Commentary: Adolescents are undertested for STIs

Despite current guidelines permitting opt-out STI screening and the ability in most states to treat adolescents 13 years old and older for STIs without parental notification, STI testing rates remain low. The articles about the 2019 survey raise several concerns.

Screening was more common with certain known risky behaviors, so risk-based screening seems prevalent. Of note, one recently reported factor increasing risky behaviors, but not noted above, is homelessness, suggesting it also be a trigger for STI screening (Child Youth Services Rev. 2022;139. doi: 10.1016/j.childyouth.2022.106538). But won’t risk-based screening inevitably lead to undertesting/treating? Are adolescents comfortable/willing to answer even the most carefully crafted, gentle, and simple questions about risky behaviors? 

Because STIs are so frequent in adolescents (many asymptomatic), is risk-based screening/testing adequate for common STIs? Could urine-based screening for gonorrhea and chlamydia be useful in any adolescent who has been sexually active or uses the ED for routine care? Syphilis seems different. Screening requires a blood draw and is more difficult to implement, so risk-based testing seems okay. Also, the CDC recommends risk-based screening for syphilis.

Chief complaints at adolescent visits are usually not STI-related, unless symptomatic or visible, e.g., genital warts or herpes. So STI screening (even opt-out) will lengthen visits, perhaps a lot, over what was scheduled – even if only to explain negative results. Multiple visits with screening in the same morning could wreck patient flow. Maybe this doesn’t influence decisions to screen/test, but reexamining our approach can maximize appropriate STI screening/testing. 

STIs run in packs, so if you detect one, expand testing to include the others. 

Christopher J. Harrison, MD, is professor, University of Missouri Kansas City School of Medicine, department of medicine, infectious diseases section, Kansas City. He has no financial conflicts of interest.
 

Despite current guidelines permitting opt-out STI screening and the ability in most states to treat adolescents 13 years old and older for STIs without parental notification, STI testing rates remain low. The articles about the 2019 survey raise several concerns.

Screening was more common with certain known risky behaviors, so risk-based screening seems prevalent. Of note, one recently reported factor increasing risky behaviors, but not noted above, is homelessness, suggesting it also be a trigger for STI screening (Child Youth Services Rev. 2022;139. doi: 10.1016/j.childyouth.2022.106538). But won’t risk-based screening inevitably lead to undertesting/treating? Are adolescents comfortable/willing to answer even the most carefully crafted, gentle, and simple questions about risky behaviors? 

Because STIs are so frequent in adolescents (many asymptomatic), is risk-based screening/testing adequate for common STIs? Could urine-based screening for gonorrhea and chlamydia be useful in any adolescent who has been sexually active or uses the ED for routine care? Syphilis seems different. Screening requires a blood draw and is more difficult to implement, so risk-based testing seems okay. Also, the CDC recommends risk-based screening for syphilis.

Chief complaints at adolescent visits are usually not STI-related, unless symptomatic or visible, e.g., genital warts or herpes. So STI screening (even opt-out) will lengthen visits, perhaps a lot, over what was scheduled – even if only to explain negative results. Multiple visits with screening in the same morning could wreck patient flow. Maybe this doesn’t influence decisions to screen/test, but reexamining our approach can maximize appropriate STI screening/testing. 

STIs run in packs, so if you detect one, expand testing to include the others. 

Christopher J. Harrison, MD, is professor, University of Missouri Kansas City School of Medicine, department of medicine, infectious diseases section, Kansas City. He has no financial conflicts of interest.
 

Despite current guidelines permitting opt-out STI screening and the ability in most states to treat adolescents 13 years old and older for STIs without parental notification, STI testing rates remain low. The articles about the 2019 survey raise several concerns.

Screening was more common with certain known risky behaviors, so risk-based screening seems prevalent. Of note, one recently reported factor increasing risky behaviors, but not noted above, is homelessness, suggesting it also be a trigger for STI screening (Child Youth Services Rev. 2022;139. doi: 10.1016/j.childyouth.2022.106538). But won’t risk-based screening inevitably lead to undertesting/treating? Are adolescents comfortable/willing to answer even the most carefully crafted, gentle, and simple questions about risky behaviors? 

Because STIs are so frequent in adolescents (many asymptomatic), is risk-based screening/testing adequate for common STIs? Could urine-based screening for gonorrhea and chlamydia be useful in any adolescent who has been sexually active or uses the ED for routine care? Syphilis seems different. Screening requires a blood draw and is more difficult to implement, so risk-based testing seems okay. Also, the CDC recommends risk-based screening for syphilis.

Chief complaints at adolescent visits are usually not STI-related, unless symptomatic or visible, e.g., genital warts or herpes. So STI screening (even opt-out) will lengthen visits, perhaps a lot, over what was scheduled – even if only to explain negative results. Multiple visits with screening in the same morning could wreck patient flow. Maybe this doesn’t influence decisions to screen/test, but reexamining our approach can maximize appropriate STI screening/testing. 

STIs run in packs, so if you detect one, expand testing to include the others. 

Christopher J. Harrison, MD, is professor, University of Missouri Kansas City School of Medicine, department of medicine, infectious diseases section, Kansas City. He has no financial conflicts of interest.