By Marie Rosenthal, MS

There was a decline in testing and diagnoses of HIV and other sexually transmitted infections (STIs) in Southern California during the beginning of the COVID-19 pandemic, which improved as the pandemic continued, but is still not up to pre-pandemic levels, according to data from Kaiser Permanente, Southern California (KPSC).

“The COVID-19 pandemic has widely disrupted routine medical services, including sexual health and treatment services,” explained Jennifer Chang, MD, during her presentation at CROI 2022. She is a KPSC physician. 
Many of the reasons for the disruptions were obvious: The pandemic decreased face-to-face visits with physicians and patients were concerned about seeing healthcare providers. However, there was also a shortage in testing reagents and materials, as well as a reallocation of public health resources from STIs to COVID-19, according to Dr. Chang.

Dr. Chang and her group conducted a retrospective cohort study to find out how these disruptions affected the testing and diagnosis of HIV and several STIs: chlamydia, gonorrhea and syphilis. They did a comprehensive search of the KPSC electronic health records of patients ages 12 years and older, comparing Jan. 1 2017 to Feb. 29, 2020 with March 1, 2020 to Dec. 1, 2020. They reviewed laboratory test data from inpatient and outpatient records.

KPSC serves more than 4.7 million patients across nine counties in Southern California. The patients are enrolled through employer-provided, prepaid or federally sponsored insurance plans.

“This is a very large healthcare system that is both an insurer and a provider, and has membership that is racially and ethnically very diverse,” Dr. Chang noted.

“Our objective was to describe temporal trends and compare rates between pre-pandemic and pandemic periods in testing and diagnosis for HIV and STIs [from] 2017 through 2020, within the Kaiser Permanente Southern California system,” Dr. Chang said.

New HIV cases were identified through the KPSC HIV AIDS registry, which uses dates of diagnosis as reported by Kaiser Permanente providers to local county jurisdictions in conjunction with lab data confirming HIV infection. New chlamydia and gonorrhea cases were defined by a newly positive nucleic acid amplification test in the absence of any other positive test within the past 30 days or a positive test found after a negative test within the immediate past 30-day period. New syphilis cases were defined using a reverse sequence algorithm.

What the investigators found were “significant declines in STI testing and diagnoses for the first three months after March 2020, with subsequent increases by July 2020, but without a return to pre-pandemic baseline testing levels,” Dr. Chang said.

“Before the COVID-19 pandemic, there were really consistent increases in screening for all STIs and HIV;  but with the onset of the pandemic, we really saw sustained reductions in screening for all STIs and HIV during the first year of the pandemic, and there were really dramatic declines in the diagnoses of HIV and chlamydia,” she said at a press briefing.   

“Chlamydia testing rates from the year prior declined by 34%, while the diagnosis rate declined by 30%. Gonorrhea testing also declined 34%, yet the diagnosis rate for gonorrhea declined by only 5% from the prior time period,” Dr. Chang said. “For syphilis, testing declined by 24%, yet diagnosis actually increased by 19% compared to the prior time period. HIV testing declined by 29% from the period prior, with a 24% decrease in new diagnoses during the pandemic.”

The rates might be underreported for infections like HIV and chlamydia, which don’t have immediate symptoms and signs that would send a patient to the doctor, as gonorrhea and syphilis do.

Dr. Chang added: “We believe that these data overall suggest an underdiagnosis of HIV and chlamydia, which are often clinically latent or asymptomatic in nature.”

The strength of the study was in its size, which included more than 4 million participants, as well as its ethnically and economically diverse population. However, the data may not be generalizable to people without insurance or who are underinsured and may not have access to diagnostic and other healthcare services.

 “We can only find what we test for in clinically latent infections,” said Dr. Chang. “Declines in HIV and STI testing limit the ability to curb forward transmission of STIs, particularly for HIV.”

Novel strategies to incentivize testing are needed to end the HIV epidemic and prevent the substantial morbidity suffered from STIs, she said.