Previous Conferences - 2004 (Philadelphia, PA)
Oral, Symposium and Workshop Abstracts
- Monday Sessions
PM Gorbach1, LN Drumright2, GP Garnett3, KK Holmes4
1University of California, Los Angeles, CA; 2University of California, San Diego, CA; 3Imperial College London, UK; 4University of Washington, Seattle, WA
Background: The potential for spread of sexually transmitted infections within a population is a function of patterns of sexual partnership including: formation, dissolution, overlap between partnerships and frequency of sexual acts within partnerships. To date limited descriptions of sexual partnership duration and its relationship to other risk behaviors have been available.
Objectives: To quantify partnership related risk behaviors in young adults in vulnerable populations.
Methods: Both partners from 96 recently formed sexual relationships were recruited from a STD clinic and a family planning clinic to a prospective cohort study with a 12 month of follow up to describe the duration of the partnership, frequency of concurrent partner acquisition and frequency of unprotected oral, vaginal anal sex, and STD incidence.
Results: The hazard of partnership dissolution decreases over time with the 73% of partnerships remaining extant at 3 months; 56% at 6 months; 52% at 9 months and 43% at 12 months follow up respectively. Over the course of the study 57.3% of individuals reported concurrent sexual partnerships and 34% of the population recruited a new main sexual partner with a short gap (<1 month) before acquiring a new sexual partner. There was a large variance in reported number of sexual acts within partnerships with a median of 10 sex acts per partner per month and low levels of condom use. At baseline 13% had chlamydia, non-gonococcal urethritis, mucopurulent cervicitis or pelvic inflammatory disease with a further 6% acquiring these STDs during follow up.
Conclusions: The high levels of concurrency, short period between partnerships and low levels of condom use provide ideal conditions for the spread of bacterial STIs.
Implications for Research: These detailed patterns of behaviour provide a unique source for the derivation of parameter values for individual based simulations of the sexual partner network and the spread of sexually transmitted diseases.
Learning Objectives: By the end of the session participants will be able to understand the observed dynamics of behaviours within high risk partnerships and why they influence the epidemiology of sexually transmitted infections.
B Abban, G Tao, T Gift, K Irwin
Centers for Disease Control and Prevention, Atlanta, GA
Background: Disparities in prevalence of chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections among different population segments, coupled with the many choices of recommended screening tests and treatments, make it difficult to select the optimal CT or NG screening and treatment strategy for asymptomatic women.
Goal: To provide a resource allocation model that would determine the optimal screening and treatment strategy for CT and NG in a public-sector family planning facility.
Methods: Data used in the model were from the published literature. Several scenarios were considered for CT and NG screening and treatment, including scenarios in which patients who tested positive and were treated for one pathogen were also presumptively treated for the other pathogen. We developed a binary programming model to define the optimal strategy in which the combination of infections screened for, age groups screened, tests, and treatments administered would maximize either cost-savings or the number of cured infections.
Results: The optimal screening and treatment strategy for CT and NG varied with CT prevalence, NG prevalence, and CT-NG co-infection rates and program budget. At CT prevalence of 5%, NG prevalence of 1%, and no budget constraint, the optimal cost-saving screening and treatment strategy was screening with LCR and treating with azithromycin for CT, and screening with culture and treating with ceftriaxone for NG when NG prevalence among patients with CT was < 18.5%, otherwise, screening with LCR and treating with azithromycin for CT, and presumptively treating with ceftriaxone for NG among patients with positive CT tests.
Conclusions: Optimal strategies for CT and NG are highly dependent on CT and NG prevalence, CT-NG co-infection rates, and total program budget.
Implications for Programs, Policy and/or Research: This resource allocation model provides a flexible, customizable tool for programs to identify the screening and treatment strategy for CT and NG that maximizes use of prevention resources.
Learning Objectives: By the end of the session, participants will understand the various factors and perspectives that should be considered in selecting screening and treatment strategies for CT and NG.
B Iritani, D Hallfors
Pacific Institute for Research and Evaluation, Chapel Hill, NC
Background: Previous research suggests discrepancies between self-reported STD prevalence and assay point prevalence, but no such studies have yet been conducted with a nationally representative sample of young adults.
Objectives: To assess self-report versus assay STD/HIV prevalence among a representative sample of young adults by their type and degree of risk behavior.
Methods: Data are from Wave 3 of the National Longitudinal Study of Adolescent Health, a nationally representative sample of 18-26 year olds (N=15,197). Data contain results of Chlamydia, Gonorrhea, and Trichomoniasis urine tests and HIV saliva test in addition to self-reports of these infections. Bivariate association between self-reported and assay STD results are examined for respondents clustered into 16 different groups based on their sexual and drug use behaviors. Then, clusters are used to predict STD outcomes in logistic regressions, adjusting for sociodemographic characteristics such as race, gender, marital status, age, and region.
Results: Approximately 7% tested positive by biological assay for an STD; only 4% self-reported a diagnosis in the past year. This discrepancy varies markedly by risk group, with one large “low risk” (median = one partner; very low substance use) group showing over double the rate with positive assays (10%) than self-reported (4%). Logistic regressions indicate similar discrepancies. Odds of infection are significantly greater among high risk (e.g., MSM, Multiple Partners) than the “low risk” cluster when predicting self-reported STDs (OR=3.5 and 2.6, respectively, p<.05) but not on assay results (OR=1.1 and .8, N.S.).
Conclusions: Prevalence estimates are markedly different when results are based on self-reported versus biological STD measures. In particular, rates are underestimated for groups considered to be at relatively low risk.
Implications for Programs, Policy, and/or Research: Persons considered to be at low risk are rarely screened for HIV/STDs. Education and outreach has increased screening among some high risk groups, but additional research is needed to identify and treat other vulnerable sub-groups.
Learning Objectives: At the completion of this presentation, participants will be able to: 1) identify HIV/STD prevalence rates among young adults in16 behavioral risk groups; 2) describe differences between prevalence rates obtained by self report versus biological assay; and 3) discuss the research and clinical implications of these findings.
P Kissinger1, G Richardson-Alston1, J Leichliter4, H Mohammed1, SN Taylor2,3, DH Martin2, TA Farley1
1Tulane University School of Public Health and Tropical Medicine; 2Louisiana State University Health Sciences Center; 3New Orleans Health Department Delgado STD/HIV Clinic, New Orleans, LA; 4Centers for Disease Control and Prevention
Background: Alternative methods of partner treatment for men are needed.
Objectives: To compare patient-delivered partner medication (PDPM) with two partner referral methods.
Methods: Men who attended the Delgado STD/HIV Clinic in New Orleans with a diagnosis of urethritis between 1/02 and 9/03 were offered the study (85.1% accepted). Intervention allocation was randomly assigned by month rather than by individual. There were three interventions: standard partner referral (PR), bookletenhanced partner referral (BR), and patient delivered partner medication (PDPM). Information about each partner was elicited from each index man at baseline and onemonth using a computer-assisted interview.
Results: Enrolled index men (n=789) reported information on 1592 partners. At baseline, mean age was 26.1 (s.d. 6.6), mean number of partners was 2.4 (s.d. 2.3), 82.1% had >1 sex partner, and 96.5% were African American. During follow-up, 13.6% acquired a new partner, 68.8% resumed sex and of those 48.7% said they used condoms all the time. These factors were similar across arms. Follow-up rate was 66.3% and was lower in BR and PDPM than PR (62.7%vs. 54.3% vs. 80.8%, P <0.01). PDPM and BR arms were more likely than PR arm to report that their partners told them they had taken medicine (77.6% vs. 45.8% vs. 34.3% P <0.01) and were less likely to test positive for CT/GC at one-month follow-up (13.9%/12.2%/30.9, P <0.01). Men in the PDPM arm were more likely than men in the BR and PR arms to report having seen their partners (64.5%/53.6%/53.1%, P <0.01), having talked to their partners (68.6%/51.5%/47.7%, P <0.001), having thought their partner took the medicine (83.3%/38.1%/20.8%, P <0.001), and to have used a condom all of the time (59.8%/44.9%/44.4%, P < .01) during follow-up.
Conclusion: In men, PDPM was better than BR and both were better than traditional PR in treatment of partners and prevention of recurrence of CT or GC.
Implications for Programs, Policy, and/or Research: PDPM can be a useful public health intervention to prevent the spread STDs.
