New research found that sexually transmitted infection (STI) and HIV testing declined at the onset of the COVID-19 pandemic, while there was an increase in positive test rates.

Published in AIDS Patient Care and STDs, the study—conducted by the Boston Medical Center—aimed to understand how the pandemic affected infection screening in safety-net settings given rising STI and HIV cases and the significant and inequitable impacts of the COVID-19 pandemic on already marginalized populations.

In April, 2020, the Centers for Disease Control and Prevention (CDC) recommended the use of telemedicine for STI-related visits and prioritizing symptomatic treatment, while deferring routine asymptomatic screening when in-person evaluations were not possible. These changes prompted concern about a potential large-scale drop off in HIV and STI prevention and testing and downstream consequences.

It is now estimated that over 150,000 tests may have been missed nationally during the first few months of the pandemic, and researchers found that STI and HIV testing did not return to original testing rates for a full year.

Reasons for Testing Decline

The decline in testing observed in the study was likely driven by public health recommendations designed to reduce COVID-19 transmission, including limitations on in-person visit volume. The height of the pandemic was associated with a decrease in routine visits where asymptomatic screening is often completed, including preventive care visits, elective appointments, and visits for other chronic conditions. Testing of symptomatic patients and, in many cases, presumptive treatment without testing, were prioritized over routine screening.

The study took place at Boston Medical Center located in Suffolk County, which has the highest incidence of chlamydia and infectious syphilis of any county in Massachusetts. Researchers collected data on chlamydia, gonorrhea, syphilis, and HIV testing rates and results from an existing BMC hospital-wide database. The study was defined in three periods: pre-pandemic (July 2019-Feburary 2020), peak pandemic (March 2020-May 2020), and post peak (June 2020 – August 2021).

There was a significant drop in testing rates in March of 2020. STI testing during the peak of the pandemic was 42% of the pre-pandemic baseline period and peak-pandemic HIV testing rates were 43% the rates of pre-pandemic rates.

“High levels of STI transmission and lack of adequate testing leads to future infectious disease crises so early diagnosis is critical in reducing the individual and community impacts of these infections and requires ready access to laboratory testing for symptomatic individuals and robust asymptomatic screening,” says lead author Tyler Lescure, MD, internal medicine resident at Boston Medical Center. “The results of this study highlight the insufficient screenings and lack of healthcare experienced by vulnerable populations during the pandemic.”

Further reading: 4 Step Plan Could ID More Sexually Transmitted Infections

Impacts on Underserved Populations

Prior to the COVID-19 pandemic, Black and Hispanic populations experienced inequitable burdens of new STIs compared to non-Hispanic white peers driven by inequitable access to health care and sexual networks characteristics and not by differences in sexual behavior. The impact on HIV/STI testing in areas where patients face disproportionate baseline HIV/STI rates rooted in structural inequalities, limited resources needed for telemedicine, and impacts of the pandemic itself is not currently known. The consequences of inadequate STI and HIV screening may be more profound in already vulnerable communities due to the compounding effects of poverty, structural racism, and stigma.

Researchers believe the results of the study should be used as a call to action for providers to introduce alternatives to traditional office-based STI and HIV testing and for the reinvestment in public health infrastructure.