Predictors identifying those at increased risk for STDs: a theory-guided review of empirical literature and clinical guidelines

Prevalence and Factors Associated With Sexually Transmitted Infections Among People who Inject Drugs in the San Diego-Tijuana Border Region

Background

Few estimates exist of the prevalence of sexually transmitted infections (STIs) and associated risk factors among people who inject drugs (PWID) in the San Diego-Tijuana border region, despite the high prevalence of HIV.

Methods

PWID living in San Diego or Tijuana underwent testing for bacterial STIs between December 2022 and February 2024. Urogenital gonorrhea and chlamydia infections were assessed using a urine test, the Aptima CT/GC assay. Syphilis was assessed using the treponemal Syphilis Health Check Rapid Point-of-Care assay and nontreponemal rapid plasma reagin Treponema pallidum Particle Agglutination test. HIV was tested using the fingerstick tests Miriad HCV/HIV POU+ Test and Oraquick HIV-1. Bacterial STI prevalence was calculated, and logistic regression was conducted to identify correlates of bacterial STI prevalence.

Results

Of 519 participants, 6.0% (95% CI, 3.9%-8.0%) tested positive for 1 or more bacterial STIs. Despite higher HIV prevalence in Tijuana, bacterial STIs were more prevalent in San Diego. Unstable housing, female birth, and US residency were associated with significantly higher adjusted odds of a bacterial STI compared with the reference groups (aOR, 2.61; 95% CI, 1.09-6.27; aOR, 2.41; 95% CI, 1.15-5.08; and OR, 2.79; 95% CI, 1.03-7.53; respectively).

Conclusions

Overall prevalence of bacterial STIs was consistent with other estimates of STIs among PWID in the United States. STI screening guidelines should recommend PWID for routine testing at least annually. Point-of-care testing should be expanded to increase access to STI screening and treatment for marginalized populations.

Prevalence and risk factors of sexually transmitted infections in the setting of a generalized HIV epidemic-a population-based study, western Kenya

BACKGROUND

Sexually transmitted infections (STIs) cause adverse health outcomes, including increasing HIV acquisition/transmission risk. We analyzed data from an HIV biomarker and behavioral survey to estimate STI prevalence, and explore associated factors in the setting of a generalized HIV epidemic in Siaya County, western Kenya.

METHODS

Data were collected in March-September 2022 through face-to-face interviews using structured questionnaires; records from 9643 sexually active participants aged 13+ years were included in the analysis. We calculated weighted self-reported STI prevalence, by sex, age, and HIV status and explored associated factors using multivariable logistic regression.

RESULTS

Median age was 37 years and 59.9% were female; HIV prevalence was 18.0%. Overall STI prevalence was 1.8%; 1.5-fold higher among males vs. females, and 2.6-fold higher among participants living with HIV vs. those without. HIV status and multiple sexual partners were independently associated with STI in both sexes. Mind-altering substance use and being circumcised were associated with STI among males.

CONCLUSIONS

This study estimates STI prevalence in the setting of high HIV prevalence. Findings underscore the importance of: effective STI screening in HIV clinics and HIV testing and counseling in STI clinics; screening and counseling on substance use, and HIV pre-exposure prophylaxis; and intensive sexual health counseling in male circumcision programmes.

Partnership types and coital frequency as predictors of gonorrhea and chlamydia among young MSM and young transgender women

BACKGROUND

Sexually transmitted infections pose a major public health challenge in the United States and this burden is especially acute in subpopulations like young men who have sex with men (YMSM) and young transgender women (YTW). Yet, the direct behavioral antecedents of these infections are not well understood making it difficult to identify the cause of recent increases in incidence. This study examines how variations in partnership rates and the number of condomless sex acts are associated with STI infections among YMSM-YTW.

METHOD

This study leveraged 3 years of data from a large longitudinal cohort of YMSM-YTW. A series of generalized linear mixed models examined the association between the number of condomless anal sex acts, number of one-time partners, number of casual partners, and number of main partners and chlamydia, gonorrhea, or any STI.

