Sexually Transmitted Infections: Compelling Case for an Improved Screening Strategy

Vaginitis and risk of sexually transmitted infections: results of a multi-center U.S. clinical study using STI nucleic acid amplification testing

Significant increases in rates of sexually transmitted infections (STIs) caused by Trichomonas vaginalis (TV), Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), and Mycoplasma genitalium (MG) are occurring in the United States. We present results of a U.S. study examining the intersection of STIs and vaginitis. Among 1,051 women with diagnoses for the presence or absence of bacterial vaginosis (BV) and/or symptomatic vulvovaginal candidiasis (VVC), 195 (18.5%) had one or more STIs, including 101 (9.6%) with TV, 24 (2.3%) with CT, 9 (0.8%) with NG, and 93 (8.8%) with MG. STI prevalence in BV-positive women was 26.3% (136/518), significantly higher than STI prevalence of 12.5% (59/474) in BV-negative women (P < 0.0002). Unlike infections with CT or NG, solo infections of MG or TV were each significantly associated with a diagnosis of BV-positive/VVC-negative (OR 3.0751; 95% CI 1.5797-5.9858, P = 0.0113, and OR 2.873; 95% CI 1.5687-5.2619, P = 0.0017, respectively) and with mixed infections containing MG and TV (OR 3.4886; 95% CI 1.8901-6.439, P = 0.0042, and OR 3.1858; 95% CI 1.809-5.6103, P = 0.0014, respectively). TV and MG infection rates were higher in all Nugent score (NS) categories than CT and NG infection rates; however, both STIs had similar comparative prevalence ratios to CT in NS 6-10 vs NS 0-5 (CT: 3.06% vs 1.4%, 2.2-fold; MG: 10.7% vs 6.1%, 1.8-fold; TV: 14.5% vs 7.0%, 2.1-fold). NG prevalence was relatively invariant by the NS category. These results highlight the complexity of associations of STIs with two major causes of vaginitis and underscore the importance of STI testing in women seeking care for abnormal vaginal discharge and inflammation.

IMPORTANCE

This study reports high rates for sexually transmitted infections (STIs) in women seeking care for symptoms of vaginitis and bacterial vaginosis, revealing highly complex associations of STIs with two of the major causes of vaginal dysbiosis. These results underscore the importance of STI testing in women seeking care for abnormal vaginal discharge and inflammation.

At-Home Self-Collection of Urine or Vaginal Samples for Gonorrhea and Chlamydia Screening Among Young People Who Were Assigned Female at Birth

Introduction

The U.S. has seen a rise in sexually transmitted infections; the need to increase access to screening is essential to reverse this trend, especially for vulnerable populations such as lesbian, gay, bisexual, and transgender/transsexual plus individuals, people of color, or those at a low SES. This study's primary objective is to assess preferences among people who were assigned female at birth for at-home self-collection for gonorrhea and chlamydia screening. This study aims to provide insight into the need for clinicians to adopt at-home self-collection of urine or vaginal samples to improve access to sexually transmitted infection screening.

Methods

A recruitment mailer was distributed in September-October 2021. Inclusion criteria included established patients (seen within the last 3 years for clinical services either in person or through telemedicine) at a local urban federally qualified health center in the state of Wisconsin, assigned female at birth, aged 18-24 years, and speaking English language. Participants completed an anonymous online survey regarding their preferences, experiences, and likelihood of self-collecting either urine or vaginal samples for gonorrhea and chlamydia screening at home.

Results

Among the total participants (N=88), 69% (n=61) overall preferred home collection for screening with no significance based on age; lesbian, gay, bisexual, and transgender/transsexual plus status; and race and/or ethnicity. However, patients were less likely to prefer at-home self-collection screening if they had lower educational attainment (OR=0.25; 95% CI=0.08, 0.77; p<0.05), lacked insurance (OR=0.19; 95% CI=0.06, 0.67; p<0.05), or were unemployed (OR=0.28; 95% CI=0.08, 0.95; p<0.05).

Conclusions

There is overall acceptability for at-home self-collection sexually transmitted infections screening (61 of 88=0.69; 95% CI=0.59, 0.79). Primary care clinics can expand needed screening by integrating such methods into workflows for established patients. Although this study showed that patients who are employed, attained a higher education level, and have their own insurance may prefer at-home self-collection, there is a need to focus on social determinants of health to decrease rising sexually transmitted infection rates in the U.S.

