Screening for Sexually Transmitted Infections in Persons Living with HIV Leads to Significant Financial Losses for a Healthcare System

Background: Sexually transmitted infections (STIs) are common in persons living with HIV (PLWH) and can facilitate the transmission of HIV. The current CDC guidelines recommend annual screening of all PLWH for Neisseria gonorrhea (GC), Chlamydia trachomatis (CT), and Treponema pallidum (Syphilis), and screening for Trichomonas vaginalis (TV) in HIV-positive women. The objective of this study was to understand the financial implications of recommended STI screening in PLWH. 

Methods: We estimated the costs of providing recommended STI screening tests annually to all eligible patients at an academically affiliated HIV clinic in Birmingham, AL from August 2014- August 2015. Expenditures for GC, CT, TV and Syphilis screening were calculated using lab charges (Table 1). Revenue was calculated using reimbursement data for the above tests based on insurer. Commercial insurance reimbursement was based on data from Blue Cross Blue Shield of Alabama, the largest commercial insurer in our population.  Uninsured patients were assumed to have commercial insurance under the provisions of the Affordable Care Act (ACA).

Results: 3,163 patients (27% Medicare, 13% Medicaid, 26% Commercial, 34% Uninsured/ACA) met study inclusion criteria. Net yield, defined as reimbursements minus charges, was calculated for each test. Providing recommended STI screening annually to all eligible patients would result in a clinic net yield of -$783,834.76.

Conclusion: Providing PLWH with recommended annual STI screening tests would potentially result in approximately  $790,000 of uncompensated expenditures for this healthcare system. Policy makers should address this lack of compensation to ensure sustainability and compliance with recommended STI screening in PLWH. Caring for uninsured patients will lead to greater losses.

Table 1. Charges and Reimbursement for Routine STI Screening by Insurer in an Urban HIV Clinic in Birmingham, AL

Screening Tests	Charge ($)	Reimbursement by Insurer ($)
		Medicare	Medicaid	Commercial
	N=3163	N=854	N=411	N=823
GC NAAT	109.00	30.71	28.00	17.50
CT NAAT	109.00	30.71	28.00	19.08
TV NAAT	84.00	30.71	0	0
Syphilis Antibody	85.00	18.03	19.29	14.88

*NAAT = nucleic acid amplification test; N= number of patients meeting test criteria based on insurance status