RESULTS

Results indicated the number of casual partners was associated with gonorrhea [aOR = 1.17 (95% CI: 1.08, 1.26)], chlamydia [aOR = 1.12 (95% CI: 1.05, 1.20)], and any STI [aOR = 1.14 (95% CI: 1.08, 1.21)] while the number of one-time partners was only associated with gonorrhea [aOR = 1.13 (95% CI: 1.02, 1.26)]. The number of condomless anal sex acts was not associated with any outcome.

CONCLUSION

These findings suggest the number of casual partners is a consistent predictor of STI infection among YMSM-YTW. This may reflect the quick saturation of risk within partnerships making the number of partners, rather than the number of acts, the more relevant factor for STI risk.

Identifying sexual risk-taking and ill health in the meeting with young people-experiences of using an assessment tool

BACKGROUND

Identifying young people exposed to sexual risk-taking or violence is fundamental, when seeking to strengthen their health. However, young people seldom share sexual health concerns or experiences of violence with healthcare professionals (HCPs). Studies evaluating how use of a risk assessment tool influences the dialogue about sexual health and violence are sparse.

AIMS

The aim of this study was to explore HCPs' experiences of using the SEXual health Identification Tool (SEXIT) in encounters with young people at Swedish youth clinics.

METHOD

Three focus group interviews were conducted with 21 HCPs from nine youth clinics, where SEXIT had been introduced. Data were analysed using thematic content analysis.

RESULTS

Three themes were identified. The theme, Facilitates dialogue about sexuality and vulnerability, describes how the questionnaire pertaining to SEXIT helped to normalise and help both HCPs and young people to take part in the dialogue about sensitive issues. Need for a trustful encounter presents HCPs' ethical concerns regarding how the questionnaire affects the integrity of young people and trust-making. Sensitive topics entail challenges describes HCPs' challenges when dealing with sensitive issues. Additionally, it describes needs for knowledge and collaboration when targeting vulnerable young people.

CONCLUSIONS

The HCPs stated that using SEXIT developed their ability to address sensitive issues and helped both them and young people to take part in the dialogue about sexuality and exposure to violence. SEXIT involves experiences of ethical concerns regarding integrity and trust-making. It also entails challenges in having dialogues about sensitive issues, how to deal with risk assessment outcomes and in improvements regarding inter-professional collaborations.

Are LARC Users Less Likely to Use Condoms? An Analysis of U.S. Women Initiating LARC in 2008-2018

INTRODUCTION

Public health professionals have raised concern that increased use of long-acting reversible contraceptives (LARC) could raise women's risk for sexually transmitted infections (STIs), because LARC's superior pregnancy protection may decrease women's motivation to use a barrier method for supplemental pregnancy prevention. This study uses population-based data to examine whether condom use is lower, particularly among young women who are at increased STI risk, after initiating LARC versus moderately effective methods.

METHODS

With the 2011-2019 data files of the National Survey of Family Growth, we examine the percent of sexually active months with condom use in the year after LARC or moderately effective method initiation for a nationally representative sample of 2,018 women aged 15-44 years. Multinomial logistic models regressed condom use on method type and age group, as well as their interaction, while adjusting for key confounders.

RESULTS

The unadjusted likelihood of any condom use is substantially lower among women who initiated LARC versus moderately effective methods (12% vs. 37%), and this difference is greater among younger versus older women. After accounting for differences in women's reproductive and sociodemographic profiles, however, a statistically significant difference in condom use by method initiated remains only for those aged 20-34 years.

CONCLUSIONS

Crude estimates suggest that condom use is lower after initiating LARC versus moderately effective methods, especially among young women. After accounting for the confounding effects of LARC users' distinct profiles-particularly in terms of parity and teenage childbearing-the difference is decreased overall and no longer significant for adolescent women. Overall results indicate a need for new STI prevention strategies and policies that emphasize the importance of dual prevention for LARC users at risk of STIs.