Improving chlamydia risk screening by using the CDC's 5 Ps approach to sexual health history

BACKGROUND

Chlamydia trachomatis is infecting service members (SMs) at a rate of two to three times that of the U.S. population. Currently, the military only screens female SMs under the age of 25 years, leaving many at-risk males to go undetected leading to further transmission.

LOCAL PROBLEM

Service members are not routinely assessed for high-risk sexual activities, leading to increased chlamydia rate in Fort Bragg. At the primary care project site, screening was only done per HEDIS measure leading to only 5% STI positivity rate. The purpose of this project was to identify and screen SMs who are at high risk for chlamydia using the CDC's 5 Ps approach.

METHODS

This project took place at a large primary care clinic that only cared for active-duty soldiers over a 3-month period.

INTERVENTIONS

The CDC's 5 Ps questionnaire was administered to SMs 30 years and younger during routine appointments. The SMs deemed high risk from the questionnaire were screened using urine G/C NAAT testing.

RESULTS

Four hundred forty-nine SMs were assessed using the CDC's 5 Ps approach. The questionnaire identified 91 SMs (20%) at higher risk for STIs. Of the 45 urine samples submitted, six were positive for STIs. Of the six positive cases, five were male. Targeted screening resulted in 13.3% positive rate compared with the 5% in the current practice.

CONCLUSION

The result suggests that targeted screening of young males and females can identify high-risk sexual behaviors leading to increased findings of asymptomatic chlamydia carriers, ultimately leading to decreased chlamydia incidence.

Delay Discounting for HIV/STI Testing

Introduction

Wait time in healthcare is an important barrier to HIV/STI testing. Using a delay discounting approach, the current study examined a systematic reduction in testing likelihood as a function of delay (wait time) until testing.

Methods

In Study 1 (N = 421; data collected in 2019), participants were randomly assigned to either a chlamydia/gonorrhea group or HIV group. A delay discounting task asked them to report how likely they would get tested for the assigned STI if they had to wait for the test (the delay durations varied within persons). In Study 2 (N = 392; data collected in 2020), we added a smaller, sooner outcome (consultation without testing) and tested whether the effect of delay was mediated by perceived severity of the STIs.

Results

In both studies, the subjective value of a delayed STI test was discounted. That is, people were less likely to undergo STI testing as the delay to STI testing increased. The chlamydia/gonorrhea group discounted delayed testing more than the HIV group (i.e., the effect of delay on testing decisions was stronger for the former). This effect was statistically mediated by perceived severity.

Conclusions

We found evidence for delay discounting for HIV/STI testing and that testing decisions were more susceptible to delay when the test was for relatively mild STIs.

Policy Implications

Even mild STIs can cause serious health damage if left untreated. The findings provide strong argument for policies aimed to reduce wait times in healthcare, especially for relatively mild STIs.

Chlamydial and gonorrheal neglected sexually transmitted diseases among Pacific Islanders of the Western Pacific Region-A narrative review and call to action

The Pacific Island countries of the Western Pacific Region have some of the highest rates of sexually transmitted Chlamydia trachomatis and Neisseria gonorrhoeae infections in the world. Despite this, there are few research studies that include Pacific Islanders. We conducted a narrative review of original research and surveys, including World Health Organization and Pacific Community reports, to determine the prevalence, management, and treatment of C. trachomatis and N. gonorrhoeae compared to HIV and syphilis from 1980 to 2022. Available epidemiologic data on C. trachomatis and N. gonorrhoeae indicated an extremely high prevalence-approximately 30% and 13%, respectively-among Pacific Islanders during this timeframe. These neglected sexually transmitted infections represent a significant burden and health disparity. Robust epidemiologic research is needed to identify modifiable risk factors for designing interventions and control strategies. Appropriate policies along with regional and international advocacy and aid are required to improve reproductive health among these vulnerable, understudied populations to avert preventable infections and sequelae.

