified by proper screening for those with other STIs. Only HIV and syphilis were evaluated as other STIs despite other STIs occurring in this population.
In summary, repeat CT/GC testing and screening for HIV and syphilis can be improved in VHA. Initiatives that incorporate clinician and patient education on CDC STI testing guidelines, leverage electronic health record tools such as clinical reminders, standardized order sets, and patient communication systems, particularly targeting younger Veterans, could improve STI follow-up testing.
Supplementary Material
Footnotes
Acknowledgment: Gayathri Shankar helped with the creation of data queries to obtain the data for this study.
Conflicts of Interest and Sources of Funding: The authors declare that they have no competing interests. This work was supported by intramural Veterans Health Administration funds.
Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US government.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (http://www.stdjournal.com).
Contributor Information
Aditya Sharma, Email: Aditya.Sharma@va.gov.
Cynthia Lucero-Obusan, Email: Cynthia.Lucero@va.gov.
Gina Oda, Email: Gina.Oda@va.gov.
Mark Holodniy, Email: Mark.Holodniy@va.gov.
REFERENCES
- 1.Workowski KA Bachmann LH Chan PA, et al. Sexually transmitted infections treatment guidelines, 2021. MMWR Recomm Rep 2021; 70:1–187. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.McWhirter L Lou Y Reingold S, et al. Rates of appropriate treatment and follow-up testing after a gonorrhea and/or chlamydia infection in an urban network of federally qualified health center systems. Sex Transm Dis 2022; 49:319–324. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Rose SB Garrett SM Stanley J, et al. Retesting and repeat positivity following diagnosis of Chlamydia trachomatis and Neisseria gonorrhoeae in New Zealand: A retrospective cohort study. BMC Infect Dis 2017; 17:526. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Rose SB Garrett SM Stanley J, et al. Chlamydia trachomatis and Neisseria gonorrhoeae retesting and reinfection rates in New Zealand health care settings: Implications for sexually transmitted infection control. Sex Transm Dis 2020; 47:151–157. [DOI] [PubMed] [Google Scholar]
- 5.Rose SB Garrett SM Hutchings D, et al. Clinician education, advice and SMS/text reminders improve test of reinfection rates following diagnosis of Chlamydia trachomatis or Neisseria gonorrhoeae: Before and after study in primary care [published online October 18, 2019]. BMJ Sex Reprod Health. [DOI] [PubMed] [Google Scholar]
- 6.Rust G Minor P Jordan N, et al. Do clinicians screen Medicaid patients for syphilis or HIV when they diagnose other sexually transmitted diseases? Sex Transm Dis 2003; 30:723–727. [DOI] [PubMed] [Google Scholar]
- 7.McCool-Myers M Turner D Henn MC, et al. Finding the gaps in retesting for chlamydia and gonorrhea: Differences across high-volume testing departments in an urban health care setting. Sex Transm Dis 2021; 48:819–822. [DOI] [PubMed] [Google Scholar]
- 8.Wijers JNAP van Liere GAFS Hoebe CJPA, et al. Test of cure, retesting and extragenital testing practices for Chlamydia trachomatis and Neisseria gonorrhoeae among general practitioners in different socioeconomic status areas: A retrospective cohort study, 2011–2016. PLoS One 2018; 13:e0194351. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Hoover KW Tao G Nye MB, et al. Suboptimal adherence to repeat testing recommendations for men and women with positive chlamydia tests in the United States, 2008–2010. Clin Infect Dis 2013; 56:51–57. [DOI] [PubMed] [Google Scholar]
- 10.Goulet JL Martinello RA Bathulapalli H, et al. STI diagnosis and HIV testing among OEF/OIF/OND veterans. Med Care 2014; 52:1064–1067. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Petsis D Min J Huang YV, et al. HIV testing among adolescents with acute sexually transmitted infections. Pediatrics 2020; 145:e20192265. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Adekeye OA Abara WE Xu J, et al. HIV screening rates among Medicaid enrollees diagnosed with other sexually transmitted infections. PLoS One 2016; 11:e0161560. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Chen JY Ma Q Everhard F, et al. HIV screening in commercially insured patients screened or diagnosed with sexually transmitted diseases or blood-borne pathogens. Sex Transm Dis 2011; 38:522–527. [DOI] [PubMed] [Google Scholar]
- 14.Tao G, Zhang CX. HIV testing of commercially insured patients diagnosed with sexually transmitted diseases. Sex Transm Dis 2008; 35:43–46. [DOI] [PubMed] [Google Scholar]
- 15.VA Pocketcard. VA Benefits & Health Care Utilization. Available at: https://www.va.gov/vetdata/docs/pocketcards/fy2022q3.pdf. Last updated April 21, 2022. Accessed August 31, 2022.
