A01A
The
Natural History of New Sexual Partnerships: A Niche for Bacterial
STDs
PM
Gorbach1,
LN Drumright2, GP Garnett3, KK Holmes4
1University
of California, Los Angeles, CA; 2University of California, San
Diego, CA; 3Imperial College London, UK; 4University of
Washington, Seattle, WA
Background:
The potential for spread of sexually transmitted
infections within a population is a function of patterns of sexual
partnership including: formation, dissolution, overlap between
partnerships and frequency of sexual acts within partnerships. To
date limited descriptions of sexual partnership duration and its
relationship to other risk behaviors have been available.
Objectives:
To quantify partnership related risk behaviors in
young adults in vulnerable populations.
Methods:
Both partners from 96 recently formed sexual
relationships were recruited from a STD clinic and a family
planning clinic to a prospective cohort study with a 12 month of
follow up to describe the duration of the partnership, frequency
of concurrent partner acquisition and frequency of unprotected
oral, vaginal anal sex, and STD incidence.
Results:
The hazard of partnership dissolution decreases
over time with the 73% of partnerships remaining extant at 3
months; 56% at 6 months; 52% at 9 months and 43% at 12 months
follow up respectively. Over the course of the study 57.3% of
individuals reported concurrent sexual partnerships and 34% of the
population recruited a new main sexual partner with a short gap
(<1 month) before acquiring a new sexual partner. There was a
large variance in reported number of sexual acts within
partnerships with a median of 10 sex acts per partner per month
and low levels of condom use. At baseline 13% had chlamydia,
non-gonococcal urethritis, mucopurulent cervicitis or pelvic
inflammatory disease with a further 6% acquiring these STDs during
follow up.
Conclusions:
The high levels of concurrency, short period
between partnerships and low levels of condom use provide ideal
conditions for the spread of bacterial STIs.
Implications
for Research:
These detailed patterns of behaviour provide a
unique source for the derivation of parameter values for
individual based simulations of the sexual partner network and the
spread of sexually transmitted diseases.
Learning
Objectives:
By the end of the session participants will be able
to understand the observed dynamics of behaviours within high risk
partnerships and why they influence the epidemiology of sexually
transmitted infections.
A01B
A Unified
Optimal Resource Allocation Model for Screening and Treating
Chlamydia Trachomatis
and
Neisseria Gonorrhoeae
Infections among Asymptomatic Women
B Abban,
G Tao, T Gift, K Irwin
Centers for Disease Control and
Prevention, Atlanta, GA
Background:
Disparities in prevalence of
chlamydia trachomatis
(CT) and
Neisseria gonorrhoeae
(NG) infections among different population
segments, coupled with the many choices of recommended screening
tests and treatments, make it difficult to select the optimal CT
or NG screening and treatment strategy for asymptomatic women.
Goal:
To provide a resource allocation model that would
determine the optimal screening and treatment strategy for CT and
NG in a public-sector family planning facility.
Methods:
Data used in the model were from the published
literature. Several scenarios were considered for CT and NG
screening and treatment, including scenarios in which patients who
tested positive and were treated for one pathogen were also
presumptively treated for the other pathogen. We developed a
binary programming model to define the optimal strategy in which
the combination of infections screened for, age groups screened,
tests, and treatments administered would maximize either
cost-savings or the number of cured infections.
Results:
The optimal screening and treatment strategy for CT
and NG varied with CT prevalence, NG prevalence, and CT-NG
co-infection rates and program budget. At CT prevalence of 5%, NG
prevalence of 1%, and no budget constraint, the optimal
cost-saving screening and treatment strategy was screening with
LCR and treating with azithromycin for CT, and screening with
culture and treating with ceftriaxone for NG when NG prevalence
among patients with CT was < 18.5%, otherwise, screening with LCR
and treating with azithromycin for CT, and presumptively treating
with ceftriaxone for NG among patients with positive CT tests.
Conclusions:
Optimal strategies for CT and NG are highly
dependent on CT and NG prevalence, CT-NG co-infection rates, and
total program budget.
Implications
for Programs, Policy and/or Research:
This resource allocation model provides a flexible,
customizable tool for programs to identify the screening and
treatment strategy for CT and NG that maximizes use of prevention
resources.
Learning
Objectives:
By the end of the session, participants will
understand the various factors and perspectives that should be
considered in selecting screening and treatment strategies for CT
and NG.
A01C
Assay
Results vs. Self-reported HIV/STDs: Does Measurement Discrepancy
Vary by Level of Risk Behavior?
B
Iritani, D Hallfors
Pacific Institute for Research and Evaluation, Chapel Hill, NC
Background:
Previous research suggests discrepancies between
self-reported STD prevalence and assay point prevalence, but no
such studies have yet been conducted with a nationally
representative sample of young adults.
Objectives:
To assess self-report versus assay STD/HIV
prevalence among a representative sample of young adults by their
type and degree of risk behavior.
Methods:
Data are from Wave 3 of the National Longitudinal
Study of Adolescent Health, a nationally representative sample of
18-26 year olds (N=15,197). Data contain results of Chlamydia,
Gonorrhea, and Trichomoniasis urine tests and HIV saliva test in
addition to self-reports of these infections. Bivariate
association between self-reported and assay STD results are
examined for respondents clustered into 16 different groups based
on their sexual and drug use behaviors. Then, clusters are used to
predict STD outcomes in logistic regressions, adjusting for
sociodemographic characteristics such as race, gender, marital
status, age, and region.
Results:
Approximately 7% tested positive by biological
assay for an STD; only 4% self-reported a diagnosis in the past
year. This discrepancy varies markedly by risk group, with one
large “low risk” (median = one partner; very low substance use)
group showing over double the rate with positive assays (10%) than
self-reported (4%). Logistic regressions indicate similar
discrepancies. Odds of infection are significantly greater among
high risk (e.g., MSM, Multiple Partners) than the “low risk”
cluster when predicting self-reported STDs (OR=3.5 and 2.6,
respectively, p<.05) but not on assay results (OR=1.1 and .8, N.S.).
Conclusions:
Prevalence estimates are markedly different when
results are based on self-reported versus biological STD measures.
In particular, rates are underestimated for groups considered to
be at relatively low risk.
Implications
for Programs, Policy, and/or Research:
Persons considered to be at low risk are rarely
screened for HIV/STDs. Education and outreach has increased
screening among some high risk groups, but additional research is
needed to identify and treat other vulnerable sub-groups.
Learning
Objectives:
At the completion of this presentation, participants will be able
to: 1) identify HIV/STD prevalence rates among young adults in16
behavioral risk groups; 2) describe differences between prevalence
rates obtained by self report versus biological assay; and 3)
discuss the research and clinical implications of these findings.
A01D
A Comparison of Three Different Strategies to Treat
Partners of Men with Urethritis
P
Kissinger1, G Richardson-Alston1, J Leichliter4, H
Mohammed1, SN Taylor2,3, DH Martin2, TA Farley1
1Tulane
University School of Public Health and Tropical Medicine;
2Louisiana State University Health Sciences Center; 3New Orleans
Health Department Delgado STD/HIV Clinic, New Orleans, LA;
4Centers for Disease Control and Prevention
Background:
Alternative methods of partner treatment for men
are needed.
Objectives:
To compare patient-delivered partner medication (PDPM)
with two partner referral methods.
Methods:
Men who attended the Delgado STD/HIV Clinic in New
Orleans with a diagnosis of urethritis between 1/02 and 9/03 were
offered the study (85.1% accepted). Intervention allocation was
randomly assigned by month rather than by individual. There were
three interventions: standard partner referral (PR),
bookletenhanced partner referral (BR), and patient delivered
partner medication (PDPM). Information about each partner was
elicited from each index man at baseline and onemonth using a
computer-assisted interview.
Results:
Enrolled index men (n=789) reported information on
1592 partners. At baseline, mean age was 26.1 (s.d. 6.6), mean
number of partners was 2.4 (s.d. 2.3), 82.1% had >1 sex partner,
and 96.5% were African American. During follow-up, 13.6% acquired
a new partner, 68.8% resumed sex and of those 48.7% said they used
condoms all the time. These factors were similar across arms.
Follow-up rate was 66.3% and was lower in BR and PDPM than PR
(62.7%vs. 54.3% vs. 80.8%,
P
<0.01). PDPM and BR arms were more likely than PR
arm to report that their partners told them they had taken
medicine (77.6% vs. 45.8% vs. 34.3%
P
<0.01) and were less likely to test positive for
CT/GC at one-month follow-up (13.9%/12.2%/30.9,
P
<0.01). Men in the PDPM arm were more likely than
men in the BR and PR arms to report having seen their partners
(64.5%/53.6%/53.1%,
P
<0.01), having talked to their partners
(68.6%/51.5%/47.7%,
P
<0.001), having thought their partner took the
medicine (83.3%/38.1%/20.8%,
P
<0.001), and to have used a condom all of the time
(59.8%/44.9%/44.4%,
P
< .01) during follow-up.
Conclusion:
In men, PDPM was better than BR and both were
better than traditional PR in treatment of partners and prevention
of recurrence of CT or GC.
Implications
for Programs, Policy, and/or Research:
PDPM can be a useful public health intervention to
prevent the spread STDs.
Learning
Objective:
By the end of this session, participants will be
able to describe the benefit of patient-delivered partner
medicine.
