2004 STD Prevention Conference - Symposium C - Oral, Symposium and Workshop Abstracts - Wednesday Afternoon Sessions

C01 Bugs, Drugs, Dollars, and Tests: Making the Most of Scarce Resources for Chlamydia and Gonorrhea Screening and Treatment

DC Gunter1, TL Gift1, B Abban1, CK Kent2, LA Schamus3, BH Butler4, BA McDonald5

1Centers for Disease Control and Prevention, Atlanta, GA; 2San Francisco Department of Public Health, San Francisco, CA; 3Arizona Family Planning Council, Phoenix, AZ; 4Pennsylvania Department of Health, Harrisburg, PA; 5Wisconsin State Laboratory of Hygiene, Madison, WI

Background and Rationale: Despite the fact that 75% of chlamydia and gonorrhea cases are in women 24 and under, screening in low yield age groups and clinics continues across the United States. This is particularly evident for gonorrhea, which has more variable prevalence in different clinic settings and populations than chlamydia. In 2001, data from the CDC’s Chlamydia Prevalence Monitoring System submitted from clinics that test for chlamydia and gonorrhea indicated that the median chlamydia positivity among women in family planning clinics was 5.6% compared to 1.0% for gonorrhea. Despite the low yield from gonorrhea screening, many programs continue to dual test women at considerable expense. Low gonorrhea prevalence, however, is forcing many programs to question whether they should continue gonorrhea screening especially at the expense of expanded chlamydia screening. How can programs make better use of scarce screening and treatment resources for chlamydia and gonorrhea without losing the progress made in gonorrhea prevention?

Objectives: (1) To present data regarding cost effectiveness of screening strategies based on test type and treatment option; (2) To provide information about program and provider interventions that improves screening coverage and increase adherence to screening criteria adherence; (3) To demonstrate how screening and cost data can influence program decisions about screening criteria and laboratory test selection.

Content: This session will provide a review of cost effectiveness data related to test technology and treatment choices for chlamydia and gonorrhea. In addition, presenters from different program disciplines will provide programmatic examples to improve chlamydia screening coverage and adherence to screening criteria, better targeting of gonorrhea screening resources, and improved efficiency of laboratory test resources.

Implication for Programs, Policy, and/or Research: Programs that provide STD screening services may use this information to guide decision making about chlamydia and gonorrhea screening strategies, test selection, and treatment options.

Panel Line-up

Dorothy C Gunter, MPH

CDC, Atlanta, GA

Thomas L Gift, PhD

CDC, Atlanta, GA

Bartholomew Abban, MSc

CDC, Atlanta, GA

Charlotte K Kent, MPH

San Francisco Department of Public Health, San Francisco, CA

Lisa A Schamus, MPH

Arizona Family Planning Council, Phoenix, AZ

Beth H Butler, BA

Pennsylvania Department of Health, Harrisburg, PA

Bobbie A McDonald, BS

Wisconsin State Laboratory of Hygiene, Madison, WI

Learning Objectives:

  1. By the end of this session, participants will be able to describe how test technologies and treatment choices can influence screening and treatment strategies for optimal resource allocation
  2. By the end of this session, participants will be able to discuss different strategies to improve use of chlamydia and gonorrhea screening and treatment resources

Contact Information: Dorothy C Gunter/Phone no. 1 404 639 8323/dgunter@cdc.gov

C02A Reassessing a Large Syphilis Epidemic Using an Estimated Infection Date

CM Schumacher1, KT Bernstein1, JM Zenilman2, AM Rompalo2

1Department of Epidemiology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD; 2Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD

Background: Ascertainment for surveillance is usually based on date of report. This may be subject to lagtime bias.

Objectives: To reassess a large syphilis epidemic using estimated infection dates rather than date of report.

Methods: We analyzed morbidity records of early syphilis (primary, secondary and early latent) reported to the Baltimore City Health Department between 1994 – June 2003. We estimated dates of infection by subtracting the median incubation time of the corresponding syphilis diagnosis stage from the date of diagnosis. We generated epidemic curves and compared them to the curves generated by report date data. Epidemic curves were stratified by stage of disease.

Results: Theoretically, with endemic disease, epidemic curves generated by report and infection date should be similar except with the report curve shifted forward in time according to the median incubation time of the disease stage. Under epidemic conditions, report rate curves accelerate less rapidly than curves based on date of infection and do not account for all infections that occurred during a certain time period. Based on the infection curve, the inflection point of the large Baltimore epidemic occurs in early 1995, during which early syphilis infections increase by 59%. Six months later, infection by report date paradoxically decline by 47%. Throughout 1995, an estimated 1170 infections occurred, but only 1014 cases were reported (87%) in the corresponding year (3Q 1995-2Q 1996). In primary and secondary syphilis, infections increase by 51% in the first quarter. Three months later, the increase in reports is only 29%.

Conclusions: Using date of report for the basis of epidemiologic investigation underestimates the early increases common with epidemic disease transmission, and underestimates the total case number.

Implications for Programs, Policy and/or Research: Programs should utilize estimated date of infection.

Learning Objectives: By the end of this session, participants should be able to understand the potential for lag-time bias when using date of report as the basis of epidemiologic investigation.

Contact Information: Christina Schumacher/cschumac@jhsph.edu

C02B Risk Factors for Early Syphilis Among Men Who Have Sex With Men Seen in an STD Clinic, San Francisco 2002-2003

W Wong1, J Chaw1, C Kent1, L Alpers2, J Klausner1,2

1San Francisco Department of Public Health, San Francisco, CA; 2University of California San Francisco, San Francisco, CA

Background: Ascertainment for surveillance is usually based on date of report. This may be subject to lag-time bias.

Objectives: To reassess a large syphilis epidemic using estimated infection dates rather than date of report.

Methods: We analyzed morbidity records of early syphilis (primary, secondary and early latent) reported to the Baltimore City Health Department between 1994 – June 2003. We estimated dates of infection by subtracting the median incubation time of the corresponding syphilis diagnosis stage from the date of diagnosis. We generated epidemic curves and compared them to the curves generated by report date data. Epidemic curves were stratified by stage of disease.

Results: Theoretically, with endemic disease, epidemic curves generated by report and infection date should be similar except with the report curve shifted forward in time according to the median incubation time of the disease stage. Under epidemic conditions, report rate curves accelerate less rapidly than curves based on date of infection and do not account for all infections that occurred during a certain time period. Based on the

Background: San Francisco and other metropolitan areas recently have experienced substantial increases in syphilis among men who have sex with men (MSM).

Objectives: To identify risk factors for early syphilis infection among MSM attending the San Francisco municipal STD clinic (City Clinic).

Methods: We analyzed data from a cross-sectional self-administered behavioral survey of MSM attending City Clinic between November 2002 and March 2003. Clinical and laboratory data were abstracted from the electronic medical record. After univariate and bivariate analyses, we performed logistic regression analyzes.

Results: Among 1318 MSM surveyed, 53 (4.0%) were diagnosed with early syphilis. No differences in age, education, income, sexual orientation, years of residence in San Francisco, and depression status were observed between participants with and without early syphilis. Factors that remained in our final multivariate model included: non-white race compared to white race (OR=1.8 [1.0-3.5]), HIV positive status compared to HIV negative status (OR = 4.2 [2.2-7.9]), using both methamphetamine and Viagra compared to no methamphetamine use (OR=6.1 [2.7-13.8]), using methamphetamine without Viagra compared to no methamphetamine use (OR=3.6 [1.7-8.0]), stronger affiliation with the gay community compared to weaker community affiliation (OR=2.9 [1.5-5.5]), and meeting recent partners on the Internet compared to nonusers of the Internet (OR=2.0 [1.0-3.9]). Age and number of sex partners were included in the model to control for confounding, but not were significant.

Conclusions: HIV infection, methamphetamine use, especially with Viagra, stronger gay community affiliation, and meeting recent partners on the Internet were associated with increased risk of early syphilis infection among MSM attending City Clinic.

Implications for Programs, Policy, and/or Research: Syphilis prevention efforts should target HIV-infected persons and those who meet partners on the Internet, HIV care providers, substance abuse treatment programs, and key community programs including HIV care and gay community organizations. Because increased affiliation with the gay community was associated with syphilis infection, gay community leaders and organizations might play a critical role in syphilis prevention.