Sugar Dating, Perceptions of Power, and Condom Use: Comparing the Sexual Health Risk Behaviours of Sugar Dating to Non-Sugar Dating Women

Sugar dating is a form of dating typically characterized by wealthier, older men providing financial support to younger, less financially secure women in exchange for companionship and sexual intimacy. The goals of the current study were to (1) quantitatively assess the sexual practices of sugar dating women in their arrangements with sugar daddies, including time spent on sexual activity, average number of current partners, and relative perceptions of relationship power, (2) examine how perceptions of power within arrangements relate to condom use with sugar daddies, and (3) compare samples of sugar dating and non-sugar dating women on both condom use consistency by partner type and rates of STI testing and diagnoses. Overall, condom use for all women was highest with casual sexual partners and lowest with romantic partners, with sugar dating women's condom use with sugar daddies in between. Consistent with social exchange theory, perception of power within sugar dating arrangements predicted condom use with sugar daddies, such that women who felt they held more power reported more consistent condom use. Further, sugar dating women were twice as likely to have been diagnosed with an STI but were more than six times as likely to have been tested for STIs.

Regulatory Focus and Sexual Health: Motives for Security and Pleasure in Sexuality are Associated with Distinct Protective Behaviors

We examined if motives for security (i.e., prevention focus) or pleasure (i.e., promotion focus) were uniquely associated with intentions to get tested for STIs and behavioral control over condom use, over and above variables already identified in theoretical models. We conducted an online survey with Portuguese adults (N = 836; M_age = 22.27, SD = 5.14). Overall, 99.4% of the participants knew at least one of eight STIs, but only 25.2% got tested in the last six months. Participants more focused on prevention had condomless sex less frequently, whereas participants more focused on promotion knew more STIs and got tested for more STIs. Furthermore, participants had stronger intentions to get tested for STIs if they got tested for more STIs in the past, were more concerned about STIs, perceived greater susceptibility to STI acquisition, and were more focused on promotion (but not prevention). Participants had greater behavioral control over condom use if they had condomless sex less often and were more focused on prevention (but not promotion). These findings suggest that promotion-focused people are more likely to consider the consequences of having condomless sex. In contrast, prevention-focused people are more likely to take control of their sexual health.

Factors Associated with Sexually Transmitted Infections among Users of Voluntary HIV Counseling and Testing Centers in Portugal

Objective: Users of publicly funded voluntary HIV Counseling and Testing Centers (VCT C) in the Portuguese National Service have been found to have higher rates of HIV risk behavior than the general population, but data concerning the relationship between socio-demographic, behavioral, and cognitive variables, and Sexually Transmitted Infections (ST Is) in this specific population are limited. This study tests the impact of socio-demographic, behavioral and cognitive variables on ST Is in a sample of 168 users of VCT C. Methods: A cross-sectional study using structured questionnaires was conducted. Results: Being older, being gay or bisexual, and having more barriers towards safer sex (e.g., negative attitudes toward safer sex behavior) were associated with increased odds of having had a ST I diagnosis. We found significant differences between heterosexual and gay men for number of sexual partners, frequency of anal sex, exchanging sex for money or drugs, history of ST Is, AIDS knowledge, and risk beliefs about the partner, with gay men showing higher rates. Conclusions: ST Is education should target older, gay or bisexual individuals, and focus on information as well as on changing barriers towards safer sex and associated health beliefs.

Violence and sexual risk taking reported by young people at Swedish youth clinics

BACKGROUND

Early identification of sexual risk taking and exposure to violence is fundamental when seeking to strengthen young people's health. The purpose of this study was to study factors associated with sexual risk taking and ill health, as well as to study gender differences, and the associations amongst exposure to multiple forms of violence, sexual risk taking and ill health.

METHODS

This was a cross-sectional study based on data from 3,205 young people answering a questionnaire belonging to the Sexual health Identification Tool (SEXIT 2.0), during consultations at 12 youth clinics in Sweden. The analyses are based on descriptive statistics and nominal multiple regression analysis.

