2002 National STD Conference - Oral, Symposium, and Workshop Abstracts - A

A1A – A Comparison of the Spatial Distribution of HIV and Syphilis Cases in Six North Carolina Counties

W Jones¹, D Enright², D Williams¹, E Foust¹

1NC Division of Public Health, HIV/STD Prevention & Care Branch; 2NC Division of Public Health, State Center for Health Statistics, Geographic Analysis Unit

Background: GIS and spatial analysis can be useful tools for public health agencies to examine STDs. The NC OASIS (Outcome Assessment through Systems of Integrated Surveillance) Project sparked a collaborative initiative to examine HIV and syphilis disease patterns in select NC counties using exploratory spatial analysis techniques. Based on field and other observations in NC, we expected syphilis and HIV disease patterns to be similar.

Objectives: To verify the similarities between the spatial distribution of HIV and syphilis cases in the year 2000 and to examine if differences exist depending on the urban/rural nature of the county.

Methods: GIS was used to map year 2000 surveillance HIV and syphilis case information for six NC counties. Spatial statistics were used to evaluate the global and local disease patterns. The mean center, standard distance deviation, and standard deviation ellipse were calculated and compared to evaluate global patterns. A nearest neighbor index and Ripley’s K statistic were used to examine local clustering.

Results: There were no differences between the global HIV and syphilis distribution in any of the counties, however there were some differences found in local clustering.

Conclusions: In the year 2000, we did not find any significant global differences in the spatial distribution for these two diseases which supports efforts to jointly plan HIV and syphilis prevention initiatives. Further evaluation is needed to determine whether the syphilis pattern is predictive of HIV in future years.

Implications for Programs/Policy: Identifying the differences between the spatial distribution of HIV and syphilis within a geographically defined area can improve understanding and prompt better planning, prevention and control measures.

Implications for Research: GIS and spatial analysis are useful exploratory tools in tracking STDs; however, there are limitations since the information gained is of a descriptive nature.

Learning Objective: Participants will be able to describe the utility of using GIS and useful GIS methods to explore the spatial distributions of STDs.

A1B – Continued High HIV Incidence Among Patients Attending STD Clinics in Four U.S. Cities, 1997–1999

L Linley, D Withum, H Weinstock, K Bell, J Royalty, M Miller

Centers for Disease Control and Prevention, Atlanta, GA

Background: STD clinics are an important venue to target HIV prevention services. Using the Serologic Testing Algorithm for Recent HIV Seroconversion (STARHS) strategy, it is possible to obtain HIV incidence estimates to guide prevention efforts.

Objectives: To estimate HIV incidence in patients attending STD clinics in four U.S. cities (1997–1999).

Methods: Remnant serum specimens were collected from an anonymous unlinked HIV serosurvey of patients attending 5 STD clinics in Denver, Los Angeles, Newark, and Miami. Applying the STARHS strategy, HIV-positive specimens were retested with a less sensitive EIA. Non-reactive specimens were classified as recent (within 140 days) HIV-1 infections.

Results: Estimated HIV incidence (percent per year [95% CI]) was 1.2 [0.7, 2.9] in Miami, 0.9 [0.5, 1.6] in Newark, 0.8 [0.5, 1.3] in Los Angeles, and 0.3 [0.1, 0.6] in Denver. Incidence among men who have sex with men (MSM) was 9 times higher than incidence among heterosexual men and women, 4.7 [2.7, 7.7] versus 0.5 [0.3, 0.7]. Thirty percent of patients did not receive voluntary HIV testing at their visit. Among those not HIV tested, incidence was twice as high as among those who were tested, 1.2 [0.7, 1.8] versus 0.6 [0.4, 0.9]. Incidence was 0.8 [0.4, 1.3] among persons not receiving testing who had not previously been tested or previously tested HIV-negative.

Conclusions: MSM seeking care at these STD clinics had a high incidence of HIV. Recent HIV infections were missed in some patients seeking evaluation and treatment for STDs.

Implications for Programs/Policy: Increase efforts to provide HIV counseling and testing and other prevention services to all persons, particularly MSM, seeking care and treatment at STD clinics.

Implications for Research: Continue HIV incidence studies in select STD clinics. Further characterize the context of HIV infection and HIV testing behaviors in these studies.

Learning Objectives: Participants will be able to describe HIV incidence estimates and related risk behaviors among patients attending STD clinics in four U.S. cities.

Contact Information: Laurie Linley / Phone: 404-639-2086 / LLinley@cdc.gov

A1C – Assessing HIV Prevention Needs Among African- American Men Who Have Sex With Men (MSM)

D Evans, R Swayzer, T Franklin

Brotherhood, Incorporated, New Orleans, LA

Background: Through December 1999, CDC had reports of 272,881 HIV/AIDS cases among African-Americans. African-Americans comprise 37% of AIDS cases reported. African-American men who have sex with men (MSM) represent the largest proportion (37%) of reported HIV/AIDS cases among African-Americans.

Objective: The determine the HIV prevention needs of African-American MSM through the identification of barriers to early HIV testing and safer sex practices and specific risk behaviors engaged in by this target population.

