Socioeconomic factors and other sources of variation in the prevalence of genital chlamydia infections: A systematic review and meta-analysis

Socioeconomic position and risk of cervical cancer in the Nordic countries: Results from the Nordic Occupational Cancer Study

The Nordic countries benefited from declines in cervical cancer incidence rates due to the implementation of screening programmes. However, it is unclear whether all social groups have equally benefited from these preventive services. We provide an assessment of the temporal trends in cervical cancer incidence by socioeconomic position (SEP) in Denmark, Norway, Finland and Sweden, using data from the Nordic Occupational Cancer Study. Truncated age-standardized incidence rates and 95% confidence intervals (CI) of cervical cancer per 100,000 person-years were computed for women aged 50-69 by SEP and country within the period 1961-2005. We used Poisson regression models to compute relative risks (RRs) and 95% CIs of cervical cancer across SEP, pooling data for the three most recent 5-year periods (except for Denmark 1991-1995 and Norway 1991-2003). Throughout the study period, declines in the rates of cervical cancer were observed among all SEP groups. Lower SEP rates, which started from higher values, declined faster than those for higher SEP. At the conclusion of the study period, we still observed a social gradient, with higher rates seen in lower SEP women. Farmers had the lowest risk in all four countries. The RRs for lowest versus highest SEP ranged from 1.33 (95% CI 1.05-1.69) in Sweden to 1.76 (95% CI 1.13-2.85) in Denmark, with a pooled RR of 1.41 (95% CI 1.22-1.64). Lower SEP women still face the highest risks, indicating a need for continued efforts to provide equitable access to preventive services.

Age, sex and sexual orientation effects in the Safetxt trial: secondary data analysis of a randomised controlled trial

BACKGROUND

Increasing rates of sexually transmitted infections (STIs) and antimicrobial resistance among young people underscore the urgent need for preventative interventions. Interventions should be evidence-based and tailored to the unique risks and needs associated with varying age, sex and sexual orientation. We used data from the Safetxt trial to explore whether young people's age, sex and sexual orientation influence (1) their risk of STI reinfection and condom use and (2) the effect of the Safetxt intervention on STI reinfection and condom use.

METHODS

We conducted exploratory secondary analyses of data from the Safetxt trial that evaluated a theory-based digital sexual health intervention tailored according to sex and sexual orientation. We recruited 6248 young people with STIs from 92 UK sexual health clinics and assessed outcomes after 1 year, including the cumulative incidence of STI reinfection and condom use at last sex. We used adjusted logistic regression and margins plots to visualise effect modification.

RESULTS

There were differences in STI reinfection and condom use by age, sex and sexuality. Age was associated with STI reinfection (OR 0.90, 95% CI 0.87 to 0.94) with evidence for interaction between age and sexuality (p<0.001). Our findings suggest that the risk of STI reinfection decreases with age among young heterosexuals but increases among men-who-have-sex-with-men (MSM). Overall, MSM had the highest likelihood of reinfection (OR 3.53, 95% CI 2.66 to 4.68) despite being more likely to use condoms (OR 1.50, 95% CI 1.18 to 1.91).Among MSM, age modified the intervention effect on condom use at 1 year with highest benefits among participants aged 16-18, moderate to minor benefits among those aged 18-21 and no effect among participants aged 22-24 years.

CONCLUSIONS

Future digital health interventions tailored for diverse sexuality groups need to target young people early enough to have an impact on sexual behaviour. Specific novel interventions are needed for older MSM.

TRIAL REGISTRATION NUMBER

ISRCTN64390461.

Treatment of Chlamydia and Gonorrhea in Primary Care and Its Patient-Level Variation: An American Family Cohort Study

PURPOSE

Chlamydia and gonorrhea are the 2 most common bacterial sexually transmitted infections in the United States. Nonadherence to the Centers for Disease Control and Prevention treatment guidelines remains a concern. We examined how well chlamydia and gonorrhea treatment in primary care settings adhered to guidelines.

METHODS

We used electronic health records from the PRIME registry to identify patients with diagnosis codes or positive test results for chlamydia and/or gonorrhea from 2018 to 2022. Outcomes were the first dates of antibiotic administered within 30 days after a positive test result for the infection. Descriptive statistics were calculated for patient sociodemographic characteristics. We used a multivariate parametric accelerated failure time analysis with shared frailty modeling to assess associations between these characteristics and time to treatment.

RESULTS

We identified 6,678 cases of chlamydia confirmed by a positive test and 2,206 cases of gonorrhea confirmed by a positive test; 75.3% and 69.6% of these cases, respectively, were treated. Females, individuals aged 10-29 years, suburban dwellers, and patients with chlamydia-gonorrhea coinfection had higher treatment rates than comparator groups. Chlamydia was infrequently treated with the recommended antibiotic, doxycycline (14.0% of cases), and gonorrhea was infrequently treated with the recommended antibiotic, ceftriaxone (38.7% of cases). Time to treatment of chlamydia was longer for patients aged 50-59 years (time ratio relative to those aged 20-29 years = 1.61; 95% CI, 1.12-2.30) and for non-Hispanic Black patients (time ratio relative to White patients = 1.17; 95% CI, 1.04-1.33).

