In the United States (U.S.), incidence of bacterial sexually transmitted infections (STIs) continue to increase. Between 2018-2022, reported gonorrhea diagnosis rates increased by 9% from 178.3 to 194.4 per 100,000. Diagnosis rates for primary & secondary syphilis, and early latent syphilis increased by 65% (from 10.7 to 17.7 per 100,000) and 45% (from 11.8 to 17.1 per 100,000), respectively. (1) Prompt treatment of bacterial STIs with U.S. Centers for Disease Control and Prevention (CDC) recommended regimens is critical to reduce ongoing STI transmission, HIV acquisition and transmission, development of severe sequelae, and emergence of antimicrobial resistance.(2–4) It is also a key strategy outlined in the STI National Strategic Plan for reducing gonorrhea and early syphilis (primary, secondary or early latent syphilis) incidence by 10% by 2030.(5)

Community healthcare providers (CHPs) report over three-quarters of STI diagnoses in the U.S.(1, 6) CHPs, which include private sector practices, federally qualified health centers (FQHCs), and acute care settings (e.g., emergency departments and urgent care facilities), are essential partners for STI treatment and prevention. However, limited existing data on gonorrhea and early syphilis (ES) treatment practices (i.e., time-to-treatment, treatment completion, etc.) among CHPs are mixed. One recent study using claims data from private healthcare settings showed that only 34.8% of patients had evidence of receiving CDC-recommended gonorrhea treatment.(7) In contrast, other studies from Denver, New York City, California, and Massachusetts reported that most (82 – 96%) patients received appropriate gonorrhea treatment.(8–11) Another study among 20 U.S. STD programs showed that a median of 63.0% of all reported gonorrhea diagnosis in 2014 were treated appropriately.(12) Data on treatment practices are more limited for ES. Recent studies, however, have shown that only about two-fifths of pregnant women in Arizona, Georgia, Michigan, New Jersey, New York State and Washington received adequate syphilis treatment,(13) and that a rapid screening process decreased time-to-treatment among sexual minority men (SMM).(14) Additional limitations of prior work include a focus on select populations (i.e., sexual health clinic patients, pregnant women, SMM)(13–15) rather than all CHPs within a specified jurisdiction, and/or examined treatment provision at the patient-level(7–15) rather than at the provider- or practice-level. Data on variation in treatment practices by CHP characteristics (i.e., practice specialty, populations served, etc.) also are lacking. Examining treatment provision among all CHPs within a jurisdiction may identify practice-specific gaps to inform locally tailored, practice-level interventions to improve treatment completion, and, ultimately, reduce STI transmission at the community level.

Performance measures, such as percent treated and time-to-treatment have previously been used to quantify, compare, and evaluate STI prevention programs.(16) Benchmarks also have been employed to identify and monitor progress towards measurable and relevant performance improvement goals.(17, 18) However, as noted in the STI National Strategic Plan, data are needed to establish national performance improvement goals to monitor the percentage of patients with gonorrhea, and separately, syphilis who are treated with a CDC-recommended regimen.(5) The goal of this analysis was to generate baseline data to monitor and evaluate gonorrhea and syphilis treatment performance among CHPs in Baltimore City, Maryland, a mid-Atlantic city with persistent gonorrhea and syphilis epidemics. The objectives were to: 1) quantify treatment performance among CHPs; 2) compare CHP treatment performance to local health department treatment performance goals (i.e., achievement measures); and 3) identify practice-level characteristics associated with achievement of local treatment performance goals among CHPs reporting gonorrhea, and separately, ES diagnoses.

For gonorrhea, the analysis included information on 171 CHPs, which collectively reported 5,576 gonorrhea diagnoses between January 1, 2018, and December 31, 2019, and accounted for 72.9% of the 7,652 gonorrhea diagnoses reported to the BCHD during this period. The median gonorrhea diagnoses reported per CHP was 5 (IQR: 2-22). Half of CHPs (49.7%) were private practices. High volume clinics included both sexual health clinics, 76.9% (10/13) of hospitals, and 36.8% (7/19) of FQHCs, and 33.3% (8/24) of acute care clinics. Among the 128 CHPs that were private, acute care, and FQHC practices, 44.5% (57/128) served pediatric populations, 54.7% (70/122) served as adult populations, and 40.6% (52/128) provided women’s health services.