A01E
Trends in Clinic Visits and Diagnosed
C. trachomatis
(CT) and
N. gonorrhoeae
(GC) Infections Following the Introduction of a
Co-Pay in an STD Clinic
C
Rietmeijer, L Lloyd, G Alfonsi
Denver
Public Health Department, Denver, CO
Background:
STD clinics usually offer services free of cost to
patients or for a nominal (often voluntary) contribution. To
offset decreases in public funding, fee for services may be
initiated or increased. Little is known what the effects of such
(co-) payments may be on access to and utilization of services.
Objective:
To evaluate trends in patient visits and diagnosed
GC and CT infections prior and subsequent to the initiation in
December, 2002, of a variable ($15 and up) co-pay for STD services
at the Denver Metro Health Clinic.
Methods:
Using the clinic’s computerized medical record
system, we compared clinic visits and diagnosed CT and GC
infections during the first 8 months of 2002 and 2003.
Results:
The total number of clinic visits declined from
13,693 to 9.742 (28.8%). Total CT diagnoses declined from 1,365 to
988 (27.6%) and total GC diagnoses from 778 to 503 (35.3%). Among
persons younger than 25, total visits were down by 38%, CT cases
by 38.2%, and GC cases by 33.8%. This age group accounted for
85.6% of fewer diagnosed CT infections, and 39.6% of fewer
diagnosed GC infections. For 2003, we anticipate to diagnose over
900 fewer cases of CT and GC at DMHC.
Conclusion:
Although there may be alternative explanations for
these trends, our findings strongly suggest a causal relationship
between the institution of the co-pay and declining service
utilization. Those at highest risk for STDs (persons younger than
25 years) may be most severely impacted by financial barriers.
Implications
for Program, Policy, and/or Research:
Even the institution of a modest co-pay may result
in significant declines in STD clinic service utilization and
diagnosed STDs, particularly among the age group at highest risk
for these infections. The cost to society for these undiagnosed
infections likely outweighs any co-pay benefit.
Learning
Objectives:
At the end of this presentation, the audience will
be able to assess the impact of a mandatory fee for service on STD
clinic utilization and diagnosed CT and GC infections.
A01F
Transmission of
Chlamydia trachomatis
Between Heterosexual Sex Partners: Preliminary
Results from a Genotype-specific Concordance Study
JA
Schillinger1, B Batteiger2, D Stothard2, J Chapin1,
K Hutchins1, P Braslins3, LA Shrier4, G Madico3, PA Rice3, B Van
der Pol3, T Breen3, B Katz3, D Orr3, J Papp1, LE Markowitz1
1Centers
for Disease Control and Prevention, Atlanta, GA; 2Indiana
University School of Medicine, Indianapolis, IN; 3Boston Medical
Center, Boston, MA; 4Children’s Hospital, Boston, MA
Background:
Few studies have described genotype-specific
concordance for
Chlamydia trachomatis
(Ct) infection in sexual partnerships.
Objective:
To measure genotype-specific concordance for Ct
infection in heterosexual partnerships (dyads).
Methods:
Sexually active males and females aged 14-24 were
recruited at clinical settings in Indianapolis and Boston,
interviewed, and tested for Ct. Sex partners of Ct-infected index
participants were offered study enrollment. Ct infection was
determined by culture (endocervical and urethral specimens), and
nucleic acid amplification testing (NAAT) (endocervical, urethral,
and urine specimens). CT-positive specimens were genotyped by
amplification and sequencing of the full-length omp1 gene.
Results:
A total of 82 dyads were enrolled (39 female and 43
male index participants and their partners). Ct infection was
detected (by culture or NAAT) in both members of 45/82 dyads
(55%). Genotype results available for 32 (71%) of these dyads
revealed different genotypes in 2 dyads (E4/F, D/E), reducing
genotype-specific concordance estimates by 2 dyads to 52% (43/82).
Genotypes identified in concordant dyads were: E/E (n=11), Ia/Ia
(n=4), D2/D2, (n=3), F/F (n=4), E7/E7 (n=2), J/J (n=2), E4/E4,
K/K, E6/E6, H/H (each, n=1). Genotype-specific concordance rates
were similar for partners of male and female index patients. There
were 13 NAAT-positive index participants who were
culture-negative; none had a partner who was Ct-infected by any
test.
Conclusions:
Genotype-specific concordance rates were high,
similar to those reported previously, however, with incomplete
genotype data, our measures of concordance must be considered
maximum estimates. Ct infection was not documented in any of the
partners of persons who were NAAT-positive, but culture-negative;
transmission risk may be lower from such persons.
Implications
for Policy, Programs, and/or Research:
The sex partners of Ct-infected persons have a high
probability of infection. Interpretation of NAAT-positive,
culturenegative specimens will be aided by measures of organism
load, and adjustment for duration of sexual partnership and
frequency of intercourse.
Learning
Objectives:
By the end of this session, participants will be
able to:
-
Explain why
concordance for infection was used as a surrogate measure of
transmission in this study
-
Describe
rates of concordance measured among heterosexual dyads in this
study
-
Discuss why
the estimates of concordance presented are likely to be maximum
estimates
A02A
Rapid Diagnostics for Syphilis in US Clinical
Settings: A Preliminary Review of the Study Data
S
Zackery1, M Sutton1, C Ciesielski2, M Zajackowski2,
M Santana2, C Langley3, L Bernard3, V Pope1, M Fears1, R Johnson1,
L Markowitz1
1Centers
for Disease Control and Prevention, Atlanta, GA; 2Chicago
Department of Public Health, Chicago, IL; 3Indiana University,
Purdue University, Indianapolis, IN
Background:
Rapid diagnostic tests for syphilis, used in many
international settings, are not approved for use in the United
States (US). Rapid tests can provide results in under 20 minutes
and may allow earlier diagnosis and treatment of persons with
syphilis.
Objectives:
To evaluate performance of immunochromatographic
strips (ICS) rapid syphilis tests on whole blood, serum, and
plasma, using TP-PA as the reference.
Methods:
Enrollees are consenting adults who present at STD
Clinics in 2 US cities. Each person has a finger prick and
venipuncture, permitting whole blood, plasma, and serum
evaluations of 3 ICS tests at the local site and serum only at the
CDC laboratory. Persons enrolled are tested and treated for
syphilis, if needed, according to established standards.
Results:
Preliminary data for 366 persons were analyzed. The
median age of enrollees was 28 years; 18 persons had an active
syphilis infection. The 3 ICS tests being evaluated at local sites
had sensitivities ranging from 35% to 83% in whole blood, 50% to
93% in serum, and 41% to 93% in plasma; specificities ranged from
92% to 99.5%.
Conclusions:
The performance of some rapid ICS tests being
evaluated suggests potential for strengthening domestic efforts at
syphilis prevention and control.
Implications
for Programs, Policy, and/or Research:
Earlier diagnosis and treatment of syphilis may
prevent transmission. These rapid, easy-to-use tests may be used
in some non-traditional settings allowing diagnosis of persons who
may not present in routine clinical settings.
A02B
Successful Prevention of Syphilis Infection With
Azithromycin in Both HIV-negative and HIV-positive Individuals,
San Francisco, 1999-2003
JD
Klausner1,2, K Steiner1, R Kohn1
1San Francisco Dept Public Health,
San Francisco, CA; 2University of California, San Francisco, San
Francisco, CA
Background:
Outbreaks of syphilis in major world cities have
challenged disease control efforts. Public health authorities are
increasingly using azithromycin by mouth rather than benzathine
penicillin G injection to treat incubating syphilis. We examined
the efficacy of azithromycin for the prevention of syphilis.
Methods:
Using the San Francisco County STD registry, we
sampled all patients who were treated for syphilis since January
1999 whose baseline rapid plasma regain (RPR) or venereal disease
research laboratory (VDRL) test was nonreactive and had a followup
RPR or VDRL between 30 and 90 days after treatment, excluding
biological false positive tests. Treatments included: azithromycin
1 gram PO once, benzathine penicillin G 2.4 million units IM once
and doxycycline 100 mg PO BID for 14 days. Success was a negative
test for syphilis 30 to 90 days after treatment, whereas failure
was any reactive test or further treatment in this period. HIV
status was determined by record review. We calculated 95%
confidence intervals and compared treatment results by Chi-square.
Results:
Azithromycin successfully prevented syphilis
infection in 96 (98%) of 98 patients versus 15 (94%) of 16
patients treated with benzathine penicillin G (p=0.32) and 5 of 5
treated with doxycycline.
Conclusions:
While a modest sample, treatment failure was
uncommon. Success did not vary by treatment or HIV status.
Azithromycin 1 gram may be as effective as benzathine penicillin G
for the treatment of incubating syphilis and thus prevent syphilis
in persons regardless of HIV status.
Implications
for Programs, Policy, and/or Research:
Further research demostrating efficacy of
azithromycin in treating syphilis using an experimental design
with a larger sample is indicated.
