Does an STI Diagnosis Spur Subsequent HIV Testing Among Adolescents?

Chlamydia, gonorrhea, syphilis, and trichomoniasis are 4 sexually transmitted infections (STI) that have seen sharp increases in occurrence over the past 10 years. Their combined overall rate rose 31% between 2013 and 2017, while gonorrhea and syphilis alone had increase of more than twice that rate: 67% and 76%, respectively.

These numbers correlate with a lower overall rate of testing for HIV among adolescents, comprising a very disappointing outcome to the research team who published their findings in Pediatrics this month. They also fall far short of 2019 testing guidelines from the CDC and US Preventive Services Task Force, which “recommend risk-based HIV testing for individuals who test positive for an STI.”

“To make strides toward the Presidential Plan to End the HIV Epidemic, we must identify missed opportunities for HIV testing and use these as gateways to treatment and prevention, especially in vulnerable AYAs,” the authors emphasized.

Where do the opportunities lie to reverse these trends and improve the HIV testing rate among both younger (13-17 years) and older (18-24 years) adolescents? Are both patient and healthcare influences responsible for the suboptimal HIV testing rate?

With their primary outcome being an HIV test in the 90 days following an STI diagnosis, the team investigated the HIV test rate in 1313 adolescents, who accounted for 1816 acute STI diagnoses between July 2014 and December 2017. Twenty-seven percent of the overall study cohort had more than 1 STI diagnosed during this time. Their mean (SD) age at diagnosis was 17.2 (1.7) years, and 75% of the STIs occurred in females and 97% in African Americans.

In addition, all patients, most of whom (79%) had Medicaid coverage, received care at 2 pediatric/adolescent primary care clinics in Philadelphia. Each of these clinics had an on-site primary care clinic and a Title X—funded adolescent program, both providing services regardless of insurance coverage status.

The results show that just over half (55.1%) of the STI diagnoses led to an HIV test in the following 90 days. Breaking this number down shows why 45% did not get an HIV test even though one was indicated. When they received positive results for an STI, physicians still did not order an HIV test for 62% of their adolescent patients and less than half (48%) even had a follow-up visit.

Among those who had a follow-up appointment, only 17% had an HIV test. And for the 31% who did not have an HIV test at that visit, a test was ordered but not completed for a mere 8%. Reasons include the patient was a no-show (18.3%), medical record/lab error (4.6%), or unknown (6.8%). Almost a quarter (23%) never even had a test ordered for them.

To improve upon their results, they proposed several solutions:

1. Include HIV testing in adolescent sexual health screening.
2. Implement rapid HIV testing in the primary care setting.
3. Educate patients on the lifetime risk of HIV with multiple STIs.
4. Connect patients in sexual health clinics to primary care resources.

“Our data underscore the need for improved HIV testing education for providers of all levels of training and the need for public health agencies to clearly communicate the need for testing at the time of STI infection to reduce the number of missed opportunities for testing,” they concluded. “It is our hope that our findings can be used to target HIV testing interventions in primary care settings.”

Reference

Petsis D, Min J, Huang Y-S, Akers AY, Wood S. HIV testing among adolescents with acute sexually transmitted infections. Pediatrics. 2020;145(4);e20192265. doi: 10.1542/peds.2019-2265.