Opt-Out Screening for STIs: A Key Strategy for Protecting Long-term Patient Health

Earlier this year, theCenters for Disease Control and Prevention (CDC) released its annual surveillance report on rates of sexually transmitted infections (STIs) and declared “STIs must be a public health priority.” More than 2.2 million new cases of chlamydia and gonorrhea were reported in the US.¹ These data underscore that current efforts have been insufficient to address the STI epidemic, and there’s a critical need for new prevention strategies.

For chlamydia and gonorrhea, the CDC recommends sexually active young women 15-24 years old receive annual screening.² In fact, the CDC updated its STI guidelines for healthcare providers (HCPs) to consider offering chlamydia and gonorrhea screening to all young women 15-24 years old—regardless of reported sexual behavior—unless they opt out.² Opt-out screening with a universal approach is where specific groups are automatically screened annually unless a person declines to be screened.^2,3 This differs from at-risk screening, where the HCP determines if STI screening is necessary based on patient history, or opt-in screening, where patients are asked if they would like to be tested.

Before reviewing why opt-out screening should be considered in young women (defined as cisgender women for this article), let’s explore why screening itself is necessary. Perhaps the most important reason is that over half of new STIs occur in the 15-24 age range, even though they only make up 13% of the US population.^4,5 Additionally, many patients with an STI are unaware they have an infection because they do not show any symptoms (over 84% of women with chlamydia or gonorrhea are asymptomatic).⁶ These infections, if undiagnosed and therefore untreated, can lead to serious impacts on women’s health. For instance, 24,000 women become infertile due to undiagnosed STIs each year and 30-50% of untreated chlamydia and gonorrhea infections are the main causes of pelvic inflammatory disease (PID),^7-9 which can lead to women experiencing chronic pelvic pain and ectopic pregnancy.⁹ Untreated STIs can have consequences that reach beyond the individual patient; they also put their sexual partners at risk of infection.¹⁰

Improving Patient Care Through Established Screening Guidelines

So why an opt-out approach to screening? Because it is the most effective method for identifying positive cases of STIs among young women.¹¹ At-risk screening relies on what the patient shares with the pediatrician/primary care provider (PCP), and patients may not be completely forthcoming about their sexual history. This was reflected in one study where >10% of individuals with a positive STI result (chlamydia, gonorrhea, or Trichomonas vaginalis) reported being abstinent within the last year, with almost 6% of STI-positive individuals reporting never having penile or vaginal sex.¹² Opt-in screening also provides suboptimal results as many young patients may decline testing due to embarrassment, concerns regarding confidentiality of results, and a desire for brief office visits.¹³ Not only will opt-out screening identify more patients with STIs,¹¹ it can also have the added the benefit of helping patients get in the habit of receiving annual STI screening, similar to the annual visits they are expected to make to their dentist or optometrist.

Major public health and medical societies such as the Centers for Disease Control and Prevention (CDC),² American Academy of Pediatrics (AAP),¹⁴ American College of Obstetricians and Gynecologists (ACOG),¹⁵ American Academy of Family Physicians (AAFP),¹⁶ and the US Preventive Services Task Force (USPSTF),¹⁷ are all aligned in their recommendations on screening for chlamydia and gonorrhea. The CDC specifically recommends that young, sexually active women who are <25 years of age should be screened annually for chlamydia and gonorrhea. Women >25 years of age who are at an increased risk of having an STI should similarly be screened. This includes women who have a new sexual partner, a history of past infection, having more than one sexual partner, or having a partner that has other sexual partners.¹¹

In fact, the USPSTF set a goal to achieve 77% screening of sexually active females between the ages of 16 and 24 for chlamydial infections by the year 2030. At the start in 2018, the rate was 55.8%, which decreased to 52.9% in 2021, most likely due to the COVID-19 pandemic interrupting patient habits and ability to see HCPs on a regular basis.^3,18 Now that access to healthcare is returning to pre-COVID levels,¹⁹ it’s imperative that we refocus our efforts on achieving our goal with the help of implementing opt-out screening.¹¹ 

Overcoming Barriers to Uptake

While the advantages of opt-out screening are abundant, there are considerable barriers that restrict its uptake. A recent study of graduate medical trainees found that the barriers they experience include focusing on higher priority illnesses, time constraints, and a lack of STI-specific training.²⁰ For patients, their resistance to STI screening may be based on a variety of factors, including an assumption that they have a low risk for STIs (especially if they are not exhibiting any symptoms);²¹ they may have feelings of embarrassment and stigma related to being sexually active or possibly having an STI;¹³ concerns with confidentiality, especially if their parents are in the room during the exam;²² and a lack of access to testing.²¹

There are ways for pediatricians to overcome these challenges to implement opt-out screening and help patients be more accepting. Some resources to help facilitate this can be found at https://hologicwomenshealth.com/universalscreening/.

