The Estimated Direct Lifetime Medical Costs of Sexually Transmitted Infections Acquired in the United States in 2018

Modeling the Potential Impact of Missing Race and Ethnicity Data in Infectious Disease Surveillance Systems on Disparity Measures: Scenario Analysis of Different Imputation Strategies

BACKGROUND

Monitoring progress toward population health equity goals requires developing robust disparity indicators. However, surveillance data gaps that result in undercounting racial and ethnic minority groups might influence the observed disparity measures.

OBJECTIVE

This study aimed to assess the impact of missing race and ethnicity data in surveillance systems on disparity measures.

METHODS

We explored variations in missing race and ethnicity information in reported annual chlamydia and gonorrhea diagnoses in the United States from 2007 to 2018 by state, year, reported sex, and infection. For diagnoses with incomplete demographic information in 2018, we estimated disparity measures (relative rate ratio and rate difference) with 5 imputation scenarios compared with the base case (no adjustments). The 5 scenarios used the racial and ethnic distribution of chlamydia or gonorrhea diagnoses in the same state, chlamydia or gonorrhea diagnoses in neighboring states, chlamydia or gonorrhea diagnoses within the geographic region, HIV diagnoses, and syphilis diagnoses.

RESULTS

In 2018, a total of 31.93% (560,551/1,755,510) of chlamydia and 22.11% (128,790/582,475) of gonorrhea diagnoses had missing race and ethnicity information. Missingness differed by infection type but not by reported sex. Missing race and ethnicity information varied widely across states and times (range across state-years: from 0.0% to 96.2%). The rate ratio remained similar in the imputation scenarios, although the rate difference differed nationally and in some states.

CONCLUSIONS

We found that missing race and ethnicity information affects measured disparities, which is important to consider when interpreting disparity metrics. Addressing missing information in surveillance systems requires system-level solutions, such as collecting more complete laboratory data, improving the linkage of data systems, and designing more efficient data collection procedures. As a short-term solution, local public health agencies can adapt these imputation scenarios to their aggregate data to adjust surveillance data for use in population indicators of health equity.

Viral Shedding 1 Year Following First-Episode Genital HSV-1 Infection

IMPORTANCE

Herpes simplex virus type 1 (HSV-1) is the leading cause of first-episode genital herpes in many countries.

OBJECTIVE

To inform counseling messages regarding genital HSV-1 transmission, oral and genital viral shedding patterns among persons with first-episode genital HSV-1 infection were assessed. The trajectory of the development of HSV-specific antibody and T-cell responses was also characterized.

DESIGN, SETTING, AND PARTICIPANTS

Prospective cohort followed up for up to 2 years, with 82 participants followed up between 2013 and 2018. Participants were recruited from sexual health and primary care clinics in Seattle, Washington. Persons with laboratory-documented first-episode genital HSV-1 infection, without HIV infection or current pregnancy, were referred for enrollment.

EXPOSURES

First-episode genital HSV-1 infection.

MAIN OUTCOMES AND MEASURES

Genital and oral HSV-1 shedding and lesion rates at 2 months, 11 months, and up to 2 years after initial genital HSV-1 infection. Participants self-collected oral and genital swabs for HSV polymerase chain reaction testing for 30 days at 2 and 11 months and up to 2 years after diagnosis of genital HSV-1. Blood samples were collected at serial time points to assess immune responses to HSV-1. Primary HSV-1 infection was defined as absent HSV antibody at baseline or evolving antibody profile using the University of Washington HSV Western Blot. HSV-specific T-cell responses were detected using interferon γ enzyme-linked immunospot.

RESULTS

Among the 82 participants, the median (range) age was 26 (16-64) years, 54 (65.9%) were women, and 42 (51.2%) had primary HSV-1 infection. At 2 months, HSV-1 was detected from the genital tract in 53 participants (64.6%) and in the mouth in 24 participants (29.3%). Genital HSV-1 shedding was detected on 275 of 2264 days (12.1%) at 2 months and declined significantly to 122 of 1719 days (7.1%) at 11 months (model-predicted rate, 6.2% [95% CI, 4.3%-8.9%] at 2 months vs 3.2% [95% CI, 1.8%-5.7%] at 11 months; relative risk, 0.52 [95% CI, 0.29-0.93]). Genital lesions were rare, reported on 65 of 2497 days (2.6%) at 2 months and 72 of 1872 days (3.8%) at 11 months. Oral HSV-1 shedding was detected on 88 of 2247 days (3.9%) at 2 months. Persons with primary HSV-1 infection had a higher risk of genital shedding compared with those with nonprimary infection (model-predicted rate, 7.9% [95% CI, 5.4%-11.7%] vs 2.9% [95% CI, 1.7%-5.0%]; relative risk, 2.75 [95% CI, 1.40-5.44]). Polyfunctional HSV-specific CD4+ and CD8+ T-cell responses were maintained during the follow-up period.

CONCLUSIONS AND RELEVANCE

Genital HSV-1 shedding was frequent after first-episode genital HSV-1, particularly among those with primary infection, and declined rapidly during the first year after infection.

Development of a usability checklist for public health dashboards to identify violations of usability principles

OBJECTIVE

To develop a usability checklist for public health dashboards.