Investigating the impact of stigma, accessibility and confidentiality on STI/STD/HIV self-testing among college students in the USA: protocol for a scoping review

INTRODUCTION

In 2019, there were 2.5 million reported cases of chlamydia, gonorrhoea and syphilis. The Centers for Disease Control and Prevention reported in the USA, young people aged 15-24 made up 61% and 42% of chlamydia and gonorrhoea cases, respectively. Moreover, the highest rates of sexually transmitted infections (STIs) were reported among college-aged students. In this paper, we outline our protocol to systematically review the published literature on, the use of STI/HIV self-test kits, increasing STI/HIV testing uptake, and stigma, access and confidentiality issues, among young adult college students in the USA.

METHODS AND ANALYSIS

This scoping review will be conducted and reported according to the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. We will search electronic databases, OVID Medline, OVID Embase, Web of Science, Cochrane Library, PubMed and CINAHL, for articles published in English from inception to the present. We will search other alternative sources such as ProQuest, Google Scholar and Google to identify grey literature. A two-step process will be used to identify eligible studies based on the defined inclusion criteria. First, the title and abstract of identified articles will be screened for possible inclusion. Second, full-text articles of relevant studies will be retrieved and screened for inclusion. Both screening steps will be done by two people independently. Finally, data will be extracted by two researchers working independently. Any arising disagreements will be resolved by consensus or by a third author.

ETHICS AND DISSEMINATION

This study is a scoping review of the literature. Therefore, ethics approval is not required. Our plan for the dissemination of findings includes peer-reviewed manuscripts, conferences and webinars.

Sexually Transmitted Infection Screening in Key Populations of Persons Living with HIV

Annual screening for bacterial sexually transmitted infections (STI), including gonorrhea/chlamydia (GC/CT) and syphilis, is recommended for persons with HIV (PWH). We used the prevention index to quantify the extent to which STI screening was completed at guideline-recommended frequency in African American and Latinx persons, women, persons with alcohol (AUD) and substance (SUD) use disorders. Data from PWH at Kaiser Permanente Northern California were collected from electronic health records. We defined receipt of GC/CT and syphilis screening consistent with recommendations as a prevention index score ≥ 75%. Among 9655 PWH (17.7% Latinx; 16.2% African American; 9.6% female; 12.4% AUD; 22.1% SUD), prevention index scores for GC/CT and syphilis increased from 2015 to 2019. African American PWH had lower odds of receiving an annual syphilis screen (aOR 0.87 [95% CI 0.79-0.97]). Female sex was associated with lower odds of GC/CT (aOR 0.30 [95% CI 0.27-0.34]) and syphilis (aOR 0.27 [95% CI 0.24-0.310) screening. AUD and SUD were not associated with differences in annual GC/CT or syphilis screening. Key PWH subgroups experience ongoing challenges to annual STI screening despite comparable healthcare access.

Closing the Equity Gap: An Intervention to Improve Chlamydia and Gonorrhea Testing for Adolescents and Young Adults in Primary Care

BACKGROUND

Chlamydia trachomatis and Neisseria gonorrhea are the most reported sexually transmitted infections in the United States. Testing rates remain suboptimal and may be subject to implicit bias. We evaluated the effectiveness of an opt-out chlamydia and gonorrhea testing program for adolescents and young adults in improving testing rates and promoting equity.

METHODS

An opt-out testing program that standardized testing to once annually for 14 to 24-year-old patients was implemented across 28 federally qualified health centers spanning 4 specialties. A quasi-experimental design using interrupted time series analyses evaluated testing and infection rates between baseline, intervention, and pandemic-associated test shortage periods. Reduction in testing inequities based on sex, race, ethnicity, insurance, and language preference were also examined.

RESULTS

A total of 57 452 encounters during the baseline, 17 320 during the intervention, and 26 993 during the test supply shortage periods were included. Testing increased from 66.8% to 81.0% (14.2% absolute increase) between baseline and intervention periods. Pediatric clinics demonstrated the largest improvement compared to other settings (absolute increase 30.9%). We found significant reductions in testing inequities for language preference (P < .001), and un-insured and public insured individuals (P < .001). More cases of chlamydia and gonorrhea were detected in the intervention period (chlamydia-29.7; gonorrhea-7.4 per 1000 patients) than in the baseline period (chlamydia-20.7; gonorrhea-4.4 per 1000 patients; P < .001).

CONCLUSIONS

An opt-out approach increased testing, reduced inequities between some groups and detected more infections than a risk-based approach. Opt-out testing should be considered as an approach to increase detection of chlamydia and gonorrhea and promote equity.

