The deployment of the STI/HIV health department workforce to support the COVID-19 public health response may have had sustained impacts on STI services in the United States. In an assessment of the impact of COVID-19 on STI programs, 96% of programs reported that reassignment of STI staff to COVID-19 work had impacted STI program efforts in April 2020, and 95% reported that these impacts were sustained in October 2020 [1]. Further findings included that it was common for programs to release guidance on testing or patient prioritization; to implement telemedicine; and experience interrupted high volume STI testing due to laboratory staffing, clinic closures, and supplies shortages. In May 2020, the National Coalition of STD Directors (NCSD) found that programs reported deferring STI services or field visits, conducting fewer sexual health tests, and were experiencing reduced capacity to treat STDs [2]. In January 2021, NCSD highlighted STI clinic strategies to eliminate or restrict walk-in visits and institute appointment-only policies [3]. Sustained reductions in STI clinic visits and unique patients were reported through December 2021 by seven jurisdictions participating in the STD Surveillance Network [4].

Public health funded STI clinics provide high-quality specialized care for testing, diagnosing, managing, and treating sexually transmitted infections; these clinics are an important safety net for under- and un-insured individuals. Reductions in services at public health STI clinics may have resulted in many undiagnosed and unreported STIs [5].

The nationally reported rate of gonorrhea (GC) steadily increased from 2013 (105.3 per 100,000 population) to 2021 (214.0), as did the rate of chlamydia (CT) (2013, 443.5; 2021, 495.5) [5, 6, 7]. But from 2021 to 2022, this trend reversed, and the rate of reported GC decreased by 9.2% overall (2022, 194.4) and by 14.5% among women (177.9 to 152.1) but was smaller (−5.4%) among men (249.7 to 236.3) [8]. CT, in contrast, stabilized (495.5 to 495.0).

CT/GC are tested for together on the same specimen and because both CT and GC can be asymptomatic, two primary drivers of rates of reported cases are testing coverage and prevalence; changes in either can result in increased or decreased case rates, particularly among women since they are more likely to be asymptomatic [9]. To determine whether changes in testing coverage and numbers of tests reflected changes in case rates, we evaluated changes in STI clinic visits, number of CT/GC tests performed, and CT/GC tests with a positive result, preceding and following the COVID-19 pandemic.

We used 2018—2022 aggregated STI clinic visits and testing data from all public health department STI clinics across diverse urban, suburban, and rural settings in five U.S. jurisdictions (District of Columbia (DC), Louisiana (LA), Michigan (MI), North Carolina (NC), and Virginia (VA)), as available; Louisiana data also included other public clinic visits for reproductive health. We calculated positivity using numbers of CT or GC positive tests divided by total CT/GC tests (‘test-based positivity’) as well as numbers of unique people testing positive for CT or GC divided by the number of unique people tested for CT/GC (‘person-based positivity’). Annual counts from 2018 and 2019 were averaged to establish a stable period preceding COVID (“pre-COVID”). We calculated the relative percentage change annually, as well as from ‘pre-COVID’ to 2022; changes <+/−10% were considered stable. All outcomes were evaluated by jurisdiction and sex at birth. The number of people tested for CT/GC was also evaluated by age and race/ethnicity to estimate a potential demographic shift in the clinic population.

Using data from five jurisdictions from 2018—2022, we found that STI clinic visits and CT/GC testing have not returned to pre-COVID levels. CT/GC testing had decreased during 2020 compared to the pre-COVID period, similar to previous findings across various settings [4, 10–17]. We further demonstrated that reductions in CT/GC testing and overall clinic attendance continued through 2022 and highlighted that those aged <30 years experienced more extensive shortfalls in testing and clinic attendance as compared to the pre-COVID period, similar to a multijurisdictional analysis of public STI clinics through 2021 [4].

It is possible that the population being tested in public health department STI clinics has changed over time: in the early pandemic, clinic prioritization of symptomatic patients may have resulted in fewer asymptomatic people and those at lower risk for STIs being tested [1]; if true, an increase in positivity would be expected. Asymptomatic testing of an at-risk group may have increased but not returned to pre-COVID levels as of 2022. In our study, positivity for GC initially increased, then stabilized, then modestly decreased, though positivity for CT was stable throughout the study period. Waning GC positivity through 2022 in our data may have indicated a shift in the case mix of the clinic population, with fewer individuals tested among the most vulnerable, such as young people. Other changes to STI clinic services may have introduced or hastened changes in the clinic population, such as eliminating or restricting walk-in services [3] which may have been preferable to young people [18]. Preceding the COVID pandemic, STI clinics increasingly offered HIV services, such as PrEP care coordination, requiring multiple visits throughout the year, as well as increasing extragenital screenings; during this time, STI clinic visits decreased among young people while utilization increased among MSM and people aged ≥25 years [19].

Our study was limited to aggregate data for specific metrics from health department STI clinics in five jurisdictions so potential analyses are limited and our findings may not be generalizable. It is possible that the frequency of asymptomatic testing, multisite testing, and/or return visits for retesting changed over time, but we lacked these data. STI clinics increasingly relied on telehealth visits and self-collection testing during the pandemic [3], but we could not discern these service types. Multiple factors can influence case-based surveillance data, including prevalence, which was unavailable, and testing; our findings cannot directly interpret surveillance trends.

Chlamydia and gonorrhea screening decreased during the COVID-19 pandemic due to severe disruptions to the STI health department workforce and test shortages which may have had a sustained impact. However, decreases in STI clinic visits among young people preceded the COVID pandemic [17], and it is likely that other factors are driving young people to seek care elsewhere or not at all, the latter of which may lead to uncontrolled STI transmission and the potential for rising healthcare costs for untreated infections. Young people may be more likely to use walk-in clinics [18] and to use STI testing in non-clinical settings such as school and home-based testing [20, 21]. It is unclear whether young people will return to STI or other public clinics without efforts to engage them. Potential strategies to improve STI testing among young people may include promoting STI care in collaboration with other providers and in alternative settings. Given the historically elevated risk of chlamydia/gonorrhea among young people, enhanced efforts are needed to ensure their access to high-quality STI testing and treatment services.