A02C
Azithromycin Resistance in
Treponema pallidum
in the United States and Ireland is Associated With
a Mutation in the 23S rRNA Gene
S
Lukehart1, C Godornes1, B Molini1, P Sonnett1, S
Hopkins2, F Mulcahy2, J Engelman3, A Rompalo4, C Marra1, J
Klausner3
1University
of Washington, Seattle, WA; 2St James Hospital, Dublin, Ireland;
3San Francisco Department of Health, San Francisco, CA; 4Johns
Hopkins University, Baltimore, MD
Background:
Recent outbreaks of syphilis have been reported in
the United States, Canada, British Isles, and Europe. Azithromycin
has been used as alternative therapy for syphilis in some settings
and cases of apparent azithromycin treatment failure have been
identified in San Francisco. The Street14 isolate of
T. pallidum
has been shown in vitro to have macrolide
resistance associated with a 23S rRNA gene mutation.
Objective:
To investigate the association of a 23S rRNA gene
mutation of
T. pallidum
with functional resistance to azithromycin and to
screen samples of
T. pallidum
for this mutation.
Methods:
A rapid PCR-based restriction digestion assay was
developed to detect the 23S rRNA gene mutation and was used to
screen
T. pallidum
in a convenience sample of lesion swabs or isolates
from Seattle, San Francisco, Baltimore, and Dublin. In separate
studies, rabbits were infected intradermally with Street14 or
Nichols strain
T. pallidum
and treated with benzathine penicillin (BPG),
erythromycin (equivalent 2 g/day x 14 days), or azithromycin
(equivalent 1 g/day x 14 days); controls were untreated.
Results:
The mutation was identified in 1 (4%) of 25 swabs
collected in San Francisco before 2003, and in 6 (27%) of 22
collected during 2003. The mutation was found in 2 (9%) of 22
Seattle isolates (2001-2003), in 2 (10%) of 21 swabs from
Baltimore (1998-2000), and in 15 (88%) of 17 swabs from Dublin
(2002). DNA sequencing in 9 samples revealed an identical A_G
mutation. Rabbits infected with Street14 had
T. pallidum
in lesions throughout erythromycin and azithromycin
therapy, but were cured by BPG; rabbits infected with Nichols
strain (lacking the mutation) were cured by all three regimens.
Conclusions:
A mutation in the 23S rRNA gene, associated with
resistance to azithromycin, was identified in samples collected
from syphilis patients from all four geographical locations.
Implications
for Programs, Policy, and/or Research:
These findings suggest that the widespread adoption
of azithromycin as an alternative treatment for syphilis may be
imprudent. The true frequency of this mutation is unknown.
Learning
Objectives:
At the end of this presentation, the audience will
understand that a mutation conferring azithromycin resistance is
present in
Treponema pallidum
strains from 4 different geographical regions.
A02D
Whose Fault is Syphilis? Physicians’ Views on
Syphilis Elimination
BP
Stoner
Washington University, St Louis, MO
Background:
The National Plan to Eliminate Syphilis calls for
significant progress toward syphilis elimination in the US by
2005. St Louis, Missouri has been designated as a syphilis
high-morbidity area (HMA), owing to persistently high rates of
infection. Despite public health officials’ best efforts to seek
broad consensus on how to achieve syphilis elimination, the voices
of practicing physicians are consistently underrepresented in
these dialogues.
Objective:
To utilize qualitative research methods to explore
physicians’ understandings of syphilis transmission, and to elicit
physicians’ perspectives on how best to reduce or eliminate
syphilis in the context of national prevention efforts.
Methods:
In-depth, ethnographic interviews and
participantobservation were conducted among 21 primary care
physicians who provide medical care for patients with or at risk
for syphilis in St Louis, Missouri. Interviews were conducted by a
trained physician-anthropologist and covered clinical, behavioral,
social, and psychological factors linked to syphilis transmission.
Qualitative data were formally analyzed to determine recurrent
themes voiced by physician informants.
Results:
Many physicians found fault in patients with
syphilis for failing to seek care in a timely fashion, for failing
to comply with medical treatment recommendations, and for failing
to refer partners for evaluation and treatment in a timely
fashion. Health officials were also faulted for lack of commitment
to achieve syphilis elimination across artificial jurisdictional
boundaries. Physicians cited time constraints in clinical
encounters as a barrier to effective risk-reduction counseling
among patients with syphilis or other sexually transmitted
infections.
Conclusions:
Qualitative research among physicians in St Louis
demonstrated widely-shared convictions that syphilis elimination
efforts are impeded by poor patient healthcare seeking behaviors,
and are frustrated by weak public health commitments to achieve
disease control.
Implications
for Programs, Policy, and /or Research:
Outreach efforts to physicians regarding community
syphilis elimination agendas may serve to alleviate concern and
suspicion with regard to public health interest in achieving
stated disease prevention goals. Additional physician training in
risk-reduction counseling and behavior change may further
contribute to reductions in syphilis transmission.
Learning
Objectives:
By the end of this presentation, participants will
be able to:
-
Understand
physician viewpoints on public health programs to eliminate
syphilis
-
Describe
perceived barriers to syphilis elimination described by physicians
-
Outline
physicians’ perspectives on methods to enhance the success of
syphilis elimination efforts in local communities
A02E
Developing, Designing, and Disseminating a Syphilis
Awareness Campaign Targeting MSM
EL
Roland
Director
of Education, Montrose Clinic, Houston, TX
Background:
A sharp 3-fold increase in cases of primary and
secondary syphilis over a 1-year period is seen among MSM in
Houston, TX.
Objectives:
To produce a targeted syphilis awareness campaign
to raise awareness and increase testing among Houston MSM.
Methods:
Phase I involved assessing the MSM community, first
by identifying anonymous-sex venues frequented by MSM then through
a brief rapid-assessment survey measuring attitudes, knowledge,
community norms, and risk behavior. This survey was administered
to 112 MSM at anonymous-sex venues revealed in the venue
identification process. Phase II utilized information learned in
Phase I to develop campaign materials designed to educate about
and increase testing for syphilis. Dissemination of the campaign
materials to MSM was the goal of Phase III. Over a 6-month period,
posters, passcards, and condom packs were distributed at
anonymous-sex venues and full-page color advertisements were
placed in local publications with large gay male/MSM readership.
Results:
Assessment activities uncovered over 70
anonymous-sex venues, including adult bookstores, bathhouses,
public parks and restrooms, and fitness centers. The
rapid-assessment survey revealed a low perception of risk for
syphilis (58% thought they were unlikely to contract an STD, yet
57% never used condoms for oral sex and 18% never used condoms for
anal sex). Furthermore, 12% didn’t think syphilis could be
transmitted through oral sex, and 53% thought a penile discharge
was a symptom of syphilis. Project staff distributed over 24,000
passcards, 100,000 condom packs with informational cards, and hung
6,000 posters at various sites in Houston. Multiple advertisements
in publications are estimated to have reached over 100,000 MSM.
Conclusions:
The number of MSM tested for syphilis increased by
22% from 1-year prior and syphilis rates among MSM have dropped
slightly in recent months.
Implications
for Programs, Policy, and/or Research:
A well-planned and designed awareness campaign can
have a serious impact on the public health of a community by
raising awareness and increasing testing.
Learning
Objectives:
By the end of this session, participants will be
able to describe how Montrose Clinic developed a syphilis
awareness campaign targeted to MSM in Houston.
A02F
Development of Innovative Health Communication
Materials to Eliminate Syphilis Among Urban MSM
J Mayer1,
T Robinson2, F Weaver2, A Holterman3, N DeArmitt2
1School
of Public Health, Saint Louis University, St. Louis MO;
2Department of Health, City of Saint Louis, St. Louis MO;
3Missouri Department of Health and Senior Services, Jefferson City
MO
Background:
Recent surveillance data from Saint Louis from
2002-03 indicate a surge in syphilis cases among MSM similar to
increases seen in several large U.S. cities since 1999. With the
introduction of highly active antiretroviral drug treatments (HAART),
many MSM have increasingly viewed HIV as a manageable chronic
disease. In addition, many MSM report fatigue or ‘burn-out’ from
repeated safe-sex messages.
Objectives:
Most current interventions do not address message
fatigue or the effects of HAART on perception of risk.
Methods:
All consecutive attendees at a Saint Louis
bathhouse from June-September 2001 were asked to complete a 9-page
survey in return for a $15 incentive. Independent variables
included HAART-related reduced HIV concern, prevention message
fatigue, fatalism, sensation-seeking, social norms and condom
benefits and barriers. Cronbach alphas ranged from .66 to .87.
Dependent variables included frequency of condom use during
insertive and receptive anal sex with casual partners.
Results:
Of 379 men approached, 350 completed the survey
(response rate = 92%). Mean age was 39 years, and one-half had a
college degree. Mean number of casual partners per month was 1.1
for receptive anal sex (range: 1-32), and 1.4 for insertive anal
sex (range: 1-25). Onethird reported using condoms half the time
or less. In stepwise regression analyses, message fatigue,
HAARTrelated reduced HIV concern, social norms and condom barriers
explained 10-12% of the variance in condom use. Moreover, after
controlling for age, education and number of partners, both
message fatigue and HAARTrelated reduced HIV concern contributed
significantly to explaining condom use (p< .05).
Conclusions:
Overcoming message fatigue and accurately
portraying the consequences of HAART are important components for
interventions promoting consistent condom use and reducing
syphilis among MSM.
Implications
for Programs, Policy, and/or Research:
Innovative health communication materials employing
HAART-related reduced HIV concern, prevention message fatigue, and
other study constructs will be presented and described.
