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Lillis R, Kuritzky L, Huynh Z, Arcenas R, Hansra A, Shah R, Yang B, Taylor SN. Outpatient sexually transmitted infection testing and treatment patterns in the United States: a real-world database study. BMC Infect Dis 2023; 23:469. [PMID: 37442964 DOI: 10.1186/s12879-023-08434-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 06/29/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) are the most common notifiable sexually transmitted infections (STIs) in the United States. Because symptoms of these infections often overlap with other urogenital infections, misdiagnosis and incorrect treatment can occur unless appropriate STI diagnostic testing is performed in clinical settings. The objective of this study was to describe STI diagnostic testing and antimicrobial treatment patterns and trends among adolescent and adult men and women with lower genitourinary tract symptoms (LGUTS). METHODS We analyzed insurance claims data from the IBM® MarketScan® Research Databases. Patients included were between 14 and 64 years old with LGUTS as determined by selected International Classification of Diseases codes between January 2010 and December 2019. Testing of STIs and relevant drug claims were captured, and distribution of testing patterns and drug claims were described. RESULTS In total, 23,537,812 episodes with LGUTS (87.4% from women; 12.6% from men) were analyzed from 12,341,154 patients. CT/NG testing occurred in only 17.6% of all episodes. For episodes where patients received treatment within 2 weeks of the visit date, 89.3% received treatment within the first 3 days (likely indicating presumptive treatment), and 77.7% received it on the first day. For women with pelvic inflammatory disease and men with orchitis/epididymitis and acute prostatitis, ≤ 15% received CT/NG testing, and around one-half received antibiotic treatment within 3 days. CONCLUSIONS Our study revealed low CT/NG testing rates, even in patients diagnosed with complications commonly associated with these STIs, along with high levels of potentially inappropriate presumptive treatment. This highlights the need for timely and accurate STI diagnosis in patients with LGUTS to inform appropriate treatment recommendations.
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Affiliation(s)
- Rebecca Lillis
- Section of Infectious Diseases, Department of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA, 70119, USA.
| | - Louis Kuritzky
- Department of Community Health and Family Medicine, University of Florida, Gainesville, FL, USA
- Clinical Faculty, University of Central Florida/Hospital Corporation of America Family Medicine Residency, Gainesville, FL, USA
| | - Zune Huynh
- Roche Molecular Systems, Inc, Pleasanton, CA, USA
| | | | | | - Roma Shah
- Roche Molecular Systems, Inc, Pleasanton, CA, USA
| | - Baiyu Yang
- Roche Molecular Systems, Inc, Pleasanton, CA, USA
| | - Stephanie N Taylor
- Section of Infectious Diseases, Department of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA, 70119, USA
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Villamagna AH, Beste LA, Borgerding J, Lowy E, Hauser RG, Ross D, Maier MM. Testing and Case Rates of Gonorrhea, Chlamydia, Syphilis, and HIV among People with Substance Use Disorders in the Veterans Health Administration. J Addict Med 2023; 17:387-393. [PMID: 37579093 DOI: 10.1097/adm.0000000000001134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Little is known about national patterns of sexually transmitted infection (STI) testing and infections among people with substance use disorders (SUDs). METHODS This study used a national retrospective analysis of people with SUDs receiving healthcare in the Veterans Health Administration in 2019 (N = 485,869). We describe testing rates, test positivity, and case rates for gonorrhea, chlamydia, syphilis, and HIV among individuals with alcohol, opioid, cocaine, and noncocaine stimulant use disorders in a national cohort of Veterans Health Administration patients. RESULTS Test and case rates for all STIs were highest among people with noncocaine stimulant use. People with alcohol use disorder had the lowest testing rates but intermediate incidence for all STIs. People with multiple SUDs had higher incidence of all STIs than those with single SUDs. Mental health diagnoses and houselessness were common. The HIV test positivity was 0.14% to 0.36% across SUD groups. CONCLUSIONS Sexually transmitted infection testing rates between SUD groups were discordant with their respective case rates. High STI rates in people with SUDs suggest a need for more comprehensive testing, particularly for those with noncocaine stimulant use and those with comorbid houselessness or mental health diagnoses.
