Subsequent sexually transmitted infection in urban adolescents and young adults

Expedited Partner Therapy in Female Adolescents: A Study of Acceptance and the Impact on Reinfection Rates

BACKGROUND

Given the high risk of sexually transmitted infections (STIs) in adolescents and young adults (AYAs), this study evaluated expedited partner therapy (EPT) acceptance and STI reinfection rates in female AYA before and after availability of EPT.

METHODS

The pre-EPT cohort was a 3-year (November 2012 to November 2015) retrospective chart review of female AYA positive for Chlamydia trachomatis (CT) and/or Trichomonas vaginalis (TV) before introduction of EPT. An EPT protocol for CT and TV infections was implemented after legalization in Ohio in 2016. The post-EPT cohort was a prospective review of patients positive for CT and TV for 2 years (5/2016-5/2018) after EPT introduction. We evaluated EPT acceptance and compared reinfection rates (positive test 1-6 months after initial infection) in the pre-EPT versus post-EPT cohorts and by EPT acceptance.

RESULTS

Among patients offered EPT, 28% (67/237) with CT and 25% (24/97) with TV accepted EPT. There were no significant differences in the reinfection rates for CT or TV in the pre-EPT versus post-EPT cohorts (CT: 24% (57/240) vs 20% (38/192), P = 0.42; TV: 23% (22/97) versus 14% (12/87), P = 0.11). Although lower, reinfections rates were not significantly different among patients who accepted versus did not accept EPT (CT, 13% (6/48) vs 21% (23/110), P = 0.50 and TV, 6% (1/18) vs 18% (9/49), P = 0.69).

CONCLUSIONS

Despite the implementation of an EPT protocol, STI reinfection rates among female AYA remained high, and many declined EPT. Further research is needed to identify barriers to the provision and acceptance of EPT and ways to address these factors.

Longitudinal association of gonorrhea and bacterial vaginosis with repeat chlamydia diagnoses among U.S. Army women: a retrospective cohort analysis

BACKGROUND

Historically, sexually transmitted infections have affected the health of the U.S. military. To determine whether gonorrhea, bacterial vaginosis, genital herpes, and trichomoniasis are predictors of repeat chlamydia diagnoses among U.S. Army women, medical data reported into the Defense Medical Surveillance System during the 2006-2012 period were analyzed.

METHODS

For all inpatient and outpatient medical records, the first and second International Classification of Diseases, version 9 (ICD-9) diagnostic positions were reviewed for each chlamydia case to determine the occurrence of repeat diagnoses. The Andersen-Gill regression model, an extension of the Cox model for multiple failure-time data, was used to study associations between predictors and repeat chlamydia diagnoses.

RESULTS

Among 28,201 women with a first chlamydia diagnosis, 5145 (18.2%), 1163 (4.1%), 267 (0.9%), and 88 (0.3%) had one, two, three, and four or more repeat diagnoses, respectively. Overall, the incidence of repeat chlamydia was 8.31 cases per 100 person-years, with a median follow-up time of 3.39 years. Gonorrhea (hazard ratio (HR) = 1.58, 95% CI: 1.44-1.73) and bacterial vaginosis (HR = 1.40, 95% CI: 1.09-1.79) were significant predictors for repeat chlamydia. These estimated hazard ratios were attenuated, but remained significant, after controlling for age, race/ethnicity, marital status, and military rank. No significant association was found for genital herpes (HR = 1.13, 95% CI: 0.55-2.29) and trichomoniasis (HR = 1.43, 95% CI: 0.43-4.68).

CONCLUSIONS

This large cohort study suggests that gonorrhea and bacterial vaginosis were associated with repeat chlamydia diagnoses among U.S. Army women. These findings can be used in formulating new interventions to prevent repeat chlamydia diagnoses.

Does the Hazard of Chlamydia Increase with the Number of Gonorrhea Diagnoses? A Large Population-Based Study Among U.S. Army Women

BACKGROUND

In the U.S. military, chlamydia and gonorrhea are common sexually transmitted infections, especially among female service members. The aim of this study was to determine whether the number of gonorrhea diagnoses sustained an increased hazard of chlamydia among military women.

METHODS

This population-based study involved an analysis of all female gonorrhea cases in the U.S. Army reported in the Defense Medical Surveillance System between 2006 and 2012. The effect of the number of gonorrhea diagnoses on the hazard of chlamydia was analyzed using the Prentice-Williams-Peterson gap-time model.

RESULTS

Among 3,618 women with gonorrhea diagnosis, 702 (19.4%) had a subsequent chlamydia diagnosis yielding a rate of 6.06 (95% CI = 5.63-6.53) cases per 100 person-years. Compared to women with one gonorrhea diagnosis, the hazard ratio of chlamydia for women with two gonorrhea diagnoses was 5.09 (95% CI = 4.42-5.86) and for women with three gonorrhea diagnoses was 6.53 (95% CI = 3.93-10.83). The median time to chlamydia diagnosis decreased from 2.39 to 0.67 years for women with two to three gonorrhea diagnoses.

CONCLUSIONS

The hazard of chlamydia increased significantly with the number of gonorrhea diagnoses and the median time to chlamydia diagnosis decreased with an increasing number of gonorrhea diagnoses among U.S. Army women.

A Review of Expedited Partner Therapy for the Management of Sexually Transmitted Infections in Adolescents

Adolescents are at high risk of acquiring and becoming reinfected with sexually transmitted infections. Partner notification and treatment are essential to preventing the spread of sexually transmitted infections. Expedited partner therapy (EPT) is a method of partner treatment used by medical providers to treat patients' sexual partners without direct medical evaluation or counseling. The objective of this article is to review the current literature regarding EPT effectiveness, patients' attitudes and acceptance of EPT, and providers' views and practices surrounding the use of this method of partner treatment. In this article potential concerns associated with EPT use, current policy statements, and the legal status of EPT are discussed. EPT results in improved or equivalent rates of reinfection in adolescents and adults with Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis. Overall, patients are accepting of this method of partner treatment, however, providers continue to have concerns that limit its routine use. Additional studies in adolescents will help providers better understand if EPT is a useful method to prevent reinfection in this population.

Sexual abstinence and other behaviours immediately following a new STI diagnosis among STI clinic patients: Findings from the Safe in the City trial

BACKGROUND

Few studies have assessed patients' sexual behaviours during the period immediately following a new diagnosis of a curable sexually transmitted infection (STI).

METHODS

Data were analysed from a behavioural study nested within the Safe in the City trial, which evaluated a video-based STI/HIV prevention intervention in three urban STI clinics. We studied 450 patients who reported having received a new STI diagnosis, or STI treatment, 3 months earlier. Participants reported on whether they seriously considered, attempted and succeeded in adopting seven sex-related behaviours in the interval following the diagnostic visit. We used multivariable logistic regression to identify, among men, correlates of two behaviours related to immediately reducing reinfection risk and preventing further STI transmission: sexual abstinence until participants were adequately treated and abstinence until their partners were tested for STIs.

RESULTS

Most participants reported successfully abstaining from sex until they were adequately treated for their baseline infection (89%-90%) and from sex with potentially exposed partners until their partners were tested for HIV and other STIs (66%-70%). Among men who intended to be abstinent until they were adequately treated, those who did not discuss the risks with a partner who was possibly exposed were more likely not to be abstinent (OR, 3.7; 95% CI 1.5 to 9.0) than those who had this discussion. Similarly, among men who intended to abstain from sex with any potentially exposed partner until the partner was tested for HIV and other STIs, those who reported not discussing the risks of infecting each other with HIV/STIs were more likely to be sexually active during this period (OR, 3.5; 95% CI 1.6 to 8.1) than were those who reported this communication.

CONCLUSIONS

Improved partner communication could facilitate an important role in the adoption of protective behaviours in the interval immediately after receiving a new STI diagnosis.

TRIAL REGISTRATION NUMBER

NCT00137670.

Urinalysis in children and adolescents

BACKGROUND

Urinalysis is the most commonly performed biochemical test in infancy and early childhood. The urine sample should be correctly obtained, age-specific aspects should be considered, and age-dependent reference values should be used.

METHOD

This review is based on a selective literature search in electronic databases, textbooks, and guidelines from Germany and abroad on the acquisition of urine samples and the performance of urinalysis in infancy and early childhood.

