Should asymptomatic men be included in chlamydia screening programs? Cost-effectiveness of chlamydia screening among male and female entrants to a national job training program

Evaluation of Chlamydia trachomatis screening from the perspective of health economics: a systematic review

Background

Most Chlamydia trachomatis (CT) infections are asymptomatic. The infection can persist and lead to severe sequelae. Therefore, screening for CT can primarily prevent serious sequelae.

Aim

To systematically evaluate CT screening from the perspective of health economics, summarize previous findings from different target populations, and make practical recommendations for developing local CT screening strategies.

Methods

PubMed, Web of Science, Embase, Cochran Library, and National Health Service Economic Evaluation Database (Ovid) were searched from January 1, 2000, to March 4, 2023. Studies reporting the cost-effectiveness, cost-benefit, or cost-utility of CT screening were eligible to be included. A narrative synthesis was used to analyze and report the results following the PRISMA guidelines. The Consensus on Health Economic Criteria (CHEC) list was used to assess the methodological quality of included studies.

Results

Our review finally comprised 39 studies addressing four populations: general sexually active people (n = 25), pregnant women (n = 4), women attending STD and abortion clinics (n = 4), and other high-risk individuals (n = 6). The total number of participants was ~7,991,198. The majority of studies assessed the cost-effectiveness or cost-utility of the screening method. The results showed that the following screening strategies may be cost-effective or cost-saving under certain conditions: performing CT screening in young people aged 15-24 in the general population, military recruits, and high school students; incorporating CT screening into routine antenatal care for pregnant women aged 15-30; opportunistic CT screening for women attending STD and abortion clinics; home-obtained sampling for CT screening using urine specimens or vaginal swab; performing CT screening for 14-30-year-old people who enter correctional institutions (i.e., jail, detention) as soon as possible; providing CT screening for female sex workers (FSWs) based on local incidence and prevalence; adding routine CT screening to HIV treatment using rectal samples from men who have sex with men (MSM).

Conclusion

We found that CT screening in general sexually active people aged 15-24, military recruits, high school students, pregnant women aged 15-30, women attending STD and abortion clinics, people entering jail, detention, FSWs, and MSM has health economic value. Due to the different prevalence of CT, diversities of economic conditions, and varying screening costs among different populations and different countries, regions, or settings, no uniform and standard screening strategies are currently available. Therefore, each country should consider its local condition and the results of health economic evaluations of CT screening programs in that country to develop appropriate CT screening strategies.

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.

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 .

Interventions to Increase Male Attendance and Testing for Sexually Transmitted Infections at Publicly-Funded Family Planning Clinics

PURPOSE

We assessed the impact of staff, clinic, and community interventions on male and female family planning client visit volume and sexually transmitted infection testing at a multisite community-based health care agency.

METHODS

Staff training, clinic environmental changes, in-reach/outreach, and efficiency assessments were implemented in two Family Health Center (San Diego, CA) family planning clinics during 2010-2012; five Family Health Center family planning programs were identified as comparison clinics. Client visit records were compared between preintervention (2007-2009) and postintervention (2010-2012) for both sets of clinics.

RESULTS

Of 7,826 male client visits during the time before intervention, most were for clients who were aged <30 years (50%), Hispanic (64%), and uninsured (81%). From preintervention to postintervention, intervention clinics significantly increased the number of male visits (4,004 to 8,385; Δ = +109%); for comparison clinics, male visits increased modestly (3,822 to 4,500; Δ = +18%). The proportion of male clinic visits where chlamydia testing was performed increased in intervention clinics (35% to 42%; p < .001) but decreased in comparison clinics (37% to 33%; p < .001). Subgroup analyses conducted among adolescent and young adult males yielded similar findings for male client volume and chlamydia testing. The number of female visits declined nearly 40% in both comparison (21,800 to 13,202; -39%) and intervention clinics (30,830 to 19,971; -35%) between preintervention and postintervention periods.

CONCLUSIONS

Multilevel interventions designed to increase male client volume and sexually transmitted infection testing services in family planning clinics succeeded without affecting female client volume or services.

Urban African American women's explanations of recurrent chlamydia infections

OBJECTIVE

To explore reasons for the high chlamydia recurrence rate among African American (AA) urban women.

DESIGN

In this phenomenological qualitative study, young AA urban women with recurrent chlamydia were interviewed using open-ended questions guided by the conceptual framework of the health belief model (HBM).

SETTING

The study was set in three urban health clinics in Michigan.

PARTICIPANTS

Ten African American adolescents, age 15 to 19, participated.

METHODS

In face-to-face recorded interviews, participants shared their personal experiences and viewpoints on what led to their recurrent chlamydia infections. The data were transcribed and analyzed through hand coding and NVivo 8 a qualitative software package.

RESULTS

Overall, participants demonstrated significant knowledge deficits about the seriousness of chlamydia compared to other sexually transmitted infections (STIs). After reinfection, their perceived susceptibility changed: condom use was seen as beneficial and perceived barriers to condom use diminished as participants gained a new sense of empowerment.