Learning Objective: By the end of this session, participants will be able to describe the benefit of patient-delivered partner medicine.
C Rietmeijer, L Lloyd, G Alfonsi
Denver Public Health Department, Denver, CO
Background: STD clinics usually offer services free of cost to patients or for a nominal (often voluntary) contribution. To offset decreases in public funding, fee for services may be initiated or increased. Little is known what the effects of such (co-) payments may be on access to and utilization of services.
Objective: To evaluate trends in patient visits and diagnosed GC and CT infections prior and subsequent to the initiation in December, 2002, of a variable ($15 and up) co-pay for STD services at the Denver Metro Health Clinic.
Methods: Using the clinic’s computerized medical record system, we compared clinic visits and diagnosed CT and GC infections during the first 8 months of 2002 and 2003.
Results: The total number of clinic visits declined from 13,693 to 9.742 (28.8%). Total CT diagnoses declined from 1,365 to 988 (27.6%) and total GC diagnoses from 778 to 503 (35.3%). Among persons younger than 25, total visits were down by 38%, CT cases by 38.2%, and GC cases by 33.8%. This age group accounted for 85.6% of fewer diagnosed CT infections, and 39.6% of fewer diagnosed GC infections. For 2003, we anticipate to diagnose over 900 fewer cases of CT and GC at DMHC.
Conclusion: Although there may be alternative explanations for these trends, our findings strongly suggest a causal relationship between the institution of the co-pay and declining service utilization. Those at highest risk for STDs (persons younger than 25 years) may be most severely impacted by financial barriers.
Implications for Program, Policy, and/or Research: Even the institution of a modest co-pay may result in significant declines in STD clinic service utilization and diagnosed STDs, particularly among the age group at highest risk for these infections. The cost to society for these undiagnosed infections likely outweighs any co-pay benefit.
Learning Objectives: At the end of this presentation, the audience will be able to assess the impact of a mandatory fee for service on STD clinic utilization and diagnosed CT and GC infections.
JA Schillinger1, B Batteiger2, D Stothard2, J Chapin1, K Hutchins1, P Braslins3, LA Shrier4, G Madico3, PA Rice3, B Van der Pol3, T Breen3, B Katz3, D Orr3, J Papp1, LE Markowitz1
1Centers for Disease Control and Prevention, Atlanta, GA; 2Indiana University School of Medicine, Indianapolis, IN; 3Boston Medical Center, Boston, MA; 4Children’s Hospital, Boston, MA
Background: Few studies have described genotype-specific concordance for Chlamydia trachomatis (Ct) infection in sexual partnerships.
Objective: To measure genotype-specific concordance for Ct infection in heterosexual partnerships (dyads).
Methods: Sexually active males and females aged 14-24 were recruited at clinical settings in Indianapolis and Boston, interviewed, and tested for Ct. Sex partners of Ct-infected index participants were offered study enrollment. Ct infection was determined by culture (endocervical and urethral specimens), and nucleic acid amplification testing (NAAT) (endocervical, urethral, and urine specimens). CT-positive specimens were genotyped by amplification and sequencing of the full-length omp1 gene.
Results: A total of 82 dyads were enrolled (39 female and 43 male index participants and their partners). Ct infection was detected (by culture or NAAT) in both members of 45/82 dyads (55%). Genotype results available for 32 (71%) of these dyads revealed different genotypes in 2 dyads (E4/F, D/E), reducing genotype-specific concordance estimates by 2 dyads to 52% (43/82). Genotypes identified in concordant dyads were: E/E (n=11), Ia/Ia (n=4), D2/D2, (n=3), F/F (n=4), E7/E7 (n=2), J/J (n=2), E4/E4, K/K, E6/E6, H/H (each, n=1). Genotype-specific concordance rates were similar for partners of male and female index patients. There were 13 NAAT-positive index participants who were culture-negative; none had a partner who was Ct-infected by any test.
Conclusions: Genotype-specific concordance rates were high, similar to those reported previously, however, with incomplete genotype data, our measures of concordance must be considered maximum estimates. Ct infection was not documented in any of the partners of persons who were NAAT-positive, but culture-negative; transmission risk may be lower from such persons.
Implications for Policy, Programs, and/or Research: The sex partners of Ct-infected persons have a high probability of infection. Interpretation of NAAT-positive, culturenegative specimens will be aided by measures of organism load, and adjustment for duration of sexual partnership and frequency of intercourse.
Learning Objectives: By the end of this session, participants will be able to:
Explain why concordance for infection was used as a surrogate measure of transmission in this study
Describe rates of concordance measured among heterosexual dyads in this study
Discuss why the estimates of concordance presented are likely to be maximum estimates
S Zackery1, M Sutton1, C Ciesielski2, M Zajackowski2, M Santana2, C Langley3, L Bernard3, V Pope1, M Fears1, R Johnson1, L Markowitz1
1Centers for Disease Control and Prevention, Atlanta, GA; 2Chicago Department of Public Health, Chicago, IL; 3Indiana University, Purdue University, Indianapolis, IN
Background: Rapid diagnostic tests for syphilis, used in many international settings, are not approved for use in the United States (US). Rapid tests can provide results in under 20 minutes and may allow earlier diagnosis and treatment of persons with syphilis.
Objectives: To evaluate performance of immunochromatographic strips (ICS) rapid syphilis tests on whole blood, serum, and plasma, using TP-PA as the reference.
Methods: Enrollees are consenting adults who present at STD Clinics in 2 US cities. Each person has a finger prick and venipuncture, permitting whole blood, plasma, and serum evaluations of 3 ICS tests at the local site and serum only at the CDC laboratory. Persons enrolled are tested and treated for syphilis, if needed, according to established standards.
Results: Preliminary data for 366 persons were analyzed. The median age of enrollees was 28 years; 18 persons had an active syphilis infection. The 3 ICS tests being evaluated at local sites had sensitivities ranging from 35% to 83% in whole blood, 50% to 93% in serum, and 41% to 93% in plasma; specificities ranged from 92% to 99.5%.
Conclusions: The performance of some rapid ICS tests being evaluated suggests potential for strengthening domestic efforts at syphilis prevention and control.
Implications for Programs, Policy, and/or Research: Earlier diagnosis and treatment of syphilis may prevent transmission. These rapid, easy-to-use tests may be used in some non-traditional settings allowing diagnosis of persons who may not present in routine clinical settings.
JD Klausner1,2, K Steiner1, R Kohn1
1San Francisco Dept Public Health, San Francisco, CA; 2University of California, San Francisco, San Francisco, CA
Background: Outbreaks of syphilis in major world cities have challenged disease control efforts. Public health authorities are increasingly using azithromycin by mouth rather than benzathine penicillin G injection to treat incubating syphilis. We examined the efficacy of azithromycin for the prevention of syphilis.
Methods: Using the San Francisco County STD registry, we sampled all patients who were treated for syphilis since January 1999 whose baseline rapid plasma regain (RPR) or venereal disease research laboratory (VDRL) test was nonreactive and had a followup RPR or VDRL between 30 and 90 days after treatment, excluding biological false positive tests. Treatments included: azithromycin 1 gram PO once, benzathine penicillin G 2.4 million units IM once and doxycycline 100 mg PO BID for 14 days. Success was a negative test for syphilis 30 to 90 days after treatment, whereas failure was any reactive test or further treatment in this period. HIV status was determined by record review. We calculated 95% confidence intervals and compared treatment results by Chi-square.
Results: Azithromycin successfully prevented syphilis infection in 96 (98%) of 98 patients versus 15 (94%) of 16 patients treated with benzathine penicillin G (p=0.32) and 5 of 5 treated with doxycycline.
Conclusions: While a modest sample, treatment failure was uncommon. Success did not vary by treatment or HIV status. Azithromycin 1 gram may be as effective as benzathine penicillin G for the treatment of incubating syphilis and thus prevent syphilis in persons regardless of HIV status.
Implications for Programs, Policy, and/or Research: Further research demostrating efficacy of azithromycin in treating syphilis using an experimental design with a larger sample is indicated.