MATERIALS AND METHODS

This study systematically evaluated all publicly available dashboards for sexually transmitted infections on state health department websites in the United States (N = 13). A set of 11 principles derived from the information visualization literature were used to identify usability problems that violate critical usability principles: spatial organization, information coding, consistency, removal of extraneous ink, recognition rather than recall, minimal action, dataset reduction, flexibility to user experience, understandability of contents, scientific integrity, and readability. Three user groups were considered for public health dashboards: public health practitioners, academic researchers, and the general public. Six reviewers with usability knowledge and diverse domain expertise examined the dashboards using a rubric based on the 11 principles. Data analysis included quantitative analysis of experts' usability scores and qualitative synthesis of their textual comments.

RESULTS

The dashboards had varying levels of complexity, and the usability scores were dependent on the dashboards' complexity. Overall, understandability of contents, flexibility, and scientific integrity were the areas with the most major usability problems. The usability problems informed a checklist to improve performance in the 11 areas.

DISCUSSION

The varying complexity of the dashboards suggests a diversity of target audiences. However, the identified usability problems suggest that dashboards' effectiveness for different groups of users was limited.

CONCLUSIONS

The usability of public health data dashboards can be improved to accommodate different user groups. This checklist can guide the development of future public health dashboards to engage diverse audiences.

Incident Chlamydia trachomatis Infection in a High School Population

Prospective cohort studies of sexually transmitted infections (STIs) are logistically impractical owing to time and expenses. In schools, students are readily available for school-related follow-ups and monitoring. Capitalizing on the logistics that society already commits to ensure regular attendance of adolescents in school, a school-based STI screening in New Orleans made it possible to naturally observe the occurrence of chlamydia and to determine its incidence among 14-19-year-old adolescents. Among participants screened repeatedly, we calculated incidence rates, cumulative incidence, and incidence times. Male (n = 3820) and female (n = 3501) students were observed for 6251 and 5143 person-years, respectively, during which 415 boys and 610 girls acquired chlamydia. Incidence rates per 100 person-years were 6.6 cases for boys and 11.9 cases for girls. In multivariable analysis, the adjusted hazard ratio was 5.34 for boys and 3.68 for girls if the student tested positive for gonorrhea during follow-up, and 2.76 for boys and 1.59 for girls if at first participation the student tested positive for chlamydia, and it increased with age among boys but not among girls. In joinpoint trend analysis, the annual percentage change in the incidence rate was 6.6% for boys (95% CI: -1.2%, 15.1%) and 0.1% for girls (95% CI: -5.3%, 5.7%). Annual cumulative incidence was 5.5% among boys and 8.6% among girls. Median incidence time was 9.7 months for boys and 6.9 months for girls. Our findings can be used to refine assumptions in mathematical modeling and in cost analysis studies of C. trachomatis infection, and provide strong evidence in support of annual chlamydia screening for adolescent boys.

"Doing it on my own terms": Transgender and nonbinary adults' experiences with HPV self-swabbing home testing kits

The human papillomavirus (HPV) carries a significant health risk for people with a cervix. Among transgender and nonbinary people, however, testing and treatment for HPV can pose difficulties, and even be traumatic at times. This current study is part of a larger mixed methods study conducted in Michigan in 2020, and it explores the experiences of transmasculine and nonbinary people with at-home self-swabbing HPV test kits and knowledge of HPV transmission/screenings. Phenomenological methods were used by conducting virtual qualitative interviews with ten transmasculine and nonbinary individuals with cervixes, ages 23-59. Interviews were independently coded by members of the research team and a tabletop theming method was used. Four themes were generated from the data: 1) Multilevel barriers; 2) "Get it done, so I know that I am safe"; 3) Contrasting preferences for care; and 4) Community calls for change. The discussion focuses on the implications of these findings for improving sexual health care for the transgender and nonbinary community, along with directions for further research.

Characterizing Financial Sustainability of Sexually Transmitted Disease Clinics Through Insurance Billing Practices

CONTEXT

Sexually transmitted infections (STIs) continue to increase in the United States. Publicly funded sexually transmitted disease (STD) clinics provide important safety net services for communities at greater risk for STIs. However, creating financially sustainable models of STI care remains a challenge.

OBJECTIVE

Characterization of clinic insurance billing practices and patient willingness to use insurance.

DESIGN

Cross-sectional survey assessment of clinic administrators and patients.

SETTING

Twenty-six STD clinics and 4138 patients attending these clinics in high STD morbidity metropolitan statistical areas in the United States.

PARTICIPANTS

Clinic administrators and patients of these clinics.

INTERVENTION

Survey assessment.

MAIN OUTCOME MEASURE

Insurance billing practices of STD clinics and patient insurance status and willingness to use their insurance.

RESULTS

Fifteen percent of clinics (4/26) indicated that they billed only Medicaid, 58% (15/26) billed both Medicaid and private insurance, 27% (7/26) did not bill for any health insurance, and none (0%) billed only private health insurance companies. Of 4138 patients surveyed, just more than one-half of patients (52.6%) were covered by some form of health insurance. More than one-half (57.2%) of all patients covered by health insurance indicated that they would be willing to use their health insurance for that visit. After adjusting for patient demographics and clinic characteristics, the patients covered by government insurance were 3 times as likely (odds ratio: 3.16; 95% confidence interval, 2.44-4.10) than patients covered by private insurance to be willing to use their insurance for their visit.

