HIV Testing Among Adolescents With Acute Sexually Transmitted Infections

Factors Associated With HIV Testing in Adolescent and Young Adult Females With a History of STI

To determine the percentage of female adolescent patients (13-26 years old) who had HIV testing ordered within 90 days of incident sexually transmitted infection (STI) diagnosis during an outpatient clinic visit. This was a retrospective chart review study evaluating 830 visits among 589 female patients 13 to 26 years who had an incident STI diagnosed in outpatient Adolescent Medicine or Pediatric Practices in an urban, nonprofit, academic, free-standing children's hospital at the main campus and a community site in the Northeast United States. Odds of HIV screening was greater at the community-based adolescent medicine practice (odds ratio [OR] = 3.17; 95% confidence interval [CI]: [1.92, 5.24]) and when seen by an adolescent medicine provider (OR = 1.44; 95% CI: [1.02, 2.03]). Only 33.5% (n = 283) of 844 clinical encounters had HIV screening obtained within 90 days of incident STI diagnosis. Overall, HIV screening rates within 90 days of STI diagnosis was low, and there is much room for improvement.

Factors Associated with HIV Testing Among Spanish and English-Speaking Latino Adolescents Aged 13-18

Adolescent Latino men who have sex with men (LMSM) in the U.S. are disproportionately impacted by HIV. However, there has been limited focus on their HIV prevention and risk behaviors. In this study, we examine the rates of HIV testing and explore the significant demographic and healthcare factors that influence HIV prevention among adolescent LMSM. The analysis for this study utilized data collected during the baseline assessment of SMART, a pragmatic trial aimed at evaluating the effectiveness of an online HIV prevention intervention for adolescent LMSM (N = 524). Only 35.5% of participants had ever had an HIV test in their lifetime. Rates of testing increased among adolescent LMSM who had a doctor with whom they spoke about their sexual health (odds ratio: 4.0; 95% confidence interval: 2.1-8.4; P < 0.001) or HIV testing (odds ratio: 5.8; 95% confidence interval: 3.1-10.7; P < 0.001). Out of the 61 participants who took part in the survey conducted in Spanish, only 26% reported ever having an HIV test. Additionally, 24.5% stated that they had discussed their sexual orientation with a doctor, and only 8.2% had undergone HIV testing. Spanish-speaking adolescents who completed the SMART survey were less likely to openly discuss their sexual orientation or sexual health with most people or have a doctor with whom they discussed these topics, compared to those who completed the survey in English. These findings suggest that Spanish-speaking adolescent LMSM may face obstacles in accessing HIV prevention services in the U.S.

Need for Sexual, Reproductive, and Mental Health Promotion Among Diverse College Students in a COVID-19 Era

In 2020, the COVID-19 pandemic forced unprecedented disruptions in higher education operations. While the adverse mental health effects experienced by college students due to these changes are well documented, less is known about the impact on their sexual and reproductive health (SRH), and the reciprocal relationships between SRH and mental health among adolescents and emerging adults. This position paper reviews existing literature on the effects of the COVID-19 pandemic on SRH, sexual violence, unintended pregnancy, sexually transmitted illness and human immunodeficiency virus rates and highlights issues specific to college-aged males, females, racial/ethnic and sexual minorities, and individuals with disabilities. The need to conceptualize SRH as an integral component of normal development, overall health, and well-being in the context of COVID-19 is discussed. The need to prioritize the design and implementation of developmentally appropriate, evidence-based SRH interventions specifically targeting college students is identified. Furthermore, an intergenerational approach to SRH that includes parents/caregivers and/or college faculty and staff (e.g., coaches, trainers) could facilitate comprehensive SRH prevention programming that enhances sexual violence prevention training programs currently mandated by many colleges. Policies and programs designed to mitigate adverse pandemic-related exacerbations in negative SRH outcomes are urgently needed and should be included in mainstream clinical psychology, not only focused on preventing unwanted outcomes but also in promoting rewarding interpersonal relationships and overall well-being. Recommendations for clinical psychologists and mental health researchers are made.

Trends in Follow-up Testing Among Patients Positive for Chlamydia and Gonorrhea in the Veterans Health Administration, 2013 to 2019

BACKGROUND

The Centers for Disease Control and Prevention (CDC) recommends testing patients with chlamydia (CT)/gonorrhea (GC) for other sexually transmitted infections (STIs) and repeating CT/GC testing 3 to 12 months later. We assessed repeat CT/GC testing and testing for HIV/syphilis in accordance with CDC guidelines in the US Veterans Health Administration.

