Abstract
Background:
Current guidelines recommend concurrent screening for HIV and syphilis with gonorrhea and chlamydia testing. Despite this, many patients are still not screened. This study describes trends in demographics and encounter locations associated with missed opportunities for HIV and syphilis screening among patients tested for gonorrhea or chlamydia.
Methods:
This is a retrospective review of all encounters with gonorrhea or chlamydia testing in a large, urban hospital from November 1, 2018, to July 31, 2021. Demographic information and encounter location were extracted from the medical record. Encounters were categorized as including both HIV and syphilis (complete) screening, HIV screening only, or neither. Logistic regression was used to examine associations between demographics and encounter location and likelihood of complete screening.
Results:
There were 42,791 patient encounters, of which 40.2% had complete screening, 6.2% had concurrent HIV screening only, and 53.6% had no concurrent screening. Increasing age, female sex (aOR 0.58, 95% CI 0.55–0.61, p<0.01), non-Hispanic Black race (aOR 0.52, 95% CI 0.49–0.55, p<0.01), and public insurance (aOR 0.72, 95% CI 0.69–0.75, p<0.01) were associated with lower odds of complete screening. Emergency department (ED) encounters were most likely to include complete screening (aOR 3.11, 95% CI 2.96–3.26, p<0.01).
Conclusions:
This study found a large proportion of patients tested for gonorrhea and chlamydia had missed opportunities for HIV and syphilis screening. Significant demographic disparities were found. The ED was most likely to screen for both HIV and syphilis. Decreasing disparities in screening could have profound effects on the HIV and syphilis epidemics.
Keywords: HIV, syphilis, screening, missed opportunities, emergency department
Short Summary:
Significant demographic disparities were found in concurrent screening for HIV and syphilis among patients tested for gonorrhea and chlamydia; the emergency department was most likely to screen for all infections.
Introduction
National guidelines to expand HIV screening in all medical settings1,2 have been continually broadened over the past two decades to improve HIV diagnosis and entry into treatment and prevention services. While HIV incidence has decreased in the setting of these directives and public health campaigns, there has been a concomitant dramatic rise in syphilis rates,3 which, in addition to its own devastating health consequences, increases the risk of HIV acquisition.4 There is considerable interest in developing efficient and effective means of achieving early diagnosis of HIV and syphilis among vulnerable populations to control the syphilis epidemic and continue towards the goals of the Ending the HIV Epidemic (EHE) plan.5 Increasing routine screening for both infections in appropriate individuals in all medical settings will be an important component of any HIV and syphilis control strategy moving forward.
Urogenital sexually transmitted infections (STIs), such as gonorrhea and chlamydia, are known risk factors for both syphilis and HIV acquisition and are frequently diagnosed together.6,7 Individuals presenting to a medical setting for STI treatment should always receive HIV screening for this reason.1 Syphilis screening is similarly recommended for all individuals diagnosed with other STIs.8 However, previous studies in emergency departments (EDs) and urgent care settings suggest that HIV and syphilis co-screening are rare with urogenital STI testing.9–13 This may relate to the different testing modalities and the consequent workflow challenges related to screening, as gonorrhea and chlamydia testing is generally performed on urine or vaginal samples, whereas HIV and syphilis testing in most cases require a blood draw. Additional barriers may include stigma related to these infections; knowledge barriers or concerns about the complexity of syphilis diagnosis on the part of physicians, non-physician providers, and patients; patient reluctance to undergo blood draws; and other workflow considerations such as not having a phlebotomist immediately available,14–16 which may contribute to the high rates of missed opportunities for co-screening among this high priority group.
Targeted interventions to address these missed opportunities must be patient-centered and address the infrastructure and cultural limitations of the locations where STI testing encounters occur. While a large proportion of STI testing originates in the ED,17 which remains a key location to reach patients who may have otherwise limited access to the healthcare system,18 there are many important opportunities for HIV and syphilis screening in other areas of the hospital system. Understanding the screening patterns and demographic trends in these other locations will be essential to closing the screening gap. This study aims to evaluate factors associated with missed opportunities for concurrent HIV and syphilis screening among patients tested for urogenital STIs at a large, urban, tertiary-care hospital, hypothesizing that patient demographics and testing location will be important factors driving the likelihood of HIV and syphilis screening.