Learning
Objectives:
At the conclusion of this presentation, attendees
will be able to:
-
Describe how
recent advances in drug treatment for HIV may lead to increases in
risky sexual behavior
-
Describe how
repeated exposure to safe-sex messages may create prevention
message fatigue that appears to be positively associated with
risky sexual behavior
-
Construct
messages for STD prevention campaigns that address prevention
message fatigue and the effects of HAART on perceptions of risk
A03
The Public Health Response to Genital Herpes: Where
Do We Stand?
HH
Handsfield1,2, CL Celum1, L Corey1,3, G Bolan4, PA
Leone5
1University
of Washington, 2Public Health – Seattle & King County, and 3Fred
Hutchinson Cancer Research Center, Seattle, WA; 4California
Department of Health Services, Berkeley, CA; and 5University of
North Carolina, Chapel Hill, NC
Background and
Rationale:
Genital herpes, due primarily to herpes simplex
virus type 2 (HSV-2), is global public health problem. Evolving
data implicate HSV-2 in enhanced sexual transmission of HIV;
diagnostic and screening tests are increasingly available; and the
potential for prevention is rising through new strategies, such as
antiviral therapy to curtail transmission, and validation of old
ones, such as condom use. Although clinical and prevention
recommendations have been promulgated by CDC and other agencies,
few if any public health agencies have implemented systematic
programmatic prevention strategies against genital herpes.
Objectives:
(1) To address the current state of the art of the
public health impact of genital herpes, potential prevention
strategies, diagnosis, and HIV/HSV-2 interactions; (2) To propose
model genital herpes prevention strategies by public health STD
control programs and assess barriers to their implementation.
Content:
Speakers will present state-of-the-art lectures on
the varied clinical presentation of genital herpes and the use and
performance of HSV-2 diagnostic and screening tests; mutual
transmission interactions between HSV-2 and HIV; and prevention of
genital herpes and its complications. Elements of a model public
health-based genital herpes prevention program will then be
presented for discussion among the speakers and other panelists,
representing academia and state and local health departments, with
audience participation.
Implications
for Programs, Policy, and/or Research:
Public health agencies and STD control programs may
use the information to assess priorities and consider
implementation of genital herpes prevention strategies.
Panel Line-up
Moderator:
H Hunter
Handsfield, MD
University of
Washington and Public Health – Seattle & King County, Seattle, WA
Panelists:
Connie L Celum, MD, MPH
University of Washington, Seattle, WA
Lawrence
Corey, MD
Fred
Hutchinson Cancer Research Center and University of Washington,
Seattle, WA
Gail Bolan,
MD, MPH
California
Department of Health Services, Berkeley, CA
Peter A.
Leone, MD, MPH
University of North Carolina, Chapel Hill, NC
Measurable
Learning Objectives:
-
Participants will be able to discuss the performance and costs of
available virologic and serologic tests for genital herpes
diagnosis, the influence of HSV- 2 on HIV transmission, and
efficacy of condoms and antiviral therapy in preventing
transmission of HSV.
-
Participants
will understand the potential efficacy, population-based impact,
and possible barriers to implementing programmatic strategies to
prevent genital herpes.
A04
Moving Clients from “Kiss
then Tell”
to “Tell
then Kiss”:
Supporting Conversations Around Patient Self Disclosure of HIV or
STD Status
G
Mehlhaff, A Gandelman, L DeSantis
California Department of Health Services, STD Control Branch, CA
STD/HIV Prevention Training Center
Background and
Rationale:
Disclosure of HIV status can be a challenging,
complex, and possibly dangerous process. HIV positive individuals
are often told to tell their partners of their serostatus, but are
often not given support with disclosure skills. Disclosure of HIV
positive status can be an effective Prevention With Positives
intervention. Given the high rates of syphilis/HIV co-infection,
coaching for self disclosure of HIV and syphilis status is an
increasingly important strategy to consider during syphilis
partner interviews. A skills-based training was developed for
helping patients explore the complex issues surrounding disclosure
and for coaching patients for successful disclosure. Of 174
training participants to date, skill efficacy rose from an average
of 3.44 to 4.78 in identifying patient benefits and concerns
related to disclosing HIV status, and from 2.78 to 4.56 regarding
provider ability to effectively coach clients through the
disclosure process, before vs. after the training (scale 1:poor-
5:excellent). Interactive trainings with practice sessions to
develop skills can build provider efficacy.
Purpose:
To apply a proven technique of training providers
to better address the issues of disclosure of HIV status to
syphilis patient interviews to enhance the outcome.
Methods:
Using adult learning theory, faculty will provide a
brief description and rationale for the course, and use
interactive exercises to identify the issues facing HIV/syphilis
infected individuals around disclosure. Participants will 1)
identify benefits and barriers to disclosing disease status, 2)
practice skills to support patient disclosure, and 3) discuss how
this intervention can be adapted and implemented by STD control
program staff. This will be an interactive skill building session.
Measurable
Learning Objectives:
By the end of the session, participants will be
able to:
-
Gain a better understanding of patient issues
surrounding disclosure including domestic/intimate partner
violence;
-
Explore potential benefits and barriers of self
disclosure with their patients;
-
Enhance coaching skills to support patient self
disclosure of syphilis and HIV positive status.
A05A
Assessing the Training Needs of Managed Care
Providers: Implications for STD Clinical Training Targeting This
Hard-to- Reach Group
S
Ratelle1, J Dyer1, T Cherneskie2, P Coury-Doniger3,
T Hogan4, J Howland5, P McGrath3, S Minsky5, S Payette6, A
Rompalo7, R Shnekendorf 2
1Division
of STD Prevention, Massachusetts Department of Public Health,
Boston, MA; 2New York City Department of Health and Mental
Hygiene, New York, NY; 3Center for Health and Behavioral Training,
University of Rochester, Rochester, NY; 4Baltimore STD/HIV
Prevention Training Center, Baltimore, MD; 5Boston University
School of Public Health, Boston, MA; 6New York State Department of
Health, Albany, NY; 7Johns Hopkins School of Medicine, Baltimore,
MD
Background:
The National Network of Prevention Training Centers
is a CDC-funded group of regional centers dedicated to increasing
the knowledge and skills of health professionals in the areas of
sexual and reproductive health. Needs assessments drive training
activities. Information elicited from managed care providers (MCPs)
can be instrumental in planning training for this hard-to-reach
group.
Objective:
To assess the STD training needs of MCPs related to
STD diagnostics use, screening practices, patient/partner
counseling, and other patient management issues to guide clinical
training activities of the Eastern Quadrant Prevention Training
Centers (EQPTCs).
Methods:
EQPTCs and Boston University School of Public
Health surveyed 649 MCPs in Boston, New York, and Baltimore.
Clinicians were randomly selected among participating
organizations and randomly assigned Syphilis, Chlamydia, or
Training needs assessments.
Results:
A total of 294 surveys were completed. Key findings
include:
Syphilis:
Overall, 58% stated that management of an HIV+
patient with reactive syphilis serology was “often” or “always” a
challenging practice issue. Nearly 25% do not screen HIV+ patients
at least annually, and 20% do not screen sex workers at least
annually. Regional differences were found in screening practices.
Chlamydia:
Nearly 25% found it “often” or “always” challenging
to determine who should be screened. Forty percent stated they
rarely screen sexually active females aged 12 to 19.
Training:
Desired topics included: new STD diagnostic
techniques, techniques for discussing sexual risk taking behavior,
behavioral counseling models. Preferred modalities included update
conferences, grand rounds, web-based/Internet formats.
Conclusions:
Data highlights areas in which MCPs can benefit
from targeted training activities of the EQPTCs.
Implications
for Programs, Policy, and/or Research:
Managed care providers’ levels of comfort in
addressing STDs, screening practices, most salient training needs,
and preferred modalities can guide training content development.
Data can also provide important quality assurance information for
STD screening and patient care.
Learning
Objectives:
By the end of the session, participants will be
able to identify STD training needs/modalities and practices of
managed care providers that have implications for clinical
training.
A05B
Assessing Training Needs Related to the Care of
Sexually Transmitted Diseases (STDs): Perspectives of Medical
Providers Working among American Indian and Alaska Native
Populations (AI/ANs)
C Mason1,
L Shelby1, R Pacheco1, S Adler2, J Pearl2, T Anderson3, C Nelson4
1Indian
Health Service, National Epidemiology Program, Albuquerque, NM;
2California STD/HIV Prevention Training Center, Berkeley, CA;
3Denver STD/HIV Prevention Training Center, Denver Public Health,
Denver, CO; 4Kaiser Permanente, Denver, CO
Background:
STDs among AI/AN populations remain a substantial
heath concern. Improved training that targets the learning needs
of providers may help in addressing STDs in AI/ANs.
Objective:
To assess STD training needs among health care
providers who provide care to AI/ANs.
Methods:
Approximately 60 in-person structured interviews
were conducted with health care providers in fourteen distinct
rural and urban AI/AN health care settings. The interviews
assessed training needs related to: 1) STD prevention, diagnosis,
treatment, and partner management; 2) preferences for STD training
logistics and modalities; and 3) receptivity to a web-based
provider training program specifically designed for providers
serving AI/ANs (ID-Web).
Results:
Most providers preferred training in the format of
brief reviews or STD updates on diagnosis and treatment. Providers
are generally receptive to online training. However, providers had
several concerns about online training. These include: time
constraints, perceived complexity of use, integrity of
information, and potential linkage to performance appraisals.
