Chlamydia and gonorrhea are among the most common sexually transmitted infections (STIs) in the United States, and research shows that 50% of sexually active individuals will contract an STI by 25 years old. Though chlamydia and gonorrhea are often asymptomatic in women, screening is important in order to prevent complications, such as pelvic inflammatory disease (PID), infertility, pregnancy complications, and increased risk for HIV transmission.
A recent article published in Medical Care addresses screening for STIs in women after cervical cancer screening guidelines were updated. The Centers for Disease Control and Prevention (CDC) and the U.S. Preventive Services Task Force (USPSTF) recommend annual chlamydia and gonorrhea screening for all sexually active women younger than 25 years, as well as older women at increased risk (e.g. women with new or multiple sex partners or a sex partner who has an STI). Approximately 20 million new STIs occur each year, with half of these diagnosed in persons 15-24 years. Women were historically screened for STIs at the same time as the annual pap smear. However, updates to cervical cancer screening guidelines in 2009 and 2012 recommended less frequent cervical cancer screening; this then resulted in increased concern that STI screening might decrease.
The recently published Medical Care article measured STI screening among women aged 16-30 years enrolled in Pennsylvania Medicaid from 2007 to 2013. The results of the study demonstrated an increase in STI screening by 48% between 2007 and 2011 that stabilized by 2013. Again, this is in the context of less frequent cervical cancer screening (via pap smear). A likely reason for the increase in STI screening, rather than decrease, is the robust family planning program that Pennsylvania Medicaid implemented in response to changes in cervical cancer screening guidelines. That is, in order to improve access to sexual healthcare in Pennsylvania, the state implemented a family planning program that ensured access to STI screening, cervical cancer screening, and contraception services for women at higher income levels (185% of federal poverty level) than would have otherwise been eligible for Medicaid services.
The results of the Pennsylvania Medicaid study are particularly remarkable given that chlamydia, gonorrhea, and syphilis all reached a record high rate of infection in 2015. In fact, approximately 1.5 million cases of chlamydia were reported in 2015, which represents the largest number of annual cases of any medical condition ever reported to the CDC. As previously stated, CDC and USPSTF recommend annual STI screening for sexually active women 15-24 years; however, fewer than half of eligible women are screened according to these guidelines.
Primary care providers ought to be on the frontlines of integration of sexual health into patient-centered care. Primary care pioneers within the field of sexual health state that “Family physicians must proactively address the sexual health of their patients… Effective sexual healthcare should address wellness considerations in addition to infections, contraception, and sexual dysfunction.”
In addition to subsidized sexual health screening for STIs (as in the Pennsylvania Medicaid family planning program) and robust primary care services, public health marketing campaigns might also influence STI rates. In a research study that looked at long-term effects of community-based STI screening and mass media HIV prevention messages on adolescent sexual risk behaviors, authors found that in the absence of the public health marketing campaign, adolescents returned to their previously high-risk sexual behaviors within six months. Authors concluded that a “culturally sensitive mass media program has the potential to achieve more stable reductions in sexual risk behavior and can help to optimize the effects of community-based STI screening.” Thus, as healthcare providers and public health professionals attempt to address STI screening, treatment, and prevention, we must always consider the public health approach.
Please see further CDC recommendations for STI and HIV screening here.
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