Repeat Chlamydia trachomatis testing among heterosexual STI outpatient clinic visitors in the Netherlands: a longitudinal study

Cognitive social capital as a health-enabling factor for STI testing among young men in Stockholm, Sweden: A cross-sectional population-based study

Objective

To assess whether different forms of cognitive social capital increased the relative probability of testing for sexually transmitted infections (STIs) among young men living in Stockholm, Sweden.

Methods

A population-based cross-sectional study was conducted in 2017 with men aged 20-29 years living in Stockholm County, Sweden (n = 523). The main outcome was STI testing patterns (never tested, tested only within a12-monthperiod, tested only beyond a12-monthperiod, repeatedly tested). The main exposure were two forms of cognitive social capital: social support (having received help, having someone to share inner feelings with) and institutionalized trust (in school, healthcare, media). Data were analyzed using weighted multivariable multinomial logistic regression to obtain adjusted weighted relative probability ratio (aRPR).

Results

After adjusting for confounding factors, receiving help (aRPR: 5.2, 95% CI: 1.7-16.2) and having someone to share inner feelings with (aRPR: 3.1, 95% CI: 1.2-7.7) increased the relative probabilities of young men testing for STIs, but only for those testing beyond a 12-month period. Trust in media increased the relative probability of STI testing for those testing only within a 12-month period (aRPR: 2.6, 95% CI: 1.1-6.1) and for those testing repeatedly (aRPR: 3.6, 95% CI: 1.5-8.8).

Conclusion

Young men in Stockholm County exhibit distinct STI testing patterns. Social support and trust in media were factors that increased the probability of being tested for STIs, with this effect varying according to the young men's STI testing pattern. Further studies are required to explore how trust in media might promote STI testing in this population.

Contribution of sexual health services to hepatitis B detection and control (Netherlands, 2008-2016)

OBJECTIVES

Case finding is one of the priority actions to reduce the disease burden of chronic hepatitis B (CHB). We estimated the contribution of CHB case finding at sexual health centres (SHCs) to the total national number of newly diagnosed CHB cases in the Netherlands and determined the characteristics of CHB cases detected at SHCs.

METHODS

This observational study used surveillance data from all outpatient SHCs in the Netherlands (SOAP database) and the number of CHB from national notification data (Osiris) from 2008 to 2016. The proportion of CHB notifications (hepatitis B surface antigen positive serology) detected at SHCs was calculated. SHC consultations without hepatitis B virus (HBV) testing (n=669 308), with acute hepatitis B diagnosis (n=73), with HBV vaccination only (n=182) or an inconclusive hepatitis B diagnosis (n=24) were excluded. Univariable and multivariable logistic regression analyses were performed, stratified by gender and sexual preference, to analyse patient characteristics associated with CHB.

RESULTS

During the study period, 12 149 CHB cases were notified. 405 646 SHC consultations were included in the analysis and 1452 CHB cases (0.4%) were detected at SHCs. The proportion of CHB cases detected at SHCs in relation to the national notified number ranged between 12.4% (200 of 1613) in 2008 and 10.8% (106 of 980) in 2016. 87% of CHB cases were among first-generation migrants (FGMs) originating from high endemic countries for sexually transmitted infections or men who have sex with men (MSM). In multivariable analysis, an older age category, migration background and being a commercial sex worker (CSW) were associated with CHB in all stratified analyses.

CONCLUSIONS

The contribution of SHCs is relevant to case finding of CHB in the Netherlands. SHCs should therefore be considered as an important health setting to screen for HBV in high-risk groups, especially among MSM, CSW and FGM, to achieve a reduction in the HBV-related disease burden.

Determinants and prediction of Chlamydia trachomatis re-testing and re-infection within 1 year among heterosexuals with chlamydia attending a sexual health clinic

Background

Chlamydia trachomatis (chlamydia) is one of the most common sexually transmitted infections (STI) globally, and re-infections are common. Current Australian guidelines recommend re-testing for chlamydia 3 months after treatment to identify possible re-infection. Patient-delivered partner therapy (PDPT) has been proposed to control chlamydia re-infection among heterosexuals. We aimed to identify determinants and the prediction of chlamydia re-testing and re-infection within 1 year among heterosexuals with chlamydia to identify potential PDPT candidates.

