Disparities in Adolescent STI Persist Post-Pandemic

Source: Pelliccione A, Modaressi S, Fireman B, et al. Trends in gonorrhea and chlamydia testing and infections across the COVID-19 pandemic in adolescents and young adults in an integrated health system. J Adolesc Health. Published online ahead of print August 15, 2024; 2024:S1054-139X(24)00314-8; doi: 10.1016/j.jadohealth.2024.06.029.Investigators from multiple institutions conducted a retrospective study to assess the impact of the COVID-19 pandemic on testing for chlamydia and gonorrhea in adolescents and young adults. Study participants were patients 15–29 years old who had membership in Kaiser Permanente Northern California between 2016 and 2022. The medical records of the participants were reviewed and data on demographics, chlamydia and gonorrhea testing, and infections (defined by a positive PCR test) abstracted. Rates of testing and of chlamydia and gonorrhea infections were determined on a monthly basis. The pre-COVID-19 period was defined as January 1, 2016 to February 29, 2020, and the COVID-19 period as March 1, 2020 to December 31, 2022. Rates of testing and infections were calculated by dividing number of tests, or infections, by the total number of persons at risk during a specific period. Rates of testing and infections during the pre-COVID-19 period and during the pandemic were compared with Poisson regression, after adjusting for multiple covariates. Rates of testing throughout the entire study period also were compared among participants in different age groups, in males and females, and in those from different racial and ethnic groups.The study population included 1,736,850 participants 15–29 years old, with a mean age of 22.5 ±4.1 years. Overall, 31.1% were white non-Hispanic, 23.5% were Hispanic, and 6.5% Black non-Hispanic. There were 979,481 PCR tests for chlamydia or gonorrhea during the pre-COVID-19 period and 546,904 during the COVID-19 period. After controlling for confounders, the rate of testing was significantly lower during the pandemic than previously (adjusted incident rate ratio [aIRR], 0.81; 95% confidence interval [CI], 0.77, 0.86). During the pre-COVID-19 period, the rate of testing was 24.9 per 1,000 patient-months and dropped to 19.7 tests per 1,000 patient months during COVID-19. The lowest rate of testing during the pandemic was April 2020 (7.46/1,000 patient-months). Subsequently, rates of testing increased to 20.14/1,000 patient-months in December 2022. When analyzing data throughout the study period 2016–2022, compared to participants who were 25–29 years old, rates of testing were significantly lower in those 15–19 years old (aIRR, 0.63; 95% CI, 0.58, 0.68), but higher in those 20–24 years old (aIRR, 1.23; 95% CI, 1.16, 1.31). Rates of testing also were significantly higher in Black participants than in White patients and in females compared to males. Compared to the pre-COVID-19 period, the rate of chlamydia infections decreased significantly during the pandemic (aIRR, 0.90; 95% CI, 0.83, 0.97), but the rate of gonorrhea infections increased (aIRR, 1.14; 95% CI, 1.04, 1.25).The authors conclude that testing for chlamydia and gonorrhea in adolescents and young adults decreased during the COVID-19 pandemic.Dr Raphael has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.Though 15–24-year-olds compose only 13% of the population, they represent half of the 2.5 million new sexually transmitted infections (STIs) in the United States annually.1 The current investigators found that there were 27% fewer tests for chlamydia and gonorrhea per month for 15–19-year-olds during COVID-19 vs 15.2% fewer tests in 20–29-year-olds. Whether this was due to a change in sexual risk behavior in 15–19-year-olds or a disproportionate impact of pandemic related disruptions to care in younger adolescents is worth future exploration.Although the results of the current study showed that sociodemographic disparities in STI care didn’t worsen during the pandemic, their persistence and the ongoing lag in STI testing in 2022 vs pre-pandemic remains concerning. White and Black high school students report similar sexual risk behaviors,2 yet prior studies also have shown that Black adolescents are more likely to be tested for STIs. (See AAP Grand Rounds. 2022;48[4]:46.)3 The current investigators found that the highest rates of gonorrhea and chlamydia infections were among Black and Hispanic youths.The findings of the current study highlight the need to strengthen the implementation of standardized STI testing guidelines across population groups and develop intervention strategies to target the higher STI rates among those most affected. A recent innovation in STI prevention is the use of doxycycline for post-exposure prophylaxis (DoxyPEP).4 This has been found to decrease gonorrhea, chlamydia, and syphilis acquisition by 50% to 70%. Even more promising is the population-wide decline in STI rates in regions with high DoxyPEP uptake as the transmission within the sexual network declines.4Testing for gonorrhea and chlamydia declined during the COVID-19 pandemic; pre-pandemic sociodemographic differences in testing and STI rates persisted.Although in the US, chlamydia infections are the most common STI followed by gonorrhea, syphilis persists.5 We recently reported the dramatic increase of congenital syphilis between 2016 and 2022, mirroring the concurrent increase in acquired syphilis. (See AAP Grand Rounds. 2024;51[2]:15.)5 We can provide only conjecture upon the effect of the COVID-19 pandemic on testing for syphilis—data not sought by the current investigators.