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

Sexual exposure and sexual behaviour in the interval between gonorrhoea treatment and test of cure: a cross-sectional cohort study

OBJECTIVES

We explored sexual contact in the interval between the treatment for gonorrhoea and attending for a test of cure (ToC) and identified factors associated with sexual contact in this period.

METHODS

Multivariable analysis of demographic, behavioural and clinical data with self-reported sexual contact prior to attending for a gonorrhoea ToC evaluation among participants recruited into the 'Gentamicin for the Treatment of Gonorrhoea' trial in England, between October 2014 and November 2016. Associations with sexual contact were expressed as prevalence ratios (PR) and their corresponding 95% CI.

RESULTS

The median time to ToC was 15 days (interquartile range 14-20 days). 197/540 (37%) participants reported sexual contact in the time between treatment and ToC. Of these, 173/197 (88%) participants reported inconsistent condom use, including with previous partners (133/197 (68%)). A history of gonorrhoea (adjusted PR (aPR) 1.32 (1.03 to 1.69)) or syphilis (aPR 1.19 (1.08 to 1.32)), being in regular (aPR 1.71 (1.41 to 2.09)) sexual relationships, high number of partners in the last 3 months (aPR 1.77 (1.25 to 2.51))-'more than 5 partners' vs '0 to 1 partner', and attending for a ToC more than 14 days after treatment (aPR 1.40 (1.08 to 1. 81)) were associated with reporting sexual contact before the ToC appointment. However, age (aPR (1.00 (0.99 to 1.01)) and presenting with specific symptoms at baseline (aPR 1.17 (0.95 to 1.44)) were not associated with sexual contact by the ToC attendance.

CONCLUSION

Sexual activity after receiving treatment for gonorrhoea and prior to a ToC evaluation was common. This was associated with previous infection history and specific behavioural characteristics. Knowledge of these factors can help guide safe sex counselling at the time of treatment.

Study protocol of the iMPaCT project: a longitudinal cohort study assessing psychological determinants, sexual behaviour and chlamydia (re)infections in heterosexual STI clinic visitors

Background

Chlamydia trachomatis (chlamydia), the most commonly reported sexually transmitted infection (STI) in the Netherlands, can lead to severe reproductive complications. Reasons for the sustained chlamydia prevalence in young individuals, even in countries with chlamydia screening programs, might be the asymptomatic nature of chlamydia infections, and high reinfection rates after treatment. When individuals are unaware of their infection, preventive behaviour or health-care seeking behaviour mostly depends on psychological determinants, such as risk perception. Furthermore, behaviour change after a diagnosis might be vital to reduce reinfection rates. This makes the incorporation of psychological determinants and behaviour change in mathematical models estimating the impact of interventions on chlamydia transmission especially important. Therefore, quantitative real-life data to inform these models is needed.

Methods

A longitudinal cohort study will be conducted to explore the link between psychological and behavioural determinants and chlamydia (re)infection among heterosexual STI clinic visitors aged 18–24 years. Participants will be recruited at the STI clinics of the public health services of Amsterdam, Hollands Noorden, Kennemerland, and Twente. Participants are enrolled for a year, and questionnaires are administrated at four time points: baseline (before an STI consultation), three-week, six-month and at one-year follow-up. To be able to link psychological and behavioural determinants to (re)infections, participants will be tested for chlamydia at enrolment and at six-month follow-up. Data from the longitudinal cohort study will be used to develop mathematical models for curable STI incorporating these determinants to be able to better estimate the impact of interventions.

Discussion

This study will provide insights into the link between psychological and behavioural determinants, including short-term and long-term changes after diagnosis, and chlamydia (re)infections. Our mathematical model, informed by data from the longitudinal cohort study, will be able to estimate the impact of interventions on chlamydia prevalence, and identify and prioritise successful interventions for the future. These interventions could be implemented at STI clinics tailored to psychological and behavioural characteristics of individuals.

