Emergency Departments Miss HIV and Syphilis Screening in 88% of STI Cases

Closing the Diagnostic Gap in Acute Care STI Screening

The global burden of sexually transmitted infections remains high, with nearly one million new curable infections occurring daily and requiring urgent public health intervention [1]. A significant challenge for clinicians is that more than half of women infected with chlamydia, gonorrhea, or trichomoniasis are asymptomatic, which often leads to undiagnosed infections and serious long-term complications such as pelvic inflammatory disease and infertility [2]. Emergency departments serve as critical touchpoints for these patients, yet adherence to established diagnostic and treatment guidelines in acute care settings is frequently inconsistent [3]. Current clinical recommendations emphasize the necessity of comprehensive screening, including co-testing for multiple pathogens when a patient presents with risk factors for any single infection [4]. A recent retrospective analysis now examines how consistently these comprehensive testing standards are applied in the high-volume emergency department environment.

Quantifying the Missed Opportunities in Comprehensive Screening

The clinical necessity for integrated screening is underscored by a worsening public health landscape. In 2023, the United States recorded over 2.4 million reported cases of chlamydia, gonorrhea, and syphilis, marking a 32.5% increase in these infections since 2014. To evaluate how emergency departments are responding to this rising prevalence, researchers conducted a retrospective observational analysis of 3,940 patients at two Los Angeles emergency departments between 2021 and 2024. The study cohort consisted of all patients who underwent testing for Neisseria gonorrhoeae and Chlamydia trachomatis, the bacterial pathogens responsible for gonorrhea and chlamydia. The primary outcome was the frequency of complete sexually transmitted infection testing, defined as the performance of both HIV and syphilis screening either during the index emergency department encounter or within the six months prior to the visit. The results demonstrated a significant diagnostic gap, as only 459 out of 3,940 patients (11.7%) received complete STI testing. This low rate of adherence suggests that nearly 90% of patients evaluated for common bacterial infections are not receiving the comprehensive screening for HIV and syphilis recommended by public health guidelines, representing a missed opportunity for early detection and linkage to care. The study further identified that repeat clinical contact did not necessarily lead to improved screening rates. Among a subset of 261 patients who had multiple emergency department encounters during the study period, 217 individuals (83.1%) never received complete testing. These findings indicate that even when patients utilize the emergency department as a recurring point of care, clinicians frequently miss opportunities to identify co-infections, potentially delaying treatment and facilitating further community transmission.

Demographic Disparities and Predictors of Testing Adherence

The demographic profile of the 459 patients who received complete sexually transmitted infection screening reveals distinct patterns in clinical practice. Among this group, 282 patients (61.4%) were male and 176 (38.3%) were female. Racial and ethnic distribution showed that 195 patients (42.5%) were non-Hispanic White, 98 (21.4%) were non-Hispanic Black, and 96 (20.9%) were Hispanic. Socioeconomic factors appeared to play a significant role in which patients were prioritized for comprehensive testing, as 225 individuals (49.0%) were experiencing homelessness at the time of their visit. Insurance status also varied, with 220 patients (47.9%) covered by Medicare and 132 (28.8%) utilizing private insurance. Regarding sexual orientation, 90 patients (19.6%) identified as heterosexual, while 14 (3.1%) identified as bisexual. To identify the specific factors driving these outcomes, the researchers used multivariable logistic regression (a statistical method that isolates the effect of one variable, such as race or housing status, while holding other factors constant to ensure they do not skew the results). This analysis revealed that patients experiencing homelessness had more than five times the odds of receiving comprehensive screening (adjusted odds ratio [aOR] 5.21; 95% CI, 4.00 to 6.78; P < .001). Other groups with significantly higher odds included bisexual patients (aOR 2.51; 95% CI, 1.32 to 4.80; P = .005) and those with Medicare insurance (aOR 1.89; 95% CI, 1.20 to 2.98; P = .006). These findings suggest that clinicians may be more likely to follow full screening protocols when they perceive a patient to be at higher risk due to housing instability or specific behavioral factors. Conversely, the study highlighted significant gaps in screening for populations that remain vulnerable to infection. Female patients had 32% lower odds of receiving complete testing compared to male patients (aOR 0.68; 95% CI, 0.54 to 0.85; P = .001). Racial disparities were also evident in the data. Hispanic patients had significantly lower odds of receiving the full diagnostic workup (aOR 0.69; 95% CI, 0.52 to 0.92; P = .01), as did non-Hispanic Black patients (aOR 0.75; 95% CI, 0.56 to 1.00; P = .05). For the practicing clinician, these results indicate a potential for implicit bias or systemic barriers that prevent female and minority patients from receiving the same level of comprehensive sexually transmitted infection care as their counterparts in the emergency department setting, potentially exacerbating existing health inequities.

References

1. Newman LM, Rowley J, Hoorn SV, et al. Global Estimates of the Prevalence and Incidence of Four Curable Sexually Transmitted Infections in 2012 Based on Systematic Review and Global Reporting. PLoS ONE. 2015. doi:10.1371/journal.pone.0143304

2. Fortas C, Delarocque-Astagneau E, Randremanana RV, Crucitti T, Huynh B. Asymptomatic infections with Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis among women in low- and middle-income countries: A systematic review and meta-analysis.. PLOS global public health. 2024. doi:10.1371/journal.pgph.0003226

3. Kane BG, Guillaume AWD, Evans EM, et al. Gender Differences in CDC Guideline Compliance for STIs in Emergency Departments.. The western journal of emergency medicine. 2017. doi:10.5811/westjem.2016.12.32440

4. Dotters-Katz SK, Kuller JA, Hughes BL. Society for Maternal-Fetal Medicine Consult Series #56: Hepatitis C in pregnancy-updated guidelines: Replaces Consult Number 43, November 2017.. American journal of obstetrics and gynecology. 2021. doi:10.1016/j.ajog.2021.06.008