Methods: Focus groups were conducted with African-American MSM by a trained facilitator according to an interview schedule designed for this study and transcribed verbatim. Thematic analysis was conducted to identify recurring themes in the areas of 1) barriers to HIV testing, 2) barriers to safer sex, and 3) risk behaviors.

Results: Seven focus groups were conducted with a total of 40 participants. Ages ranged from 19–53, with an average age of 27.3 years. Barriers to HIV testing were fear, knowledge of and location of testing site, risk of being stigmatized, and lack of perceived risk. Barriers to safer sex were careless behavior, societal/peer pressure, arousal/intimacy, drugs/alcohol use, and knowledge deficit. Risk behaviors identified included unprotected anal and oral sex, promiscuity, sex under the influence of drugs and/or alcohol, sexual exploration, and prostitution.

Conclusions: Despite broad focused HIV prevention interventions, African-American MSM continue to engage in behaviors that place them at risk for HIV infection. HIV prevention interventions in African American MSM should be directed towards reducing the barriers identified in this study.

Implications for Programs: Programs targeting African-American MSM should focus on specific risk behaviors and barriers to safer sex identified through comprehensive needs assessment.

Implications for Research: Additional behavioral research is needed to effectively design prevention interventions targeting African-American MSM.

Learning Objectives: Participants will be able to describe barriers to early HIV testing, risk behaviors, and barriers to practicing safer sex among African-American MSM.

A1D – “Barebacking” in a Diverse Sample of MSM

G Mansergh¹, G Marks¹, G Colfax², R Guzman², M Rader¹, S Buchbinder²

1Centers for Disease Control and Prevention, Atlanta, GA; 2San Francisco Department of Public Health, CA

Background: “Barebacking” was defined as intentional unprotected anal sex with a non-primary partner and assessed among MSM who had heard of the term, an assessment of barebacking as a sociocultural phenomenon.

Objectives: Session participants will be able to describe the prevalence of and motivations for barebacking in an ethnically diverse sample of HIV-positive and -negative MSM.

Methods: Cross-sectional survey of MSM from the San Francisco Bay Area. Men were recruited in 2000-01 outside multiple venues and later interviewed as participants in the MSM Prevention Messages Study.

Results: The sample (n = 554) included MSM who identified as African-American (28%), Latino (27%), white (31%) and other race/ethnicity (14%); 35% self-identified as HIV-positive. Most men (70%) were aware of the term “barebacking.” Of those who were aware, 14% barebacked in the previous 2 years (22% of HIV-positive vs. 10% of HIV-negative men, p<.001), with a median of 3 bareback partners in the past year. In their last bareback encounter, nearly half of these men had a partner whose HIV-status was different or unknown to the respondent. Increased physical stimulation and emotional connectedness were primary motivators for barebacking.

Conclusions: It is critical to reduce risk of STD/HIV transmission among MSM through new approaches that consider their needs and motivations, particularly men who engage in intentional unprotected anal sex with non-primary partners.

Implications for Programs/Policy: Innovative behavioral and biomedical interventions are needed for MSM who bareback. Policies should address the fact that both HIV-positive and -negative men intentionally engage in unprotected anal sex outside of primary relationships.

Implications for Research: More research should be undertaken regarding innovative behavioral and biomedical interventions. Research is needed on awareness and prevalence of barebacking in other MSM communities and geographical areas.

A1E – Don’t Gross Me Out! An Alternative to XXX-STD Pics

D Castellanos

Gay Men’s Health Crisis (CMHC), New York, NY

Background: Most approaches to HIV/STD prevention rely on people’s ability to assimilate and integrate health information within their sexual practices. Nonetheless, lack of appropriate sexual education impairs sustainable behavioral changes, particularly among immigrants or communities with marked differences in educational level. Through its population-specific, volunteer-based program for Latino gay men, GMHC’s prevention department developed and piloted interventions to address lack of adequate and relevant sexual health education for gay men in order to decrease the impact of HIV/STD transmission.

Objective: To increase awareness about STD transmission and other interrelated sexual health issues among gay men, particularly young men in NYC.

Methods: Drawing from several social/behavioral theories and models, interventions focused on creating a framework into which STD information could later be integrated. Interventions provided opportunities for (a) collective exploration of societal/cultural attitudes toward STD and same-sex practices; (b) learning basic information on biology and anatomy; and (c) attending to sexual health needs other than STD. Two series of four-session workshops were developed: “The Tunnel of Love” and “The Arrow of Love,” focusing on anal and penile health, respectively. Three brochures were developed: Anal Health, Penile Health, and STD for Gay Men. Finally, a marketing campaign addressing the connection of STD and other health issues was developed.

Results: Overall knowledge of STD information increased among workshop participants, as did referrals for HIV/STD screening. Most importantly, participants were able to realistically assess their personal risk based on their sexual practices and desires.

Conclusions: Effective STD prevention requires investing time and energy on creating a framework into which STD information can be integrated, particularly for populations with diverse level of education.

Implications for Programs: Programs providing STD information should incorporate sexual health issues other than STD information, as well as assessing the participants’ knowledge of sexual health and practices.

Implications for Research: More research is needed to provide a better understanding of societal/cultural attitudes toward STD in the post-AIDS era.

Learning Objectives: Participants will be able to identify factors important to the population served that will enhance STD prevention efforts.