RESULTS

The timing and mode of acquisition of the urine sample affect the assessment of hematuria, proteinuria, leukocyturia, nitrituria, and the uropathogenic bacterial colony count in the urine culture. Dipstick tests can be used for targeted screening for these features. The test results should be interpreted together with the findings of urine microscopy, the medical history, and the physical examination. Proteinuria should be quantified and differentiated; both of these things can be done either from collected urine or (especially in infants and young children) from a spontaneously voided urine sample, by determination of the protein/creatinine quotient. Orthostatic proteinuria in an adolescent requires no further evaluation or treatment. Hematuria should be characterized as either glomerular or non-glomerular erythrocyturia. Asymptomatic, isolated microhematuria in childhood is not uncommon and often transient; in the absence of a family history, it usually does not require an extensive work-up. Proteinuria combined with hematuria should arouse the suspicion of glomerulonephritis.

CONCLUSION

Urinalysis in infancy and early childhood is a simple and informative diagnostic test as long as the urine sample has been obtained properly and the results are interpreted appropriately for this age group.

Adolescent patient preferences surrounding partner notification and treatment for sexually transmitted infections

OBJECTIVES

Important barriers to addressing the sexually transmitted infection (STI) epidemic among adolescents are the inadequate partner notification of positive STI results and insufficient rates of partner testing and treatment. However, adolescent attitudes regarding partner notification and treatment are not well understood. The aim was to qualitatively explore the barriers to and preferences for partner notification and treatment among adolescent males and females tested for STIs in an emergency department (ED) setting and to explore the acceptability of ED personnel notifying their sexual partners.

METHODS

This was a descriptive, qualitative study in which a convenience sample of 40 adolescents (18 females, 22 males) 14 to 21 years of age who presented to either adult or pediatric EDs with STI-related complaints participated. Individualized, semistructured, confidential interviews were administered to each participant. Interviews were audiotaped and transcribed verbatim by an independent transcriptionist. Data were analyzed using framework analysis.

RESULTS

Barriers to partner notification included fear of retaliation or loss of the relationship, lack of understanding of or concern for the consequences associated with an STI, and social stigma and embarrassment. Participants reported two primary barriers to their partners obtaining STI testing and treatment: lack of transportation to the health care site and the partner's fear of STI positive test results. Most participants preferred to notify their main sexual partners of an STI exposure via a face-to-face interaction or a phone call. Most participants were agreeable with a health care provider (HCP) notifying their main sexual partners of STI exposure and preferred that the HCP notify the partner by phone call.

CONCLUSIONS

There are several adolescent preferences and barriers for partner notification and treatment. To be most effective, future interventions to prevent adolescent STIs should incorporate these preferences and address the barriers to partner notification. In an ED setting, using HCPs to provide partner notification of STI exposures is acceptable to adolescent patients; however, the feasibility of this type of program needs further exploration.

Prime time: 18-month violence outcomes of a clinic-linked intervention

Prime Time, a youth development intervention, aims to reduce multiple risk behaviors among adolescent girls seeking clinic services who are at high risk for pregnancy. The purpose of the current study was to examine whether Prime Time involvement produced changes in relational aggression, physical violence, and related psychosocial and behavioral outcomes. Qualitative case exemplars illustrated social contexts of intervention participants with differing longitudinal patterns of relational aggression and physical violence. Data were from a randomized efficacy trial with 13-17 year-old girls (n = 253) meeting specified risk criteria. Intervention participants were involved in Prime Time and usual clinic services for 18 months, control participants received usual clinic services. Participants in the current study completed self-report surveys at baseline and 18 months following enrollment. Outcomes analyses revealed significantly lower levels of relational aggression perpetration in the intervention group versus controls. In contrast, Prime Time involvement did not result in significant reductions in physical violence. Exploratory dose-response analyses indicated that reductions in relational aggression may have been most pronounced among girls actively involved in Prime Time case management and peer leadership activities. Qualitative findings suggested that the intervention's emphasis on modeling and building supportive relationships contributed to reductions in relational aggression. This study contributes to what has been a very limited evidence base regarding effective approaches to preventing violence among high-risk adolescent girls. Findings suggest that offering youth development interventions through clinic settings hold promise in reducing violence risk among vulnerable youth.

Prime Time: long-term sexual health outcomes of a clinic-linked intervention

CONTEXT

Evidence about long-term effects of preventive health services for youth with complex needs is lacking. Prime Time, a youth development intervention, aims to reduce pregnancy risk among vulnerable adolescent females seeking clinic services.

METHODS

In a randomized trial, 253 sexually active females aged 13-17 who were at high risk for pregnancy were assigned to the Prime Time intervention or usual clinic services. The 18-month intervention, initiated in 2007-2008, comprised regular meetings with case managers and participation in youth leadership groups. Trial participants completed surveys at baseline and 30 months. Regression analyses were used to evaluate differences between groups in sexual and psychosocial outcomes at follow-up.

RESULTS

At 30 months, the intervention group reported more months of consistent condom use (adjusted means, 1.8 vs. 1.1) and dual contraceptive use (0.9 vs. 0.3) in the past seven months than did controls. The intervention was most effective in promoting consistent use among participants with relatively high levels of connectedness to family or school. Fifteen percent of intervention participants, but only 6% of controls, reported having abstained from sex in the past six months (adjusted odds ratio, 2.9). Moreover, among high school graduates, those in the intervention group were more likely than those in the control group to have enrolled in college or technical school (72% vs. 37%; odds ratio, 4.5).

CONCLUSION

Health services grounded in a youth development framework can lead to reductions in sexual risk among vulnerable youth that are evident one year following conclusion of services.

Prime time: sexual health outcomes at 24 months for a clinic-linked intervention to prevent pregnancy risk behaviors

IMPORTANCE

Preventing early pregnancy among vulnerable adolescents requires innovative and sustained approaches. Prime Time, a youth development intervention, aims to reduce pregnancy risk among adolescent girls seeking clinic services who are at high risk for pregnancy.

OBJECTIVE

To evaluate sexual risk behaviors and related outcomes with a 24-month postbaseline survey, 6 months after the conclusion of the Prime Time intervention.

DESIGN

Randomized controlled trial.

SETTING

Community and school-based primary care clinics.

PARTICIPANTS

Of 253 sexually active 13- to 17-year-old girls meeting specified risk criteria, 236 (93.3%) completed the 24-month follow-up survey.

INTERVENTION

Offered during an 18-month period, Prime Time includes case management and youth leadership programs.

MAIN OUTCOME MEASURES

Self-reported consistency of condom, hormonal, and dual-method contraceptive use with most recent male sex partner and number of male sex partners in the past 6 months.

RESULTS

At 24-month follow-up, the intervention group reported significantly more consistent use of condoms, hormonal contraception, and dual-method contraception than the control group. Intervention participants also reported improvements in family connectedness and self-efficacy to refuse unwanted sex, and reductions in the perceived importance of having sex. No between-group differences were found in the number of recent male sex partners.

CONCLUSIONS AND RELEVANCE

This study contributes to what has been a dearth of evidence regarding youth development interventions offered through clinic settings, where access to high-risk adolescents is plentiful but few efforts have emphasized a dual approach of strengthening sexual and nonsexual protective factors while addressing risk. Findings suggest that health services grounded in a youth development framework can lead to long-term reductions in sexual risk among vulnerable youth.

Engaging vulnerable adolescents in a pregnancy prevention program: perspectives of Prime Time staff

INTRODUCTION

Evaluating interventions for reducing unintended adolescent pregnancy is necessary to ensure quality and efficacy. The purpose of this study was to examine core case management practices and processes for engaging high-risk girls in Prime Time, an intensive multi-component intervention from the perspectives of intervention program staff.

METHOD

Structured individual interviews were conducted with the entire Prime Time program staff (N = 7) to assess successes and challenges in engaging adolescent girls at high risk for early pregnancy. The girls were recruited from school and community clinics.

RESULTS

Program staff described different capacities of adolescents to engage with the program (those who connected easily, those in the middle range of connecting, and those who had difficulty connecting) and provided specific recommendations for working with the different types of connectors.

DISCUSSION

Findings from this study support the supposition that persons engaging in preventive interventions with vulnerable groups of adolescents must pay careful attention to strategies for establishing trusting youth-adult relationships. The ability of staff (e.g., case managers and nurses) to engage with adolescents is a crucial step in improving health outcomes. The identified strategies are useful in helping adolescents build skills, motivations, and supports needed for healthy behavior change.