CONCLUSIONS

Guideline adherence remains suboptimal for chlamydia and gonorrhea treatment across primary care practices. Efforts are needed to develop interventions to improve quality of care for these sexually transmitted infections.

Trends in Gonorrhea and Chlamydia Testing and Infections Across the COVID-19 Pandemic in Adolescents and Young Adults in an Integrated Health System

PURPOSE

The COVID-19 pandemic impacted testing and incidence of sexually transmitted infections (STIs), with some studies showing uneven effects across sociodemographic groups. We aim to determine whether rates of gonorrhea and chlamydia testing and infections were affected by the pandemic, overall and by subgroups, defined by sociodemographic factors and comorbidities.

METHODS

We conducted a retrospective cohort study from January 1, 2016, through December 31, 2022, among adolescents and young adults ages 15-29 years within Kaiser Permanente Northern California (KPNC). We determined the rate of testing for gonorrhea/chlamydia, and the incident rates of infections before and during the COVID-19 pandemic by sociodemographic factors. We compared incidence rates of gonorrhea/chlamydia testing and infection before and during the pandemic using Poisson regression.

RESULTS

Gonorrhea/chlamydia testing during the pandemic was 19% lower than prepandemic baseline. Testing among Black patients was 1.8-fold higher than White patients. Black patients had 5.5 and 3.6-fold higher rate of gonorrhea and chlamydia infections, respectively, compared with White patients. Patients living in more deprived neighborhoods also had higher rates of infection compared to those in the least deprived neighborhoods. In multivariable analyses stratified by the period before and during the COVID-19 pandemic, there were no significant differences in the incidence rate ratios of testing or infections for any specific sociodemographic factor.

DISCUSSION

STI testing in adolescents and young adults dropped dramatically after the start of the pandemic and has not recovered to its prior levels. Preexisting disparities in STI testing and infections were not exacerbated by the pandemic.

Young, deprived women are more at risk of testing positive for Chlamydia trachomatis: Results from a cross-sectional multicentre study in French health examination centres

Objectives

Chlamydia Trachomatis (CT) is the most sexually transmitted infection in France. This study aimed to assess the feasibility of systematic screening for CT among people attending a preventive health examination in Health Examination Centres (HECs) and to compare positive CT cases according to deprivation.

Design

A cross-sectional multicentre study in thirteen HECs in France in January 2018.

Methods

Self-sampling CT screening was proposed among 18-25 years women and 18-30 years men, who were sexually active and without recent CT treatment. Related data and referred specimens were collected among attendees for the study, including deprivation and health status. CT positivity was estimated by genders. We explored association between CT infection and deprivation by univariate and multivariate modelling.

Results

The CT screening was proposed to 1701 eligible young people. 90.1 % [88.6-91.5] accepted and participated with 43.6 % being women, 54.3 % being deprived people. 75.4 % [72.1-78.6] screened women performed self-taken vaginal swabs and others took urinary tests. Screening was conducted in 1486 people. Overall prevalence of CT infection was 4.7 % [3.7%-5.9 %], significantly higher for women than men (6.4 % vs 3.4 %, p=0.009). Among women, being deprived increased the likelihood of CT positivity (aOR 4.95; 95 % CI 2.02 to 12.00) more than it did for men.

Conclusions

Individual deprivation was significantly associated with having a CT infection among women. The feasibility of CT screening in HECs was demonstrated, with a high acceptance, and led to the implementation of CT screening in all HECs. Promoting access to CT screening to deprived population might contribute to reduce social inequalities in health.

The prevalence of Chlamydia trachomatis infection by Nucleic Acid Amplification test in women of reproductive age group under treatment for infertility

Background

In India, the prevalence of Chlamydia Trachomatis (CT) studies in different groups are focused on high-risk populations - HIV-positive women and female sex workers - and have shown a variable prevalence rate ranging from 1.1 to 45%. One concern about comparing these studies is that the enzyme-linked immunosorbent assay (ELISA) test is estimated to be only 65-70% sensitive. The data of CT prevalence among women undergoing treatment for infertility, using more sensitive methods, such as Nucleic Acid Amplification Test (NAAT), are sparse. The disease is easily treatable, and knowledge of prevalence will provide the burden of disease on fertility.

Methods

A cross-sectional hospital-based observational study was carried out on 169 patients attending an infertility clinic at assisted reproductive technology (ART) center or gynecology outpatient department (OPD) of a tertiary care hospital.

Results

The overall prevalence was 8.87% with the highest prevalence (53.84%) among the women having vaginal discharge. The prevalence in patients with secondary infertility (10.81%) was higher than in those with primary infertility (7.36%).

Conclusion

It is recommended that patients attending gynecological OPD in low resource setting to be treated for Chlamydia empirically and if facilities permit then they should undergo NAAT for CT detection. Screening programs are warranted among Indian women of child bearing age to prevent complications of Chlamydia infection like tubal blockage and dyspareunia.

