Up to half of sexually active young people will get a sexually transmitted disease by the time they are 25, yet many don't seek testing because it may be difficult, costly or embarrassing.
Public health officials nationally and in particularly affected cities like Baltimore, however, say they've found a method that seems to address the major hurdles - a website that supplies free in-home testing kits for three of the most commonly reported STDs.
"The highest prevalence is in young adults, and we knew we had to reach these kids," said Charlotte A. Gaydos, a professor of infectious diseases at Johns Hopkins University in Baltimore. "They were always on the Internet, and now, on their smart phones. They weren't going to ask their mothers to take them to a clinic."
Gaydos helped develop the program called "I Want the Kit," and its website, (iwantthekit.org), which now serves primarily teens and young adults in Maryland, Washington, West Virginia, parts of Illinois, and in Denver and Philadelphia. It's one of many nationally to try to reach this population, but public health officials say its ease and anonymity make it especially attractive.
STD experts say other effective testing and treatment efforts involve in-school clinics and a program called "Expedited Partner Therapy," which allows those who test positive for gonorrhea or chlamydia to take home antibiotics for up to three partners. Also helping get the word out is a campaign called GYT, which stands for Get Yourself Talking, Get Yourself Tested, and taps MTV to encourage discussion and screening.
The direct impact of these programs so far on infection rates isn't known - the Hopkins program has only been operating since 2004 and other programs are newer. And results on the three diseases for which the U.S. Centers for Disease Control and Prevention collects the most data are mixed: Gonorrhea cases are at the lowest level on record; chlamydia cases are up, but officials believe this is because of expanded testing; and syphilis cases are trending up after hitting a low in 2000.
But I Want the Kit and others hold promise in increasing testing and spreading information about STDs and their consequences, said Dr. Charlotte Kent, a branch chief in the CDC's Division of STD Prevention. Gonorrhea and chlamydia can cause infertility and chronic pain. Syphilis can cause malformation and death in babies, as well as heart disease, blindness and neurological problems.
Many people don't get tested because they have no symptoms, Kent said. (Gonorrhea can have symptoms, which has helped increase testing and treatment.) Private doctors' offices, where most cases are discovered, also are still not offering tests enough. And she said enough young people aren't asking about testing or trying to prevent infection.
"There are things people can do to impact STDs, and that includes talking to their providers and getting tested and using condoms," Kent said. "If everyone was getting screened and appropriately using condoms in new relationships, it could make a huge difference."
I Want the Kit was set up to be easy, said Gaydos. People can get to the website through Facebook or with a smart phone application that reads barcodes printed on program brochures, which have been left in schools and clinics. Kits are mailed in a plain envelope with the swab, questionnaire, information about STDs and consent form.
About 43 percent return the swabs.
Patients are given an identification number and passcode to get their results by phone in two weeks. Appointments are made in a local clinic of the patient's choice for those who test positive - up to 13 percent depending on the gender and STD. About 3,500 young people, half younger than 23, have gotten tests from the site, some more than once.
Almost everyone goes to their appointment, said Mathilda Barnes, who sets them up from Hopkins, and gets antibiotics.
Kent said the effort to increase testing in general should get a boost when the health care reform law begins to cover more people. Tests will be covered with no co-pays because they are considered preventive services. And because anonymity is so important to teens, the CDC is working to change a requirement that insurers notify patients of the services used - an "explanation of benefits" that is mailed home to parents.
Programs like the one at Hopkins offer confidentiality already, said Kent. That will be especially important in places like Baltimore, hard hit with infections. STDs in general have hit poor and minority communities the hardest because they tend to lack awareness and access to health care, Kent said.
Gonorrhea and chlamydia are included in the Hopkins test kit because testing requires only a swab. The kit also includes a test for trichomoniasis, and though cases are not reported to the CDC, it's estimated to be the most common STD infection with more than 7 million new cases nationally every year.
Gaydos expects an uptick in kit users in April, national sexually transmitted infections awareness month, following federally funded newspaper and radio ads.
The site may not yet be big enough to significantly bring down the infections, but users have praised the service in e-mails. They say they've relied on it after finding out a partner had sex with other people or they've had unprotected sex. Many say they don't want their parents to know they are having sex and might be infected.
Some say they can't afford to go to the doctor for testing. One thought it was an easy way for both partners to be tested before they had sex.
Gaydos and her colleagues would like to add syphilis or HIV to the program, which is paid for with government grant money. Each kit costs Hopkins about $65-$70, which includes the mailing, test and lab worker time. Those STDs, however, requires a blood test that would make an in-home kit tougher.
She also would like to continue expanding the program beyond the cities and states it now serves.
"A lot of these young women are poor with little to no health insurance, and seldom see a physician or undergo a health checkup, so this is a free means of getting them tested and cared for quickly and before they potentially pass the infection on to someone else," said Gaydos.
Gaydos said Maryland was a logical place to launch the program because of its high infection rates. CDC surveys of risky behavior show almost a third of students in Baltimore are sexually active by the ninth grade.
CDC data shows that Maryland ranks in the top 20 states for STD cases. Many of the cases are in Baltimore, where there were 2,889 cases of gonorrhea in 2009, 7,889 cases of chlamydia and 244 cases of syphilis in 2009, according to the Baltimore City Health Department - though only chlamydia cases have been rising in recent years.
They all remain a challenge for local officials, said Sherry Ketemepi, the city's assistant commissioner for clinical services.
She said the city works with Hopkins and others on programs to reach those most at risk. She said schools offer health education and encourage testing in their clinics. And city health officials sought permission from the state legislature three years ago to join the CDC's Expedited Partner Therapy program.
Another program rewards youth for referring a friend for testing at a city clinic with a movie ticket or other prize.
But she said the Hopkins program eliminates a main barrier to testing because it's anonymous.
"There's a stigma to going to a clinic to be tested for an STD," she said. "It's an easier way to get people tested."