RESULTS

Male, transgender and non-binary youths reported significantly more events of sexual risk taking and ill health compared to women. Those who reported sexual initiation before the age of 15 (OR 2.87, CI 1.81-4.56), three or more sexual partners in the past 12 months (OR 2.68, CI 1.70-4.22) and to have ever experienced an unintended pregnancy (OR 2.29, CI 1.32-3.97) were more than twice as likely to report exposure to physical, emotional and sexual violence. Transgender, non-binary youths and women were more exposed to multiple violence (OR 3.68, 13.50) compared to men.

CONCLUSIONS

Transgender and non-binary youths are exposed to significantly more violence compared to women and men. Experiences of sexual risk taking and ill health demonstrated strong associations with exposure to multiple violence.

Urban Sexual Health Clinic Patients With "Undetermined Risk" for HIV Are Less Likely to Receive Preexposure Prophylaxis

BACKGROUND

New diagnoses of HIV increasingly occur among people who fall outside traditional transmission risk categories. This group remains poorly defined, and HIV prevention efforts for this group lag behind efforts for patients in other risk groups.

METHODS

We conducted a retrospective review of patient visits at sexual health clinics in Boston, MA, over a 14-month period. Patients were classified into Centers for Disease Control and Prevention-defined HIV transmission risk categories. We compared frequencies of sexually transmitted infections (STIs), HIV, preexposure prophylaxis (PrEP) indications, and PrEP prescriptions. Predictors of HIV or STI among patients in the undetermined risk category were assessed with logistic regression.

RESULTS

There were 4723 clinic visits during the study period. Patients in the undetermined risk group constituted the largest proportion (55.8%), followed by men who have sex with men (MSM; 42.7%). The proportion of visits by patients in the undetermined risk group with an indication for PrEP was low (28.0%) compared with MSM (91.3%) and MSM who also inject drugs (93.8%); however, the absolute number was high (737). Among patients with an indication for PrEP, those in the undetermined risk group were least likely to receive a prescription. Behavioral risk factors were poorly predictive of STI or HIV among patients in the undetermined risk group.

CONCLUSIONS

Patients with undetermined risk for HIV constituted a large proportion of clinic visits and had a large volume of sexual health needs but rarely received PrEP when indicated. To end the HIV epidemic in the United States, prevention efforts must include people who fall outside traditional risk categories.

Modulation of Immune Response to Chlamydia muridarum by Host miR-135a

Previously, our laboratory established the role of small, noncoding RNA species, i.e., microRNA (miRNA) including miR-135a in anti-chlamydial immunity in infected hosts. We report here chlamydial infection results in decreased miR-135a expression in mouse genital tissue and a fibroblast cell line. Several chemokine and chemokine receptor genes (including CXCL10, CCR5) associated with chlamydial pathogenesis were identified in silico to contain putative miR-135a binding sequence(s) in the 3' untranslated region. The role of miR-135a in the host immune response was investigated using exogenous miR-135a mimic to restore the immune phenotype associated with decreased miR-135a following Chlamydia muridarum (Cm) infection. We observed miR-135a regulation of Cm-primed bone marrow derived dendritic cells (BMDC) via activation of Cm-immune CD4⁺ T cells for clonal expansion and CCR5 expression. Using a transwell cell migration assay, we explore the role of miR-135a in regulation of genital tract CXCL10 expression and recruitment of CXCR3⁺ CD4⁺ T cells via the CXCL10/CXCR3 axis. Collectively, data reported here support miR-135a affecting multiple cellular processes in response to chlamydial infection.

Predictors of Sexually Transmitted Infection Positivity Among Substance-Using Native American Adults

BACKGROUND

Sexually transmitted infections (STIs) are a public health crisis with Native Americans suffering a high burden of disease. Studies across gender and racial/ethnic groups have found varying risk factors associated with STI positivity. Understanding how risk factors are associated with STI positivity can help design interventions for those most at risk.

METHODS

Participants were Native American binge substance using adults enrolled in a randomized controlled trial evaluating a brief intervention to increase STI screening and reduce sexual risk-taking behaviors. Participants completed a self-report assessment at baseline that included questions about sexual risk factors and STI testing behaviors and diagnosis. This analysis includes those who had ever completed an STI test at baseline. Bivariate and multivariate analyses using logistical regression were utilized to identify associations between risk factors and past STI diagnosis.