CONCLUSION

Opportunities exist for sustainable STI services through the enhancement of billing practices in STD clinics. The STD clinics provide care to large numbers of individuals who are both insured and who are willing to use their insurance for their care. As Medicaid expansion continues across the country, efforts focused on improving reimbursement rates for Medicaid may improve financial sustainability of STD clinics.

Estimating the Association Between Public Health Spending and Sexually Transmitted Disease Rates in the United States: A Systematic Review

ABSTRACT

Public health spending is important for managing increases in sexually transmitted diseases (STDs) in the United States. Although previous studies suggest that a beneficial link exists between public health spending and changes in STD rates, there have been no systematic reviews synthesizing existing evidence regarding the association for STDs at the population level. The objective of this study was to synthesize evidence from studies that assessed the associations between general and STD-specific public health spending and STD rates. We conducted a systematic review using Ovid-Medline, EMBASE, CINAHL, Cochrane Library, Web of Science, and EconLit for relevant studies that examined the association between public health spending and gonorrhea, syphilis, chlamydia, and chancroid rates following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A total of 5 articles (2 regarding general public health spending and 3 regarding STD-specific public health spending) met our inclusion criteria. There was a significant decrease in gonorrhea, syphilis, chlamydia, and chancroid rates associated with increased public health spending. We also found that STD-specific public health spending has a greater effect on STD rates compared with general public health spending. Our review provides evidence that increases in general and STD-specific public health spending are associated with a reduction of STD rates. Such research regarding estimates of the impact of STD prevention spending can help policy makers identify priority funding areas and inform health resource allocation decisions.

Trends in risk behaviors and sexually transmitted infections among youth presenting to a sexually transmitted infection clinic in the United States, 2013-2017

Background: Sexually transmitted infections (STIs) are increasing among adolescents and young adults (AYA) across the United States. However, data are scarce on trends in condom use, number of partners, and other STI risk factors among AYA. The present study evaluated associations between sexual behaviors and STI diagnoses over time among AYA. Methods: We evaluated linked encounters of AYA aged 13-26 attending an urban Northeast public STI clinic from 2013-2017. Demographics, risk behaviors, self-reported past year and lifetime STI, and STI diagnosis during clinic encounter (positive test for urine, oral, or anal chlamydia; urine, oral, or anal gonorrhea; urine trichomonas; HIV; and syphilis) were extracted from electronic health records. We estimated prevalence and performed trend analyses of the repeated cross-sectional data. Cochran-Armitage and Kruskal-Wallis trend test were conducted for categorical and continuous variables, respectively. Results: Among 3822 encounters, clinical STIs demonstrated statistically significant increases including chlamydia (+9%, p = 0.001), gonorrhea (+5%, p = 0.008), and syphilis (+3%, p = 0.006) all of which significantly increased over time, as did any STI (+10%, p < 0.001). HIV and trichomonas rates remained low and unchanged. Self-reported STI increased as well, both past year (+9%) and lifetime (+14%). Greater proportions of AYA reported multiple partners (+9%, p < 0.001), and condomless oral (+12%, p = 0.001) and vaginal/anal (+7%, p = 0.001) sex. Conclusion: Among AYA presenting to a STI clinic, the proportion who engaged in condomless sex and had multiple partners increased over a 5 year period, which corresponded to increased STI prevalence during this period. Preventions efforts for AYA should continue to emphasize the importance of condoms and partner selection.

Costs Associated With Incorporation of Network Approaches Into Sexually Transmitted Disease Program Activities

BACKGROUND

Network approaches can be used to study sociosexual partnerships and identify individuals at high risk of infection. Little is known about the cost structure of these services and their association with STD diagnoses.

METHOD

We collected costs associated with using a peer network strategy to recruit men who have sex with men and transwomen of color in 4 counties in North Carolina: Guilford, Forsyth, Durham, and Wake from February through October 2019. We used a comprehensive costing approach to gather detailed retrospective information on the intervention cost, broken down by category and programmatic activity.

RESULTS

The sociosexual networks collected consisted of 31 initial seeds (index cases) and 49 peers of those seeds. In peers, 5 cases of human immunodeficiency virus (HIV) and 10 cases of syphilis were identified. The cost per case (HIV or syphilis) identified was $7325. Personnel costs accounted for 80% of total expenditures, followed by laboratory expenses (12%). Personnel cost was distributed between disease intervention specialist patient navigators (51%), nonclinical (37%), and management (12%) staff. General administration was the costliest programmatic activity (37%), followed by case management and field services (37%), and study activities (11%). The estimated average cost per patient tested was $2242.

CONCLUSIONS

Finding positive peer cases in nonclinical settings is costly but may be crucial for limiting the spread of sexually transmitted diseases. The cost of staff was the major driver. This study demonstrates that using a network strategy can be a cost-effective way to identify, test, and refer patients at high risk of syphilis and HIV infections to care.