S Lukehart1, C Godornes1, B Molini1, P Sonnett1, S Hopkins2, F Mulcahy2, J Engelman3, A Rompalo4, C Marra1, J Klausner3
1University of Washington, Seattle, WA; 2St James Hospital, Dublin, Ireland; 3San Francisco Department of Health, San Francisco, CA; 4Johns Hopkins University, Baltimore, MD
Background: Recent outbreaks of syphilis have been reported in the United States, Canada, British Isles, and Europe. Azithromycin has been used as alternative therapy for syphilis in some settings and cases of apparent azithromycin treatment failure have been identified in San Francisco. The Street14 isolate of T. pallidum has been shown in vitro to have macrolide resistance associated with a 23S rRNA gene mutation.
Objective: To investigate the association of a 23S rRNA gene mutation of T. pallidum with functional resistance to azithromycin and to screen samples of T. pallidum for this mutation.
Methods: A rapid PCR-based restriction digestion assay was developed to detect the 23S rRNA gene mutation and was used to screen T. pallidum in a convenience sample of lesion swabs or isolates from Seattle, San Francisco, Baltimore, and Dublin. In separate studies, rabbits were infected intradermally with Street14 or Nichols strain T. pallidum and treated with benzathine penicillin (BPG), erythromycin (equivalent 2 g/day x 14 days), or azithromycin (equivalent 1 g/day x 14 days); controls were untreated.
Results: The mutation was identified in 1 (4%) of 25 swabs collected in San Francisco before 2003, and in 6 (27%) of 22 collected during 2003. The mutation was found in 2 (9%) of 22 Seattle isolates (2001-2003), in 2 (10%) of 21 swabs from Baltimore (1998-2000), and in 15 (88%) of 17 swabs from Dublin (2002). DNA sequencing in 9 samples revealed an identical A_G mutation. Rabbits infected with Street14 had T. pallidum in lesions throughout erythromycin and azithromycin therapy, but were cured by BPG; rabbits infected with Nichols strain (lacking the mutation) were cured by all three regimens.
Conclusions: A mutation in the 23S rRNA gene, associated with resistance to azithromycin, was identified in samples collected from syphilis patients from all four geographical locations.
Implications for Programs, Policy, and/or Research: These findings suggest that the widespread adoption of azithromycin as an alternative treatment for syphilis may be imprudent. The true frequency of this mutation is unknown.
Learning Objectives: At the end of this presentation, the audience will understand that a mutation conferring azithromycin resistance is present in Treponema pallidum strains from 4 different geographical regions.
Washington University, St Louis, MO
Background: The National Plan to Eliminate Syphilis calls for significant progress toward syphilis elimination in the US by 2005. St Louis, Missouri has been designated as a syphilis high-morbidity area (HMA), owing to persistently high rates of infection. Despite public health officials’ best efforts to seek broad consensus on how to achieve syphilis elimination, the voices of practicing physicians are consistently underrepresented in these dialogues.
Objective: To utilize qualitative research methods to explore physicians’ understandings of syphilis transmission, and to elicit physicians’ perspectives on how best to reduce or eliminate syphilis in the context of national prevention efforts.
Methods: In-depth, ethnographic interviews and participantobservation were conducted among 21 primary care physicians who provide medical care for patients with or at risk for syphilis in St Louis, Missouri. Interviews were conducted by a trained physician-anthropologist and covered clinical, behavioral, social, and psychological factors linked to syphilis transmission. Qualitative data were formally analyzed to determine recurrent themes voiced by physician informants.
Results: Many physicians found fault in patients with syphilis for failing to seek care in a timely fashion, for failing to comply with medical treatment recommendations, and for failing to refer partners for evaluation and treatment in a timely fashion. Health officials were also faulted for lack of commitment to achieve syphilis elimination across artificial jurisdictional boundaries. Physicians cited time constraints in clinical encounters as a barrier to effective risk-reduction counseling among patients with syphilis or other sexually transmitted infections.
Conclusions: Qualitative research among physicians in St Louis demonstrated widely-shared convictions that syphilis elimination efforts are impeded by poor patient healthcare seeking behaviors, and are frustrated by weak public health commitments to achieve disease control.
Implications for Programs, Policy, and /or Research: Outreach efforts to physicians regarding community syphilis elimination agendas may serve to alleviate concern and suspicion with regard to public health interest in achieving stated disease prevention goals. Additional physician training in risk-reduction counseling and behavior change may further contribute to reductions in syphilis transmission.
Learning Objectives: By the end of this presentation, participants will be able to:
Understand physician viewpoints on public health programs to eliminate syphilis
Describe perceived barriers to syphilis elimination described by physicians
Outline physicians’ perspectives on methods to enhance the success of syphilis elimination efforts in local communities
Director of Education, Montrose Clinic, Houston, TX
Background: A sharp 3-fold increase in cases of primary and secondary syphilis over a 1-year period is seen among MSM in Houston, TX.
Objectives: To produce a targeted syphilis awareness campaign to raise awareness and increase testing among Houston MSM.
Methods: Phase I involved assessing the MSM community, first by identifying anonymous-sex venues frequented by MSM then through a brief rapid-assessment survey measuring attitudes, knowledge, community norms, and risk behavior. This survey was administered to 112 MSM at anonymous-sex venues revealed in the venue identification process. Phase II utilized information learned in Phase I to develop campaign materials designed to educate about and increase testing for syphilis. Dissemination of the campaign materials to MSM was the goal of Phase III. Over a 6-month period, posters, passcards, and condom packs were distributed at anonymous-sex venues and full-page color advertisements were placed in local publications with large gay male/MSM readership.
Results: Assessment activities uncovered over 70 anonymous-sex venues, including adult bookstores, bathhouses, public parks and restrooms, and fitness centers. The rapid-assessment survey revealed a low perception of risk for syphilis (58% thought they were unlikely to contract an STD, yet 57% never used condoms for oral sex and 18% never used condoms for anal sex). Furthermore, 12% didn’t think syphilis could be transmitted through oral sex, and 53% thought a penile discharge was a symptom of syphilis. Project staff distributed over 24,000 passcards, 100,000 condom packs with informational cards, and hung 6,000 posters at various sites in Houston. Multiple advertisements in publications are estimated to have reached over 100,000 MSM.
Conclusions: The number of MSM tested for syphilis increased by 22% from 1-year prior and syphilis rates among MSM have dropped slightly in recent months.
Implications for Programs, Policy, and/or Research: A well-planned and designed awareness campaign can have a serious impact on the public health of a community by raising awareness and increasing testing.
Learning Objectives: By the end of this session, participants will be able to describe how Montrose Clinic developed a syphilis awareness campaign targeted to MSM in Houston.
J Mayer1, T Robinson2, F Weaver2, A Holterman3, N DeArmitt2
1School of Public Health, Saint Louis University, St. Louis MO; 2Department of Health, City of Saint Louis, St. Louis MO; 3Missouri Department of Health and Senior Services, Jefferson City MO
Background: Recent surveillance data from Saint Louis from 2002-03 indicate a surge in syphilis cases among MSM similar to increases seen in several large U.S. cities since 1999. With the introduction of highly active antiretroviral drug treatments (HAART), many MSM have increasingly viewed HIV as a manageable chronic disease. In addition, many MSM report fatigue or ‘burn-out’ from repeated safe-sex messages.
Objectives: Most current interventions do not address message fatigue or the effects of HAART on perception of risk.
Methods: All consecutive attendees at a Saint Louis bathhouse from June-September 2001 were asked to complete a 9-page survey in return for a $15 incentive. Independent variables included HAART-related reduced HIV concern, prevention message fatigue, fatalism, sensation-seeking, social norms and condom benefits and barriers. Cronbach alphas ranged from .66 to .87. Dependent variables included frequency of condom use during insertive and receptive anal sex with casual partners.
Results: Of 379 men approached, 350 completed the survey (response rate = 92%). Mean age was 39 years, and one-half had a college degree. Mean number of casual partners per month was 1.1 for receptive anal sex (range: 1-32), and 1.4 for insertive anal sex (range: 1-25). Onethird reported using condoms half the time or less. In stepwise regression analyses, message fatigue, HAARTrelated reduced HIV concern, social norms and condom barriers explained 10-12% of the variance in condom use. Moreover, after controlling for age, education and number of partners, both message fatigue and HAARTrelated reduced HIV concern contributed significantly to explaining condom use (p< .05).
Conclusions: Overcoming message fatigue and accurately portraying the consequences of HAART are important components for interventions promoting consistent condom use and reducing syphilis among MSM.
Implications for Programs, Policy, and/or Research: Innovative health communication materials employing HAART-related reduced HIV concern, prevention message fatigue, and other study constructs will be presented and described.
