The Complete Story: Packaged Testing and Missed Opportunities in Sexually Transmitted Infection Screening in a Large Midwestern Healthcare System

BACKGROUND: Concurrent, or "packaged," testing for human immunodeficiency virus (HIV) and syphilis during gonorrhea and chlamydia (GC/CT) screening may improve early detection of sexually transmitted infections (STIs), but this practice remains inconsistently implemented. We aimed to assess the prevalence of, and factors associated with, packaged STI testing in a large healthcare system. METHODS: We conducted a retrospective observational study analyzing adult encounters from January 2019 through September 2025 with GC/CT testing at a large Midwestern academic hospital system. We defined packaged testing as concurrent testing for HIV, syphilis, and GC/CT. Multivariable logistic regression models using generalized estimating equations were fitted to assess associations with packaged testing, accounting for repeated encounters per patient. RESULTS: Among 318,917 eligible encounters from 170,183 patients, 31.8% of encounters received packaged testing. Those aged ≥ 25 had higher odds of receiving packaged testing compared to younger individuals, while women (adjusted odds ratio [aOR] 0.54, 95% confidence interval [CI] 0.52-0.55) had lower odds compared to men. Emergency department encounters (aOR 0.11, 95% CI 0.11-0.12) had the lowest odds, whereas outpatient infectious diseases had the highest (aOR 3.32, 95% CI 3.07-3.60), all relative to primary care. Black race, lower income, and Medicaid insurance were associated with higher likelihood of testing relative to their respective reference groups. Overall packaged testing rates increased over the study period across settings. CONCLUSIONS: In a large Midwestern healthcare system, packaged STI testing rates remain low, with disparities across demographic groups and clinical settings. These findings underscore opportunities for setting-specific and resource-aware interventions to improve screening practices.