High STI rates among returning veterans, but low rates of HIV testing

Background: The re-emerging sexually transmitted infection (STI) epidemic has worldwide health and economic consequences, including increased risk for infertility, cervical cancer, and HIV. It is recommended that all persons with STI be tested for HIV. Military service personnel represent a large and transient population with elevated STI rates. Little is known about STI and HIV testing rates among recent service Veterans. Methods: The cohort comprised US Veterans of Operations Enduring and Iraqi Freedom who used Veterans Affairs primary care services within one year after military separation between 2004 and 2010 (n=230,210). We used electronic health records to identify STI ICD-9 codes for chlamydia, gonorrhea, syphilis, herpes simplex virus (HSV), human papillomavirus (HPV), and trichomonas, within the 1st year of VA care and laboratory data for HIV testing within 1 year of the STI. Demographics, military service, and clinical characteristics were collected. Relative risks (RR) regression was used to model the association of characteristics with STI diagnosis, and among those with an STI, receipt of HIV testing. Results: Cohort characteristics: 11.7% women; mean age 31.7; 66.7% white, 13.6% black, and 11% Hispanic; 75.7% Army; 8.7% officers; 6.6% alcohol use disorder (AUD); 1.7% substance use diagnosis (SUD); and 5.1% major depressive disorder (MDD). Overall, 8,057 (3.4%) had an STI; HPV (2.2%) was the most common. Women (RR=2.61), black veterans (RR=1.15), Navy (RR=1.23), with AUD (RR=1.41), SUD (RR=1.48), or MDD (RR=1.234), were significantly more likely to have had an STI. Overall, STI rates decreased from 2004 to 2010 (4,604 to 3434/100,000 pyo), but syphilis increased from 33 to 42/100,000 pyo. Among Veterans with an STI, 19.9% had an HIV test (0.1% HIV+). Older age (RR=0.95/yr), and Army service (RR=0.90) were associated with a lower rate of HIV testing, while black race (RR=2.14), Hispanic ethnicity (RR=1.61), AUD (RR=1.53), SUD (RR=1.46), and MDD (RR=1.33), were associated with a higher rate of HIV testing.

Conclusions: We found a high prevalence of STIs among recently separated Veterans. HIV testing among STI cases is low, even among those with HIV risk factors. These findings warrant re-emphasis on STI prevention and control efforts. Limitations include reliance on administrative data and use of incident diagnoses; however, STI results are consistent with published data from the US Military Health System. In summary, developing and applying new tools such as behavioral interventions to reduce STI and increase HIV testing could yield important public health benefits.