Don't Forget These Infectious Disease Screenings

Medscape

5 days ago

For years, public health experts have encouraged primary care physicians (PCPs) to screen for infectious diseases as well as cancers, heart disease risk factors, diabetes, and more. Many assessments for risk-based infections such as hepatitis B (Hep B), hepatitis C (Hep C), HIV, and bacterial sexually transmitted infections (STIs) were convoluted and constantly changing, resulting in significant effort to figure out if patients require testing.
PCPs were tasked with asking lots of questions about behavior and risk, and patients were responsible for disclosing risk. What's more, Centers for Disease Control and Prevention (CDC) screening guidelines didn't necessarily align with guidance from the US Preventive Services Task Force. With all the confusion, it is a wonder that anyone got screened at all.
'Hepatitis C used to have targeted risk-based screening where you had to remember this laundry list of risk factors that included receipt of a blood donation before 1992 or a history of injection drug use,' explained H. Nina Kim, MD, MSc, professor, Department of Medicine, Division of Allergy & Infectious Diseases, adjunct professor, Health Services & Population Health, University of Washington Medicine in Seattle.
Thankfully, since 2020 the CDC has recommended universal Hep C screening for those older than 18 years.
The shift toward universal screening for some diseases removes part of the burden of identifying risk factors from PCPs. Now, some public health groups have stepped in to help support PCPs and raise awareness of screening recommendations for Hep B, Hep C, HIV, and STIs, as well as treatment and prevention.
Universal Screening for Hep B
'This might be one of the most underused screening tests that we have in the US,' said Chari Cohen, DrPH, MPH, president of the Hepatitis B Foundation. Estimates say there are up to 2.4 million people with Hep B in the United States, but there simply isn't much known about the disease, and many people assume it isn't an issue in the United States.
Since the CDC changed their Hep B screening recommendation from risk-based to universal in 2023 (every adult tested at least once in their lifetime) Cohen has been grateful and hopeful that detection and treatment for Hep B will improve. The newer Hep B strategy is a simpler, less stigmatizing one that doesn't burden providers with assessing risk.
There is no cure for Hep B, but there is treatment, which depends on infection type (early or long term) and liver health, among other factors. Cohen pointed to a tool, Hepatitis B Management: Guidance for the Primary Care Provider, developed recently by a multidisciplinary panel of experts designed to help PCPs address Hep B.
'We're at a critical time for hepatitis B,' she said. 'We have a very robust research pipeline, including phase 2 and 3 clinical trials for what might be functional cures,' Cohen stated, adding, 'But if we don't have people diagnosed and in care, then nobody is going to be able to take advantage of that.'
Cohen noted that universal screening also helps identify people who don't have a current chronic infection but have been exposed to Hep B. They face risk for reactivation and will benefit long term from knowing their status. 'If they undergo any kind of immune-suppressing drugs, for chemotherapy, for example, or for long-term steroid use due to orthopedic issues, they could have a reactivated hepatitis B infection, which could be deadly,' she said.
Simplified Screening and Treatments for Hep C
The CDC recommendations for Hep C screening have been universal for those older than 18 years since 2020, and this spring, the fight against the disease was bolstered with a new tool. The University of Washington Infectious Diseases Education & Assessment Program launched its Hepatitis C Online's HCV Test and Cure Module on April 30, 2025. It is a 4- to 5-hour interactive module that helps providers develop proficiency in screening and diagnosing hepatitis C.
'Hep C treatment has really become streamlined and simplified,' said Kim, who is also the associate editor of Hepatitis C Online, and noted the benefits of newer reflex diagnostic testing.
'We are talking about being able to cure someone of Hep C in as short as 8 or 12 weeks,' she said. Combination antivirals are well tolerated and very effective, yet some misconceptions about treatment being difficult persist. That said, Kim is optimistic that with the use of technology, like standardized notifications in electronic health records and other tools that prime the PCP, there is an opportunity to change the landscape.
HIV Care Has Come a Long way
While the CDC recommends all patients between the ages of 13 years and 64 years get tested for HIV at least once as part of routine care, there still are not enough regular screenings performed to end the epidemic. As many as 1.2 million people in the United States have HIV, and 13% of those people don't know they have the virus.
Too often, according to Jason Halperin, MD, MPH, director of Specialty Services at DAP Health in Palm Springs, California, people wrongly assume that their HIV status is negative because they think their physician screens them for HIV while doing other blood or laboratory work. This is what is behind the 'Know Your Status' campaign to encourage people to learn, not assume, their HIV status.
'Universal HIV screening has been shown to be more effective than risk-based screening strategies based on evidence that risk-based screening alone fails to identify a substantial proportion of people with HIV,' Kim explained.
What's more, higher rates of case identification with universal screening suggest that the recommendations are easier for physicians to remember than risk-based ones, she said.
The website for the National Clinician Consultation Center offers guidance for HIV management as well as rapid expert consultation on management of HIV/AIDS, perinatal HIV, pre-exposure prophylaxis (PrEP), and post-exposure prophylaxis management for HIV.
Strategies to Help Reduce STI Stigma, Increase Screens