CONCLUSION

Chlamydia infection among African American urban adolescents is nearly 3 times that of the general population. Lack of education is still a barrier to STI prevention. Participants reported a desire to receive counseling and support from the health care staff. A STI care model that includes education, counseling, and regular screening of high-risk adolescents should be considered. Further research, using the HBM or similar theoretical models, are needed to gauge the success of any planned or implemented intervention.

Cost-effectiveness analysis of Chlamydia trachomatis screening via internet-based self-collected swabs compared with clinic-based sample collection

BACKGROUND

Although the Centers for Disease Control and Prevention have recommended population-wide Chlamydia trachomatis screening of sexually active women less than 26 years of age, more than half of sexually active young women are not routinely screened. A Website (IWTK, www.iwantthekit.org), was developed in 2004 to promote home-based sample collection.

METHODS

A decision tree was designed to model a hypothetical cohort of 10,000 women per year who order an internet-based C. trachomatis screening kit. We compared the incremental cost-effectiveness of 2 screening strategies: self-sampling via the IWTK website, and traditional, clinic-based screening by the same cohort of women who used IWTK. Probabilities and costs were estimated for each node in the decision tree. Estimates were derived from primary data, published data, and unpublished health data.

RESULTS

The internet-based screening strategy prevented 35.5 more cases of pelvic inflammatory disease and saved an additional $41,000 in direct medical costs as compared with the clinic-based screening strategy.

CONCLUSION

Our model estimates demonstrated that an internet-based, self-swab screening strategy was cost-effective compared with the traditional, clinic-based screening strategy. Assuming that the popularity of the use of the internet as a resource for information about healthcare and sexually transmitted infections leads to an increased use of IWTK, the public health benefit of this cost-effective strategy will be even greater.

Identifying relationships between high-risk sexual behaviors and screening positive for chlamydia and gonorrhea in school-wide screening events

BACKGROUND

This article describes a school-wide sexually transmitted infection (STI) screening to identify adolescent high-risk sexual behaviors, STI history/incidence, and presence of chlamydia and gonorrhea, and examines relationships between high-risk behaviors and screening positive for chlamydia and gonorrhea in an alternative high school setting.

METHODS

School-wide chlamydia and gonorrhea education and screening was provided to 869 adolescents; 226 males and 282 females 14-20 years (mean age = 17.07) consented to urine screening. Relationships were examined between screening positive, history of STIs, and high-risk sexual behaviors.

RESULTS

A majority (69%) of the adolescents consented to screening: 17.76% (92) had a history of STI; 8.83% (46) tested positive at screening. More females than males tested positive (p = .001). Significant relationships existed between history of STIs and ≥ 4 sexual partners (p = .0022), no condom use (p = .06), and sexual intercourse in last 3 months (p = .03).

CONCLUSIONS

School-Based Health Center (SBHC) screening was well accepted by students and staff. Sexually transmitted infection history was correlated with all identified high-risk sexual behaviors supporting the need for in-depth assessment, counseling, and testing of adolescents wherever they present for care. This study also provides an example of the role SBHCs can play in the national strategy to control chlamydia and gonorrhea in adolescents.

A randomized trial of home versus clinic-based sexually transmitted disease screening among men

BACKGROUND

Preventing sexually transmitted diseases (STD) such as Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) remains a public health challenge. The U.S. Preventive Services Task Force suggests STD screening among men will likely lead to a decrease in infection rates of women. However, innovative approaches are necessary to increase the traditionally low rates of male screening. The purpose of this study is to compare the acceptability and effectiveness of home-based versus clinic-based urine screening for CT and GC in men.

METHODS

We conducted a randomized clinical trial of 200 men aged 18 to 45 years who reside in St. Louis, MO. Men were enrolled via telephone and randomly assigned to receive a free urine CT/GC screening kit either in-person at the research clinic or to have it mailed to the participant's preferred address. Participants completed questionnaires at baseline and 10 to 12 weeks postenrollment. The primary outcome was whether STD screening was completed.

RESULTS

Sixty percent (120/200) completed STD screening. Men assigned to home-based screening were 60% more likely to complete screening compared with clinic-based screening (72% vs. 48%, RRadj = 1.6, 95% CI = 1.3, 2.00). We identified 4 cases of CT or GC in the home-based group compared with 3 cases of CT in the clinic group. Men who completed screening were significantly more likely to be white, younger, and college educated.

CONCLUSIONS

Home-based screening for CT and GC among men is more acceptable than clinic-based screening and resulted in higher rates of screening completion. Incorporating home-based methods as adjuncts to traditional STD screening options shows promise in improving STD screening rates in men.

Chlamydia prevalence among women and men entering the National Job Training Program: United States, 2003-2007

OBJECTIVE

To analyze 5-year prevalence trends in Chlamydia trachomatis infections among high-risk young men and women aged 16 to 24 years entering the National Job Training Program, where universal screening is required.

