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Low sexual infection testing rates in large HIV-positive group.

Fewer than half of HIV-positive Californians using Medicaid or Medicare got tested for all three major sexually transmitted infections (STIs) in a single year-syphilis, chlamydia, and gonorrhea. (1) These rates are disappointing because US health authorities recommend yearly STI testing for sexually active people with HIV infection including gay or bisexual men with or without HIV.

Rates of gonorrhea, chlamydia, and syphilis infection rose across the United States in recent years, according to the Centers for Disease Control and Prevention (CDC). (2) People with HIV infection-especially gay or bisexual men-have particularly high rates of these three STIs. Because many people with HIV remain sexually active, they risk passing their STIs to sex partners or picking up new STIs from their sex partners. Having an STI also boosts chances of passing HIV to a sex partner or becoming infected with HIV.

For these reasons the CDC recommends yearly syphilis, gonorrhea, and chlamydia screening for all sexually active people with HIV including sexually active HIV-positive or negative gay or bisexual men. (3) People can have these STIs without having signs or symptoms of infection, so regular screening for these infections is sometimes the only way to detect them early and permit rapid treatment. Researchers in California conducted this study to determine STI testing rates in two groups with HIV-those using Medicaid for health insurance and those using Medicare.

How the study worked. Researchers based their analysis on medical insurance claims in the California Medicaid and Medicare systems for the year 2010. In the United States, Medicaid provides health insurance for low-income people and Medicare provides insurance for Social Security Disability Income recipients and everyone 65 years old or older, whatever their income.

The research team also used Medicaid and Medicare data to determine who had HIV infection in 2010 and to see which HIV-positive people got tested for three bacterial STIs in 2010: syphilis, chlamydia, and gonorrhea. They used these records to determine several traits of the people studied--sex (male or female), age, race and ethnicity, and whether they got care from an HIV specialist (a provider who treats 50 or more Medicaid or Medicare users with HIV). Finally the research team used a standard statistical method to see how these individuals traits may have affected STI testing rates.

What the study found. The study included 11,465 HIV-positive Californians (10,238 men and 1227 women) using Medicare in 2010 and 3142 people (2298 men and 844 women) using Medicaid. The Medicare group was 58% white and 19% black; the Medicaid group was 37% white and 34% black.

Among people using Medicaid, 74% got tested for syphilis in 2010, compared with 65% using Medicare (Figure 1). Much lower proportions of people got tested for chlamydia--46% using Medicaid and 30% using Medicare. About the same low proportions got tested for gonorrhea--45% on Medicaid and 29% on Medicare. Women got tested for syphilis much less often than men--68% versus 76% on Medicaid and 51% versus 67% on Medicare.

Almost everyone tested for chlamydia in 2010 (97%) got tested for gonorrhea on the same day. But testing overlaps proved less frequent among people tested for syphilis--only half of Medicaid users and one third of Medicare users got tested for chlamydia or gonorrhea on the same day they got tested for syphilis.

Statistical analysis that estimates the impact of individual factors on STI testing linked several factors to higher or lower testing chances--regardless of whatever other factors applied (Table 1). Women had lower chances of being tested for syphilis than men. Compared with whites, blacks on Medicare had higher chances of being tested for chlamydia or gonorrhea and Hispanics had higher chances of being tested for all three STIs. Compared with people under 40 years old, older people had lower chances of being tested for chlamydia or gonorrhea. Disabled people using Medicare had higher chances of being tested for all three STIs. And people whose providers saw 50 or more people with HIV got STI testing more than those whose providers saw fewer people with HIV.

What the findings mean for you. The United States has a "hidden epidemic" of sexually transmitted infections (STIs) including syphilis, chlamydia, and gonorrhea, according to the CDC. (4) Undetected STIs are dangerous for several reasons, particularly in people with HIV infection: (1) They can cause serious illness and sometimes even death. (2) They can be passed to sex partners. (3) They can make HIV infection worse.

This large study in California found that many HIV-positive people are not getting a yearly test for STIs, as the CDC recommends for sexually active people with HIV and for sexually active HIV-positive and negative gay or bisexual men.3 Only two thirds of HIV-positive people on Medicare and three quarters on Medicaid got tested for syphilis in the study year, 2010. Fewer than one third of HIV-positive Medicare users and fewer than half of Medicaid users got tested for chlamydia or gonorrhea.

Researchers who conducted this study urged HIV providers to make STI screening "a routine part of medical care" for people with HIV--and not to wait until symptoms of these infections appear before testing and treating. At the same time people with HIV who are having sex--no matter what their age or gender--should ask their provider about regular testing for sexually transmitted infections. This study produced strong evidence that people over 40 years old have a lower chance of getting these tests than younger people, and women have a lower chance than men.

The CDC Website has lots of practical information on syphilis, chlamydia, gonorrhea, and other sexually transmitted infections. Go to the links at reference 5 below.


(1.) Landovitz R, Gildner J, Leibowitz AA. Sexually transmitted infection testing of HIV-positive Medicare and Medicaid enrollees falls short of guidelines. Sex Transm Dis. 2018;45:8-13.

(2.) Centers for Disease Control and Prevention. Sexually transmitted disease surveillance 2015. Atlanta: US Department of Health and Human Services. 2016.

(3.) Workowski KA, Bolan GA. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015;64 (RR-03):1-137. Erratum in MMWR Recomm Rep. 2015;64:924.

(4.) Centers for Disease Control and Prevention. Tracking the hidden epidemics 2000. Trends in STDs in the United States.

(5.) Centers for Disease Control and Prevention. Sexually transmitted diseases (STDs).

For more details on the three infections considered in this study, go to the following links:

For chlamydia:

For gonorrhea:

For syphilis:

* Words in boldface are explained in the Technical Word List at the end of this issue.
Table 1.

Factors linked to lower or higher chances of STI testing in an HIV
group in 2010

Medicare group                    Medicaid group

Lower chance of syphilis          Lower chance of syphilis
testing                           testing

>> Female (versus male)           >> Female (versus male)

>> Age 55 or older                Lower chance of chlamydia
(versus under 40)                 and gonorrhea testing

Lower chance of chlamydia
and gonorrhea testing             >> Age 40-54 (versus under 40)

>> Age 40-54 (versus under 40)    >> Age 55 or older
                                  (versus under 40)
>> Age 55 or older
(versus under 40)                 Higher chance of syphilis

Higher chance of chlamydia        >> Cared for by provider seeing
and gonorrhea testing             50 or more
                                  HIV patients
>> Black race (versus white)
                                  Higher chance chlamydia
Higher chance of syphilis,        and gonorrhea testing
chlamydia, and gonorrhea

>> Hispanic (versus white)        >> Hispanic (versus white)

>> Disabled (versus not)

>> Cared for by provider
seeing 50 or more HIV patients

Figure 1. Two thirds to three quarters of HIV-positive
Californians got tested for syphilis in 2010. Much lower
proportions--under half-got tested for chlamydia or

Proportions of Californians with HIV who got tested
                for 3 STIs in 2010

                Medicaid     Medicare

Syphilis         65%          74%
Chlamydia        30%          46%
Gonorrhea        29%          45%

Note: Table made from bar graph.
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Title Annotation:ARTICLE 12
Publication:HIV Treatment: ALERTS!
Date:May 1, 2018
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