STI Prevalence, Incidence, and Costs in the United States: New Estimates, New Approach

Dyadic Adjustment of Couples and State Anxiety in Patients Tested for Sexually Transmitted Infections

Background: While existing literature addresses the psychological impact of HIV, there is a notable gap in data regarding other sexually transmitted infections (STIs). This study aims to fill this gap by evaluating the association between STIs, the psychological profile of patients as measured by anxiety levels, and the impact on couple adaptability. Methods: A prospective investigation was conducted in Romania, from November 2021, including individuals with high suspicion of STI and healthy controls. Data collection comprised a questionnaire, the Dyadic Adjustment Scale (DAS), and State-Trait Anxiety Inventory (STAI Y-1). Statistical methods, including multivariate logistic and linear regressions, were used to carry out the analyses. Results: The participant cohort consisted of 441 individuals. STI participants exhibited consistently lower DAS scores, notably in dyadic adaptability (DA) (p = 0.031), dyadic satisfaction (DS) (p = 0.006), and affectional expression (AE) (p = 0.016). Multivariate logistic regression with adjustment for confounders confirmed a significant association between STIs and atypical DAS responses (2.56-fold increase). STAI T scores were significantly higher in the STI suspected group (p < 0.01), remaining robust after adjusting for confounders in a multiple linear regression model. Conclusions: Our prospectively designed study highlights the mental health repercussions associated with STIs. This is evident through the diminished DAS scores and heightened STAI Y-1 scores observed in individuals with suspected STIs.

Taking a Sexual History: Best Practices

Recognizing the holistic definitions of sexual health, health-care providers must approach sexual health history taking with sensitivity, inclusivity, and a trauma-informed perspective. Many versions of what a sexual history should look like exist but certain principles are commonly found. Education of health-care providers on sexual history taking can involve reviewing the components of the sexual history but should also include the importance of using nonstigmatizing language, having a patient-centered approach, and practicing trauma-informed and culturally sensitive care.

Increasing Chlamydia and Gonorrhea Testing for Adolescents in the Pediatric Emergency Department

OBJECTIVE

Adolescents who use the emergency department are more likely to engage in high-risk sexual activity and are at an increased risk of sexually transmitted infections. We aimed to increase testing for Chlamydia and gonorrhea from 12% to 50% among adolescents presenting to our pediatric emergency department with at-risk chief complaints over 12 months.

METHODS

Plan-Do-Study-Act cycles were initiated in July 2020. A multidisciplinary team reviewed preexisting data and developed interventions to increase Chlamydia and gonorrhea testing in teens with at-risk complaints, including genitourinary and behavioral health complaints, and females with abdominal pain. Two categories of interventions were implemented: education and electronic medical record optimization. Process measures were the proportion of patients with a documented sexual history and the proportion of patients tested with a documented confidential phone number. Secondary outcome measures included the weekly number of positive test results and the proportion of patients testing positive who were contacted to arrange treatment. Statistical process control charts were used to examine changes in measures over time.

RESULTS

Within 14 months of project initiation, the proportion of at-risk patients tested increased from 12% to 59%. Teen phone number documentation remained unchanged from 23%. Sexual history documentation remained unchanged from 46%. The number of positive test results increased from 1.8 to 3.4 per month, and the proportion of patients testing positive who were contacted to arrange treatment remained unchanged at 83%.

CONCLUSIONS

We surpassed our goal and increased the proportion of at-risk patients tested for Chlamydia and gonorrhea to 59%, sustained for 4 months from the last intervention.

Highly-Specific Single-Stranded Oligonucleotides and Functional Nanoprobes for Clinical Determination of Chlamydia Trachomatis and Neisseria Gonorrhoeae Infections

Early detection of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) is the key to controlling the spread of these bacterial infections. An important step in developing biosensors involves identifying reliable sensing probes against specific genetic targets for CT and NG. Here, the authors have designed single-stranded oligonucleotides (ssDNAs) targeting mutually conserved genetic regions of cryptic plasmid and chromosomal DNA of both CT and NG. The 5'- and 3'- ends of these ssDNAs are differentially functionalized with thiol groups and coupled with gold nanoparticles (AuNP) to develop absorbance-based assay. The AuNPs agglomerate selectively in the presence of its target DNA sequence and demonstrate a change in their surface plasmon resonance. The optimized assay is then used to detect both CT and NG DNA extracted from 60 anonymized clinical samples with a clinical sensitivity of ∼100%. The limit of detection of the assays are found to be 7 and 5 copies/µL for CT and NG respectively. Furthermore, it can successfully detect the DNA levels of these two bacteria without the need for DNA extraction and via a lateral flow-based platform. These assays thus hold the potential to be employed in clinics for rapid and efficient monitoring of sexually transmitted infections.

