Chlamydia screening for sexually active young women under the Affordable Care Act: new opportunities and lingering barriers

Creating Innovative Sexually Transmitted Infection Testing Options for University Students: The Impact of an STI Self-testing Program

BACKGROUND

National-level data suggest that sexually transmitted infection (STI) testing rates among young adults are low. The purpose of this study was to evaluate the acceptability of an STI self-testing program at a university health center. Few evaluations on the acceptability of collegiate self-testing programs and their effect on testing uptake have been conducted.

METHODS

To assess acceptability and uptake of self-testing (urine and self-collected vaginal swab), we conducted a brief self-administered survey of students accessing a large US-based university health center from January to December 2015.

RESULTS

In 2015, University Health Services experienced a 28.5% increase in chlamydia (CT)/gonorrhea (GC) testing for male individuals and 13.7% increase in testing for female students compared to 2013 (baseline). In 2015, 12.4% of male students and 4.8% of female students tested positive for CT/GC via clinician testing, whereas 12.9% of male students and 12.4% of female students tested positive via self-testing. Female students were more likely to test positive for CT/GC when electing to test via self-test versus a clinician test (χ(1, N = 3068) = 36.54, P < 0.01); no significant difference in testing type was observed for male students. Overall, 22.5% of students who opted for the self-test option completed the acceptability survey; 63% reported that their main reason for testing was unprotected sex. In the past year, 42% reported 4 or more partners. The majority were very satisfied and likely to use the service again (82%).

CONCLUSIONS

Self-testing may be an efficient and effective way to provide STI testing for students and increase testing uptake. Self-reports of multiple partners, unprotected sex, and detected infections suggest that at-risk students are using the service.

Improving STD Screening Rates on a University Campus

Gonorrhea and chlamydia infections have a high incidence among young adults. To increase screening rates among individuals aged 25 years of age and younger on a university campus, this quality improvement project was implemented to improve providers' knowledge of CDC guidelines through education. Education was provided to providers and staff members at a health clinic on a private residential university campus through informational sessions to increase knowledge of guideline-directed screening for gonorrhea and chlamydia. This education was coupled with a multifaceted approach for provider-reminder interventions: flagging patients in the EHR system that fall within the age group (25 years of age and younger) to generate an alert, patients completing a questionnaire while in the exam room, and identification of a project champion. Screening rates were evaluated during pre- and post-implementation phases to determine if a change in practice occurred among providers. Post-intervention revealed the average number of patients screened for gonorrhea and chlamydia was 65.85% (349/530). This change represented a marked increase from pre-intervention screening of 2% (11/405). The testing rate increased during the post-intervention phase to 17.86% (65/364), up from 7.90% (32/405) pre-implementation. Provider education on guideline-directed screening for gonorrhea and chlamydia increased screening among providers at a university health clinic. This intervention, combined with provider-reminder interventions, increased screening of patients, leading to an increased testing rate for gonorrhea and chlamydia.

Missed Opportunities for Chlamydia Screening in Title X Family Planning Clinics

BACKGROUND

Annual chlamydia (CT) screening is recommended for women younger than 25 years, yet less than half of young women seeking health care are screened annually. We analyzed Title X family planning service data from the Northwest United States to assess factors associated with missed opportunities for CT screening. Our primary hypothesis was screening coverage is higher during annual preventive health visits compared to other visit types. Study objectives were: (1) identify gaps in screening coverage by patient demographics, visit characteristics, and clinic measures; and (2) examine the association between visit type and CT screening by controlling for other covariates and stratifying by state.

METHODS

Calendar year 2011 Title X visit records (n = 180,856) were aggregated to the patient level (n = 112,926) to assess CT screening coverage by all characteristics. Screening variation was explored by bivariate and multivariate Poisson regression. Adjusted models for each state estimated association between comprehensive examination and screening controlling for confounders.

RESULTS

Clinic and visit characteristics were associated with CT screening. Coverage ranged from 45% in Washington to 80% in Alaska. Only 34% of patients visited for a routine comprehensive examination. Visit type was associated with screening; 75% of patients who had a comprehensive examination were screened versus 34% of those without a comprehensive examination (unadjusted PR, 2.18; 95% confidence interval, 2.16-2.21). The association between comprehensive examination and CT screening varied significantly by state (interaction term, P < 0.001).

CONCLUSIONS

Missed screening opportunities are common among women who access brief appointments for specific needs but do not seek routine preventive care, particularly in some states. Structural interventions may help address these systematically missed opportunities.

The effect of health insurance on sexual health: Evidence from the Affordable Care Act's dependent coverage mandate

This study estimates changes in sexually transmitted disease rates for young adults in the United States following the Affordable Care Act's dependent coverage mandate; a provision that allows dependents to remain covered under their parents' health insurance plans until the age of 26. This study is the first to analyze changes in reported chlamydia and gonorrhea rates resulting from the dependent coverage mandate. Utilizing a difference-in-differences framework coupled with administrative data from the Centers for Disease Control and Prevention, I find that reported chlamydia rates increased for males and females ages 20-24 relative to comparison groups of males and females ages 15-19 and 25-29 following the mandate. I also find evidence of an increase in gonorrhea rates for females in this age group. I find no evidence that the mandate induced ex ante moral hazard.

Sexually Transmitted Infection Testing Among Adolescents and Young Adults in the United States

PURPOSE

Persons aged 15-25 years have high sexually transmitted infection (STI) rates and suboptimal screening. There has been limited research analyzing barriers to STI testing at a national level. We examined STI testing among 15-25 year olds and reasons for not testing.

METHODS

We used data from a national survey of youth. Bivariate and multivariable analyses examined differences in testing behaviors by demographics, separately by sex. Among sexually experienced respondents who reported never being tested, health system-related reasons for not testing were examined in bivariate and multivariable analyses.

RESULTS

Females (16.6%) were more likely to have ever been tested compared with males (6.1%, p < .01) in the last 12 months. Among sexually experienced respondents who were never tested, 41.8% did not seek testing because they felt they were not at risk for STIs. Males (60.1%) had significantly higher reports of foregoing testing for confidentiality reasons compared with females (39.9%, p < .01). Non-Hispanic whites (44.9%) the highest reports of this compared with other ethnic/racial groups (p < .01).

CONCLUSIONS

This national-level study found that most of the 15-25 year olds never received an STI test. In addition, confidentiality concerns may deter youth from seeking STI testing. Appropriate strategies to minimize these concerns may be useful. Potential strategies to ameliorate these issues may include engaging clinicians who frequently serve adolescents and young adults to address confidentiality issues with youth patients.

Sexually Transmitted Disease Prevention Policies in the United States: Evidence and Opportunities

Policies are an important part of public health interventions, including in the area of sexually transmitted disease (STD) prevention. Similar to other tools used in public health, policies are often evaluated to determine their usefulness. Therefore, we conducted a nonsystematic review of policy evidence for STD prevention. Our review considers assessments or evaluations of STD prevention-specific policies, health care system policies, and other, broader policies that have the potential to impact STD prevention through social determinants of health. We also describe potential policy opportunity in these areas. It should be noted that we found gaps in policy evidence for some areas; thus, additional research would be useful for public health policy interventions for STD prevention.