Materials and Methods
Study Setting
This study took place at a large, urban, academic, tertiary-care hospital that provides an array of outpatient primary and specialty services, inpatient and emergency care. There is no standardized protocol in place for urogenital STI testing outside of routine clinical care. This hospital system had an existing routine HIV screening program in place throughout the study period that applied to outpatient clinics, inpatient wards, and the ED. Once in a lifetime screening for patients under age 65 was prompted by a best practice alert (BPA) in the electronic medical record (EMR) in primary care clinics, HIV screening was incorporated into nursing triage workflow in the ED, and HIV screening was also included in some ED and inpatient order sets. Throughout the entire study period, the ED also employed a quick order set for STI testing that was designed with HIV and syphilis testing selected as the default setting. In May 2019, a new BPA was introduced in the ED that prompted annual opt-out HIV and syphilis screening for all patients under age 65 with no testing in the past 12 months.19 This BPA prompted screening at triage or when any orders were placed, but it was not specifically linked to any particular order, including STI test orders.
Study Design
This is a retrospective review of all encounters in the hospital system that included testing from any source for gonorrhea or chlamydia from November 1, 2018, to July 31, 2021. Demographics, including age at the time of the testing encounter, sex at birth, race, ethnicity, and insurance type, as well as the type and location of testing, were extracted from the EMR. Due to limitations of data extraction from the EMR, only private payor and public insurance categories were included, as for approximately 10% of encounters, it was unclear if the patient was uninsured or the data were missing. Locations were categorized by the origin of the testing order, which included the ED, outpatient primary care, outpatient obstetrics and gynecology (OBGYN), any other outpatient clinic, inpatient OBGYN, and any other type of inpatient setting.
As the study period encompasses 15-month periods before and after the onset of the COVID-19 pandemic, which may have impacted testing and screening patterns, data were categorized into pre-pandemic (November 1, 2018 to March 15, 2020), early pandemic (March 16, 2020 to August 31, 2020), and late pandemic (September 1, 2020 to July 31, 2021) periods. These periods were determined based on prior research using these data, which showed decreased STI testing rates during the early pandemic and a return to near baseline during the late pandemic period.17 This analysis was run both with and without ED data, as prior research has shown that ED HIV screening was maintained more consistently during the early pandemic than in other locations.20
STI testing encounters were categorized in three ways: 1) complete STI screening, defined as encounters that included both HIV and syphilis co-screening in addition to gonorrhea and/or chlamydia testing, (2) HIV co- screening with gonorrhea and/or chlamydia, without syphilis screening, and (3) gonorrhea and/or chlamydia testing only. Because the introduction of the routine screening BPA in the ED created an artificial association between syphilis and HIV test ordering in the ED that did not exist elsewhere, it was not possible to compare HIV screening rates among patients tested for syphilis independent of other STIs at different locations within the hospital, and thus concurrent syphilis and HIV screening in the absence of urogenital STI testing was not examined in this study. This study was approved by the University of Chicago Institutional Review Board.
Data Analysis
Descriptive statistics (means, standard deviations, and percentages) were used to compare the distribution of patient demographics and patterns of STI testing by location of testing and category of STI testing encounter. Overall STI testing trends were described by pandemic periods. Logistic regression was used to calculate the odds ratio (OR) for complete STI screening compared to incomplete screening (any urogenital STI testing with HIV screening only or urogenital STI testing without any additional screening), as well as the OR for any HIV screening compared to any encounter without HIV screening, across patient demographics and testing location. Regression models were then adjusted for demographics, pandemic period, and ordering department. P-values less than 0.05 were considered statistically significant. Data analysis was performed using RStudio.
Results
Over the 33-month study period, there were 42,791 unique patient encounters that included gonorrhea and/or chlamydia testing. Throughout the entire hospital system, 53.6% of these encounters did not include HIV or syphilis screening. Complete STI screening was performed in 40.2% of encounters. Patient demographics and testing location by encounter category are described in Table 1. Of all testing encounters, 77.0% of patients were female, 61.0% were non-Hispanic Black (NHB), and 59.7% had private insurance. The largest proportion of testing encounters occurred in outpatient OBGYN (39.8%), followed by the ED (21.5%), and outpatient primary care (21.3%).
Table 1.