Methods

Our baseline data included 5,806 heterosexuals with chlamydia aged ≥18 years and 2,070 re-tested for chlamydia within 1 year of their chlamydia diagnosis at the Melbourne Sexual Health Center from January 2, 2015, to May 15, 2020. We used routinely collected electronic health record (EHR) variables and machine-learning models to predict chlamydia re-testing and re-infection events. We also used logistic regression to investigate factors associated with chlamydia re-testing and re-infection.

Results

About 2,070 (36%) of 5,806 heterosexuals with chlamydia were re-tested for chlamydia within 1 year. Among those retested, 307 (15%) were re-infected. Multivariable logistic regression analysis showed that older age (≥35 years old), female, living with HIV, being a current sex worker, patient-delivered partner therapy users, and higher numbers of sex partners were associated with an increased chlamydia re-testing within 1 year. Multivariable logistic regression analysis also showed that younger age (18-24 years), male gender, and living with HIV were associated with an increased chlamydia re-infection within 1 year. The XGBoost model was the best model for predicting chlamydia re-testing and re-infection within 1 year among heterosexuals with chlamydia; however, machine learning approaches and these self-reported answers from clients did not provide a good predictive value (AUC < 60.0%).

Conclusion

The low rate of chlamydia re-testing and high rate of chlamydia re-infection among heterosexuals with chlamydia highlights the need for further interventions. Better targeting of individuals more likely to be re-infected is needed to optimize the provision of PDPT and encourage the test of re-infection at 3 months.

Patterns of sexual behaviour associated with repeated chlamydia testing and infection in men and women: a latent class analysis

BACKGROUND

Adolescents and young adults are at higher risk of acquiring Chlamydia trachomatis infection (chlamydia), so testing is promoted in these populations. Studies have shown that re-testing for chlamydia is common amongst them. We investigated how sexual risk behaviour profiles are associated with repeated testing for chlamydia.

METHODS

We used baseline data from a cohort of 2814 individuals recruited at an urban STI -clinic. We applied latent class (LC) analysis using 9 manifest variables on sexual behaviour and substance use self-reported by the study participants. We fitted ordered logistic regression to investigate the association of LC membership with the outcomes repeated testing during the past 12 months and lifetime repeated testing for chlamydia. Models were fit separately for men and women.

RESULTS

We identified four LCs for men and three LCs for women with increasing gradient of risky sexual behaviour. The two classes with the highest risk among men were associated with lifetime repeated testing for chlamydia: adjOR = 2.26 (95%CI: 1.50-3.40) and adjOR = 3.03 (95%CI: 1.93-4.74) as compared with the class with lowest risk. In women, the class with the highest risk was associated with increased odds of repeated lifetime testing (adjOR =1.85 (95%CI: 1.24-2.76)) and repeated testing during past 12 months (adjOR = 1.72 (95%CI: 1.16-2.54)). An association with chlamydia positive test at the time of the study and during the participant's lifetime was only found in the male highest risk classes.

CONCLUSION

Prevention messages with regard to testing for chlamydia after unprotected sexual contact with new/casual partners seem to reach individuals in highest risk behaviour classes who are more likely to test repeatedly. Further prevention efforts should involve potentially more tailored sex-specific interventions taking into consideration risk behaviour patterns.

Increased risk of subsequent chlamydia infection among women not tested at the anorectal anatomical location

BACKGROUND

Universal anorectal testing for Chlamydia trachomatis (chlamydia) among women is not recommended in many countries, while anorectal chlamydia infections are common. Missed anorectal infections might cause sequelae at the genital site if autoinoculation from the anorectum is possible, but evidence is limited. This study investigates the association between potentially missed anorectal infections and subsequent genital chlamydia infections in women, using not being tested at the anorectal site as a proxy for having a potentially missed anorectal infection.

METHODS

We included all women with a repeat chlamydia test within 1 year (with at least a genital test) from the Dutch sexual health centre surveillance between 2014 and 2019. Multilevel logistic regression analyses were used to identify determinants of genital chlamydia infection at the repeat test, with anorectal testing at the previous chlamydia test as the main determinant.

