Our findings show that a significant increase in GC/CT testing occurred after the 2003 guidelines were published. To our knowledge, ours is the first study to estimate this change in testing rate over time. Despite the increase, less than 17% of men enrolling after 2003 were tested upon enrollment into care and less than 50% were ever tested. Only 10% of first testing episodes in MSM included rectal and/or oral sites.
A recent study of HIV clinics in 6 US cities found similar evidence of low GC/CT screening rates among MSM; the annual GC/CT screening rate for the calendar year 2005 was approximately 21%.[11
] Our study identifies that there is a low rate of enrollment screening among non-MSM men and confirms the finding that testing rates are low among MSM. The low rate of extragenital site testing among MSM may be particularly problematic as a majority of incident GC/CT in this population may be missed when only urethral testing is performed.[4
The low rate of GC/CT testing in men contrasts rates of other HIV-related health maintenance practices such as rates of P. jirovecii
and M. avium
prophylaxis which were >85% among men during 1999–2007 in our clinic (data not shown). The reason(s) for this contrast are not clear. HIV providers may be unaware or unconvinced by the literature supporting widespread GC/CT screening in men or dissuaded by sexually transmitted infection (STI) associated stigma or by the types of specimens to be collected. Providers at our clinic are generally aware of high STI rates in Baltimore.[13
] Four negative clinical trials versus only one positive trial of community-wide GC/CT treatment to prevent HIV transmission in Africa may have convinced some providers that screening is not useful.[15
HIV providers may be overwhelmed by the required number of routine health maintenance tasks. Operational interventions such as pop-up reminders and standing orders are potential solutions which have shown effectiveness in pneumococcal vaccination programs.[20
] Sixty-six percent of women enrolled 1996–2006 in our cohort were tested at least once,[23
] with this higher rate for women potentially reflecting the effect of engagement in cervical cancer screening.
Providers may test sparingly, but they may be targeting their testing at men who give histories of recent high-risk exposures. Our finding that high CD4 count was associated with a positive result but not with being tested provides preliminary evidence that persons with high CD4 count could represent an overlooked risk group. This conclusion must be taken with caution given the low number of positive tests in our sample, but a plausible mechanism exists in that men with higher CD4 counts may be more likely to engage in high-risk sex. High CD4 was found to be an independent risk factor for GC/CT in a Los Angeles HIV-infected MSM cohort but not in a New England cohort.[4
] Our results indicate younger HIV-infected men are more likely to have GC/CT as well as to be tested for it, although 5 infections (23%) occurred in men over 40 years old. These age-related findings are similar among women in our cohort.[23
Emerging literature supporting screening includes evidence that brief, clinically-feasible counseling by providers can reduce high-risk sexual behaviors.[24
] Targeting such counseling toward men with incident GC/CT should help reduce HIV transmission. Also, screening high risk heterosexual men from the general population for GC/CT has demonstrated favorable cost-effectiveness when the reduction of GC/CT related sequelae among female partners is considered.[3
In April 2009, enrollment GC/CT screening was added to the U.S. Department of Health and Human Services HIV/AIDS Bureau’s list of clinical performance measures.[26
] Continued government (Ryan White Program) funding to clinics may depend on meeting performance standards. Future studies will be needed to determine if this increases screening rates.
A limitation of our study is that we cannot distinguish screening tests from symptom-prompted tests. We suspect that the majority of tests within 90 days of enrollment were performed for screening. While an increase in symptom-prompted testing after 2003 could explain some of the 2.7 fold increase in the rate of ever-being tested, this does not affect the conclusion that the overall screening rate since 2003 is low, and, at best, less than 50%. Some of our patients may have been tested at other locations (e.g. city public health clinics), however these data are generally not available to our providers when deciding whether to screen. Our data reflect a single HIV clinic with a high prevalence of African Americans and IDUs. Nonetheless our data may be representative of many urban HIV clinics.
In summary, this analysis demonstrates low GC/CT enrollment testing and overall testing of HIV-infected men despite a response to national guidelines. Future studies should examine the efficacy and cost-effectiveness of increasing screening of all men and/or of certain high-risk groups as well as barriers to increasing screening. Meanwhile, efforts may be focused on better disseminating the existing evidence and on operational interventions which facilitate screening in clinical practice.