Contact Information: Daniel Castellanos / Phone 212-367-1375 / danielc@gmhc.org

A1F – STD Screening in HIV Clinics: Value and Implications

TA Farley¹, DA Cohen²

1Tulane University School of Public Health and Tropical Medicine, New Orleans, LA; 2RAND Corporation, Santa Monica, CA

Background: Bacterial STDs facilitate HIV transmission. Screening and treatment for STDs among HIV-infected persons should prevent HIV spread to partners.

Objectives: To determine the prevalence of gonorrhea and chlamydia among HIV-infected persons receiving care, and to assess the relationship to STD rates in the general population.

Methods: Screening for gonorrhea and chlamydia using urine-based ligase chain reaction tests was made available for HIV-infected persons at the New Orleans HIV Outpatient Clinic beginning October 1998. Laboratory reports collected through early June 2001 were analyzed. We compared these results to screening of convenience samples of local persons age 18–29 and to surveillance data.

Results: Approximately one-third of HIV clinic attendees were screened for STDs over each 12-month period. Over three years, the prevalence of gonorrhea was 1.7% (46/2,629), and the prevalence of chlamydia was 2.1% (56/2,629). Among persons age 18-29, the prevalence of gonorrhea was slightly higher in the HIV clinic than among persons in the convenience samples (3.0% vs 2.3%, p=.33) and the prevalence of chlamydia was somewhat lower (5.8% vs 11.4%, p<.001). In the HIV clinic, the prevalence of both gonorrhea and chlamydia increased from 1998 to 2000 and then fell in 2001; this temporal pattern paralleled trends in local surveillance data for both diseases.

Conclusions: The prevalence of STDs in HIV-infected persons in care is similar to that of the demographically matched general population, and the parallel trends suggest that HIV-infected persons are integrated into general sexual networks.

Implications for Programs: Routine STD screening and treatment is needed for HIV-infected persons in care. Screening and treatment of the general population should prevent HIV transmission by reducing STD rates among HIV-infected persons.

A2 – Ties that Bind: Building Community Research Partnerships

S Blank¹, J Brown², J Parsons³, P Galatowitsch⁴

1STD Control Program New York City Department of Health (NYCDOH), New York, NY and Division of STD Prevention, Federal Centers for Disease Control and Prevention, Atlanta Georgia; 2STD Control Program NYCDOH, New York, NY and Division of STD Prevention, Federal Centers for Disease Control and Prevention, Atlanta Georgia; 3Department of Psychology, Hunter College, Center for HIV/AIDS Educational Studies and Training; 4Hunter College, Center for HIV/AIDS Educational Studies and Training

Background and Rationale: Public health responses to syphilis and other STDS, including HIV in the U.S. have required high levels of cooperation and collaboration between public health, private and non-profit organizations serving people at risk for the diseases. While public health departments have been very successfully at forging many of these relationships, inter-agency and intra-agency coordination in many locations throughout the U.S. is still stymied by conflict over STD/HIV/AIDS prevention goals, services, and the authority to carry them out.

In 1999, NYCDOH began to observe an outbreak of syphilis among men who have sex with men (MSM) in New York City. In 1999 there were 130 cases of primary and secondary (P&S) syphilis overall (1.8 cases/100,000) with a male to female ratio of 3.6:1; in 2000 there were 117 cases of P&S overall (1.6 cases/100,000), with a male to female ratio of 10.7:1. Also, over this time period, the proportion of male case persons reporting sex with men increased from 28% to 57%. Similar situations have been reported in other urban centers. NYCDOH’s response has encompassed enhanced case finding and surveillance as well as community outreach to increase awareness and screening. As a cornerstone of these activities, NYC-DOH initiated collaborations with community agencies serving people at risk for syphilis, including the Center for HIV/AIDS Educational Studies and Training (CHEST), a community-based research agency that studies HIV/AIDS and sexuality among men who have sex with men (MSM).

Purpose: Discuss the importance of public, non-profit and private sector collaboration in developing a response to the recent syphilis outbreak in New York City and highlight specific activities used to build those partnerships.

Methods: NYCDOH and CHEST will describe the rationale and methods they used to build inter-agency collaboration in the response to the recent syphilis outbreak in NYC.

Learning Objectives:

1. Explain how agencies can evaluate levels of inter-agency coordination

2. Describe ways that public, private, and non-profit sector agencies can collaborate to improve community responses to STD outbreaks.

A3 – Vaccines for HPV and HSV: Current Status and Issues Related to Implementation

S Tyring¹, LR Stanberry¹, GP Garnett², S Rosenthal¹, J Douglas³

1University of Texas Medical Branch, Galveston, Texas; 2Imperial College of Science Technology and Medicine, London, UK; 3Denver Public Health, Denver, CO.

Background: One important preventive strategy for sexually transmitted diseases (STDs) will be vaccination. This is particularly true for chronic viral STDs such as human papillomavirus (HPV) and herpes simplex virus (HSV).

