Abstract
BACKGROUND:
The primary objective of this study was to assess utilization of sexual health services at a university’s student health and wellness center and to determine whether the presence of a dedicated sexual health clinic (SHC) associated with different utilization patterns for sexual health services when compared to primary care clinics.
METHODS:
This was a retrospective chart review of patients presenting to the University of Alabama at Birmingham’s (UAB) Student Health and Wellness Center for sexual health services between January 2015 and June 2019. Utilization of sexual health services, specifically sexually transmitted infection (STI) testing, were compared between the dedicated SHC and primary care clinics.
RESULTS:
3081 cases were included. There were statistically significant differences in the proportion of males and populations more burdened by STI tested for STI in the SHC (i.e., persons who identify as black and younger females). We also observed a higher percentage of positive gonorrhea and chlamydia test results and a greater likelihood of extragenital screening in men who have sex with men (MSM) in the SHC.
CONCLUSIONS:
The dedicated SHC within the UAB Student Health and Wellness Center was associated with an increase in STI screenings. There was a significant difference between the demographics of those presenting to the SHC versus primary care clinics, proportionally more diagnoses of gonorrhea and chlamydia, and for MSM more extragenital screenings performed in the SHC. These findings suggest that there may be a benefit of an embedded SHC in college and university health and wellness centers.
Keywords: sexually transmitted infections, sexual health clinic, university, college, screening
Short Summary:
A sexual health clinic implemented for university students in Birmingham, Alabama found increased screening for certain populations and increased extra-genital screening for men who have sex with men.
Introduction
Rates of sexually transmitted infections (STI) continue to rise in the U.S resulting in substantial physical and emotional morbidity, long-term health consequences, and enhanced risk for HIV acquisition.[1] The U.S. Department of Health and Human Services published a strategic plan to address these increasing rates with goals that include prevention of new infection, improvement of health by reducing the adverse outcomes of STI, and reduction of STI-related health disparities and inequities.[2] While health department STD clinics remain an important resource for STI diagnosis and management, the majority of STIs are diagnosed in non-STD clinics.[1] Focused efforts to increase access to STI care in populations particularly vulnerable to STI is an important part of meeting the vision of the STI National Strategic Plan.
Adolescents and young adults (i.e., persons 15-24 years of age) account for almost half of new STI annually.[3] While cognitive, biological and behavioral factors collectively contribute to adolescent and young adult vulnerability to STI,[4, 5] subpopulations experience particularly high burdens of STI including persons of color, men who have sex with men (MSM), and persons living in the Southeastern US.[1, 6] Despite recommendations for widespread screening, only a small proportion of persons aged 15-24 receive STI screening and those who are screened, in particular MSM, may not receive adequate extragenital screening.[7, 8] Factors accounting, in part, for the low uptake of STI screening among adolescents and young adults are access to care, confidentiality concerns, and costs of care.[8, 9]
College students traditionally comprise late adolescents and young adults and report frequent sex.[10] While most colleges and universities provide some on-site sexual health services, few have embedded sexual health (SHC) and fewer offer STI/HIV screening without cost sharing with students.[11] In 2015, the University of Alabama at Birmingham (UAB) Student Health and Wellness Center established a dedicated SHC within the Student Health and Wellness Center to augment sexual health services. The purpose of this study was to assess student utilization of sexual health services provided by a dedicated SHC embedded in a university-based student health center in the Southeastern U.S. We compare demographic characteristics of persons seeking STI screening, STI rates, and provider screening behavior (specifically among MSM) in a dedicated sexual health clinic and the center’s primary care clinics.
Methods
We conducted a retrospective analysis of students presenting for STI screening at the UAB Student Health and Wellness Center between January 2015 and June 2019. To remove the barriers of cost and the patient concern that STI screening could be reported to policy holders by insurance companies, the clinic offers free and confidential STI screening. The clinic also offers on-site treatment for most STI, sexual health education, access to condoms, HIV testing and counseling, gender affirmation therapy, and HIV Pre-Exposure Prophylaxis. When the SHC opened, free screening and treatment services were made available to all patients presenting to either the PCC or SHC.