Trial registration

Dutch Trial Register NTR-6307. Retrospectively registered 11-nov-2016.

Repeat testing for chlamydia trachomatis, a "safe approach" to unsafe sex? a qualitative exploration among youth in Stockholm

Background

Chlamydia trachomatis testing is offered to youth in Sweden, through a network of Youth Health Clinics, free at the point of care, in an attempt to bring down the prevalence and incidence of the infection. Nevertheless, infections rates have continued to rise during the past two decades and re-testing rates among youth for Chlamydia trachomatis has been reported to be high in Stockholm County. A few literature reports suggest that testing for sexually transmitted infections and the test result itself can have an undesirable impact on the sexual behaviour for the individual, i.e. increase sexual risk-taking.

Methods

This qualitative study aimed to explore the motives for repeated testing for Chlamydia trachomatis among youth using the services of the Youth Health Clinics in Stockholm, and how testing affects their subsequent risk-taking. We interviewed 15 repeat testers aging 18–22 years.

Results

Our main findings were that the fear of social stigma related to infecting a peer was a major driver of the re-testing process. The repetitive testing process, the test result, and the encounter with personnel did not decrease sexual risk-taking among this group.

Conclusions

While testing and treatment services are an important part of Chlamydia trachomatis prevention it must not take the focus away from primary prevention strategies. Testing should be encouraged, but not to the exclusion of risk reduction measures. The testing services must be complemented with stronger emphasis on safe sex, especially for those who attend the clinics repeatedly, otherwise the easy accessible testing services risk counteracting its own purpose. Future research should focus on developing and evaluating youth appropriate interventions to increase condom use, taking into consideration factors which youth perceive as important to drive this behaviour change.

Electronic supplementary material

The online version of this article (10.1186/s12913-017-2681-6) contains supplementary material, which is available to authorized users.

Racial/Ethnic Differences in Young Women's Health-Promoting Strategies to Reduce Vulnerability to Sexually Transmitted Infections

PURPOSE

Young women of color in the United States are disproportionately affected by sexually transmitted infections (STIs). We characterize the protective behaviors used by young women to reduce their vulnerability to STI acquisition and examine how STI prevention strategies differ by race/ethnicity.

METHODS

From 2015 to 2016, women aged 13-24 years presenting to five Northern California family planning clinics were surveyed about their STI prevention strategies. The chi-squared tests and multivariable logistic regression identified associations between race/ethnicity and use of sexual health-promoting strategies.

RESULTS

Among 790 women, the most common strategies included condom use (67%), asking partners about STIs (47%), limiting sexual partners (35%), frequent STI screening (35%), and asking partners about other sexual partners (33%). Black, Hispanic, and Asian women had decreased odds of utilizing strategies before intercourse compared with white women (adjusted odds ratio [aOR]black: .25, confidence interval [.14-.47]; aORHispanic: .36, CI [.20-.65]; aORAsian: .44, CI [.23-.84]). Black women had decreased odds of using strategies requiring partner involvement (aORblack: .35, CI [.13-.92]). White women were more likely to report that providers discussed condoms (aOR: 2.53, CI [1.04-6.15]) and talked to partners about STIs (aOR: 2.56, CI [1.52-4.32]) compared with nonwhite women. Black and Hispanic women were more likely to feel very uncomfortable discussing lifetime sexual partners (aORblack: 4.26, CI [1.36-13.30] and aORHispanic: 5.35, CI [1.79-15.99]) and condom use (aORblack: 3.05, CI [1.14-8.15] and aORHispanic: 2.86, CI [1.11-7.35]) with providers.

CONCLUSIONS

Young women use diverse strategies to prevent STIs that vary by race/ethnicity. Providers can use these findings to improve sexual health counseling and promote equitable education and services.

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.

Chlamydia test results were associated with sexual risk behavior change among participants of the Chlamydia screening implementation in The Netherlands

OBJECTIVE

To examine the effect of a laboratory-confirmed Chlamydia trachomatis (Ct) test result on subsequent sexual risk behavior in a large population-based screening program.