For ES, the analysis included information on 120 CHPs, which reported 1,114 ES diagnoses between January 1, 2018 and December 31, 2019, and represented 89.2% of all reported ES diagnoses (1,249) during the two-year period. The median diagnoses reported per CHP was 3 (IQR: 1-5). One-third (34.4%) were private practices. High volume clinics included both STI clinics, and 44.4% (8/18) of hospitals, 42.7% (3/7) of HIV/ID specialty clinics, 40.0% (2/5) of corrections facilities and 25.0% (4/16) of FQHCs and (4/16) acute care clinics. Among the 74 private, acute care and FQHC CHPs, 48.7% (36/74) served pediatric populations, 74.3% (55/74) served as adult populations, and 48.6% (36/74) provided women’s health services.

We examined STI treatment practices among community health providers which collectively reported 72.9% of gonorrhea and 89.2% of ES diagnoses in Baltimore City, Maryland. More than half of CHPs reported treatment for the majority of gonorrhea (median percent treated: 71.4%) and all ES (median percent treated: 100.0%) diagnoses reported during the observation period. Substantial gaps were observed in CHP-level treatment practices for gonorrhea and ES. Fewer than one-third of CHPs achieved BCHD’s goal for reporting gonorrhea treatment for at least 90% of their reported diagnoses. However, when treatment was reported, the majority achieved appropriately treated and promptly treated goals. In contrast, nearly all CHPs that diagnosed ES achieved treated and appropriately treated goals, but only two-fifths achieved the promptly treated goal. Differences in achievement measures by CHP characteristic also were observed. For gonorrhea, all three performance achievement measures differed significantly by practice type. Additionally, CHPs reporting low (vs. high) STI diagnosis volumes more frequently (35.4% vs. 12.2%) reported any treatment for at least 90% of diagnoses, and achievement of BCHD’s goal for promptly treated differed significantly by provision (vs. no provision) of women’s health services (56.3% vs. 87.1%). For ES, prompt treatment differed significantly by reporting volume, with low (vs. high) volume CHPs more frequently treating at least 85% of syphilis diagnoses (54.4% vs. 33.3%) within 14-days of specimen collection.

The most substantial gap was report of any gonorrhea treatment information to the BCHD. This may reflect a combination of suboptimal provider reporting of gonorrhea treatment information – despite legal mandates – and patient inability or unwillingness to return for treatment. Indeed, one program found that, among 251 gonorrhea cases with missing treatment documentation, 86% had been treated appropriately.(12) This underscores the need for strategies to facilitate provider-initiated treatment reporting, which could include promulgating reporting requirements to CHPs through health commissioner letters or public health detailing campaigns, CHP staff on legal reporting requirements or implementing automated methods to transmit treatment information from electronic health record systems into STI surveillance registries.

Patients with symptomatic gonorrhea infection may be more likely to receive same-day treatment.(22) We were unable to quantify the proportion of symptomatic patients diagnosed by each CHP; however, all hospitals, acute care and sexual health clinics achieved gonorrhea prompt treatment goals, which may be explained by high proportion of patients presenting with symptoms or recent sexual exposure in these settings (vs. other settings such as primary care). Similarly, clinicians in CHPs that provide women’s health services and/or were Title X recipients (which is focused on reproductive health services) may be less likely to provide presumptive or same-day treatment than clinicians in other settings.(23) Patients assigned female (vs. male) at birth present less frequently with symptoms, and symptoms consistent with gonorrhea infection (i.e., vaginal discharge) could be due to other pathogens.(2, 22, 24) Time-to-treatment for asymptomatic patients or patients with no known exposure is dependent on laboratory processing time, time to receive notification of results, and time for the patient to return to clinic for a ceftriaxone injection by a qualified provider. Further delays may occur if patients need to obtain ceftriaxone at a pharmacy before returning to clinic for treatment. Potential solutions to decrease time from diagnosis to treatment include increased access to highly sensitive and specific point-of-care (POC) tests, incentivizing CHPs to stock ceftriaxone on-site, or allowing pharmacies to administer injectable antimicrobials when dispensing to patients.(25)