Objectives: Provide an update on the status of HPV/HSV vaccine development. Discuss the impact of genital herpes vaccines on the control of adult HSV infection. Discuss the potential of genital herpes vaccines to control neonatal HSV infection. Discuss issues associated with STD vaccine acceptability, particularly among young adults and parents of teens. Discuss strategies for development and implementation of viral STD vaccine programs

Content: Immunogenic HPV and HSV vaccines are in commercial development. HPV vaccines are in clinical trials in both developed and developing countries. A candidate HSV vaccine has shown promise in preventing genital herpes disease with an efficacy rate of 70% in HSV-1 seronegative women. Neonatal herpes is a potentially life threatening complication of maternal genital herpes in pregnancy. Vaccination against HSV infection holds promise for reducing the risk of perinatal transmission. In order to maximize vaccine utilization and have the greatest impact on disease, it will be important to understand models of impact on control and to foster acceptance among target populations. Given the advanced stage of clinical trials of HPV/HSV vaccines, it is now appropriate to develop strategies for implementing viral STD vaccine programs.

Implications for Program/Policy: Unlike other vaccines, there may be unique issues associated with developing and implementing STD vaccine programs. Being prepared for the implementation of STD vaccines will be important to maximize the impact of vaccination on the STD epidemic. This discussion will highlight key issues for policy makers and program directors regarding viral STD vaccine acceptance and implementation.

Implications for Research: The discussion will identify key research questions regarding the development and use of HPV and HSV vaccines.

Learning Objectives: The participant will be able to describe the status of HPV and HSV vaccine development. The participant will be able to describe the impact of an HSV vaccine on efforts to control neonatal HSV. The participant will be able to describe a theoretical model for the impact of HPV/HSV Vaccines: The participant will be able to discuss issues associated with STD vaccine acceptability. The participant will be able to discuss strategies for implementation for viral STD vaccines.

A4 – Sexually Transmitted Infections and Gynecologic Health in Lesbians: Research Update

JM Marrazzo

University of Washington, Seattle, WA

Background: Knowledge about lesbians’ risk of acquiring sexually transmitted infections (STI) continues to accrue.

Purpose: This session will discuss advances since last year’s meeting as described in the literature and in our research.

Methods: Current knowledge of the epidemiology of major STI in lesbians will be reviewed, with specific attention to human papillomavirus (HPV), which can be sexually transmitted between women, and bacterial vaginosis (BV) which occurs frequently in this population. A significant proportion of cervical neoplasia in lesbians occurs in women who report no prior, or remote, sex with men, bur routine Pap smears are performed less often and later in life among some lesbians. Reasons for not getting Pap smears have included lack of insurance, prior adverse experience and belief that Pap smears were unnecessary. Bacterial vaginosis is common (25%), with a high degree of concordance between sex partners. Several studies indicate that HIV-related risk behavior is not uncommon among some lesbians, particularly those seen at sexually transmitted disease clinics and who report concurrent sex with men. Assumptions that (a) sex between women confers no risk of STI transmission and (b) that lesbians do not have sex with men are erroneous. All women, regardless of sexual history, should have routine Pap tests and STI screening according to standard guidelines.

Learning Objectives:

1. Describe the status of current knowledge of the epidemiology of major STI in lesbians.

2. Understand that lesbians should receive Pap smear screening according to accepted national guidelines for all women.

3. Be familiar with current research approaches to define the etiology of lesbians’ high prevalence of bacterial vaginosis.

Contact information: Jeanne Marrazzo / Phone 206-731-3679 / jmm2@u.washington.edu

A5 – Finding Common Ground: Building Local Capacity for the Primary Prevention of Chlamydia trachomatis and other Sexually Transmitted Diseases in California

P Gibson¹, J Felix¹, J Schumann¹, A Smith¹, S Smith¹, F Alvarez², C Vera³, A Gandelman¹, G Bolan¹

1California Department of Health Services, STD Control Branch, Berkeley, CA; 2Santa Barbara County Department of Public Health, Santa Barbara, CA; 3Santa Clara County Department of Public Health, San Jose, CA

Background and Rationale: Although Chlamydia trachomatis (CT) remains the most commonly reported sexually transmitted disease (STD) in California, few local STD Programs have staff, resources, or activities dedicated to primary prevention of STDs. The Chlamydia Awareness and Prevention Program (CAPP) was created to enhance the capacity of local health jurisdictions to plan and implement primary prevention of CT and other STDs. This is the first time California has dedicated funding for the primary prevention of STDs other than HIV.

Purpose: To explore the rationale, processes, and implications of local capacity-building for primary prevention of CT and other STDs.

Content: Panelists will describe California’s approach and experience in building local capacity for the primary prevention of STDs. Topics include: background and genesis of CAPP; role of community health department partnerships in achieving public health goals; assessment as a foundation for community health education planning and implementation; integrating STD prevention into sexual and reproductive health; and local health jurisdiction capacity-building. Panelists from local jurisdictions will share experiences of crossing funding streams and creating community linkages as a means for STD prevention.

Implications for Programs/Policy: The need to work more effectively and efficiently becomes paramount with decreases in local health department funding. To achieve success in STD prevention, local programs can become more comprehensive and sustainable by working with and through existing community resources. This will require a shift from the traditional roles of STD Programs to an emphasis on assessment, collaboration, and capacity-building.

