Delayed presentation to clinics for sexually transmitted diseases by symptomatic patients. A potential contributor to continuing STD morbidity

Factors Associated With Delays in Presentation and Treatment of Gonorrhea, Massachusetts 2015-2019

BACKGROUND

Rates of gonorrhea are increasing across the United States. Understanding and addressing contributing factors associated with longer time to diagnosis and treatment may shorten the duration of infectiousness, which in turn may limit transmission.

METHODS

We used Massachusetts data from the US Centers for Disease Control and Prevention Sexually Transmitted Disease Surveillance Network collected between July 2015 and September 2019, along with routinely reported surveillance data, to assess time from gonorrhea symptom onset to presentation to care, and time from presentation to care to receipt of treatment. Factors associated with longer time to presentation (TTP) and time to treatment (TTT) were assessed using Cox proportional hazard models with a constant time variable.

RESULTS

Among symptomatic patients (n = 672), 31% did not receive medical care within 7 days of symptom onset. Longer TTP was associated with younger age, female gender, reporting cost as a barrier to care, and provider report of proctitis. Among patients with symptoms and/or known contact to gonorrhea (n = 827), 42% did not receive presumptive treatment. Longer TTT was associated with female gender, non-Hispanic other race/ethnicity, and clinics with less gonorrhea treatment experience. Among asymptomatic patients without known exposure to STI (n = 235), 26% did not receive treatment within 7 days. Longer TTT was associated with sexually transmitted disease clinic/family planning/reproductive health clinics and a test turnaround time of ≥3 days.

CONCLUSIONS

Delays in presentation to care and receipt of treatment for gonorrhea are common. Factors associated with longer TTP and TTT highlight multiple opportunities for reducing the infectious period of patients with gonorrhea.

Time to healthcare seeking following the onset of symptoms among men and women attending a sexual health clinic in Melbourne, Australia

BACKGROUND

Timely diagnosis and treatment of sexually transmitted infections (STIs) underpin their control by reducing the duration of infectiousness. There are currently limited data exploring healthcare seeking among individuals with STI symptoms.

METHODS

We analyzed data on individuals reporting STI symptoms at the Melbourne Sexual Health Centre (MSHC) between August 2017 and December 2020. We calculated the time between symptom onset and clinic attendance by risk group for 13 STI diagnoses. We performed univariable and multivariable logistic regression analyses to explore factors associated with delayed healthcare seeking (greater than 7 days).

RESULTS

Among 7,032 symptomatic clinic attendances, the shortest time to healthcare seeking was among individuals diagnosed with gonococcal urethritis (median 3 days), and the longest was among individuals diagnosed with genital warts (median 60 days). Individuals diagnosed with gonococcal urethritis sought care earlier than individuals diagnosed with non-gonococcal urethritis (median 3 vs. 6 days, p < 0.001), and individuals diagnosed with genital herpes sought care earlier than individuals diagnosed with primary syphilis (median 4 vs. 14 days, p < 0.001). Men who have sex with men, and men taking human immunodeficiency virus pre-exposure prophylaxis (PrEP), were least likely to delay healthcare seeking. Both men and women who delayed healthcare seeking were more likely to live further from the clinic than those who did not delay their presentation [p trend < 0.001 (men) and p trend = 0.049 (women)].

CONCLUSION

Improved local access to healthcare alongside targeted strategies to encourage early healthcare seeking among groups at increased likelihood of delay may reduce STI-associated morbidity and transmission.

Delay in Seeking Health Care Services After Onset of Urethritis Symptoms in Men

BACKGROUND

Symptom awareness, behavioral factors, and other barriers associated with timely sexually transmitted infection (STI) health care provision in men is not well studied.

METHODS

Men attending an STI clinic answered a questionnaire regarding their symptoms, sexual behavior, and sociodemographic and behavioral characteristics. Characteristics of symptomatic men were compared between those who did and did not delay seeking health care services. Delayed care seeking was defined as clinic attendance longer than 7 days after symptoms, whereas early care seeking was defined as clinic attendance of 7 days or less.

RESULTS

Over a quarter (n = 43 [27.7%]) of men with urethritis symptoms (urethral discharge or dysuria) delayed seeking care for more than 7 days. Compared with men who sought treatment within 7 days, those that delayed care worried for longer periods that their symptoms were STI-related, were more likely to attempt self-treatment of STI symptoms, were more likely to continue engaging in sexual activity, and were less likely to use a condom during their last sexual encounter. Conversely, men that delayed care seeking were less likely to have urethral discharge on physical examination, to have 5 or more polymorphonuclear leukocytes, and to test positive for Neisseria gonorrhoeae. When compared with men that sought care earlier, men that delayed care seeking had fewer overall and new partners in the past 30 days.

CONCLUSIONS

Our data suggest that over a quarter of men aware of STI symptoms delay seeking health services. Interventions that promote better patient understanding of the importance of symptom recognition and that facilitate timely access to care may provide new opportunities to reduce STI transmission.

Factors associated with time to presentation for individuals with symptomatic uncomplicated genital gonorrhoea: a cross sectional cohort study of GToG trial participants

OBJECTIVES

To determine the variation in the time from onset of symptoms to clinical presentation (time to presentation [TTP]) in a cohort of sexual health attendees with symptomatic uncomplicated genital gonorrhoea and to identify factors associated with TTP.

METHODS

Participants were recruited from 14 clinics across England into the 'Gentamicin for the Treatment of Gonorrhoea (GToG)' trial between October 2014 and November 2016. Multivariable analysis was performed using prospectively collected demographic, behavioural and clinical data in a subset of the GToG study cohort presenting with genital discharge and/or dysuria who tested positive for Neisseria gonorrhoeae using a nucleic acid amplification test. The results were expressed as geometric mean ratios (GMR) with 95% CI for time to presentation after onset of symptoms.

RESULTS

316 participants (269 men and 47 women) with a median age of 27.6 years (IQR 23.0-34.8) were included. 194 (61%) were Caucasian, 29 (9%) Black African, 27 (9%) Asian and 66 (21%) of other ethnicities. Median TTP was 3 days for men (IQR 2-7) and 14 days for women (IQR 7-21). Participants reported genital discharge (297/316 [94%]), dysuria (251/316 [79%]), both genital discharge and dysuria (232/316 [73%]) and other concurrent symptoms 76/316 (24%) (e.g., rectal bleeding or genital itching). 45/316 (14%) participants reported sexual contact while symptomatic, of whom TTP was more than 7 days in 32/45 (71%). A longer TTP was associated with gender (female cf. male, GMR 2.34 [1.67 to 3.26]), no prior history of gonorrhoea (GMR 1.46 [1.15 to 1.86]), 'regular' or 'ex-regular' sexual relationship (regular cf. one off GMR 1.35 [1.05 to 1.72]); ex-regular cf. one off GMR 1.88 [1.12 to 3.14]), and being heterosexual (GMR 1.69 [1.31 to 2.19]).