Learning Objectives: By the end of the session, participants will be able to describe risk factors for early syphilis infection among MSM attending San Francisco City Clinic, and to identify demographic and behavioral dynamics that are related to syphilis prevention efforts.

Author Contact: William Wong/Phone no. 1 415 487 5535/will.wong@sfdph.org

C02C Syphilis in Detroit, Michigan: Population Dynamics and Effective Interventions

C Merritt1, B Nowak1,2, D Jackson1

1Michigan Department of Community Health, Lansing, MI; 2Centers for Disease Control and Prevention, Atlanta, GA

Background: In 2001, as much of the nation was experiencing declines, Detroit, Michigan, ranked number one for both total primary and secondary syphilis (P&S) cases and rate per 100,000.

Objectives: Determine demographic, geographic and risk behavior characteristics of Detroit’s P&S population. Develop successful interventions based upon this data and CDC recommendations.

Methods: Demographic, geographic and risk behavior data were collected on all P&S cases reported to the Detroit Health Department and analyzed. Interventions and community-based outreach, such as canvassing high morbidity regions and increased education to ER physicians were developed and implemented.

Results: In the second quarter of 2002, syphilis in Detroit began to decline and has continued so do into 2003. During the 1st six months of 2003, 67% of Detroit’s 114 P&S cases were male, 92% were African American and they averaged 36 years of age. Syphilis was found throughout the city but with pockets of high morbidity. 39% of cases were members of the core group, i.e. they reported exchange of money or drugs for sex (18% of cases), anonymous partners (22%), hard drug use (16%) and/or 4 or more partners (11%) in the year prior to investigation. 9% of males reported having sex with men; 33% of these were known to be HIV positive. Detection through ERs increased from 13% of all reported P&S cases in the 9-months prior to intervention to 22% in the 9-months following.

Conclusions: Self-reported sexual behavior and male-to-female ratios suggest mainly heterosexual transmission. A high percentage of cases reported high-risk core group behaviors. Community outreach and targeted physician education were useful tools for decreasing syphilis in this urban setting.

Implications for Programs, Policy, and/or Research: Increased surveillance at ERs, community outreach efforts targeting specific high-risk populations and areas, and increased population level awareness can be effective tools for decreasing syphilis.

Learning Objectives: After this session participants will be able to describe the demographic and behavioral characteristics of Detroit’s P&S syphilis population and discuss specific interventions implemented by the DHD STD staff and their effects.

Contact Information: Carla Merritt/Phone no. 1 313 876 4193/merrittc@michigan.gov

C02D Syphilis Surveillance: What Are We Looking At?

T Peterman1, R Kahn1, C Ciesielski1,2, E Otiz-Rios1,3, B Furness1,4, J Schillinger1,5, S Blank1,5, M Taylor1,6, R Gunn1,7

1Centers for Disease Control and Prevention, Atlanta, GA; 2Chicago Department of Public Health; 3Puerto Rico Department of Public Health; 4Washington DC Department of Health; 5New York City Department of Health; 6Los Angeles County Department of Health Services; 7San Diego County Health and Human Services Agency

Background: Syphilis surveillance is based on stage of disease which can be confusing, especially latent stages defined (hierarchically) as: early latent (EL) (seroconversion, symptoms, or exposure documented in the past year), unknown duration (Unk) (both: RPR titer > 1:32 and age 13-35), and late latent (LL). Inconsistent classification can create artificial trends.

Objective: Identify variations in syphilis classification in different cities.

Methods: We reviewed reported rates of primary and secondary (P&S), EL, Unk, and LL from Chicago, San Juan, Washington DC, New York City, Los Angeles, and San Diego for 1992-2002, then visited cities to identify definitions used, and reviewed syphilis investigation records to describe approaches to classification.

Results: Marked differences were apparent in the distribution of cases by stage. For example, in 2000, the ratios of P&S to EL, Unk, and LL were:

Interviews and chart reviews have been completed for Chicago and Puerto Rico. Reported classifications agreed with CDC definitions for: P&S 110/120 (86%), EL 56/88 (64%), Unk 4/31 (13%), and LL 54/66 (82%). The CDC-defined classification for those reported as EL were: P&S 2%; Unk 12%; and LL 22%. The CDC classification for the Unk were: LL 64% and EL 10%. Investigations at other sites are underway and will be completed by the meeting.

C02E How Reactor Grids Affect Syphilis Surveillance and Outbreak Detection

EH Koumans, CA McLean, R Kahn, K Seechuk

Centers for Disease Control, Atlanta, GA

Background and Rationale: Syphilis reactor grids (SRGs) are administrative tools used by public STD programs to prioritize follow-up of persons with reactive syphilis serologies. Reactor grids, tables based on sex, age and titer, are used to focus health department investigative resources on those persons with reactive serologic tests who are more likely to have infectious syphilis. National program guidelines recommend periodically evaluating reactor grids and adjusting them as needed to maximize grid sensitivity for identifying infectious syphilis cases. Several recent evaluations of SRGs and their use in public programs will assist all programs in determining how best to address national recommendations.

Objectives: To present methods and findings from recent evaluations of different reactor grids and discuss program implications of these studies in the context of current national guidelines.

Content: Presenters will discuss current national guidelines regarding SRGs and findings from two recently published articles on reactor grid evaluation. Advantages and disadvantages of SRG use, comparisons of performance of different SRGs when applied to a single data set; the impact of local syphilis prevalence on SRG use, and guidance on how to implement national recommendations will be discussed. Discussion will focus on how programs may use findings to positively impact STD program operations.

Implications: STD prevention and control programs may use information presented to guide local practice regarding evaluation of SRGs and, in turn, have this practice guide decision-making regarding program improvement and use of program resources.

Conclusions: We found large variations in definitions used for staging syphilis. Latent cases were more likely to be staged inconsistently.

Implications for Policy, Programs, and Research: Syphilis trends may be due to changes in incidence or changes in definitions. Definitions should be clearly and consistently applied in different areas and over time. Revising the definitions may help.

Learning objectives: Participants will identify inconsistencies in syphilis surveillance, consequences of these inconsistencies, and approaches to improving surveillance.

Contact Information: Tom Peterman/Phone no. 1 404 639 6102/tpeterman@cdc.gov

C03A The Seroepidemiology of HPV-16 Infection Among Men and Women Attending STD Clinics in the United States

DL Thompson1,2, JM Douglas Jr2,3, M Foster2, ME Hagensee4, C DiGuiseppi1, AE Barón1, JE Cameron4, TC Spencer4, J Zenilman5, CK Malotte6, G Bolan7, ML Kamb3, TA Peterman3 for the Project RESPECT Study Group

1University of Colorado Health Sciences Center, Denver, CO; 2Denver Public Health Department, Denver Health Medical Center, Denver, CO; 3Centers for Disease Control and Prevention, Atlanta, GA; 4Department of Medicine, Section of Infectious Diseases, Louisiana State University Health Sciences Center, New Orleans, LA; 5Baltimore City Health Department, Baltimore, MD; 6California State University, Long Beach, CA; 7San Francisco Department of Public Health, San Francisco, CA

Background: Genital human papillomavirus (HPV) is of public health concern because of its role in cervical and other anogenital cancers.

Objective: To characterize the prevalence, persistence, incidence, and behavioral risk factors for HPV-16 seropositivity.

Methods: This study used a cross-sectional design to analyze HPV-16 seroprevalence and a retrospective cohort design to analyze antibody persistence and seroincidence. The study used data from Project RESPECT, a randomized controlled trial of risk-reduction counseling in STD clinics and included 1595 participants. HPV-16 antibody testing was performed by capture ELISA using virus-like particles.

Results: Overall HPV-16 seroprevalence was 24.5% (95% CI 22.4, 26.6) and was higher among women than men (30.2% vs. 18.7%, p<0.05). In multivariate analysis, seroprevalence was significantly associated with female sex, age >20 years, and recent number of episodes of sex with an occasional partner. Of those with prevalent infections at baseline, antibody response persisted to 12 months in 72.5% of women and 45.6% of men (p<0.05). HPV-16 incidence density was 20.2/100 person-years (py) overall, 25.4/100 py among women and 15.7/100 py among men. Independent predictors of HPV 16 seroincidence were female sex, age >20 years, baseline adjusted optical density greater than the median, and number of episodes of unprotected sex with an occasional partner in the past 3 months.