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Affiliation(s)
- Angela Holly Villamagna
- From the Division of Infectious Diseases, Department of Medicine, Oregon Health and Science University, Portland, OR (AHV, MMM); Division of General Internal Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, WA (LAB); General Medicine Service, VA Puget Sound Health Care System, Seattle, WA (LAB, JB, EL); Pathology and Laboratory Medicine Department, VA Connecticut Health Care System, New Haven, CT (RGH); Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT (RGH); Infectious Diseases Section, VA Portland Health Care System, Portland, OR (MMM); Department of Health Services, University of Washington School of Public Health, Seattle, WA (EL); Office of Specialty Care Services, Veterans Health Administration, Washington, DC (DR)
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Schirmer P, Sharma A, Lucero-Obusan C, Oda G, Holodniy M. Trends in Follow-up Testing Among Patients Positive for Chlamydia and Gonorrhea in the Veterans Health Administration, 2013 to 2019. Sex Transm Dis 2023; 50:258-264. [PMID: 36649595 PMCID: PMC10097481 DOI: 10.1097/olq.0000000000001765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 01/03/2023] [Indexed: 01/19/2023]
Abstract
BACKGROUND The Centers for Disease Control and Prevention (CDC) recommends testing patients with chlamydia (CT)/gonorrhea (GC) for other sexually transmitted infections (STIs) and repeating CT/GC testing 3 to 12 months later. We assessed repeat CT/GC testing and testing for HIV/syphilis in accordance with CDC guidelines in the US Veterans Health Administration. METHODS Molecular laboratory testing for CT/GC during January 1, 2013-December 31, 2020 was retrieved from Veterans Health Administration data sources. Patients were evaluated for syphilis, HIV, and repeat CT/GC testing within 1 year after a positive CT/GC test result. Differences of CT/GC-positive patients associated with receiving recommended testing were assessed using χ2 /Fisher exact tests. RESULTS A total of 41,630 of 1,005,761 CT (4.1%) and 17,649 of 1,013,198 GC (1.7%) results were positive. Median ages of positive CT/GC patients were 29 and 36 years, respectively. Repeat testing rates for CT/GC within 90 to 119 days were 3.9% and 2.9%, and rates within 90 to 365 days were 32.8% and 34.7%, with 8.6% and 15% being positive again, respectively. Guideline-compatible repeat testing in known HIV-positive patients nearly doubled (75.7% for CT and 67.8% for GC). The CDC-recommended HIV testing was performed for 72.4% and 65.5% CT and GC first positives, respectively, whereas syphilis testing was completed for 66.5% and 60.5% CT and GC, respectively. Compared with 25- to 34-year-old patients with CT or GC, those younger than 25 years had higher odds of guideline-discordant repeat testing but had lower odds of not receiving HIV/syphilis testing. CONCLUSIONS Nearly two-thirds of patients did not receive recommended repeat testing, and nearly one-third were not tested for HIV/syphilis. Veterans Health Administration providers may benefit from additional education on CDC-recommended sexually transmitted infection guidelines and testing recommendations.
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Affiliation(s)
| | - Aditya Sharma
- From the VHA Public Health National Program Office, Palo Alto
| | | | - Gina Oda
- From the VHA Public Health National Program Office, Palo Alto
| | - Mark Holodniy
- From the VHA Public Health National Program Office, Palo Alto
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA
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Katon JG, Rodriguez A, Yano EM, Johnson AM, Frayne SM, Hamilton AB, Miller LJ, Williams K, Zephyrin L, Patton EW. Research Priorities to Support Women Veterans' Reproductive Health and Health Care Within a Learning Health Care System. Womens Health Issues 2023; 33:215-221. [PMID: 36702724 DOI: 10.1016/j.whi.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 12/15/2022] [Accepted: 12/19/2022] [Indexed: 01/26/2023]
Affiliation(s)
- Jodie G Katon
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Adriana Rodriguez
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Elizabeth M Yano
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California; Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California; Department of Health Policy and Management, Jonathan and Karen Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California
| | - Amanda M Johnson
- Office of Women's Health, U.S. Department of Veterans Affairs, Washington, District of Columbia
| | - Susan M Frayne
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, California; Stanford University School of Medicine, Stanford, California
| | - Alison B Hamilton
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California; Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Laura J Miller
- Office of Mental Health and Suicide Prevention, Women's Mental Health, U.S. Department of Veterans Affairs, Washington, District of Columbia; Loyola Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois
| | | | | | - Elizabeth W Patton
- Division of Gynecology, Department of Surgery, VA Boston Healthcare System, Boston, Massachusetts; Department of Obstetrics and Gynecology, Boston University School of Medicine, Boston, Massachusetts.