Learning Objectives: At the conclusion of this presentation, attendees will be able to:
Describe how recent advances in drug treatment for HIV may lead to increases in risky sexual behavior
Describe how repeated exposure to safe-sex messages may create prevention message fatigue that appears to be positively associated with risky sexual behavior
Construct messages for STD prevention campaigns that address prevention message fatigue and the effects of HAART on perceptions of risk
HH Handsfield1,2, CL Celum1, L Corey1,3, G Bolan4, PA Leone5
1University of Washington, 2Public Health – Seattle & King County, and 3Fred Hutchinson Cancer Research Center, Seattle, WA; 4California Department of Health Services, Berkeley, CA; and 5University of North Carolina, Chapel Hill, NC
Background and Rationale: Genital herpes, due primarily to herpes simplex virus type 2 (HSV-2), is global public health problem. Evolving data implicate HSV-2 in enhanced sexual transmission of HIV; diagnostic and screening tests are increasingly available; and the potential for prevention is rising through new strategies, such as antiviral therapy to curtail transmission, and validation of old ones, such as condom use. Although clinical and prevention recommendations have been promulgated by CDC and other agencies, few if any public health agencies have implemented systematic programmatic prevention strategies against genital herpes.
Objectives: (1) To address the current state of the art of the public health impact of genital herpes, potential prevention strategies, diagnosis, and HIV/HSV-2 interactions; (2) To propose model genital herpes prevention strategies by public health STD control programs and assess barriers to their implementation.
Content: Speakers will present state-of-the-art lectures on the varied clinical presentation of genital herpes and the use and performance of HSV-2 diagnostic and screening tests; mutual transmission interactions between HSV-2 and HIV; and prevention of genital herpes and its complications. Elements of a model public health-based genital herpes prevention program will then be presented for discussion among the speakers and other panelists, representing academia and state and local health departments, with audience participation.
Implications for Programs, Policy, and/or Research: Public health agencies and STD control programs may use the information to assess priorities and consider implementation of genital herpes prevention strategies.
H Hunter Handsfield, MD
University of Washington and Public Health – Seattle & King County, Seattle, WA
Connie L Celum, MD, MPH
University of Washington, Seattle, WA
Fred Hutchinson Cancer Research Center and University of Washington, Seattle, WA
California Department of Health Services, Berkeley, CA
Leone, MD, MPH
University of North Carolina, Chapel Hill, NC
Measurable Learning Objectives:
Participants will be able to discuss the performance and costs of available virologic and serologic tests for genital herpes diagnosis, the influence of HSV- 2 on HIV transmission, and efficacy of condoms and antiviral therapy in preventing transmission of HSV.
Participants will understand the potential efficacy, population-based impact, and possible barriers to implementing programmatic strategies to prevent genital herpes.
G Mehlhaff, A Gandelman, L DeSantis
California Department of Health Services, STD Control Branch, CA STD/HIV Prevention Training Center
Background and Rationale: Disclosure of HIV status can be a challenging, complex, and possibly dangerous process. HIV positive individuals are often told to tell their partners of their serostatus, but are often not given support with disclosure skills. Disclosure of HIV positive status can be an effective Prevention With Positives intervention. Given the high rates of syphilis/HIV co-infection, coaching for self disclosure of HIV and syphilis status is an increasingly important strategy to consider during syphilis partner interviews. A skills-based training was developed for helping patients explore the complex issues surrounding disclosure and for coaching patients for successful disclosure. Of 174 training participants to date, skill efficacy rose from an average of 3.44 to 4.78 in identifying patient benefits and concerns related to disclosing HIV status, and from 2.78 to 4.56 regarding provider ability to effectively coach clients through the disclosure process, before vs. after the training (scale 1:poor- 5:excellent). Interactive trainings with practice sessions to develop skills can build provider efficacy.
Purpose: To apply a proven technique of training providers to better address the issues of disclosure of HIV status to syphilis patient interviews to enhance the outcome.
Methods: Using adult learning theory, faculty will provide a brief description and rationale for the course, and use interactive exercises to identify the issues facing HIV/syphilis infected individuals around disclosure. Participants will 1) identify benefits and barriers to disclosing disease status, 2) practice skills to support patient disclosure, and 3) discuss how this intervention can be adapted and implemented by STD control program staff. This will be an interactive skill building session.
Measurable Learning Objectives: By the end of the session, participants will be able to:
Gain a better understanding of patient issues surrounding disclosure including domestic/intimate partner violence;
Explore potential benefits and barriers of self disclosure with their patients;
Enhance coaching skills to support patient self disclosure of syphilis and HIV positive status.
S Ratelle1, J Dyer1, T Cherneskie2, P Coury-Doniger3, T Hogan4, J Howland5, P McGrath3, S Minsky5, S Payette6, A Rompalo7, R Shnekendorf 2
1Division of STD Prevention, Massachusetts Department of Public Health, Boston, MA; 2New York City Department of Health and Mental Hygiene, New York, NY; 3Center for Health and Behavioral Training, University of Rochester, Rochester, NY; 4Baltimore STD/HIV Prevention Training Center, Baltimore, MD; 5Boston University School of Public Health, Boston, MA; 6New York State Department of Health, Albany, NY; 7Johns Hopkins School of Medicine, Baltimore, MD
Background: The National Network of Prevention Training Centers is a CDC-funded group of regional centers dedicated to increasing the knowledge and skills of health professionals in the areas of sexual and reproductive health. Needs assessments drive training activities. Information elicited from managed care providers (MCPs) can be instrumental in planning training for this hard-to-reach group.
Objective: To assess the STD training needs of MCPs related to STD diagnostics use, screening practices, patient/partner counseling, and other patient management issues to guide clinical training activities of the Eastern Quadrant Prevention Training Centers (EQPTCs).
Methods: EQPTCs and Boston University School of Public Health surveyed 649 MCPs in Boston, New York, and Baltimore. Clinicians were randomly selected among participating organizations and randomly assigned Syphilis, Chlamydia, or Training needs assessments.
Results: A total of 294 surveys were completed. Key findings include:
Syphilis: Overall, 58% stated that management of an HIV+ patient with reactive syphilis serology was “often” or “always” a challenging practice issue. Nearly 25% do not screen HIV+ patients at least annually, and 20% do not screen sex workers at least annually. Regional differences were found in screening practices.
Chlamydia: Nearly 25% found it “often” or “always” challenging to determine who should be screened. Forty percent stated they rarely screen sexually active females aged 12 to 19.
Training: Desired topics included: new STD diagnostic techniques, techniques for discussing sexual risk taking behavior, behavioral counseling models. Preferred modalities included update conferences, grand rounds, web-based/Internet formats.
Conclusions: Data highlights areas in which MCPs can benefit from targeted training activities of the EQPTCs.
Implications for Programs, Policy, and/or Research: Managed care providers’ levels of comfort in addressing STDs, screening practices, most salient training needs, and preferred modalities can guide training content development. Data can also provide important quality assurance information for STD screening and patient care.
Learning Objectives: By the end of the session, participants will be able to identify STD training needs/modalities and practices of managed care providers that have implications for clinical training.
C Mason1, L Shelby1, R Pacheco1, S Adler2, J Pearl2, T Anderson3, C Nelson4
1Indian Health Service, National Epidemiology Program, Albuquerque, NM; 2California STD/HIV Prevention Training Center, Berkeley, CA; 3Denver STD/HIV Prevention Training Center, Denver Public Health, Denver, CO; 4Kaiser Permanente, Denver, CO
Background: STDs among AI/AN populations remain a substantial heath concern. Improved training that targets the learning needs of providers may help in addressing STDs in AI/ANs.
Objective: To assess STD training needs among health care providers who provide care to AI/ANs.
Methods: Approximately 60 in-person structured interviews were conducted with health care providers in fourteen distinct rural and urban AI/AN health care settings. The interviews assessed training needs related to: 1) STD prevention, diagnosis, treatment, and partner management; 2) preferences for STD training logistics and modalities; and 3) receptivity to a web-based provider training program specifically designed for providers serving AI/ANs (ID-Web).
Results: Most providers preferred training in the format of brief reviews or STD updates on diagnosis and treatment. Providers are generally receptive to online training. However, providers had several concerns about online training. These include: time constraints, perceived complexity of use, integrity of information, and potential linkage to performance appraisals.