METHODS

The study population consisted of 16- to 29-year-old participants of the Chlamydia Screening Implementation who completed Ct testing and questionnaires in 2 or more rounds. The influence of a Ct test result on sexual behavior was analyzed by generalized estimating equation models, in which the Ct test result of the previous round was the independent variable and 1 of the 8 sexual risk behavior indicators was the dependent variable, adjusted for covariates.

RESULTS

Of 48,910 Chlamydia Screening Implementation participants with completed questionnaires and test results, 14.1% (n = 6802) and 2.6% (n = 1272) completed 2 and 3 rounds, respectively, and were included in this study. Analysis showed that Ct positives less often reported to "never" use condoms with a casual partner (%change pretest/posttest = -5.7% [-10.3 to -0.9]), whereas Ct negatives less often reported to "always" use condoms with a casual partner (-4.6% [-6.4 to -2.8]; odds ratio [95% confidence interval], 1.75 [1.09 to 2.80]). Ct positives also had more sexual partners in the subsequent round than did participants with a Ct-negative test result (relative risk [95% confidence interval], 1.14 [1.01 to 1.29]).

CONCLUSIONS

Ct test results were associated with subsequent sexual risk behavior. In general, Ct positives were more likely to change their behavior after a Ct test result in a more positive and protective direction than Ct negatives, who were more likely to change their behavior toward more risky behavior. Effects over time after a Ct test should be investigated further, especially in the Ct negatives.

An application of propensity score weighting to quantify the causal effect of rectal sexually transmitted infections on incident HIV among men who have sex with men

Background

Exploring causal associations in HIV research requires careful consideration of numerous epidemiologic limitations. First, a primary cause of HIV, unprotected anal intercourse (UAI), is time-varying and, if it is also associated with an exposure of interest, may be on a confounding path. Second, HIV is a rare outcome, even in high-risk populations. Finally, for most causal, non-preventive exposures, a randomized trial is impossible. In order to address these limitations and provide a practical illustration of efficient statistical control via propensity-score weighting, we examine the causal association between rectal STI and HIV acquisition in the InvolveMENt study, a cohort of Atlanta-area men who have sex with men (MSM). We hypothesized that, after controlling for potentially confounding behavioral and demographic factors, the significant STI-HIV association would attenuate, but yield an estimate of the causal effect.

Methods

The exposure of interest was incident rectal gonorrhea or chlamydia infection; the outcome was incident HIV infection. To adjust for behavioral confounding, while accounting for limited HIV infections, we used an inverse probability of treatment weighted (IPTW) Cox proportional hazards (PH) model for incident HIV. Weights were derived from propensity score modeling of the probability of incident rectal STI as a function of potential confounders, including UAI in the interval of rectal STI acquisition/censoring.

Results

Of 556 HIV-negative MSM at baseline, 552 (99%) men were included in this analysis. 79 men were diagnosed with an incident rectal STI and 26 with HIV. 6 HIV-infected men were previously diagnosed with a rectal STI. In unadjusted analysis, incident rectal STI was significantly associated with subsequent incident HIV (HR (95%CI): 3.6 (1.4-9.2)). In the final weighted and adjusted model, the association was attenuated and more precise (HR (95% CI): 2.7 (1.2-6.4)).

Conclusions

We found that, controlling for time-varying risk behaviors and time-invariant demographic factors, diagnosis with HIV was significantly associated with prior diagnosis of rectal CT or GC. Our analysis lends support to the causal effect of incident rectal STI on HIV diagnosis and provides a framework for similar analyses of HIV incidence.

Electronic supplementary material

The online version of this article (doi:10.1186/s12874-015-0017-y) contains supplementary material, which is available to authorized users.

Improving sexually transmitted infection results notification via mobile phone technology

PURPOSE

To improve adolescent notification of positive sexually transmitted infection (STI) tests using mobile phone technology and STI information cards.

