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Improving access and patient outcomes for sexually transmitted infections in the US

Contributing lab leaders: Barbara Van der Pol & Casey Pinto

Sexually transmitted infections (STIs) have a profound impact on sexual and reproductive health worldwide. Although they are often curable, if left undiagnosed and untreated they can lead to complications such as pelvic inflammatory disease, ectopic pregnancy, and infertility.1,2

The World Health Organization reports that more than one million curable STIs, such as chlamydia, gonorrhea, trichomonas, and syphilis, are acquired worldwide every day.3 In the US one in five people are estimated to have an STI with 1.7 million cases of chlamydia reported by the CDC in 2022. However, due to a gap in diagnosed cases, the actual number of cases is estimated to be up to 60% higher.4

At the recent Association for Diagnostics and Laboratory Medicine (ADML) conference, Barbara Van Der Pol, PhD, MPH UAB School of Medicine, and Casey Pinto, PhD, MPH, CRNP, Department of Public Health Sciences, Division of Epidemiology, Penn State University, discussed strategies for enhancing access to testing for STIs and how this might impact patient lives as well as public health outcomes.

Article highlights:

  • Sexually transmitted infections are extremely common with an estimated 1 in 5 people in the US being infected on any given day, totaling nearly 68 million infections.
  • Stigmatization of sexually transmitted infections and difficulties with access to testing means the true numbers are likely up to 60% higher.
  • Point of care testing solutions could provide an option for addressing gaps in access. 
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Stigmatization impacts access to testing

Despite the rising number of cases of STIs in the US, discussing sexual health still suffers from stigmatization.5 This creates the first stumbling block for diagnosis. In order to get tested, patients have to feel comfortable going to see their primary care provider which they often don’t. “It’s really unfortunate, but at the institutional level, we stigmatize these diseases so much. How can people access care when their providers won’t talk to them about their sexual health,” says Dr. Van Der Pol, “How many times has my provider asked me about my sexual health? Zero. And that's our problem in this country.”

Different groups can face further obstacles. For example, young people who have the highest rates of STIs, face the added stigma of sharing sexual health information with their parents. As Dr. Van Der Pol points out, “If you’re 16 years old and you have to get tested, you don’t want your Mom to find out.”

Alternative testing for STIs

The first place to go for testing in the US is a primary care provider, but if people aren’t comfortable with this, or they find providers are unhelpful, then alternative ways of increasing access to STI tests are required.

Online testing

Dr. Pinto believes telemedicine, or online ordering/direct-to-consumer testing, is increasingly an option for those seeking an STI test, but access can still be an issue. Patients need to have access to the internet and have health insurance or enough money to cover the cost of a test. Amazon can now deliver a testing kit directly, but Dr. Van Der Pol points out that the kits cost from $100 to $200 noting, “If we are talking about a 16-year-old, she/he/they don’t have that kind of money.” Overall, the speakers agree that if it could be made confidential, affordable, and accessible and if quality could be ensured with regulatory oversight, online ordering could prove to be a good strategy, but it is not yet fully optimized. Further, we have to acknowledge the electronic divide that will preclude access to this strategy for some disadvantaged populations.

Point of care testing

If patients are comfortable seeing a provider and are able to pay for testing, rapid point of care testing (POCT) at clinics is a good option. People who wish to be tested can go in and talk to somebody, get tested straight away, and get results immediately. Therefore, if the person is found to have something, they can immediately get treated avoiding any insurance documentation or prescriptions being sent to their home. 

Increasing access to POCT at more locations would also help. Dr. Van Der Pol suggests these tests could be made available at easily accessible places such as Kroger’s The Little Clinics, Walmart, or Walgreens. “If you can go in there and get a rapid test, you could take care of everything right then right there. Wouldn’t that be wonderful?”, she asks.

The flexibility to take POCT to patients is especially helpful for rural areas. Dr. Pinto shares details of a project for testing migrant workers who work in the fields, and who may not otherwise have the opportunity to test, and Dr. Van Der Pol notes that in areas of Alabama where there is limited healthcare provision, access is being expanded through community health workers. 

The doctors also note that the tests themselves are easy to conduct using self-collection methods. Even in clinics, self-collection samples are preferred as they give people some sense of control as they’re participating in their own health care. “Self-collection is a really positive thing and it’s super easy to do”, says Dr. Van Der Pol.

Wider benefits of point of care testing

The use of POCT could also have wider benefits for healthcare systems by helping to alleviate challenges associated with testing for STIs in the emergency department. “This is one of the biggest burdens I’m seeing,” says Dr. Pinto, “Patients are going to the ER and saying, ‘I am having sex, I want an STI test’.” Patients are often only provided chlamydia and gonorrhea testing because the treatment was provided empirically, or they send an oral prescription to the pharmacy (even though cefixime is no longer recommended for gonorrhea) for treatment if results come back positive. However, this leaves missed opportunities for additional screening, education, and expedited partner therapy.

By increasing access to POC rapid testing, providers would be able to test and treat a patient during their initial visit, reducing the risk of further transmission, supporting effective antimicrobial stewardship, and streamlining the continuum of care for patients. Dr. Pinto believes this is important because if people can be diagnosed earlier and more often, it will decrease the rate of transmission to partners and therefore reduce the overall testing burden on healthcare systems.

The role of laboratory testing for STIs

Although POCT show great promise for improving patient options, Dr. Van Der Pol highlights that they are just one element of improving care. “The tests are a way to get people understanding that tests can really help improve patient management, and sometimes those tests have to be done in the lab,” she says. 

Where patients test positive for one STI, they may also have been exposed to other STIs which are not covered by a point of care. For example, if a POCT identifies gonorrhea, for optimum patient management it would be best to know that antimicrobial profile. Similarly with Mycoplasma genitalium, as between 44%-90% of infections are resistant to azithromycin, which is the most commonly used drug for chlamydia in the US, a resistance profile is required in order to treat the disease effectively.6 In these cases, the clinic would need to collect a specimen and send it off to the lab.

Dr. Van Der Pol notes that although this is the case now, the picture is ever-changing. There are new diseases to tackle every so often, and technology is constantly progressing. She concludes, “10 years from now…we'll be doing all this in a 30-second test, maybe from a breathalyzer for all I know. But the point is, right now we're not there yet.”


If you want to hear more from Dr. Van Der Pol and Dr. Pinto on testing for STIs you can watch the full presentation ‘Improving Access and Patient Outcomes for Sexually Transmitted Infections’.

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  1. World Health Organization. (2023). Article available from https://www.who.int/news-room/fact-sheets/detail/chlamydia [Accessed September 2024]

  2. World Health Organization. (2023). Article available from https://www.who.int/news-room/fact-sheets/detail/gonorrhoea-(neisseria-gonorrhoeae-infection) [Accessed September 2024]

  3. World Health Organization. (2024). Article available from https://www.who.int/news-room/fact-sheets/detail/sexually-transmitted-infections-(stis) [Accessed September 2024]

  4. Crowley J et al. (2021). Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington DC: National Academies Press. Book available from https://pubmed.ncbi.nlm.nih.gov/34432397/ [Accessed October 2024]

  5. National Geographic. (2023). Article available from https://www.nationalgeographic.com/science/article/stds-are-at-a-shocking-high-how-do-we-reverse-the-trend [Accessed September 2024]

  6. CDC. (2021). Guidelines available from https://www.cdc.gov/std/treatment-guidelines/mycoplasmagenitalium.htm [Accessed October 2024]