CONCLUSION

Specific demographic and behavioural factors are associated with a longer TTP in individuals with symptomatic genital gonorrhoea. Detailed knowledge of these factors can be used to prioritise and optimise gonorrhoea management and prevention.

Help-seeking for genitourinary symptoms: a mixed methods study from Britain's Third National Survey of Sexual Attitudes and Lifestyles (Natsal-3)

OBJECTIVES

Quantify non-attendance at sexual health clinics and explore help-seeking strategies for genitourinary symptoms.

DESIGN

Sequential mixed methods using survey data and semistructured interviews.

SETTING

General population in Britain.

PARTICIPANTS

1403 participants (1182 women) from Britain's Third National Survey of Sexual Attitudes and Lifestyles (Natsal-3; undertaken 2010-2012), aged 16-44 years who experienced specific genitourinary symptoms (past 4 weeks), of whom 27 (16 women) who reported they had never attended a sexual health clinic also participated in semistructured interviews, conducted May 2014-March 2015.

PRIMARY AND SECONDARY OUTCOME MEASURES

From survey data, non-attendance at sexual health clinic (past year) and preferred service for STI care; semistructured interview domains were STI social representations, symptom experiences, help-seeking responses and STI stigma.

RESULTS

Most women (85.9% (95% CI 83.7 to 87.9)) and men (87.6% (95% CI 82.3 to 91.5)) who reported genitourinary symptoms in Natsal-3 had not attended a sexual health clinic in the past year. Around half of these participants cited general practice (GP) as their preferred hypothetical service for STI care (women: 58.5% (95% CI 55.2% to 61.6%); men: 54.3% (95% CI 47.1% to 61.3%)). Semistructured interviews elucidated four main responses to symptoms: not seeking healthcare, seeking information to self-diagnose and self-treat, seeking care at non-specialist services and seeking care at sexual health clinics. Collectively, responses suggested individuals sought to gain control over their symptoms, and they prioritised emotional reassurance over accessing medical expertise. Integrating survey and interview data strengthened the evidence that participants preferred their general practitioner for STI care and extended understanding of help-seeking strategies.

CONCLUSIONS

Help-seeking is important to access appropriate healthcare for genitourinary symptoms. Most participants did not attend a sexual health clinic but sought help from other sources. This study supports current service provision options in Britain, facilitating individual autonomy about where to seek help.

Teledermatology: Comparison of Store-and-Forward Versus Live Interactive Video Conferencing

A decreasing number of dermatologists and an increasing number of patients in Western countries have led to a relative lack of clinicians providing expert dermatologic care. This, in turn, has prolonged wait times for patients to be examined, putting them at risk. Store-and-forward teledermatology improves patient access to dermatologists through asynchronous consultations, reducing wait times to obtain a consultation. However, live video conferencing as a synchronous service is also frequently used by practitioners because it allows immediate interaction between patient and physician. This raises the question of which of the two approaches is superior in terms of quality of care and convenience. There are pros and cons for each in terms of technical requirements and features. This viewpoint compares the two techniques based on a literature review and a clinical perspective to help dermatologists assess the value of teledermatology and determine which techniques would be valuable in their practice.

Using Multiple Outcomes of Sexual Behavior to Provide Insights Into Chlamydia Transmission and the Effectiveness of Prevention Interventions in Adolescents

BACKGROUND

Mathematical models are important tools for assessing prevention and management strategies for sexually transmitted infections. These models are usually developed for a single infection and require calibration to observed epidemiological trends in the infection of interest. Incorporating other outcomes of sexual behavior into the model, such as pregnancy, may better inform the calibration process.

METHODS

We developed a mathematical model of chlamydia transmission and pregnancy in Minnesota adolescents aged 15 to 19 years. We calibrated the model to statewide rates of reported chlamydia cases alone (chlamydia calibration) and in combination with pregnancy rates (dual calibration). We evaluated the impact of calibrating to different outcomes of sexual behavior on estimated input parameter values, predicted epidemiological outcomes, and predicted impact of chlamydia prevention interventions.

RESULTS

The two calibration scenarios produced different estimates of the probability of condom use, the probability of chlamydia transmission per sex act, the proportion of asymptomatic infections, and the screening rate among men. These differences resulted in the dual calibration scenario predicting lower prevalence and incidence of chlamydia compared with calibrating to chlamydia cases alone. When evaluating the impact of a 10% increase in condom use, the dual calibration scenario predicted fewer infections averted over 5 years compared with chlamydia calibration alone [111 (6.8%) vs 158 (8.5%)].

CONCLUSIONS

While pregnancy and chlamydia in adolescents are often considered separately, both are outcomes of unprotected sexual activity. Incorporating both as calibration targets in a model of chlamydia transmission resulted in different parameter estimates, potentially impacting the intervention effectiveness predicted by the model.

Knowledge of sexually transmitted infections and sources of information amongst men

The objective of this study was to investigate menís awareness of sexually transmitted infections (STIs) and sexual health services, together with the best ways of providing information about them.

Information was collated via a self-administered questionnaire, which was answered by 429 men, giving a response rate of 31%.

Men aged 16+ living in two primary care trusts (PCTs) in the north-west of England were accessed through a range of different sources, including social, educational, health, work and religious facilities.

Despite the high rates of STIs in the north-west, approximately one in five men had not heard of herpes, syphilis or chlamydia. One in ten had not heard of gonorrhoea. The majority of men were unaware that many STIs could be asymptomatic. Only 13% knew where their local genitourinary medicine (GUM) clinic was. The main deterrents to accessing the clinic were embarrassment and not knowing where it was.

Menís knowledge of STIs is limited, particularly in relation to the symptoms. The best way of providing information, according to the respondents, was through their general practitioner (GP). However, in practice this might be difficult, as men are reluctant users of GP services in general. Knowledge of the whereabouts of the local GUM clinics is also limited. Although most men thought that they would visit their GP if they thought they might have an STI, this may result from them not knowing the alternatives, rather than having a real choice. More information, targeted wisely, is thus necessary in order to educate men about STIs and service provision.

Abused Women and Risk for Pelvic Inflammatory Disease1

Mexican and African American women with sexually transmitted diseases (STDs) underwent targeted physical exams and questioning regarding sexual or physical abuse, current genitourinarysymptomatology, and pelvic inflammatory disease (PID) risk behaviors to determine the relationship of sexual or physical abuse to the pathology of genitourinary symptoms affecting diagnoses of STDs and risk for PID. Bivariate comparisons found abused women reported more PID risk behaviors including earlier coitus, more sex partners, higher STD recurrence, and delayed health-seeking behavior. Multivariate comparisons found abused women were more likely to report pathologic genitourinary symptomatology than nonabused women. Clinicians made more presumptive diagnosesof PID for abused than for nonabused women upon physical examination. These findings indicate abused women are at high risk for PID. Its considerable impact on genitourinary symptomatology and risk for PID make assessment for abuse essential in clinical management of women with STDs and diagnosis of PID.