Galectins as potential therapeutic targets in STIs in the female genital tract

Every day, more than one million people worldwide acquire a sexually transmitted infection (STI). This public health problem has a direct effect on women's reproductive and sexual health as STIs can cause irreversible damage to fertility and can have negative consequences associated with discrimination and social exclusion. Infection with one sexually transmitted pathogen predisposes to co-infection with others, suggesting the existence of shared pathways that serve as molecular links between these diseases. Galectins, a family of β-galactoside-binding proteins, have emerged as endogenous mediators that facilitate cell-surface binding, internalization and cell invasion of many sexually transmitted pathogens, including Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, Candida albicans, HIV and herpes simplex virus. The ability of certain galectins to dimerize or form multimeric complexes confers the capacity to interact simultaneously with glycosylated ligands on both the pathogen and the cervico-vaginal tissue on these proteins. Galectins can act as a bridge by engaging glycans from the pathogen surface and glycosylated receptors from host cells, which is a mechanism that has been shown to be shared by several sexually transmitted pathogens. In the case of viruses and obligate intracellular bacteria, binding to the cell surface promotes pathogen internalization and cell invasion. Inflammatory responses that occur in cervico-vaginal tissue might trigger secretion of galectins, which in turn control the establishment, evolution and severity of STIs. Thus, galectin-targeted therapies could potentially prevent or decrease STIs caused by a diverse array of pathogenic microorganisms; furthermore, anti-galectin agents might reduce treatment costs of STIs and reach the most vulnerable populations.

Diagnosis and Treatment of Sexually Transmitted Infections: A Review

IMPORTANCE

Approximately 1 in 5 adults in the US had a sexually transmitted infection (STI) in 2018. This review provides an update on the epidemiology, diagnosis, and treatment of gonorrhea, chlamydia, syphilis, Mycoplasma genitalium, trichomoniasis, and genital herpes.

OBSERVATIONS

From 2015 to 2019, the rates of gonorrhea, chlamydia, and syphilis increased in the US; from 1999 to 2016, while the rates of herpes simplex virus type 1 (HSV-1) and HSV-2 declined. Populations with higher rates of STIs include people younger than 25 years, sexual and gender minorities such as men and transgender women who have sex with men, and racial and ethnic minorities such as Black and Latinx people. Approximately 70% of infections with HSV and trichomoniasis and 53% to 100% of extragenital gonorrhea and chlamydia infections are asymptomatic or associated with few symptoms. STIs are associated with HIV acquisition and transmission and are the leading cause of tubal factor infertility in women. Nucleic acid amplification tests have high sensitivities (86.1%-100%) and specificities (97.1%-100%) for the diagnosis of gonorrhea, chlamydia, M genitalium, trichomoniasis, and symptomatic HSV-1 and HSV-2. Serology remains the recommended method to diagnose syphilis, typically using sequential testing to detect treponemal and nontreponemal (antiphospholipid) antibodies. Ceftriaxone, doxycycline, penicillin, moxifloxacin, and the nitroimidazoles, such as metronidazole, are effective treatments for gonorrhea, chlamydia, syphilis, M genitalium, and trichomoniasis, respectively, but antimicrobial resistance limits oral treatment options for gonorrhea and M genitalium. No cure is available for genital herpes. Effective STI prevention interventions include screening, contact tracing of sexual partners, and promoting effective barrier contraception.

CONCLUSIONS AND RELEVANCE

Approximately 1 in 5 adults in the US had an STI in 2018. Rates of gonorrhea, chlamydia, and syphilis in the US have increased, while rates of HSV-1 and HSV-2 have declined. Ceftriaxone, doxycycline, penicillin, moxifloxacin, and the nitroimidazoles are effective treatments for gonorrhea, chlamydia, syphilis, Mycoplasma genitalium, and trichomoniasis, respectively, but antimicrobial resistance limits oral therapies for gonorrhea and Mycoplasma genitalium, and no cure is available for genital herpes.

Inequities in Chlamydia trachomatis Screening Between Black and White Adolescents in a Large Pediatric Primary Care Network, 2015-2019

Objectives. To identify associations between patient race and annual chlamydia screening among adolescent females. Methods. We performed a retrospective cohort study of females aged 15 to 19 years in a 31-clinic pediatric primary care network in Pennsylvania and New Jersey from 2015 through 2019. Using mixed-effect logistic regressions, we estimated associations between annual chlamydia screening and patient (race/ethnicity, age, previous chlamydia screening and infection, insurance type) and clinic (size, setting) characteristics. We decomposed potential effects of clinician's implicit racial bias and screening, using covariates measuring the proportion of Black patients in each clinician's practice. Results. There were 68 935 well visits among 37 817 females, who were 28.8% Black and 25.8% Medicaid insured. The mean annual chlamydia screening rate was 11.1%. Black females had higher odds of screening (adjusted odds ratio [AOR] = 1.67; 95% confidence interval [CI] = 1.51, 1.84) than did White females. In the clinician characteristics model, individual clinicians were more likely to screen their Black versus non-Black patients (AOR = 1.88; 95% CI = 1.65, 2.15). Conclusions. Racial bias may affect screening practices and should be addressed in future interventions, given the critical need to increase population-level chlamydia screening.(Am J Public Health. 2022;112(1):135-143. https://doi.org/10.2105/AJPH.2021.306498).

Trends in Chlamydia and Gonorrhea Testing and Positivity Rates in a Safety Net Hospital in Georgia: 2014 to 2017

BACKGROUND

Sexually transmitted infections (STIs) in the United States continue to increase at an alarming rate. Since 2015, reported cases of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC), the 2 most prevalent reportable STIs, have increased by 19% and 56%, respectively. Characterizing testing patterns could elucidate how CT/GC care and positivity have evolved over time in a high-risk urban setting and illustrate how patients use the health care system for their STI needs.

METHODS

Using electronic medical record data from a large safety net hospital in Georgia, patient demographics and clinical characteristics were extracted for all nucleic acid amplification tests ordered from 2014 to 2017 (n = 124,793). Descriptive statistics were performed to understand testing patterns and assess positivity rates.

