STBBI prevention guide: Screening and diagnostic testing

On this page

• Screening and diagnostic testing
• Barriers to screening and testing
• References

Screening and diagnostic testing

STBBIs are frequently asymptomatic and can lead to serious complications if left undiagnosed or untreated. STBBI screening can raise awareness about signs and symptoms and provide an opportunity to discuss transmission and prevention measures. Screening increases the possibility of early detection and treatment, prevents or limits complications and lessens potential for transmission. Offer screening for STBBIs during routine care, with special attention to individuals who are more likely to be exposed. Age, gender, medical and sexual history as well as risk factors all inform the decision to screen. More frequent screening may be appropriate for individuals with ongoing risk factors. Screening for STBBIs can be normalized by using statements such as, “I always suggest testing for STBBIs. Are you okay with being tested?”

Many STBBIs have similar risk factors and transmission modes, and co-infection is common. If an STBBI is suspected, take the opportunity to screen for other STBBIs. Some STBBIs can cause inflammation, ulcers or both and increase the risk of HIV acquisition and transmission. Consult etiology specific guides for screening recommendations.

Clinical presentation and sexual and substance use history will help inform what specimens and samples to collect, from which anatomical sites (pharyngeal, genital, rectal) and the type of diagnostic tests. Depending on type of sexual activity, it may be necessary to collect specimens from multiple anatomical sites. Consult etiology specific guides or the STI-associated Syndromes guide for information on diagnostic tests.

Barriers to screening and testing

Underscreening for STBBIs results in missed opportunities to detect infection and thereby prevent transmission. There are several common STBBI screening barriers at the individual, healthcare and social level.

Individual barriers

• Underestimated personal risk
• Lack of awareness about STBBI screening and benefits
• Perception that STBBIs are minor health concerns
• Fear of invasive procedures such as urethral swabbing, speculum exam and venipuncture
• Self-consciousness about or previous negative experience with physical examination including genital, gynecological or rectal examination
• Shame, or internalized stigma about sexual or substance use practices
• Concerns around confidentiality
• Lack of access or poor connection to the health care system (e.g. men can be less likely to seek care)^{Footnote 1}
• Fear of disclosing sexual orientation, gender identity or gender-affirming surgery

Healthcare barriers

• Attitudes and behaviours, which lead to stigma^{Footnote 2Footnote 3}
• Lack of confidence in taking a sexual history, screening, testing and treating STBBIs
• Topic avoidance
• Lack of time due to competing medical priorities
• Lack of knowledge, preparedness or discomfort in providing:
  • Culturally safe care
  • Trauma-informed care
  • Care that recognizes syndemic conditions which place some populations at increased risk for STBBI^{Footnote 4Footnote 5Footnote 6Footnote 7Footnote 8}

Social barriers

• Stigma
• Discrimination
• Lack of anonymity in smaller communities

Individuals may be more vulnerable to STBBI and more likely to experience barriers to screening and testing if they have experienced^{Footnote 9}:

• Stigma
• Exclusion
• Marginalization
• Mental health issues
• Discrimination based on race, immigration status, sexual orientation, gender identity or substance use
• Involvement in sex work

These barriers and STBBI-related stigma can be reduced by offering screening in a person-centred, culturally safe and trauma-informed manner, as part of routine care. Motivational interviewing techniques can be used to identify barriers and the means to overcome them^{Footnote 10}.

The use of urine and other self-obtained specimens, like vaginal and rectal swabs, can increase acceptance of screening in persons reluctant to be examined. Self-testing (e.g., HIV self-testing) and point of care (POC) testing (where available) can also facilitate uptake of screening.

References