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Htet KZ, Lindrose AR, O'Connell S, Marsh J, Kissinger P. The burden of chlamydia, gonorrhea, and syphilis in older adults in the United States: A systematic review. Int J STD AIDS 2023; 34:288-298. [PMID: 36626249 DOI: 10.1177/09564624221149770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Increases in life expectancy, the availability of sexual performance enhancing medication, and changes in sexual partnering suggest that sexually transmitted infections (STIs) among older persons could be on the rise, yet there have been relatively few studies examining STIs in this demographic. Our systematic review aimed to further characterize the incidence and prevalence of chlamydia, gonorrhea, and syphilis, along with associated risk factors among older adults (45 years or older) in the United States. METHODS We searched five electronic databases (PubMed, Embase, Cinahl, Web of Science, and Global Health) for data published from inception to January 2021. The retrieved articles were screened based on eligibility criteria, and subsequent review of relevant article bibliographies was conducted. RESULTS Of 4748 articles identified, 23 studies met our inclusion criteria and one additional article was identified through bibliography review. Of the 23 included articles, only 3 (11.5%) were focused exclusively on evaluating STIs in an older population. We found prevalence to be the following ranges: syphilis (0-18%), chlamydia (0-14.2%) and gonorrhea (0-15%). Few studies specifically investigated risk factors in this demographic. CONCLUSIONS The understudied burden of STIs in the older adult population substantiates the need to recognize issues surrounding sexuality in this demographic.
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Affiliation(s)
- Kyaw Zin Htet
- 12255Tulane University - School of Medicine, 2339 Saint Thomas St New Orleans LA 70112-2632, US
| | - Alyssa R Lindrose
- 25812Tulane University - School of Public Health and Tropical Medicine, New Orleans, LA US
| | - Samantha O'Connell
- 25812Tulane University - School of Public Health and Tropical Medicine, New Orleans, LA US
| | - James Marsh
- 12255Tulane University - School of Medicine, 2339 Saint Thomas St New Orleans LA 70112-2632, US
| | - Patricia Kissinger
- 25812Tulane University - School of Public Health and Tropical Medicine, New Orleans, LA US
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Kukhta OP, Aleksandruk OD, Neiko OV, Romash IB, Romash IR, Romash NI, Reevu N. CLINICAL EFFICACY OF TREATMENT OF WOMEN WITH CHRONIC RECURRENT UROGENITAL CHLAMYDIA INFECTION. Pol Merkur Lekarski 2023; 51:239-244. [PMID: 37589109 DOI: 10.36740/merkur202303109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
OBJECTIVE Aim: To to increase the efficacy of the treatment of women diagnosed with complicated urogenital chlamydia infection based on the study of the immune status, clinical and pathogenetic features of the course, development and implementation of pathogenetically substantiated therapy methods. PATIENTS AND METHODS Materials and methods: Laboratory diagnostics of chlamydia infection was conducted with the use of direct immunofluorescence, enzyme immunoassay and cytological method. The dynamics of clinical symptoms was studied in the patients of Group I (64 women) who received Wobenzym in combination with Doxycycline and Group II (64 women) who were treated with conventional therapy (CT). RESULTS Results: Clinical effectiveness of the treatment of women in Groups I and II was analyzed. The treatment according to our developed method was well tolerated by all the patients. No manifestations of the disease exacerbation which could be associated with the inclusion of these drugs in the comprehensive treatment were noted. The insignificant effectiveness of our treatment in the examined patients with complicated urogenital chlamydia infection in Groups I and II was distributed as follows: only 1 (1.56%) woman (Group I) had an insignificant improvement in clinical manifestations after the treatment according to our method. An insignificant improvement in the clinical manifestations after the treatment with conventional therapy (Group II) was observed in 4 women constituting 6.25%. Unfortunately, a small percentage of women in Groups I and II with no changes in clinical symptoms after the treatment was observed. In particular, the absence of treatment effectiveness was noted in 3 (4.69%) women after the application of our method and in 6 women (9.38%) who were treated by the conventional therapy. Therefore, these women were prescribed an additional course of treatment. CONCLUSION Conclusions: The dynamics of clinical symptoms was found to be significantly more pronounced and fast in the patients of Group I compared to the patients in Group II who were treated with conventional therapy.