RESULTS

Annual nucleic acid amplification test volume grew by 12.0% from 2014 to 2017. Obstetrics/gynecology consistently accounted for half of all tests ordered; volume in emergency medicine grew by 45.2% (n = 4108 in 2014 to n = 5963 in 2017), whereas primary care volume fell by -4.3% (n = 4186 in 2014 to n = 4005 in 2017). The largest number of positive results was detected among 15- to 24-year-olds. The positivity of CT was higher among females, and GC among males. The percent positivity of CT remained stable (range, 6.4%-7.0%). The percent positivity of GC increased from 2.7% to 4.3% over time.

CONCLUSIONS

Testing volume in emergency medicine has increased at a faster rate than other specialties; point-of-care testing could ensure more accurate treatment and improve antibiotic stewardship. The rates of CT/GC were high among adolescents and young adults. Tailored approaches are needed to lower barriers to care for this vulnerable population.

Demographic, Behavioral, and Clinical Characteristics of Persons Seeking Care at Sexually Transmitted Disease Clinics - 14 Sites, STD Surveillance Network, United States, 2010-2018

PROBLEM

Sexually transmitted diseases (STDs) are a major cause of morbidity in the United States, with an estimated $15.9 billion in lifetime direct medical costs. Although the majority of STDs are diagnosed in the private sector, publicly funded STD clinics have an important role in providing comprehensive sexual health care services, including STD and HIV screening, for a broad range of patients. In certain cases, STD clinics often are the only source of sexual health care for patients, particularly among gay, bisexual, and other men who have sex with men (MSM).

PERIOD COVERED

2010-2018.

DESCRIPTION OF THE SYSTEM

The STD Surveillance Network (SSuN) is an ongoing sentinel surveillance system for monitoring clinical information among patients attending STD clinics. SSuN is a collaboration of competitively selected state and city health departments that conduct facility-based sentinel surveillance in STD clinics. Information routinely collected through the course of patient encounters is obtained for all patients seeking care in the participating STD clinics. This information includes demographic, behavioral, and clinical characteristics (e.g., STD and HIV tests performed and STD and HIV diagnoses). This report presents 2010-2018 SSuN data from 14 STD clinics in five cities (Baltimore, Maryland; New York City, New York; Philadelphia, Pennsylvania; San Francisco, California; and Seattle, Washington) to describe the patient populations seeking care in these STD clinics. Estimated numbers and percentages of patients receiving selected STD-related health services were calculated for each year by using an inverse variance weighted random-effects model, adjusting for heterogeneity among SSuN jurisdictions. Trends in receipt of selected STD-related health services were examined and included HIV screening after an acute STD diagnosis among persons not previously known to have HIV infection, annual chlamydia screening among adolescent and young females, and extragenital chlamydia and gonorrhea screening among MSM.

RESULTS

During 2010-2018, the total number of annual visits made in the 14 participating STD clinics decreased 29.8% (from 145,728 to 102,275 visits), and the total number of unique patients examined in the clinics decreased 35.1% (from 94,281 to 61,172 patients). Decreases in the number of unique patients occurred both among men who have sex with women only (42.4%; from 37,842 in 2010 to 21,781 in 2018) and among females (51.4%; from 36,485 in 2010 to 17,721 in 2018). The decreases in the number of female patients were observed across all age groups, although they were more pronounced among females aged ≤24 years (66.4%; from 17,721 in 2010 to 5,962 in 2018). In contrast, the number of patients identified as MSM increased 44.0% (from 12,859 in 2010 to 18,512 in 2018), with the greatest increase among MSM aged ≥25 years (58.6%; from 9,918 in 2010 to 15,733 in 2018). Among visits during which an acute STD (defined as chlamydia, gonorrhea, or primary or secondary syphilis) was diagnosed, the percentage of visits during which an HIV test was performed within approximately 14 days of the STD diagnosis increased from 58.2% in 2010 to 70.2% in 2018. Among those patients tested, 1,672 HIV infections were identified, of which 84.0% were among MSM. Among females aged 15-24 years, the percentage screened for chlamydia in any calendar year increased from 88.6% in 2010 to 90.6% in 2018. However, because fewer females aged 15-24 years attended these clinics during the study period, the crude number of adolescent and young females tested for chlamydia decreased from 14,249 in 2010 to 4,507 in 2018. During 2010-2018, the percentage of females retested after their first positive chlamydia diagnosis during the same year ranged from 11.4% to 13.3%. During 2010-2018, the percentage of MSM tested for rectal chlamydia and rectal gonorrhea increased (from 54.7% to 57.8% and from 55.0% to 58.4%, respectively). During the same period, increases were noted in the percentage of MSM with diagnosed rectal chlamydia (from 15.5% in 2010 to 17.7% in 2018) and rectal gonorrhea (from 13.3% in 2010 to 17.1% in 2018). In contrast with pharyngeal chlamydia, pharyngeal gonorrhea screening was more common (from 69.5% in 2010 to 74.6% in 2018), and the percentage positive doubled during the study period (from 7.3% in 2010 to 14.8% in 2018). Pharyngeal chlamydia testing also increased (from 50.3% in 2010 to 72.9% in 2018), with concurrent decreases in positivity (from 4.2% in 2010 to 2.6% in 2018).