Reduction of HPV infections through vaccination among at-risk urban adolescents

INTRODUCTION

Human papillomavirus (HPV) vaccine trials have demonstrated high efficacy in preventing HPV infections and HPV related disease in females ages 16-26. However, there is no source data to demonstrate the impact of the vaccine in other populations who may be at higher risk for HPV related disease. This study examines the impact of HPV vaccination on subsequent HPV detection and sexual behaviors among urban adolescents in a clinical setting.

METHODS

A cohort of adolescent women, ages 14-17, were recruited prospectively and matched to historical controls to assess the impact of HPV vaccination. All women completed the same questionnaire and face-to-face interview that assessed sexual behaviors; all provided a clinician or self-collected vaginal swab that was used to test for sexually transmitted infections, including HPV. Logistic regression models, incorporating random pair effects, were used to assess the impact of the HPV vaccine on HPV detection and sexual behaviors between the two groups.

RESULTS

Each woman recruited (N=75) was matched to 2 historical controls (HC); most of the recruited women (89.3%) had received one or more doses of the HPV vaccine. At enrollment, detection of quadrivalent vaccine types (HPV 6, 11, 16 and 18) was significantly less in the recruited group (5.3%) as compared to the HC (24%): OR=5.6 (CI=1.9, 16.5), p=0.002. Adolescent women in the HC had a 9.5 times greater odds of HPV infection when the analysis was adjusted to compare those who had 2 or more vaccine doses to their matched controls. The only behavioral difference found was that the recruited women used condoms more frequently.

CONCLUSION

This study demonstrates that HPV vaccination was associated with fewer vaccine-type HPV infections despite incomplete vaccination and high risk sexual behaviors. These data also suggest that sexual behaviors were not altered because of the vaccine.

Retrospective review of intrauterine device in adolescent and young women

STUDY OBJECTIVE

To examine our experience with intrauterine device (IUD) use in adolescents and young women.

DESIGN

Retrospective descriptive study evaluating outcomes after IUD insertion for patients 21 years or less over an 8-year period.

SETTING

Three sites including a Pediatric and Adolescent gynecology private practice, a Title X clinic, and community based, grant funded clinic serving a high risk teen population.

PARTICIPANTS

Females from menarche to age 21.

MAIN OUTCOMES MEASURED

The probability of IUD retention, differences in IUD retention probabilities between two age groups, and risk factors for IUD removal, expulsion, and infection were evaluated.

RESULTS

233 records showed 50% of the <18-year-old age group and 71.5% of the 18-21-year-old group had their IUD in place at 5 years. Age was found to be a significant factor for removal (P < 0.001), with under 18-year-olds at greater risk of removal/expulsion (hazard ratio (HR) = 2.85). Parity (RR = 5.6 for nulliparous vs multiparous patients, P < 0.001) and prior STI (RR = 5.5, P < 0.001) were significant risk factors for infection. Nulliparous patients were at higher risk of expulsion (P = 0.045), though age was not a statistically significant risk factor.

CONCLUSIONS

The rate of continuation was lower in adolescents under 18 compared to 18-21-year-olds, but was still higher than for other hormonal contraceptives. Despite this groups' high risk for STI the IUD did not increase the risk of infection and may offer some degree of protection. IUDs appear to be a safe option in young adolescents (<18 years old) and nulliparous women.

Sexual behaviours, knowledge and attitudes regarding safe sex, and prevalence of non-viral sexually transmitted infections among attendees of youth clinics in St. Petersburg, Russia

BACKGROUND

Adolescents and young adults are at increased risk of sexually transmitted infections (STIs). Knowledge of STI prevalence and risk factors are essential tools to elaborate preventive strategies. However, internationally reported studies on epidemiology of STIs among the youth in Russia are mainly lacking.

OBJECTIVES

To ascertain sexual behaviours, knowledge and attitudes about safe sex and prevalence and correlates with STIs in attendees of youth clinics in St. Petersburg, Russia.

METHODS

A total of 301 women and 131 men, who self-referred for STI testing, completed a questionnaire and were screened for Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium, and Trichomonas vaginalis using nucleic acid amplification tests.

RESULTS

The overall STI prevalence was 16.9%, and similar in the female patients and male patients (15.6% and 19.8% respectively). C. trachomatis, N. gonorrhoeae, M. genitalium and T. vaginalis were detected in 13%, 2.5%, 4.6% and 1.2% of the attendees respectively. The men displayed riskier sexual behaviours and worse knowledge and attitudes regarding safe sex compared to the women, with the most distinguishing features being younger age at first intercourse (P < 0.0005), higher numbers of sex partners during lifetime (P = 0.001) and latest 6 months (P < 0.0005), more frequently consuming alcohol (P < 0.0005), poorer knowledge of STI/HIV prevention measures (P < 0.0005), and less positive attitudes towards safe sex (P = 0.001). However, no significant predictors of STI positivity were found in the men. In the women, the strongest predictors of STI positivity were young age (15-19 years) and multiple sex partners (≥ 2) during latest 6 months.

CONCLUSIONS

The overall prevalence of STIs among users of STI services at youth clinics in St. Petersburg was high. Comprehensive epidemiological data on STI prevalence and sexual behaviour correlates are necessary to initiate new and strengthen existing STI prevention programmes for the youth, in Russia as well as in many other settings.

Prime Time: 12-month sexual health outcomes of a clinic-based intervention to prevent pregnancy risk behaviors

PURPOSE

Prime Time, a youth development intervention, aims to reduce pregnancy risk among adolescent girls seeking clinic service who are at high risk for pregnancy. This article examines sexual risk behaviors and hypothesized psychosocial mediators after 12 months of the Prime Time intervention.

METHODS

This study was a randomized controlled trial with 253 girls aged 13-17 years meeting specified risk criteria. Intervention participants were involved in Prime Time programming plus usual clinic services for 18 months, control participants received usual clinic services. The intervention used a combination of case management and peer leadership programs. Participants in this interim outcomes study completed self-report surveys at baseline and 12 months after enrollment. Surveys assessed sexual risk behaviors and psychosocial factors targeted for change by Prime Time.

RESULTS

At the 12-month interim, the intervention group reported more consistent use of condoms, hormonal contraception, and dual contraceptive methods with their most recent partner as compared with the control group. The intervention group also reported greater stress management skills with trends toward higher levels of prosocial connectedness at school and with family. No between-group differences were noted in psychosocial measures specific to sex and contraceptive use.

CONCLUSION

Preventing early pregnancy among high-risk adolescents requires multifaceted, sustained approaches. An important research focus involves testing youth development interventions offered through clinic settings, where access to high-risk adolescents is plentiful and few efforts have emphasized a dual approach of building protective factors while addressing risk. Findings suggest that youth development interventions through clinic settings hold promise in reducing pregnancy risk among high-risk youth.

A comparison of sexual and reproductive health services provided by genitourinary and family planning clinics for adolescents

The purpose of the study was to assess the use of sexual and reproductive health services by adolescents aged 15 years and younger. A case-note review was conducted at both a genitourinary medicine clinic and a family planning clinic in Edinburgh, UK. The demographics of the attendees, reasons for attending, risk factors, diagnostic tests undertaken and contraceptive advice given differed between the two clinics. Approximately 73% of attendees with documented responses used alcohol and 21% used recreational drugs, 5% reported self-harm, 25% reported being victims of sexual assault, 13% had a current sexually transmitted infection and 6% of girls had already been pregnant. While this group of young people understand the differences in emphasis between the clinics, adolescents may be intimidated and discouraged from attending or may fail to return, and the combination of overlap, together with omissions in cross-clinic function, suggests that for this age group the services of these clinics should be combined.

Factors associated with sexually transmitted infection testing among men who utilize an internet-based men who have sex with men community

Public health messaging encourages men who have sex with men (MSM) to be tested for sexually transmitted infections (STI) and HIV at least yearly, and more frequently depending on sexual behaviors. However, despite engaging in a range of sexual behaviors, many MSM do not participate in regular STI testing. The objective of this study was to understand factors associated with STI testing among a nonclinic-based population of men accessing an Internet-based social and sexual networking site. We asked 25,736 men to complete a comprehensive behavioral and health assessment after being recruited from an Internet site popular among men seeking social or sexual interactions with other men. Analyses were performed using multivariate logistic regression with effects significant at p < 0.05. Two separate predictive models were assessed: STI diagnosis within the past 2 years and STI testing within the past year. Regarding previous STI diagnosis, men who used a condom some of the time or never during both insertive (odds ratio [OR] = 1.72) and receptive (OR = 1.41) anal sex were significantly more likely to have had an STI in the past 2 years. For STI testing, men who never used condoms during receptive anal sex were more likely to have had an STI test within the past year (OR = 1.31), but men who had a STI history were less likely to have been tested (O  = 0.24). Public health efforts directed toward MSM should continue to emphasize screening for STI other than HIV, particularly among those men prioritized during condom promotion campaigns. In addition to the benefits of learning one's STI status, the STI screening and treatment environment itself may provide an important venue for encouraging a range of sexual health promoting behaviors.