Conclusion: Gender and age differences in seropositivity and seroincidence persisted after adjustment for behavioral and sociodemographic risk factors. Recent behavioral risk factors were stronger predictors of both HPV-16 prevalence and incidence than lifetime sexual behaviors.

Implications for Programs, Policy and/or Research: Our study confirms the large burden of prevalent and incident infections seen in sexually active adults and emphasizes the importance of female sex as a predictor of HPV-16 antibody persistence and seroincidence, as well as seroprevalence. It also raises the question of the potential contribution of recent sexual behavior to measured seroprevalence.

Learning Objectives: At the end of this session, participants will be able to describe risk factors associated with HPV-16 seropositivity. Participants will be able to describe risk factor differences between women and men for HPV-16 seropositivity.

Contact information: Deborah Thompson/Phone no. 1 970 493 2251/dlt3@cornell.edu

C03B Incidence, Clearance, and Persistence of HPV in a Cohort of Female Adolescents

E Samoff1, E Koumans1, L Markowitz1, M Sawyer2, D Swan3, J Papp4, W Secor5, ER Unger3

1Division of Sexually Transmitted Diseases (STDs), National Center for HIV, STDs, and Tuberculosis (TB) (NCHSTP), Centers for Disease Control and Prevention (CDC); 2Emory University, Atlanta, Georgia; 3Division of Viral and Rickettsial Disease, National Center for Infectious Diseases (NCID), CDC; 4Division of AIDS, STD, and TB Laboratory Research, NCHSTP, CDC; 5Division of Parasitic Diseases, NCID, CDC

Background: Susceptibility to human papillomavirus (HPV) may be increased with exposure at a young age; little is known about persistence of HPV and associated risk factors among high risk adolescents.

Methods: Adolescent clinic attendees were recruited for this longitudinal cohort. Interview data and samples for HPV, C. trachomatis (CT), N. gonorrhoeae (NG) and T. vaginalis (TV) detection were collected at 6 month visits. Consensus PCR was used to detect and type HPV; cervical or urine CT and NG were detected by NAAT, and TV by wet mount or Affirm VP. Associations with persistence (detection of the same HPV type at >1 visit and for >6 months) were assessed among those with >1 visit and at least 6 months follow-up. Chi-squares were used to evaluate associations with HPV.

Results: This cohort included 282 sexually active females, with data from 2-5 visits. Median age at enrollment was 16.5; 272 (96%) were African American. Cumulative prevalence of HPV was 78% (219/282); with 125 incident cases. Low-risk HPV types were detected in 144 participants (51%); the same type was detectable in 16/106 (15%) after 6 months and in 0/55 after 12 months. Similarly, high-risk types were detected in 202 participants (72%), in 38/139 (27%) after 6 months, and in 7/67 (10%) after 12 months. Cumulative detection of CT, NG, and TV was 43%, 20%, and 23% respectively. Compared to women with at least 6 months follow-up after HPV detection but without persistence, those with persistence were more likely to have CT detected at the first HPV positive visit (p=0.01 for high risk , p=0.07 for low risk).

Conclusion: Persistence of HPV is associated with CT; this may reflect an association between these outcomes and high risk behavior, or a biological interaction between these organisms.

Implications for Research: The possible interactions between CT and HPV persistence should be further studied.

Measurable Learning Objective: Participants will understand past and current research evaluating associations between STDs and HPV persistence.

Contact Info: Erika Samoff/Phone no. 1 404 639 1817

C03C Trends in Herpes Simplex Virus Type 2 Infection in the United States

F Xu1, G McQuillan1, B Kottiri1, M Sternberg1, F Lee2, A Nahmias2, L Markowitz1

1Centers for Disease Control and Prevention (CDC), Atlanta, GA; 2Emory University School of Medicine, Atlanta, GA

Background: Herpes simplex virus type 2 (HSV-2) is the cause of most genital herpes and may increase the risk for HIV acquisition and transmission. HSV-2 seroprevalence can be a maker of lifetime sexual risk behaviors leading to STIs, including HIV infection. In adolescents and young adults, it is a measure of recent risky sexual behaviors.

Objectives: To describe trends in the seroprevalence of HSV-2 infection in the United States using data from two National Health and Nutrition Examination Surveys that were conducted in 1988-1994 (NHANES III) and in 1999-2000 (NHANES 1999-2000).

Methods: Serum samples collected as part of NHANES III and NHANES 1999-2000 were tested for antibodies to HSV-2. The same type-specific immunodot assay was used for both surveys, utilizing purified glycoprotein gG-2 of HSV-2 as antigen to detect antibodies to HSV-2.

Results: The response rate was similar for the two surveys. The sample size from NHANES III (n=9165), which was conducted over six years, was larger than the 2-year survey from NHANES 1999-2000 (n=3590). The age-adjusted seroprevalence of HSV-2 was 21.3% (95% CI 19.4-23.3%) in NHANES III and 17.6% (95% CI 15.4-20.0%) in NHANES 1999-2000, a significant overall decrease of 17% between the two surveys. The largest significant decreases were in younger age groups (74% decrease in 14-19-year-olds, from 5.8% to 1.5%; 48% decrease in 20-29-year-olds, from 17.2% to 8.9%), in males (35% decrease, from 17.2% to 11.2%) and in Mexican Americans (46% decrease, from 22.5% to 12.1%). These results will be updated in early 2004 when 4 years of data (NHANES 1999-2002) become available.

Conclusion: HSV-2 seroprevalence has significantly decreased between NHANES III and NHANES 1999-2000 in adolescents and young adults, in males, and in Mexican Americans. These findings are consistent with data from behavioral surveys that suggest sexual risk behaviors have decreased in US adolescents in the 1990s.

Implications for Programs, Policy and/or Research: Continuation of adolescent risk behavior reduction programs may further reduce HSV-2 infection in these populations.

Learning Objectives: By the end of this session, participants will be able to describe methods of the NHANES and the trend in HSV-2 infection in the United States.

Contact Information: F Xu/fax1@cdc.gov

C03D The Epidemiological Impact of Suppressive Therapy to Reduce Transmission of Genital Herpes

G Garnett1, J Williams1, J Jordan2, EA Davis2

1Imperial College, London, UK; 2GlaxoSmithKline, Research Triangle Park, North Carolina, USA

Background: Approximately 22% of US adults are infected with HSV2. Transmission of genital herpes to a sexual partner is of great concern to patients. A clinical trial in heterosexual, HSV2 discordant couples found that suppressive therapy (ST) with valacyclovir (500mg once daily) and safer sex counseling decreased transmission of HSV2 infection by 48%.

Objective: The objective was to model the impact of ST on HSV2 incidence in the US population.

Methods: The model calculated a susceptible individual’s risk of HSV2 infection as a function of their sex, age, number of partners and sex acts per partnership. The proportion of the HSV2 infected population taking ST was assumed to range from the current US value of 3% to a hypothetical value of 15%. ST treatment duration was assumed to average 5 years, while time between infection and beginning ST was assumed to be random for each patient. Impact of ST on population incidence was evaluated over 25 years and calculated relative to no ST use. Sensitivity analyses were done to evaluate changes in treatment duration and time between infection and treatment.

Results: The model predicts that use of ST by 3% of the HSV2 infected population results in a 2.5% relative reduction in incidence, while increasing use of ST to 15% results in a 14% relative reduction. Both longer treatment duration and a shorter time interval between infection and starting ST were predicted to further decrease HSV2 incidence.

Conclusions: The predicted impact of ST on HSV2 incidence is strongly dependent on ST uptake. Each percentage point increase in the population taking ST corresponds to a relative reduction in incidence of almost 1%.

Implications for Policy: Increased HSV2 diagnosis, increased use of ST among diagnosed patients, earlier initiation of therapy and longer treatment duration may impact the HSV2 epidemic.

Learning Objectives: By the end of the session, participants will understand the potential impact of suppressive antiviral therapy on the genital herpes epidemic

Contact Information: G Garnett/Phone no. 011 44 207 5943215/g.garnett@imperial.ac.uk

C03E Suppressive Valacyclovir Therapy Soon After Initial Genital Herpes: Clinical Efficacy and Impact on Herpes-Related Quality of Life

HH Handsfield1,2, T Warren3, VL Murphy1,2, MAS Werner3

1University of Washington and 2Public Health – Seattle & King County, Seattle, WA; 3Westover Heights Clinic, Portland, OR

Background: Symptomatic outbreaks, viral shedding and psychological impact are maximum in the first 6 months after initial genital herpes, but suppressive therapy has been studied only in persons with recurrent genital herpes of >1 year duration.