Rates of several STIs continue to increase — there were more than 2.5 million cases of gonorrhea, chlamydia, and syphilis reported to the CDC in 2022. Syphilis, which has the potential to cause severe complications, has resurged as a public health concern. The highest number of reported cases of syphilis in the United States since 1950 was reported in 2023.
Complex STI-related guidelines are frequently updated, making it challenging to stay up on current guidance, according to a review published in the Journal of Women's Health in June 2024.
'The point of screening is to pick up people with a condition before they manifest any clinical signs or symptoms,' according to Matthew Hamill, MBCHB, PhD, MPH, associate professor of medicine, The Johns Hopkins University School of Medicine, Baltimore. 'It is particularly important with sexually transmitted infections because the vast majority of people with STIs will have no signs or symptoms, and it may not be for years that they develop a pathology or disease as a result of those previous infections that weren't screened for and therefore weren't treated,' he said. In women, for example, STIs can lead to pelvic inflammatory disease, infertility, chronic pelvic pain, and more.
Not surprisingly, stigma plays a big role in the lack of screening for diseases related to sexual or risky activity. Screening for most STIs is risk-related, and there is bias on the part of the providers as well as the patients.
Of course, people who don't know they have STIs can spread them. 'In an ideal world, we'd have widespread screening for sexually transmitted infections. I understand why organizations like the CDC will provide these very tailored recommendations based on different population characteristics,' he said. 'But unless recommendations are very clear, like screening for chlamydia in sexually active women aged less than 25 years, it gets complicated.'
'Whereas, with syphilis, for example, you have to go through all the different kinds of groups of patients, and then figure out, should I be screening this person or not?' Hamill said.
In addition to automated reminders for screenings in electronic medical records, which both Kim and Cohen mentioned, Hamill has a few ideas on how providers can help reduce stigma and increase STI screens.
Take sexual histories as a matter of routine. This gives the patient an opportunity to ask for screening. Then the provider can say, Okay, would you benefit from HIV PrEP? Or would you benefit from doxycycline, or doxy PrEP, which is a fantastic way of reducing the risk for bacterial STIs…The sexual history bit opens the door to all of these different kinds of conversations around prevention, normalizes those conversations, and empowers patients, Hamill said.
This gives the patient an opportunity to ask for screening. Then the provider can say, Okay, would you benefit from HIV PrEP? Or would you benefit from doxycycline, or doxy PrEP, which is a fantastic way of reducing the risk for bacterial STIs…The sexual history bit opens the door to all of these different kinds of conversations around prevention, normalizes those conversations, and empowers patients, Hamill said. Get trained to talk about and treat STIs. The National Network of STI Clinical Prevention Training Centers offers intensive virtual courses on things such as how to talk to patients about sex and sexuality. American Sexual Health Association provides free online education for providers.
The National Network of STI Clinical Prevention Training Centers offers intensive virtual courses on things such as how to talk to patients about sex and sexuality. American Sexual Health Association provides free online education for providers. Use STI treatment consultations. Many may hesitate to screen because they aren't sure what to do with the results. The STD Clinical Consultation Network answers healthcare provider questions, usually within 24 hours.
Many may hesitate to screen because they aren't sure what to do with the results. The STD Clinical Consultation Network answers healthcare provider questions, usually within 24 hours. Give patients a short questionnaire on paper right before they see a provider . Ask just a few questions along the lines of 'Have you been sexually active since the last time you were here? Have you had a new sex partner since you were last here? When did you last get tested for an STI?' Seeing the answers in advance will allow the provider to have a direct conversation with the patient.
. Ask just a few questions along the lines of 'Have you been sexually active since the last time you were here? Have you had a new sex partner since you were last here? When did you last get tested for an STI?' Seeing the answers in advance will allow the provider to have a direct conversation with the patient. Explore mail-in or at-home testing. (Free kits available in some areas from clinics such as IWTK - I Want the Kit - in Baltimore and Take Me Home are ideal; drug stores and other companies offer fee-based testing.) Find more information on the American Sexual Health Association website.
Consider the Rewards
Each case of congenital syphilis is an entirely preventable tragedy, Hamill said. 'I've seen more cases of syphilis involving the neurological system (affecting the brain, eyes, and ears) in the last 5 years than in the previous 20. If we're more careful about screening then we can detect people earlier. We could treat them,' he said.
Screening and treatment for STIs is really satisfying as a medical provider, according to Hamill. 'Ninety-nine percent of the time it's really easy and straightforward, much less complicated than the other work we do,' he explained.
Kim concurred. 'Hep C treatment is transformative. I never get tired of telling someone they're cured of hepatitis C. Speaking for my patients who have gone through the treatment, it's really something else, they feel like they can do anything.'
Cohen represented the Hepatitis B Foundation on community advisory boards for Gilead Sciences, Roche, and GSK. All consulting fees were paid directly to the Hepatitis B Foundation.