RESULTS

A total of 40 217 women were included in the analyses, of whom 15.4% tested chlamydia-positive genitally at their second test. Not being tested anorectally at the first test was an independent risk factor for genital chlamydia infection at the repeat test (adjusted OR 1.24, 95% CI 1.15 to 1.33). This association was in the same range as most other significant risk factors in the model: low education level, no condom use, STI symptoms and previous STI diagnosis. Young age (<20 years) (2.67, 2.39-2.98) and those who received partner notification (3.11, 2.91-3.31) showed stronger associations. The findings were robust; correcting for interactions and a sensitivity analysis stratifying by chlamydia infection at first visit did not show significant differences in the adjusted OR of not being tested anorectally at first test.

CONCLUSION

The results are suggestive of an autoinoculation process from the anorectal to the genital anatomical site in women. To enhance chlamydia control, future studies on the role of extragenital testing and autoinoculation in chlamydia transmission are needed.

Modelling the impact of tailored behavioural interventions on chlamydia transmission

Behavioural interventions tailored to psychological characteristics of an individual can effectively achieve risk-reducing behaviour. The impact of tailored interventions on population-level chlamydia prevalence is unknown. We aimed to assess the impact on overall chlamydia prevalence five years after the introduction of an intervention aimed at increasing self-efficacy, social norms, attitudes and intentions towards condom use (i.e., condom intervention), and an intervention aimed at increasing health goals and decreasing impulsiveness (i.e., impulsiveness intervention). A pair model, informed by longitudinal psychological and behavioural data of young heterosexuals visiting sexual health centers, with susceptible-infected-susceptible structure was developed. The intervention effect was defined as an increased proportion of each subgroup moving to the desired subgroup (i.e., lower risk subgroup). Interventions tailored to subgroup-specific characteristics, assuming differential intervention effects in each subgroup, more effectively reduced overall chlamydia prevalence compared to non-tailored interventions. The most effective intervention was the tailored condom intervention, which was assumed to result in a relative reduction in chlamydia prevalence of 18% versus 12% in the non-tailored scenario. Thus, it is important to assess multiple psychological and behavioural characteristics of individuals. Tailored interventions may be more successful in achieving risk-reducing behaviour, and consequently, reduce chlamydia prevalence more effectively.

The characteristics of patients frequently tested and repeatedly infected with Chlamydia trachomatis in Southwest Limburg, the Netherlands

Background

Repeat Chlamydia trachomatis (CT) infections are common. To better understand the characteristics of patients frequently infected with CT at our sexually transmitted infection (STI) care services, we assessed the differences between patients repeatedly infected with CT and those who repeatedly tested negative.

Methods

In this cross-sectional analysis of cohort data, we assessed individuals tested for CT at different STI care providers between 2011 and mid-2018 in Southwest Limburg, the Netherlands (n = 17,616). Patients with ≥2 repeat CT infections in the study period were categorized as “patients with repeat CT infections.” Multivariable logistic regression analyses were performed for the binary outcome measure: patients with repeat CT infections versus patients who repeatedly tested negative (reference group). Additional analyses were performed for only the STI clinic population.

Results

Patients aged < 25 years (OR: 1.83; 95%CI:1.38–2.43), co-infected with HIV (OR: 2.07; 95%CI: 1.02–4.22) or co-infected with Neisseria gonorrhoeae (NG) (OR: 5.04; 95%CI: 3.33–7.63) had more repeat CT infections. In additional analyses among exclusively STI clinic visitors, patients with urogenital symptoms (OR: 2.17; 95%CI: 1.41–3.35), and patients notified for STIs (OR: 4.55; 95%CI: 3.17–6.54) had more frequent repeat CT infections.

Conclusions

Patients aged < 25 years and patients coinfected with HIV or NG had more frequent repeat CT infections, accounting for ~ 20% of the diagnosed CT infections. These patients are likely at the highest risk for transmitting and acquiring CT. Therefore, testing and retesting this group remains important to enhance CT control.

Repeat testing without having 'the talk' is not meaningful'-healthcare providers' perceptions on finding a balance between Chlamydia trachomatis testing and primary prevention strategies. A qualitative study in Stockholm, Sweden

OBJECTIVES

Chlamydia trachomatis is a public health problem. Widespread testing and re-testing after a sexually transmitted infection (STI) is recommended to contain the epidemic and has been adopted by many countries. A recent study in Stockholm found that serial testing was used as a substitute for condom use by youth presenting at the Youth Health Clinics (YHC). The objectives of this study are to explore frontline healthcare provider's perception of youth testing repeatedly for C. trachomatis as a substitute for condom use and their views on how this might be addressed.