Implications for Research or Evaluation: Collaborative primary prevention efforts and capacity-building require at least two levels of evaluation. First, process and impact evaluation should be implemented to ensure the effectiveness of capacity-building efforts. Second, voluntary multi-agency collaborations, not tied to contract or grant monies, will require innovative approaches to process and impact evaluation to ensure program quality and effectiveness in the primary prevention of STDs.

Learning Objectives:

By the end of this symposium, participants will be able to: 1. Explain the rationale for establishing partnerships / collaborations with community agencies and non-governmental organizations for the primary prevention of STDs.

2. Describe processes and methods of local capacity-building for the primary prevention of STDs.

Contact Information: Paul Gibson / Phone 408-277-2083 / pgibson@dhs.ca.gov

A6 – The Other Glass Ceiling . . . How to Increase Chlamydia Screening in the Private Sector

C Walsh, J Armstrong, M Finch, P Nathanson, R Neiman, S Shih

Background and Rationale: Several recent developments have increased the acceptability and feasibility of screening young women for Chlamydia trachomatis (Ct): national guidelines that recommend screening; a new HEDIS performance measure that promotes screening in managed care organizations (MCO); highly sensitive and specific nucleic acid amplification tests using endocervical or urine specimens; effective single dose therapy; and federal funding to expand screening in public sector settings, e.g., family planning and correctional sites.

Although more than 50% of women seeking care in publicly funded STD, family planning and prenatal clinics are screened for Ct, only about 20% of MCO enrollees eligible for screening are tested. Research indicates several barriers to Ct screening in the private sector and MCOs.

Objective: To present the perspectives of MCOs on Ct screening, the barriers to Ct screening in these settings, and to learn about activities to overcome barriers to screening in private sector settings.

Content: After an overview describing this issue, panelists will describe: the barriers that many MCOs face in implementing Ct screening; the profile of MCOs with high Ct screening rates; the process of negotiating with a major MCO to assess screening practices; a pilot study to determine whether Ct prevalence in private practices is high enough to merit special screening initiatives.

Implications for Programs/Policy: This presentation will assist decision makers in understanding the perspective, priorities and pragmatic details that facilitate initiation and continued implementation of Ct screening in MCOs.

Implications for Research: There is a critical need for data on barriers to Ct screening in individuals served in the private sector. Strategies to facilitate Ct screening in non-public sites need to be developed, tested, and widely disseminated.

Learning Objective: By the end of this session, participants will be able to describe the barriers to initiating Ct screening in non-public settings, and several strategies to overcome them.

A7A – The Collectivity of Sexual Behavior

DA Cohen¹, TA Farley², K Mason³

1Rand Corporation; 2Tulane University School of Public Health and Tropical Medicine; 3Louisiana State University Health Sciences Center

Background: The distribution of risk behavior in a population provides clues as to how to reduce risk. Several other risk behaviors and health outcomes have a normal or log-normal distribution and the average risk of the population determines the proportion of the population at high risk. This can be thought of as collectively determined risk.

Objective: To determine whether sexual behavior is a collectively determined risk behavior.

Methods: Data from the General Social Survey from 1988 to 1998 were obtained and then analyzed by state. The data were weighted by state, race, sex, and age. The average number of lifetime sex partners was calculated in several ways, by eliminating persons with more than 10, 20, and 40 lifetime partners. The average was then correlated with the percentage of persons with 10, 20, and 40 sex partners, respectively.

Results: Fourteen percent of respondents had over 10 lifetime sex partners. After removing those with over 10 lifetime sex partners, the mean number of lifetime sex partners by state was 2.52 (SD .59) This was highly correlated with the proportion of the population with over 10 lifetime sex partners (r = 0.79). Correlations between the mean and the percent population with more than 20 (5.9%) and 40 (2.5%) lifetime partners were r = 0.66 and r = 0.60 respectively. If one could reduce the average number of lifetime sex partners in the population by 0.5 (from 2.5 to 2.00), then the proportion of the population with more than 10 lifetime sex partners would decline by 29% (from 14% to 10%).

Conclusions: There are collectivities of sexual behavior among the US population. This suggests that in order to reduce the proportion of the population with large numbers of sex partners, we need to target the average person in the population. Universal programs targeting the general population are likely to have a larger and more lasting impact than programs that only target high risk groups.

Implications for Programs: Prevention interventions should target the general population, rather than limiting interventions to those believed to be at highest risk.

Implications for Research: Population level dynamics need to be studied further in order to reduce population level morbidity.

Learning Objectives:

1) To understand the principle of collectivity of risk. 2) To show the evidence that sexual behavior follows a single distribution.

3) To understand the implication that universal programs are likely to be more effective than targeted programs.

Contact Information: Deborah Cohen / Phone 310-393-0411 ext 6023/ dcohen@rand.org

A7B – Behavioral Cognitive Intervention, Shown to Reduce STDs, Increases Self-Efficacy

JE Korte, RN Shain, S Perdue, JM Piper, AEC Holden, JD Champion, E Newton

University of Texas Health Science Center, San Antonio, TX USA

Background: In a controlled, randomized trial, a cognitive/behavioral intervention significantly reduced STD re-infection rates in high-risk minority women. The intervention was based on extensive ethnography and an adaptation of the AIDS Risk Reduction Model (ARRM), which posits three stages of behavior change: risk perception, commitment to change (facilitated by self-efficacy), and behavior change.