Objectives: To assess the clinical efficacy and influence on herpes-related quality of life (HRQoL) of valacylcovir (VCV) suppression initiated within 3 months of initial genital herpes.

Methods: In a placebo-controlled, double-blind randomized controlled trial, patients received VCV 1.0 g daily or placebo for 6 months. Symptomatic recurrences were treated with open-label VCV 500 mg bid for 5 days. Diagnosis was confirmed by culture, polymerase chain reaction, or type-specific serology (Focus or Western blot). Subjects completed the standard HRQoL instrument and were followed at 1, 3, and 6 months.

Results: The 119 subjects (60 VCV, 59 placebo) were mean age 28.8 yr, 67% female, 80% white. HSV type was 23% HSV-1, 60% HSV-2, and 17% indeterminate or virologically unconfirmed; 79% of subjects were followed >3 months and 75% for 6 months. These characteristics and baseline HRQoL scores were similar in both groups. By intent-to-treat analysis regardless of virologic confirmation or HSV type, symptomatic herpes recurred during follow-up in 25 (42%) of 60 VCV and 40 (68%) of 59 placebo recipients (P=0.006). During follow-up VCV recipients had 0.7+1.0 (mean+SD) outbreaks vs 1.6+2.0 for placebo (P=0.004). From baseline to 6 months, HRQoL score rose 15.5+15.0 for VCV and 9.7+11.1 for placebo (P=0.052). Results for documented HSV-2 infection are being analyzed and will be presented.

Conclusions: Suppressive therapy with VCV initiated soon after initial genital herpes reduces the frequency of symptomatic recurrences and probably improves quality of life.

Implications: Although further study is indicated to validate and extend these findings, clinicians should offer suppressive therapy to selected patients soon after resolution of initial genital herpes.

Learning Objective: To understand the potential utility of initiating suppressive antiviral therapy early after resolution of initial genital herpes.

Contact Information: H. Hunter Handsfield/Phone no. 1 206 731 5899

C03F The Impact of Genital Herpes on Health Status Preferences

R Patel1, G Harding2, K Beusterien2, J Malkin3

1University of Southampton, Southampton, England; 2Medtap International Inc, Bethesda, MD; 3Centre Medical Institut Pasteur, Paris, France

Background: Although the impact of genital herpes on health-related quality of life has been assessed previously, utilities (preferences) for health status associated with genital herpes have not. The advantage of utilities is that they combine measurement of the physical and psychosocial effects of a disease into one number that represents the overall impact of the condition and that can be used to quality-adjust life expectancy.

Objective: To obtain utilities for health states associated with genital herpes.

Methods: Cross-sectional study of a random sample (n=938) of the general US population using an internet-based survey. The recommended standard gamble technique was used to obtain utilities for 8 health states reflecting experience by adults with genital herpes and their partners.

Results: Among the states describing adults with genital herpes, respondents expressed the strongest preference for the “asymptomatic while taking suppressive therapy” state (mean=0.78) (0.0 = death; 1.0 = perfect health) and they preferred this state more than being asymptomatic and not on suppressive therapy. The least preferred health state was “primary, classic episode of genital herpes” (mean=0.46). Differences across health states were consistent with severity levels and clinically meaningful based on previously reported utility values of infectious disease states.

Among the partner health states, respondents preferred the “HSV-infected partner taking suppressive therapy” health state to the “HSV-infected partner not taking therapy” (mean utilities = 0.79 vs 0.76, respectively). Differences in utility values as small as 0.01 have been reported to be significant.

Conclusions: From a general population perspective, genital herpes can have substantial detrimental impacts on an individual’s overall health state. Interventions that prolong asymptomatic health states and reduce transmission risk can improve a patient’s and their partner’s quality-adjusted life.

Implications for Programs, Policy and/or Research: Access to suppressive antiviral therapy may need to be improved in order to positively affect quality-adjusted life expectancy of individuals with genital herpes and their partners.

Learning Objectives: By the end of this session, participants will be able to evaluate the overall impact (physical and psychosocial) of genital herpes.

Contact Information: Raj Patel/Phone no. +44 (0) 2380 825 438/RP_SUHT@email.msn.com

C04 A Transgender Client Walks In…Now What? Meeting the Needs of Your Transgender Clients

LA Sausa, A Gandelman

California STD/HIV Prevention Training Center, Berkeley, Berkeley, CA

Background and Rationale: There is a high prevalence of HIV infection (11-35%) reported among transgender people (Bemis, Simon, Reback, & Gatson, 2000; Clements, Katz, & Marx, 1999; Kenagy, 1998; Sykes, 1999; Xavier, 2000). Yet, studies continue to report a low perceived risk of STD and HIV infection, a lack of STD and HIV prevention knowledge, and a low usage of latex barriers (Clements, Katz, & Marx, 1999; Kenagy, 1998). Current health service providers often are not knowledgeable of or sensitive to the needs of transgender clients. Providers may feel discomfort working with transgender clients or unsure of transgender health concerns. In addition, few transgender-specific resources and health care services are available. Assessment of the needs of HIV positive transgender people revealed inadequate psychological support and a lack of knowledge and sensitivity on the part of health providers and STD and HIV prevention workers (Bockting, Robinson, and Rosser, 1998).

Purpose: To provide training for health professionals to learn about the diversity within the transgender community, the current language used among transgender clients, and to increase participants’ comfort and skills working with transgender clients. Enhancing health professionals’ understanding of specific STD and HIV prevention needs of transgender clients will improve STD prevention and health services in a variety of settings.

Methods: This interactive workshop will address three learning components, including cognitive, affective, and behavioral learning for transgender clients and their STD prevention needs. Through Social Learning Theory and the Schuchman Inquiry Model participants will acquire current knowledge, increase comfort, and develop skills to assist them in providing effective STD prevention. Participants will examine the impact of race, culture, and socioeconomic status on sex and gender, and learn tools in increasing access to care and improve the quality of health care services for transgender clients. Participants will be provided with a comprehensive resource folder that includes: (1) a national list of transgender-specific social service and health care organizations; (2) current articles on STD and HIV prevention among transgender people and a list of current books; and (3) guidelines and recommendations for health professionals about how to improve health care services for their transgender clients.

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

  1. Cognitive Learning Goal: Acquire current knowledge about the different transgender identities within various cultures and ethnicities, and address the specific STD and HIV prevention needs of transgender clients
  2. Affective Learning Goal: Increase comfort with transgender clients, and help explore feelings and beliefs about transgender issues to improve access to and quality of health care
  3. Behavioral Learning Goal: Develop strategies for improving STD and HIV prevention services and increasing resources for transgender clients

Contact Information: Lydia A Sausa/Phone no. 1 415 554 0130/lydiasausa@hotmail.com

C05A Commercial Sex Venues: A Closer Look at Their Impact on the Syphilis Epidemics Among Men Who Have Sex With Men (MSM) in Los Angeles

LV Smith, G Aynalem, C Bemis, K Kenney, J Montoya, H Rotblatt, PR Kerndt

Los Angeles County Department of Health Services, STD Program, Los Angeles, CA

Background: Although it has been shown that HIV-positive MSM are more likely to attend bathhouses and sex clubs than their HIV-negative counterparts, little is known about the difference between those with early syphilis infection who frequent these venues and those who do not.

Objective: To identify the demographic and behavioral characteristics of MSM diagnosed with syphilis who reported using commercial sex venues for sexual encounter and to assess whether they were also using other venues for the same purpose.

Methods: Demographic, behavioral and venue information were collected from 658 MSM who were diagnosed with syphilis. Associations between demographic and behavioral variables with sexual encounter at commercial sex venue were identified using Chi-square (x2) analysis. Logistic regression analyses were performed to explore the influence of demographic and behavioral characteristics on frequenting commercial and other sex venues.