Conclusions: STD-focused training should be integrated with existing, widely attended medical conferences for providers serving AI/ANs. While providers are receptive to online training, ID-Web may present implementation and acceptance challenges.
Implications for Programs, Policy, and/or Research: Provider training in STD care may need to focus on updates in diagnosis and treatment that are integrated into existing medical conferences. Online training may require sitespecific efforts to overcome initial barriers to implementation and acceptance.
Learning Objectives: Participants will be able to identify providers’ preferred learning modalities related to the treatment of STDs in AI/ANs.and describe the acceptability and perceived utility of computerized learning methods in largely underserved health care settings.
A Pérez1, J Delgado2, A Smith3, A Gandelman3
1California Department of Health Services, STD Control Branch, California STD/HIV Prevention Training Center, Long Beach, CA, 2Fresno, CA, 3Berkeley CA
Background: Prevention staff who work with monolingual Spanish-speaking clients often face cultural and linguistic challenges when assessing knowledge, attitudes, and behaviors of persons at risk for STD/HIV. Staff who can address these challenges can more effectively assess client risk(s) and identify appropriate interventions that meet community needs.
Objectives: Discuss the design, implementation, and evaluation of a 1-day skills-based training (Resumen de Enfermedades Transmitidas Sexualamente) that integrates Hispanic/Latino attitudes and beliefs about sexuality and STD/HIV; reinforce cultural norms that support safer sex practices; and describe a set of instructional games derived from popular US/Mexico culture used to enhance training.
Methods: Spanish language STD/HIV trainings were conducted for staff from health department, family planning, and community agencies. Interactive activities were used to 1) reinforce concepts of basic STD/HIV epidemiology, transmission, prevention messages, and STD/HIV interaction issues, and 2) integrate into Latino culture and participants’ personal experiences. Participants learned about the prevention and transmission of numerous STDs.
Results: Participant evaluations indicated increased levels of confidence in 1) understanding of STD/HIV prevention and transmission, 2) educating co-workers and clients about STDs, and 3) effectively integrating these messages from a Latino cultural perspective. These results will be discussed in greater detail during the presentation.
Implications for Programs, Policy, and/or Research: Latino and/or Spanish-speaking staff can be trained to effectively disseminate accurate STD/HIV prevention messages in their respective communities. Since many are wellrespected among their existing peers, they have the potential to be powerful community leaders in efforts to reduce STD/HIV.
Learning Objectives: By the end of the session, participants will be able to:
Learn how the training: Resumen de Enfermedades Transmitidas Sexualamente was developed and implemented for Spanish-speaking educators/program staff
Become familiar with 2 culturally appropriate interactive exercises that were integrated into the training and how they enhanced the course
R Thomas1, FB Coles1, S Payette1, H Battles2, K Heavner2, J Tesoriero2, S Leung2, K Rowe2
1New York State Department of Health, Bureau of STD Control and NYS STD/HIV Prevention Training Center; Albany, NY; 2New York State Department of Health, AIDS Institute, Albany, NY
Background: NYS has a strong STD/HIV public health infrastructure for partner notification (PN). State law requires medical providers to report known partners/PN plans for HIV. Given the role of provider as gatekeeper/arbiter for PN, the NYS STD/HIV Prevention Training Center (CDC-funded PTC) collaborated on a statewide survey to assess physician proficiency/training needs in partner elicitation and notification skills.
Objective: To assess physician proficiency in and interest in training for key PN skills/tasks.
Methods: In 2003, a stratified random sample of physicians in specialties treating STDs was surveyed. Respondents self-rated a) 13 PN proficiencies (1=limited to 4=excellent); and b) training interest for each skill. Response rate: 60% (N=835).
Results:Weighted results show 45% of physicians were “very interested” and 42 % “somewhat interested” in additional information on best practices related to partner elicitation/notification. Proficiency was lowest for “describing services available through health department’s partner notification program” (48% limited proficiency); “collecting additional identifying/locating information when name/address or phone number of partner is unknown” (47%); “establishing specific plan for notification with agreed upon timeframes” (46%); “confirming notification was completed for partners patients want to self-notify” (42%). Physicians had more confidence in asking patients about same-sex partners and partners outside marriage (15/17% “limited” ability). Proficiency varied by specialty, and level of STD treatment (P <.001). Training interest varied by proficiency (less skilled most interested), and specialty. Forty-four percent expressed interest in training on one or more PN proficiency areas.
Conclusions: Results show differential skill levels for key PN skills/tasks, limited familiarity with health department PN programs, and interest in PN-specific best practices/additional training.
Implications for Programs, Policy, and/or Research: Expanded models for PN/PCRS are being explored nationwide. Survey results show the potential of physicians as strong partners in PN, an interest in information/ training related to STD/HIV partner services, and provide direction for tailored training.
Measurable Learning Objectives: By the end of the session, participants will be able to discuss the level of NYS physician proficiency in (and characteristics associated with) key skills related to STD/HIV partner elicitation/notification; to describe the level of interest in receiving information on best practices and/or training in this area; and consider implications for structuring and tailoring training.
L Fischer, CK Kent, JD Klausner
STD Prevention and Control Services, San Francisco Department of Public Health (SFDPH), San Francisco, CA
Background: California law requires health care providers to report treatment for STDs. In San Francisco during 2001, only 3% of providers outside the municipal STD clinic reported treatment of their clients with gonorrhea (GC) or chlamydia (CT).
Objectives: To develop, implement and evaluate an STD treatment verification program.
Methods: Providers were divided into three categories; Community Screening sites, County Hospital based clinics and large volume Private Providers. Education about the importance of STD treatment and the legal requirements of reporting were reviewed with providers. Barriers were cited and identified such as providers not believing it was important information to report or not realizing reporting treatment was required. SFDPH STD staff was assigned to follow-up with providers not reporting GC or CT treatment within 72 hours of report of disease to document appropriate treatment.We compared treatment information about persons with CT and/or GC from January through June 2002 with January through June 2003, by provider type.
Results: All three provider types saw a substantial increase in reporting treatment between 2002 and 2003: Community Based screening clinics went from 16% (314/1946) to 92% (1,417/1,537); high volume private providers increased from 27% (156/571) to 46% (176/385); and the county hospital based clinics went from 15% (33/213) to 36% (77/217).
Conclusions: Barriers to reporting treatment by all providers can be overcome. However, there are more challenges in obtaining treatment information from the county hospital and private providers than STD Program supported sites. Assigning staff to follow up about treatment within specific time frames after receiving report and educating and providing technical assistance about the requirement and importance of this information improves reporting procedures.
Implications for Programs, Policy and/or Research: Understand the development and implementation of consistent and timely GC/CT treatment reporting utilizing existing screening and surveillance staff.
Learning Objectives: By the end of the session, participants will be able to develop and implement a GC/CT treatment verification program utilizing existing staff.
BF Ulin1, T Foskey2
1Centers for Disease Control and Prevention, Atlanta, GA; 2Texas Department of Health
Background: Viral hepatitis is a major health problem in the United States. The routes of transmission for HIV, HBV, and HCV overlap substantially, and the major risk factors for HBV and HCV infections are often identical to those for HIV and other sexually transmitted diseases. Integrating viral hepatitis prevention messages into HIV and STD programs was identified as an essential step towards prevention and control of these infections.
Objective: Provide HIV/STD prevention counselors and Disease Intervention Specialists (DIS) with the necessary knowledge and training to integrate viral hepatitis prevention services into existing HIV/STD prevention programs.
Methods: A model curriculum was developed by the Texas Department of Health (TDH) to integrate viral hepatitis prevention messages into existing HIV/STD prevention programs. The curriculum consists of two precourse modules followed by a one-day training. The training includes a knowledge assessment, review of counseling skills, overview of viral hepatitis risk behaviors, and role-plays to build skills in transitioning from HIV to viral hepatitis and providing positive HCV results.
Results: Between October 1, 2000 and February 28, 2001, 176 prevention staff were trained. TDH began funding 25 sites in October 2000 to conduct HCV testing for high-risk populations. Between October 1, 2000 and September 30, 2003, a total of 54,282 specimens were submitted to the TDH lab. Of those, 12,933 (24%) HCV reactive EIA tests were identified.
Conclusions: After the training, staff members were more prepared to address client risk factors and questions related to HCV. Staff members were also able to transition to a discussion of viral hepatitis and develop risk reduction plans to reduce the risk for viral hepatitis is addition to reducing risk for HIV/STD.