Blind evaluation of the microwave-accelerated metal-enhanced fluorescence ultrarapid and sensitive Chlamydia trachomatis test by use of clinical samples

Accurate point-of-care (POC) diagnostic tests for Chlamydia trachomatis infection are urgently needed for the rapid treatment of patients. In a blind comparative study, we evaluated microwave-accelerated metal-enhanced fluorescence (MAMEF) assays for ultrafast and sensitive detection of C. trachomatis DNA from vaginal swabs. The results of two distinct MAMEF assays were compared to those of nucleic acid amplification tests (NAATs). The first assay targeted the C. trachomatis 16S rRNA gene, and the second assay targeted the C. trachomatis cryptic plasmid. Using pure C. trachomatis, the MAMEF assays detected as few as 10 inclusion-forming units/ml of C. trachomatis in less than 9 min, including DNA extraction and detection. A total of 257 dry vaginal swabs from 245 female adolescents aged 14 to 22 years were analyzed. Swabs were eluted with water, the solutions were lysed to release and to fragment genomic DNA, and MAMEF-based DNA detection was performed. The prevalence of C. trachomatis by NAATs was 17.5%. Of the 45 samples that were C. trachomatis positive and the 212 samples that were C. trachomatis negative by NAATs, 33/45 and 197/212 were correctly identified by the MAMEF assays if both assays were required to be positive (sensitivity, 73.3%; specificity, 92.9%). Using the plasmid-based assay alone, 37/45 C. trachomatis-positive and 197/212 C. trachomatis-negative samples were detected (sensitivity, 82.2%; specificity, 92.9%). Using the 16S rRNA assay alone, 34/45 C. trachomatis-positive and 197/212 C. trachomatis-negative samples were detected (sensitivity, 75.5%; specificity, 92.9%). The overall rates of agreement with NAAT results for the individual 16S rRNA and cryptic plasmid assays were 89.5% and 91.0%, respectively. Given the sensitivity, specificity, and rapid detection of the plasmid-based assay, the plasmid-based MAMEF assay appears to be suited for clinical POC testing.

Delay in Seeking Care for Sexually Transmitted Diseases in Young Men and Women Attending a Public STD Clinic

BACKGROUND

Delay in seeking care for sexually transmitted diseases (STDs) has adverse consequences for both the individual and population. We sought to identify factors associated with delay in seeking care for STDs.

METHODS

Subjects included 300 young men and women (aged 15-24) attending an urban STD clinic for a new STD-related problem due to symptoms or referral for an STD screening. Subjects completed a structured interview that evaluated STD history, attitudes and beliefs about STDs, depression, substance use, and other factors possibly associated with delay. Delay was defined as waiting > 7 days to seek and obtain care for STDs.

RESULTS

Nearly one-third of participants delayed seeking care for > 7 days. Significant predictors for delay included self-referral for symptoms as the reason for visit (OR 5.3, 95% CI: 2.58 - 10.98), and the beliefs "my partner would blame me if I had an STD" (OR 2.44, 95% CI: 1.30 - 4.60) and "it's hard to find time to get checked for STDs" (OR 3.62, 95% CI: 1.95 - 6.69), after adjusting for age, race, sex, and other factors. Agreeing with the statement "would use a STD test at home if one were available" was associated with a decrease in delay (OR 0.24, 95% CI: 0.09 - 0.60).

CONCLUSIONS

Many young persons delay seeking care for STDs for a number of reasons. Strategies to improve STD care-seeking include encouragement of symptomatic persons to seek medical care more rapidly, reduction of social stigmas, and improved access to testing options.

Relationships between perceived STD-related stigma, STD-related shame and STD screening among a household sample of adolescents

CONTEXT

Important barriers to STD testing may include individuals' perceptions of STD-related stigma (negative societal attitudes toward STD infection) and expectations of STD-related shame (negative personal feelings) that would result from a positive STD test. Obtaining a clear understanding of the relationship between STD-related stigma, STD-related shame and STD testing may help inform programs and policies aimed at reducing STD transmission.

METHODS

Measures derived from previously published scales were used to assess perceived STD-related stigma, anticipated STD-related shame and receipt of an STD test in the past year in an urban, household sample of 594 sexually active 15-24-year-olds interviewed in 2004-2007. Logistic regression was used to examine associations between recent STD testing and perceived stigma, shame and other participant characteristics.

RESULTS

Thirty-seven percent of males and 70% of females reporting having had an STD test in the past year; the largest proportions of tests (42% among males and 59% among females) had occurred in the context of a routine health care visit, not because adolescents had had disease symptoms or were concerned about exposure to infection. For both males and females, the level of STD-related stigma was negatively associated with the odds of having been tested (odds ratio, 0.5 for each). STD-related shame was not related to STD testing.

CONCLUSIONS

Adolescents who view STDs as stigmatizing have a reduced likelihood of being screened, but it is unclear whether this relationship reflects their care seeking or providers' practice of offering STD screening at a routine health visit.

Syndromic management and STI control in urban Peru

Background

Syndromic management is an inexpensive and effective method for the treatment of symptomatic sexually transmitted infections (STIs), but its effectiveness as a method of STI control in at-risk populations is questionable. We sought to determine the potential utility of syndromic management as a public health strategy to control STI transmission in high-risk populations in urban Peru.

Methodology

We surveyed 3,285 at-risk men and women from three Peruvian cities from 2003–05. Participants were asked about the presence of genital ulcers, discharge, or dysuria in the preceding six months. Participants reporting symptoms were asked about subsequent health-seeking and partner notification behavior. Urine and vaginal swab samples were tested for Neisseria gonorrhoeae and Chlamydia trachomatis by nucleic acid testing. Serum was tested for syphilis and Herpes Simplex Virus-Type 2 antibodies.

Findings

Recent urogenital discharge or dysuria was reported by 42.1% of participants with gonorrhea or chlamydia versus 28.3% of participants without infection. Genital ulceration was reported by 6.2% of participants with, and 7.4% of participants without, recent syphilis. Many participants reporting symptoms continued sexual activity while symptomatic, and approximately half of all symptomatic participants sought treatment. The positive and negative predictive values of urogenital discharge or genital ulcer disease in detecting STIs that are common in the study population were 14.4% and 81.5% for chlamydia in women and 8.3% and 89.5% for syphilis among gay-identified men.

Conclusions

In our study, STIs among high-risk men and women in urban Peru were frequently asymptomatic and symptomatic participants often remained sexually active without seeking treatment. Additional research is needed to assess the costs and benefits of targeted, laboratory-based STI screening as part of a comprehensive STI control program in developing countries.

