Testing for Sexually Transmitted Infections: Providers Cannot Opt Out of the Conversation

“Take awkward off the table” by adopting an opt-out approach to screening for sexually transmitted infections (STI): this is the approach debated in recent discussions about testing adolescents for gonorrhea and chlamydia. For several years, the Centers for Disease Control and Prevention (CDC) has encouraged providers to adopt an opt-out approach to HIV testing in persons >13 years old. In the recently released Sexually Transmitted Infections Treatment Guidelines, 2021,¹  CDC proposes that providers “might consider” opt-out screening for gonorrhea and chlamydia in adolescent girls during clinical encounters. Some may feel that such an approach to testing may relieve pediatric providers of the need to have an “awkward” conversation with their patients about sex.

In this issue of Pediatrics, Liddon et al²  provide national data on STI testing among sexually active youth and evidence that opt-out screening is worthy of our consideration. The authors present findings from the 2019 Youth Risk Behavior Survey (YRBS), a nationally representative, cross-sectional survey of high school students in the United States that is conducted every 2 years. In 2019, for the first time, this self-administered survey included the question, “During the past 12 months, have you been tested for an STD other than HIV, such as chlamydia or gonorrhea?” Of students who reported sexual activity in the 3 months leading up to the survey and who answered the question, only 20.4% reported that they had been tested for STIs within the past year. Among sexually active females, 26.1% reported testing; findings were only slightly better among male students who reported sexual activity with male partners, 29.8% of whom stated they had been tested. These 2 groups are notable because multiple national guidelines (eg, from CDC, the American Academy of Pediatrics, and the US Preventive Services Task Force) are clear and consistent in the recommendation that sexually active females <25 years of age and males who report sexual activity with male partners should be tested for STIs at least annually. The findings from Liddon et al²  make it evident that this is not occurring.

There are limitations to this cross-sectional survey study that leave us with unanswered questions. Did those who were not tested have any contact with the health care system in the previous year? If so, were they sexually active at that time, or was the onset of sexual activity more recent? Of the many potential barriers to STI testing (eg, lack of knowledge, limited access or resources, fear of disclosure to parents, provider discomfort), which contributed the most to the overall lack of testing? The YRBS samples high school students. What is the prevalence of testing in out-of-school youth, who may experience even more barriers? Although these questions cannot be answered by this study, the authors’ finding that less than one-third of sexually active students report testing underscores the need for more research.

Before the COVID-19 pandemic, gonorrhea, chlamydia, and syphilis were all reported at record-high rates in the United States. About one-half of all new infections occur in adolescents and young adults, and female adolescents and young adults have the highest reported rates of chlamydial infections.³  YRBS data shows that ∼20% of high school freshman and >50% of high school seniors have had sex, and less than one-half report having used a condom with their most recent sexual encounter.⁴  It is, therefore, critical that those who care for adolescents provide STI testing.

Opt-out STI screening may be one means of addressing this need. With opt-out screening, the patient is notified that STI testing will be performed, and they may decline this testing if desired. This process may occur outside of a more comprehensive conversation about sexual behaviors, for example, when a nurse is initially preparing a patient to be seen by the provider. Although robust research on this practice is lacking, some data suggests that opt-out testing may improve detection rates and be cost-effective in some populations.^5,6  Additional support for opt-out testing comes from literature suggesting that adolescents do not always disclose sexual activity to their provider when asked.^6,7  Practices implementing opt-out screening must have mechanisms in place to follow up positive results in a manner that is respectful, confidential, and will not damage the provider’s relationship with the adolescent. Providers must also adhere to state laws regarding minor consent and confidentiality regarding STI testing and treatment.

STI testing, however, is only 1 element of sexual and reproductive health (SRH) care. A recent study by Sieving et al found that gender identity, sexual orientation, pregnancy prevention, and healthy relationships are all topics that adolescents and their parents feel are important and appropriate to discuss with their providers.⁸  Nevertheless, fewer than one-third of adolescents reported that their health care provider ever asked them about these topics, including whether they were sexually active, and less than one-half had spent time alone with their provider during their most recent preventive health visit. In a study by Copen et al adolescents noted similarly low rates of alone time with providers and indicated that confidentiality was an important element of SRH care. Those who did spend some time alone with their provider were more likely to have received SRH services within the past year.⁹  Resources such as confidentiality policies, checklists, and written screening tools may facilitate SRH discussions.

Liddon et al²  demonstrate that providers need to better serve their adolescent patients by increasing rates of STI screening, but they go on to caution that opt-out testing does not obviate the need for comprehensive SRH. With a little practice, respect, and intention, a caring provider can take the awkward out of discussing sexual health but must not opt out of the conversation.

CDC

Center for Disease Control and Prevention

SRH

sexual and reproductive health

STI

sexually transmitted infection

YRBS

Youth Risk Behavior Survey