Associations of hospital-treated infections with subsequent dementia: nationwide 30-year analysis

Infections, which can prompt neuroinflammation, may be a risk factor for dementia1-5. More information is needed concerning associations across different infections and different dementias, and from longitudinal studies with long follow-ups. This New Zealand-based population register study tested whether infections antedate dementia across three decades. We identified individuals born between 1929 and 1968 and followed them from 1989 to 2019 (n = 1,742,406, baseline age = 21-60 years). Infection diagnoses were ascertained from public hospital records. Dementia diagnoses were ascertained from public hospital, mortality and pharmaceutical records. Relative to individuals without an infection, those with an infection were at increased risk of dementia (hazard ratio 2.93, 95% confidence interval 2.68-3.20). Associations were evident for dementia diagnoses made up to 25-30 years after infection diagnoses. Associations held after accounting for preexisting physical diseases, mental disorders and socioeconomic deprivation. Associations were evident for viral, bacterial, parasitic and other infections, and for Alzheimer's disease and other dementias, including vascular dementia. Preventing infections might reduce the burden of neurodegenerative conditions.

Overadjustment bias in systematic reviews and meta-analyses of socio-economic inequalities in health: a meta-research scoping review

BACKGROUND

Overadjustment bias occurs when researchers adjust for an explanatory variable on the causal pathway from exposure to outcome, which leads to biased estimates of the causal effect of the exposure. This meta-research review aimed to examine how previous systematic reviews and meta-analyses of socio-economic inequalities in health have managed overadjustment bias.

METHODS

We searched Medline and Embase until 16 April 2021 for systematic reviews and meta-analyses of observational studies on associations between individual-level socio-economic position and health outcomes in any population. A set of criteria were developed to examine methodological approaches to overadjustment bias adopted by included reviews (rated Yes/No/Somewhat/Unclear).

RESULTS

Eighty-four reviews were eligible (47 systematic reviews, 37 meta-analyses). Regarding approaches to overadjustment, whereas 73% of the 84 reviews were rated as Yes for clearly defining exposures and outcomes, all other approaches were rated as Yes for <55% of reviews; for instance, 5% clearly defined confounders and mediators, 2% constructed causal diagrams and 35% reported adjusted variables for included studies. Whereas only 2% included overadjustment in risk of bias assessment, 54% included confounding. Of the 37 meta-analyses, 16% conducted sensitivity analyses related to overadjustment.

CONCLUSIONS

Our findings suggest that overadjustment bias has received insufficient consideration in systematic reviews and meta-analyses of socio-economic inequalities in health. This is a critical issue given that overadjustment bias is likely to result in biased estimates of health inequalities and accurate estimates are needed to inform public health interventions. There is a need to highlight overadjustment bias in review guidelines.

Seroepidemiology of Treponema pallidum, Mycoplasma hominis, and Ureaplasma urealyticum in fertility treatment-seeking patients in the Emirate of Abu Dhabi, United Arab Emirates

BACKGROUND

Several genital pathogens affect fertility. The study estimated the seroprevalence of Treponema pallidum, Ureaplasma urealyticum, and Mycoplasma hominis and identify specific factors associated with exposure to at least one of these pathogens in patients seeking fertility treatment in the Emirate of Abu Dhabi, United Arab Emirates.

METHODS

A seroepidemiological survey was conducted in a major fertility clinic in the Emirate of Abu Dhabi. Serum samples were screened for eight immunoglobulins (IgG, IgM, and IgA) against T. pallidum, U. urealyticum, and M. hominis using enzyme-linked immunoassays. Factors associated with seropositivity to at least one of the pathogens were investigated.

RESULTS

The study surveyed 308 patients seeking fertility treatment (mean age: 36.1 ± 6.8 years). Most patients were female (88.0%), 24.9% had at least one chronic comorbidity, 19.3% had a previous genital infection, and 68.1% had been diagnosed with infertility for ≥ 6 months. Ig seroprevalence of T. pallidum (IgG: 3.0%, IgM: 3.2%), U. urealyticum (IgG: 2.6%, IgM: 2.0%), and M. hominis (IgG: 33.9%) was 6.4%, 4.6%, and 49.0%, respectively. Nearly one quarter (23.0%) and one decile (9.2%) of the patients exhibited evidence of ongoing infection (IgM seropositivity) or recent infection (IgA seropositivity) with M. hominis, respectively. Overall, 53.0% of the patients were seropositive for at least one of the screened immunoglobulins. Patients with an education level of secondary schooling or below (66.2%) or those who were unemployed (61.1%) had a higher seroprevalence of IgG antibodies compared with patients with college or higher-level education (48.4%) or those who were employed (48.1%) (p < 0.05).

CONCLUSION

Exposure to T. pallidum or U. urealyticum was relatively low, whereas that to M. hominis was common in the surveyed patients. Enhanced awareness and screening programmes for genital pathogens are crucial to prevent and control the transmission of infections and reduce the growing burden of infertility.

Health inequalities in infectious diseases: a systematic overview of reviews

OBJECTIVES

The aim of this systematic overview of reviews was to synthesise available evidence on inequalities in infectious disease based on three dimensions of inequalities; inclusion health groups, protected characteristics and socioeconomic inequalities.

METHODS

We searched MEDLINE, Embase, Web of Science and OpenGrey databases in November 2021. We included reviews published from the year 2000 which examined inequalities in the incidence, prevalence or consequences of infectious diseases based on the dimensions of interest. Our search focused on tuberculosis, HIV, sexually transmitted infections, hepatitis C, vaccination and antimicrobial resistance. However, we also included eligible reviews of any other infectious diseases. We appraised the quality of reviews using the Assessment of Multiple Systematic Reviews V.2 (AMSTAR2) checklist. We conducted a narrative data synthesis.