Condoms and developmental contexts in younger adolescent boys

BACKGROUND

Condom use is a key part of sexually transmitted infection (STI) prevention for young men. Yet little is known about how younger adolescent boys initially learn about and use condoms. We examined sources of information, attitudes towards, acquisition, practice and early use of condoms among 14-16-year-old boys.

METHODS

Thirty 14-16-year-old boys were recruited from a teen clinic serving a community with high STI rates and were asked open-ended questions about condoms, such as, "Where did you learn about condoms?" and "In what situations would you/would you not, use condoms." Interviews were audio recorded, transcribed and coded. Qualitative analysis focused upon key concepts and shared social cognitions related to condom use.

RESULTS

Both sexually inexperienced and experienced participants perceived that sex feels or would feel less pleasurable with condoms. For almost all participants, families were the primary source of both information about condoms and of condoms themselves. This information focused on pregnancy prevention, with STIs secondary. Participants' views of condoms fell into three developmental groups: not interested in condoms and equating their use with interest in sex; exploring condoms out of either curiosity or in preparation for sex; and experienced with condom use. Exploring included behaviours such as checking condoms out and trying them on.

CONCLUSIONS

Our findings of existing negative perceptions of condoms, the importance of families in learning about condoms and the developmental need to test and try on condoms before use have implications for adolescent STI prevention programmes.

Repeat infection with Chlamydia and gonorrhea among females: a systematic review of the literature

Determining the magnitude of chlamydia and gonorrhea reinfection is critical to inform evidence-based clinical practice guidelines related to retesting after treatment. PubMed was used to identify peer-reviewed English language studies published in the past 30 years that estimated reinfection rates among females treated for chlamydia or gonorrhea. Included in this analysis were original studies conducted in the United States and other industrialized countries that reported data on chlamydia or gonorrhea reinfection in females. Studies were stratified into 3 tiers based on study design. Reinfection rates were examined in relation to the organism, study design, length of follow-up, and population characteristics. Of the 47 studies included, 16 were active cohort (Tier 1), 15 passive cohort (Tier 2), and 16 disease registry (Tier 3) studies. The overall median proportion of females reinfected with chlamydia was 13.9% (n = 38 studies). Modeled chlamydia reinfection within 12 months demonstrated peak rates of 19% to 20% at 8 to 10 months. The overall median proportion of females reinfected with gonorrhea was 11.7% (n = 17 studies). Younger age was associated with higher rates of both chlamydia and gonorrhea reinfection. High rates of reinfection with chlamydia and gonorrhea among females, along with practical considerations, warrant retesting 3 to 6 months after treatment of the initial infection. Further research should investigate effective interventions to reduce reinfection and to increase retesting.

Repeat infection with Chlamydia trachomatis: a prospective cohort study from an STI-clinic in Stockholm

Background

Infection with genital Chlamydia trachomatis (Ct) is the most common notifiable sexually transmitted infection (STI) in Sweden. A mutated Chlamydia, nvCT, has contributed to the increase. The occurrence of repeat infections is not investigated in Sweden. The current paper presents the study protocol for the first Swedish clinical investigation of repeat Chlamydial infection. The concern of the study is whether a Chlamydia infection at inclusion indicates an increased risk for Chlamydia at follow-up after 6–8 months, gender-specific risk factors for and clinical presentation of repeat infections.

Methods and design

Sesam City is a drop-in clinic in the city centre of Stockholm. Patients 20 years and older are admitted. During 2007, the clinic had 15 000 visits, 60% made by men. In December 2007, a cohort study began, and data collection was finished in April 2009. A total of 2813 study participants aged 20–39 years were recruited. Data collection included an anonymous self-administered paper-and-pen questionnaire on sexual behaviour, reproductive health and history of Chlamydia, and condom use. Chlamydia tests were performed by self-sampled specimens, analyzed by the ProbeTec (Becton Dickinson) method, Ct-positive specimens also analyzed with a nvCT-specific method. Data from medical records were summarized in clinical report forms. Patients positive for Chlamydia were retested 4 weeks after treatment. Contact tracing covered sexual contacts during the last 12 months. At follow-up 6–8 months after inclusion, Chlamydia tests were performed, and a new questionnaire and CRF completed.

Discussion

A STI-clinic-based prospective cohort study allowed us to survey 2813 adult patients. The collected data will provide gender-specific information on the occurrence of and risk for repeat Chlamydia infection, the occurrence of nvCT, and clinical data and information on sexual behaviour and reproductive health, risk-taking and condom use.

Determining risk markers for gonorrhea and chlamydial infection and reinfection among adolescents in public high schools

BACKGROUND

In response to high adolescent rates of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC), Philadelphia began screening in all public high schools in 2003.

METHODS

Data from 14,862 students who tested more than once in the Philadelphia High School STD Screening Program (PHSSSP) during the 2002-2006 school years were analyzed for factors associated with CT and GC infection. Multivariable Cox proportional hazards models and logistic regression models were constructed to identify characteristics associated with measured STD rates. A secondary analysis assessed short-term reinfection rates among participants retesting within the same school year.

RESULTS

In the primary analysis, over multiple years, the unadjusted female CT/GC rate was more than double that in males (6.0 vs. 2.4 cases per 100 person-years, respectively). Among students with a baseline positive, males had a higher rate than females (19.9 vs. 17.7 cases per 100 person-years, respectively). Among students with a positive test result, 13.6% were reinfected within the same school year. Females with named partners not treated had a higher reinfection rate than all others (85.5 vs. 40.1-45.2 cases per 100 person-years, respectively).

CONCLUSIONS

Clinicians and screening programs that offer STD testing to urban high school students, regardless of gender, should encourage those with a prior STD history to test more frequently. Clinicians should work with infected patients, especially females, to ensure their partners are treated.

Vaginal wet mounts on asymptomatic adolescent females; are they beneficial?

BACKGROUND

Wet mounts are commonly performed at the time of pelvic exam in some settings; however, there is a paucity of data on their usefulness in asymptomatic teen patients.

OBJECTIVE

To determine if wet mounts in asymptomatic teen women are useful in detecting gonorrhea or chlamydia, when compared with DNA amplification testing.

DESIGN AND METHODS

93 consecutive charts for asymptomatic adolescent female patients seen for a routine visit were retrospectively reviewed. Data was collected for vaginal pH, presence or absence of discharge on physical exam, appearance of cervix, wet mount results, and cervical testing results. Outcome measures were wet mount findings and result of DNA amplification test on cervical sample for gonorrhea and chlamydia

RESULTS

Wet mounts were abnormal in 29 (31.2%) patients. There was no significant relationship between abnormal wet mount and positive Neisseria gonorrhoeae and Chlamydia trachomatis cultures (P = 0.083). After excluding abnormal wet mounts due to Trichomonas vaginalis, BV or Candida, all remaining patients with positive N gonorrhoeae and C trachomatis had normal wet mounts. For N gonorrhoeae, the wet mount had a sensitivity of 0% and specificity of 92.6%. For C trachomatis, the wet mount had a sensitivity of 0% and specificity of 92.1%.

CONCLUSION

Wet mounts were not useful to detect N gonorrhoeae and C trachomatis in asymptomatic teen patients. The finding of T vaginalis and BV in these asymptomatic patients may justify continuing wet mount evaluation but this practice needs further study to determine if treatment in this population will result in clinically significant effects.

Effect of a brief video intervention on incident infection among patients attending sexually transmitted disease clinics

BACKGROUND

Sexually transmitted disease (STD) prevention remains a public health priority. Simple, practical interventions to reduce STD incidence that can be easily and inexpensively administered in high-volume clinical settings are needed. We evaluated whether a brief video, which contained STD prevention messages targeted to all patients in the waiting room, reduced acquisition of new infections after that clinic visit.

