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Patterns in Receipt and Source of STI Testing Among Young People in the United States, 2013–2019

Open AccessPublished:June 09, 2022DOI:https://doi.org/10.1016/j.jadohealth.2022.04.014

      Abstract

      Purpose

      Rates of sexually transmitted infections (STIs) among adolescents and young adults (15–24) continue to increase. Limited national information exists about the frequency and source of STI testing among this population.

      Methods

      We performed a cross-sectional analysis of National Survey of Family Growth data from 2013–2019 to describe patterns in STI testing and assess associations with individual characteristics.

      Results

      We found that non-Hispanic Black women, non-Hispanic Black and Hispanic men, and individuals with public insurance are more likely to receive an STI test. The two sexes have different sources of care for STI testing and publicly supported providers provide the bulk of services to marginalized populations.

      Discussion

      STI testing frequencies of this age group fall below what national guidelines suggest. Multiple socioecological factors may affect the likelihood that a young person receives an STI test. All providers should be supported and encouraged to provide confidential and unbiased STI care.

      Keywords

      Implications and Contribution
      This nationally representative study highlights inequities in young people's receipt of sexually transmitted infections testing by sex, race and ethnicity, family income level, insurance status, and source of care. By understanding these patterns, policies, and programs to reduce STI cases can be better tailored and modified for the population.
      See Related Editorial on p.521
      Young people (aged 15–24 years) experience a disproportionate burden of sexually transmitted infections (STIs), acquiring almost half of new reported infections [
      Adolescents and Young Adults. Centers for Disease Control and Prevention.
      ]. Barriers to accessing quality STI services are identified as one reason for the higher and increasing STI incidence [
      • Tilson E.C.
      • Sanchez V.
      • Ford C.L.
      • et al.
      Barriers to asymptomatic screening and other STD services for adolescents and young adults: Focus group discussions.
      ]. A recent study found that the Affordable Care Act led to an increase in the proportion of young women obtaining STI care from private providers and a corresponding decrease served by publicly supported clinics [
      • Frost J.J.
      • Mueller J.
      • Pleasure Z.H.
      Trends and differentials in receipt of sexual and reproductive health services in the United States: Services received and sources of care, 2006–2019.
      ]. Still, there is a little information on STI testing patterns among the population [
      • Sharma A.
      • Wang L.Y.
      • Dunville R.
      • et al.
      HIV and sexually transmitted disease testing behavior among adolescent sexual minority males: Analysis of pooled youth risk behavior survey data, 2005–2013.
      ,
      • Mustanski B.
      • Moskowitz D.A.
      • Moran K.O.
      • et al.
      Factors associated with HIV testing in teenage men who have sex with men.
      ,
      • Cuffe K.M.
      • Newton-Levinson A.
      • Gift T.L.
      • et al.
      Sexually transmitted infection testing among adolescents and young adults in the United States.
      ] and limited attention on STI testing inequities. We use nationally representative data to describe recent patterns in receipt of STI testing for sexually active people aged 15–24 years.

      Materials & Methods

      Background & study sample

      We used the data from the National Survey of Family Growth (NSFG) continuously collected between September 2013 and September 2019 [
      ,
      ,
      ]. The NSFG is a nationally representative household survey of females and males (The NSFG does not ask each respondent directly about their sex assigned at birth or gender identity. A respondent receives either the female or male questionnaire depending on how they or a family member answered a question about sex assigned at birth of household members during the household report. We use female, male, women, and men throughout to match the language used by the NSFG. There is no information in the NSFG about non-binary individuals.) administered by the National Center for Health Statistics, which oversamples non-Hispanic Black and Hispanic individuals, and adolescents [
      ]. We limited our analytic sample to sexually-active (Sexually active is defined as sex with opposite or same-sex partner(s) in the 12 months preceding the interview. Male respondents were asked specifically about oral or anal sex with a male partner in all survey periods, and additionally asked about any other “sexual experience” with a male partner in 2015–2019; female respondents were asked to report oral sex or any other “sexual experience” with a female partner in all survey periods.) respondents aged 15–24. The National Center for Health Statistics Institutional Review Board's protections of human subjects approved data collection methods and dissemination of the public-use dataset.

      Variable definitions

      The primary outcome was receiving an STI test in the last 12 months, measured in both the computer-assisted personal interviews (CAPI) and audio computer-assisted self-interviews (ACASI). ACASI is designed to improve reporting of sensitive behaviors [
      • Lindberg L.
      • Scott R.H.
      Effect of ACASI on reporting of abortion and other pregnancy outcomes in the U.S. National survey of family growth.
      ]. We also examined the source of STI test measured through CAPI (further source of care variable definitions available in Table A1) [
      • Frost J.J.
      • Mueller J.
      • Pleasure Z.H.
      Trends and differentials in receipt of sexual and reproductive health services in the United States: Services received and sources of care, 2006–2019.
      ]. Demographic covariates include categorical measures of age, race and ethnicity, household poverty level, type of sexual partnerships, number of sexual partners, and insurance (see details in Table A1). All measures used are self-reported.

