July 1, 2021, 2:02 p.m. Michael Devitt — Screening for sexually transmitted infections can officially be added to the list of health care services negatively affected by the COVID-19 pandemic.
A new article in press from the American Journal of Preventive Medicine reported on an analysis of more than 18 million STI test results obtained prior to and during the first few months of the pandemic. The analysis found that the pandemic had an adverse effect on sexual health screening by causing significant declines in testing for both men and women, resulting in potentially tens of thousands of missed cases of chlamydia and gonorrhea.
“STI screening is an aspect of health care that suffered during the pandemic,” said Alexis “Alex” Vosooney, M.D., of West St. Paul, Minn., a member of the Academy’s Commission on Health of the Public and Science and chair of its Subcommittee on Clinical Recommendations and Policies. “As we strive to get patients caught up on their preventative and risk-based screenings, we should be sure to discuss STI testing.”
“The quickest way for people to spread STIs is to not know that they have one,” stated Casey Pinto, Ph.D., M.P.H., N.P-C., an assistant professor of public health sciences at Penn State College of Medicine in Hershey and the study’s corresponding author, in a press release. “The inability to detect asymptomatic cases could have negative repercussions for years to come.”
For family physicians, the findings could be of even greater concern when contrasted with recent information from the CDC. A report published earlier this year indicated that in 2019, the last year for which data were available, the number of cases of chlamydia and gonorrhea in the United States reached an all-time high for the sixth consecutive year, with the two diseases combining for more than 2.4 million infections.
In the analysis, researchers examined data on STI screening tests performed by Quest Diagnostics, a national reference clinical laboratory. The study population consisted of individuals ages 14 to 49 years, and patients were categorized by sex, age group at the time of testing and geographic area.
The testing period under review spanned the first full calendar week of January 2019 through the last full calendar week of June 2020. To simplify matters, the researchers used March 1, 2020, through June 27, 2020, as the pandemic period, and the preceding 60-week period as a baseline. The researchers then calculated the weekly numbers of tests and positive cases obtained during baseline to estimate the potential number of tests and STIs that were missed during the pandemic.
Prior to the pandemic, an average of 131,114 tests for chlamydia and 130,831 tests for gonorrhea were performed each week, resulting in an average of 6,195 cases of chlamydia and 1,819 cases of gonorrhea.
Not surprisingly, STI testing decreased sharply beginning in mid-March. According to the researchers, testing reached a nadir the week of April 5, 2020, with decreases of 59% for female patients and 63% for male patients compared with baseline testing volumes. Although test volumes increased in the following weeks, by the end of the study period, they were still 15% lower than baseline values.
The researchers also noted a strong association between declines in STI testing and increased STI positivity rates, which peaked in mid-April. For the week of April 12, 2020, positivity rates were 5.9% for chlamydia and 2.4% for gonorrhea — both significantly higher than in the weeks preceding the pandemic. At the final week of the study period, these rates remained significantly higher compared with baseline (5.1% for chlamydia, 1.9% for gonorrhea).
The researchers also used test volumes and positive STI cases that occurred before the pandemic to estimate the number of STIs missed in the early stages of the pandemic. Based on their analysis, the research team estimated that between March 2020 and June 2020, more than 27,000 cases of chlamydia and more than 5,500 cases of gonorrhea were potentially missed.
The study authors suggested that a variety of factors may have contributed to the decreased test volumes and increased positivity rates. These include social distancing restrictions, changes in the delivery of care and a lack of testing supplies, along with recommendations the CDC published in the early stages of the pandemic.
In May 2020, two months after President Trump declared the pandemic a national emergency, the agency published updated guidance on sexual health services.
Among other things, the CDC recommended that STI clinics that remained open should prioritize patients with symptoms and those at risk of complications, and that routine screening visits be deferred until after the emergency. The guidance also recommended using phone or telemedicine-based triage for some patients, and if the clinic were closing, the CDC recommended referring patients to other clinics and pharmacies that could continue to provide sexual health services.
Because of these factors, the authors speculated that many patients who were at risk for STIs or asymptomatic may not have received timely testing or treatment during the pandemic. The authors also stated that because the laboratory data represented only about one-fifth of all STI case reports in the United States, the total number of missed cases was likely more than 150,000 — considerably higher than what was reported in the study.
“The likely decrease in risk-based screening, although necessary, ultimately means that there will be future negative health outcomes from the large number of missed cases, owing to the often asymptomatic nature of both chlamydia and gonorrhea,” they wrote, adding, “Because the impact of social distancing guidelines remains unknown, the ramifications of this large number of missed cases are not yet fully understood.”
The authors concluded that further research is needed to better understand the long-term implications of COVID-19 on STI rates. They added that, although the results were limited by a lack of clinical information on individuals who tested positive for chlamydia or gonorrhea, the findings “should serve as a warning of the potential sexual and reproductive health complications that can be expected because of limited STI screening services in the United States.”
Vosooney, who also serves as chair of the AAFP’s Subcommittee on Clinical Recommendations and Policies, told AAFP News that the researchers’ findings were not surprising. The pandemic, she said, caused many people to lose access to an STI clinic, while other patients may have avoided going to a clinic because of safety concerns.
Vosooney additionally stated that the findings should serve as reminder to both patients and clinicians of the importance of discussing STI screening.
“The reminder that STIs are prevalent, and that screening for them is key for identification and decreasing risks of long-term health consequences,” can help clinicians and their patients have frank discussions of sexual practices and risks, and make decisions about testing, said Vosooney.
Vosooney also offered a brief recommendation on how to speak with patients on the subject.
“When discussing sexual health, be open and direct with your patients. Let them know that when they share information about their sexual practices, it helps their clinician make the best recommendations for their health.”
The AAFP has several resources to help increase screening for STIs, including a Screening for Sexually Transmitted Infections Practice Manual that contains an overview of key recommendations, workflow considerations, and billing and coding information. Additionally, a guide for FPs on obtaining an accurate sexual history is available for members.