RESULTS

We included 108 reviews in our synthesis covering all the dimensions of inequalities for most of the infectious disease topics of interest, however the quality and volume of review evidence and consistency of their findings varied. The existing literature reviews provide strong evidence that people in inclusion health groups and lower socioeconomic status are consistently at higher risk of infectious diseases, antimicrobial resistance and incomplete/delayed vaccination. In the protected characteristics dimension, ethnicity, and sexual orientation are important factors contributing to inequalities across the various infectious disease topics included in this overview of reviews.

CONCLUSION

We identified many reviews that provide evidence of various types of health inequalities in different infectious diseases, vaccination, and antimicrobial resistance. We also highlight areas where reviews may be lacking. The commonalities in the associations and their directions suggest it might be worth targeting interventions for some high risk-groups that may have benefits across multiple infectious disease outcomes rather than operating purely in infectious disease siloes.

Chlamydia trachomatis prevalence in females in São Paulo, Brazil: 11 years' surveillance of the infection

BACKGROUND

Chlamydia trachomatis (CT) infection is the most prevalent sexually transmitted bacterial disease worldwide whose greatest impact is on the female reproductive system. The objective was to assess the prevalence of Chlamydia infection in a large population of female patients from a private health service in São Paulo (Brazil), identifying the main age groups affected by the agent and the evolution of the prevalence.

METHODS

A cross-sectional study was conducted based on the results of all molecular biology tests. The tests were carried out between January 2005 and December 2015. The positivity of test results was determined by year and age group.

RESULTS

A total of 85,292 patients who performed 103,576 tests for Chlamydia were considered eligible for the statistical data. The overall prevalence of C. trachomatis infection in the study population was 2.2% (95% CI: 2.07-2.25). A higher prevalence of infection was observed in the ≤ 25 years and ≤ 30 years age groups, with rates of 6.0% (95% CI: 5.59-6.35) and 4.4% (95% CI: 4.08-4.50), respectively. There was a significant increase in the positivity of the exams over time, especially in the ≤ 35 years age group. The prevalence at 26-30 years was 3.1% (95% CI: 2.82-3.30); 31-35 years 1.7% (95% CI: 1.50-1.82); 36-40 years 1.0% (95% CI: 0.86-1.16); 41-60 years 0.6% (95% CI: 0.50-0.70) and the prevalence at ≥ 61 years was 0.4% (95% CI: 0.11-0.75).

CONCLUSION

The screening of asymptomatic young women would have the potential to reduce infection, transmission, and sequelae of infection by this agent.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Socioeconomic, behavioural and health factors associated with chlamydia testing in sexually active young women: an Australian observational cohort study

BACKGROUND

Chlamydia trachomatis is the most frequently notified sexually transmitted infection in Australia. Untreated infections in women can cause health problems. Professional guidelines encourage opportunistic testing of young people. To increase understanding of who is being tested, we investigated factors associated with testing in a population of young women.

METHODS

In total, 14002 sexually active women, aged 18-23 years at baseline (2013), from the Australian Longitudinal Study on Women's Health, were included. We used random intercepts, mixed-effects binary logistic regression with robust standard errors to assess associations between socioeconomic, health and behavioural factors and chlamydia testing.

RESULTS

Associations between chlamydia testing and partner status varied by a woman's body mass index (BMI). Compared to women with a stable partner/BMI <25kg/m2 , women with a stable partner/BMI ≥25kg/m2 were less likely to be tested (adjusted odds ratios [AOR]=0.79, 95% CI: 0.71-0.88). In contrast, although women without a partner were more likely to be tested irrespective of BMI, the odds were higher for those with a BMI <25kg/m2 (AOR=2.68, 95% CI: 2.44-2.94) than a BMI ≥25kg/m2 (AOR=1.65, 95% CI: 1.48-1.84). Women who reported a prior chlamydia infection were also more likely to be tested (AOR=2.01, 95% CI: 1.83-2.20), as were women engaging in any combination of cannabis use and/or heavy episodic drinking compared to doing neither of these activities.

CONCLUSIONS

Women without a partner, women with a prior chlamydia infection and those engaging in risk-taking behaviours are more likely to have chlamydia testing. Additional research is needed to understand whether there are deficits in testing among overweight/obese women.

What is the effectiveness of community-based health promotion campaigns on chlamydia screening uptake in young people and what barriers and facilitators have been identified? A mixed-methods systematic review

BACKGROUND

The UK National Chlamydia Screening Programme uses an opportunistic approach. Many programmes use campaigns to raise awareness of chlamydia screening in young people. This review aimed to assess the effectiveness of campaigns on uptake of chlamydia screening in young people.

METHODS

We conducted a mixed-methods systematic review of articles assessing the outcomes of community-based health-promotion campaigns to increase chlamydia screening in young people, their experiences of the campaigns and other facilitators and barriers to the conduct of the campaigns. We searched four databases for quantitative and qualitative studies with no language restrictions.