Results: Overall, 28% MSM diagnosed with syphilis had sex or met their sex partners at commercial sex venues and they more frequently reported anonymous partner, condom nonuse and IV and non-IV drug use (p<0.05). They were also less likely to have sexual encounters at dance halls, bars and clubs and more likely at motels, parks and through the Internet (p<0.05). In logistic regression analysis, they were twice more likely to be HIV positive (OR=2.04, 95% CI 1.29-3.24, p<0.05) and six times more likely to have anonymous partner (OR=5.79, 95% CI 2.59-12.94, p < 0.05).

Conclusions: MSM diagnosed with syphilis who frequent commercial sex venues are more likely to be HIV infected and report anonymous partner, condom nonuse and IV and non-IV drug use than those who do not.

Implications For Programs, Policy and/or Research: Development and implementation of HIV and STDs prevention interventions tailored to MSM who frequent commercial sex venues is an immediate priority if we were to control the rising HIV and syphilis epidemics in this population.

Learning Objectives: By the end of this presentation, participants will be able to identify the demographic and behavioral characteristics of MSM diagnosed with syphilis who frequent commercial sex venues for sexual encounter. Participants will be able to assess whether they were also using other venues for the same purpose.

Contact Information: Lisa Smith/Phone no. 1 213 744 3093/lsmith@dhs.co.la.ca.us

C05B Screening Massage Parlor Sex Industry Workers-How Often Should Sex Industry Workers Be Screened?

BP Schumann1

1Guam Department of Public Health, and Social Services Mangilao, Guam

Background: Quarterly screenings for asymptomatic women working in massage parlors for sexually transmitted diseases is a mandate issued by The Department of Public Health and Social Services. This mandate requires that massage parlor management ensures that its workers are tested and certified to be free of the following infections every three months: syphilis, chlamydia, gonorrhea and HIV. This regulation, established in 1984, is to prevent and control STD outbreaks in the massage parlors and transmission to community.

Objectives: (1) To describe prevalence of STDs among massage parlor workers, (2) To determine the impact of screening of STD morbidity, and (3) To analyze cost effectiveness of screening massage parlor workers.

Methods: Content: Investigators will explore the current records of active massage parlor workers who undergo required tests every three months during the renewal process. Tests to detect chlaymdia, gonorrhea and trichomonisis are referred to a private clinic. Data will be examined whether all massage parlor workers are in compliance in obtaining required health certificate versus those who are not in compliance (i.e., missed a screening). Screening data, such as number of gonorrhea, chlamydia, syphilis and HIV Antibody Tests conducted and number of reactive tests, positive screenings over a 3-year period will be presented. A cost breakdown for screenings will also be reviewed and analyzed over a 3-year period.

Results: The results will reflect the overall compliance of massage parlor workers who renew their health certificate. Currently, data is being compiled, collected and analyzed by the investigators.

Conclusions: In this study, the current screening measures will be explored to determine whether the current mandate is appropriate for sex industry workers.

Implications for Programs, Policy and/or Research: Based on the data, this will guide decision-making regulations for massage parlors. The symposium will assess the current regulations established by the Health Department, assess cost-effectiveness and revise the current regulations appropriate to STD screenings for sex industry workers.

Measurable Learning Objectives: By the end of the sessions, participants will be able to discuss appropriate screening measures for sex industry workers and to present approaches applicable in their respective jurisdictions. Participants will also be able to discuss the kinds of data that are needed to evaluate regulations relevant to sex industry workers in their jurisdictions, as well as how to determine cost saving measures appropriate screening sex industry workers.

Contact information: Bernadette P. Schumann/Phone no. 1 671 735 7137

C05C Anonymous Sex Venues for MSM: Implementing Outreach Screening for Syphilis & HIV at Adult Bookstores

B Collins1, A Alvarez1, E Katchy1, B Pendleton2

1Houston Department of Health and Human Services, Houston, TX; 2Montrose Clinic, Houston, TX

Background and Rationale: Increases in primary and secondary syphilis among men who have sex with men (MSM) in Houston/Harris County, Texas were first noted in December, 2000. In 2002, MSM accounted for 60% of reported primary and secondary syphilis. Anonymous sex in venues such as adult bookstores, clubs and bathhouses had been increasingly reported as a risk factor. Outreach screening activities in clubs and bathhouses are well-established by community based organizations(CBOs) and health department staff. Owners of adult bookstores had not been receptive to efforts to conduct prevention and screening activities on their premises. In March, 2003, health department staff successfully initiated outreach screening at an adult bookstore identified through case management activities. Screening in an adult sex environment presents many challenges. Collaborations with CBOs were undertaken to enhance outreach in this environment.

Purpose: To heighten an awareness of the role of adult bookstores as anonymous sex venues in Houston/Harris County, Texas. To describe the challenges encountered in conducting outreach screening in this environment.

Methods: Syphilis and HIV cases will be presented to describe characteristics and risk factors of individuals engaging in anonymous sex at adult bookstores. Presenters will discuss approaches taken in engaging bookstore staff to initiate outreach screening. The adult bookstore environment ( including the physical layout, customers and staff) will be described. Responses of customers to outreach efforts will be described. Collaborations undertaken with CBOs will be described.

Measurable Learning Objectives: At the end of this session, participants will be able to:

  1. Understand the challenges in implementing Syphilis/HIV outreach screening in adult sex venues
  2. Describe different techniques for working with customers of adult bookstores

Contact Information: Barbara Collins/Phone no. 1 713 794 9640/ barbara.collins@cityofhouston.net

C05D The Internet: Emerging Venue for Syphilis Epidemics Among Men Who Have Sex With Men in Los Angeles

G Aynalem, C Bemis, LV Smith, K Kenney, J Montoya, H Rotblatt, PR Kerndt

Los Angeles County Department of Health Services, STD Program, Los Angeles, CA

Objective: To identify the characteristics of men who have sex with men (MSM), diagnosed with syphilis infection that had initiated sexual encounter through the Internet during the period when syphilis infection likely occurred.

Methods: Associations of Internet use and demographic and behavioral characteristics were assessed using Chi-square (X2) statistics for categorical variables. Using logistic regression analysis, independent predictors of Internet use and the odds of initiating sexual contact through the Internet were calculated. The most frequent Internet sites used by MSM in Los Angeles were also documented.

Results: Overall 22% (n=132) of 587 MSM who were diagnosed with early syphilis infection met their sexual partner through the Internet of which 67% were HIV infected. Compared to those who do not use Internet to met their sexual partners, those who meet their sexual partners through the Internet were 1.23 times more likely to be HIV infected, 3.49 time more likely to have anonymous sex, 2.04 times more likely to use injection drugs. In a multivariate logistic regression model analysis, the only variables that were significantly associated with and independent predictors of meeting sex partners through the Internet were being White (OR=4.34, 95% CI 1.99-9.47) and HIV infected (OR=1.83, 95% CI 1.20-2.80).

Conclusions: The Internet is becoming an important emerging venue for STD/HIV epidemics.

Implications For Programs, Policy, and/or Research: Interventions like online outreach, automated behavioral interventions, and online partner notification should be incorporated with other services by sites that are most frequented.

Learning Objectives: By the end of this presentation, participants will be able to identify the demographic and behavioral characteristics of MSM diagnosed with syphilis who use the Internet for sexual encounter. Participants will be able to assess whether they were also using other venues for the same purpose.

Contact Information: Getahun Aynalem/Phone no. 1 213 744 5966/gaynalem@dhs.co.la.ca.us

C05E An Outcome Evaluation of the Internet Alert Project

R Kachur, M McFarlane, S Middlekauff

Centers for Disease Control and Prevention, Atlanta, GA

Background: Since 1998, the Division of STD Prevention at the CDC has been providing Public Health Internet Alerts to headquarters-based and in-field staff. The objective of the Internet Alert project is to provide useful information about high-risk sexual behaviors advertisedon-line to project areas that do not have access to either the Internet itself or to sexually explicit material on the Internet. Ultimately, the goal is to assist programs in using this information to improve STD/HIV health education, prevention, counseling and testing.

Objectives: An outcome evaluation was conducted to determine whether the Internet Alert Project is meeting its objectives of raising awareness and knowledge among project participants.

Methods: A survey, including both quantitative and qualitative items, was distributed to all known recipients of the Internet Alerts (n=26). Quantitative data were analyzed using descriptive statistics. Qualitative results were analyzed and salient themes were identified.