METHODS

Molecular laboratory testing for CT/GC during January 1, 2013-December 31, 2020 was retrieved from Veterans Health Administration data sources. Patients were evaluated for syphilis, HIV, and repeat CT/GC testing within 1 year after a positive CT/GC test result. Differences of CT/GC-positive patients associated with receiving recommended testing were assessed using χ2 /Fisher exact tests.

RESULTS

A total of 41,630 of 1,005,761 CT (4.1%) and 17,649 of 1,013,198 GC (1.7%) results were positive. Median ages of positive CT/GC patients were 29 and 36 years, respectively. Repeat testing rates for CT/GC within 90 to 119 days were 3.9% and 2.9%, and rates within 90 to 365 days were 32.8% and 34.7%, with 8.6% and 15% being positive again, respectively. Guideline-compatible repeat testing in known HIV-positive patients nearly doubled (75.7% for CT and 67.8% for GC). The CDC-recommended HIV testing was performed for 72.4% and 65.5% CT and GC first positives, respectively, whereas syphilis testing was completed for 66.5% and 60.5% CT and GC, respectively. Compared with 25- to 34-year-old patients with CT or GC, those younger than 25 years had higher odds of guideline-discordant repeat testing but had lower odds of not receiving HIV/syphilis testing.

CONCLUSIONS

Nearly two-thirds of patients did not receive recommended repeat testing, and nearly one-third were not tested for HIV/syphilis. Veterans Health Administration providers may benefit from additional education on CDC-recommended sexually transmitted infection guidelines and testing recommendations.

Missed opportunities for HIV testing among those who accessed sexually transmitted infection (STI) services, tested for STIs and diagnosed with STIs: a systematic review and meta-analysis

INTRODUCTION

Of 37.7 million people living with HIV in 2020, 6.1 million still do not know their HIV status. We synthesize evidence on concurrent HIV testing among people who tested for other sexually transmitted infections (STIs).

METHODS

We conducted a systematic review using five databases, HIV conferences and clinical trial registries. We included publications between 2010 and May 2021 that reported primary data on concurrent HIV/STI testing. We conducted a random-effects meta-analysis and meta-regression of the pooled proportion for concurrent HIV/STI testing.

RESULTS

We identified 96 eligible studies. Among those, 49 studies had relevant data for a meta-analysis. The remaining studies provided data on the acceptability, feasibility, barriers, facilitators, economic evaluation and social harms of concurrent HIV/STI testing. The pooled proportion of people tested for HIV among those attending an STI service (n = 18 studies) was 71.0% (95% confidence intervals: 61.0-80.1, I2 = 99.9%), people tested for HIV among those who were tested for STIs (n = 15) was 61.3% (53.9-68.4, I2 = 99.9%), people tested for HIV among those who were diagnosed with an STI (n = 13) was 35.3% (27.1-43.9, I2 = 99.9%) and people tested for HIV among those presenting with STI symptoms (n = 3) was 27.1% (20.5-34.3, I2 = 92.0%). The meta-regression analysis found that heterogeneity was driven mainly by identity as a sexual and gender minority, the latest year of study, country-income level and region of the world.

DISCUSSION

This review found poor concurrent HIV/STI testing among those already diagnosed with an STI (35.3%) or who had symptoms with STIs (27.1%). Additionally, concurrent HIV/STI testing among those tested for STIs varied significantly according to the testing location, country income level and region of the world. A few potential reasons for these observations include differences in national STI-related policies, lack of standard operation procedures, clinician-level factors, poor awareness and adherence to HIV indicator condition-guided HIV testing and stigma associated with HIV compared to other curable STIs.

CONCLUSIONS

Not testing for HIV among people using STI services presents a significant missed opportunity, particularly among those diagnosed with an STI. Stronger integration of HIV and STI services is urgently needed to improve prevention, early diagnosis and linkage to care services.