SHC services are advertised at annual student orientations and on the clinic’s webpage where students can schedule their own appointments. The clinic’s phone-tree also allows students to select care in the SHC for a sexual health concern. Providers in the SHC include trained experts on staff at the Student Health and Wellness Center and specialists from the university’s division of infectious dieases.
Data were extracted from the clinic’s electronic medical record for all students who received STI screening (gonorrhea, chlamydia, trichomoniasis, syphilis, and HIV) and supplemented by individual chart review to capture sexual behaviors. Persons > 18 years of age were included in this study. Because the primary investigator was a medical student, and one investigator was an administrator, a conservative approach was used to ensure protected health information and confidentiality were maintained and thus, medical students were excluded. For students with more than 1 visit for STI screening during the study period, only information from their first visit was included. The university’s institutional review board and the UAB Student Health and Wellness Center administrative and clinical directors approved the study.
Clinic type was set as a two-level variable (Sexual Health Clinic [SHC] vs Primary Care Clinic [PCC]). Demographics of persons seeking care in each clinic type included sex at birth (female, male), age (continuous); race/ethnicity (American Indian or Alaskan Native, Asian/Pacific Islander, Black, Multi-cultural, Other, Unreported, White; Hispanic and Non-Hispanic); and academic level (Freshman, Sophomore, Junior, Senior, Graduate). Gender of students was not included in the study because of limitations in capturing gender in the electronic medical record. Sex of sex partner(s) (same sex, opposite sex) was included only when explicitly reported in the provider’s documentation. Results of chlamydia and gonorrhea testing are reported. Syphilis, HIV, and trichomoniasis are not reported because of low rates of positivity. In cases where male same sex behavior was documented by the provider, we recorded if extragenital screening was performed (Y/N) and the site of screening (pharyngeal and/or anorectal).
Patient characteristics were summarized using frequencies and percents for categorical variables and medians and range for continuous variables. Characteristics were summarized by type of clinic where STI screening occurred (SHC v PCC). Because of differences in screening recommendation for STI for females and males, that could influence health seeking behavior and provider screening behavior, the cohort was first sub-grouped by sex (cis-female, cis-male), then using logistic regression, we compared cis-male and cis-female patient variables by clinic type (referent = PCC). Multivariate binomial regression models were fit for the primary outcome of clinic type where STI screening occurred. Positivity rates for chlamydia and gonorrhea were compared by clinic type using chi-square analysis. Sub analysis was performed using chi-square for MSM to understand genital and extragenital screening practices. Statistical analysis was performed with JMP Statistical Computing, version 14, SAS Institute Inc., Cary, NC, 1989-2022.
RESULTS
Characteristics of persons receiving STI testing in PCC and SHC.
Between January 2015 and June of 2019, a total of 3,081 persons presented at least once for STI screening. Data represents all STI testing during this period. Overall, most people receiving testing reported their race as white (47.2%) or black (35.2%). Mean age was 22 ± 3.93 years. The majority presented for screening (60.4%); 34.9% presented with symptoms, and 4.7% as a sexual contact to someone with an STI. In total, PCC performed 2,278 STI tests (Females tested: N = 1,853; 81.3%. Males tested: N = 425; 18.7%). The SHC performed 803 STI tests (Females tested: N = 416; 51.8%. Males tested: N = 387; 48.2%). In the multivariate regression models, age was removed due to its covariance with academic year.
Males receiving STI testing in the SHC were more likely to report their race as black (P=.007). They were less likely to report symptoms as their reason for presenting for STI testing (P<.0001) and no more or less likely to present to the SHC as a contact to STI (P=1.000) (Table 1). Females receiving STI testing in the SHC were similarly more likely to report their race as black (P=.0296). Females presenting to the SHC were more often freshman (P<0.05). They were less likely to report symptoms as their reason for presenting for screening (P<.0001). Females were more likely to seek testing at the SHC as a contact to an STI (P<.0001) (Table 2).
Table 1.
