Stemming the Tide of Sexually Transmitted Infections in the U.S.: Lessons Learned on How to Increase Screening
March 5th, 2020 | Viewpoint
March 5th, 2020 | Viewpoint
Over the past several years, the Centers for Disease Control and Prevention (CDC) has reported dramatic increases in sexually transmitted infections (STIs). In 2018, nearly 2.5 million cases of syphilis, gonorrhea, and chlamydia were reported to the CDC. The rising tide of STIs has led many people to ask—with urgency—how we can reverse this trend.
Throughout our history, our work has included dozens of projects with federal, state, and local health agencies to support the provision of evidence-based sexual and reproductive health care. Through our experience working with providers on the ground, we have gained an understanding of the literature and evidence-based practice, challenges to implementation, and strategies for overcoming them. We’ve seen that improving screening programs is a great opportunity to reduce the STI epidemic  and recommend applying the following three strategies to increase screening rates.
Systems are already in place to facilitate increased chlamydia screening. First, the cost has been removed for a large portion of the population because most health plans cover the cost of annual chlamydia and gonorrhea screening for sexually active females under 25. Second, since 2001, the Healthcare Effectiveness Data and Information Set (HEDIS) has included a chlamydia screening measure. Yet despite nearly 20 years of measurement, screening rates have not increased as expected. However, evidence suggests that when health plans focus attention on this measure, it results in large increases in screening rates among the covered population.  Publicly and privately funded health plans should be incentivized to focus on the HEDIS measure, which should be used in high-quality programs such as the CMS Quality Payment Measure and Healthy People Leading Health Indicators. In addition, federally qualified health centers should report the measure on their uniform data system reports.
Through the implementation of three learning collaboratives with 37 family planning clinics, JSI has shown that organizations can increase screening. In partnership with the Office of Population Affairs as the Family Planning National Training Center (FPNTC), we developed the Chlamydia Screening Change Package, a collection of best practice recommendations for increasing screening. Across the three collaboratives we facilitated, median screening rate increased from 62% to 69%; 50% to 78%; and 41% to 50%. The training resources from these collaboratives are available here.
Providers who participated in our learning collaboratives showed the greatest increases in screening when they: a) integrated screening into all visit types—not just annual well-visits, new patient, and STI screening visits; and b) adopted standard scripts that normalize screening and use an opt-out approach. As the FPNTC, JSI developed a training activity, sample scripts, and palm cards to help staff become comfortable with normalizing and opt-out language. Publicly funded health centers should be supported to implement these best practices, both through clinical workforce development programs and expanded distribution of implementation support tools such as sample scripts.
It is also critical to provide alternative options to screening individuals who are not in the health care system. Increasingly, people—especially youth and young adults—are accessing resources online rather than traditional in-person physical services: travel agents have been replaced by online booking, movie rentals have been replaced by streaming, take-out by food delivery, etc. There is now a generation that has only registered for classes, applied for jobs, and purchased car insurance online. It is imperative that STI prevention strategies reflect the changing preferences and expectations; we must find solutions that do not require adolescents to seek care at a physical location. Increasing access to STI services through telemedicine, express clinics, and mail-in test kits will help engage these individuals. Policymakers can support efforts to make these strategies available, reimbursable, and widely promoted in all states and territories.
 Peterman TA, Carter MW. Effective Interventions to Reduce Sexually Transmitted Disease: Introduction to the Special Issue. Sexually Transmitted Diseases. 2016;43:S1–S2.
 Burstein GR, Snyder MH, Conley D, et al. Chlamydia screening in a health plan before and after a national performance measure introduction. Obstet Gynecol. 2005;106:327–334.