Implications for Programs, Policy, and/or Research: The development of viral hepatitis training curricula offers an opportunity for all public health programs to learn about how to integrate hepatitis prevention messages into existing HIV/STD health prevention messages. These services can be easily and effectively provided, even in the context of limited financial and human resources.
Learning Objectives: By the end of this session, participants will be able to:
Describe key elements of a viral hepatitis curriculum.
Understand the importance of integrating viral hepatitis prevention into existing HIV and STD programs.
LH Bachmann1,2, J Feldman1, Y Waithaka1, EW Hook III1
1University of Alabama at Birmingham, Birmingham, AL; 2Birmingham Veterans Administration Medical Center, Birmingham, AL
Background: Few data are available regarding STI risk and prevalence among patients receiving outpatient psychiatric treatment.
Objective: To determine sexual and substance use risk behaviors and the prevalence of C. trachomatis, N. gonorrhoeae, and T. vaginalis in patients between 18-50 receiving care at the University of Alabama at Birmingham (UAB) Community Care Psychiatric Outpatient Clinic.
Methods: Male and female patients received an intervieweradministered survey and submitted urine (male) or selfobtained vaginal swabs (female) for testing for C. trachomatis, N. gonorrhoeae and T. vaginalis (women only).
Results: In this ongoing study, 82 participants (38 (46%) female and 44 (54%) male) have been enrolled. The majority were black (68%) or white (27%) with a mean age of 38 (22-50). Over 97% receive medication for a variety of chronic psychiatric conditions. Alcohol use (46%) and illicit drug use (21%) were relatively common during the 6 months prior to study enrollment. Most participants had never married (66%) or were separated/divorced (27%). Among enrollees, 59% reported sexual activity within the last 6 months with a median of 1 partner (1-12) and of 38 (46%) participants engaging in activity within the previous 30 days, 21% (N=8) reported 1 or more new partners. Almost a quarter (22%) of the women were infected with T. vaginalis and 1% of the population was infected with C. trachomatis.
Implications for Programs, Policy and/or Research: A substantial proportion of patients receiving outpatient psychiatric care are at risk for STI. Screening in older outpatient psychiatric populations should focus on detection of T. vaginalis. Results should not be generalized to younger populations receiving chronic outpatient psychiatric care.
Learning Objectives: By the end of this session, participants will be able to describe the sexual and substance use behaviors and STI prevalence in patients receiving chronic outpatient psychiatric care.
GR Burstein1, MA Snyder2, D Conley2, DR Newman1, CM Walsh1, G Tao1, K Irwin1
1Centers for Disease Control and Prevention, Atlanta, GA; 2Kaiser Permanente Mid-Atlantic States, Rockville, MD
Background: In 2000, a new HEDIS performance measure was introduced to monitor the proportion of sexually active 15-26 year-old females screened annually for chlamydia.
Objectives: To determine changes in chlamydia screening policies, testing, and positivity rates after introduction of the HEDIS measure.
Methods: We reviewed electronic medical records of a large, commercial, managed care organization (MCO) serving a diverse patient population for endocervical chlamydia tests performed during 1998-2001 on 15-26 year-old females who were classified as sexually active according to administrative data elements specified by HEDIS. We used chi-square testing to compare chlamydia screening rates and positive tests for 2 years before and after introduction of the chlamydia HEDIS measure. We queried MCO departmental chiefs about practice changes implemented to meet the new HEDIS measure.
Results: During 1998-1999, 20,571/37,404 (55%) of eligible 15-26 year-old females were tested for chlamydia, of whom 1,681 (8%) tested positive. During 2000-2001, 26,801/37,237 (72%; P <0.0001) of eligible females were tested for chlamydia, of whom 1,852 (7%;P <0.0002) tested positive. Each year, approximately _ of the eligible females were seen at least once in obstetrics/ gynecology offices. In January 2000, the obstetrics/gynecology department instituted a policy of performing chlamydia tests with all Pap tests on 15-26 year-old females. During 1998-1999, 17,382/28,614 (61%) of eligible females seen in obstetrics/gynecology offices were tested for chlamydia while in 2000-2001, 23,797/28,663 (83%;P <0.0001) of eligible females seen in obstetrics/gynecology offices were tested for chlamydia.
Conclusions: Following HEDIS measure introduction in this MCO, the proportion of sexually active 15-26 year-old females tested for chlamydia increased overall with only a 1% decline in the proportion of positive tests. Most of the increase resulted from the new obstetrics/gynecology policy of coupling chlamydia screening with routine Pap tests.
Implications for Programs, Policy, and/or Research: Simple system changes and access to obstetrics/gynecology providers can improve chlamydia screening rates and detect a significant number of asymptomatic infections in a private sector MCO.
By the end of this session, participants will be able to describe interventions that can enhance chlamydia screening of sexually active young females in an MCO.
By the end of this session, participants will be able to demonstrate that chlamydia screening of sexually active young females can detect a large burden of asymptomatic infection in the private sector.
By the end of this session, participants will be able to identify at least one system-level intervention that has been used to attempt to increase screening rates.
J Armstrong, H Sangi-Haghpeykar
Baylor College of Medicine, Houston, TX
Background and Rationale: Chlamydia trachomatis (Ct) screening rates in the private health care sector remain poor despite the fact that several national guidelines recommend routine screening and a HEDIS measure that monitors screening rates in health plans has been in place for three years. In 2002, commercial health plans screened fewer than 25% of women for whom Ct screening was recommended. Physician screening practices in the private sector have not been fully characterized.
Objective: To describe the chlamydia screening practices of obstetrician-gynecologists caring for commercially insured women.
Methods: A total of 410 US Ob-Gyns who provide care to privately insured women were surveyed. Information was collected on rates of compliance with Ct screening guidelines and demographic and practice characteristics associated with screening.
Results: Of the respondents, 64%, 22%, and 9% were classified as screeners of pregnant women, sexually active women less than age 20 years, and sexually active women ages 20 to 25 years, respectively. Black physicians were 4.5 times more likely to screen compared to white physicians after adjusting for patient race (Adjusted OR=4.5, 95% CI 1.2, 15.6). Nearly three-fourth (73%) of respondents estimated that the prevalence of infection in their primary practice site was less than 5%. Nonscreeners were more likely than screeners to believe that the prevalence of infection in their primary practice setting was too low to warrant routine screening (p<.001) and report that knowledge of the prevalence of infection would positively influence compliance with screening recommendations (p=0.02).
Conclusions: Ob-Gyns do not routinely screen eligible women for chlamydia infection. Factors associated with non-compliance with established screening protocols have been identified.
Implications for Programs, Policy, and/or Research: This presentation will assist policy makers in understanding provider perspectives on the initiation and continuation of Ct screening in the private health care sector.
Learning Objective: Participants will be able to describe factors associated with Ct screening in the private sector and identify potential strategies to improve screening rates.
JM Chow1, LJ Packel1, L Creegan1, HM Bauer1, J Treat2, G Bolan1
1Sexually Transmitted Disease Control Branch, 2Office of Family Planning, California Department of Health Services, Berkeley, CA
Background: Young women accessing family planning/reproductive healthcare services are a target population for providing quality STD care. National guidelines recommend that women age 25 years and younger be annually screened for chlamydia. Reports of screening coverage suggest that most young women are not being screened.
Objective: To estimate the proportion of female clients age 15-25 that are screened for chlamydia by family planning providers and to develop a targeted provider quality improvement strategy to improve adherence to chlamydia screening guidelines.
Methods: Paid claims data from laboratories and clinician providers serving female clients in the Family PACT (Planning, Access, Care, Treatment) program were used to estimate the proportion of female clients age 15-25 years served in FY01/02 that were screened for chlamydia. Analysis was restricted to providers who served >100 female clients in this age group during 2002. These data were used to determine a targeted intervention based on screening rates.
Results: The median proportion of females age 15-25 years (n=567,284) who were screened for chlamydia for 866 providers was 52.5%. Forty-five percent of providers tested less than 50% of clients compared to 49% tested 50-79% of clients and 6.5% tested 80% or more of clients. The proportion of clients tested by public sector providers was not significantly different than private sector providers. A quality initiative was designed to provide individual feedback to providers with their specific screening rates and targeted messages based on screening level in September 2003.