MAIN RESULTS

From 10 329 records identified, 19 studies (20 articles) were included in the review: 14 quantitative, 2 qualitative and 3 mixed methods. All studies with quantitative outcomes were before-after study designs or interrupted time series. The prediction interval for relative change (RC) in test counts ranged from 0.95 to 1.56, with a summary pooled estimate of RC 1.22 (95% CI 1.14 to 1.30, 13 studies, I²=97%). For test positivity rate, 95% prediction interval was 0.59 to 1.48, with a summary pooled estimate of RC 0.93 (95% CI 0.81 to 1.07, 8 studies, I²=91.8%). Large variation in characteristics between studies precluded exploring outcomes by type of campaign components. Seven major qualitative themes to improve screening were identified: targeting of campaigns; quality of materials and message; language; anonymity; use of technology; relevance; and variety of testing options.

CONCLUSIONS

Health promotion campaigns aiming to increase chlamydia testing in those aged 15-24 years may show some effectiveness in increasing overall numbers of tests, however numbers of positive tests do not follow the same trend. Qualitative findings indicate that campaigns require clear, relevant messaging that displays the full range of testing options and assures anonymity in order to be effective.

Management of chlamydia and gonorrhoea infections diagnosed in primary care using a centralised nurse-led telephone-based service: mixed methods evaluation

BACKGROUND

Up to 18% of genital Chlamydia infections and 9% of Gonorrhoea infections in England are diagnosed in Primary Care. Evidence suggests that a substantial proportion of these cases are not managed appropriately in line with national guidelines. With the increase in sexually transmitted infections and the emergence of antimicrobial resistance, their timely and appropriate treatment is a priority. We investigated feasibility and acceptability of extending the National Chlamydia Screening Programme's centralised, nurse-led, telephone management (NLTM) as an option for management of all cases of chlamydia and gonorrhoea diagnosed in Primary Care.

METHODS

Randomised feasibility trial in 11 practices in Bristol with nested qualitative study. In intervention practices patients and health care providers (HCPs) had the option of choosing NLTM or usual care for all patients tested for Chlamydia and Gonorrhoea. In control practices patients received usual care.

RESULTS

One thousand one hundred fifty-four Chlamydia/gonorrhoea tests took place during the 6-month study, with a chlamydia positivity rate of 2.6% and gonorrhoea positivity rate of 0.8%. The NLTM managed 335 patients. Interviews were conducted with sixteen HCPs (11 GPs, 5 nurses) and 12 patients (8 female). HCPs were positive about the NLTM, welcomed the partner notification service, though requested more timely feedback on the management of their patients. Explaining the NLTM to patients didn't negatively impact on consultations. Patients found the NLTM acceptable, more convenient and provided greater anonymity than usual care. Patients appreciated getting a text message regarding a negative result and valued talking to a sexual health specialist about positive results.

CONCLUSION

Extension of this established NLTM intervention to a greater proportion of patients was both feasible and acceptable to both patients and HCP, could provide a better service for patients, whilst decreasing primacy care workload. The study provides evidence to support the wider implementation of this NLTM approach to managing chlamydia and gonorrhoea diagnosed in primary care.

Association of Sexual Health Interventions With Sexual Health Outcomes in Black Adolescents: A Systematic Review and Meta-analysis

IMPORTANCE

Black adolescents are at increased risk of contracting HIV and other sexually transmitted infections (STIs) and experiencing unplanned pregnancy. Although sexual health interventions aimed at decreasing these risks exist, evidence of the association between sexual health interventions and the sexual behavior of black adolescents has not been synthesized to our knowledge.

OBJECTIVE

To examine the associations between sexual health interventions and behavioral, biological, and psychological outcomes.

DATA SOURCES

For this systematic review and meta-analysis, a systematic search was conducted of studies published through January 31, 2019, using the PubMed, PsycINFO, and CINAHL databases and relevant review articles. The following key words were used: youth, adolesc* or teen*; sexual health or safe* sex or sexually transmitted disease or sexually transmitted infection or STD or STI or HIV or AIDS or pregnancy or reproductive health or condom* or contracept* or unprotected sex or abstinence; intervention or program or education or prevention or promotion or trial; latino* or latina* or latinx* or minorit* or ethnic* or hispanic or african american* or black* or race or racial or biracial.

STUDY SELECTION

Studies were included if they included a US-based sample of black adolescents, evaluated a sexual health intervention using experimental or quasi-experimental designs, included a behavioral outcome, and were published in English.

DATA EXTRACTION AND SYNTHESIS

Standardized mean differences and 95% CIs were extracted and meta-analyzed using random-effects models.

MAIN OUTCOMES AND MEASURES

Behavioral outcomes were abstinence, condom use, and number of sex partners. Biological outcomes were pregnancy and STI contraction. Psychological outcomes were sexual health intentions, knowledge, and self-efficacy.

RESULTS

Across 29 studies including 11 918 black adolescents (weighted mean age, 12.43 years), there was a significant weighted mean association of sexual health interventions with improvements in abstinence (Cohen d = 0.14; 95% CI, 0.05-0.24) and condom use (Cohen d = 0.25; 95% CI, 0.11-0.39). No significant mean association of these interventions with number of sex partners, pregnancy, or STI contraction was found. Sexual health interventions were significantly associated with improvements in psychological outcomes: sexual health intentions (Cohen d = 0.17; 95% CI, 0.05-0.30), knowledge (Cohen d = 0.46; 95% CI, 0.30-0.63), and self-efficacy (Cohen d = 0.19; 95% CI, 0.09-0.28). Intervention effect sizes were consistent across factors, such as participant sex and age and intervention dose.

