STIs Among Youth During COVID-19 May Be the Tip of the Iceberg

Editor’s note: This is part of our Teen Health Week blog post series, which focuses on understanding and addressing the unique health needs of adolescents. We invite you to check back for new posts or to follow along for updates on Twitter at @PolicyLabCHOP.

When the COVID-19 pandemic forced schools to close last spring and the mayor issued a stay-at-home order for Philadelphia, adolescents and young adults found themselves in a completely new social environment. Many were living in close quarters with family, had limited access to transportation and faced a host of new stressors. Under these unfamiliar circumstances, getting to their health care provider for a sexually transmitted infection (STI) test was a potentially challenging prospect.

To understand how the pandemic affected youth access to STI testing services, our team conducted a study that explored STI-related outcomes at the 31 urban, suburban and rural clinics in Children’s Hospital of Philadelphia’s (CHOP) Primary Care Network. We compared the number of STI tests that were performed in these clinics during the pandemic (March-October 2020), as well as the number of tests that came back positive, to a similar time frame from the year prior (March-October 2019).

In the months immediately after the pandemic began, there was a dramatic reduction in the number of STI tests that were being performed. This change was expected, given limitations to in-person clinical services in the early weeks of the pandemic, but is still a concerning pattern. Additionally, as testing numbers fell, the proportion of tests indicating positive STI results began to rise. For example, in May 2020, nearly 1 in 5 chlamydia tests were coming back positive as compared to 1 in 10 tests in May 2019. Testing volume leveled out during the summer of 2020, but we saw another big drop in testing and a corresponding spike in test positivity in the fall, when demand for COVID-19 testing caused a nationwide shortage of the supplies needed to run STI tests.

While it is concerning that STI testing fell short during the pandemic, our study highlights the critical role that CHOP’s Primary Care Network plays in providing sexual health services for young people in Philadelphia. Despite several weeks of very limited in-person services at these clinics in the spring and a nationwide shortage of STI testing supplies in the fall, the CHOP network was still able to identify and treat nearly as many STI cases during the pandemic as they did the year before (529 cases pre-pandemic vs. 505 during the pandemic). This tells us that STIs remained prevalent during the pandemic and that STI testing services at CHOP continued to be a crucial resource for young people.

The combination of low testing volume and high test positivity rates during the pandemic suggests that providers were prioritizing patients with STI symptoms for testing, and that preventive screening was likely deferred for many asymptomatic patients. While focusing on testing and treating symptomatic patients is a strategy that several published guidelines have recommended for use during the pandemic, this practice could result in a significant number of undetected and untreated STI cases during this time, given that some STIs commonly occur without symptoms. A gap in testing and treatment for STIs could negatively impact the health of teens, as untreated infections can have serious and potentially lasting consequences, including pelvic inflammatory disease, infertility and increased susceptibility to HIV. 

Interruptions to sexual health services can impact the physical, mental and social wellness of teens. As health care systems continue to adapt to the new context presented by COVID-19, we need to invest in public health infrastructure for robust STI testing, treatment and prevention that can continue to function during a global pandemic. We should scale up community STI testing beyond clinical environments, incorporating innovative strategies around mobile testing, point-of-care testing and at-home self-testing to expand reach and accessibility. Health care system leaders should also be aware that the current data on STI rates is likely only the tip of the iceberg, given that many asymptomatic cases were potentially missed over the last year. Testing strategies will need to continue to expand post-pandemic to accommodate those who didn't access care during the pandemic.

Even in the face of unforeseen public health challenges, STI testing services remain a crucial piece of health infrastructure for young people. By finding creative solutions to improve access to STI testing amid COVID-19, we can help to keep the adolescents and young adults we serve at CHOP—and those seeking care across the country—safe, healthy and ready to thrive.

Stephen Bonett, PhD, RN, is a postdoctoral researcher with the Program on Sexuality, Technology, and Action Research (PSTAR) at the University of Pennsylvania School of Nursing and works with the adolescent health research team at PolicyLab at Children’s Hospital of Philadelphia.