- 16.Wilkinson LA Carter MT Wattengel BA, et al. Societal factors contributing to infections caused by Chlamydia trachomatis and Neisseria gonorrhoeae in a veteran population. Int J STD AIDS 2021; 32:845–851. [DOI] [PubMed] [Google Scholar]
- 17.Evans MW Borrero S Yabes J, et al. Sexual behaviors and sexually transmitted infections among male veterans and nonveterans. Am J Mens Health 2017; 11:791–800. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Beste LA Maier MM Borgerding J, et al. Testing practices and incidence of chlamydial and gonococcal infection in the Veterans Health Administration, 2009–2019. Clin Infect Dis 2021; 73:e3235–e3243. [DOI] [PubMed] [Google Scholar]
- 19.National Academies of Sciences, Engineering, and Medicine; Division of Behavioral and Social Sciences and Education; Board on Human-Systems Integration; Division on Engineering and Physical Sciences; Board on Infrastructure and the Constructed Environment; Committee on Facilities Staffing Requirements for Veterans Health Administration. Washington (DC): National Academies Press (US), 2019. Available at: https://www.ncbi.nlm.nih.gov/books/NBK555777/#pz126-1. Accessed August 31, 2022. [PubMed] [Google Scholar]
- 20.Fung M Scott KC Kent CK, et al. Chlamydial and gonococcal reinfection among men: A systematic review of data to evaluate the need for retesting. Sex Transm Infect 2007; 83:304–309. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Hosenfeld CB Workowski KA Berman S, et al. Repeat infection with chlamydia and gonorrhea among females: A systematic review of the literature. Sex Transm Dis 2009; 36:478–489. [DOI] [PubMed] [Google Scholar]
- 22.National Center for Veterans Analysis and Statistics . VA Utilization Profile 2017. Available at: https://www.va.gov/vetdata/docs/Quickfacts/VA_Utilization_Profile_2017.pdf. Accessed December 15, 2022.
- 23.Burton J Brook G McSorley J, et al. The utility of short message service (SMS) texts to remind patients at higher risk of STIs and HIV to reattend for testing: A controlled before and after study. Sex Transm Infect 2014; 90:11–13. [DOI] [PubMed] [Google Scholar]
- 24.Unutzer A Dombrowski JC Katz DA, et al. Evaluation of text message reminders to encourage retesting for chlamydia and gonorrhea among female patients at the municipal sexually transmitted disease clinic in Seattle, Washington. Sex Transm Dis 2020; 47:458–463. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Guy R Wand H Knight V, et al. SMS reminders improve re-screening in women and heterosexual men with chlamydia infection at Sydney sexual health centre: A before-and-after study. Sex Transm Infect 2013; 89:11–15. [DOI] [PubMed] [Google Scholar]
- 26.Nyatsanza F McSorley J Murphy S, et al. ’It's all in the message’: The utility of personalised short message service (SMS) texts to remind patients at higher risk of STIs and HIV to reattend for testing-a repeat before and after study. Sex Transm Infect 2016; 92:393–395. [DOI] [PubMed] [Google Scholar]
- 27.Zou H Fairley CK Guy R, et al. Automated, computer generated reminders and increased detection of gonorrhoea, chlamydia and syphilis in men who have sex with men. PLoS One 2013; 8:e61972. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Paneth-Pollak R Klingler EJ Blank S, et al. The elephant never forgets: Piloting a chlamydia and gonorrhea retesting reminder postcard in an STD clinic setting. Sex Transm Dis 2010; 37:365–368. [DOI] [PubMed] [Google Scholar]
- 29.In-Iw S Braverman PK Bates JR, et al. The impact of health education counseling on rate of recurrent sexually transmitted infections in adolescents. J Pediatr Adolesc Gynecol 2015; 28:481–485. [DOI] [PubMed] [Google Scholar]