Welcome to ReachMD. This medical industry feature, titled “Combatting the Surge of Chlamydia & Gonorrhea with Universal Screening” is sponsored by Quest Diagnostics. The non-employee guest speaker is being compensated by Quest Diagnostics for her time.
Here’s your host, Dr. Jennifer Caudle.
For many years now, cases of chlamydia, gonorrhea, and syphilis have been at an all-time high in the United States. And these cases are being seen in people as young as 15 years old. So what can clinicians do to put a stop to this? This is ReachMD, and I'm your host, Dr. Jennifer Caudle. And joining me to help us overcome barriers to screening for STIs, or sexually transmitted infections, is Dr. Kameelah Phillips, a Board-Certified Obstetrician and Gynecologist at Calla Women's Health in New York City. Dr. Phillips, welcome to the program.
Great to be here.
Well, we're happy that you're here. We have a lot to discuss today. So let's begin with some background. Uh, Dr. Phillips, what can you tell us about the prevalence and burden of STIs in the United States, specifically in young patients?
Sure, so in 2021, 2.5 million cases of chlamydia and gonorrhea were reported, which is an all-time high for many years now.1 And a primary risk factor for that is certainly age.2,3 For example, 67 percent of females with chlamydia4 and 54 percent of females with gonorrhea4 are between the ages of 15 and 24. But patients are often asymptomatic, so they are otherwise healthy. Many may not know they have an STI.5 Plus, 86 percent of patients don’t even think they’re at risk.6 Now if left untreated, these infections can lead to long-lasting complications, including pelvic inflammatory disease, chronic pelvic pain, ectopic pregnancy, and infertility.7 In fact, STIs are estimated to cause infertility in more than 20,000 females each year.8
So with all that in mind, what screening guidelines do we have that address these challenges?
Yes, so first I’d like to note that the guidelines are not just for young cisgender women. They also apply to all young transgender men and young gender-diverse individuals assigned female at birth. The CDC and the US Preventive Services Task Force, or the USPSTF, both recommend sexually active females under 25 years of age be screened for chlamydia and gonorrhea.7,9 But the CDC takes this a step further recommending yearly screenings starting at early adolescence regardlessof sexual activity.7 Yet despite these recommendations, we see low screening rates among young patients. For example, data show that even those who identify as sexually active are only receiving chlamydia screening 50 percent of the time.10 So that’s still a major concern.
Absolutely. And why are these screening rates so low?
Well, there are actually several barriers preventing screening for both patients and clinicians. First, patients may not fully understand chlamydia and gonorrhea infections and their consequences.7,12,13 Young people don’t believe that they are at risk ,7,12,13 and many patients may be reluctant to share their sexual history with their clinicians.7,12,13 Second, some clinicians may not yet be aware of the latest changes to screening guidelines and recommendations and may miss opportunities to screen.11 Also in my experience, young people understandably aren’t upfront with parents about their sexual activity, or parents may be in denial about their child’s sexual activity. And so regular screening is not discussed or encouraged—these are missed opportunities to demystify STIs and to encourage screening as well.
For those just tuning in, you’re listening to ReachMD. I’m Dr. Jennifer Caudle and today I’m speaking with Dr. Kameelah Phillips about STI screening rates for young patients. So we just talked about the barriers to proper STI screening. Let’s now discuss how we can overcome these issues. Dr. Phillips, what can we do to screen more young patients for STIs?
Well, the CDC encourages clinicians to consider providing universal screening with opt-out for chlamydia and gonorrhea for all adolescents and young adult patients during clinical encounters as a best practice.7 This means health care providers should screen all young patients between 15 and 24 years old, regardless of sexual activity, as a standard practice unless the patient decides to opt out of testing.7 Again, this includes young cisgender women, young transgender men, and young gender-diverse people with a cervix. According to the CDC, universal screening with opt-out for chlamydia, for example, could substantially increase screening rates, reduce costs, and identify infections in patients who choose not to reveal their sexual behaviors.7 It has also shown to reduce prevalence of chlamydia by 55 percent.14 And all states and the District of Columbia allow minors to consent to their own STI screenings.7 So, in my opinion, universal screening with opt-out may help patients feel less judged or singled out, and it can help facilitate positive sexual health discussions between a patient and their clinician.
Those are excellent points, thank you so much for that Dr. Phillips. Now how can clinicians adopt universal screening with opt-out protocols into their practices, and what does this implementation look like?
So, clinicians can turn to The American Sexual Health Association to find resources on adopting chlamydia and gonorrhea screening protocols for all young patients ages 15 to 24 as a routine part of preventive health care visits.15 It’s important to make patients aware of this protocol through email or mail before their scheduled visit, or this information can be included on the intake forms at check-in. Next in the waiting room, make sure the patient meets the requirements for testing. We can remind the patient of the screening protocol, and that screening is done regardless of sexual history, but they have the option to opt-out. Also in the exam room, after discussing options to receive results privately, educating her about the benefits of STI prevention through screening, and reviewing the consequences of untreated infections, then you can collect the specimen with a vaginal swab, Pap vial, or urine sample. It’s important that we stress that they do not need an exam to be tested. It’s also very important to prepare patients about the possibility of a positive test result, and we can talk about this in a bit.
Excellent. And what suggestions do you have when talking to patients and their parents about universal screening with opt-out? You know, what types of phrases do you think resonate most?
Well, prior to testing, I let parents know that- “All patients between 15 and 24 are screened for chlamydia and gonorrhea because it’s important to protect their long-term health and prevent infertility." This helps normalize discussions about STIs and regular testing. I stress that all patients with a cervix in this age group should be tested for these infections because they could have an infection and not know it. "Testing is the only way to diagnose these infections.” And in the event of a positive test result, use phrases like, “the good news is that we caught it early, it’s easy to treat with antibiotics, and it’s inexpensive because it’s covered by most insurances” to help ease the patient or the parent’s mind.
