Sunday, January 30, 2011

What's Wrong With the Way
We Think About Chlamydia

The New York Times reported this week on a study in Pediatrics that found racial disparities in the likelihood that a woman received chlamydia testing. The authors reviewed medical charts and while all of the more than 23,000 women included met the CDC's criteria for routine chlamydia testing (i.e., under 25 and sexually active), black and hispanic women were significantly more likely to have been tested for chlamydia than white women.

Even more likely to have received testing were those who had public insurance (i.e., Medicaid) and those who were eligible for--but not enrolled in--public insurance programs. Basically, women who are poor. What this shows is that healthcare providers are less likely to screen women who are white and/or have private insurance.

The article's authors suggest the following:
...clinicians may simply be less likely to consider white women in association with a stigmatized STI such as chlamydia. An inference regarding this “reverse health care disparity” is that white women, who typically are more likely to receive routine health screening tests such as mammography, are not considered for chlamydia screening because of the stigma of STIs. (p. e341)
But here's what's wrong with this picture: the Chlamydia trachomatis bacteria is transmitted by infected fluids, meaning that in order to contract it, a person's mucosal tissue (vagina, rectum, urethra, eye, or mouth/throat) has to come into contact with (read: receive) infected semen or vaginal secretions. If a woman is tested, diagnosed with chlamydia, and receives treatment, her infection goes away--but the person who infected her, unless he's also received treatment, still has chlamydia.

In 2008, the CDC reported 1,210,523 Chlamydia infections, the majority of which were in women. We can fairly assume that the overwhelming majority of these cases were the result of sex with men who may not have not been tested or treated. To wit, the CDC says: "The lower rates among men also suggest that many of the sex partners of women with chlamydia are not being diagnosed or reported as having chlamydia." This is one explanation for the frequency of reinfection. In contrast to the often self-resolving HPV, chlamydia doesn't go away unless a person receives antibiotic treatment so the majority of the men who infected these women are still walking around none the wiser.

While far fewer men than women with untreated chlamydia will become infertile as a result of their infection, if the majority of men with chlamydia are not getting tested we should anticipate male infertility will become more common and that the disease burden related to chlamydia--in both men and women--will not decrease if we only increase testing among women. So if our plan as sexual health professionals is to routinely screen all sexually active women under the age of 25, but we're not aggressively targeting men for screening, we are literally missing 50% of the chlamydia picture.

Article citation:
Sarah E. Wiehe, MD, MPH, Marc B. Rosenman, MD, MS, Jane Wang, PhD, Barry P. Katz, PhD, and J. Dennis Fortenberry, MD, MS. "Chlamydia Screening Among Young Women: Individual- and Provider-Level Differences in Testing."
Pediatrics. Online early release 1/27/11. (accessed 1/30/11)


  1. EPT is great, if you have a regular partner/know you have a partner/have a partner who won't punish you for having an STI. i haven't seen any data supporting the actual effectiveness of EPT at the population level. sort of like plan b & pregnancy rates, i would imagine. i also think that STD clinics and health depts do it, but many other HCPs don't. we don't offer it at our clinic, i know that, because the partner isn't our 'patient.'

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