METHODS

A randomized intervention among 14- to 21-year olds in a pediatric emergency department (PED). A 2 × 3 factorial design with replication was used to evaluate the effectiveness of six combinations of two factors on the proportion of STI-positive adolescents notified within 7 days of testing. Independent factors included method of notification (call, text message, or call + text message) and provision of an STI information card with or without a phone number to obtain results. Covariates for logistic regression included age, empiric STI treatment, days until first attempted notification, and documentation of confidential phone number.

RESULTS

Approximately half of the 383 females and 201 males enrolled were ≥18 years of age. Texting only or type of card was not significantly associated with patient notification rates, and there was no significant interaction between card and notification method. For females, successful notification was significantly greater for call + text message (odds ratio, 3.2; 95% confidence interval, 1.4-6.9), and documenting a confidential phone number was independently associated with successful notification (odds ratio, 3.6; 95% confidence interval, 1.7-7.5). We found no significant predictors of successful notification for males. Of patients with a documented confidential phone number who received a call + text message, 94% of females and 83% of males were successfully notified.

CONCLUSIONS

Obtaining a confidential phone number and using call + text message improved STI notification rates among female but not male adolescents in a pediatric emergency department.

Detecting re-infection in patients after an initial diagnosis of gonorrhoea: is routine recall for re-screening useful?

To assess the outcome of routine sexually transmitted infection re-screening after a three-month interval in unselected patients diagnosed with gonorrhoea, we sought to assess whether this active approach would result in an increase in the number of people attending clinic and subsequently diagnosed with gonorrhoea re-infection, compared with normal re-presentation rates. A recall group of patients were invited for re-screening three months after their initial diagnosis of gonorrhoea. Permission was sought to send a reminder two weeks prior to their scheduled recall appointment. Comparisons were made with a historical control group of patients with gonorrhoea in the absence of any formal recall. Of the 242 patients in the intervention arm, 96 (40%) re-attended within six months, and 15 (6%) tested gonorrhoea positive. Two hundred and two patients were assessed in the control group, of whom 45 (22%) re-attended within six months, and 13 (6%) tested gonorrhoea positive. Women were more likely than men to re-attend following active recall, but they were not at higher risk of re-attending while re-infected with gonorrhoea. Active recall following a gonorrhoea diagnosis significantly increases re-attendance rates for repeat screening but did not result in an increased number of subsequent gonorrhoea diagnoses.

Differences in correlates of condom use between young adults and adults attending sexually transmitted infection clinics

Despite developmental differences between young adults and adults, studies of condom use have not typically considered young adults as a distinct age group. This study sought to examine how condom use and its correlates differed between high-risk young adults and adults. Sexually transmitted infection (STI) clinic patients (n = 763) reported STI history, contraception, negative condom attitudes, fear of partner reaction to condom use and risky behaviours. Past 3-month condom use was examined as unprotected vaginal sex (UVS) acts, proportional condom use and consistent condom use. Regression models tested associations of age group and potential correlates with each condom use outcome. Interaction models tested whether associations differed by age group. Proportional condom use was greater in young adults than adults (mean 0.55 vs. 0.47); UVS and consistent condom use were similar between age groups. Young adults with a recent STI reported less condom use, whereas for older adults, a distant STI was associated with less condom use, compared to others in their age groups. Negative condom attitudes were more strongly linked to UVS acts for younger versus older adults. STI prevention efforts for younger adults may be improved by intensifying counselling about condom use immediately following STI diagnosis and targeting negative condom attitudes.