Objectives: To begin to test whether the intervention helped women advance through theorized stages, we evaluated specific questionnaire items assessing self-efficacy.

Methods: In multivariate regression analyses, we tested the intervention effect on self-reported measures of self-efficacy at the 12-month follow-up, controlling for baseline values.

Results: Women in the intervention group showed significant increases in most measures, compared to the control group; specifically, saying that she would be comfortable examining a man for symptoms (p=.008), asking a man about sexual history (p=.009), asking a man to use condoms (p=.016), or putting a condom on a man (p=.001). In addition, more women in the intervention group reported actually putting a condom on a man (p=.003), and knowing how to eroticize condom use (p<.0001). The intervention had only a modest effect on whether the woman actually did eroticize condom use, however, and no effect on whether the woman carried condoms. The only measure differing at baseline between groups was comfort putting a condom on a man (intervention group more comfortable, p=.022).

Conclusions: The intervention was successful in giving women the skills and confidence to negotiate safer sex with their partners.

Implications for Programs/Policy: The impact of this successful intervention on a component of the ARRM helps to demonstrate the utility and validity of this model of behavior change.

Implications for Research: Sexual behavior is determined by many different factors, including knowledge, attitudes, skills, and opportunity. All research into STD infection should consider sociocultural environment, skill acquisition, and self-efficacy.

Learning Objectives: By the end of this session the participants will understand the theory and underpinnings of the AIDS Risk Reduction Model, and its application to interventions. Participants will also understand the ways in which women randomized to the intervention and control group responded to assessments of their cognitive position in the behavior change model, and the ways in which women differed between the intervention and control group. Participants will understand the impact of the intervention on increasing women’s ability to negotiate safer sex behaviors with their sexual partners.

A7C – The Relationship Between Repeat Infections and Behavioral Risk Factors and Clinician Counseling: Findings from a Philadelphia STD Clinic

M Eberhart¹, N Liddon², M Goldberg¹, JS Leichliter², L Asbel¹

1Philadelphia Department of Public Health, Philadelphia, PA; 2Centers for Disease Control and Prevention, Atlanta, GA

Background: Repeat infections with bacterial STDs (gonorrhea, chlamydia) are relatively common, and adverse sequelae are associated with untreated bacterial STDs.

Objectives: To investigate the relationship between repeat infections among patients seen in an urban STD clinic to behavioral risk factors and clinician counseling.

Methods: Electronic patient records from Philadelphia STD clinics between 1994 and 2000 were reviewed to identify patients with a repeat (between 30 days and 2 years) gonorrhea and/or chlamydia infection. These data were matched with reports of condom use, numbers of recent partners, and clinician counseling (e.g., partner notification, contraception, and drug use). Relevant data were available for 17,969 patients over age 12. Chi-square and logistic regression identified differences between individuals with and without repeat infections.

Results: Patients were predominantly male (67.5%), African-American (85.8%), and under the age of 30 (53.2%). One-quarter of patients contracted repeat infections. Chi-square results showed significant differences in repeat infections by gender, age, race, number of recent sex partners, and all counseling messages. Logistic regression found that women (OR = 2.2) and African Americans (OR = 1.4) were more likely to repeat infection. Compared to patients over the age of 25, 12–18 year olds and 19–24 year olds were 2.4 and 1.8 times more likely of repeating. Patients receiving HIV risk reduction (OR = .69), contraception (OR = .67), and future disease susceptibility (OR = .89) counseling were less likely to repeat infection than those not receiving counseling.

Conclusions: Women, African-Americans and young adults are groups most at risk of repeat STD infections. Clinician counseling about HIV risk, contraception, and future disease susceptibility reduces the likelihood that a patient contracts a repeat STD. Self-reports of known behavioral risk factors did not predict repeat STDs.

Implications for Program/Policy: Counseling messages may reduce repeat infections in STD clinic clients.

Implications for Research: Further research on intervention strategies for repeaters is needed.

A7D – Risks and Benefits of the Internet for Populations at Risk for Sexually Transmitted Infections (STI): Results from an STI Clinic Survey

CA Rietmeijer^1, SS Bull², JM Douglas¹, M McFarlane³

1Denver Public Health and 2AMC Cancer Center, Denver, CO; 3Centers for Disease Control and Prevention, Atlanta, GA

Background and Rationale: The Internet is increasingly used for the recruitment of sex partners, potentially leading to increased risks for STI. Less is known about the use of the Internet as a resource for STI education and prevention.

Objective: To evaluate the use of the Internet for sex seeking and STI information purposes by clients of a large STI clinic.

Methods: Survey among clients of the Denver Metro Health (STI) Clinic between September 2000 and May 2001.

Results: Among 4,825 clients surveyed, 2,159 (44.7%) had Internet access. Of these, 146 (6.8%) reported to have had sex with a partner they found over the Internet. Internet sex seeking was more common among men who have sex with men (MSM: 77/269; 28.6%) than among men who have sex with women (MSW: 52/1,176; 4.4%, p<.0001), and higher among MSW than among women (9/714; 1.3%, p<.01). The Internet was accessed by 604 (28%) persons to find information on STIs. Of these, 66% did so for general STI information, 39% for information on HIV, 22% for herpes, 18% for gonorrhea, 18% for chlamydia, 18% for HPV, 12% for syphilis, and 11% for other information. Of persons seeking sex, 54.4% accessed the Internet for STI information compared to 26.2% of persons not seeking sex (p<.0001).