Patient demographics and encounter location by STI screening categories for all patients tested for gonorrhea and/or chlamydia
| Complete STI Screening GC and/or CT, HIV and SP |
HIV Screening Only GC and/or CT, HIV |
No HIV or Syphilis Screening GC and/or CT Only |
Total* | |
|---|---|---|---|---|
| Age (mean, SD) | 30.1 (SD 9.9) | 32.4 (SD 10.4) | 31.8 (SD 10.5) | 31.1 (SD 10.3) |
| Age Categories (years) | ||||
| 18–24 | 6038 (44.9%) | 713 (5.3%) | 6696 (49.8%) | 13447 (31.4%) |
| 25–34 | 7372 (41.2%) | 981 (5.5%) | 9514 (53.2%) | 17867 (41.8%) |
| 35–44 | 2334 (32.6%) | 681 (9.5%) | 4152 (57.9%) | 7167 (16.8%) |
| 45–54 | 886 (33.6%) | 168 (6.4%) | 1585 (60.1%) | 2639 (6.2%) |
| 55+ | 599 (35.8%) | 95 (5.7%) | 977 (58.5%) | 1671 (3.9%) |
| Sex at Birth | ||||
| Female | 11183 (33.9%) | 1456 (4.4%) | 20308 (61.6%) | 32946 (77.0%) |
| Male | 6044 (61.4%) | 1183 (12.0%) | 2616 (26.6%) | 9843 (23.0%) |
| Race/Ethnicity | ||||
| Non-Hispanic Black | 9358 (37.6%) | 1266 (5.1%) | 14280 (57.3%) | 24904 (61.0%) |
| Non-Hispanic White | 4016 (42.5%) | 705 (7.5%) | 4738 (50.1%) | 9459 (23.2%) |
| Hispanic | 1293 (42.7%) | 222 (7.4%) | 1515 (50.0%) | 3030 (7.4%) |
| Other | 1658 (48.5%) | 334 (9.8%) | 1428 (41.7%) | 3420 (8.4%) |
| Insurance | ||||
| Private | 9417 (36.2%) | 1828 (7.0%) | 14745 (56.6%) | 26030 (59.7%) |
| Medicaid/Medicare | 5241 (41.4%) | 513 (4.1%) | 6902 (54.5%) | 12656 (28.4%) |
| Encounter location | ||||
| Emergency Department | 5858 (65.0%) | 167 (1.9%) | 2978 (33.1%) | 9003 (21.5%) |
| Inpatient Other | 96 (13.5%) | 78 (11.2%) | 531 (75.3%) | 705 (1.7%) |
| Inpatient OBGYN | 280 (11.8%) | 228 (9.6%) | 1858 (78.5%) | 2366 (5.7%) |
| Outpatient OBGYN | 3507 (21.1%) | 225 (1.4%) | 12911 (77.6%) | 16643 (39.8%) |
| Outpatient Primary Care | 4628 (51.9%) | 1422 (16.0%) | 2861 (32.1%) | 8911 (21.3%) |
| Outpatient Other | 2160 (51.6%) | 448 (10.7%) | 1581 (37.7%) | 4189 (10.0%) |
| Total | 17229 (40.2%) | 2638 (6.2%) | 22924 (53.6%) | 42791 (100%) |
Percents in the Total column are column percents, whereas all other percents shown are row percents. Abbreviations: Gonorrhea (GC), chlamydia (CT), Human immunodeficiency virus (HIV), Syphilis (SP); obstetrics and gynecology (OBGYN); Other under race and ethnicity includes Asian/Mideast Indian, Native Hawaiian/Other Pacific Islander, more than one race, and American Indian or Alaska Native. Outpatient Other includes Outpatient Subspecialty Care, Outpatient Urgent Care and Outpatient Unspecified; Unknown values for: sex at-birth (n=2, <0.1%); Race/Ethnicity (n=1978, 4.6%), Insurance (n=4105, 9.6%), ordering department (n=974, 2.3%).
The proportion of encounters in which patients received no HIV or syphilis co-screening increased with age, with a slight decrease in the age group over 55 years, although this was the smallest group overall (3.9% of encounters). Differences were observed by sex, with 33.9% of females receiving complete STI screening, compared to 61.4% of males. HIV co- screening without syphilis screening was also more common among males than females (12.0% vs 4.4%). NHB patients more frequently received only urogenital STI testing (57.3%), than White (50.1%) or Hispanic (50.0%) patients. Among encounters with available insurance data, patients with private insurance received only urogenital STI testing slightly more frequently (56.6%) than patients with public insurance (54.5%). The ED demonstrated the highest proportion of complete screening encounters (65.0%), followed by outpatient primary care (51.9%), other outpatient clinics (51.6%), and outpatient OBGYN (21.1%). Considering missed opportunities for HIV screening, outpatient primary care clinics had the lowest proportion of urogenital STI testing only (32.1%), followed by the ED (33.1%), while inpatient (78.5%) and outpatient (77.6%) OBGYN had the highest proportion.
Temporal trends related to the COVID-19 pandemic (Table 2) showed a 4% decrease in complete STI screening rates through the entire hospital system during the early pandemic, from 41.7% of encounters pre-pandemic to 37.7% in the early pandemic, then recovering slightly to 38.7% in the late pandemic. The proportion of encounters in which only urogenital STI testing was performed increased by 2.7%, from 52.4% of encounters pre-pandemic to 55.1% in the early pandemic. Excluding the ED from this analysis showed a much larger change early in the pandemic, with a 10.6% drop in complete STI screening encounters during the early pandemic, from 36.1% pre-pandemic to 25.5% in the early pandemic. Encounters with only urogenital STI testing also increased more when the ED was excluded, from 57.0% to 65.3%, an 8.3% increase.