While opt-out screening allows an option to screen regardless of the patient’s reported sexual history, there is still a benefit to obtaining this information if possible as it can help pediatricians/PCPs to optimize care. One way to make this process more efficient is to provide a questionnaire to patients before the office visit, allowing the patient to provide the information in a discreet and confidential way.²⁰ By basing the patient questionnaire on the “5 P’s” (Partners [all genders], Practices [oral, anal, vaginal], Protection from STIs [condoms, PrEP, or Pre-exposure Prophylaxis for HIV], Past history of STIs [partners treated? When last tested?], Pregnancy intention [plans to be pregnant, actively trying to prevent pregnancy]) recommended by the CDC’s How Do I Discuss Sexual Health with Patients?, pediatricians/PCPs can ensure their questions use inclusive language and address all patient groups.²³

For patients, the ability to discuss STI test results easily and comfortably with their pediatrician/PCP is pivotal. As HCPs, we can reassure patients that test results, regardless of outcome, are confidential and will not be disclosed to anyone else. Actively screening for STIs, regardless of symptoms, is the only way to tell if they have an infection and get treatment, preventing serious, long-term health issues.⁷ It is also important that inclusive language be used so that patients feel they are accepted and that the health concerns still relate to them. For instance, you may want to refer to the patient’s sex partner as ‘their partner’ until the patient discloses how they and their partner self-identify. ²³ 

Incorporating into Clinical Practice

Implementing opt-out screening successfully will require that practices have adequate testing supplies available. Fortunately, there are screening options available to practices that provide versatility, flexibility, reliability, and convenience. The preferred sampling method recommended by the CDC for chlamydia and gonorrhea testing is a vaginal swab,²⁴ which has proven to yield a decrease in patient callback for re-collection or add-on testing.^24-29 Most women (90%) prefer self-collection with a vaginal swab over a pelvic exam (76%) or urine specimen collection (60%).³⁰ However, first catch urine from women, while acceptable for screening, might detect up to 10% fewer infections when compared with vaginal and endocervical swab samples.²⁴

Single swab testing creates a simplified sample collection and enhanced workflow for all involved, benefiting not only the HCP and patient, but also the laboratory professional. The Aptima® Multitest Swab can be used to detect seven different infections and disease states (i.e., bacterial vaginosis, C. glabrata, Candida species, chlamydia, gonorrhea, Mycoplasma genitalium, Trichomonas vaginalis) from a single swab. The sexual and vaginal health portfolio offers a broad assay menu that provides timely and accurate results to empower patients to protect their sexual and reproductive health while reducing the need for re-testing or testing for more infections. Also, for patients over the age of 21 also receiving cervical cancer screening, the ThinPrep® Pap Test can also be used for testing chlamydia, trichomonas, and gonorrhea, in addition to detecting abnormal cervical cells, and high-risk HPV mRNA.³¹

Conclusions

Pediatricians/PCPs are uniquely positioned to help turn the tide of the STI public health crisis by creating a safe space for these conversations and instilling healthy habits among young adults. By implementing an opt-out screening approach for chlamydia and gonorrhea, it provides consistent opportunities to educate patients about the importance of understanding their sexual health and well-being. Additionally, it's important to emphasize that by undergoing regular testing, patients safeguard themselves from potential long-term health risks. As HCPs, we have the opportunity to safeguard the patient health of a younger generation now and in the future.