For a negative test result, it’s important to reinforce STI prevention methods and the need for regular screening. And the message is similar for patients as well. We say things like, “our office screens all patients around your age annually for chlamydia and gonorrhea. These are common infections, but you may not know you have one, and they can cause long-term problems if not caught and treated early enough.”
Those are great suggestions. Now unfortunately, we're almost out of time for today, but I'd like to get some final thoughts from you. You know, what key takeaways would you like to leave with our audience?
So, I would like to stress the importance of open discussion and testing so we can remove the stigma from STIs and encourage regular screening. I believe the conversation and education will help us close the gap between STI rates and screening. Universal screening with opt-out has proven to increase screening rates in a meaningful way16,17 while also potentially reducing STI prevalence, as is the case for chlamydia.14 We also need to normalize conversations about sexual health with our patients.18 Luckily, we have education at our disposal to start the conversation and explain opt-out testing.18 Finally, if we can get ahead of STIs using universal screening with opt-out, then young patients will be at less risk for lifelong complications, especially infertility.7
Well that’s a great way to round out our discussion on STIs and universal screening with opt-out. I’d like to thank my guest, Dr. Phillips, for helping us better understand the importance of universal screening for adolescents and young people. Dr. Phillips, it was great speaking with you today.
Thanks for having me!
This program was sponsored by Quest Diagnostics. If you missed any part of this discussion, visit ReachMD.com/IndustryFeature. This is ReachMD. Be Part of the Knowledge.
- CDC. Preliminary 2021 STD Surveillance Data. Accessed February 28, 2023. https://www.cdc.gov/std/statistics/2021/default.htm.
- CDC. Sexually Transmitted Infections Treatment Guidelines, 2021. Accessed January 3, 2022. https://www.cdc.gov/std/treatment-guidelines/STI-Guidelines-2021.pdf.
- Davidson KW, Barry MJ, Mangione CM, et al; US Preventive Services Task Force. Screening for chlamydia and gonorrhea: US Preventive Services Task Force Recommendation Statement. JAMA. 2021;326(10):949-956. doi:10.1001/jama.2021.14081
- CDC. Sexually Transmitted Disease Surveillance 2019. Accessed January 27, 2022. https://www.cdc.gov/std/statistics/2019/std-surveillance-2019.pdf.
- Detels R, Green AM, Klausner JD, et al. The incidence and correlates of symptomatic and asymptomatic Chlamydia trachomatis and Neisseria gonorrhoeae infections in selected populations in five countries. Sex Transm Dis. 2011;38(6):503-509.
- Quest Diagnostics. Universal STI testing research among young women and moms: topline report. December 2017.
- Workowski KA, Bachmann LH, Chan PA, et al. Sexually transmitted infections treatment guidelines, 2021. MMWR Recomm Rep. 2021;70(4):1-187. doi:10.15585/mmwr.rr7004a1
- Reported STDs in the United States, 2019. Centers for Disease Control and Prevention. Accessed February 3, 2022. https://www.cdc.gov/nchhstp/newsroom/docs/factsheets/std-trends-508.pdf.
- US Preventive Services Task Force. Screening for chlamydia and gonorrhea: US Preventive Services Task Force Recommendation Statement. JAMA. 2021;326(10):949-956. doi:10.1001/jama.2021.14081
- Chlamydia screening in women (CHL). NCQA. Accessed January 27, 2022. https://www.ncqa.org/hedis/measures/chlamydia-screening-in-women/.
- Davis M, Hoskins K, Phan M, et al. Screening adolescents for sensitive health topics in primary care: a scoping review. J Adolesc Health. 2021:S1054-139X(21)00559-0. doi:10.1016/j.jadohealth.2021.10.028
- Wood SM, McGeary A, Wilson M, et al. Effectiveness of a quality improvement intervention to improve rates of routine chlamydia trachomatis screening in female adolescents seeking primary preventive care. J Pediatr Adolesc Gynecol. 2019;32(1):32-38. doi:10.1016/j.jpag.2018.10.004
- Llata E, Cuffe KM, Picchetti V, et al. Demographic, behavioral, and clinical characteristics of persons seeking care at sexually transmitted disease clinics - 14 sites, STD Surveillance Network, United States, 2010-2018. MMWR Surveill Summ. 2021;70(7):1-20. doi:10.15585/mmwr.ss7007a1
- Owusu-Edusei K Jr, Hoover KW, Gift TL. Cost-effectiveness of opt-out chlamydia testing for high-risk young women in the US. Am J Prev Med. 2016;51(2):216-224. doi:10.1016/j.amepre.2016.01.007
- American Sexual Health Association, National Chlamydia Coalition. Opt-Out Screening. Accessed February 10, 2023. http://chlamydiacoalition.org/opt-out-screening.
- Elattma A, Laves E, Taber B, et al. Using provider incentives and an opt-out strategy in a successful quality initiative to increase chlamydia screening. Jt Comm J Qual Patient Saf. 2020;46(6):326-334. doi:10.1016/j.jcjq.2020.03.003
- Allison BA, Park RV, Walters EM, et al. Increased detection of gonorrhea and chlamydia after implementation of a universal screening protocol in a pediatric primary care clinic. Sex Transm Dis. 2022;49(2):117-122. doi:10.1097/OLQ.0000000000001534
- Using normalizing and opt-out language for chlamydia and gonorrhea screening. Family Planning National Training Center. Accessed February 11, 2022. https://rhntc.org/sites/default/files/resources/fpntc_norm_optout_lang_script_2019-04-25.pdf.