Disparities in Sexually Transmitted Infection Testing and the Need to Strengthen Comprehensive Sexual Health Services for Trans Women

Purpose

Few studies have examined the importance of improving the sexual health delivery system beyond HIV among trans women. We assessed survey data from the National HIV Behavioral Surveillance Transgender Woman (NHBS-Trans) Study in San Francisco to characterize the utilization of sexual health services among HIV-negative trans women and to explore opportunities to improve sexual health services for trans women.

Methods

Trans women were recruited through respondent-driven sampling from July 2019 to February 2020. The analytic sample was restricted to 116 HIV-negative trans women. We identified trends in data using chi-squared tests to assess significance between sexual risk behavior and the use of preventative sexual health services and built logistic regression models to assess the relationships between sexual risk behaviors and sexually transmitted infection (STI) testing.

Results

The majority of sample was trans women of color with most identifying as Latinx (42.2%). Over half were low income (56%), and majority had been homeless in past 12 months (62.9%). The prevalence of condomless receptive anal sex was 52.6% with about two-thirds (62.1%) recently having an STI test. Participants who engaged in recent condomless receptive anal sex had more than fivefold greater odds of having a recent STI test compared to their counterparts who did not (adjusted odds ratio [aOR] 5.60, 95% confidence interval [CI] 1.83-17.11; p=0.003). We also found age- and education-related disparities in STI testing.

Conclusion

This study characterized the utilization of sexual health services among HIV-negative trans women and identified important disparities in STI testing. We discuss opportunities to strengthen sexual health care delivery systems.

Consumer-Based STI Screening among Young Adult Women: The Negative Influence of the Social System

BACKGROUND

Young adults (ages 18-24) are disproportionately burdened by sexually transmitted infections (STIs), but STI screening rates are low among this age group. Negative social factors, such as stigma, influence STI screening behavior, but it is unknown if alternative methods such as consumer-based screening can reduce these barriers. This study examined how stigma impacts consumer-based STI testing among young adult women.

METHODS

Qualitative data were collected via in-depth interviews with sexually active women, age 18-24, enrolled at a large public university in the South (n = 24). Interviews were audio recorded, transcribed, and analyzed thematically with a priori and emergent codes by two coders (Kappa = .83).

RESULTS

Participants from this study perceived sexual activity was viewed positively for men, but negatively stigmatized for women. Further, lack of sexuality education in schools was another contributor to stigma since abstinence-only education is commonly provided in this region. Participants felt offering information on consumer-based STI screening methods may be beneficial to address these barriers.

CONCLUSIONS

Stigma and social influences must be accounted for in future research and interventions to meet the STI screening needs of young adult women. Findings from this research can inform the development of targeted interventions for women who may perceive heightened stigma to STI screening.

An Intervention to Improve Chlamydia and Gonorrhea Testing Among Adolescents in Primary Care

BACKGROUND AND OBJECTIVES

Rates of chlamydia and gonorrhea among adolescents continue to rise. We aimed to evaluate if a universal testing program for chlamydia and gonorrhea improved testing rates in an urban general pediatric clinic and an urban family medicine clinic within a system of federally qualified health care centers and evaluated the feasibility, cost, and logistic challenges of expanding implementation across 28 primary care clinics within a federally qualified health care centers system.

METHODS

A universal testing quality improvement program for male and female patient 14 to 18 years old was implemented in a general pediatrics and family medicine clinic in Denver, Colorado. The intervention was evaluated by using a controlled pre-post quasi-experimental design. The difference in testing rates due to the intervention was assessed by using a difference-in-differences regression model weighted with the inverse probability of treatment.

RESULTS

In total, 15 541 pediatric encounters and 5420 family medicine encounters were included in the analyses. In pediatrics, the unadjusted testing rates increased from 32.0% to 66.7% in the intervention group and from 20.9% to 28.9% in the comparison group. For family medicine, the rates increased from 38.5% to 49.9% in the intervention group and decreased from 26.3% to 24.8% in the comparison group. The intervention resulted in an adjusted increase in screening rates of 25.2% (P < .01) in pediatrics and 11.8% (P < .01) in family medicine. The intervention was well received and cost neutral to the clinic.