Conclusions: There is significant variation in chlamydia testing with few providers testing the vast majority of their young female family planning clients.
Implications for Programs, Policy, and/or Research: Monitoring provider-specific adherence to chlamydia screening guidelines may be useful for identifying specific groups of providers in need of additional training. Targeted chlamydia testing data feedback to family planning providers may raise awareness of STD standards of care and potentially improves screening practices.
Learning Objectives: By the end of this session, participants will be able to describe a methodology for estimating provider-specific chlamydia screening based on claims data, describe the profile of providers who perform chlamydia screening in a large family planning program, and describe a targeted intervention for improving chlamydia screening based on provider data feedback.
NR Glick1, A Silva2, S Lyss3, S Whitman2
1Mt. Sinai Hospital, Chicago, IL; 2Sinai Urban Health Institute, Chicago, IL; 3Centers for Disease Control and Prevention, Division of HIV/AIDS Prevention, Atlanta, GA
Background: Recent studies show that patients in emergency departments (ED) have high rates of asymptomatic sexually transmitted infections (STIs) as well as a willingness to test for them during their visit. Therefore, routinely screening for STIs in EDs can identify asymptomatic patients who may otherwise go unrecognized. However, limited evidence exists on whether patients who test positive for STIs in EDs are successfully treated.
Objectives: To assess the prevalence of STIs and receipt of treatment among patients identified with STIs in an inner-city ED.
Methods: As part of an ongoing study assessing routine, voluntary HIV/STD screening in the ED, patients aged 15 to 25 years were offered free chlamydia and gonorrhea testing, Monday-Friday, 10AM-8PM. Patients were eligible if they provided informed consent and were not being treated for STI symptoms at the current visit. Urine samples were collected and tested by nucleic acid amplification. Patients testing positive for either STI were notified and referred to a public health or hospitalbased clinic for free treatment. Prevalence and treatment rates were assessed.
Results: In four months of screening, 188 patients were approached, and 78 (41%) consented to testing. Males and females tested were similar in terms of age and race/ethnicity to those who refused testing and to the ageeligible ED population. Of the 70 patients who provided a urine sample, 8 tested positive for chlamydia only, 1 for gonorrhea only, and 2 for both; the prevalence was 14% for chlamydia and 4% for gonorrhea. Of the 11 patients who tested positive for an STI, 9 (82%) received treatment.
Conclusions: Preliminary data show that patients with asymptomatic STIs can be identified in the ED and successfully linked to treatment.
Implications for Programs, Policy, and/or Research: Public health departments should consider working with EDs to identify and treat patients with asymptomatic STIs. Research is needed on the cost-effectiveness of STI screening and treatment in EDs.
Learning Objectives: By the end of the session, participants will be able to discuss the feasibility of integrating STI screening and treatment as part of routine care in an ED as part of a collaborative effort with a local public health department to decrease the prevalence of STIs.
MA Shafer1, K Tebb1, T Ko2, C Wibbelsman3, S Pecson-Cruz1, A Tipton2, M Pai-Dhungat1, J Neuhaus1, R Pantell1
1University of California San Francisco, Division of Adolescent Medicine, San Francisco, CA; 2Kaiser Permanente, Oakland, CA; 3Kaiser Permanente, San Francisco, CA
Background: Chlamydia trachomatis (CT) is the most common reportable bacterial infection in teen girls. Despite recommendations for annual CT screening, less than 25% are being screened. Our systems intervention significantly improved screening rates during health check-ups; however, since 2/3 of adolescents only use urgent care, the next obvious step was to screen in this venue.
Objectives: To evaluate the effectiveness of a modified clinical practice improvement intervention (CPI) to increase CT screening among 14-18 yo sexually active girls attending pediatric urgent care in an HMO setting.
Methods: As part of a larger, randomized control trial, the CPI was extended to 2 pediatric urgent-care clinics. A CPI team was formed at each clinic to establish protocols for confidential sexual history taking and urine collection. CPI teams met monthly, reviewed protocols, screening rates and problem-solved barriers using a rapid cycle change format. Screening rates were analyzed over three, 3-month periods (baseline and two post-tests). The proportion screened = number tested/(number seen x sexual activity rate).
Results: Compared to well care, teen girls attending urgent care had higher sexual activity rates (42% vs 26%; P<0.01), were older (15.6 vs 15.4; P<0.05) and more ethnically diverse. At baseline, 92/1072 (9%) girls were tested for CT with 11/92 (12%) positive. At timetwo, 472/1248 (38%) were tested; 33/472 (7%) were positive. At time-three, 407/659 (62%) were tested; 26/407 (6%) positive This represents a 7-fold screening increase and identification of 2-3 times as many CT infected girls.
Conclusions: Adolescent females attending urgent care appear to be at greater risk for CT and screening in this setting is feasible.
Implications for Programs, Policy and/or Research: The high rate of positives shows CT testing to be necessary in urgent care to reach the majority of at-risk girls who would otherwise remain undetected. Future research needs to include larger number of clinics and should assess the quality of follow-up care.
Learning Objectives: Participants will have identify barriers to CT screening and strategies for to increase CT screening in the urgent care setting.
H Weinstock, D Mosure, L Newman, S Wang, J Heffelfinger
Centers for Disease Control and Prevention, Atlanta, GA
Background and Rationale: STD surveillance data are critical for helping guide programmatic and policy decisions. Although national surveillance data for syphilis, gonorrhea, and chlamydia suggest that control programs have achieved considerable success over the past decade, trends over the past 2 years are worrisome for the emergence of new patterns of disease that may require local and state programs to re-evaluate their efforts.
Objectives: To describe the latest trends for each of the three major notifiable STDs using nationally reported surveillance data and to describe the program and policy implications of the changing epidemiology of these diseases.
Content: This symposium will include presentations on each of the notifiable STDs. Increases in primary and secondary syphilis among men who have sex with men in the United States as well as trends in other populations will be discussed as will implications for the Syphilis Elimination program. The presentation on gonorrhea will highlight those populations most impacted by this disease, notably young African-American men and women. Increases in antimicrobial resistance to the fluoroquinolones, the only remaining oral therapies recommended by CDC for treating gonorrhea (given the unavailability of Cefixime), will be described as will the implications on treatment recommendations. Trends in chlamydia case reports and prevalence monitoring data will also be presented, including findings from the Regional Infertility Prevention projects.
Implications for Programs, Policy, and/or Research: As new populations are impacted by STDs and as resistance to recommended therapies emerges, new strategies to prevent and control these diseases must be evaluated. These trends highlight priorities for research, including the identification of reasons for and interventions to address recent increases in STDs among men who have sex with men, the need to identify effective oral drugs to treat fluoroquinolone-resistant gonorrhea, and identification of more effective methods for gonorrhea and chlamydia control.
Learning Objectives: By the end of this session, participants should be able to:
Describe the latest trends in syphilis, gonorrhea, and chlamydia in the United States
Describe the impact of these trends on STD prevention and control programs
Community Health Awareness Group (CHAG), Detroit, MI
Background & Rationale: In the last decade of HIV prevention it has been explained that the population of African-American MSMs have been and remain one of the hardest hit groups in America’s HIV epidemic. While several attempts have been made to access this population for prevention & services, current methods that only imitate processes successful in the white gay population do not prove effective or appropriate with African-American men who have sex with men. This model attempts to bridge that gap in a manner that is culturally specific and inclusive of multiple agencies’ expertise in a way that preserves the unique spirit of the population for which it is designed.
Purpose: a) To explain the collaborative process and illustrate a specific way in which such practice can work in a community that bridges the services among multiple organizations to meet the needs of the population in question. b) To explain and advocate the use of a best practices model of HIV/AIDS prevention & services that is culturally specific for African-American men who have sex with men (AAMSM).
Methods: I will also use brief scenarios to describe the population of AAMSMs within four levels that more accurately reflect the uniqueness of this population alongside the barriers such as stigma, discrimination, and the struggle associated with sexual identity that impacts the provision of care and services. Then through the use of guided discussion I will elicit a listing of the specific needs of the AAMSM population in terms of prevention & care and help participants determine how such services are best received by the population through various community organizations.