Provider Perspectives on Barriers to Routine HIV Testing of Adolescent and Young Adult Patients in Emergency Department Settings

HIV testing rates among US youth aged 13-24 years are sub-optimal, with high rates of missed testing opportunities in emergency departments (EDs). We assessed barriers to routine HIV testing of youth in urban ED settings from the perspective of healthcare providers. Ten physicians and nurses were recruited from the pediatric and adult EDs at a high-volume hospital in New York City, USA to complete in-depth interviews to provide their perspectives on barriers to routine HIV testing of youth ages 13 to 24 in EDs. Interviews were conducted using a semi-structured interview guide with questions and probes. All interviews were conducted via Zoom due to the COVID-19 pandemic and were audio-recorded and transcribed verbatim. Transcripts were coded independently by two researchers using an inductive thematic analysis approach. Participants often offered HIV testing to youth in the ED based on their perceptions of patients' HIV risk, with pediatric providers sometimes discouraging adolescents they perceived to be at low HIV risk from testing. Participants cited other priorities, logistics of blood-based testing, and discomfort discussing HIV as other reasons for not offering HIV testing to all youth in the ED. Efforts are needed to encourage providers to offer HIV testing to all youth regardless of perceived risk, as the ED often serves as youths' only point of contact with the healthcare system. Emphasis on this and the importance of early detection, along with institutional change, clear guidance, and support for the testing process may help increase youth testing and avoid missed HIV diagnosis opportunities.

Provider perspectives on clinical decision support to improve HIV prevention in pediatric primary care: a multiple methods study

BACKGROUND

Clinical decision support (CDS) is a promising intervention for improving uptake of HIV testing and pre-exposure prophylaxis (PrEP). However, little is known regarding provider perspectives on acceptability, appropriateness, and feasibility of CDS for HIV prevention in pediatric primary care, a key implementation setting.

METHODS

This was a cross-sectional multiple methods study utilizing surveys and in-depth interviews with pediatricians to assess acceptability, appropriateness, and feasibility of CDS for HIV prevention, as well as to identify contextual barriers and facilitators to CDS. Qualitative analysis utilized work domain analysis and a deductive coding approach grounded in the Consolidated Framework of Implementation Research. Quantitative and qualitative data were merged to develop an Implementation Research Logic Model to conceptualize implementation determinants, strategies, mechanisms, and outcomes of potential CDS use.

RESULTS

Participants (n = 26) were primarily white (92%), female (88%), and physicians (73%). Using CDS to improve HIV testing and PrEP delivery was perceived as highly acceptable (median score 5), IQR [4-5]), appropriate (5, IQR [4-5]), and feasible (4, IQR [3.75-4.75]) using a 5-point Likert scale. Providers identified confidentiality and time constraints as two key barriers to HIV prevention care spanning every workflow step. With respect to desired CDS features, providers sought interventions that were integrated into the primary care workflow, standardized to promote universal testing yet adaptable to the level of a patient's HIV risk, and addressed providers' knowledge gaps and bolstered self-efficacy in providing HIV prevention services.

CONCLUSIONS

This multiple methods study indicates that clinical decision support in the pediatric primary care setting may be an acceptable, feasible, and appropriate intervention for improving the reach and equitable delivery of HIV screening and PrEP services. Design considerations for CDS in this setting should include deploying CDS interventions early in the visit workflow and prioritizing standardized but flexible designs.

Multidisciplinary Approach to Improve Human Immunodeficiency Virus and Syphilis Testing Rates in Emergency Departments

BACKGROUND

Best practice guidelines recommend that patients at risk for sexually transmitted infections (STIs), such as gonorrhea (GC) and chlamydia, should also be tested for human immunodeficiency virus (HIV) and syphilis. This prospective quality assurance study aimed to increase HIV and syphilis testing rates in emergency departments (EDs) across the Cleveland Clinic Health System from January 1, 2020 through January 1, 2022.

METHODS

A multidisciplinary team of emergency medicine, infectious diseases, pharmacy, and microbiology personnel convened to identify barriers to HIV and syphilis testing during ED encounters at which GC/chlamydia were tested. The following interventions were implemented in response: rapid HIV testing with new a workflow for results follow-up, a standardized STI-screening order panel, and feedback to clinicians about ordering patterns.

RESULTS

There were 57 797 ED visits with GC/chlamydia testing completed during the study period. Human immunodeficiency virus testing was ordered at 5% of these encounters before the interventions were implemented and increased to 8%, 23%, and 36% after each successive intervention. Syphilis testing increased from 9% before the interventions to 12%, 28%, and 39% after each successive intervention. In multivariable analyses adjusted for age, gender, and location, the odds ratio for HIV and syphilis testing after all interventions was 11.72 (95% confidence interval [CI], 10.82-12.71; P ≤.001) and 6.79 (95% CI, 6.34-7.27; P ≤.001), respectively.