METHODS AND FINDINGS

In a controlled trial among patients attending three publicly funded STD clinics (one in each of three US cities) from December 2003 to August 2005, all patients (n = 38,635) were systematically assigned to either a theory-based 23-min video depicting couples overcoming barriers to safer sexual behaviors, or the standard waiting room environment. Condition assignment alternated every 4 wk and was determined by which condition (intervention or control) was in place in the clinic waiting room during the patient's first visit within the study period. An intent-to-treat analysis was used to compare STD incidence between intervention and control patients. The primary endpoint was time to diagnosis of incident laboratory-confirmed infections (gonorrhea, chlamydia, trichomoniasis, syphilis, and HIV), as identified through review of medical records and county STD surveillance registries. During 14.8 mo (average) of follow-up, 2,042 patients (5.3%) were diagnosed with incident STD (4.9%, intervention condition; 5.7%, control condition). In survival analysis, patients assigned to the intervention condition had significantly fewer STDs compared with the control condition (hazard ratio [HR], 0.91; 95% confidence interval [CI], 0.84 to 0.99).

CONCLUSIONS

Showing a brief video in STD clinic waiting rooms reduced new infections nearly 10% overall in three clinics. This simple, low-intensity intervention may be appropriate for adoption by clinics that serve similar patient populations.

TRIAL REGISTRATION

http://www.ClinicalTrials.gov (#NCT00137670).

Formulas for estimating the costs averted by sexually transmitted infection (STI) prevention programs in the United States

Background

Sexually transmitted infection (STI) prevention programs can mitigate the health and economic burden of STIs. A tool to estimate the economic benefits of STI programs could prove useful to STI program personnel.

Methods

We developed formulas that can be applied to estimate the direct medical costs and indirect costs (lost productivity) averted by STI programs in the United States. Costs and probabilities for these formulas were based primarily on published studies.

Results

We present a series of formulas that can be used to estimate the economic benefits of STI prevention (in 2006 US dollars), using data routinely collected by STI programs. For example, the averted sequelae costs associated with treating women for chlamydia is given as (C_w)(0.16)(0.925)(0.70)($1,995), where C_w is the number of infected women treated for chlamydia, 0.16 is the absolute reduction in the probability of pelvic inflammatory disease (PID) as a result of treatment, 0.925 is an adjustment factor to prevent double-counting of PID averted in women with both chlamydia and gonorrhea, 0.70 is an adjustment factor to account for the possibility of re-infection, and $1,995 is the average cost per case of PID, based on published sources.

Conclusion

The formulas developed in this study can be a useful tool for STI program personnel to generate evidence-based estimates of the economic impact of their program and can facilitate the assessment of the cost-effectiveness of their activities.

Trichomonas vaginalis in Vanuatu

OBJECTIVE

To assess the prevalence of Trichomonas vaginalis in two island populations of Vanuatu using the Pap smear as the screening technique.

STUDY DESIGN

Women were randomly selected from specific sites on the islands of Efate (urban setting) and Ambae (rural setting). Pap smears were collected, screened and reported.

SETTING

The first collection site was the Women's Health/Antenatal Care Clinic at Vila Central Hospital in Port Vila, the capital city located on the island of Efate, and the second collection site was a rural village on a sparsely populated inhabited northern island, Ambae.

PARTICIPANTS

A total of 905 Ni-Vanuatu women participants: Efate (n = 562) 62%, and Ambae (n = 343) 38%. The mean age was 35.8 years: Efate 32.6 years, and Ambae 40.8 years.

MAIN OUTCOME MEASURE

The presence or absence of T. vaginalis in these Pap smears was documented during the study's cervical screening process.

RESULTS

The overall prevalence of T. vaginalis within the study participants was 25.3%. Almost half of the infected sample group were in the age group of 30-39 years (43.8%). The prevalence of T. vaginalis in Efate was 14.7%, compared with 43.4% in Ambae.

CONCLUSION

The prevalence of T. vaginalis in Vanuatu women is significantly higher compared with developed countries. Women in rural settings are less likely to have access to sexually transmitted disease prevention and treatment programs, thus contributing to high infection rates compared with women in urban settings. Cultural and educational differences in the rural setting might also contribute to higher sexually transmitted disease rates among these women.

Pregnancy intentions and contraceptive behaviors among adolescent women: a coital event level analysis

PURPOSE

Measuring pregnancy intentions has been difficult. This study examines questions regarding pregnancy intentions and their association with adolescents' sexual and contraceptive behaviors longitudinally.

METHODS

Adolescent women completed an interview about pregnancy intentions followed by a 3-month daily diary period reporting coital activity and contraception use. Interviews assessed pregnancy intentions with: "Are you trying to get pregnant now?," "Are you trying to keep from getting pregnant now?," and "I'm very committed to not getting pregnant at this time in my life." The measured outcome was the occurrence of contraceptive protected versus non-protected coitus collected from diary data. Logistic regression was used to assess this relationship.

RESULTS

A total of 289 women completed 677 face-to-face interviews and subsequent 3 months of diary collection. In all, 194 reported having sex during diary collection. Women trying to keep from getting pregnant (n = 265) had 51.8% of 2533 coital events covered by contraception, whereas 13.1% of 818 coital events were protected in those women who were not trying to keep from getting pregnant (OR = 9.2, 95% CI = 6.0, 13.9). Women who agreed that they were committed to not getting pregnant were more likely to have coital events protected (50.5% of 2574 events) than those who disagreed (21.2% of 576 events) (OR = 9.8, 95% CI = 5.5, 17.3).

CONCLUSIONS

Adolescents' contraceptive behaviors were associated with reported intentions. However, approximately one half of coital events were not protected in women who agreed that they were committed to not getting pregnant. These women may represent a group at risk for unintended pregnancy.

New sexually transmitted infections among adolescent girls infected with HIV

OBJECTIVES

Although the prevalence of sexually transmitted infections (STIs) among girls infected with HIV has been reported, the incidence of STI diagnoses has not been well documented. The objectives of this study were to examine (1) incident STI diagnoses and (2) the association between viral load (VL) and incident STI diagnosis among HIV-infected adolescent girls in care.

METHODS

This was a prospective longitudinal 18-month study of girls enrolled in the Adolescent HIV trials network. Cox proportional hazard modelling was performed to evaluate the incidence of STI by baseline viral load.

RESULTS

The mean (SD) age of participants was 20.6 (2.0) years, viral load of participants was 66,917 (165,942) copies/ml and median viral load was 7,096 copies/ml. The incidence of STIs for the entire cohort was 1.4 per 100 person-months. During the 18-month follow-up period, there were no significant differences in the STI incidence between the high and low viral load groups (hazard ratio (HR) = 0.86, 95% CI 0.37 to 1.95) There was also no significant association between STI incidence and log-transformed viral load (HR = 1.10, 95% CI 0.92 to 1.3).

CONCLUSIONS

Adolescent girls with HIV infection continue to acquire sexually transmitted infections after diagnosis. This analysis does not suggest that VL is a critical factor in STI acquisition over time. Additional work exploring the role of other contextual factors on STI acquisition among HIV-infected adolescent girls is warranted.

Chlamydial and gonococcal reinfection among men: a systematic review of data to evaluate the need for retesting

This study aimed to systematically review and describe the evidence on chlamydia and gonorrhoea reinfection among men, and to evaluate the need for retesting recommendations in men. PubMed and STI conference abstract books from January 1995 to October 2006 were searched to identify studies on chlamydia and gonorrhoea reinfection among men using chlamydia and gonorrhoea nucleic acid amplification tests or gonorrhoea culture. Studies were categorised as using either active or passive follow-up methods. The proportions of chlamydial and gonococcal reinfection among men were calculated for each study and summary medians were reported. Repeat chlamydia infection among men had a median reinfection probability of 11.3%. Repeat gonorrhoea infection among men had a median reinfection probability of 7.0%. Studies with active follow-up had moderate rates of chlamydia and gonorrhoea reinfection among men, with respective medians of 10.9% and 7.0%. Studies with passive follow-up had higher proportions of both chlamydia and gonorrhoea reinfections among men, with respective medians of 17.4% and 8.5%. Proportions of chlamydia and gonorrhoea reinfection among men were comparable with those among women. Reinfection among men was strongly associated with previous history of sexually transmitted diseases and younger age, and inconsistently associated with risky sexual behaviour. Substantial repeat chlamydia and gonorrhoea infection rates were found in men comparable with those in women. Retesting recommendations in men are appropriate, given the high rate of reinfection. To optimise retesting guidelines, further research to determine effective retesting methods and establish factors associated with reinfection among men is suggested.