Conclusions: Among STI clinic clients in Denver, nearly half have access to the Internet. Sex-seeking appears to be most prevalent among MSM. Internet use for STI information is more widespread than sex seeking, suggesting that prevention benefits of Internet access likely outweigh risk enhancement.

Implications for Programs: A large proportion of sex-seekers also use the Internet for STI education; this group may be accessible to Internet-based interventions.

Implications for Research: Future research should focus on the development and evaluation of Internet-based interventions for persons at risk for STI.

Learning Objectives: Participants will be able to describe the use of the Internet for sex seeking and information seeking purposes by persons at risk for STI.

Contact Information: Cornelis A. Rietmeijer / Phone 303-436-7363 / krietmei@dhha.org

A7E – Focus on Kids Intervention for Adolescents in High School to Prevent STDs/HIV

CA Gaydos¹, J Galbraith², C Arcari¹, L White¹, T Walker¹, G Waterfield³, A Joffe¹, C Latkin¹, B Stanton⁴

1Johns Hopkins University; 2University of Maryland; 3Baltimore City Health Department, Baltimore, MD; 4West Virginia University, Morgantown, WV

Background: Sexually active adolescents are at increased risk for STDs. An intervention, such as the Focus on Kids (FOK) Program can reduce risk. School-based health centers (SBHC) provide sites for screening for STDs that can be linked to evaluating interventions

Objectives: To determine whether high schools provide an effective platform for implementation of the FOK Program. To measure changes in risk behavior after the provision of FOK. To use urine-based testing for STDs to follow the success of such an Intervention.

Methods: We enrolled ninth graders with parental consent from 5 schools in FOK, which was presented during lunch in small groups for 12 weeks. An anonymous survey instrument was given, which collected information regarding demographics, communication, sexual risk behavior, and STD/HIV knowledge. Sexually active students were encouraged to attend the SBHC for STD screening using urine based testing. The survey was re-administered post-intervention. Students will be followed and resurveyed at 6/12 months post-intervention.

Results: The school lunch period was a successful platform for reaching adolescents with 216 enrolled. After the intervention, 165/216 (76.4%) youth were re-surveyed. Of the 207 youth with baseline data, 51.2% were age 14, 35% were age 15, 134 (65%) were female, 45.7% reported being sexually active. Of those, 34.9% reported >1 partner, 56.0% reported condom use at last intercourse, <1% reported being told they had a STD in the past 6 months. For HIV knowledge, 66.0% knew HIV/AIDS was caused by a virus, 9.1% believed that touching an HIV infected person can result in infection, and 38.4% believed HIV/AIDS can be cured. To date, 20 students consented to have STD data linked with surveys. Of those, 3 (15%) were positive for chlamydia, 2 (10%) were positive for gonorrhea, and 6 (30%) were positive for trichomonas. Data from post-intervention surveys are undergoing analysis.

Conclusions: FOK was successfully conducted during school lunch periods. Knowledge regarding STDs, HIV, and AIDS needed improvement. STDs were documented among the students. Continuation of the program will increase our ability to change behavior, increase knowledge of, and prevent STDs.

Implications for Programs/Policy: This research will help determine whether interventions given in school can reach and influence adolescents at risk for STDs/HIV.

Implications for Research: Future research should monitor success of interventions by both questionnaire data and acquisition of new STDs.

Learning Objectives:

1. Participants will be able to describe the results of a sexual risk behavior intervention given in schools. 2. Participants will be able to identify how measuring incident STDs can be used to validate questionnaire data.

Contact Information: Charlotte A. Gaydos / Phone 410-614-0932 / cgaydos@jhmi.edu

A7F – The Use of Focus Groups in Examining Prevention Strategies for Men with Previous Jail Incarcerations

C Sperling and R Burton

Stand, Inc. Decatur, GA

Background and Rationale: There is a paucity of literature regarding effective STD prevention practices for men newly released from jail. Gathering and synthesizing data specific to the behavior, intent, knowledge and attitudes of newly released men is critical to the development of successful interventions.

Objective: To identify risk reduction strategies for men newly released from jail and to explore the environment in which open discussion regarding risk behavior, STDs, prevention, incarceration and drug use can be facilitated.

Methods: Twenty-four men with previous jail incarcerations participated in two audio-taped focus groups. Participants were asked to respond to questions in four categories: men’s health, incarceration, substance use and recovery, and program (intervention) needs. Qualitative data from the focus groups were examined for themes.

Results: Themes included the impact of unstable living situations on the acquisition and transmission of STDs. Drug abuse or its use emerged as the catalysts for risky sexual behavior. Only 8% of our participants reported stable living situations. Participants were forthcoming with very personal information: 18% reported being gay or bisexual, and 46% reported being HIV positive.

Conclusion: A successful intervention developed to prevent STD among men released from jail must include strategies that address substance use and dependence, recidivism, and unstable living conditions. Interventions that include such components, combined with case management and a referral system may prevent risk behaviors and STDs, as well as improve men’s health.