CONCLUSIONS AND RELEVANCE

The findings suggest that sexual health interventions are associated with improvements in sexual well-being among black adolescents. There appears to be a need for wide-scale dissemination of these programs to address racial disparities in sexual health across the US.

Concurrent and Time-Lagged Effects of Social Disorganization on Chlamydia Rate Trajectories Among United States Counties and the District of Columbia, 2010-2015

OBJECTIVE

To examine the longitudinal relationship between social disorganization (SD) and genital Chlamydia trachomatis infection.

METHODS

US county-level data for 2010 to 2015 were used. Reliability and principal component analysis revealed 2 SD factors: socioeconomic deprivation and demographic instability. Growth curve models examined the degree to which SD factors affected chlamydia rates (number of new reported cases per 100,000 population) at baseline and over time adjusting for population percentage aged 15 to 24 years, male to female ratio for population aged 15 to 24 years, and rural percentage. Regression models explored 1- and 3-year time-lagged effects.

RESULTS

Among 2961 counties, the average baseline chlamydia rate was 320.3 with an average increase of 7.7 cases per year. Higher baseline deprivation was associated with higher baseline chlamydia rates (P < 0.0001) but lower increases over time (P < 0.0001). Higher demographic instability was associated with lower baseline rates (P < 0.0001) but higher increases over time (P < 0.0001). Deprivation was associated with 1- and 3-year lagged rates (P < 0.0001).

CONCLUSIONS

On average, chlamydia rates increased across US counties, and more rapidly for counties with the highest demographic instability.

Primary care integration of sexual and reproductive health services for chlamydia testing across WHO-Europe: a systematic review

OBJECTIVE

To identify current uptake of chlamydia testing (UCT) as a sexual and reproductive health service (SRHS) integrated in primary care settings of the WHO European region, with the aim to shape policy and quality of care.

DESIGN

Systematic review for studies published from January 2001 to May 2018 in any European language.

DATA SOURCES

OVID Medline, EMBASE, Maternal and Infant Care and Global Health.

ELIGIBILITY CRITERIA

Published studies, which involved women or men, adolescents or adults, reporting a UCT indicator in a primary care within a WHO European region country. Study designs considered were: randomised control trials (RCTs), quasi-experimental, observational (eg, cohort, case-control, cross-sectional) and mixed-methods studies as well as case reports.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers screened the sources and validated the selection process. The BRIGGS Critical Appraisal Checklist for Analytical Cross-Sectional Studies, the Mixed Methods Appraisal Tool 2011 and Critical Appraisal Skills Programme (CASP) checklists were considered for quality and risk of bias assessment.

RESULTS

24 studies were finally included, of which 15 were cross-sectional, 4 cohort, 2 RCTs, 2 case-control studies and 1 mixed-methods study. A majority of the evidence cites the UK model, followed by the Netherlands, Denmark, Norway and Belgium only. Acceptability if offered test in primary healthcare (PHC) ranged from 55% to 81.4% in women and from 9.5% to 70.6% when both genders were reported together. Men may have a lower UCT compared with women. When both genders were reported together, the lowest acceptability was 9.5% in the Netherlands. Denmark presented the highest percentage of eligible people who tested in a PHC setting (87.3%).

CONCLUSIONS

Different health systems may influence UCT in PHC. The regional use of a common testing rate indicator is suggested to homogenise reporting. There is very little evidence on integration of SRHS such as chlamydia testing in PHC and there are gaps between European countries.

Antibody Testing in Estimating Past Exposure to Chlamydia trachomatis in the Netherlands Chlamydia Cohort Study

The asymptomatic course of Chlamydia trachomatis (CT) infections can result in underestimated CT lifetime prevalence. Antibody testing might improve this estimate. We assessed CT antibody positivity and predictive factors thereof in the Netherlands Chlamydia Cohort Study. Women who had ≥1 CT Nucleic Acid Amplification Test (NAAT) in the study (2008–2011) and who provided self-reported information on NAATs were tested for CT major outer membrane protein specific IgG in serum (2016). CT antibody positivity was assessed and predictive factors were identified using multivariable logistic regressions, separately for CT-positive women (≥1 positive NAAT or ≥1 self-reported positive CT test) and CT-negative women (negative by study NAAT and self-report). Of the 3,613 women studied, 833 (23.1%) were CT -positive. Among the CT-negative women, 208 (7.5%, 95% CI 6.5–8.5) tested positive for CT antibodies. This increased CT lifetime prevalence with 5.8% (95% CI 5.0–6.5). Among women with a CT-positive history, 338 (40.6%, 95% CI 38.5–44.1) tested positive. Predictive factors for antibody positivity related to lower social economic status, sexual risk behavior, multiple infections, higher body mass index, and non-smoking. CT antibody testing significantly increased the lifetime prevalence. Combining NAAT outcomes, self-reported positive tests, and antibody testing reduced misclassification in CT prevalence estimates.

Genital Chlamydia infection in hyperlipidemic mouse models exacerbates atherosclerosis

BACKGROUND AND AIMS

Atherosclerosis is a chronic inflammatory disease, and recent studies have shown that infection at remote sites can contribute to the progression of atherosclerosis in hyperlipidemic mouse models. In this report, we tested the hypothesis that genital Chlamydia infection could accelerate the onset and progression of atherosclerosis.