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Affiliation(s)
- O P Kukhta
- IVANO-FRANKIVSK NATIONAL MEDICAL UNIVERSITY, IVANO-FRANKIVSK, UKRAINE
| | - O D Aleksandruk
- IVANO-FRANKIVSK NATIONAL MEDICAL UNIVERSITY, IVANO-FRANKIVSK, UKRAINE
| | - O V Neiko
- IVANO-FRANKIVSK NATIONAL MEDICAL UNIVERSITY, IVANO-FRANKIVSK, UKRAINE
| | - I B Romash
- IVANO-FRANKIVSK NATIONAL MEDICAL UNIVERSITY, IVANO-FRANKIVSK, UKRAINE
| | - I R Romash
- IVANO-FRANKIVSK NATIONAL MEDICAL UNIVERSITY, IVANO-FRANKIVSK, UKRAINE
| | - N I Romash
- IVANO-FRANKIVSK NATIONAL MEDICAL UNIVERSITY, IVANO-FRANKIVSK, UKRAINE
| | - Neogi Reevu
- MEDICA SUPERSPECIALITY HOSPITAL, KOLKATA, WEST BENGAL INDIA
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Beste LA, Keddem S, Borgerding J, Lowy E, Gardella C, McFarland L, Comstock E, Fonseca GA, Van Epps P, Ohl M, Hauser RG, Ross D, Maier MM. Sexually Transmitted Infection Testing in the National Veterans Health Administration Patient Cohort During the Coronavirus Disease 2019 Pandemic. Open Forum Infect Dis 2022; 9:ofac433. [PMID: 36514443 PMCID: PMC9452156 DOI: 10.1093/ofid/ofac433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 08/21/2022] [Indexed: 12/15/2022] Open
Abstract
Background We performed a retrospective study of chlamydia, gonorrhea, syphilis, and human immunodeficiency virus (HIV) testing in the Veterans Health Administration (VHA) during 2019-2021. Methods We determined the annual number of chlamydia, gonorrhea, syphilis, and HIV tests from 2019 through 2021 using electronic health record data. We calculated rates by age, birth sex, race, census region, rurality, HIV status, and use of preexposure prophylaxis. Results The VHA system experienced a 24% drop in chlamydia/gonorrhea testing, a 25% drop in syphilis testing, and a 29% drop in HIV testing in 2020 versus 2019. By the conclusion of 2021, testing rates had recovered to 90% of baseline for chlamydia/gonorrhea, 91% for syphilis, and 88% for HIV. Declines and subsequent improvements in sexually transmitted infection (STI) testing occurred unequally across age, sex, race, and geographic groups. Testing for all 4 STIs in 2021 remained below baseline in rural Veterans. Excluding those aged <25 years, women experienced a steeper decline and slower recovery in chlamydia/gonorrhea testing relative to men, but quicker recovery in HIV testing. Asian Americans and Hawaiian/Pacific Islanders had a steeper decline and a slower recovery in testing for chlamydia/gonorrhea. Black and White Veterans had slower recovery in HIV testing compared with other race groups. People living with HIV experienced a smaller drop in testing for syphilis compared with people without HIV, followed by a near-total recovery of testing by 2021. Conclusions After dramatic reductions from 2019 to 2020, STI testing rates returned to near-baseline in 2021. Testing recovery lagged in rural, female, Asian American, Hawaiian/Pacific Islander, and Black Veterans.