Nearly all CHPs that diagnosed ES during the observation period achieved goals for diagnoses treated and appropriately treated. This, in part, reflects differences in BCHD’s treatment verification and assurance practices for syphilis compared to gonorrhea. It is possible that providers are more familiar with CDC-recommended treatment for syphilis, which has remained unchanged for years, while gonorrhea treatment guidelines have been frequently updated.(26, 27) The observed lower frequency of prompt treatment for ES compared to gonorrhea, could be explained partially by differences in symptom presentation and same-day treatment practices. Indeed, 90.1% of gonorrhea cases compared to 77.2% of ES cases were treated within 14-days of specimen collection (data not shown). Given syphilis is often asymptomatic and diagnosis is dependent on serology,(27) treatment, therefore, depends on the patient returning to a CHP upon notification of positive results. This underscores the need for better syphilis diagnostics, and specifically, implementation of POC tests to decrease time from diagnosis to treatment.(14)

Our observation that more than half of CHPs reported any treatment for a majority of their reported diagnoses is consistent with previous studies on gonorrhea treatment provision among 20 STD programs throughout the U.S.,(12) family planning and infectious disease specialty clinics in New York City(9), and throughout California,(10) but was higher than the proportion reported by Tao et al. for patients diagnosed in private healthcare settings.(7) The Tao et al., study was conducted from 2016-2018, and it is possible that our results reflect increasing provider awareness of treatment guidelines over time. Additionally, our observation that CHPs specializing in women’s health less frequently achieved BCHD’s prompt treatment goal is consistent with previous findings. OB/GYNs had been found to have lower rates of knowledge about CDC-recommended treatment for uncomplicated gonorrhea (when compared to a random sample that also included pediatricians, internists, and family medicine physicians) and had lower likelihoods of treating patients with CDC-recommended regimens.(28)

In contrast with prior work,(29) we found that that high STI diagnosis volume reporters were less frequently reported any gonorrhea treatment. We hypothesize this may be due to barriers to provider-initiated treatment reporting by high-volume CHPs, which, in Baltimore City, mostly consist of large practices or affiliates of larger provider group networks, and automated reporting systems to submit morbidity forms may improve treatment reporting. Based on previous findings for chlamydia,(30) we expected Title X-funded practices to have higher estimates across all measures compared to non-recipients. Although most Title X-funded CHPs achieved the BCHD’s goal for prompt ES treatment, most Title X-funded CHPs that reported diagnoses of gonorrhea during the observation period did not. This could represent differences in populations served by Title X-funded clinics, or given that many Title X-funded clinics also provide obstetric care, findings could reflect an increased focus on maternal syphilis (vs. gonorrhea) screening and treatment.

Some additional limitations should be considered when interpreting these results. We were limited in the practice-level characteristics we could evaluate from public health surveillance data. There may be other unmeasured factors –for example, staff turnover – that may influence treatment performance. The sexual health clinics are managed by the BCHD, and treatment information is readily available;. differences in observed estimates among sexual health clinics (compared to other settings) may reflect differences in the ascertainment of treatment information rather than true differences in treatment provision. Gonorrhea treatment only was verified with the diagnosing provider; patients treated by another facility may have been misclassified as not treated. Though most patients with treatment documentation were appropriately treated, CHPs prescribing CDC-recommended treatments may be more likely to report treatment, introducing information bias. Lastly, data were collected prior to the COVID-19 pandemic and the 2021 updated STD Treatment Guidelines and, therefore, may not be generalizable to current treatment practices in this or other settings.

This analysis provides a model for using surveillance data to identify jurisdiction-wide gaps in STI treatment practices. To improve treatment performance metrics, data generated as part of this analysis were used to generate individualized treatment performance dashboards that were disseminated to each CHP along with information on updated CDC treatment guidelines. Identification of CHP characteristics associated with lower treatment performance can inform practice-level interventions, such as tailored public health detailing campaigns to narrow observed gaps. Similar analyses could inform the establishment of baseline estimates and incremental performance goals for assessing progress towards achieving overall STI treatment outcomes, and ultimately, reduce gonorrhea and ES incidence.