CONCLUSIONS

The multidisciplinary intervention resulted in improved testing rates for HIV and syphilis.

Chlamydia Trachomatis/Neisseria Gonorrhea Retesting Among Adolescents and Young Adults in a Primary Care Network

PURPOSE

Chlamydia trachomatis/Neisseria gonorrhea (CT/NG) retesting three months after diagnosis is a guideline-recommended strategy to detect re-infections. Adolescents and young adults are priority populations in the U.S. Sexually Transmitted Infections National Strategic Plan, but there is a lack of research examining CT/NG retesting among these populations. This study describes retesting following CT/NG diagnosis among adolescent and young adult patients at Title X and non-Title X clinics and measures the association of patient-level factors with CT/NG retesting.

METHODS

We evaluated electronic medical records from 2014 to 2020 from an academic urban-suburban primary care network. The primary outcome was retesting, defined as a diagnostic test for CT or NG ordered 8-16 weeks after index diagnosis. Mixed effects logistic regression modeling stratified by Title X funding was conducted to evaluate the association of patient-level factors with CT/NT retesting.

RESULTS

Overall, 23.5% (n = 731) of patients were retested within 8-16 weeks following index CT/NG diagnosis. A significantly greater proportion of Title X patients were retested compared to non-Title X patients. Males were significantly less likely to be retested compared to females, and the proportion of patients retested decreased significantly over the study period.

DISCUSSION

Guideline-recommended retesting following CT/NG diagnosis was low in this young primary care cohort, especially among male and non-Title X clinic patients. Decreases in CT/NG retesting over the study period may be contributing to worsening of the STI epidemic. Our results provide insights into CT/NG retesting that can inform efforts to end the STI epidemic.

Rates of Appropriate Treatment and Follow-Up Testing After a Gonorrhea and/or Chlamydia Infection in an Urban Network of Federally Qualified Health Center Systems

BACKGROUND

Reinfection and partner transmission are common with Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT). We assessed treatment and follow-up laboratory testing for GC and CT and evaluated associations with patient- and system-level factors.

METHODS

The analysis included positive GC and/or CT nucleic acid amplification test results from patients aged 14 to 24 years at a federally qualified health center system site in Denver, CO, from January 2018 to December 2019. Outcomes assessed include treatment within 14 days, HIV/syphilis testing within 6 months, and repeat GC and CT testing within 2 to 6 months. Bivariate and multivariable regression modeling assessed associated factors.

RESULTS

Among 27,168 GC/CT nucleic acid amplification tests performed, 1.8% (484) were positive for GC and 7.8% (2125) were positive for CT. Within the assessed time frames, 87% (2275) of patients were treated, 54.1% (1411) had HIV testing, 50.1% (1306) had syphilis testing, and 39.9% (1040) had GC and CT retesting. Older patients were more likely to receive treatment (adjusted odds ratio 1.13; 95% confidence interval, 1.00-1.27; P = 0.05) than younger patients, whereas males were less likely to receive GC and CT retesting (adjusted odds ratio, 0.19; 95% confidence interval, 0.11-0.33; P < 0.001) than females. Patients treated on the day of testing were less likely to receive follow-up laboratory tests than those treated 2 to 14 days after.

CONCLUSIONS

Although most patients received antibiotic treatment, only about half received HIV/syphilis testing and less than half received GC and CT retesting. It is critical to find innovative strategies to improve treatment and follow-up management of these infections to decrease complications, reduce transmission, and combat the rising rates of sexually transmitted infections.

A retrospective study of HIV pre-exposure prophylaxis counselling among non-Hispanic Black youth diagnosed with bacterial sexually transmitted infections in the United States, 2014-2019

INTRODUCTION

Youth account for a disproportionate number of new HIV infections; however, pre-exposure prophylaxis (PrEP) use is limited. We evaluated PrEP counselling rates among non-Hispanic Black youth in the United States after a bacterial sexually transmitted infection (STI) diagnosis.