Update on the management of gonorrhea in adults in the United States

Gonorrhea, the second most commonly reported notifiable disease, is an important cause of cervicitis, urethritis, and pelvic inflammatory disease. The selection of appropriate therapy for gonorrhea (i.e., safe, highly effective, single dose, and affordable) is complicated by the ability of Neisseria gonorrhoeae to develop resistance to antimicrobial therapies. This article reviews the key questions and data that informed the 2006 gonorrhea treatment recommendations of the Centers for Disease Control and Prevention. Key areas addressed include the criteria used to select effective treatment for gonorrhea, the level of antimicrobial resistance at which changing treatment regimens is recommended, the epidemiology of resistance, and the use of quinolones, cephalosporins, and other classes of antimicrobials for the treatment of uncomplicated gonorrhea.

Predictors of Gonorrhea Reinfection in a Cohort of Sexually Transmitted Disease Patients in Alberta, Canada, 1991–2003

OBJECTIVE

The objective of this study was to identify characteristics associated with reinfection in sexually transmitted disease (STD) patients in Alberta, Canada.

METHODS

A retrospective cohort of 5,701 STD patients with gonorrhea diagnosed between 1991 and 2003 were followed for incident gonorrhea. Rates of reinfection were estimated and multivariate logistic regression was used to identify patient characteristics associated with reinfection.

RESULTS

There were 568 reinfections in 460 individuals, with reinfection occurring at a median of 9.2 months with an incidence rate of 2.34 per 100 person-years (95% confidence interval [CI], 2.09-2.59). The highest risk of reinfection was found in patients of black ethnicity (adjusted hazard ratio [aHR], 3.31; 95% CI, 2.27-4.81), aboriginal ethnicity (aHR, 2.64; 95% CI, 1.96-3.56), those reporting homo-/bisexual practice (aHR, 2.05; 95% CI, 1.40-3.02), or treated at an STD clinic (aHR, 1.49; 95% CI, 1.15-1.94).

CONCLUSION

The recognition of key demographic and behavioral characteristics can help focus interventions for patients at higher risk of gonorrhea reinfection.

Predicting Subsequent Infection in Patients Attending Sexually Transmitted Disease Clinics

OBJECTIVE/GOAL

The objective of this study was to identify characteristics associated with subsequent infection in patients attending a sexually transmitted disease (STD) clinic.

STUDY DESIGN

Records were retrospectively reviewed for patients from public STD clinics in 4 cities for 12 months after their initial visit to assess subsequent infection with gonorrhea, chlamydia, mucopurulent cervicitis, nongonococcal urethritis, pelvic inflammatory disease, primary or secondary syphilis, or trichomoniasis.

RESULTS

Among 64,463 patients, 33.9% had an initial STD and 7.0% had a subsequent STD. Patients with an initial STD had significantly higher probability of a subsequent STD than patients without (12.0% vs. 4.4%). A subsequent STD was significantly more likely for both sexes for those with an initial STD, who were symptomatic at initial visit, reporting exchange of sex, or under age 20 as well as for men reporting sex with men.

CONCLUSIONS

Patients with an initial STD were more likely to return with a subsequent STD. Routinely collected information such as initial diagnosis or age can help identify patients at increased risk of a subsequent STD.

Cervicitis: to treat or not to treat? The role of patient preferences and decision analysis

PURPOSE

Mucopurulent cervicitis is neither a sensitive nor a specific indicator of antibiotic sensitive infection. This analysis examines the positive and negative ramifications of treating cervicitis empirically as a Chlamydial (CT) infection. It begins where prior analyses leave off, with the number of cases of pelvic inflammatory disease (PID) prevented.

METHODS

Three treatments were compared: 1) treat empirically/refer partner; 2) test, treat, and base partner treatment on results; 3) test, base treatment on results. The outcomes were the physical sequelae of PID and the psychological sequelae of being diagnosed with CT in a hypothetical cohort of 500 teenagers with cervicitis, among whom the prevalence of CT averaged 33%, but ranged between 10% and 70%.

RESULTS

At a CT prevalence of 33%, Treatments 1 and 2 prevented three times as many cases of PID-related physical sequelae (n = 14) as Treatment 3 (n = 5). However, to prevent these 14 cases of physical sequelae, with Treatment 1, 163 teens needlessly suffer the psychological sequelae of a false CT diagnosis and with Treatment 2, 101 do so. The ratio of physical sequelae prevented to psychological sequelae caused, changed in relationship to the prevalence of CT, but was always numerically most favorable with Treatment 3. Moreover, it was the only therapeutic approach for which overall morbidity never exceeded the PID-related physical morbidity incurred in the absence of treatment.

CONCLUSIONS

By including the effects of over diagnosing and treating CT, we have demonstrated how the risks and benefits of empiric and nonempiric cervicitis therapy vary in relationship to CT prevalence. Failure to consider both the physical and the psychological aspects of patient well-being may mean that well-intentioned policies to reduce physical morbidity do not result in an overall improvement in health of teenagers.

Urine gonococcal/Chlamydia testing in adolescents

PURPOSE OF REVIEW

This review will highlight the recent literature findings regarding urine-based Chlamydia and gonorrhea testing in adolescents.

RECENT FINDINGS

Rates of Chlamydia trachomatis are increasing, likely due to increased detection efficiency, but have not yet begun to decrease. Neisseria gonorrhoeae is at an all-time low. Urine-based testing for sexually transmitted infections is readily available and convenient but underutilized. Interesting approaches to a more universal screening program, including self-collected, mail-in urine samples, have been shown to be effective.

SUMMARY

In spite of recommendations urging universal screening for C. trachomatis and N. gonorrhoeae and the availability of highly accurate and convenient tests, screening rates for adolescents and young adults remain below the universal recommendations. Strategies to improve screening rates should take advantage of urine-based screening methodologies for sexually transmitted infections because of their cost-effectiveness as well as the convenience for patient and provider.

Sexually transmitted infections: screening, syndromes, and symptoms

STI are among the most common pathological conditions affecting sexually active adolescents. Both screening of asymptomatic adolescents and a thoughtful, thorough approach to the evaluation of symptoms are critical measures in STI identification and control.

Rifalazil pretreatment of mammalian cell cultures prevents subsequent Chlamydia infection

Chlamydia species are widely disseminated obligate intracellular pathogens that primarily cause urogenital, ocular, and respiratory infections. In these studies, we show that exposing mammalian cells to antibacterial agents prior to Chlamydia inoculation protects the host cells against subsequent challenge by chlamydiae (the protective effect [PE]). Rifalazil exhibited a considerably stronger PE than did azithromycin, rifampin, doxycycline, and ofloxacin. Specifically, 0.002 microg/ml rifalazil incubated for 1 day with a monolayer of McCoy cells was sufficient to protect against a challenge 2 days later with Chlamydia trachomatis serovar D (UW-3). The PE was observed with five different mammalian cell lines and with a variety of C. trachomatis and Chlamydia pneumoniae isolates. The duration of the PE was 6 to 12 days for rifalazil (depending on the cell line), a maximum of 3 days for azithromycin, and less than a day for the other drugs tested. For rifalazil, the PE was shown to be mediated by inhibition of the chlamydial RNA polymerase since mutants with altered RNA polymerases had correspondingly altered PEs. These results suggest that rifalazil may be unique in its ability to prevent infection with obligate intracellular pathogens for a considerable time after treatment. This characteristic may be of particular public health value in reducing reinfection with chlamydiae.

Gender-based differences in fertility beliefs and knowledge among adolescents from high sexually transmitted disease-prevalence communities

PURPOSE

Limited information is available about adolescents' beliefs about fertility in women and its link to sexually transmitted disease (STD) and whether men and women differ in their beliefs. This information may be useful for developing messages intended to motivate youth to seek STD screening while they are asymptomatic. The purpose of this study was to examine gender-based differences in fertility beliefs and knowledge.

METHODS

Data were derived from the Adolescent Health Study, a population-based telephone survey study in which urban household adolescents from a high STD-prevalence community were queried about their sexual experience, fertility-related knowledge, beliefs related to timing of childbearing, and risk assessment of future fertility problems. Chi2 and regression analyses were used to evaluate group differences.