DESIGN

Qualitative study, in-depth interviews and analysed using content analysis.

SETTING

YHC in Stockholm County, Sweden.

PARTICIPANTS

Healthcare providers (HCPs) working at the YHC.

FINDINGS

Testing used as a method of prevention of STIs by youth has been a well-known phenomenon observed by HCPs at the YHC. Despite frustration regarding this behaviour, attitudes towards youth visiting the clinics repeatedly were overall positive. It is seen as an opportunity to reach youth with primary prevention strategies. Time for in-depth conversations with the youth is considered essential to understand the various reasons behind sexual risk-taking and to tailor counselling accordingly. Introducing concepts of self-compassion and self-respect in relation to sex is thought of as an effective intervention to improve sexual health among youth.

CONCLUSION

HCPs' views on testing repeatedly for C. trachomatis as means of prevention, range widely from seeing this as 'a positive strategy for C. trachomatis prevention' to 'a waste of healthcare resources'. There was a more unified view on how this should be addressed. Testing without having time to problematise sexual risk-taking was seen as meaningless. In depth, one-on-one counselling was deemed important. While scaling up accessibility to testing services, primary prevention strategies must not be neglected.

Contribution of general practitioners and sexual health centres to sexually transmitted infection consultations in five Dutch regions using laboratory data of Chlamydia trachomatis testing

Effective sexually transmitted infection (STI) control requires opportunities for appropriate testing, counselling and treatment. In the Netherlands, people may attend general practitioners (GPs) and sexual health centres (SHCs; also known as STI clinics) for STI consultations. We assessed the contribution of GPs and SHCs to STI consultations in five Dutch regions with different urbanization levels, using data of urogenital Chlamydia trachomatis (CT) testing. Data (2011–2016) were retrieved from laboratories, aggregated by gender and age group (15–24 and 25–64 years). Results show that test rates and GP contribution varied widely between regions. GP contribution decreased over time in Amsterdam (60–48%), Twente (79–61%), Maastricht (60–50%) and Northeast-Netherlands (82–77%), but not in Rotterdam (65–67%). Decreases resulted from increases in SHC test rates and slight decreases in GP test rates. GPs performed more tests for women and those aged 25–64 years compared to SHCs (relative risks ranging from 1.49 to 4.76 and 1.58 to 7.43, respectively). The average yearly urogenital CT positivity rate was 9.2% at GPs and 10.7% at SHCs. Overall, GPs accounted for most STI consultations, yet SHC contribution increased. Continued focus on good quality STI care at GPs is essential, as increasing demands for care can not be entirely covered by SHCs.

High Rates of Repeat Chlamydial Infections Among Young Women-Louisiana, 2000-2015

BACKGROUND

Chlamydial infections are common among young women and can lead to serious reproductive health complications. We assessed the risk of reported repeat chlamydial infection among young women in Louisiana and time interval between infections by age and race/ethnicity.

METHODS

We analyzed surveillance data on chlamydial infections reported among women in Louisiana from January 1, 2000, to December 31, 2015. Multiple reports for the same person were matched using unique codes. Chlamydial infections reported more than 30 days after a previous positive test were considered new infections. Women aged 15 to 34 years at first infection during 2000 to 2012 were censored after 3 years or after they had a repeat infection. Cumulative incidence and incidence rate of repeat chlamydial infection among women were determined by year of first infection. Race- and age-specific results were obtained using stratified analyses.

RESULTS

One in 4 women diagnosed with a chlamydial infection at 15-34 years of age in Louisiana had a reported repeat infection in 3 years or less. Risk of repeat infection increased for younger women, racial/ethnic minorities, and women in more recent cohorts. Young black women aged 15 to 19 years in 2012 had the highest risk (44%). Black women also had shorter intervals between infections than white women.

CONCLUSIONS

Repeat chlamydial infections were common, especially among young black women. The true number is likely higher because surveillance data only count infections that were detected and reported. Comprehensive prevention strategies are needed to address high rates of repeat chlamydial infections among women.