      Analysis

      We describe patterns in receipt and source of STI test in the last 12 months among sexually-active young people aged 15–24. We estimate associations with these outcomes and the demographic covariates using logistic regression and chi-squared. We applied 6-year sampling weights for the pooled 2013–2019 period.

      Results

      Receipt of STI test by demographics

      During 2013–2019, 53% of women aged 15–24 reported receiving an STI test compared to 22% of men in the combined CAPI and ACASI measure (Table 1). Receipt of STI test varied by survey mode and respondents' characteristics. For men, the reported STI testing rates were consistently higher via ACASI than CAPI. We use the combined CAPI and ACASI measure for the remainder of this logistic regression analysis.
      Table 1Results from unadjusted logistic regressions predicting receipt of STI test reported using CAPI or ACASI among U.S. women and men ages 15–24 who had any sexual partner in the last 12 months, National Survey of Family Growth, 2013–2019
      CharacteristicFemale (N = 3,508)Male (N = 3,054)
      CAPIACASICAPI + ACASICAPIACASICAPI + ACASI
      %OR (95% CI)%OR (95% CI)%OR (95% CI)%OR (95% CI)%OR (95% CI)%OR (95% CI)
      Overall474553122022
      Age group
       15–17 (ref)261.0291.0331.061.0121.0141.0
       18–24502.9 (2.1–3.9)
      Significantly different from the reference group in respective category at p < .05.
      482.2 (1.6–3.1)
      Significantly different from the reference group in respective category at p < .05.
      572.6 (2.0–3.5)
      Significantly different from the reference group in respective category at p < .05.
      142.3 (1.5–3.6)
      Significantly different from the reference group in respective category at p < .05.
      211.9 (1.3–2.6)
      Significantly different from the reference group in respective category at p < .05.
      241.9 (1.4–2.6)
      Significantly different from the reference group in respective category at p < .05.
      Income level, % of FPL
       <100% (ref)511.0511.0601.0131.0221.0251.0
       100%–249%470.8 (0.7–1.1)420.7 (0.6–0.9)
      Significantly different from the reference group in respective category at p < .05.
      520.7 (0.6–1.0)
      Significantly different from the reference group in respective category at p < .05.
      121.0 (0.7–1.4)200.9 (0.6–1.2)230.9 (0.7–1.3)
       ≥250%420.7 (0.5–0.9)
      Significantly different from the reference group in respective category at p < .05.
      430.7 (0.6–0.9)
      Significantly different from the reference group in respective category at p < .05.
      490.6 (0.5–0.8)
      Significantly different from the reference group in respective category at p < .05.
      121.0 (0.7–1.4)180.7 (0.5–1.0)210.8 (0.6–1.1)
      Race and ethnicity
       Non-Hispanic white (ref)451.0421.0511.081.0131.0151.0
       Non-Hispanic Black601.8 (1.4–2.4)
      Significantly different from the reference group in respective category at p < .05.
      622.3 (1.7–2.9)
      Significantly different from the reference group in respective category at p < .05.
      702.2 (1.7–2.9)
      Significantly different from the reference group in respective category at p < .05.
      233.3 (2.2–4.9)
      Significantly different from the reference group in respective category at p < .05.
      363.6 (2.6–5.0)
      Significantly different from the reference group in respective category at p < .05.
      413.8 (2.7–5.3)
      Significantly different from the reference group in respective category at p < .05.
       Hispanic430.9 (0.7–1.2)390.9 (0.7–1.2)490.9 (0.7–1.2)151.9 (1.3–2.8)
      Significantly different from the reference group in respective category at p < .05.
      231.9 (1.4–2.7)
      Significantly different from the reference group in respective category at p < .05.
      272.0 (1.5–2.8)
      Significantly different from the reference group in respective category at p < .05.
       Non-Hispanic other or multiple race410.8 (0.6–1.2)471.2 (0.9–1.7)501.0 (0.7–1.4)121.5 (0.8–2.5)191.5 (0.9–2.5)211.5 (0.9–2.4)
      Type of sexual partners
      Type of partner(s) in last 12 months.
       Opposite sex partner (ref)461.0441.0531.0121.0181.0211.0
       Same sex partner491.1 (0.9–1.4)491.3 (1.0–1.6)
      Significantly different from the reference group in respective category at p < .05.
      561.2 (0.9–1.4)252.6 (1.6–4.3)
      Significantly different from the reference group in respective category at p < .05.
      413.1 (2.0–4.8)
      Significantly different from the reference group in respective category at p < .05.
      432.9 (1.9–4.4)
      Significantly different from the reference group in respective category at p < .05.
      Number of partners
      Type of partner(s) in last 12 months.
       One partner (ref)421.0391.0481.091.0131.0161.0
       Multiple partners551.7 (1.3–2.1)
      Significantly different from the reference group in respective category at p < .05.
      562.0 (1.6–2.4)
      Significantly different from the reference group in respective category at p < .05.
      621.8 (1.4–2.2)
      Significantly different from the reference group in respective category at p < .05.
      182.2 (1.6–3.0)
      Significantly different from the reference group in respective category at p < .05.
      292.8 (2.1–3.8)
      Significantly different from the reference group in respective category at p < .05.
      332.6 (2.0–3.5)
      Significantly different from the reference group in respective category at p < .05.
      Insurance coverage
       Private insurance/military (ref)451.0441.0511.0111.0181.0201.0
       Medicaid/public521.3 (1.1–1.6)
      Significantly different from the reference group in respective category at p < .05.
      491.3 (1.0–1.6)591.4 (1.1–1.7)
      Significantly different from the reference group in respective category at p < .05.
      161.5 (1.0–2.1)
      Significantly different from the reference group in respective category at p < .05.
      241.5 (1.1–2.0)
      Significantly different from the reference group in respective category at p < .05.
      291.6 (1.2–2.1)a
       Uninsured420.9 (0.7–1.1)420.9 (0.7–1.3)501.0 (0.7–1.3)121.1 (0.7–1.6)211.2 (0.8–1.7)241.3 (0.9–1.8)
      ACASI = audio computer-assisted self-interviews; CAPI = computer-assisted personal interview; FPL = federal poverty level; STI = sexually transmitted infection.
      a Significantly different from the reference group in respective category at p < .05.
      b Type of partner(s) in last 12 months.
      A higher proportion of individuals aged 18–24 years received STI testing (odds ratio OR = 2.6, 57% women; OR = 1.9, 24% men) than those aged 15–17 (33% women, 14% men). For women, those with a family income of over 100% of the federal poverty level (FPL) (OR = 0.7, 52% FPL 100%–249%; OR = 0.6, 49% FPL ≥250%) were less likely to receive an STI test compared to those with a family income below 100% of FPL (60%). More than two-thirds of non-Hispanic Black women (OR = 2.2, 70%) received an STI test, a proportion significantly higher than that of non-Hispanic White women (51%). For men, both non-Hispanic Black (OR = 3.8, 41%) and Hispanic (OR = 2.0, 27%) men received STI tests at higher proportions than non-Hispanic White men (15%). Men who had same sex partners (43%) were more likely to receive an STI test compared to those with only opposite sex partners (OR = 2.9, 21%). The share of women and men receiving an STI test was greater among those with multiple partners (OR = 1.8, 62% women; OR = 2.6, 33% men) than those who had one partner (48% women, 16% men). A larger proportion of individuals with Medicaid (OR = 1.4, 59% women; OR = 1.6, 29% men) received STI testing than those with private insurance (51% women, 20% men).