Conclusions:
STD-focused training should be integrated with
existing, widely attended medical conferences for providers
serving AI/ANs. While providers are receptive to online training,
ID-Web may present implementation and acceptance challenges.
Implications
for Programs, Policy, and/or Research:
Provider training in STD care may need to focus on
updates in diagnosis and treatment that are integrated into
existing medical conferences. Online training may require
sitespecific efforts to overcome initial barriers to
implementation and acceptance.
Learning
Objectives:
Participants will be able to identify providers’
preferred learning modalities related to the treatment of STDs in
AI/ANs.and describe the acceptability and perceived utility of
computerized learning methods in largely underserved health care
settings.
A05C
Developing STD/HIV Training Capacity Among
Spanish-Speaking Community Prevention Providers
A Pérez1,
J Delgado2, A Smith3, A Gandelman3
1California
Department of Health Services, STD Control Branch, California
STD/HIV Prevention Training Center, Long Beach, CA, 2Fresno, CA,
3Berkeley CA
Background:
Prevention staff who work with monolingual
Spanish-speaking clients often face cultural and linguistic
challenges when assessing knowledge, attitudes, and behaviors of
persons at risk for STD/HIV. Staff who can address these
challenges can more effectively assess client risk(s) and identify
appropriate interventions that meet community needs.
Objectives:
Discuss the design, implementation, and evaluation
of a 1-day skills-based training (Resumen
de Enfermedades Transmitidas Sexualamente)
that integrates Hispanic/Latino attitudes and beliefs about
sexuality and STD/HIV; reinforce cultural norms that support safer
sex practices; and describe a set of instructional games derived
from popular US/Mexico culture used to enhance training.
Methods:
Spanish language STD/HIV trainings were conducted
for staff from health department, family planning, and community
agencies. Interactive activities were used to 1) reinforce
concepts of basic STD/HIV epidemiology, transmission, prevention
messages, and STD/HIV interaction issues, and 2) integrate into
Latino culture and participants’ personal experiences.
Participants learned about the prevention and transmission of
numerous STDs.
Results:
Participant evaluations indicated increased levels
of confidence in 1) understanding of STD/HIV prevention and
transmission, 2) educating co-workers and clients about STDs, and
3) effectively integrating these messages from a Latino cultural
perspective. These results will be discussed in greater detail
during the presentation.
Implications
for Programs, Policy, and/or Research:
Latino and/or Spanish-speaking staff can be trained
to effectively disseminate accurate STD/HIV prevention messages in
their respective communities. Since many are wellrespected among
their existing peers, they have the potential to be powerful
community leaders in efforts to reduce STD/HIV.
Learning
Objectives:
By the end of the session, participants will be
able to:
-
Learn how
the training:
Resumen de Enfermedades Transmitidas Sexualamente
was developed and implemented for Spanish-speaking
educators/program staff
-
Become
familiar with 2 culturally appropriate interactive exercises that
were integrated into the training and how they enhanced the course
A05D
What Do Physicians Know and Want to Learn about
STD/HIV Partner Notification?
R
Thomas1, FB Coles1, S Payette1, H Battles2, K
Heavner2, J Tesoriero2, S Leung2, K Rowe2
1New
York State Department of Health, Bureau of STD Control and NYS
STD/HIV Prevention Training Center; Albany, NY; 2New York State
Department of Health, AIDS Institute, Albany, NY
Background:
NYS has a strong STD/HIV public health
infrastructure for partner notification (PN). State law requires
medical providers to report known partners/PN plans for HIV. Given
the role of provider as gatekeeper/arbiter for PN, the NYS STD/HIV
Prevention Training Center (CDC-funded PTC) collaborated on a
statewide survey to assess physician proficiency/training needs in
partner elicitation and notification skills.
Objective:
To assess physician proficiency in and interest in
training for key PN skills/tasks.
Methods:
In 2003, a stratified random sample of physicians
in specialties treating STDs was surveyed. Respondents self-rated
a) 13 PN proficiencies (1=limited to 4=excellent); and b) training
interest for each skill. Response rate: 60% (N=835).
Results:Weighted
results show 45% of physicians were “very interested” and 42 %
“somewhat interested” in additional information on best practices
related to partner elicitation/notification. Proficiency was
lowest for “describing services available through health
department’s partner notification program” (48% limited
proficiency); “collecting additional identifying/locating
information when name/address or phone number of partner is
unknown” (47%); “establishing specific plan for notification with
agreed upon timeframes” (46%); “confirming notification was
completed for partners patients want to self-notify” (42%).
Physicians had more confidence in asking patients about same-sex
partners and partners outside marriage (15/17% “limited” ability).
Proficiency varied by specialty, and level of STD treatment (P
<.001). Training interest varied by proficiency
(less skilled most interested), and specialty. Forty-four percent
expressed interest in training on one or more PN proficiency
areas.
Conclusions:
Results show differential skill levels for key PN
skills/tasks, limited familiarity with health department PN
programs, and interest in PN-specific best practices/additional
training.
Implications
for Programs, Policy, and/or Research:
Expanded models for PN/PCRS are being explored
nationwide. Survey results show the potential of physicians as
strong partners in PN, an interest in information/ training
related to STD/HIV partner services, and provide direction for
tailored training.
Measurable
Learning Objectives:
By the end of the session, participants will be
able to discuss the level of NYS physician proficiency in (and
characteristics associated with) key skills related to STD/HIV
partner elicitation/notification; to describe the level of
interest in receiving information on best practices and/or
training in this area; and consider implications for structuring
and tailoring training.
A05E
Developing and Implementing an STD Treatment
Verification Program in San Francisco
L
Fischer, CK Kent, JD Klausner
STD
Prevention and Control Services, San Francisco Department of
Public Health (SFDPH), San Francisco, CA
Background:
California law requires health care providers to
report treatment for STDs. In San Francisco during 2001, only 3%
of providers outside the municipal STD clinic reported treatment
of their clients with gonorrhea (GC) or chlamydia (CT).
Objectives:
To develop, implement and evaluate an STD treatment
verification program.
Methods:
Providers were divided into three categories;
Community Screening sites, County Hospital based clinics and large
volume Private Providers. Education about the importance of STD
treatment and the legal requirements of reporting were reviewed
with providers. Barriers were cited and identified such as
providers not believing it was important information to report or
not realizing reporting treatment was required. SFDPH STD staff
was assigned to follow-up with providers not reporting GC or CT
treatment within 72 hours of report of disease to document
appropriate treatment.We compared treatment information about
persons with CT and/or GC from January through June 2002 with
January through June 2003, by provider type.
Results:
All three provider types saw a substantial increase
in reporting treatment between 2002 and 2003: Community Based
screening clinics went from 16% (314/1946) to 92% (1,417/1,537);
high volume private providers increased from 27% (156/571) to 46%
(176/385); and the county hospital based clinics went from 15%
(33/213) to 36% (77/217).
Conclusions:
Barriers to reporting treatment by all providers
can be overcome. However, there are more challenges in obtaining
treatment information from the county hospital and private
providers than STD Program supported sites. Assigning staff to
follow up about treatment within specific time frames after
receiving report and educating and providing technical assistance
about the requirement and importance of this information improves
reporting procedures.
Implications
for Programs, Policy and/or Research:
Understand the development and implementation of
consistent and timely GC/CT treatment reporting utilizing existing
screening and surveillance staff.
Learning
Objectives:
By the end of the session, participants will be
able to develop and implement a GC/CT treatment verification
program utilizing existing staff.
A05F
Integration of Viral Hepatitis Prevention with STD
Prevention: What Health Professionals Should Know
BF Ulin1,
T Foskey2
1Centers for Disease Control and Prevention,
Atlanta, GA; 2Texas Department of Health
Background:
Viral hepatitis is a major health problem in the
United States. The routes of transmission for HIV, HBV, and HCV
overlap substantially, and the major risk factors for HBV and HCV
infections are often identical to those for HIV and other sexually
transmitted diseases. Integrating viral hepatitis prevention
messages into HIV and STD programs was identified as an essential
step towards prevention and control of these infections.
Objective:
Provide HIV/STD prevention counselors and Disease
Intervention Specialists (DIS) with the necessary knowledge and
training to integrate viral hepatitis prevention services into
existing HIV/STD prevention programs.
Methods:
A model curriculum was developed by the Texas
Department of Health (TDH) to integrate viral hepatitis prevention
messages into existing HIV/STD prevention programs. The curriculum
consists of two precourse modules followed by a one-day training.
The training includes a knowledge assessment, review of counseling
skills, overview of viral hepatitis risk behaviors, and role-plays
to build skills in transitioning from HIV to viral hepatitis and
providing positive HCV results.
Results:
Between October 1, 2000 and February 28, 2001, 176
prevention staff were trained. TDH began funding 25 sites in
October 2000 to conduct HCV testing for high-risk populations.
Between October 1, 2000 and September 30, 2003, a total of 54,282
specimens were submitted to the TDH lab. Of those, 12,933 (24%)
HCV reactive EIA tests were identified.
Conclusions:
After the training, staff members were more
prepared to address client risk factors and questions related to
HCV. Staff members were also able to transition to a discussion of
viral hepatitis and develop risk reduction plans to reduce the
risk for viral hepatitis is addition to reducing risk for HIV/STD.