CONCLUSIONS

Universal testing for chlamydia and gonorrhea in primary care pediatrics and family medicine is a feasible approach to improving testing rates .

A Quality Improvement Project Using Microlearning to Increase Provider Adherence to Extragenital Sexually Transmitted Infection Screening Guidelines in Men Who Have Sex With Men

ABSTRACT

The Centers for Disease Control and Prevention (CDC) recommend screening men who have sex with men who are living with HIV for sexually transmitted infections at appropriate extragenital contact sites for bacterial sexually transmitted infections. In an effort to increase provider adherence to CDC recommended guidelines at a Ryan White Clinic, microlearning educational sessions were used. A quality improvement project was designed to determine the rate of provider adherence to CDC guidelines pre/post microlearning sessions. Student t-test was used to compare the number of patients who received urine and extragenital screening to those who received urine-only screening, to before and after the microlearning sessions. The rate of extragenital screening significantly increased after the microlearning sessions (4/460 vs. 70/507, p < .0001). The rate of urine screening remained unchanged (p = 1). Although extragenital screening significantly increased, it remained low. A decision tree in the electronic medical record to prompt providers to screen was developed.

A portable magnetofluidic platform for detecting sexually transmitted infections and antimicrobial susceptibility

Effective treatment of sexually transmitted infections (STIs) is limited by diagnostics that cannot deliver results rapidly while the patient is still in the clinic. The gold standard methods for identification of STIs are nucleic acid amplification tests (NAATs), which are too expensive for widespread use and have lengthy turnaround times. To address the need for fast and affordable diagnostics, we have developed a portable, rapid, on-cartridge magnetofluidic purification and testing (PROMPT) polymerase chain reaction (PCR) test. We show that it can detect Neisseria gonorrhoeae, the pathogen causing gonorrhea, with simultaneous genotyping of the pathogen for resistance to the antimicrobial drug ciprofloxacin in <15 min. The duplex test was integrated into a low-cost thermoplastic cartridge with automated processing of penile swab samples from patients using magnetic beads. A compact instrument conducted DNA extraction, PCR, and analysis of results while relaying data to the user via a smartphone app. This platform was tested on penile swab samples from sexual health clinics in Baltimore, MD, USA (n = 66) and Kampala, Uganda (n = 151) with an overall sensitivity and specificity of 97.7% (95% CI, 94.7 to 100%) and 97.6% (95% CI, 94.1 to 100%), respectively, for N. gonorrhoeae detection and 100% concordance with culture results for ciprofloxacin resistance. This study paves the way for delivering accessible PCR diagnostics for rapidly detecting STIs at the point of care, helping to guide treatment decisions and combat the rise of antimicrobial resistant pathogens.

Development and Evaluation of a Point-of-Care Test in a Low-Resource Setting with High Rates of Chlamydia trachomatis Urogenital Infections in Fiji

Rapid and precise detection of Chlamydia trachomatis, the leading global cause of sexually transmitted infections (STI), at the point of care (POC) is required for treatment decisions to prevent transmission and sequelae, including pelvic inflammatory disease, ectopic pregnancy, tubal factor infertility, and preterm birth. We developed a rapid POC test (POCT), termed LH-POCT, which uses loop-mediated amplification (LAMP) of nucleic acids. We performed a head-to-head comparison with the Cepheid Xpert CT/NG assay using clinician-collected, deidentified paired vaginal samples from a parent study that consecutively enrolled symptomatic and asymptomatic females over 18 years of age from the Ministry of Health and Medical Services Health Centers in Fiji. Samples were processed by the Xpert CT/NG assay and LH-POCT, blinded to the comparator. Discrepant samples were resolved by quantitative PCR. Deidentified clinical data and tests for Trichomonas vaginalis, Candida, and bacterial vaginosis (BV) were provided. There were a total of 353 samples from 327 females. C. trachomatis positivity was 16.7% (59/353), while the prevalence was 16.82% (55/327) after discrepant resolution. Seven discrepant samples resolved to four false negatives, two false positives, and one true positive for the LH-POCT. The sensitivity of the LH-POCT was 93.65% (95% confidence interval [CI], 84.53% to 98.24%), and specificity was 99.31% (95% CI, 97.53% to 99.92%). Discrepant samples clustered among women with vaginal discharge and/or BV. The prototype LH-POCT workflow has excellent performance, meeting many World Health Organization ASSURED criteria for POC tests, including a sample-to-result time of 35 min. Our LH-POCT holds promise for improving clinical practice to prevent and control C. trachomatis STIs in diverse health care settings globally.