INTERPRETATION

During 2010-2018, changes occurred in the demographic composition of patients attending STD clinics participating in SSuN. Understanding trends in the demographic profile of STD patients and services provided can help identify addressable gaps in STD control efforts and direct public health action. Overall, fewer females, especially those aged 15-24 years, accessed care in these STD clinics during the study period. Untreated STDs among adolescent and young females can have serious consequences, including pelvic inflammatory disease and infertility. Additional efforts to monitor where adolescent and young females seek care and to ensure they are receiving quality STD-related health services are needed, especially considering increases in reported cases of STDs among females. Increases in the number of MSM attending STD clinics present a unique opportunity to reach this population with STD and HIV prevention services. Although a large percentage of STD cases are diagnosed outside of STD clinics, publicly funded STD clinics are an important safety-net provider of STD-related health services and provide vital STD-related health services for patient populations at risk for the consequences of STDs and HIV infection.

PUBLIC HEALTH ACTIONS

STD-related health services represent effective strategies for preventing STD and HIV transmission and acquisition or STD-related sequelae. Ensuring that all persons receive quality HIV and STD prevention and treatment services is vital for an effective public health approach to reducing STDs. STD clinics provide crucial safety-net services for preventing STD-related morbidity, including timely identification and treatment of curable STDs such as chlamydia, gonorrhea, and syphilis. Increases in the numbers of MSM attending STD clinics participating in SSuN provide additional opportunities for linking patients to high-impact HIV preventive services (e.g., pre-exposure prophylaxis), and the clinics are positioned to facilitate initiation or resumption of treatment among persons living with HIV.

Comparing the Ecological Niches of Chlamydial and Gonococcal Infections in Winnipeg, Canada: 2007-2016

BACKGROUND

Previous studies have shown substantial differences in geographic clustering of sexually transmitted infections (STI), such as chlamydia (CT) and gonorrhea (NG), conditional on epidemic phase. Chlamydia and NG have recently shown resurgent epidemiology in the northern hemisphere. This study describes the recent epidemiology of CT and NG in Winnipeg, Canada, combining traditional surveillance tools with place-based analyses, and comparing the ecological niches of CT and NG, in the context of their evolving epidemiology.

METHODS

Data were collected as part of routine public health surveillance between 2007 and 2016. Secular trends for CT and NG, and CT/NG coinfection were examined. Gini coefficients and population attributable fractions explored the distribution, and concentration of infections over time and space.

RESULTS

Rates of CT increased from 394.9/100,000 population to 476.2/100,000 population from 2007 to 2016. Gonorrhea rates increased from 78.0/100,000 population to 143.5/100,000 population during the same period. Each pathogen had its own ecological niche: CT was widespread geographically and socio-demographically, while NG was clustered in Winnipeg's inner-core. CT/NG co-infections had the narrowest space and age distribution. NG was shown to be undergoing a growth phase, with clear signs of geographic dispersion. The expansion of NG resembled the geographic distribution of CT.

CONCLUSIONS

We demonstrated that NG was experiencing a growth phase, confirming theoretical predictions of geographic dispersion during a growth phase. During this phase, NG occupied similar geographic spaces as CT. Knowledge of different ecological niches could lead to better targeting of resources for subpopulations vulnerable to STIs.

Pelvic inflammatory disease in the adolescent and young adult: An update

Pelvic inflammatory disease (PID) is an infection of the female upper genital tract that is typically polymicrobial with classic core involvement of Neisseria gonorrhoeae and/or Chlamydia trachomatis, though other endogenous flora from the vagino-cervical areas can be involved as well. It is often a sexually transmitted disease but other etiologic routes are also noted. A variety of risk factors have been identified including adolescence, young adulthood, adolescent cervical ectropion, multiple sexual partners, immature immune system, history of previous PID, risky contraceptive practices and others. An early diagnosis and prompt treatment are necessary to reduce risks of PID complications such as chronic pelvic pain, ectopic pregnancy and infertility. Current management principles of PID are also reviewed. It is important for clinicians to screen sexually active females for common sexually transmitted infections such as Chlamydia trachomatis and provide safer sex education to their adolescent and young adult patients. Clinicians should provide comprehensive management to persons with PID and utilize established guidelines such as those from the US Centers for Disease Control and Prevention (CDC).

Vaccine Candidates for the Control and Prevention of the Sexually Transmitted Disease Gonorrhea

The World Health Organization (WHO) has placed N. gonorrhoeae on the global priority list of antimicrobial resistant pathogens and is urgently seeking the development of new intervention strategies. N. gonorrhoeae causes 86.9 million cases globally per annum. The effects of gonococcal disease are seen predominantly in women and children and especially in the Australian Indigenous community. While economic modelling suggests that this infection alone may directly cost the USA health care system USD 11.0–20.6 billion, indirect costs associated with adverse disease and pregnancy outcomes, disease prevention, and productivity loss, mean that the overall effect of the disease is far greater still. In this review, we summate the current progress towards the development of a gonorrhea vaccine and describe the clinical trials being undertaken in Australia to assess the efficacy of the current formulation of Bexsero^® in controlling disease.

The Estimated Lifetime Medical Cost of Chlamydia, Gonorrhea, and Trichomoniasis in the United States, 2018

BACKGROUND

The purpose of this study was to provide updated estimates of the average lifetime medical cost per infection for chlamydia, gonorrhea, and trichomoniasis.