RESULTS

A total of 193 people were included in the analysis. Over half (50.6%) of the participants had ever been diagnosed with an STI. Risk behaviors varied by gender. More women with a self-reported history of STI reported having sex with someone they thought had an STI, past experience of physical/sexual violence, and having passed out from drinking. Men with a self-reported history of STI were more likely to report past marijuana and other drug use. Among women with a self-reported history of STI, having sex with someone they thought had an STI was associated with STI positivity, whereas other drug use was associated with STI positivity among men with a self-reported history of STI.

CONCLUSIONS

Findings provide information for those working to reduce STIs in Native Communities to better identify and design programs for those at highest risk for STIs. Additional studies examining gender dynamics and sexual risk taking among native adults are warranted.

Sexually transmitted infections in male heterosexual Dutch clients who visited German cross-border female sex workers; a 3 year retrospective study

BACKGROUND

Some male heterosexual clients prefer to visit a cross-border Female Sex Worker (FSW) because of cheaper sex and unsafe sex practices, and may therefore be at risk for sexually transmitted infections (STI). The objective of this study was to assess whether having commercial cross-border sex is an independent risk factor for being diagnosed with a STI.

METHODS

An observational retrospective study was performed using data of 8 Dutch STI clinics bordering Germany, between 2011 and 2013. All male heterosexual clients of FSWs were selected and data on country of FSW visit and occurrence of STI were used for multivariable regression analysis.

RESULTS

The study population consisted of 2664 clients of FSW. Most clients visited the Netherlands (82.4%), followed by visits to another country (beyond cross-border) (9.9%) and cross-border visits (7.8%). Clients of FSW were less likely to be STI positive when they were younger than 25 years(OR = 0.6, 95%CI 0.4 to 0.8 25-44 years and OR = 0.5, 95%CI 0.4 to 0.7 older than 45 years), and more likely when they had 20 or more sex partners in the last 6 months (OR = 2.9, 95%CI 1.9 to 4.4), did not use a condom during last sexual contact (OR = 2.2, 95%CI 1.6 to 2.9) and made cross-border visits (OR = 1.7, 95%CI 1.1 to 2.6).

CONCLUSIONS

As cross-border visits appears to be a novel independent risk factor for STI in clients of FSW, this group should therefore be advised on STI prevention.

Prevalence of Trichomonas vaginalis Infection Among US Males, 2013-2016

Background

Trichomoniasis results from adhesion of Trichomonas vaginalis to the mucous membrane of the urethra or vagina. It has been estimated to have a higher incidence rate than both gonorrhea and chlamydia combined. Although females can experience both clinical symptoms and obstetrical complications, male infections are largely asymptomatic and often unreported. We aim to estimate the prevalence of trichomoniasis in US males using the National Health and Nutrition Examination Survey (NHANES) database.

Methods

The NHANES database was queried for all men aged 18-59 years during the years 2013-2016. During these years, the survey included urine testing for trichomoniasis using transcription-mediated amplification. Information was also obtained regarding patient demographics and other sexually transmitted infections.

Results

Overall, 0.49% of men aged 18-59 years tested positive for trichomoniasis. The highest rate was seen in black men (3.6%). There was no significant association with trichomoniasis and age. Higher rates of infection were seen in smokers, those with herpes simplex virus type 2 (HSV-2) infection, men who had sex at an early age, those with less condom usage, and those with more lifetime sexual partners.

Conclusion

The rates of trichomonas infection in US males are lower than in women. Infections are strongly associated with black males, HSV-2 infection, and other factors known to increase rates of sexually transmitted infection. This information may be helpful for counseling, screening, and management of patients.