      Receipt of STI test by source of care

      In 2013–2019, 66% of women and 39% of men who obtained an STI test (CAPI measure for women, combined measure for men) were served by private providers (Table 2). In contrast, a higher percentage of men (43%) relied on publicly supported clinics than women (28%). Eighteen percent of men visited some other place for care, while only 7% of women did. Use of publicly supported clinics for STI testing was most common among those who were uninsured (55% women, 57% men), men who had Medicaid or other public insurance (58%), men under 100% of the FPL (58%), and non-Hispanic Black (53%) and Hispanic men (50%).
      Table 2Weighted number and percent distribution, of U.S. women and men ages 15–24 who had any sexual partner in the last 12 months receiving any STI test
      Responses to CAPI question are used for females. Combined responses to CAPI + ACASI are used for males.
      in the prior year, National Survey of Family Growth, 2013–2019
      CharacteristicsFemale (N = 1,715)Male (N = 762)
      Weighted No. receiving STI services (in 000s)Type of provider visitedWeighted No. receiving STI services (in 000s)Type of provider visited
      Private providerPublicly supported clinicOther
      Other providers include hospital inpatient care, emergency room, urgent care center, in-store clinic, employer-based clinic, or some other place.
      Private providerPublicly supported clinicOther
      Other providers include hospital inpatient care, emergency room, urgent care center, in-store clinic, employer-based clinic, or some other place.
      %%%%%%
      Overall6,113662872,900394318
      Age group
       15–1750363297319344818
       18–245,609662772,581404218
      Income level, % of FPL
      Statistically significant Pearson chi-squared test at p < .05.
      Statistically significant Pearson chi-squared test at p < .05.
       <100%2,11560328705265816
       100%–249%2,09067285983404317
       ≥250%1,908712271,212473320
      Race/ethnicity
      Statistically significant Pearson chi-squared test at p < .05.
      Statistically significant Pearson chi-squared test at p < .05.
       Non-Hispanic white3,130732251,020542719
       Non-Hispanic Black1,219543610794345313
       Hispanic1,26559356840295021
       Non-Hispanic other or multiple race498622712246344818
      Type of sexual partners
      Type of partner(s) in last 12 months.
       Opposite sex partner4,481672762,525404118
       Same sex partner1,62962299375325315
      Number of partners
      Responses to CAPI question are used for females. Combined responses to CAPI + ACASI are used for males.
      Statistically significant Pearson chi-squared test at p < .05.
      Statistically significant Pearson chi-squared test at p < .05.
       One partner3,438712361,193413622
       Multiple partners2,669593481,707384815
      Insurance coverage
      Statistically significant Pearson chi-squared test at p < .05.
      Statistically significant Pearson chi-squared test at p < .05.
       Private insurance/military3,406751971,676503219
       Medicaid/public1,94161336750315811
       Uninsured76536559474165727
      ACASI = audio computer-assisted self-interviews; CAPI = computer-assisted personal interview; FPL = federal poverty level.
      a Statistically significant Pearson chi-squared test at p < .05.
      b Responses to CAPI question are used for females. Combined responses to CAPI + ACASI are used for males.
      c Other providers include hospital inpatient care, emergency room, urgent care center, in-store clinic, employer-based clinic, or some other place.
      d Type of partner(s) in last 12 months.