METHODS

We adapted a published decision tree model that allowed for 7 possible outcomes of infection: (1) symptomatic infection, treated, no sequelae; (2) symptomatic infection, not treated, sequelae; (3) symptomatic infection, not treated, no sequelae; (4) asymptomatic infection, treated, sequelae; (5) asymptomatic infection, treated, no sequelae; (6) asymptomatic infection, not treated, sequelae; and (7) asymptomatic infection, not treated, no sequelae. The base case values and ranges we applied for the model inputs (i.e., the probability and cost assumptions) were based on published studies.

RESULTS

The estimated lifetime medical costs per infection for men and women, respectively, were $46 (95% credibility interval, $32-$62) and $262 ($127-$483) for chlamydia, $78 ($36-$145) and $254 ($96-$518) for gonorrhea, and $5 ($1-$14) and $36 ($17-$58) for trichomoniasis. Cost estimates for men were most sensitive to assumptions regarding the probability that the infection is symptomatic, the probability of treatment if asymptomatic, and the cost of treatment of infection. Cost estimates for chlamydia and gonorrhea in women were most sensitive to assumptions regarding the probability and cost of subsequent pelvic inflammatory disease.

CONCLUSIONS

These estimates of the lifetime medical cost per infection can inform updated estimates of the total annual cost of sexually transmitted infections in the United States, as well as analyses of the value and cost-effectiveness of sexually transmitted infection prevention interventions.

Lifetime Medical Costs of Genital Herpes in the United States: Estimates From Insurance Claims

BACKGROUND

The purpose of this study was to estimate the lifetime direct medical costs per incident case of genital herpes in the United States.

METHODS

We used medical claims data to construct a cohort of people continuously enrolled in insurance for at least 48 consecutive months between 2010 and 2018. From this cohort, we identified initial genital herpes diagnoses as well as the cost of related clinical visits and medication during the 36 months after an initial diagnosis. Lifetime costs beyond 36 months were estimated based on treatment use patterns observed in the 36 months of follow-up.

RESULTS

The present value of lifetime direct medical costs of genital herpes was estimated to be $972 per treated case or $165 per infection (2019 dollars), not including costs associated with prevention or treatment of neonatal herpes. The clinical visit at which genital herpes was first diagnosed accounted for 27% of lifetime costs. Subsequent clinical visits and medications related to genital herpes accounted for an additional 13% and 60% of lifetime costs, respectively.

CONCLUSIONS

The results from this study can inform cost-effectiveness analysis of genital herpes control interventions as well as help quantify the cost burden of sexually transmitted infections in the United States.

Estimates of the Prevalence and Incidence of Genital Herpes, United States, 2018

BACKGROUND

Although there are more recent estimate of genital herpes prevalence, incidence estimates in the United States (US) have not been updated since 2008.

METHODS

We estimated genital herpes prevalence and incidence for 2018 among adults aged 18 to 49 years. We estimated prevalence using 2015-2018 National Health and Nutrition Examination Survey herpes simplex virus type 2 (HSV-2) seroprevalence data among the noninstitutionalized civilian population and extrapolated this prevalence to the full US population using 2018 American Community Survey data. We estimated incidence using 2011 to 2018 National Health and Nutrition Examination Survey HSV-2 data as inputs to a simple mathematical model. We used Monte Carlo simulation to generate 10,000 input parameter sets for age and sex subpopulations and summarized our estimates by their median; uncertainty intervals for these estimates are characterized by their first (Q1) and third (Q3) quartiles. We conducted sensitivity analyses investigating the impact of HSV type 1 (HSV-1) infection on estimates of genital herpes burden.

RESULTS

In 2018, there were an estimated 18.6 (Q1 = 18.1, Q3 = 19.0) million prevalent and 572,000 (Q1 = 479,000, Q3 = 673,000) incident genital herpes infections among 18- to 49-year-olds. Women accounted for two thirds of prevalent infections with an estimated 12.1 (Q1 = 11.9, Q3 = 12.5) million infections. Incidence was highest among 18- to 24-year-olds with an estimated 242,000 (Q1 = 210,000, Q3 = 274,000) infections. Sensitivity analyses indicated that HSV-1 could be responsible for millions more prevalent genital herpes infections, and tens of thousands of additional incident genital herpes infections, depending on the percentage of HSV-1 infections that are genital.

DISCUSSION

Genital herpes is a common sexually transmitted disease in the United States. Future research to understand the burden of genital infections attributable to HSV-1 would refine estimates of genital herpes burden.

The Estimated Lifetime Medical Cost of Diseases Attributable to Human Papillomavirus Infections Acquired in 2018

INTRODUCTION

We estimated the lifetime medical costs of diagnosed cases of diseases attributable to human papillomavirus (HPV) infections acquired in 2018.

METHODS

We adapted an existing mathematical model of HPV transmission and associated diseases to estimate the lifetime number of diagnosed cases of disease (genital warts; cervical intraepithelial neoplasia; and cervical, vaginal, vulvar, penile, anal, and oropharyngeal cancers) attributable to HPV infections that were acquired in 2018. For each of these outcomes, we multiplied the estimated number of cases by the estimated lifetime medical cost per case obtained from previous studies. We estimated the costs of recurrent respiratory papillomatosis in a separate calculation. Future costs were discounted at 3% annually.