Overall Data and Univariate Analysis between clinics
| Variable | Overall (N=3081) | PCP (N=2278) | SHC (N=803) | Univariate Analysis | p-value |
|---|---|---|---|---|---|
|
| |||||
| N (%) | N (%) | N (%) | X (95% CI) | ||
|
| |||||
| Sex at Birth | |||||
| Female | 2269 (73.6) | 1853 (81.3) | 416 (51.8) | REF | - |
| Male | 812 (26.4) | 425 (18.7) | 387 (48.2) | 4.06 (3.41-4.83) | <.0001 |
|
| |||||
| Race/Ethnicity | |||||
| American Indian or Alaskan Native | 16 (0.1) | 11 (0.5) | 5 (0.6) | 16.84 | 0.0048 |
| Asian/Pacific Islander | 207 (6.9) | 165 (7.4) | 42 (5.4) | ||
| Black | 1063 (35.2) | 744 (33.5) | 319 (40.6) | ||
| Hispanic | 186 (6.2) | 145 (6.5) | 41 (5.2) | ||
| Multi-cultural | 119 (3.9) | 94 (4.2) | 25 (3.2) | ||
| White | 1425 (47.2) | 1072 (45.1) | 353 (45.0) | ||
|
| |||||
| Age | |||||
| Mean, STD | 22.05, 3.93 | 22.18, 4.02 | 21.67, 3.62 | 3.35 (3.20-3.50) | 0.0008 |
| Median, Range | 21, 18-55 | 21, 18-55 | 21, 18-47 | 3.35 (3.20-3.50) | |
|
| |||||
| Academic Year | |||||
| Freshman | 614 (20.2) | 427 (19.0) | 187 (23.6) | 20.540 | 0.0004 |
| Sophomore | 507 (16.6) | 370 (16.4) | 137 (17.3) | ||
| Junior | 561 (18.4) | 410 (18.2) | 151 (19.0) | ||
| Senior | 568 (18.6) | 412 (18.3) | 156 (19.6) | ||
| Graduate | 796 (26.1) | 633 (28.1) | 163 (20.5) | ||
|
| |||||
| Reported Contact | 145 (4.7) | 69 (3.0) | 76 (9.5) | 3.35 (2.39-4.69) | <.0001 |
|
| |||||
| Reported Symptoms | 1073 (34.9) | 866 (38.0) | 207 (25.8) | 0.57 (0.47-0.68) | <.0001 |
|
| |||||
| Reported Sex of Partner | 1551 (50.3) | 897 (39.4) | 654 (81.4) | 6.76 (5.55-8.23) | <.0001 |
Table 2.
Data analysis for Male cohort.
| Variable | Male (N=812) | Univariate Analysis | Multivariable Analysis (Lack of Fit p=0.54) | ||||
|---|---|---|---|---|---|---|---|
|
| |||||||
| Overall | PCP (N=425) | SHC (N=387) | |||||
|
| |||||||
| N (%) | N (%) | N (%) | X (95% CI) | p-value | p-value | ||
|
| |||||||
| Race/Ethnicity | |||||||
| American Indian or Alaskan Native | 3 (0.4) | 2 (0.5) | 1 (0.3) | 16.91 | 0.0047 | 0.53 (0.04-7.15) | 0.6299 |
| Asian/Pacific Islander | 61 (7.8) | 37 (9.0) | 24 (6.4) | 0.81 (0.45-1.47) | 0.4925 | ||
| Black | 259 (33.0) | 111 (27.1) | 148 (39.4) | 1.59 (1.13-2.23) | 0.0076 | ||
| Hispanic | 44 (5.6) | 30 (7.3) | 14 (3.7) | 0.58 (0.29-1.17) | 0.1298 | ||
| Multi-cultural | 19 (2.4) | 11 (2.7) | 8 (2.1) | 0.86 (0.32-2.33) | 0.7718 | ||
| White | 399 (50.8) | 218 (53.3) | 181 (48.1) | REF | - | ||
|
| |||||||
| Age | |||||||
| Mean, STD | 22.81, 4.24 | 23.21, 4.67 | 22.36, 3.67 | 2.90 | 0.0039 | ||
| Median, Range | 22, 18-55 | 22, 18-55 | 21, 18-46 | (2.61-3.19) | |||
|
| |||||||
| Academic Year | |||||||
| Freshman | 120 (15.1) | 60 (14.4) | 60 (15.9) | 5.45 | 0.2446 | ||
| Sophomore | 128 (16.1) | 64 (15.4) | 64 (16.9) | ||||
| Junior | 169 (21.3) | 81 (19.5) | 88 (23.3) | ||||
| Senior | 150 (18.9) | 78 (18.8) | 72 (19.0) | ||||
| Graduate | 227 (28.6) | 133 (32.0) | 94 (24.9) | ||||
|
| |||||||
| Reported Contact | 89 (11.0) | 47 (11.1) | 42 (10.9) | 0.98 (0.63-1.52) | 1.0000 | - | - |
|
| |||||||
| Reported Symptoms | 248 (30.5) | 157 (36.9) | 91 (23.5) | 0.52 (0.39-0.71) | <.0001 | 0.48 (0.34-0.67) | <.0001 |
|
| |||||||
| Reported Sex of Partner | 562 (69.2) | 233 (54.8) | 329 (85.0) | 4.67 (3.33-6.56) | <.0001 | 4.84 (3.40-6.87) | <.0001 |
Comparison of GC and CT Genital Positivity in the PCC and SCH.