Improving Effective Chlamydia Screening for Women at Risk at a Rural Family Planning Clinic

Background: Chlamydia is the most common bacterial sexually transmitted infection (STI) in the United States, with an incidence of 1.7 million infections annually. It results in an estimated $691 million in lifetime medical costs. Objective: The objective of the project was to improve effective care for women at risk of chlamydia infection in a rural family planning clinic to 80% in 90 days. Methods: The Plan-Do-Study-Act process of quality improvement (QI) was implemented over four 2-week cycles. Qualitative and quantitative data were collected and analyzed iteratively and informed tests of change for each cycle. Results: Results indicated an improvement in effective care from a baseline of 42%-81%. Patient visit time decreased from 38 minutes at baseline to 23 minutes. Compared with pre-implementation, the number of positive chlamydia test results went from three to six, doubling the positivity rate, while the number of chlamydia tests billed increased by 32%. Conclusions: This project was successful in improving effective care. Implementing a standardized risk assessment decreased patient visit time. Implications for nursing: QI projects directed at meeting national standards for STI screening can be implemented in rural health clinics at low cost and with high impact.

Young, Black/African American, and Latino communities are left behind despite legislative efforts in California to reduce HIV/STI disparities

Objectives

Sexually transmitted infections (STI) have been on the rise in the United States with racial/ethnic minority groups, gay and bisexual men, and youth experiencing the highest STI and HIV infection rates. In 2022, California became the first state in the nation to pass legislation, Senate Bill 306 (SB 306), requiring health care plans to cover the costs of home test kits for STIs, including HIV. This study examines provisions within SB 306 and its potential to reduce STI and HIV disparities among key demographic groups and geographic regions within California.

Study design

Ecological cross-sectional study involving 58 California counties.

Methods

Descriptive statistics and choropleth maps compared HIV/STI prevalence rates, uninsured rates, demographic composition, and healthcare provider coverage across California counties. Three geographically weighted Poisson regression analyses were conducted to separately examine the association between proportion of uninsured and HIV, gonorrhea, and chlamydia prevalence rates.

Results

HIV/STI rates were significantly and positively associated with the proportion of uninsured residents in Central and Southern California counties. These counties had a higher proportion of demographic groups vulnerable to HIV/STI including a large Latino, Black/African American, and younger (age 15-24) population but had a lower rate of healthcare providers with prescription authority for home testing kits, which is a requirement under SB 306.

Conclusions

Cutting-edge solutions are needed to stem the rising tide of new STI and HIV infections. While SB 306 is novel and innovative in intent, its coverage gaps will increase disparities and inequities among historically underserved populations.

Cervical cancer screening in menopause: when is it safe to exit?

IMPORTANCE AND OBJECTIVE

Despite a decreasing incidence of cervical cancer in North America overall, disparities in screening and cervical cancer rates persist, especially in the postmenopausal age group.

METHODS

We reviewed the literature regarding cervical cancer screening considerations for postmenopausal persons, with a focus on cervical cancer in postmenopausal persons, existing guidelines, screening methods, and gaps in care.

DISCUSSION AND CONCLUSION

Postmenopausal persons are an important population at risk because age 65 years in the United States and up to 70 years in some parts of Canada is a milestone for screening cessation if the criteria are met. Unfortunately, inadequate screening is common, with most women 65 years or older discontinuing ( exiting ) screening despite not meeting the criteria to do so. Screening cessation recommendations are nuanced, and if not all criteria are met, screening should be continued until they are. Cervical cancer screening should be stopped at the recommended age if adequate screening has occurred or at any age if life expectancy is limited or the patient has had a hysterectomy in the absence of high-grade preinvasive cervical lesions or cervical cancer. Human papillomavirus infection, which is causally linked to almost all cervical cancer cases, can persist or reactivate from a prior infection or can be newly acquired from sexual contact. With more persons aging with a cervix in place, the potential for cervical cancer has increased, and higher cancer rates may be observed if recommended screening is not adhered to. We propose an algorithm based on current cervical cancer screening guidelines to aid providers in identifying whether exit criteria have been met. Until adequate screening has been confirmed, cervical cancer screening should continue.