RESULTS

The majority of adolescents reported that having children was somewhat or very important, but that the 15- to 19-year-old age group was not the optimal time for a woman to have a child. Regression analyses indicated that female adolescents were more likely than male adolescents to identify chlamydia and pelvic inflammatory disease as causes of fertility problems. Seventy-two percent of adolescent girls thought there was some chance they would have future fertility problems and 58% thought they had little or no control over developing fertility problems in the future.

CONCLUSION

Additional health education is needed if we are to motivate adolescents to participate in asymptomatic STD screening programs. Involving male adolescents may be a more significant challenge given that fewer male adolescents understand the link between female fertility and common STD-related conditions. Given our findings, fertility preservation may be a valuable teaching tool and social marketing agent for STD prevention in adolescents.

Knowledge of sex partner treatment for past bacterial STI and risk of current STI

OBJECTIVES

Effective partner management is critical in reducing the spread of bacterial sexually transmitted infections (STIs). The purpose of this study was to determine the relation between knowledge of partner treatment for a past STI and current infection in the index patient.

METHODS

In a cross sectional analysis, 97 adolescent females sampled from community based health clinics reported that they had a past diagnosis of chlamydia or gonorrhoea in structured, face to face interviews. At the time of the interview, adolescents were also tested for chlamydia and gonorrhoea using urine based ligase chain reaction testing.

RESULTS

66% of the adolescents reported knowing that their partner was treated for the past infection. Those who knew their partner was treated were less likely to have a current infection, compared to those who did not know (11% v 30%, adjusted odds ratio and 95% confidence interval 4.46 (1.41 to 14.29), p<0.05). Correlates of not knowing the sex partner was treated included younger age and being in new sex partnership.

CONCLUSIONS

Efforts to encourage young women to follow up directly with their partners regarding treatment may help to reduce repeat infections and further spread. Furthermore, alternative strategies such as patient delivered therapy may help with partner treatment in this vulnerable population.

Recent trends in HIV and other STIs in the United Kingdom: data to the end of 2002

Sexual health in the United Kingdom has deteriorated in recent years with further increases in HIV and other sexually transmitted infections (STIs) reported in 2002. This paper describes results from the available surveillance data in the United Kingdom from the Health Protection Agency and its national collaborators. The data sources range from voluntary reports of HIV/AIDS from clinicians, CD4 cell count monitoring, a national census of individuals living with HIV, and the Unlinked Anonymous Programme, to statutory reports of STIs from genitourinary medicine (GUM) clinics and enhanced STI surveillance systems. In 2002, an estimated 49500 adults aged over 15 years were living with HIV in the United Kingdom, of whom 31% were unaware of their infection. Diagnoses of new HIV infections have doubled from 1997 to 2002, mainly driven by heterosexuals who acquired their infection abroad. HIV transmission also continues within the United Kingdom, particularly among homo/bisexual men who, in 2002, accounted for 80% of all newly diagnosed HIV infections acquired in the United Kingdom. New diagnoses of syphilis have increased eightfold, and diagnoses of chlamydia and gonorrhoea have doubled from 1997 to 2002 overall; STI rates disproportionately affect homo/bisexual men and young people. Effective surveillance is essential in the provision of timely information on the changing epidemiology of HIV and other STIs; this information is necessary for the targeting of prevention efforts and through providing baseline information against which progress towards targets can be monitored.

Chlamydia and gonorrhea screening in asymptomatic young women

BACKGROUND

Adolescent and young adult minority women are at high risk for chlamydia (CT) and gonorrhea (NGC) cervical infections, which are significant causes of pelvic inflammatory disease, impaired fertility, ectopic pregnancy and chronic pain. The purpose of this article is to review among young women in the United States: (1) the epidemiology of CT and NGC cervical infection and their medical complications; (2) current public health recommendations to promote asymptomatic CT and NGC screening; (3) current screening practices and challenges of implementing public health recommendations; (4) testing and cost issues; and (5) future directions in promoting asymptomatic CT and NGC screening.

METHODS

We conducted a MEDLINE search for articles published over the last two decades relating to CT and NGC screening in young women and then systematically reviewed all relevant articles.

RESULTS

The data indicate that CT and NGC infection are geographically widespread in the U.S. and asymptomatic infection is highly prevalent among economically disadvantaged young females. Public health recommendations promoting CT and NGC screening in asymptomatic young women are directed to both health care providers and clients. However, strategies to promote screening efforts have been primarily directed toward health care providers; there are no published studies on client-initiated screening strategies. Challenges of implementing public health recommendations and future directions for CT and NGC screening are discussed.

CONCLUSIONS

Young sexually active women continue to be at high risk for CT and NGC infection. The data indicate that implementation of health provider-based and client-initiated screening in private and public health care settings is a challenge. However, there is a great need to develop strategies to understand and promote client-initiated screening.

Associations between sexually transmitted disease diagnosis and subsequent sexual risk and sexually transmitted disease incidence among adolescents

BACKGROUND

Empiric evidence is lacking in regard to the subsequent sexually transmitted disease (STD)-associated risk behaviors of adolescents diagnosed and treated for an STD.

GOAL

The goal of this study was to prospectively identify associations between STD diagnosis and subsequent sexual risk and STD incidence among a sample of U.S. adolescents.

STUDY DESIGN

A cohort of 455 adolescents (age 15-21 years) was followed for 3 months. Adolescents were recruited from primary care clinics and through outreach activities.

RESULTS

A total of 10.8% were initially diagnosed with at least one STD. After adjusting for observed covariates, these adolescents (compared with those testing negative) were 2.8 times (P = 0.0001) more likely to be abstinent from sex and 2.2 times more likely to report always using condoms (P = 0.04). However, during the ensuing 3 months, they were approximately 2.4 times more likely to report having sex with multiple partners (P = 0.01), 8.9 times more likely to test positive for trichomonas (P = 0.009), and 3.0 times more likely to test positive for chlamydia (P = 0.04).

CONCLUSIONS

Compared with those testing negative, adolescents diagnosed with an STD may subsequently adopt safer sex behaviors, including abstinence. However, perhaps in part as a result of having sex with multiple partners, they might fail to practice safer sex behaviors stringently enough to avoid subsequent STD acquisition.

Developments in the screening for Chlamydia trachomatis: a review

Many studies have evaluated selective screening criteria for women in various settings. Most have concluded and all guidelines recommend that all women aged < 25 be screened yearly for C. trachomatis infection. Behavioral criteria, such as the number of sex partners, new or more than one sex partners, and previous infection, also can serve as criteria for screening women aged > 25. Because re-infection rates are high and occur within a few months, complications may be reduced further if partners are treated and women rescreened 4 to 6 months after initial infection. Revised recommendations for C. trachomatis screening programs have stated that more frequent screening may be considered among women < 20 and those with recent infection. Screening in nontraditional settings and careful evaluation of local prevalence and risk factor information should be encouraged. Private providers and emergency room providers should discuss screening recommendations and adopt a C. trachomatis screening policy for the population they serve. The HEDIS measure should serve to encourage at least annual screening of 15- to 25-year-old sexually active females through providers linked to managed care organizations. In general, high yields (ie, percentage of tests that are positive) in nontraditional settings and enhanced feasibility and acceptability of urine-based tests may encourage further innovative approaches to reach and screen populations at risk. Several issues remain to be addressed to increase the effectiveness of screening efforts. If more sensitive amplification tests are used widely, more infected persons will be identified and treated, and transmission patterns may change, particularly if partner treatment also occurs. Current screening criteria should continue to be re-evaluated. An important issue that affects testing methods includes the possible need for confirmation testing when using NAATs if the prevalence of C. trachomatis is less than 2%. If the sensitivity of an NAAT is 85% and specificity is 99%, in a hypothetical population of 10,000 with a prevalence of 2%, the positive predictive value is 170/268 (63%). A second important issue affecting testing methods and feasibility of using NAATs for screening large numbers of individuals is the pooling of urine specimens, which has been evaluated in several studies and found to be very effective for reducing costs. A research issue for pooling is the determination of the most cost-effective prevalence levels for pooling. An additional research question is in which populations should a NAAT be used for detection of C. trachomatis and N. gonorrhoeae. There are no recommendations for the routine screening of men because of the paucity of data showing that this strategy can reduce sequelae. The CDC is conducting a multisite study to examine the feasibility, acceptability, and usefulness of screening of asymptomatic men. There are a few studies have determining cost-effective prevalence threshold levels, particularly with NAATs. A recently developed decision analysis model by CDC designed to maximize the effectiveness of screening strategies for C. trachomatis infections may be useful for decision makers. It is intended to serve as an easy and flexible tool to determine cost effectiveness at a local level and takes into account positivity rates and test performance characteristics (SOCRATES). It is unclear if recurrent infection is caused by true re-infection by the same or a different partner or recurrence of initial infection. Recurrence may be caused by persistence of C. trachomatis or antibiotic resistance. This distinction is of scientific interest because the appropriate intervention differs (eg, identification of risk factors for the former and microbiologic investigations for the latter). Effective partner management and retesting are critical to reducing sequelae of C. trachomatis infection. Screening for C. trachomatis infection remains an essential component of C. trachomatis control. It is cost effective, most infections are asymptomatic, and symptom-based health care seeking and testing identify few of those infected. The likelihood that opportunities for screening are missed is high particularly in non-STD clinic settings. Local studies using NAATs to determine C. trachomatis prevalence and risk factors are helpful to health care providers so they can make evidence-based decisions on who to screen. The use of nontraditional, non-clinic-based test settings should be explored further. We have focused on summarizing the medical evidence regarding recommendations for screening for C. trachomatis. High-risk populations for C. trachomatis infection may overlap with populations for other STDs, and comprehensive STD prevention programs that involve a range of STD service providers are needed to successfully reduce the STD-related health burden in the population.