Results: Of the 14 respondents, 13 found the Alerts to be useful. Eleven respondents use the information from the Alerts to conduct outreach, counseling and testing in the field. Results indicated that the Alerts helped increase participants’ knowledge and understanding of the use of the Internet for meeting sex partners. Finally, many respondents would be negatively affected if Alerts were stopped.

Conclusions: The evaluation found that the Internet Alert Project is a useful and valuable tool. The project provides valuable information to in-field public health workers, who use the information to conduct health education, outreach, counseling and testing. The results also have a trickle-down effect, because it is common for recipients of the Alerts to share it with others.

Implications for Programs, Policy, and/or Research: Results from this evaluation show the need to continue and expand the Internet Alert Project. In addition, it would be extremely valuable for local and state health departments to implement similar programs.

Learning Objectives: By the end of this session, participants will be able to identify ways in which the internet is being used for STD transmission and prevention. Additionally, participants will be able to explain how the Internet Alerts are a useful STD prevention tool for local and state health departments.

Contact Information: Rachel E. Kachur/Phone no. 1 404 639 2387

C06A STD/HIV Risk From Adolescence to Adulthood: Longitudinal Risk Behavior Patterns and Infection Status

D Hallfors1, B Iritani1, DJ Bauer2, CT Halpern3

1Pacific Institute for Research and Evaluation, Chapel Hill, NC; 2North Carolina State University, Raleigh, NC; 3University of North Carolina at Chapel Hill, Chapel Hill, NC

Background: Both sexual and drug-taking behaviors are related to HIV/STDs among adolescents and young adults. However, few studies have examined both together as behavior patterns among different sub-groups, nor their persistence and trajectory related to HIV/STD prevalence.

Objectives: To describe longitudinal patterns of sex and drug use behavior in adolescence, the persistence of such behavior in young adulthood, and associated prevalence of HIV/STD.

Methods: Participants are from Waves I – III of the National Longitudinal Study of Adolescent Health (N=10,776). Data include STD and HIV test results of biospecimens collected at Wave III. Cluster analysis techniques were used to group individuals at each wave on 16 patterns of self-reported substance use and sexual behavior. Movement among risk patterns is tracked across time to identify modal trajectories. Cluster patterns are examined along with sociodemographic attributes to predict STD and HIV rates.

Results: While the majority of adolescents in the three normative clusters (Abstainer, Light Substance Dabbler, Sex Dabbler) had stable cluster membership from Wave I to II (approximately one year), all others showed dispersion among many clusters. From Wave II to III (approximately five years), only those in Smokers, Male-Male Sex, and Sex Dabblers showed relatively stable cluster membership. At Wave III, participants in both highly risky (Sex for Money and IV Drug Users) and less risky (Sex Dabblers and Smokers) clusters had the highest rates of STDs. By far, those in the Male-Male Sex cluster showed the highest rate of HIV. Almost all other cases were found among low to moderate risk clusters, and almost all among African Americans.

Conclusions: Participation in risky behaviors is highly fluid during adolescence and young adulthood. African-Americans in low as well as high risk groups are at disproportionate risk.

Implications: Along with continued outreach to high risk groups, universal HIV/STD prevention programs for African Americans are critically needed.

Learning Objectives: By the end of the session, participants will be able to identify patterns of sexual and substance use risk behavior in adolescence and young adulthood associated with STD/HIV outcomes.

Contact Information: Denise Hallfors/Phone no. 1 919 265 2612/hallfors@pire.org

C06B Adolescent Screening Project -Partnerships within the Community

L Byer, B Draper

Oakland County Children’s Village, Pontiac, MI

Background: Eight county adolescents sites participate in screening for gonorrhea and chlamydia, with computerized sexual questionnaire and risk-reduction counseling. Sites include county detention facilities, jail, shelters, school-based clinics, correctional and drug court.

Objectives: To determine adolescent incidence of gonorrhea and chlamydia in non-traditional settings. To evaluate effectiveness of computerized questionnaire.

Methods: Newly admitted adolescents are offered urine testing for chlamydia and gonorrhea at all sites except school. Students accessing school-based clinics are offered testing, regardless of reason for clinic visit. Nurses interview participants, and sexual questionnaire is obtained with handheld touch-screen computers at point of service.

Results: Over 3000 adolescents have been screened. Sexual questionnaire reveals high number of lifetime partners, average 9(males) and 6 (females), 58% report condom use, 17% have a history of STDS, 16% females report history of pregnancies. Majority of the chlamydial infections are asymptomatic (males – 80%, females – 55%), overall chlamydia positivity 18%. School clinics have highest positivity (21%). Students accessing school clinic for reasons other than STD symptoms had 15% chlamydia positivity. Nearly 50% of infections would be missed if only students requesting STD services were tested.

Conclusions: By screening adolescents at multiple community sites, asymptomatic infections can be detected, treated, partners notified, decreasing complications and spread of infections into broader community. Partnering with other adolescent sites helps develop collegial support and increases awareness of silent epidemic.Computerization of questionnaire decreased staff time, eased data entry and facilitated analysis.

Implications for Programs, Policy and/or Research: Other demonstration projects needed in communities with varying demographics and morbidity to determine need for adolescent screening. Explore other non-traditional settings to offer noninvasive screening to adolescents who rarely seek health care and are asymptomatic.

Learning Objectives: By the end of the session, participants will identify nontraditional adolescent settings for assessing, screening and treating STIs. Discuss the benefits of handheld computers at point of service.

Contact Information: Lynda Byer/Phone no. 1 248 452 9188/byerl@co.oakland.mi.us

C06C STD Risk Behaviors Among Incarcerated Youth

C Baird1, A Robertson2

1Mississippi Health Policy Research Center, MississippiState University, Jackson, MS; 2Social Science Research Center, Mississippi State University, Starkville, MS

Background: Previous research indicates that incarcerated youth are more likely than their peers to engage in high-risk sex behaviors that increase the likelihood of them contracting a sexually transmitted disease. Numerous factors have been linked to high-risk behaviors, but gender differences have not been clearly defined.

Objectives: To examine predictors of sexually transmitted disease risk factors among incarcerated youth.

Methods: Data were collected from 690 male and female youth housed in an urban youth detention center. Participants completed a self-administered survey using automated computer assisted interviewing technology. Urine samples were collected from all participants and tested for Chlamydia trachomatis and Neisseria gonorrhoeae.

Results: Odds ratio analyses show that the odds of testing positive for either chlamydia or gonorrhea was greater for females than males. Juveniles reporting one or more joint occurrences of sex and alcohol in the three months prior to incarceration were more likely to test positive for an STD than those not engaging in this behavior. Multiple regression models indicate that predictors of STD status vary by gender. Age and STD history are predictors for males, but not for females. Family structure, number of recent partners and engaging in sex while under the influence of alcohol are more important for females than for males. Alcohol and drug expectancy are related to STD status in male delinquents, but not female delinquents.

Conclusions: The incidence of STDs is this population is higher among females. Predictors of STD status varies by gender.

Implications for Programs, Policy, and/or Research: Factors affecting sexual risk behaviors vary by gender. Consequently, any efforts to prevent sexually transmitted diseases with incarcerated youth must take into account gender-specific risk factors as they are related to decisions to engage in sexually risky behaviors.

Learning Objectives: By the end of this session, participants will be able to identify gender-specific risk factors for sexually transmitted diseases among incarcerated juveniles.

Contact Information: Connie Baird/Phone no. 1 601 898 9534/connie.baird@ssrc.msstate.edu; Angela Robertson/Phone no. 1 662 325 7797/angela.robertson@ssrc.msstate.edu

C06D Community Health Investigator Project: A Project-Based Science Curriculum on Communicable and Sexually Transmitted Diseases

B Hug1, JS Krajcik2, K Ford3

1University of Illinois Urbana-Champaign, Illinois; 2University of Michigan School of Education, Ann Arbor, MI; 3University of Michigan School of Public Health, Ann Arbor, MI

Background: The Community Health Investigator Project (CHIP) is an innovative approach to sexually transmitted disease (STD) prevention education for middle school students in Detroit, Michigan. While school-based health education promoted by public health agencies has traditionally been in conflict with core academic subjects, this curriculum is designed to be an integral part of middle school science education.