Table 2.
STI screening encounters by time period during the COVID-19 pandemic, stratified by location, including and excluding ED encounters
| Pre-pandemic (Nov 01, 2018 to Mar 15, 2020) |
Early pandemic (Mar 15 to Aug 31, 2020) |
Late pandemic (Aug 31, 2020 to Jul 31, 2021) |
p-value | ||||
|---|---|---|---|---|---|---|---|
|
All locations N=23589 |
All locations excluding ED
N=18379 |
All locations N=3678 |
All locations excluding ED N=2617 |
All locations N=15524 |
All locations excluding ED N=12792 |
||
| Complete STI screening | 9833 (41.7%) | 6626 (36.1%) | 1390 (37.8%) | 667 (25.5%) | 6006 (38.7%) | 4078 (31.9%) | <0.01 |
| HIV screening only | 1392 (5.9%) | 1277 (6.9%) | 261 (7.1%) | 242 (9.2%) | 985 (6.3%) | 952 (7.4%) | |
| GC and/or CT only | 12364 (52.4%) | 10476 (57.0%) | 2027 (55.1%) | 1708 (65.3%) | 8533 (55.0%) | 7762 (60.7%) | |
Almost all demographic factors studied were significantly associated with odds of complete STI screening (Table 3), and with odds of any HIV screening (Table 4), except for ages between 25 and 44 years. Increasing age was associated with decreasing odds of complete STI screening in both unadjusted and adjusted analyses. Increasing age was also associated with decreasing odds of any HIV screening compared to patients ages 18 to 24 years old. Females had lower odds of both complete STI screening (aOR 0.58, 95% CI 0.55–0.61, p<0.01) and any HIV screening (aOR 0.49, 95% CI 0.47–0.52, p<0.01) compared to males. Compared to white patients, NHB and Hispanic patients had lower odds of both complete STI screening and any HIV screening in the adjusted analyses. Public insurance was associated with lower odds of complete STI screening (aOR 0.72, 95% CI 0.69–0.75, p<0.01) and any HIV screening (aOR 0.67, 95% CI 0.63–0.69, p<0.01) compared to private insurance. Encounters in the ED were the most likely to include complete STI screening (aOR 3.11, 95% CI 2.96–3.26, p<0.01), followed by other outpatient clinics (aOR 1.43, 95% CI 1.34–1.52, p<0.01). ED encounters were also most likely to include any HIV screening (aOR 1.68, 95% CI 1.60–1.76, p<0.01).
Table 3:
Logistic regression comparing demographics and location for encounters with complete STI screening versus encounters without complete STI screening
| uOR (95% CI) | p-value | aOR (95% CI) | p-value | |
|---|---|---|---|---|
| Age Categories (years) | ||||
| 18–24 | Ref | Ref | ||
| 25–34 | 0.86 (0.83, 0.90) | <0.01 | 0.94 (0.91, 0.98) | 0.03 |
| 35–44 | 0.59 (0.56, 0.63) | <0.01 | 0.68 (0.64, 0.72) | <0.01 |
| 45–54 | 0.62 (0.57, 0.67) | <0.01 | 0.63 (0.58, 0.69) | <0.01 |
| 55+ | 0.69 (0.62, 0.76) | <0.01 | 0.57 (0.51, 0.63) | <0.01 |
| Sex at Birth | ||||
| Male | Ref | Ref | ||
| Female | 0.32 (0.31, 0.34) | <0.01 | 0.58 (0.55, 0.61) | <0.01 |
| Race/Ethnicity | ||||
| Non-Hispanic White | Ref | Ref | ||
| Non-Hispanic Black | 0.82 (0.77, 0.86) | <0.01 | 0.52 (0.49, 0.55) | <0.01 |
| Hispanic | 1.01 (0.94, 1.09) | 0.83 | 0.91 (0.84, 0.98) | 0.05 |
| Other | 1.28 (1.19, 1.37) | <0.01 | 1.14 (1.06, 1.22) | <0.01 |
| Insurance | ||||
| Private | Ref | Ref | ||
| Medicaid/Medicare | 1.25 (1.19, 1.30) | <0.01 | 0.72 (0.69, 0.75) | <0.01 |
| Encounter location | ||||
| Outpatient Primary Care | Ref | Ref | ||
| Emergency Department | 1.72 (1.64, 1.81) | <0.01 | 3.11 (2.96, 3.26) | <0.01 |
| Inpatient Other | 0.15 (0.12, 0.18) | <0.01 | 0.23 (0.19, 0.29) | <0.01 |
| Inpatient OBGYN | 0.12 (0.11, 0.14) | <0.01 | 0.20 (0.18, 0.23) | <0.01 |
| Outpatient OBGYN | 0.25 (0.24, 0.26) | <0.01 | 0.37 (0.36, 0.39) | <0.01 |
| Outpatient Other | 0.99 (0.92, 1.05) | 0.69 | 1.43 (1.34, 1.52) | <0.01 |
Bold, p ≤ 0.05; Acronyms: uOR, unadjusted Odds Ratio; aOR, adjusted Odds Ratio, which included adjustment for demographics, ordering department, and pandemic period; CI, Confidence Interval, obstetrics and gynecology (OBGYN); Complete STI screening refers to HIV, Syphilis, GC, and CT in a single encounter.