Using Composite Scores to Summarize Adolescent Sexual Risk Behavior: Current State of the Science and Recommendations

Composite scores offer the advantage of summarizing across multiple sexual risk behaviors to both simplify results and better capture the influence of core contextual, interpersonal, and intrapersonal dynamics that affect multiple sexual risk behaviors. There is inconsistency in how researchers utilize composite scores with minimal guidance on the advantages and disadvantages of frequently used approaches. Strengths and weaknesses of each approach are discussed in the context of assessing adolescent sexual risk behavior. A latent variable model and three commonly used composites were applied to data combined across four clinical trials (n = 1322; 50% female). Findings suggested that the latent variable approach was limited due to minimal correlations among sexual risk behaviors, that choice of composite had minimal impact on cross-sectional results so long as there is sufficient variability in risk behavior in the sample, but composite choice could impact results from clinical trials particularly for subgroup analyses. There are unique challenges to creating composites of adolescent risk behavior, including the fluidity and infrequency of adolescent sexual relationships that result in many participants reporting no sexual behavior at any given assessment and a low correlation between the number of partners and condomless sex acts. These challenges impede application of data-driven approaches to defining sexual risk composites. Recommendations to improve consistency in reporting include: (1) reporting each type of risk behavior separately prior to forming a composite, (2) aggregating across assessments to increase the chance of observing sexual risk behaviors, and (3) continued work toward a unified definition of adolescent sexual risk behavior that can guide the development of appropriate measurement models.

Substance use preferences and sexually transmitted infections among Canadian post-secondary students

BACKGROUND

In Canada, substance use is one of the key predisposing factors that may lead to risky sexual behaviors among post-secondary students. There is considerable economic burden and significant public health concern posed by substance use and sexually transmitted infections (STIs). The purpose of this study was to examine the prevalence of substance use preferences (alcohol, cannabis, and other drugs) and its association with STIs among Canadian post-secondary students.

MATERIALS AND METHODS

This is a cross-sectional study using data from the National College Health Assessment II, Spring 2016 survey conducted by the American College Health Association. There were 31,642 sexually active participants, representing 41 post-secondary institutions in Canada. Descriptive analysis and logistic regression were conducted to estimate the effect of substance use preferences on STIs.

RESULTS

This study found that participants reported being current users of alcohol (80%), cannabis (23%), and other drugs (8%). Additionally, 3.96% of the participants self-reported being diagnosed or treated for an STI in the last 12 months. Multivariate logistic analysis revealed current cannabis use to be significantly associated with self-reported STIs (aOR, 1.34; 95% CI, 1.12-1.6). There was a significant association between current drug use and STIs among male (aOR, 3.04; 95% CI, 2.27-4.06) and female participants (aOR, 1.87; 95% CI, 1.52-2.30). Having multiple sexual partners, a history of sexual assault, being homosexual, Black, and >21 years old were also found to have a significant association with self-reported STIs (P-value <0.001).

CONCLUSION

In this study, significant associations were found between cannabis and other drug use and STIs among post-secondary students in Canada. The results of this study can help inform institutions of higher learning and public health professionals in the design, implementation, and evaluation of substance use and STI policies and effective school-based health programming.

Prevalence of Chlamydia trachomatis Infection and Its Association with Sexual Behaviour and Alcohol Use in the Population Living in Separated and Segregated Roma Settlements in Eastern Slovakia

The aim of the study was to explore sexual behaviour and the occurrence of Chlamydia trachomatis (CT) infection in the population living in Roma settlements compared to the majority population in Slovakia and to assess the association between alcohol use and sexual behaviour within both populations. A cross-sectional population-based Hepa-Meta study was conducted in Slovakia in 2011. The final sample comprised 452 Roma and 403 non-Roma respondents. The occurrence of CT was detected by direct proof of the pathogen by PCR. The association between alcohol use and the prevalence of risky sexual behaviour were assessed using a logistic regression. First intercourse at age 15 or younger was reported by 27.9% of Roma (vs. 4.5% of non-Roma); 93.4% of Roma (vs. 77.9% of non-Roma) used condom inconsistently, 22.8% of Roma (vs. 43.9% of non-Roma) used a condom for protection from unwanted pregnancies and only 8.8% of Roma (vs. 21.8% of non-Roma) due to protection against infectious diseases. However, Roma reported having had five or more sexual partners less often compared to the majority (11.5% of Roma vs. 20.6% of non-Roma). Binge drinking at least once a month was associated with a higher number of sexual partners in both groups, but not with condom non-use. The prevalence of CT infection in the Roma population was higher (3.8%) compared to non-Roma (2.7%); however, the difference was not statistically significant. Our study found no differences in the prevalence of CT infection between Roma and non-Roma despite differences in sexual behaviour. Roma begin their sexual life earlier and have unprotected sex more often, but on the other hand, they seem to be much more restrained in terms of the number of sexual partners compared to the majority population.