Gonorrhea and chlamydia in emergency departments: Screening, diagnosis, and treatment

Failure to screen sexually active adolescents and adults for gonorrhea and chlamydia at the time of acute care visits to urban emergency departments (ED) results in missed treatment opportunities for 38% to 82% of infected persons. The prevalence of gonorrhea and chlamydia infections among ED patients presenting with genitourinary or pregnancy-related complaints or providing urine specimens as part of routine medical care ranges from 4.3% to 16.4%. Notably, prevalence among general ED patients is similar (9.7%-14.3%). Due to the asymptomatic or nonspecific presentation of these infections, expanded screening is recommended to increase detection, treatment, and partner notification. A lower threshold of empiric treatment in the ED setting is recommended due to the difficulty and incompleteness of follow-up subsequent to ED discharge. Specific recommendations to improve the quality of ED care for sexually transmitted infections and to expand detection are provided.

Are home sampling kits for sexually transmitted infections acceptable among men who have sex with men?

Objective:

There is an urgent need to increase opportunistic screening for sexually transmitted infections (STIs) in community settings, particularly for those who are at increased risk including men who have sex with men (MSM). The aim of this qualitative study was to explore whether home sampling kits (HSK) for multiple bacterial STIs are potentially acceptable among MSM and to identify any concerns regarding their use. This study was developed as part of a formative evaluation of HSKs.

Methods:

Focus groups and one-to-one semi-structured interviews with MSM were conducted. Focus group participants (n = 20) were shown a variety of self-sampling materials and asked to discuss them. Individual interviewees (n = 24) had experience of the self-sampling techniques as part of a pilot clinical study. All data were digitally recorded and transcribed verbatim. Data were analysed using a framework analysis approach.

Results:

The concept of a HSK was generally viewed as positive, with many benefits identified relating to increased access to testing, enhanced personal comfort and empowerment. Concerns about the accuracy of the test, delays in receiving the results, the possible lack of support and potential negative impact on ‘others’ were raised.

Conclusion:

The widespread acceptability of using HSKs for the diagnosis of STIs could have important public health impacts in terms of earlier diagnosis of asymptomatic infections and thus a decrease in the rate of onward transmission. In addition, HSKs could potentially optimize the use of genitourinary medicine services and facilitate patient choice.

Time from sexually transmitted infection acquisition to pelvic inflammatory disease development: influence on the cost-effectiveness of different screening intervals

OBJECTIVES

To prevent pelvic inflammatory disease (PID), some experts recommend screening for sexually transmitted infection (STI) every 12 months, with more frequent screening suggested in higher-risk women. Nevertheless, the time from STI acquisition to PID development, possibly an important factor to consider in screening interval choice, is unknown and its influence on the effectiveness and cost-effectiveness of screening is unclear.

METHODS

Using a Markov model, we estimated PID cases averted and the incremental cost-effectiveness resulting from 6- or 12-month screening strategies for high-risk young women (6%/year infection risk, 2.8%/year PID risk with 12-month screening) while varying PID development time from 1 to 12 months after initial infection. Lower-risk women and alternative parameter values were examined in sensitivity analyses.

RESULTS

Relative to 12-month screening, 6-month screening decreases PID cases from 6.0% (1 month development time)to 19.4% (12 months); the incremental cost per quality-adjusted life-year (QALY) gained compared with the other strategies varies from $16,600 (12 months development time) to $31,800 (1 month) for high-risk women. In lower-risk women, every 6-month screening is more economically unfavorable, with greater costs per QALY gained at shorter PID development time.

CONCLUSION

From a cost-effectiveness standpoint, uncertainty about PID development time is not a significant factor in choosing a screening interval in high-risk women, but could be important in lower-risk groups. Significant increases in PID cases averted occur with more frequent screening when PID development time is lengthened, which may allow estimation of this interval through the use of more sophisticated modeling techniques.

Youth United Through Health Education: community-level, peer-led outreach to increase awareness and improve noninvasive sexually transmitted infection screening in urban African American youth

PURPOSE

To evaluate the effectiveness of the Youth United Through Health Education (YUTHE) program, a community-level, peer-led outreach program to increase awareness and improve noninvasive sexually transmitted infection (STI) screening in youth residing in the targeted community.

METHODS

Sexually experienced youth, aged 12-22 years, anonymously participated in the YUTHE program (a 15-minute encounter, including a risk assessment with feedback and prevention messages). A street- and venue-based intercept approach using a nonequivalent control group design was implemented to evaluate the YUTHE program.

RESULTS

YUTHE community respondents were more likely to know that STIs could be asymptomatic (odds ratios [OR] 1.36, 95% confidence interval [CI] 1.08-1.72), know about urine-based STI screening tests (OR 1.34, 95% CI 1.04-1.72), perceive themselves to be at risk for STIs (OR 1.71, 95% CI 1.11-2.62), and worried about acquiring an STI (OR 1.50, 95% CI 1.04-2.18). No other community differences were identified. However, respondents who reported a single contact (OR = 2.12, 95% CI = 1.11-4.03) or multiple contacts (OR 2.78, 95% CI 1.81-4.26) with the YUTHE program were more likely to have been tested for STIs in the previous six months.

CONCLUSIONS

We did not accomplish our overall goal of increasing STI screening in our outreach community relative to the comparison community; our findings suggest that a peer-led, street- and venue-based community outreach approach is a feasible means for reaching large numbers of adolescents for STI prevention.

HIV-related knowledge, stigma, and willingness to disclose: A mediation analysis

Increasing HIV knowledge is a focus of many HIV education and prevention efforts. While the bivariate relationship of HIV serostatus disclosure with HIV-related knowledge and stigma has been reported in the literature, little is known about the mediation effect of stigma on the relationship of HIV knowledge with HIV serostatus disclosure. Data from 4,208 rural-to-urban migrants in China were analyzed to explore this issue. Overall, 70% of respondents reported willingness to disclose their HIV status if they were HIV-positive. Willingness to disclose was negatively associated with misconceptions about HIV transmission and stigma. Stigma mediated the relationship between misconceptions and willingness to disclose among women but not men. The mediation effect of stigma suggests that stigmatization reduction would be an important component of HIV prevention approaches. Gender inequality needs to be addressed in stigmatization reduction efforts.

Epidemiological correlates of asymptomatic gonorrhea

OBJECTIVES

To assess correlates of asymptomatic gonorrhea among patients attending Genitourinary Medicine Clinics participating in the Gonococcal Resistance to Antimicrobials Surveillance Programme (GRASP) in England for 2001-2003.

STUDY DESIGN

GRASP is a sentinel surveillance program that monitors antimicrobial resistance to Neisseria gonorrhoeae. Data collection occurs annually in June to August each year.

RESULTS

Women with previously diagnosed gonorrhea had decreased odds of asymptomatic gonococcal infection, as did women diagnosed with other sexually transmitted infections (all except chlamydia, syphilis, herpes, and warts). Heterosexual men, but not women, coinfected with chlamydia had significantly higher likelihood of being diagnosed with asymptomatic gonorrhea, as did homosexual men coinfected with syphilis and warts.

CONCLUSION

The heterogeneity in correlates of asymptomatic gonorrhea has implications for screening in clinical settings. Such findings also depend on the extent of testing on sexually transmitted infections from different sites of infection, which has particular relevance in homosexual men and would thus need to be investigated in other studies.