Table 4:
Logistic regression comparing demographics and location for encounters with HIV screening versus encounters without HIV screening
| uOR (95%CI) | p-value | aOR (95%CI) | p-value | |
|---|---|---|---|---|
| Age Categories (years) | ||||
| 18–24 | Ref | Ref | ||
| 25–34 | 0.87 (0.84, 0.91) | <0.01 | 1.02 (0.98, 1.06) | 0.58 |
| 35–44 | 0.72 (0.68, 0.76) | <0.01 | 0.94 (0.89, 0.99) | 0.08 |
| 45–54 | 0.66 (0.61, 0.71) | <0.01 | 0.71 (0.66, 0.77) | <0.01 |
| 55+ | 0.70 (0.64, 0.78) | <0.01 | 0.55 (0.50, 0.61) | <0.01 |
| Sex at Birth | ||||
| Male | Ref | Ref | ||
| Female | 0.23 (0.21, 0.24) | <0.01 | 0.49 (0.47, 0.52) | <0.01 |
| Race/Ethnicity | ||||
| Non-Hispanic White | Ref | Ref | ||
| Non-Hispanic Black | 0.75 (0.71, 0.79) | <0.01 | 0.53 (0.50, 0.56) | <0.01 |
| Hispanic | 1.00 (0.93, 1.08) | 0.93 | 0.89 (0.82, 0.96) | 0.01 |
| Other | 1.40 (1.30, 1.50) | <0.01 | 1.21 (1.12, 1.30) | <0.01 |
| Insurance | ||||
| Private | Ref | Ref | ||
| Medicaid/Medicare | 1.10 (1.05, 1.14) | <0.01 | 0.67 (0.64, 0.69) | <0.01 |
| Encounter location | ||||
| Outpatient Primary Care | Ref | Ref | ||
| Emergency | 0.96 (0.91, 1.00) | 0.17 | 1.68 (1.60, 1.76) | <0.01 |
| Inpatient | 0.15 (0.13, 0.18) | <0.01 | 0.23 (0.20, 0.28) | <0.01 |
| Inpatient OBGYN | 0.13 (0.12, 0.14) | <0.01 | 0.22 (0.20, 0.24) | <0.01 |
| Outpatient OBGYN | 0.14 (0.13, 0.14) | <0.01 | 0.21 (0.20, 0.22) | <0.01 |
| Outpatient Other | 0.78 (0.73, 0.83) | <0.01 | 1.04 (0.97, 1.11) | 0.41 |
Bold, p ≤ 0.05; Acronyms: uOR, unadjusted Odds Ratio; aOR, adjusted Odds Ratio, which included adjustment for demographics, ordering department, and pandemic period.; CI, Confidence Interval, obstetrics and gynecology (OBGYN).
Discussion
This study demonstrated major differences in missed opportunities for concurrent HIV and syphilis screening by age, sex, race, insurance type, and location of STI testing encounter. Increasing age, female sex, non-White race, and public insurance were all associated with lower odds of complete STI screening, even after adjusting for other demographics and location of testing. This is consistent with earlier ED studies showing that women are less likely to undergo co-screening for HIV or syphilis with gonorrhea or chlamydia testing,9,13,21 and younger patients are more likely to receive HIV co-screening.10 Published data on HIV co-screening and complete STI screening rates outside of the ED are limited. In general, while Black individuals represent 41% of new HIV infections nationally,22 only 40% have ever been tested for HIV.23 Similarly 43.4% of new HIV diagnoses in the US in 2019 were among people ages 35 and older.24 Efforts are needed to increase screening for HIV in these populations, who may face lower participation in HIV screening due to bias, stigma, or limited access to care. As this was a retrospective study, the reasons for missed HIV or syphilis screening are unknown, and it is impossible to ascertain if the tests were offered and refused, not offered, not indicated, or not completed for other reasons. For example, it is possible that some portion of the individuals not screened for HIV were people already known to be living with HIV, who therefore would not require screening, though this likely represents a very small proportion of encounters.25 However, the demographic differences found even after adjusting for location of testing suggest a need for more robust interventions to improve screening rates and decrease disparities in screening.