Associations of a sexually transmitted disease diagnosis during a relationship with condom use and psychosocial outcomes: (short) windows of opportunity

Few studies have examined whether and how receiving an sexually transmitted disease (STD) diagnosis while in a romantic relationship relates to condom use and psychosocial sexual outcomes. Using dyadic data, we examined associations of a personal or a partner's STD diagnosis during a relationship with condom use, monogamy intentions, condom intentions and attitudes, and STD susceptibility and communication. Because beliefs about how the STD was acquired may shape associations with behavior and cognitions, gender and suspecting that one's partner had other sexual partners (i.e., partner concurrency) were examined as moderators. Participants were 592 individuals in 296 couples expecting a baby; 108 individuals had been diagnosed with an STD during the relationship. Personal STD diagnosis was unrelated to outcomes or was associated with increased risk. A partner's diagnosis related to more positive condom intentions and attitudes. Among men who suspected concurrency, both a personal and a partner's STD diagnosis were associated with less condom use. Receiving the STD diagnosis during pregnancy was associated with greater susceptibility and marginally greater condom use. Results suggest potential benefits of enhancing communication and encouraging joint risk reduction counseling among couples, engaging men more fully in preventive efforts, and capitalizing on the short window during which risk reduction occurs.

Long term effects of community-based STI screening and mass media HIV prevention messages on sexual risk behaviors of African American adolescents

We examined the long-term effects of two interventions designed to reduce sexual risk behavior among African American adolescents. African American adolescents (N = 1383, ages 14-17) were recruited from community-based organizations over a period of 16 months in two northeastern and two southeastern mid-sized U.S. cities with high rates of sexually transmitted infection (STI). Participants were screened for three STIs (gonorrhea, chlamydia, and trichomoniasis) and completed an audio computer-assisted attitude, intention, and behavior self-interview. Youth who tested positive for an STI (8.3%) received treatment and risk reduction counseling. In addition, television and radio HIV-prevention messages were delivered during the recruitment period and 18 months of follow-up in one randomly selected city in each region. Analyses determined effects of the media program for those receiving a positive versus negative STI test result on number of sexual partners and occurrence of unprotected sex. Adolescents who tested STI-positive reduced their number of vaginal sex partners and the probability of unprotected sex over the first 6 months. However, in the absence of the mass media program, adolescents returned to their previously high levels of sexual risk behavior after 6 months. Adolescents who tested STI-positive and received the mass media program showed more stable reductions in unprotected sex. Community-based STI treatment and counseling can achieve significant, but short-lived reductions in sexual risk behavior among STI-positive youth. A culturally sensitive mass media program has the potential to achieve more stable reductions in sexual risk behavior and can help to optimize the effects of community-based STI screening.

Integration of five health behaviour models: common strengths and unique contributions to understanding condom use

The purpose of this research was to select from the health belief model (HBM), theories of reasoned action (TRA) and planned behaviour (TPB), information-motivation-behavioural skills model (IMB) and social cognitive theory (SCT) the strongest longitudinal predictors of women's condom use and to combine these constructs into a single integrated model of condom use. The integrated model was evaluated for prediction of condom use among young women who had steady versus casual partners. At Time 1, all constructs of the five models and condom use were assessed in an initial and a replication sample (n = 193, n = 161). Condom use reassessed 8 weeks later (Time 2) served as the main outcome. Information from IMB, perceived susceptibility, benefits, and barriers from HBM, self-efficacy and self-evaluative expectancies from SCT, and partner norm and attitudes from TPB served as indirect or direct predictors of condom use. All paths replicated across samples. Direct predictors of behaviour varied with relationship status: self-efficacy significantly predicted condom use for women with casual partners, while attitude and partner norm predicted for those with steady partners. Integrated psychosocial models, rich in constructs and relationships drawn from multiple theories of behaviour, may provide a more complete characterisation of health protective behaviour.

The impact of community-based sexually transmitted infection screening results on sexual risk behaviors of African American adolescents

PURPOSE

To examine the effect of a community-based sexually transmitted infection (STI) screening program on sexual risk behavior among African American adolescents. We hypothesized that adolescents testing positive for an STI and receiving post-test counseling would reduce risky sexual practices, whereas STI-negative adolescents would show little or no change in protective sexual behavior after screening.