METHODS

Entrance exams conducted in over 100 National Job Training Program centers from 2003 to 2007 were considered. Women provided cervical specimens tested using either a DNA hybridization probe (PACE 2, Gen-Probe, San Diego, CA) or a strand displacement amplification test (SDA, BD ProbeTec ET, Becton-Dickinson, Sparks, MD). In the absence of a pelvic exam, urine specimens were tested using SDA. PACE 2 testing was performed predominately from 2002 to 2005; from 2005 to 2007, SDA was used. All male testing was conducted using SDA on urine specimens. Chlamydia prevalence trends were assessed for women and men, using logistic regression models. Adjusted odds ratios (AOR), 95% confidence intervals (CI), and P-values were calculated.

RESULTS

Approximately 15,000 women and 30,000 men were screened annually for chlamydia. Among both sexes, adjusted prevalence declined significantly from 2003 to 2007. In 2003, crude prevalence among women was 9.9%; in 2007, prevalence was 13.7%. However, after controlling for covariates, including increasingly sensitive tests, the model indicated a significant declining prevalence trend (AOR: 0.95, CI: 0.93-0.97, 4.6% decrease in odds per year). Among men, crude prevalence in 2003 was 8.4%; in 2007, prevalence was 8.3%; after controlling for possible confounding, a significant decline in prevalence was also detected (AOR: 0.98, CI: 0.96-0.99, 1.9% decrease in odds per year).

CONCLUSIONS

In a relatively stable, high-risk population of young women and men, adjusted chlamydia prevalence declined from 2003 to 2007. Test technology plays a critical role in interpreting rates and should be considered whenever chlamydia rates are examined.

The cost-effectiveness of screening men for Chlamydia trachomatis: a review of the literature

BACKGROUND

An important consideration in determining whether to implement or continue a program to screen men for chlamydia is its cost-effectiveness. A review of the literature on the cost-effectiveness of screening men for chlamydia could potentially provide guidance.

METHODS

An Ovid Medline search was conducted for articles published between 1990 and July 2007 using terms for cost, chlamydia, and male. This search returned 175 articles; 25 were retained after eliminating those not relevant to cost-effectiveness studies of male chlamydia screening. We added 4 articles that were in-press or are published in this issue, for a total of 29. These articles were examined for common themes and their results summarized.

RESULTS

The reviewed studies examined both proactive and opportunistic screening and included screening of risk groups and of the general population. Some older studies included enzyme immunoassays; more recent studies featured nucleic acid amplification assays. Six studies used dynamic transmission models. Fourteen studies analyzed male and female chlamydia screening interventions. Several contained sufficient data to examine the cost-effectiveness of male screening compared with female screening. Male screening was preferred to expanded female screening in 1 study. In other studies, combined male and female screening programs were cost-saving.

CONCLUSIONS

Studies comparing chlamydia screening in men with chlamydia screening in women may be the most useful for guidance to programs. The studies which compare the 2 generally have found that screening men from the general population is not preferred to screening women from the general population, although 1 study found that screening of men from risk groups can be cost-effective compared with screening women from the general population.

Reproductive tract complications associated with Chlamydia trachomatis infection in US Air Force males within 4 years of testing

BACKGROUND

Chlamydia trachomatis (CT) is a common sexually transmitted infection for which young, sexually active persons are at highest risk. Health consequences such as orchitis/epididymitis, prostatitis, infertility, and urethral stricture have been described among CT-infected males, although not all of these are indisputably linked to CT. Current literature lacks population-based studies needed to examine these associations on a larger scale, to evaluate the true risk of developing complications after a CT infection. The US Air Force contains a large population of young, sexually active males, making it suitable for conducting such a study.

METHODS

We conducted a retrospective cohort study between 2001 and 2005 comparing the incidence of orchitis/epididymitis, prostatitis, infertility, and urethral stricture among male Air Force members with and without prior CT infections. Cumulative incidence rates were calculated and Cox proportional hazard models were generated to evaluate the risk of developing complications and to adjust for potential confounders.

RESULTS

Among 17,764 men enrolled in the study, 913 (5.14%) experienced a reproductive tract outcome. Among CT-positive men, cumulative incidences of orchitis/epididymitis, prostatitis, infertility, and urethral stricture were 4.28%, 1.41%, 1.27%, and 0.13%, respectively. Orchitis/epididymitis [Hazard ratio (HR) = 1.38 (1.13-1.70)] and "any" outcome [HR = 1.37 (1.16-1.61)] were positively associated with CT; infertility was marginally associated [HR = 1.36 (0.93-2.00)].

CONCLUSIONS

Overall, the burden of reproductive health outcomes among Air Force males is small. Significant associations were observed between CT and both orchitis/epididymitis and any outcome; a larger cohort or longer follow-up may have detected a significant association between CT and infertility.