Gonorrhea and Chlamydia Rates Among 12- to 24-Year-Old Patients in an Urban Health System

BACKGROUND

Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) infection rates continue to rise. Screening guidelines have largely focused on sexually active female individuals and men who have sex with men populations. Health care system testing and infection rates, particularly among heterosexual male individuals, are poorly understood. Our aim was to evaluate CT and GC testing and prevalence among 12- to 24-year-old patients in an urban federally qualified health center system.

METHODS

This retrospective study analyzed electronic health record data from 2017 to 2019 in a large system of federally qualified health centers in Denver, CO. Abstracted data included demographics, sexual activity, sexual orientation, and laboratory results. χ2 Tests were used to evaluate differences between groups.

RESULTS

Of the 44,021 patients included, 37.6% were tested, 15.0% were positive for CT, and 3.4% were positive for GC. Heterosexual male patients had a testing rate of 22.8% and positivity rates of CT and GC at 13.1% and 3.0%, respectively. Among tested patients documented as not sexually active, 7.5% were positive for CT. Multiple or reinfections were detected in 29% of patients.

CONCLUSIONS

This study shows low testing rates and high rates of CT and GC infections among all patients, including heterosexual male patients and those documented as not sexually active. Improved screening of these populations in the primary care setting may be key to combating the sexually transmitted disease epidemic.

Attitudes of women participating in a clinical trial on point-of-care testing and home testing for STIs

Neisseria gonorrhoeae, Chlamydia trachomatis and Trichomonas vaginalis infections are a public health concern and cost the United States' healthcare system 16 billion dollars annually. By minimizing barriers to testing, an increased number of infections can be detected and treated. A home-based point-of-care (POC) sexually transmitted infection (STI) test may reduce personal, structural, social and system-level barriers to STI testing. This study assesses patient preferences and acceptance of home-based POC STI testing. We performed a cross-sectional, single-visit study of women aged 18 years and older at a single site. Women completed an anonymous online survey evaluating interest in POC STI testing, comfort in self-collecting vaginal swabs and participant reaction to a positive STI result. 138 participants completed the anonymous online survey. The survey results indicate high acceptability with self-collection of samples and home POC STI testing. A majority of participants were interested or very interested in a home POC STI device-especially amongst women with a past history of a STI. If receiving a positive test result, participants indicated they would want to have someone to discuss their results with, most preferring to speak with their primary care provider. Women on lower incomes were less comfortable and less interested with home testing. Women are likely to be receptive to home POC STI testing. Adapting to home-based testing will require engagement of primary care providers for management and surveillance of STIs.

Using Provider Incentives and an Opt-Out Strategy in a Successful Quality Initiative to Increase Chlamydia Screening

BACKGROUND

Chlamydia trachomatis (CT) is a highly prevalent sexually transmitted infection in adolescents that can lead to serious complications. San Francisco has one of the highest rates of CT infections in the United States. At baseline, screening rates at the Children's Health Center were significantly below national and network levels. This project aimed to increase screening rates for female patients age 16-24 from 29.2% to 44% in an 18-month period.

METHODS

The organization engaged providers, residents, and nursing staff to understand the root causes and choose the screening approach. The following strategies were used to implement this approach in primary and urgent care: (1) universal urine collection, (2) provider and staff education, and (3) adoption of faculty Maintenance of Certification (MOC) credit and resident physician financial incentives.

RESULTS

The annual screening rate for CT in primary care female patients 16-24 years old increased from 29.2% to 61.5% in 18 months, and improved to 71.2% one year after the project. Screening rates for female patients over age 15 seen in the colocated urgent care also increased significantly. The research team found no instances of false positive results and had 4 positive results in high-risk patients who initially reported abstinence.

CONCLUSIONS

The intervention design and engagement of stakeholders with incentives was associated with significant and sustainable improvements in the CT screening rate for female adolescent primary care patients. This work shows how universal opt-out screening can be a sustainable and effective method to address common barriers to increasing screening for CT in adolescents.