METHODS

Apolipoprotein E (Apoe^-/-) and LDL receptor knockout (Ldlr^-/-) mice on a high-fat diet were infected intra-vaginally with Chlamydia muridarum. Atherosclerotic lesions on the aortic sinuses and in the descending aorta were assessed at 8-weeks post-infection. Systemic, macrophage, and vascular site inflammatory responses were assessed and quantified.

RESULTS

Compared to the uninfected groups, infected Apoe^-/- and Ldlr^-/- mice developed significantly more atherosclerotic lesions in the aortic sinus and in the descending aorta. Increased lesions were associated with higher circulating levels of serum amyloid A-1, IL-1β, TNF-α, and increased VCAM-1 expression in the aortic sinus, suggesting an association with inflammatory responses observed during C. muridarum infection. Genital infection courses were similar in Apoe^-/-, Ldlr^-/-, and wild type mice. Further, Apoe^-/- mice developed severe uterine pathology with increased dilatations. Apoe-deficiency also augmented cytokine/chemokine response in C. muridarum infected macrophages, suggesting that the difference in macrophage response could have contributed to the genital pathology in Apoe^-/- mice.

CONCLUSIONS

Overall, these studies demonstrate that genital Chlamydia infection exacerbates atherosclerotic lesions in hyperlipidemic mouse and suggest a novel role for Apoe in full recovery of uterine anatomy after chlamydial infection.

Prevalence, risk factors and molecular characterization of Chlamydia trachomatis in pregnant women from Córdoba, Argentina: A prospective study

Background

Chlamydia trachomatis causes the most prevalent bacterial Sexual Transmitted Infection. In pregnant women, untreated chlamydial infections are associated with abortions, premature rupture of membranes, postpartum endometritis, low birth weight and transmission to the newborn. In Córdoba, Argentina, there is little knowledge about the prevalence of Chlamydia trachomatis in women in their third trimester of pregnancy, so, the aim of this study was to evaluate Chlamydia trachomatis prevalence and genotypes present in Cordovan pregnant women with different age and socioeconomic status.

Methods and findings

Design: prospective study.

Settings: Women population from Cordoba city, Argentina.

Population: Pregnant women having 35 to 37 weeks of gestation.

Methods: Five hundred and nine cervical swabs were collected. Each sample was subjected to DNA extraction and PCR for Chlamydia trachomatis using primers NRO/NLO and CTP1/CTP2. Positives samples were sequenced to determine genotype. Main outcome measures: Demographic data of the patients were collected to detect a population at risk for this infection.

Results

A prevalence of 6.9% (35/509) for Chlamydia trachomatis infection was detected, with 32/295 and 3/214 from pregnant women with low or better economic resources respectively (p = 0,0001). Results showed a significantly increased rate of 11.6% (30/258) in women under 25 years compared with 2% (5/251) in patients over that age (p = 0,00003). Genotype E was the most prevalent.

Conclusions

With these results, we can say that pregnant women under 25 years old and low economic resources are one of the populations in which the screening programs of Chlamydia trachomatis should focus.

The Impact of Screening and Partner Notification on Chlamydia Prevalence and Numbers of Infections Averted in the United States, 2000-2015: Evaluation of Epidemiologic Trends Using a Pair-Formation Transmission Model

Population-level effects of control strategies on the dynamics of Chlamydia trachomatis transmission are difficult to quantify. In this study, we calibrated a novel sex- and age-stratified pair-formation transmission model of chlamydial infection to epidemiologic data in the United States for 2000–2015. We used sex- and age-specific prevalence estimates from the National Health and Nutrition Examination Surveys, case report data from national chlamydia surveillance, and survey data from the Youth Risk Behavior Survey on the proportion of the sexually active population aged 15–18 years. We were able to reconcile national prevalence estimates and case report data by allowing for changes over time in screening coverage and reporting completeness. In retrospective analysis, chlamydia prevalence was estimated to be almost twice the current levels in the absence of screening and partner notification. Although chlamydia screening and partner notification were both found to reduce chlamydia burden, the relative magnitude of their estimated impacts varied in our sensitivity analyses. The variation in the model predictions highlights the need for further data collection and research to improve our understanding of the natural history of chlamydia and the pathways through which prevention strategies affect transmission dynamics.

Prevalence of Chlamydia Trachomatis, Neisseria Gonorrhoeae, and Trichomonas Vaginalis Infection in Chilean Adolescents and Young Adults

STUDY OBJECTIVE

To determine the prevalence of Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis infection in sexually active Chilean adolescents and young adults. A comparative analysis was performed between genders to identify demographic, clinical, and sexual behavior characteristics to predict the occurrence of C trachomatis.

DESIGN

Analytical observational study.

SETTING

Santiago, Chile.

PARTICIPANTS

Two hundred eighty-six sexually active volunteers aged 24 years or younger (171 female and 115 male); 82.9% (237/286) of them were classified as having high socioeconomic status.

INTERVENTIONS

Confidential survey and self-collected samples (urine for men and vaginal swabs for women).

MAIN OUTCOME MEASURES

Prevalence, demographic characteristics, symptoms, and sexual behavior characteristics.