Implications
for Programs, Policy, and/or Research:
The development of viral hepatitis training
curricula offers an opportunity for all public health programs to
learn about how to integrate hepatitis prevention messages into
existing HIV/STD health prevention messages. These services can be
easily and effectively provided, even in the context of limited
financial and human resources.
Learning
Objectives:
By the end of this session, participants will be
able to:
-
Describe key
elements of a viral hepatitis curriculum.
-
Understand
the importance of integrating viral hepatitis prevention into
existing HIV and STD programs.
A06A
Sexual Risk Behaviors and Sexually Transmitted
Infection (STI) Prevalence in an Outpatient Psychiatry Clinic
LH
Bachmann1,2, J Feldman1, Y Waithaka1, EW Hook III1
1University
of Alabama at Birmingham, Birmingham, AL; 2Birmingham Veterans
Administration Medical Center, Birmingham, AL
Background:
Few data are available regarding STI risk and
prevalence among patients receiving outpatient psychiatric
treatment.
Objective:
To determine sexual and substance use risk
behaviors and the prevalence of
C. trachomatis,
N. gonorrhoeae,
and
T. vaginalis
in patients between 18-50 receiving care at the
University of Alabama at Birmingham (UAB) Community Care
Psychiatric Outpatient Clinic.
Methods:
Male and female patients received an
intervieweradministered survey and submitted urine (male) or
selfobtained vaginal swabs (female) for testing for
C. trachomatis,
N. gonorrhoeae
and
T. vaginalis
(women only).
Results:
In this ongoing study, 82 participants (38 (46%)
female and 44 (54%) male) have been enrolled. The majority were
black (68%) or white (27%) with a mean age of 38 (22-50). Over 97%
receive medication for a variety of chronic psychiatric
conditions. Alcohol use (46%) and illicit drug use (21%) were
relatively common during the 6 months prior to study enrollment.
Most participants had never married (66%) or were
separated/divorced (27%). Among enrollees, 59% reported sexual
activity within the last 6 months with a median of 1 partner
(1-12) and of 38 (46%) participants engaging in activity within
the previous 30 days, 21% (N=8) reported 1 or more new partners.
Almost a quarter (22%) of the women were infected with
T. vaginalis
and 1% of the population was infected with
C. trachomatis.
Implications
for Programs, Policy and/or Research:
A substantial proportion of patients receiving
outpatient psychiatric care are at risk for STI. Screening in
older outpatient psychiatric populations should focus on detection
of
T. vaginalis.
Results should not be generalized to younger populations receiving
chronic outpatient psychiatric care.
Learning
Objectives:
By the end of this session, participants will be
able to describe the sexual and substance use behaviors and STI
prevalence in patients receiving chronic outpatient psychiatric
care.
A06B
Screening Rates Before and After the Introduction
of the Chlamydia HEDIS (Health Plan Employer Data and Information
Set) Measure in a Managed Care Organization
GR
Burstein1, MA Snyder2, D Conley2, DR Newman1, CM
Walsh1, G Tao1, K Irwin1
1Centers
for Disease Control and Prevention, Atlanta, GA; 2Kaiser
Permanente Mid-Atlantic States, Rockville, MD
Background:
In 2000, a new HEDIS performance measure was
introduced to monitor the proportion of sexually active 15-26
year-old females screened annually for chlamydia.
Objectives:
To determine changes in chlamydia screening
policies, testing, and positivity rates after introduction of the
HEDIS measure.
Methods:
We reviewed electronic medical records of a large,
commercial, managed care organization (MCO) serving a diverse
patient population for endocervical chlamydia tests performed
during 1998-2001 on 15-26 year-old females who were classified as
sexually active according to administrative data elements
specified by HEDIS. We used chi-square testing to compare
chlamydia screening rates and positive tests for 2 years before
and after introduction of the chlamydia HEDIS measure. We queried
MCO departmental chiefs about practice changes implemented to meet
the new HEDIS measure.
Results:
During 1998-1999, 20,571/37,404 (55%) of eligible
15-26 year-old females were tested for chlamydia, of whom 1,681
(8%) tested positive. During 2000-2001, 26,801/37,237 (72%;
P
<0.0001) of eligible females were tested for
chlamydia, of whom 1,852 (7%;P
<0.0002) tested positive. Each year, approximately
_ of the eligible females were seen at least once in obstetrics/
gynecology offices. In January 2000, the obstetrics/gynecology
department instituted a policy of performing chlamydia tests with
all Pap tests on 15-26 year-old females. During 1998-1999,
17,382/28,614 (61%) of eligible females seen in
obstetrics/gynecology offices were tested for chlamydia while in
2000-2001, 23,797/28,663 (83%;P
<0.0001) of eligible females seen in
obstetrics/gynecology offices were tested for chlamydia.
Conclusions:
Following HEDIS measure introduction in this MCO,
the proportion of sexually active 15-26 year-old females tested
for chlamydia increased overall with only a 1% decline in the
proportion of positive tests. Most of the increase resulted from
the new obstetrics/gynecology policy of coupling chlamydia
screening with routine Pap tests.
Implications
for Programs, Policy, and/or Research:
Simple system changes and access to
obstetrics/gynecology providers can improve chlamydia screening
rates and detect a significant number of asymptomatic infections
in a private sector MCO.
Learning
Objectives:
-
By the end
of this session, participants will be able to describe
interventions that can enhance chlamydia screening of sexually
active young females in an MCO.
-
By the end
of this session, participants will be able to demonstrate that
chlamydia screening of sexually active young females can detect a
large burden of asymptomatic infection in the private sector.
-
By the end of
this session, participants will be able to identify at least one
system-level intervention that has been used to attempt to
increase screening rates.
A06C
Genital
Chlamydia trachomatis
Screening Practices in the Private Sector: Who,
Why, and How Much?
J
Armstrong, H Sangi-Haghpeykar
Baylor College of Medicine, Houston, TX
Background and
Rationale:
Chlamydia trachomatis
(Ct) screening rates in the private health care
sector remain poor despite the fact that several national
guidelines recommend routine screening and a HEDIS measure that
monitors screening rates in health plans has been in place for
three years. In 2002, commercial health plans screened fewer than
25% of women for whom Ct screening was recommended. Physician
screening practices in the private sector have not been fully
characterized.
Objective:
To describe the chlamydia screening practices of
obstetrician-gynecologists caring for commercially insured women.
Methods:
A total of 410 US Ob-Gyns who provide care to
privately insured women were surveyed. Information was collected
on rates of compliance with Ct screening guidelines and
demographic and practice characteristics associated with
screening.
Results:
Of the respondents, 64%, 22%, and 9% were
classified as screeners of pregnant women, sexually active women
less than age 20 years, and sexually active women ages 20 to 25
years, respectively. Black physicians were 4.5 times more likely
to screen compared to white physicians after adjusting for patient
race (Adjusted OR=4.5, 95% CI 1.2, 15.6). Nearly three-fourth
(73%) of respondents estimated that the prevalence of infection in
their primary practice site was less than 5%. Nonscreeners were
more likely than screeners to believe that the prevalence of
infection in their primary practice setting was too low to warrant
routine screening (p<.001) and report that knowledge of the
prevalence of infection would positively influence compliance with
screening recommendations (p=0.02).
Conclusions:
Ob-Gyns do not routinely screen eligible women for
chlamydia infection. Factors associated with non-compliance with
established screening protocols have been identified.
Implications
for Programs, Policy, and/or Research:
This presentation will assist policy makers in
understanding provider perspectives on the initiation and
continuation of Ct screening in the private health care sector.
Learning
Objective:
Participants will be able to describe factors
associated with Ct screening in the private sector and identify
potential strategies to improve screening rates.
A06D
Integrating STD Standards of Care Into Family
Planning Services: Evaluation of Chlamydia Screening Practices and
Development of a Quality Improvement Intervention
JM Chow1,
LJ Packel1, L Creegan1, HM Bauer1, J Treat2, G Bolan1
1Sexually
Transmitted Disease Control Branch, 2Office of Family Planning,
California Department of Health Services, Berkeley, CA
Background:
Young women accessing family planning/reproductive
healthcare services are a target population for providing quality
STD care. National guidelines recommend that women age 25 years
and younger be annually screened for chlamydia. Reports of
screening coverage suggest that most young women are not being
screened.
Objective:
To estimate the proportion of female clients age
15-25 that are screened for chlamydia by family planning providers
and to develop a targeted provider quality improvement strategy to
improve adherence to chlamydia screening guidelines.
Methods:
Paid claims data from laboratories and clinician
providers serving female clients in the Family PACT (Planning,
Access, Care, Treatment) program were used to estimate the
proportion of female clients age 15-25 years served in FY01/02
that were screened for chlamydia. Analysis was restricted to
providers who served >100 female clients in this age group during
2002. These data were used to determine a targeted intervention
based on screening rates.
Results:
The median proportion of females age 15-25 years
(n=567,284) who were screened for chlamydia for 866 providers was
52.5%. Forty-five percent of providers tested less than 50% of
clients compared to 49% tested 50-79% of clients and 6.5% tested
80% or more of clients. The proportion of clients tested by public
sector providers was not significantly different than private
sector providers. A quality initiative was designed to provide
individual feedback to providers with their specific screening
rates and targeted messages based on screening level in September
2003.