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Affiliation(s)
- Lauren A Beste
- Correspondence: Lauren A. Beste, MD, MSc, VA Puget Sound Health Care System,1660 S Columbian Way, Seattle, WA 98108 ()
| | - Shimrit Keddem
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Veterans Affairs Center for Health Equity Research and Promotion, Philadelphia, Pennsylvania, USA
- Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Joleen Borgerding
- Health Services Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, Washington, USA
| | - Elliott Lowy
- Health Services Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, Washington, USA
- University of Washington School of Public Health, Seattle, Washington, USA
| | - Carolyn Gardella
- Gynecology Service, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
- Department of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Lorenzo McFarland
- Office of Specialty Care Services, Veterans Health Administration, Washington, District of Columbia, USA
| | - Emily Comstock
- Department of Infectious Diseases, Baltimore Veterans Affairs Medical Center, Baltimore, Maryland, USA
| | - Giuseppe Allan Fonseca
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Puja Van Epps
- Division of Infectious Diseases, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- Veterans Affairs Northeast Ohio Healthcare System,Cleveland, Ohio, USA
| | - Michael Ohl
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs, Iowa City, Iowa, USA
- Department of Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Ronald G Hauser
- Pathology and Laboratory Medicine Department, Veterans Affairs Connecticut Healthcare, New Haven, Connecticut, USA
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - David Ross
- Office of Specialty Care Services, Veterans Health Administration, Washington, District of Columbia, USA
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Keddem S, Maier M, Gardella C, Borgerding J, Lowy E, Chartier M, Haskell S, Hauser RG, Beste LA. Gonorrhea and Chlamydia Testing and Case Rates Among Women Veterans in the Veterans Health Administration. J Gen Intern Med 2022; 37:706-713. [PMID: 36042092 PMCID: PMC9481769 DOI: 10.1007/s11606-022-07578-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 04/01/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND United States (US) rates of sexually transmitted infection (STI) in women, especially gonorrhea and chlamydia, have increased over the past decade. Women Veterans may be at increased risk for STIs due to high rates of sexual trauma. Despite the availability of effective diagnostic tests and evidence-based guidelines for annual screening among sexually active women under age 25, screening rates for gonorrhea and chlamydia remain low in the US and among Veterans. OBJECTIVE To examine patient characteristics and health system factors associated with gonorrhea and chlamydia testing and case rates among women Veterans in the Veterans Health Administration (VHA) in 2019. DESIGN We performed a retrospective cohort study of all women Veterans in VHA care between January 1, 2018, and December 31, 2019. PARTICIPANTS Women Veteran patients were identified as receiving VHA care if they had at least one inpatient admission or outpatient visit in 2019 or the preceding calendar year. KEY RESULTS Among women under age 25, 21.3% were tested for gonorrhea or chlamydia in 2019. After adjusting for demographic and other health factors, correlates of testing in women under age 25 included Black race (aOR: 2.11, CI: 1.89, 2.36), rural residence (aOR: 0.84, CI: 0.74, 0.95), and cervical cancer screening (aOR: 5.05, CI: 4.59, 5.56). Women under age 25 had the highest infection rates, with an incidence of chlamydia and gonorrhea of 1,950 and 267 cases/100,000, respectively. Incidence of gonorrhea and chlamydia was higher for women with a history of military sexual trauma (MST) (chlamydia case rate: 265, gonorrhea case rate: 97/100,000) and those with mental health diagnoses (chlamydia case rate: 263, gonorrhea case rate: 72/100,000.) CONCLUSIONS: Gonorrhea and chlamydia testing remains underutilized among women in VHA care, and infection rates are high among younger women. Patient-centered, system-level interventions are urgently needed to address low testing rates.
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Affiliation(s)
- Shimrit Keddem
- Corporal Michael J. Crescenz Veterans Affairs (VA) Medical Center, VA Center for Health Equity Research and Promotion (CHERP), Philadelphia, PA, USA.
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Marissa Maier
- Division of Infectious Diseases, Department of Medicine, Oregon Health & Science University, Portland, OR, USA
- VA Portland Health Care System, Veterans Health Administration (VHA), Portland, OR, USA
| | - Carolyn Gardella
- VA Puget Sound Health Care System, Veterans Health Administration (VHA), Seattle, WA, USA
- Department of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, WA, USA
| | - Joleen Borgerding
- VA Puget Sound Health Care System, Veterans Health Administration (VHA), Seattle, WA, USA
| | - Elliott Lowy
- VA Puget Sound Health Care System, Veterans Health Administration (VHA), Seattle, WA, USA
| | - Maggie Chartier
- Office of Specialty Care Services, Veterans Health Administration, Washington, DC, USA
| | - Sally Haskell
- Pathology and Laboratory Medicine Department, Veterans Affairs Connecticut Health Care, West Haven, USA
- Yale University School of Medicine, New Haven, CT, USA
| | - Ronald G Hauser
- Pathology and Laboratory Medicine Department, Veterans Affairs Connecticut Health Care, West Haven, USA
- Yale University School of Medicine, New Haven, CT, USA
| | - Lauren A Beste
- VA Puget Sound Health Care System, Veterans Health Administration (VHA), Seattle, WA, USA
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
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