Primary Care and Chronic Illness

Please see the comment in the attached letter. 

This comment is for CBE #3755e STI Testing for People with HIV.  Some members of the committee questioned the rationale for including all three STIs into one measure; not including an option for providers to achieve a score if they did not test for all three STIs; and whether introducing mandatory or routine STI testing for persons with HIV would cause unintentional stigma and discrimination. These concerns are directly addressed by the current Centers for Disease Control and Prevention (CDC) Sexually Transmitted Infections Treatment Guidelines (CDC STI Guidelines, 2021). Per the STI Screening of Persons with HIV Infection in HIV Care Settings, section of the CDC STI Guidelines:

“At the initial HIV care visit, providers should screen all sexually active persons for syphilis, gonorrhea, and chlamydia, and perform screening for these infections at least annually during the course of HIV care. 

“More frequent screening for syphilis, gonorrhea, and chlamydia (e.g., every 3 or 6 months) should be tailored to individual risk and the local prevalence of specific STIs.” 

The HIV Medicine Association of the Infectious Diseases Society of America (updated 2022) similarly recommends performing syphilis, gonorrhea, and chlamydia testing at least annually in asymptomatic persons with HIV with the option to repeat every 3–6 months in asymptomatic persons if risk of acquisition is high. 

These recommendations notably include screening for all three infections and doing so will reduce the potential for unintentional stigma or discrimination by making it clear it is a recommendation for all persons with HIV, not needing any specific risks or behaviors to be asked about or disclosed. While more than annual testing may be beneficial for some persons, the measure is more conservative to represent the recommendations applicable to all persons with HIV. 

In addition, members questioned the correlation between annual testing and better patient outcomes. Chlamydia, gonorrhea, and syphilis cause substantial health losses. Among adults with chlamydia or gonorrhea, these losses are most pronounced among women, for whom length of infection increases risk of pelvic inflammatory disease (Li 2023). Annual screening could reduce the length of infection, thus reducing the risk of pelvic inflammatory disease. Similarly, among adults with syphilis, models estimate lower health losses among men who have sex with men (MSM) than in men who have sex with women because MSM have higher rates of screening and treatment (Lee 2023). The benefits of screening go beyond the patient as well. It's estimated that about 20% of HIV infections among MSM are caused by bacterial STIs because they double the probability of acquisition or transmission of HIV; thus routine screening for these infections among people with HIV benefits their partners as well. 

The measure testing performed well in the measure score validity and data element reliability. 

Considering these recommendations, I encourage the committee to vote “high” for the evidence and validity of the CBE #3755e STI Testing for People with HIV.

I am writing on behalf of the HIV Medicine Association in support of the STI Testing for People with HIV Measure that is stewarded by the Health Resources and Services Administration (3755e STI Testing).  HIVMA represents nearly 5,000 working on the frontlines of the HIV epidemic in communities across the country. 

We urge the committee to support the proposed measure to help address the low rates of STI screening for people with HIV and to encourage STI screening in line with the Centers for Diseases Control and Prevention’s screening recommendations for chlamydia, gonorrhea and syphilis for people with HIV.

Identifying and treating STIs in people with HIV is important for their health and to reduce the risk of onward transmission of HIV. People with HIV who are not virally suppressed have an increased risk of transmitting HIV when they have an STI. 

We offer specific comments below related to the concerns raised during the committee’s July meeting when the measure was considered. 

Evidence:  Committee members raised concerns that the measure did not address the differences in the recommendations for STI screen for people who are sexually active versus those who are not. We know that sexual history is not being taken consistently by providers and that providers are not well trained in taking a proper and sensitive history and that patients are not always forthcoming with their sexual history because of stigma. Given these limitations, expert guidelines recommend at least annual screening in a population that is burdened with high rates of STIs, like people with HIV, makes clinical and public health sense. 

Validity:  Committee members raised concerns that the validity testing conducted did not explore the correlation between annual testing and reduced infection rates or better patient outcomes. We urge the committee to consider that the Centers for Disease Control and Prevention STI guidelines, and the HIVMA Guidance for the Primary Care of Persons with HIV recommend at least annual screening for syphilis, gonorrhea and chlamydia for people with HIV. It is difficult to quantify preventive benefits and given the increased vulnerability of people with HIV and the implications for new HIV infections, it is important to incentivize more clinicians to conduct at least annual screening for STIs in people with HIV.  

Usability:  Concerns were raised that the measure may contribute to the stigma associated with HIV.  Not adopting quality measures that help prevent STI and HIV transmissions by addressing performance gaps in guidelines and clinical practice for HIV and other STIs will perpetuate HIV and STI-associated stigma, including among the provider community.  In addition, when STI testing is operationalized like annual testing, it normalizes STI testing and further destigmatizes it.

Thank you for considering our comments. Please do not hesitate to reach out to the HIVMA executive director Andrea Weddle at [email protected] with any questions or if we can be of assistance.  NOTE:  Submitted by Andrea Weddle with permission from Dr.  Cespedes.