Cost-Effectiveness of Screening Strategies for Gonorrhea Among Females in Private Sector Care

OBJECTIVE

To identify the optimal screening algorithm for gonorrhea infection among females in private sector care, using cost-effectiveness analysis.

METHODS

We compared 6 strategies using decision analysis for urine nucleic acid amplification testing for gonorrhea testing in a theoretical cohort of 10,000 females aged 15-35 years: 1) screen women aged younger than 25 years; 2) screen women aged younger than 30 years; 3) screen women aged younger than 25 years who report any risk (pregnant, drug use, new sexual partner < 30 days); 4) screen women aged younger than 30 years who report any risk; 5) screen women aged younger than 25 years or those who report any risk; and 6) screen women aged younger than 30 years or those who report any risk. Infection prevalence and sensitivity and specificity were by direct observation from a retrospective cohort of females attending the Baltimore City Sexually Transmitted Disease Clinics between 1999 and 2002. The main outcome measures were untreated gonorrhea cases and their sequelae in women, transmission to a male partner, congenital outcomes, and cost to prevent a case.

RESULTS

Prevalence of gonorrhea was 3.0%. Not screening would result in 300 untreated cases. Not screening was cost-saving over all screening strategies. Strategy 6 resulted in the fewest cases of untreated infection (82), although Strategy 3 was the most cost-effective of the screening strategies. Univariate sensitivity analysis identified a threshold of 4.75% gonorrhea prevalence, more than which Strategy 3 became cost-saving over not screening.

CONCLUSION

Screening is recommended for females aged younger than 25 years with specific risks in populations with a gonorrhea prevalence of 4.75% or greater.

LEVEL OF EVIDENCE

II-2.

Partner Notification Methods for African American Men Being Treated for Trichomoniasis: A Consideration of Main Men, Second Hitters, and Third Players

This pilot study sought information on African American men's preferences for partner notification methods for a common sexually transmitted infection called trichomoniasis. Two focus groups of African American men were convened at a public STI clinic where they were being treated for trichomoniasis. The groups identified a sexual hierarchy in men's preferences for methods of partner notification. The hierarchy consisted of main men (Cake Daddies), second men (Second Hitters), and third or fourth men (Third Players), with placement depending on age, income, and social status. Health department employees affirmed the existence of a sexual hierarchy in a separate focus group. Sexual and economic bartering formed the basis of the hierarchy, and the secrecy involved in such arrangements presented a considerable challenge for STI control. Disease intervention specialists who were responsible for contact tracing spoke of cat-and-mouse methods in contacting the men without understanding fully exactly how the hierarchy influenced men's responses to partner notification. The findings suggest that STI control efforts must take the sexual hierarchy and its privacy implications into account if partner notification methods are to be acceptable to African American men.

Optimizing treatment of antimicrobial-resistant Neisseria gonorrhoeae

The increasing prevalence of ciprofloxacin-resistant Neisseria gonorrhoeae has required replacing inexpensive oral ciprofloxacin treatment with more expensive injectable ceftriaxone. Further, monitoring antimicrobial resistance requires culture testing, but nonculture gonorrhea tests are rapidly replacing culture. Since the strategies were similar in effectiveness (> 99%), we evaluated, from the healthcare system perspective, cost-minimizing strategies for both diagnosis (culture followed by antimicrobial susceptibility tests versus nonculture-based tests) and treatment (ciprofloxacin versus ceftriaxone) of gonorrhea in women. Our results indicate that switching from ciprofloxacin to ceftriaxone is cost-minimizing (i.e., optimal) when the prevalence of gonorrhea is > 3% and prevalence of ciprofloxacin resistance is > 5%. Similarly, culture-based testing and susceptibility surveillance are optimal when the prevalence of gonorrhea is < 13%; nonculture-based testing is optimal (cost-minimizing) when gonorrhea prevalence is > or = 13%.

Youth united through health education: building capacity through a community collaborative intervention to prevent HIV/STD in adolescents residing in a high STD prevalent neighborhood

The early detection and treatment of STDs is an effective strategy for slowing the sexual transmission of HIV. The goal of the YUTHE (Youth United Through Health Education) program, a collaborative effort between the San Francisco Department of Public Health (SFDPH) and the University of California, San Francisco, is to increase sexually transmitted disease screening and treatment among adolescents in a neighborhood with a high incidence of STDs in San Francisco. Youth health educators residing in the intervention neighborhood recruited sexually active youth between the ages of 12 and 22 years to participate in the YUTHE program's intervention between January 2001 and May 2002. Sixty-three percent had two or more sexual partners, 47% did not use condoms consistently, and 18% had a history of STDs. When the intervention neighborhood was contrasted with a sociodemographically matched comparison neighborhood results indicate that both females and males in the YUTHE intervention neighborhood were significantly less likely to have Chlamydia trachomatis infection than their counterparts in the comparison neighborhood.

Understanding the role of perceived severity in STD-related care-seeking delays

PURPOSE

To gain a more in-depth understanding of the relationship between perceived severity of symptoms and STD-related care-seeking behavior among adolescent African-American females in Baltimore City.

METHODS

Twenty-one female adolescents were interviewed in depth to elicit their experiences with an STD in the previous 3 months. Comparisons were made between those who sought care on account of their symptoms and those who did not.

RESULTS

High perceived seriousness about symptoms has both cognitive and emotional components that may function independently to either promote or delay STD-related care seeking.

CONCLUSIONS

Both cognitive and emotional responses to STD symptoms must be considered when examining the effect of perceived severity on adolescents' STD-related care-seeking behaviors.

Relationship of abuse and pelvic inflammatory disease risk behavior in minority adolescents

PURPOSE

Little is known about the relationship between minority adolescent's experiences of sexual or physical abuse and the pathology of gynecological symptoms that might have an impact on the diagnosis of sexually transmitted disease (STD) or risk for pelvic inflammatory disease (PID). The objective of this study was to determine the relationship of sexual or physical abuse to the pathology of genitourinary symptoms that impact diagnoses of STD and risk for PID among Mexican American and African American adolescent women with a current STD.

METHODS

Mexican American and African American adolescent women (n = 373) with an STD underwent a targeted physical exam and questioning regarding sexual or physical abuse, current genitourinary symptomatology, and risk behaviors known to be associated with PID to determine the relationship of sexual or physical abuse to the pathology of genitourinary symptoms that impact diagnoses of STD and risk for PID.

RESULTS

Bivariate comparisons found that abused adolescents (n = 232) reported more behaviors associated with increased risk for PID, including earlier coitus, more sex partners, higher STD recurrence, and delayed health-seeking behavior. Multivariate comparisons found that abused adolescents were more likely to report pathologic genitourinary symptomatology than those who were not abused. Clinicians reported more abnormal physical exams but did not make any more presumptive diagnoses of PID for abused than nonabused adolescents.

CONCLUSIONS

Delayed treatment for PID dramatically worsens future fertility and chronic pelvic pain. These findings demonstrate that abused adolescent women are at high risk for PID. Because of its considerable impact on risk for PID, an assessment for abuse is essential in clinical management of adolescent women with STD and diagnosis of PID.