Objective: Develop, demonstrate and disseminate an interactive, technology enhanced curriculum integrating science and public health concepts relating to STD prevention.

Methods: The curriculum was developed by a team consisting of science education and technology specialists from the School of Education, a specialist in HIV/AIDS and STDs from the School of Public Health, and a science curriculum specialist from the Detroit Public Schools (DPS). In three years, the curriculum was presented to almost 2000 middle school students in over 15 schools. Pre- and post-tests of knowledge, attitudes and beliefs and open-ended questions about the curriculum content were administered each year.

Results: In the third year, the curriculum was enacted in 15 schools in Detroit (1235 students total). Pre- and post-tests of students in the intervention classrooms yielded 1093 matched pre-test/post-test pairs. The results from the close-ended questions show a statistically significant increase in STD knowledge and changes in attitudes/beliefs for students who completed both the pre-and post-tests. Open-ended questions show that most of the students talked with friends and family members about the curriculum content.

Conclusions: The results of this study show that student knowledge and attitudes about STD prevention can be impacted through the science curriculum.

Implications for Programs, Policy, and/or Research: Public health goals can be achieved in the science classroom through the project-based science curriculum. Sample copies of the curriculum will be available at this session, as well as an order form for receiving a complete dissemination package.

Learning objectives: By the end of this presentation, participants will be able to 1) describe how school-based health education goals can be achieved through project-based science education while enhancing student learning linked with standardized testing; and 2) explain how to obtain curriculum materials for use in schools and other settings.

Contact Information: Barbara Hug/Phone no. 1 217 244 9090/bhug@uiuc.edu

C06E Taking the Test – Making the Grade: Implementing a Broad-based GC/CT Screening Program in Philadelphia’s Public High Schools

M Salmon1, L Asbel1,2, M Goldberg1

1Philadelphia Department of Public Health, Philadelphia, PA; 2 Drexel University College of Medicine, Philadelphia, PA

Background and Rationale: In 2002, Philadelphia ranked highest among cities for rates of chlamydia, exceeding 1,000 cases per 100,000 population. The rates were highest among adolescent females (8,251.8/100,000). In response to this epidemic, a collaborative effort between the School District and the Department of Public Health was initiated in January 2003. This initiative targeted Philadelphia public high school students with an educational program regarding STDs and voluntary urine-based testing for gonorrhea and chlamydia. Treatment was also provided. Between January-June 2003, the STD program presented STD information to over 30,000 students; 19,713 students volunteered for urine-based screening and 1,050 were successfully treated for gonorrhea, chlamydia or both.

Objectives: To provide a historical background for the implementation of the program. To present preliminary data from the screening program and describe the benefits and challenges of initiating and maintaining such an effort. To discuss possible future initiatives.

Content: Presenters will describe the history of this initiative as well as the process of implementation and maintenance of the program. Data will be presented describing overall screening and treatment results, volume of testing, acceptance rates for testing, positivity rates, and treatment rates. Presenters will describe the resources necessary for the program and the impact of this resource-intensive initiative on other STD program areas.

Implications for Programs, Policy and/or Research: STD Programs will be able to use the information to determine whether a similar initiative is warranted in their jurisdiction and if program resources and supporting regulations are in place to duplicate the effort. In addition, preliminary research questions will be presented which will help to guide targeted screening programs and future screening program enhancements.

Panel Line Up:

Melinda Salmon
Philadelphia Department of Public Health, Philadelphia, PA

Lenore Asbel, MD
Philadelphia Department of Public Health, Philadelphia, PA

Martin Goldberg
Philadelphia Department of Public Health, Philadelphia, PA

Learning Objectives:

  1. By the end of the session participants will be able to determine if High School Screening would be appropriate in their jurisdiction and whether their program has the resources to support such an initiative
  2. By the end of the session participants will be able to discuss the benefits and challenges of such as effort and to define the research questions that are necessary to further refine a school screening program

Contact Information: Melinda Salmon/Phone no. 1 215 685 6741/Melinda.salmon@phila.gov

C06F The Need for Sexually Transmitted Disease Screening in School-Based Health Centers

M Nsuami1, SN Taylor1, LS Sanders1, TA Farley2, DH Martin1

1Louisiana State University Health Sciences Center, New Orleans, LA; 2Tulane School of Public Health and Tropical Medicine, New Orleans, LA

Background: Sexually transmitted disease (STD) screening and treatment constitutes a key component of STD prevention and control.

Objectives: To determine the prevalence of chlamydia and gonorrhea among students who recently sought routine care in School-Based Health Centers (SBHCs) and to assess the extent to which high school adolescents receive STD screening and treatment in SBHCs.

Methods: Among 487 students who participated in a dedicated school-based chlamydia and gonorrhea screening during the school year 2002-2003, 251 (51.5%) reported having made 578 visits to their SBHCs in the previous 90 days (mean: 2.3 visits/student). They were inquired about any STD testing/treatment they independently received at the SBHCs during the 90-day-period.

Results: Of those 251 students, 15 (6.0%) reported having had symptoms of STDs, 14 (5.6%) visited the SBHCs for STD testing/treatment, 21 (8.4%) reported having received STD testing/treatment and 228 (90.8%) reported not having received STD testing/treatment at the SBHCs in the previous 90 days. The prevalence of either chlamydia or gonorrhea was 34/249 (13.7%), 4/21 (19.0%) among students who reported having received STD testing/treatment at the SBHCs and 30/228 (13.2%) among those who reported not receiving STD testing/treatment at the SBHCs in the previous 90 days (p=ns).

Conclusions: Among students who recently received health services in SBHCs that did not include STD testing/treatment, the prevalence of chlamydia and gonorrhea exceeded 10%, which speaks to the need for the SBHCs to implement routine screening for the two STDs.

Implications for Programs, Policy, and/or Research: The need for STD screening services among high school students may outweigh STD screening services they receive in SBHCs, especially in high prevalence areas. Local STD prevalence, and not the frequency of STD symptoms, should guide screening services provided in SBHCs that serve high school adolescents.

Learning Objectives: By the end of this session, participants will be able to discuss provision of STD screening in SBHCs based on an objective assessment of students’ needs for services.

C07 Ethical Principles and Regulatory Requirements in the Prevention and Control of Sexually Transmitted Infections: Seminal and Emerging Topics

S Semaan1, KM MacQueen2, DC Des Jarlais3, JV Lavery4, D Borasky2, R Bayer5

1Centers for Disease Control and Prevention, Atlanta, GA; 2Family Health International, Durham, NC; 3Beth Israel Medical Center, New York, NY; 4St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada; 5Columbia University, New York, NY

Background and Rationale: Investigators, providers, participants, and communities continue to seek clear information on how to develop and implement ethically sound scientific studies and programs and how to collaborate effectively to prevent and control sexually transmitted infections (STIs).

Objectives: (1) To provide information facilitating adherence to scientific and ethical principles, protection of participants, and promotion of respect for all stakeholders; (2) To advance the knowledge base on the ethics of prevention and control of STIs.

Content: We will discuss five questions: (1) What are the existing and recommended procedures for informing and treating participants and partners in studies of partner notification, medical management, and syndromic management in resource-poor countries? (2) What are the ethical obligations for treating participants who have controllable but not curable viral STIs and how do these obligations compare with those for providing HAART in resource-poor countries? (3) Do reimbursements for participation in scientific studies affect the magnitude and generalizability of return rates to obtain results of tests conducted in clinical care or public health practice where such reimbursements are not made? (4) How do the interpretations of the principles of respect for persons and beneficence compare for activities aimed at the control of STIs and those aimed at the control of severe acute respiratory disease syndrome (SARS)? (5) How can we enhance community representation on institutional review boards (IRBs) and encourage collegial relationships between investigators, IRBs, and communities for advancing ethically-sound science that has community utility?

Implications for Programs, Policy, and/or Research: We offer suggestions to enhance the compatibility of scientific goals, public health practice, ethical principles, and federal regulations in our efforts to prevent and control STIs.