Overall, positive chlamydia (P<.001) and gonorrhea (P=.0001) results were observed more often at the SHC compared to PCC. When analyzed by sex, gonorrhea was more frequently positive in males tested in the SHC (P=.0280). There was no difference in frequency of chlamydia positivity in males tested in the PCC and SHC (P=.7804). For cis-females, chlamydia was positive more frequently in the SHC (P=.0002) while there was no difference in positive gonorrhea screenings between clinic type (P=.1730).
Comparison of STI screening behaviors in MSM in the PCC and SCH.
Sex of sex partner(s) (same sex, opposite sex) was included in the analysis only when explicitly reported in the provider’s documentation. Reported sex of partner(s) was documented for 1,551 (50.3%) patients. Providers in the SHC were more likely to report sex of sex partner for both males (P<.0001) and females (P<.0001) (Tables 1–2). Providers recorded same sex partner(s) in 170 cis-males (SHC = 99, PCC = 71) and 66% received extragenital screening. Extragenital screening for chlamydia (P<.0001) and gonorrhea (P<.0001) on MSM was performed more frequently in the SHC. While there was no difference in the percent positives from oral and rectal screenings in the SHC and PCC, the total number of positive results was higher in the SHC compared to the PCC (22 versus 7) (Table 4).
Table 4.
Data analysis for urine positivity between clinic types.
| Variable | PCP | SHC | Univariate Analysis | |
|---|---|---|---|---|
|
| ||||
| N (%) | N (%) | OR (95% CI) | p-value | |
|
| ||||
| Total | ||||
| Gonorrhea | 35 (1.54) | 32 (3.99) | 2.66 (1.64-4.33) | .0001 |
| Chlamydia | 156 (6.85) | 94 (11.71) | 1.80 (1.38-2.36) | <.0001 |
|
| ||||
| Male Cohort | ||||
| Gonorrhea | 12 (2.82) | 23 (5.94) | 2.17 (1.07-4.43) | .0280 |
| Chlamydia | 50 (11.76) | 48 (12.40) | 1.06 (0.70-1.62) | .7804 |
|
| ||||
| Female Cohort | ||||
| Gonorrhea | 23 (1.24) | 9 (2.16) | 1.76 (0.81-3.83) | .1730 |
| Chlamydia | 106 (5.72) | 46 (11.06) | 2.05 (1.42-2.95) | .0002 |
Discussion
Expansion of easily accessible STI screening and management resources are needed to meet the rising rates of STI, particularly among the most vulnerable populations. One such population is college students. They are most frequently comprised of late adolescents and young adults, the age groups most impacted by STI. Initiation of sex with others often occurs in college. College students report frequent condomless sex and many report more than 1 sex partner in the past 12 months.[10] For college students, their interface with healthcare often occurs at a student health and wellness center affiliated with their college or university. While STI screening and management are delivered in most student health and wellness centers, few have clinics dedicated to sexual healthcare staffed by sexual health experts. In 2015, the University of Alabama at Birmingham embedded a sexual health clinic within its Student Health and Wellness Center to provide for the sexual health needs of all students. Overall, our findings suggest that the SHC enhances STI testing and identification of STI.