Learning Objectives: By the end of this workshop participants will be able to:
Identify the level of collaboration operating within their organization’s current services and identify the multiple identities that are a part of the AAMSM population
Describe at least 2 factors that have acted as barriers to the acquisition of prevention & services for AAMSMs and how they can be overcome through effective collaboration with other agencies within their own communities
Create an action plan toward preparing your organization, to contribute to a prevention or service related effort in his/her own community through the use of one or more of a variety of evidence-based behavioral interventions
Centers for Disease Control and Prevention (CDC), Atlanta, GA
Background and Rationale: The field of STD epidemiology and prevention has evolved in the direction of population level approaches over the past two decades, while individual level analyses and interventions continue to play an important role. Some of the most remarkable advances have been in the areas of pathogen – population interactions; pathogen characteristics; impact of sexual mixing patterns, concurrent partnerships, structure of prevalent sexual networks on the spread of STI; impact of newly available therapies on STD spread; and societal determinants of sexual mixing patterns, concurrent partnerships, and sexual networks and their impact on changes in these determinants. In addition, there have been remarkable advances in methodologies employed in the study of populations and individuals in populations.
Objectives: To discuss cutting edge issues in partnership dynamics; network based risk factors and interventions; and social determinants of STD spread.
Content: The panelists will discuss the most recent advances in the methodological approaches to the study of multilevel risk factors and multilevel interventions in STD epidemiology and prevention. Particular attention will be paid to inter-level synergistic interactions. Specific discussions will include risk factors and interventions at the partnership, social network and societal levels.
Implications for Programs, Policy, and/or Research: Available research results will provide new directions for policy formulation and program development at more aggregate levels while highlighting remaining questions to be explored by future research.
Sevgi O. Aral
Centers for Disease Control and Prevention, Atlanta, GA
The University of North Carolina at Chapel Hill, NC
University of California, Los Angeles
University of Washington, Center for AIDS and STD, Seattle, WA
Wohlfeiler, JD, MPH STD
Control Branch, Berkeley, California
Measurable Learning Objectives: Attendees will be able to:
Identify STD risk factors at the partnership, sexual and social network, and societal levels.
Identify and choose among STD prevention interventions at the partnership, network and societal levels.
SM Goodreau, MR Golden
University of Washington, Seattle, WA
Background: STIs (including HIV) disproportionately affect men who have sex with men (MSM). STI transmission dynamics are determined by partner change rates, hostparasite biological factors and network structure. The relative impact of these factors in creating the disparity in STI between MSM and heterosexuals is ill-defined.
Objectives: To assess relative contributions of behavioral (partner number) and intrinsic biological (transmissibility) and structural (population size, number of sexes) factors in creating observed disparities in HIV rates between MSM and heterosexuals.
Methods: A deterministic compartmental model with 12 groups for MSM (2 activity classes by 2 serostatuses by 3 role classes—insertive, receptive, versatile) and 8 for heterosexuals (2 activity classes by 2 serostatuses by 2 sexes) is solved numerically 10 and 20 years after introduction of a single susceptible, and at endemic prevalence. The UMHS and NHSLS studies provide data to parameterize simulations.
Results: A fully versatile MSM population with observed rates of unprotected partnerships and anal intercourse transmissibility yields a prevalence of 15.6% at year 20 and 28.8% at equilibrium. A two-sex heterosexual population of the same size, partner change rate and HIV transmissibility yields 5.0% and 14.7%, respectively. A heterosexual population that is 10x larger yields 0.9% prevalence at year 20. When transmissibility is lowered to current estimates for vaginal sex, the epidemic dies out in heterosexuals.
Conclusions: Biological and structural factors inherent in male homosexuality result in substantial disparities in HIV morbidity between MSM and heterosexuals. These appear to dwarf the impact of currently observed disparities in unprotected anal/vaginal sex partner change rates.
Implications for Programs, Policy, and/or Research: Homosexuality imposes structural vulnerabilities to the introduction and promulgation of an STI epidemic that are independent of partner change rates. As a result, even if MSM had substantial reductions in high-risk sexual behavior, MSM remain relatively vulnerable to STI epidemics.
Learning Objectives: By the end of the session, participants will understand that being a relatively small, single-sex population combined with relatively high transmissibility makes MSM far more susceptible to an STI epidemic than heterosexuals. They will further understand that current efforts at HIV prevention in MSM generally focus on lowering unprotected contact rates and transmissibility without considering these structural factors.
BL Rapatski2, JA Yorke1,2,3, F Suppe1,4
1Institute for Physical Sciences and Technology, 2Department of Mathematics, 3Department of Physics, University of Maryland, College Park, MD; 4CMLL, Texas Tech University, Lubbock, TX
Background: We view HIV as a 3-stage model in which a person progresses through the primary, asymptomatic and symptomatic stage. A person’s infectivity, or the probability a contact between an infected and susceptible will transmits the disease, varies with stage of infection.We model the San Francisco “gay epidemic.” Beginning in 1978, blood samples from 6875 men were taken and behavioral data recorded as part of a Hepatitis-B vaccine trial. Subsequent reanalysis of some of those blood samples for HIV provides the most accurate incidence data describing the onset of HIV in any population. From the behavioral data collected we determine that the SF gay population can be broken into six sexual activity groups ranging from 231 partners per year to none.
Objective: To determine how infectious HIV is.
Methods: We use mathematical modeling which reflects the great variation in contact rates between gay men. Results: The infectivities for the primary, asymptomatic and symptomatic stages are 0.015, 0.006, 0.223 respectively. The third stage infectivity is significantly higher than the other two stages and ultimately drives the HIV epidemic.
Conclusions: A reduction of the effective contact rate (infectivity times frequency of contacts) by a factor of 100 would have been necessary for the gay epidemic to have ceased to be endemic. If we lower the effective contact rate by a factor of 10, similar to Sub-Saharan Africa, large outbreaks occur but are delayed by many years. The model suggests countries such as India have an epidemic doubling every year.
Implications for Programs, Policy, and/or Research: We provide a systematic way for predicting the growth of the epidemic in Third World countries and for evaluating the efficacy of diverse HIV reduction strategies including vaccination.
Learning Objectives: By the end of this session, participants will learn how infectious HIV is for gay men and will learn how to predict the fate of epidemics in the Third World.
Guidelines for the Use of Herpes Simplex Virus Type 2 Serologies: Recommendations From the California Sexually Transmitted Diseases Controllers Association and the California Department of Health Services
S Guerry1, H Bauer1, J Klausner2, B Branagan3, P Kerndt4, B Allen5, G Bolan1
1California Department of Health Services, STD Control Branch, Berkeley, CA; 2San Francisco City and County Health Department, San Francisco, CA; 3Sonoma County Health Department, Sonoma, CA; 4Los Angeles County Department of Health Services, Los Angeles, CA; 5Alameda County Public Health Department, Alameda, CA
Background: Although herpes simplex virus type-specific serology tests are now widely available, indications for their use have not been well-defined. Due to the lack of formal guidelines, the California Department of Health Services, in conjunction with the California STD Controllers Association, convened a committee to make recommendations for the use of HSV-2 type-specific serologies.
Objectives: To review all relevant literature to develop best practice guidelines for the use of type-specific HSV- 2 serology tests.
Methods: Published articles related to herpes, herpes screening, type-specific serology tests, herpes and HIV, herpes in pregnancy, neonatal herpes, condom efficacy, behavior intervention efficacy and antiviral suppression efficacy were identified using MEDLINE. In addition, bibliographies of identified articles, personal files of committee members, and unpublished manuscripts from HSV researchers were reviewed. Screening recommendations were developed by applying standard screening criteria to each specific population.
Results: HIV infected patients, patients with partners known to be infected with HSV-2, and highly motivated STD patients will likely benefit most from identifying HSV-2 status. There is less evidence that universal screening of pregnant women and the sexually active population will be beneficial to either the individual patient or to the public health of the community. Type-specific serology tests should be available for diagnostic purposes in conjunction with virologic tests at any clinical setting where patients are evaluated for STDs.
Conclusions: HSV-2 screening of asymptomatic patients will likely have patient and public health advantages if used in conjunction with proven interventions such as risk-reduction counseling and anti-viral suppressive therapy—for those identified with symptomatic infections— and if screening is targeted.
Implications for Programs, Policy, and/or Research: Screening and intervention resources should be directed towards the patient populations at highest risk for herpes acquisition and transmission and those most motivated to change behavior or to comply with treatment regimens.
Learning Objectives: By the end of the session, participants will be familiar with the recommended uses of HSV-2 serologies as well as the evidence supporting these recommendations.