In this study, the ED was more likely than any other location to perform complete STI screening. This may reflect, in part, the effects of the BPA on HIV and syphilis test ordering. This EMR alert has been shown to result in large increases in HIV and syphilis screening in the ED, as well as an increase in HIV co-screening among patients tested for STIs, even though the alert was not targeted to patients undergoing STI testing.26 Notably, a recent study of multiple EDs in one health system found that only 5% of urogenital STI testing encounters included HIV co-screening.10 An intervention that included rapid HIV tests, an STI order panel including HIV and syphilis screening, and an improved workflow for results follow up only increased the rate of HIV co-screening to 36% and syphilis co-screening to 39%, as compared to 66.9% and 65.0% respectively in the present study, which took place in an ED that had a similar STI order panel and follow-up workflow. Previous work in the study institution showed that over the eight years prior to implementation of the BPA, ED encounters were already the least likely to experience missed opportunities for HIV screening.21 The high rates of screening in this ED may reflect different needs of ED patients compared to those in other settings, differences in education or training of ED staff, or increased awareness about screening among patients or staff, in addition to the effects of the BPA. Although other locations also utilized a BPA, it was designed to trigger for once-in-a-lifetime screening. The findings of this study suggest that the use of a more frequent screening schedule or a BPA triggered by STI test ordering might be a successful strategy to increase screening in locations outside the ED. It is also possible that clinicians in outpatient clinics are more likely to defer screening to a follow up visit once an STI diagnosis is confirmed; however, this study is unable to assess delayed screening as it only included tests performed at the same encounter as the STI testing.
The ED had the highest proportion of encounters with complete screening, and the second lowest proportion of missed opportunities for any screening, after outpatient primary care. When adjusted for demographic factors, ED encounters were more than three times as likely to include complete STI screening than primary care. This finding is especially important as the ED is often the primary source of care for the populations most vulnerable to HIV and syphilis and may perform a disproportionate share of the STI testing in the hospital system.17 As such, there is considerable interest in means of increasing ED HIV and syphilis screening to reach communities with elevated STI rates and limited access to healthcare. While the use of a screening BPA may have increased complete STI screening rates in this ED, thereby making the results by location less generalizable to other EDs without a robust screening program, this suggests that such a screening program may help reduce missed opportunities for screening and should be considered in EDs in communities with a high prevalence of HIV and STIs.
Notably, outside of the ED and outpatient OBGYN, all other testing locations had relatively high rates of encounters including HIV but not syphilis screening, ranging from 9.6% to 16.0% of encounters. Given that HIV and syphilis both require blood draws and no additional consent is required to include syphilis screening, this represents an opportunity for intervention that could have profound consequences on the syphilis epidemic. The exclusion of syphilis screening may relate to a general lack of awareness of syphilis as an important public health issue, even among physicians, whereas there has been ongoing education about the importance of HIV screening for decades, and the hospital has a policy that patients should be screened for HIV, which itself raises awareness. This speaks to the need for greater education about rising syphilis rates and the importance of screening,27 and in particular the need for consistent screening of pregnant women and women of reproductive potential in all settings, in light of the recent rapid increase in congenital syphilis.3 Relatively high rates of syphilis screening in the ED in this study underscore the impact of leveraging the EMR to link the two test orders together, as has been previously described.26
Outpatient OBGYN represented the largest proportion of overall testing encounters, and OBGYN had the highest proportion of encounters with only urogenital STI testing. Due to the nature of retrospective studies, it is impossible to ascertain the reason for low co-screening rates. It is possible that the high rates of isolated urogenital STI testing reflect a higher volume of routine screening with annual exams or pre-procedure screening that is required before insertion of an intrauterine device or other gynecologic procedures. Because this is not symptomatic testing, clinicians may not perceive the patients to have an elevated risk of STIs and thus not order blood testing. Nonetheless, patients undergoing family planning interventions should be screened for HIV and syphilis, and further research may be warranted to understand the significance of this observation. Unfortunately, this study was unable to obtain the pregnancy status of patients undergoing testing, although this would be a rich area for further study, as pregnant women are considered a high priority group for both HIV and syphilis screening.