METHODS

We conducted a retrospective cohort study of Black youth receiving care at two academically affiliated clinics in Philadelphia between June 2014 and June 2019. We compared PrEP counselling for youth who received primary care services versus those who did not receive primary care services, all of whom met PrEP eligibility criteria due to STI diagnosis per U.S. Centers for Disease Control and Prevention clinical practice guidelines. Two logistic regression models for receipt of PrEP counselling were fit: Model 1 focused on sexual and gender minority (SGM) status and Model 2 on rectal STIs with both models adjusted for patient- and healthcare-level factors.

RESULTS

Four hundred and sixteen patients met PrEP eligibility criteria due to STI based on sex assigned at birth and sexual partners. Thirty patients (7%) had documentation of PrEP counselling. Receipt of primary care services was not significantly associated with receipt of PrEP counselling in either Model 1 (adjusted OR (aOR) 0.10 [95% CI 0.01, 0.99]) or Model 2 (aOR 0.52 [95% CI 0.10, 2.77]). Receipt of PrEP counselling was significantly associated with later calendar years of STI diagnosis (aOR 6.80 [95% CI 1.64, 29.3]), assigned male sex at birth (aOR 26.2 [95% CI 3.46, 198]) and SGM identity (aOR 317 [95% CI 39.9, 2521]) in Model 1 and later calendar years of diagnosis (aOR 3.46 [95% CI 1.25, 9.58]), assigned male sex at birth (aOR 18.6 [95% CI 3.88, 89.3]) and rectal STI diagnosis (aOR 28.0 [95% CI 8.07, 97.5]) in Model 2. Fourteen patients (3%) started PrEP during the observation period; 12/14 (86%) were SGM primary care patients assigned male sex at birth.

CONCLUSIONS

PrEP counselling and uptake among U.S. non-Hispanic Black youth remain disproportionately low despite recent STI diagnosis. These findings support the need for robust investment in PrEP-inclusive sexual health services that are widely implemented and culturally tailored to Black youth, particularly cisgender heterosexual females.

Technology-Based Interventions to Increase Point-of-Care HIV Testing and Linkage to Care Among Youth in the US: A Systematic Review

HIV testing rates remain low among youth ages 13–24 in the US, with only 55% of HIV-positive youth aware of their serostatus. We conducted a systematic review to assess the utility of technology-based interventions to increase point-of-care youth HIV testing and linkage to care. We searched PubMed, Embase, CINAHL, and Cochrane CENTRAL for randomized controlled trials of technology-based interventions aimed at increasing point-of-care youth HIV testing, published between 2008 and 2020. All identified citations were independently screened for inclusion by two authors, and the Cochrane Risk of Bias Tool for Randomized Controlled Trials was used to assess the quality of included studies. Three studies met all inclusion criteria. Two interventions were effective in increasing HIV testing, while one was effective at linkage to care. Technology-based interventions have the potential to increase youth HIV testing in clinical settings and facilitate linkage to care, possibly reducing undiagnosed HIV among adolescents and emerging adults.

Asymptomatic Adolescent HIV: Identifying a Role for Universal HIV Screening in the Pediatric Emergency Department

Adolescents account for most undiagnosed HIV infections in the United States. Although the Centers for Disease Control and Prevention (CDC) recommends universal HIV screening for all patients ≥13 years, <10% of adolescents have been tested for HIV. To identify earlier opportunities for adolescent HIV prevention and diagnosis in a region of high HIV prevalence, we sought to describe pediatric emergency department (PED) visits made by a retrospective cohort of adolescents who were later diagnosed with HIV as young adults (<25 years) through an adult emergency department (ED) universal HIV screening program. CD4+ count was used to estimate the time of HIV infection before diagnosis and all PED visits in the 10 years before diagnosis were analyzed. Universal HIV screening in the adult ED diagnosed 193 young adults (median 22 years; 90% men; 29% stage 3); 70% had CD4+ at diagnosis that was used to estimate time of infection (mean 3.8 years). Thirty-eight HIV-infected young adults had a total of 109 PED visits in the 10 years before HIV diagnosis. Sexual history was documented in 12% of PED visits and a sexually transmitted infection test was sent in 6%. Ten HIV-infected young adults had 26 PED visits during the time in which they were likely already infected with HIV, each a potential missed opportunity for earlier diagnosis. HIV-infected and at-risk adolescents are underrecognized in PED visits. Implementation of CDC-recommended universal screening may lead to earlier diagnoses and improve outcomes; the PED may also be critical in identifying adolescents eligible for preexposure prophylaxis.