Conclusions:
There is significant variation in chlamydia testing
with few providers testing the vast majority of their young female
family planning clients.
Implications
for Programs, Policy, and/or Research:
Monitoring provider-specific adherence to chlamydia
screening guidelines may be useful for identifying specific groups
of providers in need of additional training. Targeted chlamydia
testing data feedback to family planning providers may raise
awareness of STD standards of care and potentially improves
screening practices.
Learning
Objectives:
By the end of this session, participants will be
able to describe a methodology for estimating provider-specific
chlamydia screening based on claims data, describe the profile of
providers who perform chlamydia screening in a large family
planning program, and describe a targeted intervention for
improving chlamydia screening based on provider data feedback.
A06E
Screening and Treating Patients for Asymptomatic
Sexually Transmitted Infections in an Inner-City Emergency
Department
NR
Glick1, A Silva2, S Lyss3, S Whitman2
1Mt.
Sinai Hospital, Chicago, IL; 2Sinai Urban Health Institute,
Chicago, IL; 3Centers for Disease Control and Prevention, Division
of HIV/AIDS Prevention, Atlanta, GA
Background:
Recent studies show that patients in emergency
departments (ED) have high rates of asymptomatic sexually
transmitted infections (STIs) as well as a willingness to test for
them during their visit. Therefore, routinely screening for STIs
in EDs can identify asymptomatic patients who may otherwise go
unrecognized. However, limited evidence exists on whether patients
who test positive for STIs in EDs are successfully treated.
Objectives:
To assess the prevalence of STIs and receipt of
treatment among patients identified with STIs in an inner-city ED.
Methods:
As part of an ongoing study assessing routine,
voluntary HIV/STD screening in the ED, patients aged 15 to 25
years were offered free chlamydia and gonorrhea testing,
Monday-Friday, 10AM-8PM. Patients were eligible if they provided
informed consent and were not being treated for STI symptoms at
the current visit. Urine samples were collected and tested by
nucleic acid amplification. Patients testing positive for either
STI were notified and referred to a public health or hospitalbased
clinic for free treatment. Prevalence and treatment rates were
assessed.
Results:
In four months of screening, 188 patients were
approached, and 78 (41%) consented to testing. Males and females
tested were similar in terms of age and race/ethnicity to those
who refused testing and to the ageeligible ED population. Of the
70 patients who provided a urine sample, 8 tested positive for
chlamydia only, 1 for gonorrhea only, and 2 for both; the
prevalence was 14% for chlamydia and 4% for gonorrhea. Of the 11
patients who tested positive for an STI, 9 (82%) received
treatment.
Conclusions:
Preliminary data show that patients with
asymptomatic STIs can be identified in the ED and successfully
linked to treatment.
Implications
for Programs, Policy, and/or Research:
Public health departments should consider working
with EDs to identify and treat patients with asymptomatic STIs.
Research is needed on the cost-effectiveness of STI screening and
treatment in EDs.
Learning
Objectives:
By the end of the session, participants will be
able to discuss the feasibility of integrating STI screening and
treatment as part of routine care in an ED as part of a
collaborative effort with a local public health department to
decrease the prevalence of STIs.
A06F
Extending Preventive Care to Pediatric Urgent Care:
A New Venue for CT Screening?
MA Shafer1, K Tebb1, T Ko2, C Wibbelsman3, S
Pecson-Cruz1, A Tipton2, M Pai-Dhungat1, J Neuhaus1, R Pantell1
1University
of California San Francisco, Division of Adolescent Medicine, San
Francisco, CA; 2Kaiser Permanente, Oakland, CA; 3Kaiser
Permanente, San Francisco, CA
Background:
Chlamydia trachomatis
(CT) is the most common reportable bacterial
infection in teen girls. Despite recommendations for annual CT
screening, less than 25% are being screened. Our systems
intervention significantly improved screening rates during health
check-ups; however, since 2/3 of adolescents only use urgent care,
the next obvious step was to screen in this venue.
Objectives:
To evaluate the effectiveness of a modified
clinical practice improvement intervention (CPI) to increase CT
screening among 14-18 yo sexually active girls attending pediatric
urgent care in an HMO setting.
Methods:
As part of a larger, randomized control trial, the
CPI was extended to 2 pediatric urgent-care clinics. A CPI team
was formed at each clinic to establish protocols for confidential
sexual history taking and urine collection. CPI teams met monthly,
reviewed protocols, screening rates and problem-solved barriers
using a rapid cycle change format. Screening rates were analyzed
over three, 3-month periods (baseline and two post-tests). The
proportion screened = number tested/(number seen x sexual activity
rate).
Results:
Compared to well care, teen girls attending urgent
care had higher sexual activity rates (42% vs 26%; P<0.01), were
older (15.6 vs 15.4; P<0.05) and more ethnically diverse. At
baseline, 92/1072 (9%) girls were tested for CT with 11/92 (12%)
positive. At timetwo, 472/1248 (38%) were tested; 33/472 (7%) were
positive. At time-three, 407/659 (62%) were tested; 26/407 (6%)
positive This represents a 7-fold screening increase and
identification of 2-3 times as many CT infected girls.
Conclusions:
Adolescent females attending urgent care appear to
be at greater risk for CT and screening in this setting is
feasible.
Implications
for Programs, Policy and/or Research:
The high rate of positives shows CT testing to be necessary in
urgent care to reach the majority of at-risk girls who would
otherwise remain undetected. Future research needs to include
larger number of clinics and should assess the quality of
follow-up care.
Learning
Objectives:
Participants will have identify barriers to CT screening and
strategies for to increase CT screening in the urgent care
setting.
A07
Emerging Patterns and Trends in Nationally
Notifiable Sexually Transmitted Diseases, United States
H
Weinstock, D Mosure, L Newman, S Wang, J Heffelfinger
Centers for Disease Control and Prevention,
Atlanta, GA
Background and
Rationale:
STD surveillance data are critical for helping
guide programmatic and policy decisions. Although national
surveillance data for syphilis, gonorrhea, and chlamydia suggest
that control programs have achieved considerable success over the
past decade, trends over the past 2 years are worrisome for the
emergence of new patterns of disease that may require local and
state programs to re-evaluate their efforts.
Objectives:
To describe the latest trends for each of the three
major notifiable STDs using nationally reported surveillance data
and to describe the program and policy implications of the
changing epidemiology of these diseases.
Content:
This symposium will include presentations on each
of the notifiable STDs. Increases in primary and secondary
syphilis among men who have sex with men in the United States as
well as trends in other populations will be discussed as will
implications for the Syphilis Elimination program. The
presentation on gonorrhea will highlight those populations most
impacted by this disease, notably young African-American men and
women. Increases in antimicrobial resistance to the
fluoroquinolones, the only remaining oral therapies recommended by
CDC for treating gonorrhea (given the unavailability of Cefixime),
will be described as will the implications on treatment
recommendations. Trends in chlamydia case reports and prevalence
monitoring data will also be presented, including findings from
the Regional Infertility Prevention projects.
Implications
for Programs, Policy, and/or Research:
As new populations are impacted by STDs and as
resistance to recommended therapies emerges, new strategies to
prevent and control these diseases must be evaluated. These trends
highlight priorities for research, including the identification of
reasons for and interventions to address recent increases in STDs
among men who have sex with men, the need to identify effective
oral drugs to treat fluoroquinolone-resistant gonorrhea, and
identification of more effective methods for gonorrhea and
chlamydia control.
Learning
Objectives:
By the end of this session, participants should be
able to:
-
Describe the
latest trends in syphilis, gonorrhea, and chlamydia in the United
States
-
Describe the
impact of these trends on STD prevention and control programs
A08
Finding the Invisible Man: A Best Practices Model
for HIV/AIDS-STD Prevention & Services for AAMSM Through Community
Collaboration
O
Johnson
Community Health Awareness Group (CHAG), Detroit, MI
Background &
Rationale:
In the last decade of HIV prevention it has been
explained that the population of African-American MSMs have been
and remain one of the hardest hit groups in America’s HIV
epidemic. While several attempts have been made to access this
population for prevention & services, current methods that only
imitate processes successful in the white gay population do not
prove effective or appropriate with African-American men who have
sex with men. This model attempts to bridge that gap in a manner
that is culturally specific and inclusive of multiple agencies’
expertise in a way that preserves the unique spirit of the
population for which it is designed.
Purpose:
a) To explain the collaborative process and
illustrate a specific way in which such practice can work in a
community that bridges the services among multiple organizations
to meet the needs of the population in question. b) To explain and
advocate the use of a best practices model of HIV/AIDS prevention
& services that is culturally specific for African-American men
who have sex with men (AAMSM).
Methods:
I will also use brief scenarios to describe the
population of AAMSMs within four levels that more accurately
reflect the uniqueness of this population alongside the barriers
such as stigma, discrimination, and the struggle associated with
sexual identity that impacts the provision of care and services.
Then through the use of guided discussion I will elicit a listing
of the specific needs of the AAMSM population in terms of
prevention & care and help participants determine how such
services are best received by the population through various
community organizations.
