Sexually transmitted infections (STIs) are infections caused by pathogens spread through sexual contact. STIs can progress from an infection into a sexually transmitted disease (STD). Chlamydia, gonorrhea, syphilis and HIV are the most commonly screened for STIs in the US. The CDC STD Surveillance Data estimates that there were more than 2.5 million cases of chlamydia, gonorrhea, and syphilis in 2021.

We analyzed health insurance claims for 55 million Americans with employer-sponsored insurance to examine the utilization of STI screenings for chlamydia, gonorrhea, syphilis, HIV, herpes, trichomonas, hepatitis B, and chancroid.

Between 2016 and 2019, screenings for these STIs increased 19% overall - 36% for men and 14% for women (Figure 1). Utilization of screenings declined from 2019 to 2020. Because STI screening methods often involve a blood test or self-collection of bodily fluids that are generally performed in-person, the decrease is likely related to COVID-19, including lockdown protocols in the pandemic's early months. 

The incidence of STI infections is highest among adolescents and young adults, therefore, screening efforts have been focused on these age groups. From 2016 to 2020, young adults aged 18-24 and adults aged 25-34 had the highest use of all STI screenings. Women accounted for 80% of STI tests. Prior to the decline in utilization in 2020, women aged 18-24 had 423 STI screening visits per 1,000 enrollees in 2019 compared to men aged 18-24 who had 95 STI screening visits per 1,000 enrollees (Figure 2). For adults aged 25-34, women had 443 STI screening visits per 1,000 people in 2019 compared to men with 119 visits per 1,000 people. 

STI Screening by State

In 2019, STI screenings are highest in Washington, DC and New York at a rate of 348 and 219 screening visits per 1,000 people, respectively. STI screenings are lowest in Nebraska and Wyoming, at a rate of 63 and 66 screenings per 1,000 people, respectively (Figure 3).This is consistent with the CDC's STD Surveillance Report, which finds the largest share of STD cases in large cities and low incidence of STDs in Nebraska and Wyoming. Screening rates may vary geographically due to different incidence of STIs, awareness and information about STIs, stigma, and accessibility of testing.

Public and private clinics specializing in STI testing can improve access to screening and reduce the stigma around testing by providing information to the community to increase awareness. In Washington DC, for example, there are over 160 public clinics and 61 private STI clinic testing centers available. Moreover, many clinics offer free STI testing to residents. In New York City, sexual health clinics provide low to no cost services for all STIs. There are 380 public clinics and 106 private STI testing centers available in the New York City. In Nebraska there are 63 public clinics and 7 private STD clinics available for residents to receive testing, and in Wyoming there are 12 public clinics and 3 private STD clinics available in the state for residents to receive testing. While many of the STI screenings for people with health insurance through their employer may be performed as part of an office visit to a primary care provider of OB/GYN rather than at a public clinic, the proximity of STI testing centers could increase awareness and reduce stigma associated with STI screenings, especially for asymptomatic cases.

Although STI screening rates have increased since 2016, access and stigma remain a barrier to STI testing. To combat stigma, there are alternatives for STI testing such as at-home testing kits and lab tests, which can make a patient's experience more private. 

Limitations

These are trends for people with commercial health insurance obtained through their employer and may not reflect trends in other patient populations – Medicaid, Medicare, individual market, or uninsured. Some people with private health insurance may receive STI screenings at public clinics and not use their insurance to pay for these services. These patients' claims may not be included in the HCCI data.