METHODS

From August 2006 to January 2008, we recruited 636 sexually active African American adolescents (age, 14-17) from community-based organizations in two mid-sized U.S. cities with high STI prevalence. Participants were screened for three STIs (gonorrhea, chlamydia, and trichomoniasis) and completed an audio computer-assisted self-interview. Youth who tested positive for an STI (6.6%) received treatment and counseling. Youth testing negative received no further intervention. Approximately 85% of participants completed 3- and 6-month follow-up assessments. Generalized estimating equations determined the effects of STI screening on adolescents' number of sexual partners and occurrence of unprotected sex.

RESULTS

Adolescents who tested positive for an STI reduced their number of vaginal and oral sex partners and the probability of unprotected sex. STI-negative adolescents demonstrated no change for numbers of partners or unprotected sex.

CONCLUSIONS

Community-based STI screening can help to reduce sexual risk behavior in youth who test positive for STIs. Alternative approaches will be needed to reduce risk behavior in youth who test negative but who are nevertheless at risk for acquiring an STI.

Type of contraception method used at last intercourse and associations with health risk behaviors among US adolescents

BACKGROUND

This study was conducted to examine associations with contraception methods used at last sexual intercourse among US adolescents.

STUDY DESIGN

Data consisted of sexually active adolescents (9th-12th grade, weighted n=24,638) from the 1999-2007 Youth Risk Behavior Surveillance System (YRBSS). We performed multinomial multivariable logistic regression analyses with condom users at last sexual intercourse as the reference group.

RESULTS

Males who used alcohol, cigarettes, marijuana and cocaine were more likely to use no method/unsure of method (OR=2.4, CI=1.7-3.4) or rely on withdrawal (OR=2.6, CI=1.5-4.3). Females with six or more sexual partners were more likely to rely on withdrawal (OR=2.9, CI=2.1-3.9) or contraception methods that offer no STI protection [i.e., birth control pills: OR=1.9, CI=1.4-2.5; and depot medroxyprogesterone acetate (DMPA, marketed as Depo-Provera): OR=2.6, CI=1.6-4.2]. Earlier age of sexual debut was also associated with nonuse.

CONCLUSION

Prevention efforts should focus on at-risk adolescents including substance-using males, females with six or more sexual partners, and those who initiate sexual intercourse at an early age.

Characteristics associated with sex after periods of abstinence among sexually experienced young women

CONTEXT

Adolescent pregnancy prevention is difficult because adolescent sex is intermittent. Understanding why sexually experienced adolescents have sex after a period of abstinence will help clinicians to tailor counseling.

METHODS

For up to 4.5 years between 1999 and 2006, a sample of 354 adolescent women recruited at urban primary care clinics were interviewed and tested for STDs every three months, and were asked to complete three months of daily diaries twice a year. Survival analyses were used to estimate associations between intrapersonal, relationship and STD-related characteristics and the risk of ending an abstinence period with sex.

RESULTS

Participants reported 9,236 abstinence periods, which averaged 31 days. The risk that an abstinence period ended with sex increased steeply for periods of fewer than 17 days (short), rose less steeply for 17-39-day (intermediate) periods and was fairly steady for longer periods. For short periods, the risk increased with age, sexual interest, positive mood, partner support, relationship quality and history of STD diagnosis more than three months ago (hazard ratios, 1.02-1.2); it decreased as negative mood increased (0.98) and was reduced among adolescents with a recent STD diagnosis (0.9). For intermediate periods, the association with a recent STD diagnosis became positive (1.4). For long periods, sex was associated only with age, sexual interest and relationship quality.

CONCLUSIONS

To provide targeted and timely sexual health counseling, clinicians may want to ask adolescents not only whether they are sexually active but also when they last had sex.

Point-of-care testing for sexually transmitted infections increases awareness and short-term abstinence in adolescent women

PURPOSE

To evaluate the effect of point-of-care (POC) testing for sexually transmitted infections (STIs) on reported awareness of test results and STI risk-reduction behaviors in adolescents.