Learning
Objectives:
By the end of this workshop participants will be
able to:
-
Identify
the level of collaboration operating within their organization’s
current services and identify the multiple identities that are a
part of the AAMSM population
-
Describe
at least 2 factors that have acted as barriers to the acquisition
of prevention & services for AAMSMs and how they can be overcome
through effective collaboration with other agencies within their
own communities
-
Create an
action plan toward preparing your organization, to contribute to a
prevention or service related effort in his/her own community
through the use of one or more of a variety of evidence-based
behavioral interventions
A09A
Multilevel Risk Factors/Multilevel Interventions:
Complexities in STD Population Dynamics and STD Prevention
SO Aral
Centers for Disease Control and Prevention (CDC), Atlanta, GA
Background and
Rationale:
The field of STD epidemiology and prevention has
evolved in the direction of population level approaches over the
past two decades, while individual level analyses and
interventions continue to play an important role. Some of the most
remarkable advances have been in the areas of pathogen –
population interactions; pathogen characteristics; impact of
sexual mixing patterns, concurrent partnerships, structure of
prevalent sexual networks on the spread of STI; impact of newly
available therapies on STD spread; and societal determinants of
sexual mixing patterns, concurrent partnerships, and sexual
networks and their impact on changes in these determinants. In
addition, there have been remarkable advances in methodologies
employed in the study of populations and individuals in
populations.
Objectives:
To discuss cutting edge issues in partnership
dynamics; network based risk factors and interventions; and social
determinants of STD spread.
Content:
The panelists will discuss the most recent advances
in the methodological approaches to the study of multilevel risk
factors and multilevel interventions in STD epidemiology and
prevention. Particular attention will be paid to inter-level
synergistic interactions. Specific discussions will include risk
factors and interventions at the partnership, social network and
societal levels.
Implications
for Programs, Policy, and/or Research:
Available research results will provide new
directions for policy formulation and program development at more
aggregate levels while highlighting remaining questions to be
explored by future research.
Panel Line-up
Moderator:
Sevgi O. Aral
Centers for
Disease Control and Prevention, Atlanta, GA
Panelists:
Adaora
Adimora, MD
The
University of North Carolina at Chapel Hill, NC
Pamina
Gorbach, DrPh
University of
California, Los Angeles
Lisa Manhart,
PhD
University of
Washington, Center for AIDS and STD, Seattle, WA
Dan
Wohlfeiler, JD, MPH STD
Control
Branch, Berkeley, California
Measurable
Learning Objectives:
Attendees will be able to:
-
Identify STD
risk factors at the partnership, sexual and social network, and
societal levels.
-
Identify and
choose among STD prevention interventions at the partnership,
network and societal levels.
A09B
Behavioral, Biological and Structural Components of
MSM STI Morbidity
SM
Goodreau, MR Golden
University of Washington, Seattle, WA
Background:
STIs (including HIV) disproportionately affect men
who have sex with men (MSM). STI transmission dynamics are
determined by partner change rates, hostparasite biological
factors and network structure. The relative impact of these
factors in creating the disparity in STI between MSM and
heterosexuals is ill-defined.
Objectives:
To assess relative contributions of behavioral
(partner number) and intrinsic biological (transmissibility) and
structural (population size, number of sexes) factors in creating
observed disparities in HIV rates between MSM and heterosexuals.
Methods:
A deterministic compartmental model with 12 groups
for MSM (2 activity classes by 2 serostatuses by 3 role
classes—insertive, receptive, versatile) and 8 for heterosexuals
(2 activity classes by 2 serostatuses by 2 sexes) is solved
numerically 10 and 20 years after introduction of a single
susceptible, and at endemic prevalence. The UMHS and NHSLS studies
provide data to parameterize simulations.
Results:
A fully versatile MSM population with observed
rates of unprotected partnerships and anal intercourse
transmissibility yields a prevalence of 15.6% at year 20 and 28.8%
at equilibrium. A two-sex heterosexual population of the same
size, partner change rate and HIV transmissibility yields 5.0% and
14.7%, respectively. A heterosexual population that is 10x larger
yields 0.9% prevalence at year 20. When transmissibility is
lowered to current estimates for vaginal sex, the epidemic dies
out in heterosexuals.
Conclusions:
Biological and structural factors inherent in male
homosexuality result in substantial disparities in HIV morbidity
between MSM and heterosexuals. These appear to dwarf the impact of
currently observed disparities in unprotected anal/vaginal sex
partner change rates.
Implications
for Programs, Policy, and/or Research:
Homosexuality imposes structural vulnerabilities to
the introduction and promulgation of an STI epidemic that are
independent of partner change rates. As a result, even if MSM had
substantial reductions in high-risk sexual behavior, MSM remain
relatively vulnerable to STI epidemics.
Learning
Objectives:
By the end of the session, participants will
understand that being a relatively small, single-sex population
combined with relatively high transmissibility makes MSM far more
susceptible to an STI epidemic than heterosexuals. They will
further understand that current efforts at HIV prevention in MSM
generally focus on lowering unprotected contact rates and
transmissibility without considering these structural factors.
A09C
The Same Transmission Dynamics Drive the Fast Gay
and Slow African HIV Epidemics
BL
Rapatski2, JA Yorke1,2,3, F Suppe1,4
1Institute
for Physical Sciences and Technology, 2Department of Mathematics,
3Department of Physics, University of Maryland, College Park, MD;
4CMLL, Texas Tech University, Lubbock, TX
Background:
We view HIV as a 3-stage model in which a person
progresses through the primary, asymptomatic and symptomatic
stage. A person’s infectivity, or the probability a contact
between an infected and susceptible will transmits the disease,
varies with stage of infection.We model the San Francisco “gay
epidemic.” Beginning in 1978, blood samples from 6875 men were
taken and behavioral data recorded as part of a Hepatitis-B
vaccine trial. Subsequent reanalysis of some of those blood
samples for HIV provides the most accurate incidence data
describing the onset of HIV in any population. From the behavioral
data collected we determine that the SF gay population can be
broken into six sexual activity groups ranging from 231 partners
per year to none.
Objective:
To determine how infectious HIV is.
Methods:
We use mathematical modeling which reflects the
great variation in contact rates between gay men.
Results:
The infectivities for the primary, asymptomatic and
symptomatic stages are 0.015, 0.006, 0.223 respectively. The third
stage infectivity is significantly higher than the other two
stages and ultimately drives the HIV epidemic.
Conclusions:
A reduction of the effective contact rate
(infectivity times frequency of contacts) by a factor of 100 would
have been necessary for the gay epidemic to have ceased to be
endemic. If we lower the effective contact rate by a factor of 10,
similar to Sub-Saharan Africa, large outbreaks occur but are
delayed by many years. The model suggests countries such as India
have an epidemic doubling every year.
Implications
for Programs, Policy, and/or Research:
We provide a systematic way for predicting the
growth of the epidemic in Third World countries and for evaluating
the efficacy of diverse HIV reduction strategies including
vaccination.
Learning
Objectives:
By the end of this session, participants will learn
how infectious HIV is for gay men and will learn how to predict
the fate of epidemics in the Third World.
Sponsored
Symposium
Guidelines for the Use of Herpes Simplex Virus Type 2 Serologies:
Recommendations From the California Sexually Transmitted Diseases
Controllers Association and the California Department of Health
Services
S
Guerry1, H Bauer1, J Klausner2, B Branagan3, P
Kerndt4, B Allen5, G Bolan1
1California
Department of Health Services, STD Control Branch, Berkeley, CA;
2San Francisco City and County Health Department, San Francisco,
CA; 3Sonoma County Health Department, Sonoma, CA; 4Los Angeles
County Department of Health Services, Los Angeles, CA; 5Alameda
County Public Health Department, Alameda, CA
Background:
Although herpes simplex virus type-specific
serology tests are now widely available, indications for their use
have not been well-defined. Due to the lack of formal guidelines,
the California Department of Health Services, in conjunction with
the California STD Controllers Association, convened a committee
to make recommendations for the use of HSV-2 type-specific
serologies.
Objectives:
To review all relevant literature to develop best
practice guidelines for the use of type-specific HSV- 2 serology
tests.
Methods:
Published articles related to herpes, herpes
screening, type-specific serology tests, herpes and HIV, herpes in
pregnancy, neonatal herpes, condom efficacy, behavior intervention
efficacy and antiviral suppression efficacy were identified using
MEDLINE. In addition, bibliographies of identified articles,
personal files of committee members, and unpublished manuscripts
from HSV researchers were reviewed. Screening recommendations were
developed by applying standard screening criteria to each specific
population.
Results:
HIV infected patients, patients with partners known
to be infected with HSV-2, and highly motivated STD patients will
likely benefit most from identifying HSV-2 status. There is less
evidence that universal screening of pregnant women and the
sexually active population will be beneficial to either the
individual patient or to the public health of the community.
Type-specific serology tests should be available for diagnostic
purposes in conjunction with virologic tests at any clinical
setting where patients are evaluated for STDs.
Conclusions:
HSV-2 screening of asymptomatic patients will
likely have patient and public health advantages if used in
conjunction with proven interventions such as risk-reduction
counseling and anti-viral suppressive therapy—for those identified
with symptomatic infections— and if screening is targeted.
Implications
for Programs, Policy, and/or Research:
Screening and intervention resources should be
directed towards the patient populations at highest risk for
herpes acquisition and transmission and those most motivated to
change behavior or to comply with treatment regimens.
Learning
Objectives:
By the end of the session, participants will be
familiar with the recommended uses of HSV-2 serologies as well as
the evidence supporting these recommendations.
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