We hypothesize that higher frequency of chlamydia and gonorrhea positivity seen in the SHC may be due to 3 primary factors—patients with perceived increased risk for STI motivates them to seek care at the SCH, greater emphasis on the sexual history in the SHC, and appropriate STI testing based on a patient’s specific needs identified in the sexual history. While studies suggest that on average a person’s perceived risk of STI falls below their actual risk, persons who perceive risk are more likely to take protective measures including use of condoms and receipt of STI testing. [12, 13]
Patient visits in the SHC emphasize the sexual history. Patients understand that this is the focus of the visit and anticipate sexual-health related questions, and providers are trained to gather a respectful, inclusive, and complete sexual history. Studies show that most healthcare providers feel comfortable taking a sexual history and do so if a patient’s complaint is related to sexual health but that sexual history as a part of routine and preventive healthcare occurs less frequently and, when it occurs, does not include essential components of a comprehensive sexual history.[14] While PCC providers may have gathered a sexual history, we observed a low level of reporting of sex of sex partners in persons screened for STI in PCCs, relevant information since it guides testing and management of STI.
Extragenital screening by NAAT for gonorrhea and chlamydia is recognized as an important sexual health consideration for MSM [15] because these infections can increase risk for HIV and lead to further STI transmission.[16–18]. Reports suggest that most STI are missed in MSM when only genital screening is performed.[19] MSM more frequently received extragenital screening in the SHC clinic than the PCC. Percent positive of pharyngeal GC was similar between clinic type and percent positives were similar to previous reports.[19] However, because more pharyngeal and rectal screenings were performed in MSM in the SHC, more infection was found and treated.
We anticipated that females would comprise most patients presenting for STI testing in both the PCC and SHC. Females are more likely to suffer serious complications including pelvic inflammatory disease and infertility from STI. STI screening is emphasized in female’s health and a built-in part of female’s health visits in primary care.[15, 20] We did see proportionally more Freshmen females and females with a contact to STI seeking care in the SHC (Table 2). However, overall females underwent STI testing much more frequently in the PCC than in the SHC. For males, studies suggest that they seek healthcare less frequently than females and are less likely to engage in preventive health services.[21, 22] Further, patients perceive their risk of STI as low and without strong screening recommendations in males, may be less likely to seek out STI screening.[20, 23, 24] While females comprised most persons tested for STI in the PCC (> 80%), they comprised just over half of patient tested in the SHC suggesting that males may see the SHC as a resource for care.
We also observed higher utilization of the SHC by Black students. Education has been widely studied and reported as inversely associated with having had an STI diagnosis.[25] However, this may not be consistent across all races/ethnicities. Anang et al reported that educational status was not uniformly protective against STI and black females did not see the same beneficial relationship to education observed in other racial groups. This suggests that other factors play a more prominent role in determining a person’s STI vulnerability and contribute to the disproportionate rates of STIs in the U.S.[25]
This study adds a novel approach to addressing the burden of STIs on college campuses but there were some limitations. This was a retrospective analysis and subject to the inherent limitations of such studies. In particular, the analysis of sex of sex partners was limited because providers often did not include this information in the notes. Further, this study assessed only first-time testing and test positivity. Finally, we were not able to compare numbers of patients receiving STI screening prior to and after implementation of the SHC because of the center’s transition to a new electronic medical record in 2015. Despite these limitations, we believe that our data provide a useful review of a change in clinical process.
Conclusions
We observed differences in the proportion of males and populations more burdened by STIs tested for STI in the SHC (i.e., persons who identify as black and younger females). We also observed higher percentage of positive gonorrhea and chlamydia test results and a greater likelihood of extragenital screening in MSM in the SHC. This is despite more persons with symptoms presenting to PCCs. These findings suggest that there may be a benefit of an embedded SHC in college and university health and wellness clinics. Further work is needed to evaluate the full benefit of such a clinic model.
Table 3.