Public tolerance, private pain: stigma and sexually transmitted infections in the American Deep South

This pilot telephone survey sought to identify social barriers to treating sexually transmitted infections (STIs) in a socially conservative state (Alabama, USA). The sample consisted of 250 household residents aged 19-50 years, mostly African-American and White, who were drawn from the general population. The participants reported that infected persons, per se, should not be stigmatized. However, almost half of respondents stated that they would seek revenge against a partner who infected them. Feelings of embarrassment negatively affected willingness to seek health care; almost half of the respondents stated that, if infected, they would delay treatment or not seek treatment at all. Differences in responses emerged in relation to ethnicity and religiosity, with African-Americans and regular churchgoers being more likely than others to say they would delay or refuse treatment because of embarrassment. Gender differences also emerged: respondents reported that women would be more stigmatized than men if they were infected, even though men should be held responsible for spreading STIs. These findings suggest that stigma may be a compelling barrier to STI control in the American Deep South, and that ethnicity, gender and religiosity play an important role in attitudes toward treatment.

Host immunity and synchronized epidemics of syphilis across the United States

A central question in population ecology is the role of 'exogenous' environmental factors versus density-dependent 'endogenous' biological factors in driving changes in population numbers. This question is also central to infectious disease epidemiology, where changes in disease incidence due to behavioural or environmental change must be distinguished from the nonlinear dynamics of the parasite population. Repeated epidemics of primary and secondary syphilis infection in the United States over the past 50 yr have previously been attributed to social and behavioural changes. Here, we show that these epidemics represent a rare example of unforced, endogenous oscillations in disease incidence, with an 8-11-yr period that is predicted by the natural dynamics of syphilis infection, to which there is partially protective immunity. This conclusion is supported by the absence of oscillations in gonorrhoea cases, where a protective immune response is absent. We further demonstrate increased synchrony of syphilis oscillations across cities over time, providing empirical evidence for an increasingly connected sexual network in the United States.

Correlates of engaging in unprotected sex while experiencing dysuria or discharge: a study of men with confirmed gonorrhea

OBJECTIVES

To identify the prevalence and correlates of engaging in unprotected sex while experiencing symptoms of gonorrhea among a sample of men with a laboratory confirmed diagnosis.

METHODS

Cross-sectional interview data were analyzed from 237 men, reporting dysuria or discharge, with a laboratory-confirmed diagnosis of gonorrhea.

RESULTS

A total of 21.1% reported engaging in unprotected sex while having symptoms. In multivariate analyses, men engaging in sex > or = 5 times in the past 30 days were 3.5 times more likely to report unprotected sex while symptomatic (P = 0.001). Men reporting condom use < or = 50% of the time (past month) were 2.7 times more likely to report the risk behavior under investigation (P = 0.008). Men never having a previous STD were 2.7 times more likely to engage in the risk behavior (P = 0.006).

CONCLUSIONS

The prevalence of this risk behavior was markedly lower compared to a recent study that was not restricted to gonorrhea. Counseling protocols specifically designed for men who continue to engage in unprotected sex after experiencing gonorrhea-related dysuria and discharge may be valuable for preventing the transmission of gonorrhea to women.

Barriers to asymptomatic screening and other STD services for adolescents and young adults: focus group discussions

Background

Sexually transmitted diseases (STDs) are a major public health problem among young people and can lead to the spread of HIV. Previous studies have primarily addressed barriers to STD care for symptomatic patients. The purpose of our study was to identify perceptions about existing barriers to and ideal services for STDs, especially asymptomatic screening, among young people in a southeastern community.

Methods

Eight focus group discussions including 53 White, African American, and Latino youth (age 14–24) were conducted.

Results

Perceived barriers to care included lack of knowledge of STDs and available services, cost, shame associated with seeking services, long clinic waiting times, discrimination, and urethral specimen collection methods. Perceived features of ideal STD services included locations close to familiar places, extended hours, and urine-based screening. Television was perceived as the most effective route of disseminating STD information.

Conclusions

Further research is warranted to evaluate improving convenience, efficiency, and privacy of existing services; adding urine-based screening and new services closer to neighborhoods; and using mass media to disseminate STD information as strategies to increase STD screening.

[An epidemiological model of genital herpes for assessment of potential impact of therapy and prophylaxis: application to France]

OBJECTIVES

This study was performed to quantify the development of the number of cases of genital herpes and to assess the impact of different treatment strategies in France.

METHOD

A model for the natural history of herpes simplex virus genital infection is presented and applied to the French population. The model encompasses infection by herpes simplex virus type 1 (HSV-1) or type 2 (HSV-2), first episodes, recurrences, viral shedding and the effect of treatment on infected individuals.

RESULTS

In the Year 2000, 270,000 individuals would have suffered from genital herpes in France. A total annual cumulated number of 1.5 million episodes of recurrence and 23 million days of viral shedding were estimated. Seventy percent of viral shedding occurred in sub-clinical seropositive individuals. The expected number of attributable neonatal deaths remained very low. Systematic treatment of clinical episodes might reduce the number of days with lesions (- 27 p. 100), and is also effective on viral shedding (symptomatic: - 50 p. 100). Continuous treatment of the most severe patients (>or=6 recurrences per Year) might reduce viral shedding slightly more (- 85 p. 100). Antiviral treatment might have a major impact on the quality of life of these patients but would only slightly curb the number of new infections.

DISCUSSION

This model tries to integrate the various data currently available at international level on the epidemiology of genital herpes. However, many aspects are still not well documented and remain uncertain. It is therefore necessary to define various assumptions in order to simulate the natural history of the disease in a population. The lack of French data especially on the HSV-1 and HSV-2 seroprevalence profiles reinforces these uncertainties. Our results should hence be considered as exploratory. However, this modeling approach is the only possible way to integrate the multiple parameters describing the pathology and predicting of the public health impact of different interventions. This model is an open tool which may be modified when new data become available.

Risk-taking and health-seeking behavior in men with a history of urethritis: is there a learning curve?

BACKGROUND AND OBJECTIVES

Studies addressing how past experience with sexually transmitted diseases (STD) influence health-seeking behaviors among at-risk men are few.

GOAL

The goal of this study was to determine whether health-seeking behaviors among men diagnosed with urethritis differ based on whether they report prior urethritis.

STUDY DESIGN

Male STD clinic attendees answered a questionnaire regarding their demographic, sexual, and health-seeking characteristics. The men were stratified based on whether they reported prior urethritis.

RESULTS

Of 466 men, 297 reported prior urethritis. Symptomatic men diagnosed with urethritis who reported prior urethritis did not recognize their symptoms as a possible STD earlier than those reporting no urethritis history; there was also no difference between the groups in their interval to presenting for care once symptoms were recognized as a possible STD. Furthermore, men with prior urethritis were as likely to engage in sex acts once they recognized their symptoms as a possible STD manifestation.