      Discussion

      STI testing is a vital component of quality sexual health care for young people [
      • Barrow R.Y.
      • Ahmed F.
      • Bolan G.A.
      • Workowski K.A.
      Recommendations for providing quality sexually transmitted Diseases clinical services, 2020.
      ]. Our study found that STI testing is substantially below Centers for Disease Control and Prevention guidelines for testing of sexually-active women [
      ]. Testing rates are also low for men, which may be due to national guidelines not recommending STI testing for all sexually-active young men. The lack of comparability between the ACASI and CAPI measures of STI testing among males raises concerns for measurement quality; future analyses should incorporate the ACASI measures when possible. Our findings that non-Hispanic Black women, non-Hispanic Black and Hispanic men, and individuals with public insurance are more likely to receive an STI test align with previous patterns observed [
      • Goyal M.K.
      • Witt R.
      • Hayes K.L.
      • et al.
      Clinician adherence to recommendations for screening of adolescents for sexual activity and sexually transmitted infection/human immunodeficiency virus.
      ,
      • Wiehe S.E.
      • Rosenman M.B.
      • Wang J.
      • et al.
      Chlamydia screening among young women: Individual- and provider-level differences in testing.
      ]. More work should be done to investigate these trends further.
      These data show that private providers play a central role in providing STI testing for young people and should be supported in these efforts. Still, publicly supported clinics should be expanded to continue serving young people who face barriers to care. In addition, to provider and systems-level reasons why someone may not be screened for STIs, individual-level factors, such as desire to not be tested and concerns about confidentiality, may affect STI testing [
      • Keller L.
      Adolescents deserve better: What the biden-harris administration and congress can do to bolster young people’s sexual and reproductive health.
      ,
      • Hoopes A.J.
      • Benson S.K.
      • Howard H.B.
      • et al.
      Adolescent perspectives on patient-provider sexual health communication: A qualitative study.
      ]. Providers need to be sensitive to these issues and support young people in feeling they have safe access to STI testing.

      Acknowledgments

      This study was made possible by an anonymous donor. The views expressed are those of the authors and do not necessarily reflect the positions and policies of the donor.

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        Clinician adherence to recommendations for screening of adolescents for sexual activity and sexually transmitted infection/human immunodeficiency virus.
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        Chlamydia screening among young women: Individual- and provider-level differences in testing.
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        Adolescents deserve better: What the biden-harris administration and congress can do to bolster young people’s sexual and reproductive health.
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      Linked Article

      • Sexually Active Young People are Inadequately Screened for Sexually Transmitted Infection
        Journal of Adolescent HealthVol. 71Issue 5
        • Preview
          US Preventive Services Task Force guidelines recommend asymptomatic gonorrhea and chlamydia screening of sexually experienced adolescents and young adult women [1]. The current US Preventive Services Task Force does not see sufficient evidence to support a recommendation for screening of men who have sex with women exclusively. However, the Centers for Disease Control and Prevention (CDC) recommends screening for men who have sex with men, transgender persons depending on their anatomy, and allows for routine screening of heterosexual young men “in high prevalence clinical settings such as adolescent clinics, correctional facilities, STI/sexual health clinic” [2].
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