REFERENCES

1. Centers for Disease Control and Prevention. Sexually Transmitted Infections Surveillance, 2022. Available from: https://www.cdc.gov/std/statistics/2022/default.htm. Accessed February 27, 2024.
2. Centers for Disease Control and Prevention. Sexually Transmitted Infections Treatment Guidelines, 2021: Adolescents. Available from https://www.cdc.gov/std/treatment-guidelines/adolescents.htm. Accessed February 15, 2024.
3. Holland-Hall C and Bonny AE. Testing for sexually transmitted infections: providers cannot opt out of the conversation. Pediatrics. 2022;149:e2021055954.
4. Centers for Disease Control and Prevention. Sexually transmitted diseases: adolescents and young adults. Available from https://www.cdc.gov/std/life-stages-populations/adolescents-youngadults.htm. Accessed February 15, 2024.
5. United States Census Bureau. 2022. Available from: https://www.census.gov/popclock/data_tables.php?component=pyramid. Accessed February 15, 2024.
6. Detels R, et al. The incidence and correlates of symptomatic and asymptomatic Chlamydia trachomatis and Neisseria gonorrhoeae infection in selected population in five countries. Sex Transm Dis. 2011;38:503-509.
7. Centers for Disease Control and Prevention. CDC Fact Sheet: 10 ways STDs impact women differently from men. Available from https://www.cdc.gov/std/health-disparities/stds-women-042011.pdf. Accessed February 16, 2024.
8. American College of Obstetricians and Gynecologists. Pelvic Inflammatory Disease (PID): Frequently Asked Questions. Available from https://www.acog.org/womens-health/faqs/pelvic-inflammatory-disease. Accessed February 16, 2024.
9. Centers for Disease Control and Prevention. What causes pelvic inflammatory disease? Available from https://www.cdc.gov/std/pid/stdfact-pid-detailed.htm#:~:text=Women%20develop%20PID%20when%20certain,of%20a%20woman's%20reproductive%20organs. Accessed February 16, 2024.
10. Centers for Disease Control and Prevention. CDC Fact Sheet: Information for Teens and Young Adults: Staying Healthy and Preventing STDs. Available from https://www.cdc.gov/std/life-stages-populations/stdfact-teens/htm. Accessed February 15, 2024.
11. Workowski KA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep. 2021;70(No. RR-4):1-192.
12. DiClemente RJ, et al. Association between sexually transmitted diseases and young adults’ self-reported abstinence. Pediatrics. 2011;127:208-213.
13. Tilson EC, et al. Barriers to asymptomatic screening and other STD services for adolescents and young adults: focus group discussions. BMC Public Health. 2004;4:21.
14. American Academy of Pediatrics. AAP issues advice on screening teens for STIs. Available from https://www.contemporarypediatrics.com/view/aap-issues-advice-screening-teens-stis. Accessed February 16, 2024.
15. American College of Obstetricians and Gynecologists. FAQs: chlamydia, gonorrhea, and syphilis. Available from https://www.acog.org/womens-health/faqs/chlamydia-gonorrhea-and-syphilis. Accessed February 16, 2024.
16. Lee KC, et al. Sexually transmitted infections: recommendation from the U.S. Preventive Services Task Force. Am Fam Physician. 2016;94:907-915.
17. US Preventive Services Task Force. Screening for chlamydia and gonorrhea US Preventive Services Task Force recommendation statement. JAMA 2021;326:949-956.
18. OASH. Increase the proportion of sexually active female adolescents and young women who get screened for chlamydia – STI-01. Available from https://health.gov/healthypeople/objectives-and-data/browse-objectives/sexually-transmitted-infections/increase-proportion-sexually-active-female-adolescents-and-young-women-who-get-screened-chlamydia-sti-01. Accessed February 17, 2024.
19. Hartman M, et al; and The National Health Expenditure Accounts Team. National Health Care Spending in 2022: Growth similar to prepandemic rates. Health Affairs. 2024;43:6-17.
20. Zucker J, et al. Attitudes and perceived barriers to sexually transmitted infection screening among graduate medical trainees. Sex Transm Dis. 2021;48:e149-e152.
21. Shafi T and Levine D. Office-based screening for sexually transmitted infections in adolescents. Pediatrics. 2020;145:e20192056K.
22. Leichliter JS, et al. Confidentiality issues and use of sexually transmitted disease services among sexually experienced persons aged 15-25 years – United States, 2013-2015. MMWR Morb Mortal Wkly Rep. 2017;66:237-242.
23. Centers for Disease Control and Prevention. How do I discuss sexual health with patients? Available from https://www.cdc.gov/hiv/clinicians/screening/sexual-health.html. Accessed February 16, 2024.
24. Centers for Disease Control and Prevention. Recommendations for the Laboratory-Based Detection of Chlamydia trachomatis and Neisseria gonorrhoeae. MMWR Recomm Rep. 2014;63(2).
25. Aptima Trichomonas vaginalis Assay [package insert]. 503684, San Diego, CA; Hologic, Inc., 2020.
26. Aptima Mycoplasma genitalium assay [package insert]. AW-17946, San Diego, CA; Hologic, Inc., 2022.
27. Aptima CV/TV assay [package insert]. AW-18812, San Diego, CA; Hologic, Inc., 2021.
28. Aptima BV assay [package insert]. AW-18811, San Diego, CA; Hologic, Inc., 2020.
29. Aptima Combo 2 Assay [package insert]. AW-20535, San Diego, CA; Hologic, Inc., 2021.
30. Chernesky MA, et al. Women find it easy and prefer to collect their own vaginal swabs to diagnose Chlamydia trachomatis or Neisseria gonorrhoeae infections. Sex Trans Dis. 2005;32:729-733.
31. Aptima HPV + ThinPrep Cervical Health from Hologic. Available from www.hologic.com/hologic-products/cytology/aptima-hpv-thinprep-cervical-health?utm_source=google&utm_medium=cpc&utm_term=thinprep%20pap%20smear&utm_campaign=2023_ThinPrep&gad_source=1&gclid=CjwKCAiAuNGuBhAkEiwAGId4alpfAa5RmShKCAjES7HpeLcTIyXvrOBrWs0nKsMxrWVaoFuXQOSmZxoCwPYQAvD_BwE. Accessed March 4, 2024.