Adherence to Sexually Transmitted Infection Screening in Pregnancy

Objective: Professional guidelines and state law require screening for sexually transmitted infections (STI) during pregnancy. Our objective was to evaluate adherence to these recommendations. Methods: This is a retrospective cohort study of patients initiating prenatal care before 20 weeks' gestation. Demographic characteristics and STI screening were abstracted from prenatal records. Tests of interest included initial syphilis, human immunodeficiency virus (HIV), hepatitis B, chlamydia, and gonorrhea tests, as well as repeat (third trimester) syphilis and HIV tests. All patients were eligible for initial screening. Patients were eligible for analysis of whether they received adherent repeat third trimester screening for syphilis (mandated by state law) and HIV (institutional protocol) if they delivered at or after 32 weeks' gestation. Adherent screening was defined as performance of all recommended screening. Results: Of 2370 patients, 1816 (76.6%) received adherent initial STI screening and 181 (7.8% of 2308 patients who delivered at or after 32 weeks' gestation) received adherent repeat third trimester STI screening. After adjusting for covariates, private insurance (adjusted odds ratio [aOR] 1.45, confidence interval [95% CI] 1.12-1.95) was associated with adherent initial screening, whereas being non-Hispanic Black or Hispanic were associated with lower odds of adherent initial screening. Factors associated with adherent repeat third trimester STI screening were younger age (aOR 0.93, 95% CI 0.90-0.97) and non-Hispanic Black race (aOR 3.24, 95% CI 1.94-5.42). Those with private insurance (aOR 0.10, 95% CI 0.06-0.15) were less likely to receive adherent repeat third trimester screening. Conclusion: STI screening rates remain suboptimal. Multiple disparities exist in performance both of initial and repeat third trimester screening.

Assessing knowledge, attitudes, and practices toward sexually transmitted infections among Baghdad undergraduate students for research-guided sexual health education

Background

Sexually transmitted infections are common and tend to cause a lot of public misconceptions. This study was conducted to identify knowledge gaps and negative attitudes toward sexually transmitted infections and infected individuals among undergraduate students and give recommendations accordingly for the development of more objective research-guided health campaigns and school sex education programs.

Method

A cross-sectional study was conducted between May 17, 2022 and June 2, 2022 using a self-administrated questionnaire containing 84 items related to sexually transmitted infections distributed online to Baghdad-based university students.

Result

The sample consisted of 823 respondents; 332 men and 491 women. Overall knowledge was moderate to high, with 628 individuals (76.3%) answering more than half the questions correctly. There was no difference according to gender or previous sexual experience, but knowledge increased by an average of 2.73 points (p < 0.001) when a participant knew a previously infected individual. Less than half identified systemic symptoms of STIs, and their knowledge of other HIV items was also poor. Most respondents (85.5%) agreed to the need for sex education during middle or high school and cited traditional barriers as the most critical barrier (64.8%); in comparison, those who did not agree on its need cited the sensitivity of the subject (40.3%) or religious barriers (20.2%) as more important.

Conclusion

Specific knowledge gaps exist for HIV and non-HIV sexually transmitted infections; these should be addressed during sex education, focusing on specific high-risk groups. Negative attitudes and stigmatizing behavior should be addressed as well by increasing focused STI knowledge.

Educational interventions to improve women's preventive behavior of sexually transmitted infections (STIs): study protocol for a randomized controlled trial

BACKGROUND

Sexually active women aged 18 to 48 are within the population at risk for acquiring sexually transmitted infections. Some STIs can cause serious complications in women's reproductive health. Accordingly, this practical randomized trial aims to evaluate the effect of an interventional education based on the ISD model on improving preventive behaviors for Iranian women.