Get Checked… Where? The Development of a Comprehensive, Integrated Internet-Based Testing Program for Sexually Transmitted and Blood-Borne Infections in British Columbia, Canada

Background

Testing for sexually transmitted and blood-borne infections (STBBI) is an effective public health strategy that can promote personal control of one’s health and prevent the spread of these infections. Multiple barriers deter access to testing including fear of stigmatization, inaccurate health care provider perceptions of risk, and reduced availability of clinic services and infrastructure. Concurrent increases in sexually transmitted infection (STI) rates and demands on existing clinical services make this an even more pressing concern. Web-based testing offers several advantages that may alleviate existing clinical pressures and facilitate appropriate testing access.

Objective

This paper describes the planning, development, and usability testing of a novel Web-based testing service, GetCheckedOnline (GCO), as a complementary testing option integrated within existing sexual health services within British Columbia (BC).

Methods

From 2009 to 2014, we engaged a multidisciplinary team in the design and development of GCO. We conducted 3 initial research studies to ascertain the opinions of youth, men who have sex with men (MSM), and STI clinic clients regarding Web-based testing and elicited perspectives of sexual health care providers through focus groups. We developed an informed consent process, risk assessment questions, and test recommendations based on provincial and national guidelines and evaluated these through consultations with clinical and community stakeholders. We also conducted a preliminary health equity impact assessment whose findings also informed the GCO program mode. Finally, from April 2011 to December 2012 we gathered qualitative data from 25 participants on the functionality and usability of a GCO prototype and incorporated their recommendations into a final model.

Results

GCO launched in the fall of 2014 across 6 pilot sites in Vancouver, BC. The service involves 3 main steps: (1) create an account, complete an assessment, and print a laboratory requisition, (2) provide blood and urine specimens at participating laboratory locations, and (3) receive test results on the Internet or by phone. During this pilot phase, we promoted GCO to existing STI clinic clients and MSM in the Greater Vancouver region. A rigorous mixed-method evaluation of GCO’s uptake, acceptability, and health system impacts is currently underway.

Conclusions

GCO is the first comprehensive Web-based STBBI testing program in Canada that is integrated with existing sexual health services, with the potential to reduce pressures on existing clinical services and reach populations facing the greatest barriers to testing. Our experience highlights the facilitators and challenges of developing and implementing novel complex eHealth interventions within the health care system, and underscores the importance of considering broader implementation contexts.

An assessment of population-based screening guidelines versus clinical prediction rules for chlamydia and gonorrhea case finding

INTRODUCTION

Much remains to be learned regarding the epistemology and utility of guidelines and clinical prediction rules (CPR), as well as the extent to which knowledge about risk at a population level might be pertinent to any given patient in terms of case finding accuracy. In the current paper, we offer an empirical examination that juxtaposes population-based guidelines and CPR for sexual health decision-making.

MATERIALS AND METHODS

We analyzed electronic medical records from asymptomatic patient visits involving tests for chlamydia or gonorrhea between 2000 and 2012 at nine publicly funded STI clinics in British Columbia to compare the case-finding accuracy for infection risk under two scenarios: (1) if the population had been screened using the Public Health Agency of Canada (PHAC) screening guidelines for chlamydia and gonorrhea; or (2) if the population has been screened using a CPR. Performance metrics evaluated included the area under the ROC curve (AUC).

RESULTS

In total, 35,818 individuals met the study inclusion criteria. The overall infection rate was 3.0%. Using the PHAC guidelines, the discriminatory performance of using any versus no risk factors and counts of risk factors were: AUC=0.55, 95% CI: 0.54-0.56 and AUC=0.64, 95% CI: 0.63-0.66, respectively. The model used to derive the CPR demonstrated good discrimination (AUC=0.73, 95% CI: 0.71-0.74).