CONCLUSION

Compared with men without prior urethritis, men with urethritis symptoms who reported prior urethritis did not recognize symptoms earlier, alter health-seeking behavior, or curtail sexual activity.

Stigma as a barrier to treatment of sexually transmitted infection in the American deep south: issues of race, gender and poverty

Sexually transmitted infections (STI) occur at high rates in the US compared to other Western nations. Sociocultural indicators such as race and ethnicity, lower socioeconomic status and historically higher rates of certain diseases, such as syphilis, are correlated factors but do not explain fully why STI rates are particularly high in the American Deep South. One salient factor is the stigma associated with STI and its effect on screening and treatment. This paper presents the results of six focus group interviews that were conducted among mainly African-American health workers, patients and students in Alabama, USA. The results showed that STI-related stigma directly and indirectly affected willingness to be treated for STI at public health clinics. Four dimensions of stigma emerged: (1) Religious ideation affected how health workers felt about 'promiscuous' patients (especially women), (2) privacy fears discouraged male patients from seeking treatment at local clinics, (3) racial attitudes affected willingness to be treated for STI and (4) Stigma transference (being "scarlet lettered") emerged as a potent disincentive to treatment. Partner notification was more likely if patients felt betrayed by a sexual partner. Further research is needed to clarify these stigma-related dimensions and the impact on screening, treatment and partner services.

Acceptability of urine screening for Neisseria gonorrheae and Chlamydia trachomatis in adolescents at an urban emergency department

OBJECTIVE

The objective of this study was to determine the acceptability of urine screening for Neisseria gonorrhoeae and Chlamydia trachomatis in adolescents in a pediatric emergency department.

STUDY DESIGN

We used a prospective enrollment of adolescents aged 14-20 visiting an urban pediatric emergency department.

MAIN OUTCOME MEASURES

The main outcome measure was acceptance of urine STD screening rates.

RESULTS

Of 1231 potential participants, 879 (71%) agreed to participate and 352 (29%) declined screening. Participants were similar to those refusing to participate in terms of gender. In multivariate analysis, age, race/ethnicity, and insurance status were associated with variation in sexually transmitted disease (STD) test acceptance, whereas the presence of a parent was not. Despite similar training, 1 of 3 recruiters had significantly lower acceptance rates than her peers. Overall, 10% of patients enrolled were found to have one or both infections.

CONCLUSION

Urine screening for STDs can be efficiently conducted in an emergency department setting. This screening appears to be acceptable to most patients.

Clinical management of chlamydia and gonorrhea infection in a county teaching emergency department--concerns in overtreatment, undertreatment, and follow-up treatment success

To date, several studies have examined overtreatment or undertreatment of Neisseria gonorrheae, Chlamydia trachomatis, or both in women. However, no study has looked at both subpopulations together, along with eventual treatment of disease-positive patients who were not empirically treated. This study is unique, for it looks at all of these subpopulations to assess overall efficacy of management of these diseases in women. A 1-year prospective, descriptive study was performed in a teaching county hospital Emergency Department (ED). There were 1260 women receiving a pelvic examination and routine GEN-PROBE testing for gonorrhea and chlamydia who were studied. The main outcome measures were the proportion of women disease positive and initially not treated (undertreated), the proportion of women disease negative who were initially treated (overtreated), as well as the follow-up treatment rate for those undertreated. Finally, the subpopulation of women disease positive and not empirically treated was examined in detail. Of 1260 GEN-PROBE-tested women, 81 (6.4%, 95% CI 1.1-11.7%) were disease positive and 31/81 (38.3%, 95% CI 21.2-55.4%) of these women were undertreated. Furthermore, 20/31 (64.5%, 95% CI 43.5-85.5%) women did not return for follow-up treatment. The billable health care dollars of routine GENPROBE testing per woman (n = 11/1260, 0.9%) returning for treatment as a result of the test was $4762.80 US dollars. Four hundred twenty-six (33.8%) of the 1260 women were empirically treated on the initial visit. Of these 426 initially treated women, 376 (88.3%, 95% CI 85.1-91.5%) were GEN-PROBE negative for disease (overtreated). The billable health care dollars of this overtreatment was $12,449.51 US dollars. This study demonstrates that health care providers are substantially overtreating women who are gonorrhea and chlamydia negative. This generates moral, ethical, health care, and financial concerns. Additionally, one-third of disease-positive women are not treated on initial visit and the majority of undertreated patients are not returning for subsequent treatment. This study provides support for investigating improved methods in the management of chlamydia and gonorrhea in women.

Maintaining patient access to GUM clinics: is it compatible with appointments?

OBJECTIVES

To determine whether a planned change from a walk-in service to a system in which 35% of appointments were prebooked and 65% obtained on the day, preserved access to the service for patients with, or at risk of, STIs. To describe patients' attitudes and behaviours in relation to accessing the clinic, and relate these to disease status and other epidemiological factors. To evaluate the effect of the change on clinical outcomes. To develop a tool for evaluating access to services.

METHOD

A natural experiment was studied, in which a cohort of patients attending just before the change in appointments policy (phase 1) was compared with a cohort following the change (phase 2). A questionnaire was administered to all new patients, and linked to disaggregated epidemiological and demographic data and case notes.

RESULTS

The age, ethnic, symptom status, and disease mix of the clinic did not change significantly, and more patients were seen in phase 2. Time from telephoning to being seen did not change. Under 25s and Afro-Caribbeans used prebooked appointments less than others. Partner notification improved and HIV testing rates increased, while staff preferred the new system.

CONCLUSION

This specific appointment system in a GUM clinic preserved access for high risk groups. However, this may not generalise to systems with a higher proportion of prebooked appointments.

Family-related correlates of sexually transmitted disease and barriers to care: a pilot study of pregnant African American adolescents

This study explored associations between family-related measures and sexually transmitted disease (STD) history among 170 pregnant African American adolescent females, 14 to 20 years of age, attending prenatal care clinics in a large urban area of the South. Measures of low family support and infrequent mother-daughter communication were significant bivariate correlates of having at least one STD. Mother-daughter communication about preventing acquired immune deficiency syndrome remained significant in a multivariate model. The study also explored barriers to STD care-seeking behavior and found that few adolescents perceived access or financial issues as reasons to delay entry into the medical system. Low perceived family support was marginally associated with greater perceived barriers to STD care.

Stigma, delayed treatment, and spousal notification among male patients with sexually transmitted disease in China

BACKGROUND

Stigmatization may prevent effective control of sexually transmitted diseases (STDs) in China. Thus, its impact needs to be studied.

GOAL

The goal of the study was to explore the effect of perceived stigmatization on control of STDs.

STUDY DESIGN

A cross-sectional study was conducted among males attending four STD clinics for the first time for a current STD.