RESULTS

The estimated discounted lifetime medical cost of diseases attributable to HPV infections acquired in 2018 among people aged 15 to 59 years was $774 million (in 2019 US dollars), of which approximately half was accounted for by infections in those aged 15 to 24 years. Human papillomavirus infections in women accounted for approximately 90% of the lifetime number of diagnosed cases of disease and 70% of the lifetime cost attributable to HPV infections acquired in 2018 among those aged 15 to 59 years.

CONCLUSIONS

We estimated the lifetime medical costs of diseases attributable to HPV infections acquired in 2018 to be $774 million. This estimate is lower than previous estimates, likely due to the impact of HPV vaccination. The lifetime cost of disease attributable to incident HPV infections is expected to decrease further over time as HPV vaccination coverage increases.

The Estimated Number and Lifetime Medical Cost of HIV Infections Attributable to Sexually Transmitted Infections Acquired in the United States in 2018: A Compilation of Published Modeling Results

BACKGROUND

The purpose of this study was to estimate the number and lifetime medical cost of HIV infections attributable to incident sexually transmitted infections (STIs) in the United States in 2018.

METHODS

We combined data from published models regarding the number or percentage of HIV infections attributable to STIs with updated estimates of the lifetime medical cost per HIV infection. We used 2 distinct calculation methods. Our first calculation used recent estimates of the percentage of HIV infections in men who have sex with men (MSM) attributable to gonorrhea and chlamydia. Our second calculation, based on older studies, used estimates of the expected number of STI-attributable HIV infections per new STI infection, for gonorrhea, chlamydia, syphilis, and trichomoniasis.

RESULTS

Our first calculation method suggested that 2489 (25th-75th percentiles, 1895-3000) HIV infections in 2018 among MSM could be attributed to gonorrhea and chlamydia, at an estimated lifetime medical cost of $1.05 billion (25th-75th percentiles, $0.79-$1.26 billion). Our second calculation method suggested that 2349 (25th-75th percentiles, 1948-2744) HIV infections in the general population (including MSM) could be attributed to chlamydia, gonorrhea, syphilis, and trichomoniasis acquired in 2018, at an estimated lifetime medical cost of $0.99 billion (25th-75th percentiles, $0.80-$1.16 billion).

CONCLUSIONS

Despite ambiguity regarding the degree to which STIs affect HIV transmission, our combination of data from published STI/HIV transmission models and an HIV lifetime medical cost model can help to quantify the estimated burden of STI-attributable HIV infections in the United States.

Incidence and Prevalence of Trichomonas vaginalis Infection Among Persons Aged 15 to 59 Years: United States, 2018

BACKGROUND

Trichomonas vaginalis (TV) is a sexually transmitted parasite associated with multiple adverse outcomes in women. Estimating TV incidence is challenging because of its largely asymptomatic presentation.

METHODS

Per-capita prevalence was estimated using the National Health and Nutrition Examination Survey, 2013 to 2018. Incidence was estimated using ordinary differential equations assuming static incidence at steady state and fit using Bayesian techniques. Model inputs included estimates of proportion of asymptomatic cases, natural clearance, and time to symptomatic treatment seeking. Posterior distributions were drawn, and uncertainty was reported, from 25th (Q1) to 75th (Q3) percentiles. Aggregated measures were estimated by combining component distributions.

RESULTS

Among 15- to 59-year-olds in 2018, the number of prevalent TV infections was 2.6 (Q1, 2.4; Q3, 2.7) million overall, 470,000 (Q1, 414,000; Q3, 530,000) among men, and 2.1 (Q1, 2.0; Q3, 2.2) million among women; the numbers of incident infections were 6.9 (Q1, 6.2; Q3, 7.6) million, 3.3 (Q1, 2.8; Q3, 3.8) million, and 3.5 (Q1, 3.1; Q3, 4.0) million among all persons, men, and women, respectively. Persons aged 15 to 24 years comprised 15.6% and 16.3% of all prevalent and incident infections, respectively; prevalence and incidence in both sexes increased with age. Incidences in both sexes were highly dependent on estimates of natural clearance, which were based on few data.

CONCLUSIONS

Prevalence and incidence of TV are substantial in the United States, particularly among those 25 years or older. Although estimated prevalence is higher in women, estimated incidence is similar in men and women. Data on key parameters of TV infection are limited; future research should focus on clarifying the natural history of TV.

Genital Mycoplasma, Shigellosis, Zika, Pubic Lice, and Other Sexually Transmitted Infections: Neither Gone Nor Forgotten

ABSTRACT

Most estimates of the combined burden and cost of sexually transmitted infections (STIs) in the United States have focused on 8 common STIs with established national surveillance strategies (chlamydia, gonorrhea, syphilis, trichomoniasis, genital herpes, human papillomavirus, and sexually transmitted human immunodeficiency virus and hepatitis B). However, over 30 STIs are primarily sexually transmitted or sexually transmissible. In this article, we review what is known about the burden of "other STIs" in the United States, including those where sexual transmission is not the primary transmission route of infection. Although the combined burden of these other STIs may be substantial, accurately estimating their burden due to sexual transmission is difficult due to diagnostic and surveillance challenges. Developing better estimates will require innovative strategies, such as leveraging existing surveillance systems, partnering with public health and academic researchers outside of the STI field, and developing methodology to estimate the frequency of sexual transmission, particularly for new and emerging STIs.