Lastly, this study briefly examined the effects of the COVID-19 pandemic on complete STI screening and missed opportunities for HIV screening. There was overall a small decrease in complete screening during the pandemic, worse during the early pandemic period, and a small increase in isolated urogenital STI testing during the pandemic. This may reflect pandemic effects on access to outpatient testing, as patients may have not wanted or been able to go to a lab for a blood draw, and instead provided a urine sample or self-collected swab only. It may also relate to staffing limitations during the pandemic, workflow changes that limited where and when patients could be seen, especially during the early pandemic, or policy changes limiting screening and preventive care early in the pandemic. This was seen in reduced HIV screening rates nationwide early in the pandemic as priorities shifted away from routine screening.28,29 In the study hospital, the ED was able to maintain screening rates at near pre-pandemic rates,30 which may in part account for the drop in complete STI screening being relatively low. This is supported by the fact that the decrease in complete screening rates was much larger when the ED was excluded from the analysis.
To meet the goals of the EHE plan and impact rising national syphilis rates, reducing missed opportunities for HIV and syphilis screening will be of vital importance. This study found significant disparities in concurrent HIV and syphilis screening, with women, NHB individuals, older patients, and those using public insurance less likely to receive complete screening. These communities are considered high priority for screening and prevention, and efforts must be made to evaluate the best means of improving screening rates. In this study, the ED was the most likely to perform complete STI screening and also the least likely to miss opportunities for HIV screening. This may be attributable to increased awareness among patients and staff due to the routine screening program, to the use of an automated EMR alert, or to other factors unique to this ED. Given that the ED serves as a safety net for the communities most vulnerable to HIV and syphilis and that it is often where individuals with limited access to care seek STI testing, it is of critical importance to identify strategies to decrease missed opportunities for HIV and syphilis screening there, such as automated alerts and increased patient and staff education. Similar interventions could easily be deployed in other settings, such as outpatient clinics, to improve rates of missed HIV and syphilis screening opportunities there as well. This has the potential to address important gaps in screening, which will be crucial to slowing the spread of HIV and syphilis and improving health outcomes throughout the country.
Funding:
Dr. Stanford is supported in part by NIAID of the National Institutes of Health under award number K23AI166277.
Footnotes
Conflicts of interest: Dr. McNulty has served on an advisory board for Gilead Sciences, Inc. Dr. Hazra has served on an advisory board for Gilead Sciences, Inc, and ViiV Healthcare. All other authors have no conflicts of interest to disclose.
References
- 1.Centers for Disease Control and Prevention (CDC), Branson BM, Handsfield HH, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep 2006;55(RR-14):1–17; quiz CE1–4. [PubMed] [Google Scholar]
- 2.US Preventive Services Task Force, Owens DK, Davidson KW, et al. Screening for HIV Infection: US Preventive Services Task Force Recommendation Statement. JAMA 2019;321(23):2326. [DOI] [PubMed] [Google Scholar]
- 3.Centers for Disease Control and Prevention. Sexually Transmitted Infections Surveillance, 2022; 2024. [Google Scholar]
- 4.Wu MY, Gong HZ, Hu KR, et al. Effect of syphilis infection on HIV acquisition: a systematic review and meta-analysis. Sex Transm Infect 2021;97(7):525–533. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Fauci AS, Redfield RR, Sigounas G, et al. Ending the HIV Epidemic: A Plan for the United States. JAMA 2019;321(9):844. [DOI] [PubMed] [Google Scholar]
- 6.Dionne-Odom J, Workowski K, Perlowski C, et al. Coinfection With Chlamydial and Gonorrheal Infection Among US Adults With Early Syphilis. Sexual Trans Dis 2022;49(8):e87–e89. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Skinner JM, Distefano J, Warrington J, et al. Trends in Reported Syphilis and Gonorrhea among HIV-Infected People in Arizona: Implications for Prevention and Control. Public Health Rep 2014;129(1_suppl1):85–94. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Centers for Disease Control and Prevention. Sexually Transmitted Infections Treatment Guidelines, 2021. Published January 16, 2024. Accessed March 16, 2024. https://www.cdc.gov/std/treatment-guidelines/syphilis.htm
- 9.White DAE, Alter HJ, Irvin NA, et al. Low Rate of Syphilis Screening Among High-Risk Emergency Department Patients Tested for Gonorrhea and Chlamydia Infections. Sexually Transmitted Diseases. 2012;39(4):286–290. [DOI] [PubMed] [Google Scholar]