METHODS

Adolescent and young adult women aged 14-21 years were recruited from the Emergency Department or Teen Health Clinic for this longitudinal study and were tested for STIs. Baseline demographics, risk behaviors, treatment, POC tests (wet mount and rapid antigen tests for Trichomonas vaginalis), and other STI test results (available 24-48 hours postvisit) were measured. These were compared to subject's report of test results, abstinence, partner discussion, and partner testing during a postvisit telephone contact.

RESULTS

Of 294 subjects, 155 (53%) were contacted: 65 (42%) had a positive STI test result; 28 (43%) were POC positive; and 52 (33.5%) believed their STI results were positive. A positive POC test result increased the proportion of subjects aware of being positive for an STI (89 vs 21%, p < .01). Postvisit, 62% reported abstinence, 82% discussed testing with her partner, and 48% reported partner testing. Predictors of abstinence included a positive POC test result (adjusted odds ratio (AOR) = 4.6, confidence interval (CI) = 1.5-13.6, prior abstinence of >14 days (AOR = 3.9, CI = 1.7-9.0), and black race (AOR = 3.5, CI = 1.2-9.7). Women who believed their STI results were positive were more likely to report partner discussion (odds ratio [OR] = 3.0, CI = 1.0-8.8) and partner testing (OR = 5.1, CI = 2.4-11.2).

CONCLUSIONS

Awareness of STI results increases with POC testing. Effective communication of results can increase patient understanding and compliance with risk reduction strategies, which may affect the STI epidemic.

Multilevel predictors of inconsistent condom use among adolescent mothers

OBJECTIVES

We used Bronfenbrenner's ecological systems theory to identify factors that predicted never or sometimes using condoms in a multiethnic cohort of adolescent mothers.

METHODS

We interviewed adolescent mothers within 48 hours of delivery and surveyed them 6 and 12 months after delivery (n = 636). We used multinomial logistic regression to identify individual-, dyad-, family-, and peer and community-level factors associated with never or sometimes using versus always using condoms during intercourse at 12 months postpartum.

RESULTS

Pregnancy status, partner refusal to use condoms, intimate partner violence, and race/ethnicity predicted both never and sometimes using condoms. Condom use 6 months earlier and church attendance also predicted never using condoms, whereas maternal monitoring was an additional predictor for sometimes using condoms.

CONCLUSIONS

Overlapping yet distinct risk profiles predicted never or sometimes using versus always using condoms. Factors from multiple levels of influence affected the condom use behaviors of adolescent mothers indicating that multilevel interventions are needed to promote safer sexual practices among these young women.

Differences in HIV-related knowledge, attitudes, and behavior among psychiatric outpatients with and without a history of a sexually transmitted infection

HIV infection among the mentally ill is estimated to be at least eight times the prevalence in the general population. Psychiatric patients may also be disproportionately vulnerable to other sexually transmitted infections (STIs), but this has not been well studied. We sought to characterize the prevalence and correlates of STIs in a sample of psychiatric outpatients (N=464). Over one-third of the sample (38%) reported a lifetime history of one or more STIs. Multivariate analyses showed that, relative to those without an STI history, patients with a lifetime STI history were more knowledgeable about HIV, expressed stronger intentions to use condoms, and perceived themselves to be at greater risk for HIV. However, those with a past STI were also more likely to report sex with multiple partners and reported more frequent unprotected sex in the past 3 months. Treatment for an STI may increase HIV knowledge and risk reduction motivation, but does not necessarily lead to changes in sexual risk behavior among psychiatric patients. Findings highlight the need for STI/ HIV risk reduction interventions in psychiatric settings, particularly for patients with high-risk profiles.

Sexual behaviors after universal screening of sexually transmitted infections in healthy young women

OBJECTIVE

To prospectively study the relationship between diagnosis of sexually transmitted infections (STIs) at entry to U.S. Marines recruit training and subsequent sexual behaviors during vacation.