Panel Line-up


Salaam Semaan, DrPH
Centers for Disease Control and Prevention, Atlanta, GA


Salaam Semaan, DrPH
Centers for Disease Control and Prevention, Atlanta, GA

Kate MacQueen, PhD
Family Health International, Durham, NC

Don Des Jarlais, PhD
Beth Israel Medical Center, New York, NY

Jim Lavery, PhD
St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada

David Borasky, BA, CIP
Family Health International, Durham, NC


Ronald Bayer
Columbia University, New York, NY

Learning Objectives:

  1. By the end of the symposium, participants will be able to discuss different concerns and suggestions to reconcile ethical principles and regulatory requirements for six topics in the prevention and control of sexually transmitted infections.
  2. By the end of the symposium, participants will be able to articulate procedures that advance the compatibility of scientific goals, ethical principles, regulatory requirements, and collegial relationships in out efforts to prevent and control sexually transmitted infections.

Contact Information: Salaam Semaan/Phone no. 1 404 639 8870/ssemaan@cdc.gov

C08 Disease Intervention Specialist Activities: How Sexually Transmitted Disease Control Programs Can Most Effectively Utilize DIS in the 21st Century

S Coulter1, K Myers1, D Broussard2, L Shroeder3

1California Department of Health Services, STD Control Branch, Berkeley, CA; 2Chicago Department of Public Health, Chicago, IL; 3California Department of Health Services, STD Control Branch, Long Beach, CA

Background and Rationale: Disease intervention specialists (DIS) have assisted with communicable disease (mainly sexually transmitted diseases [STD]) follow-up for more than 50 years, often with communities with few resources. The recent increase in MSM syphilis cases has highlighted the need for DIS and partner services to adapt to address high numbers of partners with little or no locating information, increased travel, use of the Internet, and ongoing distrust of the public health system by gay men/MSM. California’s syphilis and HIV PCRS efforts have relied on an increased use of client-centered counseling, improving understanding of issues correlated with high HIV and STD rates among gay men/MSM, and developing stronger relationships with key stakeholders.

Objectives: 1) To describe approaches used to improve working with patients, community leaders, venue owners, and medical care providers; 2) To compare traditional partner services and follow up programs with those adapting to reduce risk of transmission among gay men/MSM.

Content: Panelists will review their experiences working with MSM syphilis patients, their health care providers, and owners of venues where patients are socializing and meeting sex partners. Highlighted efforts include: 1) working in a client-centered, non-judgmental manner with clients; 2) working with Internet service providers to provide STD education to their clients and to be able to inform individuals in a client-centered fashion; 3) involving leaders in the MSM community, key venue owners, medical care providers; 4) sharing updates with colleagues nationwide; 5) the benefits and need to analyze and modify efforts as needed on an ongoing basis.

Implications for Programs, Policy, and /or Research: With limited resources available to address the syphilis and other STD outbreak among MSM, the need for continuing collaboration among key players as well as careful evaluation of prevention and control efforts is critical.

Panel Line-up


Stewart Coulter, BA
California Department of Health Services, STD Control Branch, Berkeley, CA


Fern Orenstein, MEd
California Department of Health Services, STD Control Branch, Berkeley, CA

Dawn Broussard, MPH
Chicago Department of Public Health, Chicago, IL

Lisa Schroeder, BA
California Department of Health Services, STD Control Branch, Long Beach, CA

Learning Objectives:

  1. By the end of the session, participants will be able to identify challenges in syphilis and other STD control efforts among MSM populations
  2. By the end of the session, participants will be able to identify which strategies and efforts have proven most effective in addressing the STD problem in the MSM community

Contact Information: Stewart Coulter/Phone no. 1 510 883 6776/scoulter@dhs.ca.gov

C09 Mujer Sana ~ Healthy Woman: A Participatory Action Research Model for HIV, STD, TB, Hepatitis A, B, and C Prevention

R Andrade, P Manning, S Stevens, B Estrada

Southwest Institute for Research on Women, College of Social and Behavioral Sciences, University of Arizona, Tucson, AZ

Background and Rationale: Best practices for STD/HIV risk reduction for women take into account age, culture, language, sexual orientation, and gender issues.

The Mujer Sana curriculum includes: 1) Five, 2-hour group sessions on HIV, STDs, TB, and Hepatitis A, B, and C; 2) Five 45-minute individual sessions to address individual risks, develop and monitor an individualized risk reduction plan, and provide referrals; 3) A disease testing, results, treatment/vaccinations and referral component, and 4) Following completion of the curriculum, ongoing social support sessions. This curriculum is embedded within 3 existing treatment programs and an outreach site for women not in treatment.

Purpose: Theoretical models and/or frameworks help to guide the design and delivery of successful interventions. A social ecology framework has been successfully applied to various health-related issues and high-risk populations. In addition, participatory action research has been cited as an effective model for mobilizing and facilitating change in communities. The application of these frameworks to Mujer Sana allows for an intervention that takes into account not only the individual but the complex family, community, and peer environment that is specific to the target population, including issues of age/development, gender, culture, sexual identity, and disabilities.

Methods: The instructional approach of this workshop is interactive. Participants will be guided through the theoretical underpinnings of participatory action research and Freire’s liberatory action research as they have informed the pedagogical preparation of project staff and the development of the Mujer Sana curriculum. In addition, workshop participants will step in and out of roles as facilitator and client as they participate in a mock session. This mock session is a composite of the curriculum’s 5 group sessions which include: The Self and Sexuality; Reproductive Anatomy and Women-Specific Risks; STD Education; HIV, TB, Hepatitis A, B, and C Education, and HIV Transmission Game; Social Relationships.

Measurable Learning Objectives: Workshop participants will:

  1. Gain knowledge of participatory action research as a model for STD prevention and research;
  2. Learn pedagogical implications of using participatory action research;
  3. Have the opportunity to gain practical experience based on the Mujer Sana curriculum.

Contact Information: Rosi Andrade/Phone no. 1 520 670 9075/rosiandrade@yahoo.com

Sponsored Symposium – Seroprevalence of HSV-2 in Suburban Primary Care Offices

D Fleming1, P Leone2, A Gilsenan3, L Li3, S Justus4

1Mathematica Policy Research, Inc, Princeton, New Jersey; 2UNC-Chapel Hill, North Carolina; 3RTI Health Solutions, North Carolina; 4GlaxoSmithKline, Inc, North Carolina

Background: Studies have shown that herpes simplex virus type 2 (HSV-2) seroprevalence is high nationwide, and that most persons with HSV-2 antibody experience unrecognized genital herpes outbreaks and/or shed virus. Nevertheless, many primary care physicians (PCPs) relate that genital herpes is infrequent among their patients.

Objective: To provide HSV-2 seroprevalence estimates from a weighted sample of adults attending 36 PCP offices for routine visits.

Methods: Six PCP offices in relatively affluent areas in each of six cities (Atlanta, Baltimore, Boston, Chicago, Dallas, Denver) were recruited from a database of PCP offices. At each site, field interviewers selected approximately 150 patients aged 18-59, based on random sampling design with 8 age-group/gender cells. The field interviewers obtained informed consent and administered a risk assessment questionnaire via audio computer-assisted self-interview. A central laboratory used the FOCUS HerpeSelect 2 ELISA IgG kit to detect type-specific HSV-2 antibody.

Results: 5,732 patients were screened; 5,452 (95%) provided an analyzable blood sample and 5,433 completed a questionnaire. The sample was 75% white, 14% African-American, and 4% Hispanic; 44.9% of patients had household income >$60,000 (US). The overall weighted HSV-2 seroprevalence was 25.5% (95% confidence interval = 20.2% to 30.8%). Seroprevalence increased from 13.4% (18-29 years), to 25.2% (30-39 years), to 31.2% (40-49 years), and 28.0% (50-59 years). Seroprevalence among women (28.3%) was greater than that among men (22.0%). Only 11.9% of HSV-2 seropositive patients reported a history of genital herpes. Independent predictors of HSV-2 infection were gender, age, race, and number of lifetime partners.

Conclusions: HSV-2 seroprevalence was high in this relatively affluent suburban population, and few infected patients had been diagnosed.

Implications for Programs, Policy, and/or Research: The results emphasize the need for a high index of suspicion for genital herpes even among patients considered by many to be at low risk.

Learning Objectives: By the end of this session, participants will be able to quantify the seroprevalence of HSV-2 in suburban primary care offices in six areas, identify the predictors of HSV-2 positivity in these patients, and discuss the implications of these findings.

Contact Information: Douglas T Fleming/Phone no. 1 609 936 2713; DFleming@Mathematica-MPR.comus