- 10.Klein PW, Martin IBK, Quinlivan EB, et al. Missed Opportunities for Concurrent HIV-STD Testing in an Academic Emergency Department. Public Health Rep 2014;129(1_suppl1):12–20. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Barnes A, Jetelina KK, Betts AC, et al. Emergency Department Testing Patterns for Sexually Transmitted Diseases in North Texas. Sexual Trans Dis 2019;46(7):434–439. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Erickson JL, Wu J, Fertel BS, et al. Multidisciplinary Approach to Improve Human Immunodeficiency Virus and Syphilis Testing Rates in Emergency Departments. Open Forum Infect Dis 2022;9(12):ofac601. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Seballos SS, Lopez R, Hustey FM, et al. Cotesting for Human Immunodeficiency Virus and Sexually Transmitted Infections in the Emergency Department. Sex Transm Dis 2022;49(8):546–550. [DOI] [PubMed] [Google Scholar]
- 14.Arbelaez C, Wright EA, Losina E, et al. Emergency provider attitudes and barriers to universal HIV testing in the emergency department. J Emerg Med 2012;42(1):7–14. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Haukoos JS, Hopkins E, Byyny RL. Denver Emergency Department HIV Testing Study Group. Patient acceptance of rapid HIV testing practices in an urban emergency department: assessment of the 2006 CDC recommendations for HIV screening in health care settings. Ann Emerg Med 2008;51(3):303–309, 309.e1. [DOI] [PubMed] [Google Scholar]
- 16.Mumma BE, Suffoletto BP. Less encouraging lessons from the front lines: barriers to implementation of an emergency department-based HIV screening program. Ann Emerg Med 2011;58(1 Suppl 1):S44–48. [DOI] [PubMed] [Google Scholar]
- 17.Stanford KA, Mason JA, Friedman EE. Trends in STI testing and diagnosis rates during the COVID-19 pandemic at a large urban tertiary care center, and the role of the emergency department in STI care. Front Reprod Health. 2023;5:1082429. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Cheung PT, Wiler JL, Lowe RA, Ginde AA. National Study of Barriers to Timely Primary Care and Emergency Department Utilization Among Medicaid Beneficiaries. Annals of Emergency Medicine. 2012;60(1):4–10.e2. [DOI] [PubMed] [Google Scholar]
- 19.Stanford KA, Hazra A, Friedman E, et al. Opt-out, routine emergency department syphilis screening as a novel intervention in at-risk populations. Sex Transm Dis Published online October 1, 2020. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Stanford KA, Friedman EE, Schmitt J, et al. Routine Screening for HIV in an Urban Emergency Department During the COVID-19 Pandemic. AIDS Behav 2020;24(10):2757–2759. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Anderson S, Friedman EE, Eller D, et al. HIV testing in a high prevalence urban area in the US: Identifying missed opportunities two ways. Int J STD AIDS 2022;33(11):970–977. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Centers for Disease Control and Prevention. HIV and African American People: HIV Incidence. Accessed September 29, 2023. https://www.cdc.gov/hiv/group/racialethnic/africanamericans/incidence.html
- 23.Seth P, Walker T, Hollis N, et al. Centers for Disease Control and Prevention (CDC). HIV testing and service delivery among Blacks or African Americans−-61 health department jurisdictions, United States, 2013. MMWR Morb Mortal Wkly Rep 2015;64(4):87–90. [PMC free article] [PubMed] [Google Scholar]
- 24.Centers for Disease Control and Prevention. HIV by Age: HIV Diagnoses. Accessed September 29, 2023. https://www.cdc.gov/hiv/group/age/diagnoses.html
- 25.Chicago Department of Public Health. HIV+STI Data Report, 2020.; 2022. [Google Scholar]
- 26.Stanford KA, Almirol E, Meyer M, McNulty MC. An automated best practice advisory increases both routine HIV screening and HIV cotesting with sexually transmitted infections in the emergency department. Am J Infect Control. Published online February 1, 2024:S0196–6553(24)00057–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.US Preventive Services Task Force, Mangione CM, Barry MJ, et al. Screening for Syphilis Infection in Nonpregnant Adolescents and Adults: US Preventive Services Task Force Reaffirmation Recommendation Statement. JAMA 2022;328(12):1243. [DOI] [PubMed] [Google Scholar]
- 28.Mude W, Mwenyango H, Preston R, et al. HIV Testing Disruptions and Service Adaptations During the COVID-19 Pandemic: A Systematic Literature Review. AIDS Behav Published online August 7, 2023. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Moitra E, Tao J, Olsen J, et al. Impact of the COVID-19 pandemic on HIV testing rates across four geographically diverse urban centres in the United States: An observational study. The Lancet Regional Health - Americas. 2022;7:100159. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Stanford KA, Friedman EE, Schmitt J, et al. Routine Screening for HIV in an Urban Emergency Department During the COVID-19 Pandemic. AIDS Behav 2020;24(10):2757–2759. [DOI] [PMC free article] [PubMed] [Google Scholar]