Data analysis for Female cohort.
| Variable | Female (N=2269) | Univariate Analysis | Multivariable Analysis (Lack of Fit p=0.0794) | ||||
|---|---|---|---|---|---|---|---|
|
| |||||||
| Overall | PCP (N=1853) | SHC (N=416) | |||||
|
| |||||||
| N (%) | N (%) | N (%) | X (95% CI) | p-value | Adjusted OR | p-value | |
|
| |||||||
| Race/Ethnicity | |||||||
| American Indian or Alaskan Native | 13 (0.6) | 9 (0.5) | 4 (1.0) | 11.39 | 0.0442 | 1.67 (0.46-6.02) | 0.4336 |
| Asian/Pacific Islander | 146 (6.5) | 128 (7.0) | 18 (4.4) | 0.78 (0.45-1.35) | 0.3728 | ||
| Black | 804 (36.0) | 633 (34.7) | 171 (41.8) | 1.34 (1.03-1.74) | 0.0296 | ||
| Hispanic | 142 (6.4) | 115 (6.3) | 27 (6.6) | 1.03 (0.63-1.68) | 0.9153 | ||
| Multi-cultural | 100 (4.5) | 83 (4.6) | 17 (4.2) | 1.02 (0.56-1.86) | 0.9509 | ||
| White | 1026 (46.0) | 854 (46.9) | 172 (42.1) | REF | - | ||
|
| |||||||
| Age | |||||||
| Mean, STD | 21.78, 3.77 | 21.94, 3.82 | 21.02,3.45 | 4.83 | <.0001 | ||
| Median, Range | 21, 18-54 | 21, 18-54 | 20, 18-47 | (4.64-5.02) | |||
|
| |||||||
| Academic Year | |||||||
| Freshman | 494 (21.9) | 367 (20.0) | 127 (30.5) | 35.04 | <.0001 | REF | - |
| Sophomore | 379 (16.8) | 306 (16.7) | 73 (17.5) | 0.72 (0.51-1.03) | 0.0711 | ||
| Junior | 392 (17.4) | 329 (17.9) | 63 (15.1) | 0.63 (0.44-0.92) | 0.0150 | ||
| Senior | 418 (18.6) | 334 (18.2) | 84 (20.2) | 1.00 (0.71-1.41) | 0.9951 | ||
| Graduate | 569 (25.3) | 500 (27.2) | 69 (16.6) | 0.56 (0.39-0.80) | 0.0015 | ||
|
| |||||||
| Reported Contact | 56 (2.5) | 22 (1.2) | 34 (8.2) | 7.41 (4.28-12.81) | <.0001 | 5.13 (2.78-9.47) | <.0001 |
|
| |||||||
| Reported Symptoms | 825 (36.4) | 709 (38.3) | 116 (27.9) | 0.62 (0.49-0.79) | <.0001 | 0.55 (0.42-0.71) | <.0001 |
|
| |||||||
| Reported Sex of Partner | 989 (43.6) | 664 (35.8) | 325 (78.1) | 6.40 (4.98-8.22) | <.0001 | 6.36 (4.89-8.26) | <.0001 |
Table 5.
Data analysis for males who have sex with males (MSM).
| Variable | PCP | SHC | Univariate Analysis | |
|---|---|---|---|---|
|
| ||||
| N (%) | N (%) | OR (95% CI) | p-value | |
|
| ||||
| Extragenital Screening | ||||
| Gonorrhea | 31 (43.66) | 80 (87.91) | 9.38 (4.28-20.59) | <.0001 |
| Chlamydia | 31 (46.97) | 81 (92.05) | 13.07 (5.25-32.49) | <.0001 |
|
| ||||
| Oral Positivity | ||||
| Gonorrhea | 4 (12.90) | 11 (13.75) | 1.07 (0.32-3.67) | .9064 |
| Chlamydia | 2 (6.45) | 1 (1.23) | 0.22 (0.02-2.51) | .2054 |
|
| ||||
| Rectal Positivity | ||||
| Gonorrhea | 0 (−) | 4 (5.00) | - | .1018 |
| Chlamydia | 1 (3.23) | 6 (7.41) | 1.28 (0.25-6.60) | .7658 |
|
| ||||
| Urine Positivity | ||||
| Gonorrhea | 0 (−) | 4 (4.55) | - | .0328 |
| Chlamydia | 2 (3.23) | 6 (7.23) | 2.34 (0.46-12.00) | .2823 |
Sources of Support:
Research reported in this publication was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under award number TL1TR003106 (to AC). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Footnotes
Disclosure Statement: All authors have no relevant conflicts of interest to disclose.
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