RESULTS

Among 406 patients, 80% felt stigmatized, 28% sought treatment only after suffering symptoms for at least 1 week, and 40% reported continuing to have sex while having symptoms. No association was observed between feelings of stigmatization and delay in seeking treatment. Among those married, 77% expressed unwillingness to notify their spouses. Patients who felt stigmatized were less likely to agree to notify their spouses (odds ratio, 0.42; 95% CI, 0.21-0.85).

CONCLUSION

Policies are needed to reduce stigmatization, reduce time to treatment, and promote disclosure to sex partners.

Learning from Clients

This article summarizes sexually transmitted disease (STD) knowledge, health care-seeking behaviors, and perceived advantages to seeking care from the perspective of 397 STD clinic clients interviewed between 1997 and 1999 in three northeastern cities. More than half reported a prior STD. Mean days delay in seeking treatment was 10.8. Reasons for delay included lack of knowledge especially about symptoms (44%) and inconvenience, especially clinic hours (46%). Major disadvantages to receiving care centered around embarrassment and stress (24%). Programs need to develop more intensive counseling for repeat clients, offer more flexible hours, address sources of stress inherent in their services, and develop better marketing strategies. Successful behavioral interventions, behavioral training, and creative approaches from the popular literature may be helpful.

Cost-effectiveness of five strategies for gonorrhea and chlamydia control among female and male emergency department patients

BACKGROUND

Previous studies have shown screening for gonorrhea and chlamydia to be cost-effective for limiting the sequelae of infection and the associated costs of management.

GOAL

To evaluate the cost-effectiveness of enhanced screening for gonorrhea and chlamydia in an emergency department (ED) setting.

STUDY DESIGN

Five strategies were compared with use of decision analysis for theoretical cohorts of 10,000 female and 10,000 male ED patients aged 18 years to 31 years: standard ED practice, three enhanced screening strategies, and mass treatment. Main outcome measures were untreated gonorrhea or chlamydia cases and their sequelae, transmission to a partner, congenital outcomes, and cost to prevent a case. This analysis, from the perspective of the healthcare sector, included medical case costs expressed in US dollars (1999), discounted at an annual rate of 3%.

RESULTS

Mass treatment was the most cost-effective strategy among women and men. Of the screening strategies for women, universal screening combined with standard practice was the most cost-effective; it was used for treating 499 more cases of gonorrhea and chlamydia than was standard practice, saving $95.70 per case treated. Standard ED practice remained the most cost-effective strategy for men under a variety of circumstances.

CONCLUSION

The authors recommend urine ligase chain reaction screening for gonorrhea and chlamydia in women aged 18 years to 31 years in the ED, in conjunction with standard ED practice, to decrease the occurrence of the sequelae and costs associated with infection.

Social stigma and negative consequences: factors that influence college students' decisions to seek testing for sexually transmitted infections

College students often delay or avoid seeking testing for sexually transmitted infections (STIs), even if the services are readily available. We used in-depth, semistructured interviews to survey 41 college students aged 18 to 23 years about factors that influence decisions about STI testing. We grouped statements into 9 themes that represent influences on the decision. The most frequently mentioned factors were negative consequences of testing and perceived vulnerability to infection; other issues that influenced decision making included perceived benefits, perceived severity of diseases, public knowledge and opinion, social norms, provider characteristics, test-site characteristics, and personal considerations. Social stigmas and negative consequences appear to represent significant barriers to college students' being tested, which could increase the risk of spreading infections to others. Clinicians and health educators should raise students' awareness of the need for screening and should work to reduce the barriers to screening, including social stigmas and negative consequences.

Clinical aspects of diagnosis of gonorrhea and Chlamydia infection in an acute care setting

We found a 10.4% prevalence of unrecognized genital gonorrhea and Chlamydia infection among young adults of an urban emergency department. Intensified detection and treatment policies are needed to prevent continued transmission and complications of sexually transmitted infections.

Minority women with sexually transmitted diseases: sexual abuse and risk for pelvic inflammatory disease

Mexican American and African American women (N = 617) with a sexually transmitted disease (STD) underwent a targeted physical exam and questioning regarding sexual abuse, current genitourinary symptomatology, and pelvic inflammatory disease (PID) risk behaviors to determine the relationship between sexual abuse and risk for PID. Sexually abused women (n = 194) reported higher PID risk behaviors, including earlier coitus, more sex partners, higher STD recurrence, and a tendency toward delayed health-seeking behavior. They also reported more severe genitourinary symptomatology, confirmed by physical exam, and presumptive diagnoses of PID. These characteristics identify sexually abused women at high risk for PID. Because of its considerable impact on risk for PID, assessment for sexual abuse is essential in clinical management of women with STD and for diagnosis of PID.

[Delay in the diagnosis of cancer]

OBJECTIVE

A reduction in the time used to be able to diagnose an illness influences not only the well being of the patient but also the quality of the medical care. In this work, we have studied the amount of time needed to diagnose cancer.

MATERIAL AND METHOD

Descriptive methods have been used: average, median, mode and standard deviation in order to know how long it takes to diagnose and treat cancer. The data have been taken from a hospital register.

RESULTS

The longest time elapsed between the periods appears to be the one between the first symptoms and the date the diagnosis is made, which has been calculated to be 96 days on average. The remaining time periods studied showed a time lapse of about 26 days on median.

DISCUSSION

The median has been taken as the measurement chosen to assess these time periods, which have been notably reduced in the last decade.

CONCLUSIONS

The performance of the primary care doctor is of great importance, as he is normally the one who is faced with the precocious symptoms, as well as with the risk factors that persist in the patients. This doctor is therefore the one who can initiate both the early diagnosis and the medical education of the patients.

Opportunistic urine ligase chain reaction screening for sexually transmitted diseases in adolescents seeking care in an urban emergency department

STUDY OBJECTIVE

Neisseria gonorrhoeae and Chlamydia trachomatis are the most common bacterial sexually transmitted diseases (STDs) in sexually active youth and many infections are asymptomatic or unrecognized. This study used ligase chain reaction assays for determination of prevalence of gonococcal and chlamydial infections in adolescents seeking care at an urban emergency department.

METHODS

An unlinked prevalence study was performed with ligase chain reaction tests on voided urine specimens from a convenience sample of adolescents 14 years or older who sought care at the Children's Hospital of Alabama ED. Demographic data and data on care provided in the ED were determined from retrospective chart review of those patients whose urine specimens were tested.

RESULTS

Of 282 urine specimens screened, 13.5% (38) yielded positive findings on ligase chain reaction testing for either or both pathogens (20 [7%] positive for N gonorrhoeae, 23 [8%] positive for C trachomatis). In the context of acute care, gonorrhea or chlamydial infection was diagnosed in 5 (1.8%). STD prevalence did not vary significantly by age. Only 39% (15/38) of patients with infections detected by ligase chain reaction testing received potentially effective antibiotics as a result of their urgent care evaluation.

CONCLUSION

Many adolescents use the ED for nonurgent care and unsuspected STDs are often missed. Urine ligase chain reaction testing is a sensitive, noninvasive means of detecting STDs by which unsuspected adolescent STD cases can be detected in an ED setting.