CONCLUSIONS

The current paper provides empirical evidence that demonstrates that population-based guidelines may not necessarily be a perfect fit for application at the individual level. Thus, we recommend risk estimation algorithms for use in sexual health services and programs.

A Survey of Current Knowledge on Sexually Transmitted Diseases and Sexual Behaviour in Italian Adolescents

Worldwide, 500 million people a year acquire a sexually transmitted disease (STD). Adolescents, accounting for 25% of the sexually active population, are the most affected. To analyze sexual behavior among Italian adolescents and their knowledge of STDs, with the goal of preventing their transmission, a questionnaire was administered to 2867 secondary school students (1271 males and 1596 females) aged 14–21 years. For the study, 1492 students were interviewed in Genoa (Northern Italy) and 1375 in Lecce (Southern Italy). For 37% of the respondents, parents and teachers were the main source of information on sex, and 95% believed that school should play the primary role in sex education. However, only 9% considered the sex education they received in school good. Noteworthy, only 0.5% of the teenagers recognized the sexually transmitted diseases from a list of diseases, and 54% of them did not know what a Pap test was. Confusion about the meaning of contraception and prevention was evident; only 22% knew that condoms and abstinence are the only methods for preventing STDs. Finally, a consistent number of students are exposed to risk factors for STDs transmission; e.g., alcohol and recreational drug use, promiscuity and improper condom use. On the basis of our study, there is an urgent need for the introduction of sex education as a proper subject in Italian schools.

Denominators count: supplementing surveillance data for genital Chlamydia trachomatis infection with testing data, Norway, 2007 to 2013

As genital Chlamydia trachomatis (chlamydia) infection is often asymptomatic, surveillance of diagnosed cases is heavily influenced by the rate and distribution of testing. In 2007, we started supplementing case-based surveillance data from the Norwegian Surveillance System for Communicable Diseases (MSIS) with aggregated data on age group and sex of individuals tested. In this report, annual testing rates, diagnosis rates and proportion positive for chlamydia in Norway between 1990 and 2013 are presented. From 2007, rates are also stratified by age group and sex. The annual testing rate for chlamydia culminated in the early 1990s, with 8,035 tested per 100,000 population in 1991. It then declined to 5,312 per 100,000 in 2000 after which it remained relatively stable. Between 1990 and 2013 the annual rate of diagnosed cases increased 1.5 times from ca 300 to ca 450 per 100,000 population. The proportion of positive among the tested rose twofold from ca 4% in the 1990s to 8% in 2013. Data from 2007 to 2013 indicate that more women than men were tested (ratio: 2.56; 95% confidence interval (CI): 2.56-2.58) and diagnosed (1.54; 95% CI: 1.52-1.56). Among tested individuals above 14 years-old, the proportion positive was higher in men than women for all age groups. Too many tests are performed in women aged 30 years and older, where 49 of 50 tests are negative. Testing coverage is low (15%) among 15 to 24 year-old males. Information on sex and age-distribution among the tested helps to interpret surveillance data and provides indications on how to improve targeting of testing for chlamydia. Regular prevalence surveys may address remaining limitations of surveillance.

Alcohol Use Predicts Number of Sexual Partners for Female but not Male STI Clinic Patients

This study tested the hypothesis that greater alcohol involvement will predict number of sexual partners to a greater extent for women than for men, and that the hypothesized sex-specific, alcohol-sexual partner associations will hold when controlling for alternative sex-linked explanations (i.e., depression and drug use). We recruited 508 patients (46 % female, 67 % African American) from a public sexually transmitted infections (STI) clinic. Participants reported number of sexual partners, drinks per week, maximum drinks per day, frequency of heavy drinking; they also completed the AUDIT-C and a measure of alcohol problems. As expected, men reported more drinking and sexual partners. Also as expected, the association between alcohol use and number of partners was significant for women but not for men, and these associations were not explained by drug use or depression. A comprehensive prevention strategy for women attending STI clinics might include alcohol use reduction.