METHODS

Women aged 18-48 years that refer to Tehran Municipality Health Houses will be invited to join the study. Recruitment will continue until a sample of 150 women participants. The study will be conducted using a mixed-methods protocol in three phases. In the first phase, women's educational and learning needs about STIs will be identified using a qualitative approach. In the second phase, the results from the qualitative approach will be used to design a training program based on an ISD model. The educational intervention will be performed in the third phase. Participants will be randomly allocated into two groups: (1) the intervention group and (2) the control group. Data will be collected using STI Four-Scale of Preventive Behaviors at baseline, immediately, 1-month, and 3-month follow-up assessments. The impact of the intervention on the promotion of preventive behaviors from STIs will then be evaluated.

DISCUSSION

This study provides an educational program for empowering and promoting behaviors that prevent STIs. If the designed interventions in the present study are effective, it has practical potential to be generalized for Iranian women at risk of STIs.

TRIAL REGISTRATION

ClinicalTrials.gov IRCT20200602047638N1 . Registered on 22 May 2021 with the IRCTID, V1.0.

Cotesting for Human Immunodeficiency Virus and Sexually Transmitted Infections in the Emergency Department

BACKGROUND

The Centers for Disease Control and Prevention (CDC) and US Preventive Services Task Force (USPSTF) guidelines recommend screening for human immunodeficiency virus (HIV) in patients aged 15 to 65 years, as well as those at increased risk. Patients screened in the emergency department (ED) for gonorrhea (GC) and/or chlamydia represent an increased-risk population. Our aim was to assess compliance with CDC and USPSTF guidelines for HIV testing in a national sample of EDs.

METHODS

We examined data from the 2010 to 2018 Nationwide Emergency Department Sample, which can be used to create national estimates of ED care to query tests for GC, chlamydia, HIV, and syphilis testing. Weighted proportions and 95% confidence intervals (CIs) were reported, and Rao-Scott χ 2 tests were used.

RESULTS

We identified 13,443,831 (weighted n = 3,094,214) high-risk encounters in which GC/chlamydia testing was performed. HIV screening was performed in 3.9% (95% CI, 3.4-4.3) of such visits, and syphilis testing was performed in 2.9% (95% CI, 2.7-3.2). Only 1.5% of patients with increased risk encounters received both HIV and syphilis cotesting.

CONCLUSIONS

Despite CDC and USPSTF recommendations for HIV and syphilis screening in patients undergoing STI evaluation, only a small proportion of patients are being tested. Further studies exploring the barriers to HIV screening in patients undergoing STI assessment in the ED may help inform future projects aimed at increasing guidance compliance.

Variation in Patterns of Racial and Ethnic Disparities in Primary and Secondary Syphilis Diagnosis Rates Among Heterosexually Active Women by Region and Age Group in the United States

BACKGROUND

Syphilis rates have increased substantially over the past decade. Women are an important population because of negative sequalae and adverse maternal outcomes including congenital syphilis. We assessed whether racial and ethnic disparities in primary and secondary (P&S) syphilis among heterosexually active women differ by region and age group.

METHODS

We synthesized 4 national surveys to estimate numbers of heterosexually active women in the United States from 2014 to 2018 by region, race and ethnicity, and age group (18-24, 25-29, 30-44, and ≥45 years). We calculated annual P&S syphilis diagnosis rates, assessing disparities with rate differences and rate ratios comparing White, Hispanic, and Black heterosexually active women.

RESULTS

Nationally, annual rates were 6.42 and 2.20 times as high among Black and Hispanic than among White heterosexually active women (10.99, 3.77, and 1.71 per 100,000, respectively). Younger women experienced a disproportionate burden of P&S syphilis and the highest disparities. Regionally, the Northeast had the highest Black-White and Hispanic-White disparities using a relative disparity measure (relative rate), and the West had the highest disparities using an absolute disparity measure (rate difference).

CONCLUSIONS

To meet the racial and ethnic disparity goals of the Sexually Transmitted Infections National Strategic Plan, tailored local interventions that address the social and structural factors associated with disparities are needed for different age groups.

Direct and Indirect Cost Savings From Sexually Transmitted Infection Testing, Treatment, and Counseling Among Foster Youth

BACKGROUND

Sexually transmitted infection (STI) prevention programs can decrease the economic burden of STIs. Foster youth have higher rates of STIs compared with their peers; however, information on direct costs and indirect costs averted by STI testing, treatment, and counseling among foster youth is lacking.