METHODS

Of all women entering recruit training (June 1999-June 2000), 2,157 (94%) voluntarily enrolled. At baseline, women received universal screening for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis and treatment and counseling for positive STIs. Recruit training (13 weeks) precluded any social activities. Unrestricted vacation followed (median 10 days). After training resumed (3 weeks), questionnaires and repeat STI screening were administered. Multivariable logistic regression examined STI diagnosis at baseline as a predictor for risky sexual behaviors at vacation and STI-positive diagnosis after vacation.

RESULTS

The study was completed by 1,712 (79%) women (median age 18 years); 1,038 reported sexual activity during vacation; 71% used condoms inconsistently; 19% had casual partners. At baseline, 152 (15%) tested STI-positive. Baseline STI diagnosis was unrelated to inconsistent condom use, nonmonogamous partnerships, or multiple partnerships. However, women testing STI-positive at baseline were more likely to test STI-positive after vacation (adjusted odds ratio 3.74, 95% confidence interval 2.10-6.65). Baseline STI diagnosis predicted casual partnerships among women aged 19-21 years (adjusted odds ratio 2.48, 95% confidence interval 1.12-5.50).

CONCLUSION

Substantial numbers of women engaged in risky sexual behaviors after universal STI screening and counseling. Compared with STI-negative women, STI-positive women were at increased risk for subsequent STI acquisition regardless of their similar behaviors. As universal STI screening is increasingly implemented, follow-up care will likely be required to further reduce risky behaviors and address network-level factors.

LEVEL OF EVIDENCE

II.

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.

Predictors of inconsistent contraceptive use among adolescent girls: findings from a prospective study

PURPOSE

To assess the independent effects of various behavioral and psychosocial antecedents on contraceptive use among a sample of low-income African-American adolescent females.

METHODS

Stepwise logistic regression was used to calculate odds ratios for baseline predictors of inconsistent contraceptive use six months later. Study participants include 375 nonpregnant African-American girls aged 14-18 years who reported sexual activity in the previous six months. Data were collected using a self-administered survey, individual interview and urine pregnancy test.

RESULTS

Adolescents who were inconsistent contraceptive users at follow-up were more likely to have reported a desire for pregnancy, previous inconsistent contraceptive use, less frequent communication with their partners about prevention issues, and an increased number of lifetime sexual partners at the baseline assessment. Of equal importance was the finding that a previous pregnancy or sexually transmitted infection did not influence future contraceptive behaviors.

CONCLUSIONS

Clinicians can play an important role in counseling adolescents about sexual health and dispelling misperceptions that hinder consistent contraceptive use. Findings from this research could have significant implications for the development of effective sexually transmitted infection (STI) and pregnancy prevention programs for adolescents and can help in guiding clinicians toward relevant treatment practices.

Sexually transmitted infections. Screening and diagnosis guidelines for primary care pediatricians

Sexually transmitted infections are an important aspect of clinical care for adolescents. Recognition of common STI syndromes allows more efficient diagnosis and treatment. Prevention of infections by counseling, provision of condoms, periodic screening of at-risk teens, and treatment of partners all contribute to the sexual health of adolescent patients.

Sexual risk following a sexually transmitted disease diagnosis: the more things change the more they stay the same

The purpose of this study is to assess changes in sexual risk behaviors, attitudes toward using condoms, and perceived susceptibility to fiuture STDs for adolescent females who recently were diagnosed with an incident STD compared to those who were not diagnosed with an incident STD. Adolescent females (N = 308) were assessed at two time points, 6 months apart. Ninety-two participants were diagnosed with an STD, and 216 were not diagnosed with an STD in between the two time points. Results indicated that adolescents did not significantly change their behaviors, attitudes, or perceptions following the diagnosis of an incident STD compared to those who were not diagnosed with an incident STD. This suggests that an STD diagnosis alone is not sufficient to motivate adolescent females to reduce their sexual risk behavior and change their sexual risk attitudes and perceptions.

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.