Implications for Programs/Policy: The utilization of focus groups to determine “Best Practice” approaches is central to the development of successful interventions.

Implications for Research: Establish the benefit in facilitating cross-site focus groups comprised of post-completion participants from programs of similar focus.

Learning Objectives: By the end of the session, participants will be able to identify key STD risk reduction strategies for men newly released from jail.

A8 – The Gonorrhea Community Action Project

S Middlestad¹, N VanDevanter², CK Malotte³, T Gift⁴, P Messen², R Ledsky¹, C Merzel², A Bleakley², M Larro³, JS St Lawrence⁴, M Hogben⁴, W Pequegnat⁵

1Academy for Educational Development, Washington DC; 2Columbia University, New York, NY; 3California State University, Long Beach, Long Beach, CA; 4Centers for Disease Control and Prevention, Atlanta, GA; 5National Institute for Mental Health, Bethesda, MD

Background and Rationale: Many bacterial STDs, including gonorrhea, persist at elevated rates among adolescents and young adults. Since 1997, the Institute of Medicine has recommended a focus upon adolescents and collaboration among different levels of the health care system.

Objectives: The Gonorrhea Community Action Project’s objectives are to evaluate the feasibility, effectiveness, and cost-effectiveness of interventions aimed at improving access and care at multiple levels of health care systems, particularly among adolescents and young adults.

Content: Three sites tailored up to four interventions to local conditions while observing a common protocol with respect to content and measurement. At STD clinics, patients with either gonorrhea or chlamydia were encouraged to return for a three-month check-up. Patients in a motivational interview condition were more likely to return than either those receiving brief encouragement or those receiving a $20 incentive (OR = 6.2). Community partners helped develop an awareness campaign with print and web media, promoting health care seeking. Street intercepts, conducted at three-month intervals over the course of a year, show media materials recognition rose from less than 10% to 40%. At CBOs, adolescents attended a three-session intervention encouraging them to seek regular health care, including a sexual history. Post-intervention, 42% of those attending the intervention scheduled check-ups, compared to 23% of those in a control condition. Health care providers were encouraged to take a sexual history from their patients and to screen routinely for STDs. Subsequent urine-based screening at one site has yielded 47% of all new chlamydia diagnoses at that site.

Implications for Program/Policy: The effects of this multilevel research in community, clinic, and provider settings suggest that STD control programs should consider both integrated services and collaborative service provision efforts.

Implications for Research: Results suggest the interventions are feasible in multiple settings. Further research running the studies to scale in experimental settings would add value.

Learning Objectives: Attendees will become familiar with the conceptual and practical issues in matching health care-seeking interventions to levels of the health care system. Attendees will also learn which elements of interventions produced meaningful changes in patient, provider, and system behaviors.

Contact: Matthew Hogben / Phone 404-639-1833 / mhogben@cdc.gov

A9 – Applications of GIS in Integrated Public Health Surveillance Systems

R Kakkar¹, S Arbona², O Devine¹, T Gerber³, T Kellogg⁴, R Kohn⁴

1Centers for Disease Control and Prevention; 2Texas Department of Health; 3New York State Department of Health; 4San Francisco Department of Health

Background and Rationale: Geographic Information Systems (GIS) provide a range of powerful analytic tools for spatial exploration of disease risk. GIS software has been used for applications ranging from illustrating the geographic distribution of prevalence to identifying potential disease clusters. Application of this technology to STD surveillance presents an opportunity for focusing intervention and prevention activities in areas with the greatest need. To fully exploit the power of GIS, however, it is essential to create an efficient approach for integrating data from a variety of ongoing disease surveillance systems and provide a mechanism for simplified spatial analyses of these data. With this objective in mind, several state and local health departments have undertaken a range of innovative GIS activities to improve the planning, implementation and evaluation of their STD and HIV prevention programs.

Purpose: (a) To profile the use of GIS for relating measures of disease morbidity to spatially referenced demographic and behavioral data from STD and HIV/AIDS surveillance systems; (b) To illustrate how GIS can be a powerful tool for exploratory analyses, etiologic hypothesis generation and public health policy evaluation if spatial surveillance is conducted simultaneously for multiple disease outcomes.

Methods: We will use an interactive case study approach. A series of invited discussants will focus on their real-life experiences in using GIS tools, addressing the methods utilized, analyses conducted and lessons learned. Discussants will include representatives from the New York State Department of Health, the Texas Department of Health and the San Francisco Department of Public Health. Participants will gain an insight into a wide range of GIS-related issues: the fine points of establishing mapping data marts to provide rapid access to and reporting capability for case management and morbidity data; and mapping strategies to detect patterns of disease distribution and real-time identification of core geographic areas of disease risk.

Learning Objectives: By the end of this workshop participants will be able to:

1. Identify methods to efficiently store and retrieve STD/HIV data for spatial analysis and presentation 2. Illustrate approaches for identification of areas with potentially elevated risk

3. Describe tools for real-time spatial analysis of STD/HIV surveillance data

Contact Information: Reshma Kakkar / Phone 404-639-8362 / rmk5@cdc.gov