METHODS

This study used data from a comprehensive medical center for foster youth over a 3-year study period from July 2017 to June 2020. Direct and indirect costs averted by testing and treatment of chlamydia, gonorrhea, and syphilis, as well as HIV testing and counseling, were calculated based on formulas developed by the Centers for Disease Control and Prevention and adjusted for inflation.

RESULTS

Among the 316 youth who received medical services during this time, 206 were sexually active and tested for STIs and/or HIV. Among 121 positive STI test results, 64.5% (n = 78) were positive for chlamydia, 30.6% (n = 37) were positive for gonorrhea, and 5.0% (n = 6) were positive for syphilis. Treatment was provided to all. Overall, $60,049.68 in direct medical costs and $73,956.36 in indirect costs were averted.

CONCLUSIONS

Given the rates of STIs among this population and the economic benefit of STI treatment, it is imperative to continue to provide intensive and comprehensive, individualized sexual health care for foster youth. Traditional care management may miss the opportunity to prevent, identify, and treat STIs that comprehensive wraparound care can achieve. This study suggests that comprehensive wraparound care is a cost-effective way to identify, treat, and prevent STIs among foster youth.

Trends in Sexually Transmitted Infections in United States Ambulatory Care Clinics from 2005-2016

We examined the prevalence trends of non-human immunodeficiency virus (HIV) sexually transmitted infections (STI) and associated patient characteristics in U.S. ambulatory-care settings from 2005-2016. We conducted a retrospective repeated cross-sectional analysis using data from the National Ambulatory Medical Care Survey (NAMCS) for individuals aged 15-64 with a non-HIV STI-related visit. Data were combined into three periods (2005-2008, 2009-2012, and 2013-2016) to obtain reliable estimates. Logistic regression was used for analysis. A total of 19.5 million weighted, non-HIV STI-related ambulatory visits from 2005-2016 were identified. STI-related visits per 100,000 ambulatory care visits increased significantly over the study period: 206 (95% CI = 153-259), 343 (95% CI = 279-407), and 361 (95% CI = 277-446) in 2005-2008, 2009-2012, and 2013-2016, respectively (P_trend = 0.003). These increases were mainly driven by increases in HPV-related visits (56 to 163 per 100,000 visits) from 2005-2008 to 2009-2012, followed by syphilis- or gonorrhea-related visits (30 to 67 per 100,000 visits) from 2009-2012 to 2013-2016. Higher odds of having STI-related visit were associated with younger age (aged 15-24: aOR = 4.45; 95% CI = 3.19-6.20 and aged 25-44: aOR = 3.59; 95% CI = 2.71-4.77) vs. 45-64-year-olds, Black race (aOR = 2.41; 95% CI = 1.78-3.25) vs. White, and HIV diagnosis (aOR = 10.60; 95% CI = 5.50-20.27) vs. no HIV diagnosis. STI-related office visits increased by over 75% from 2005-2016, and were largely driven by HPV-related STIs and syphilis- or gonorrhea-related STIs.

Maternal HPV Infection: Effects on Pregnancy Outcome

The human papilloma virus (HPV) infection, caused by a ubiquitous virus typically transmitted through the direct contact of infected organs, either through the skin or mucosa, is the most common sexually transmitted infection, placing young women at a high risk of contracting it. Although the vast majority of cases spontaneously clear within 1-2 years, persistent HPV infection remains a serious concern, as it has repeatedly been linked to the development of multiple malignancies, including cervical, anogenital, and oropharyngeal cancers. Additionally, more recent data suggest a harmful effect of HPV infection on pregnancy. As the maternal hormonal environment and immune system undergo significant changes during pregnancy, the persistence of HPV is arguably favored. Various studies have reported an increased risk of adverse pregnancy outcomes among HPV-positive women, with the clinical impact encompassing a range of conditions, including preterm birth, miscarriage, pregnancy-induced hypertensive disorders (PIHD), intrauterine growth restriction (IUGR), low birth weight, the premature rupture of membranes (PROM), and fetal death. Therefore, understanding the mechanisms employed by HPV that negatively impact pregnancy and assessing potential approaches to counteract them would be of interest in the quest to optimize pregnancy outcomes and improve child survival and health.