High postpartum rates of sexually transmitted infections among teens: pregnancy as a window of opportunity for prevention

OBJECTIVES

To identify incidence and predictors of Chlamydia trachomatis and Neisseria gonorrhoeae among postpartum adolescents. These estimates are compared to similar estimates among a cohort of non-pregnant, sexually active teens.

METHODS

203 pregnant and 208 non-pregnant adolescents aged 14-19 years were recruited from 10 community based health clinics in Connecticut, United States. Structured interviews and sexually transmitted infection (STI) testing using ligase chain reaction (LCR) were conducted at a baseline visit (during the third trimester for the pregnant adolescents), and at 6 and 12 month follow up visits (3 and 9 months post partum, for those pregnant at baseline).

RESULTS

Among pregnant teens, new infections of C trachomatis and N gonorrhoeae increased from 7.1% at the 6 month follow up interview to 14.3% at the 12 month follow up interview; among non-pregnant teens, new infections remained relatively stable over the 6 and 12 month follow up interviews (9.0% to 8.3%) (group by time interaction, p = 0.005). C trachomatis and N gonorrhoeae prevalence was 1.9 times higher (95% CI: 0.97 to 3.89, p = 0.06) among teens in the late postpartum follow up compared to the non-pregnant teens, controlling for baseline STIs. Predictors of postpartum STIs included having a new partner and number of partners per year of sexual activity.

CONCLUSIONS

Postpartum adolescents are vulnerable to STIs. Routine prenatal and postpartum care provide unique opportunities to promote condom use and other risk reduction interventions among adolescents. If sustained post partum, long term reproductive health can be promoted.

Sexually transmitted diseases treatment guidelines

Sexually transmitted diseases (STDs) are a major health problem for adolescents. Health care providers for adolescents play a critical role in preventing and treating STDs. In May 2002, the Centers for Disease Control and Prevention published the Sexually Transmitted Diseases Treatment Guidelines 2002. These evidence-based guidelines are based on a systematic literature review focusing on information that had become available since the 1998 Guidelines for Treatment of STDs. This article reviews the new STD treatment guidelines for gonorrhea, chlamydia, bacterial vaginosis, trichomonas, vulvovaginal candidiasis, pelvic inflammatory disease, genital warts, herpes simplex virus infection, syphilis, and scabies. Although these guidelines emphasize treatment, prevention strategies and diagnostic recommendations also are discussed.

Gonorrhoea reinfection in heterosexual STD clinic attendees: longitudinal analysis of risks for first reinfection

OBJECTIVES

Gonorrhoea is associated with adverse reproductive health outcomes, including pelvic inflammatory disease and increased HIV transmission. Our objective was to determine the association of demographic factors, sexual risk behaviours, and drug use with incident gonorrhoea reinfection among public STD clinic clients.

METHODS

A retrospective cohort study conducted from January 1994 through October 1998, of heterosexual public STD clinic attendees age >/=12 years having at least one gonorrhoea infection in Baltimore, MD. The outcome was first incident gonorrhoea reinfection over a maximum 4.8 years, compared in STD clinic clients with or without sexual risk behaviours and drug use at initial gonorrhoea infection.

RESULTS

910 reinfections occurred among 8327 individuals and 21 246 person years of observation, for an overall incidence of 4.28 reinfections per 100 person years (95% CI 4.03 to 4.53). Median time to reinfection was 1.00 year (95% CI 0.91 to 1.07 years). In multivariate Cox regression, increased reinfection risk was associated with male sex, younger age, greater number of recent sex partners, and having a sex partner who is a commercial sex worker. Injection drug use and coming to the clinic as an STD contact were protective. Among risk factors that differed significantly between men and women, injection drug use was protective of reinfection in men, and "any" condom use was a risk factor for reinfection in women

CONCLUSIONS

Reinfection represents a significant proportion of STD clinic visits for gonorrhoea. Prevention counselling and routine screening for patients at high risk for reinfection should be considered to maximally reduce transmission and resource utilisation.

Fuzzy-trace theory, risk communication, and product labeling in sexually transmitted diseases

Health care professionals are a major source of risk communications, but their estimation of risks may be compromised by systematic biases. We examined fuzzy-trace theory's predictions of professionals' biases in risk estimation for sexually transmitted infections (STIs) linked to: knowledge deficits (producing underestimation of STI risk, re-infection, and gender differences), gist-based mental representation of risk categories (producing overestimation of condom effectiveness for psychologically atypical but prevalent infections), retrieval failure for risk knowledge (producing greater risk underestimation when STIs are not specified), and processing interference involving combining risk estimates (producing biases in post-test estimation of infection, regardless of knowledge). One-hundred-seventy-four subjects (experts attending a national workshop, physicians, other health care professionals, and students) estimated the risk of teenagers contracting STIs, re-infection rates for males and females, and condom effectiveness in reducing infection risk. Retrieval was manipulated by asking estimation questions in two formats, a specific format that "unpacked" the STI category (infection types) and a global format that did not provide specific cues. Requesting estimates of infection risk after relevant knowledge was directly provided, isolating processing effects, assessed processing biases. As predicted, all groups of professionals underestimated the risk of STI transmission, re-infection, and gender differences, and overestimated the effectiveness of condoms, relative to published estimates. However, when questions provided better retrieval supports (specified format), estimation bias decreased. All groups of professionals also suffered from predicted processing biases. Although knowledge deficits contribute to estimation biases, the research showed that biases are also linked to fuzzy representations, retrieval failures, and processing errors Hence, interventions that are designed to improve risk perception among professionals must incorporate more than knowledge dissemination. They should also provide support for information representation, effective retrieval, and accurate processing.

Post-treatment sexual and prevention behaviours of adolescents with sexually transmitted infections

OBJECTIVE

To evaluate sexual behaviour (including abstinence), sex partner change, and condom use during the 3 month period following treatment for Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, or non-gonococcal urethritis.

METHODS

251 14-21 year old participants (83% female; 83% African-American) diagnosed with gonorrhoea, chlamydia, trichomonas, or non-gonococcal urethritis or sexual contacts of infected partners. Participants were clients of a public sexually transmitted diseases clinic or primary care adolescent clinics. Data were collected by structured interview at treatment, 1 month post-treatment, and 3 months post-treatment. At each visit, participants were asked about coital frequency and condom use for each recent partner. At 1 month, participants were asked when coitus occurred following treatment. At each follow up visit, sex partners were compared to partners named at treatment and classified as "same partner(s)," "new partner(s)," or both "same and new partner(s)."

RESULTS

Post-treatment abstinence was reported by 26% and 19% for the 1 month and 3 month visits, respectively. Abstinence was associated with greater likelihood of infection at enrolment although abstainers reported fewer lifetime STI and fewer lifetime sex partners. A substantial proportion of participants reported additional sexual contact with a previous partner. The average proportion of condom protected coital events increased from about 45% at enrolment to 64% at 1 month and 58% at 3 months (p<0.05). Higher levels were sustained for the 3 months following treatment.

CONCLUSIONS

Many adolescents adopt, at least temporarily, risk reduction behaviours such as abstinence or increased condom use. Sexual re-exposure to potentially untreated previous partners may increase risk of subsequent reinfection.