RESULTS

The prevalence rate of C trachomatis was 8.7% (10/115) in men and 8.8% (15/171) in women (P = .58). N gonorrhoeae was detected in 1 subject, whereas no T vaginalis cases were detected. In multivariate analysis, having some college education was protective (odds ratio [OR], 0.28; 95% confidence interval [CI], 0.09-0.89), whereas having a higher number of sexual partners was a risk factor (OR, 1.19; 95% CI, 1.1-1.3) for C trachomatis infection. The latter was also predicted by postcoital bleeding (OR, 4.6; 95% CI, 1.30-16.23) in the female model.

CONCLUSION

C trachomatis infection rates were similar between both genders. Protective characteristics for the occurrence of this infection were having some college education, lower number of sexual partners, and if female, the absence of postcoital bleeding. This study highlights the importance of C trachomatis screening among the Chilean affluent population younger than 25 years. However, further studies are needed in a more diverse and representative sample to recommend universal screening in Chilean adolescents and young adults.

Trichomonas vaginalis is most frequently detected in women at the age of peri-/premenopause: an unusual pattern for a sexually transmitted pathogen

BACKGROUND

Trichomonas vaginalis is the most common nonviral sexually transmitted infection. However, because it is not a reportable disease in the United States, there is limited information on the age of infected individuals and their geographic distribution.

OBJECTIVE

The purpose of this study was to evaluate the detection rates of T vaginalis infection compared with Chlamydia trachomatis by age and state in a commercial laboratory setting.

STUDY DESIGN

Quantitative real-time polymerase chain reactions were used to detect the presence of T vaginalis and C trachomatis in cervicovaginal samples that were obtained during gynecologic examinations. A total of 1,554,966 and 1,999,077 samples from females 10-79 years old were analyzed retrospectively for the presence of T vaginalis and C trachomatis, respectively.

RESULTS

The highest detection rate of an infection with T vaginalis was ages 47-53 years. For C trachomatis, the highest detection rate was ages 14-20 years. T vaginalis detection rate distribution by age shows a bimodal pattern with first peak at ages 21-22 years (4.0-4.1%) and a higher second peak at ages 48-51 years (5.4-5.8%). C trachomatis prevalence distribution by age shows a maximum peak of 8.6% at age 17 years and a rapid decline thereafter. In general, the detection rates of both pathogens were higher in the southeast and in states along the Mississippi River Valley than in other parts of the country. A nucleotide polymorphism associated with T vaginalis metronidazole resistance (ntr6_TVK80STOP) was not associated with age and was found most frequently in specimens from New Mexico and Vermont.

CONCLUSIONS

The detection rate of T vaginalis does not appear to decrease with age as observed for C trachomatis and reaches maximum rates in women 48-51 years old. The geographic distribution of T vaginalis appears to be broadly similar to that of other sexually transmitted diseases. The ntr6_TVK80STOP polymorphism did not have a specific association with age or geography.

Chlamydia trachomatis Incidence Using Self-Reports and Serology by Gender, Age Period, and Sexual Behavior in a Birth Cohort

BACKGROUND

Although understanding chlamydia incidence assists prevention and control, analyses based on diagnosed infections may distort the findings. Therefore, we determined incidence and examined risks in a birth cohort based on self-reports and serology.

METHODS

Self-reported chlamydia and behavior data were collected from a cohort born in New Zealand in 1972/3 on several occasions to age 38 years. Sera drawn at ages 26, 32, and 38 years were tested for antibodies to Chlamydia trachomatis Pgp3 antigen using a recently developed assay, more sensitive in women (82.9%) than men (54.4%). Chlamydia incidence by age period (first coitus to age 26, 26-32, and 32-38 years) was calculated combining self-reports and serostatus and risk factors investigated by Poisson regression.

RESULTS

By age 38 years, 32.7% of women and 20.9% of men had seroconverted or self-reported a diagnosis. The highest incidence rate was to age 26, 32.7 and 18.4 years per 1000 person-years for women and men, respectively. Incidence rates increased substantially with increasing number of sexual partners. After adjusting age period incidence rates for partner numbers, a relationship with age was not detected until 32 to 38 years, and then only for women.

CONCLUSIONS

Chlamydia was common in this cohort by age 38, despite the moderate incidence rates by age period. The strongest risk factor for incident infection was the number of sexual partners. Age, up to 32 years, was not an independent factor after accounting for partner numbers, and then only for women. Behavior is more important than age when considering prevention strategies.

Community-Level HIV Stigma as a Driver for HIV Transmission Risk Behaviors and Sexually Transmitted Diseases in Sierra Leone: A Population-Based Study

INTRODUCTION

Although HIV stigma has been identified as an important risk factor for HIV transmission risk behaviors, little is known about the contribution of community-level HIV stigma to HIV transmission risk behaviors and self-reported sexually transmitted diseases (STDs) or how gender may modify associations.

METHODS

We pooled data from the 2008 and 2013 Sierra Leone Demographic and Health Surveys. For HIV stigma, we examined HIV stigmatizing attitudes and HIV disclosure concerns at both individual and community levels. Outcomes of HIV transmission risk behaviors were recent condom usage, consistent condom usage, and self-reported STDs. We assessed associations with multivariable logistic regressions. We also analyzed gender as an effect modifier of these associations.

RESULTS

Of 34,574 respondents, 24,030 (69.5%) who had heard of HIV were included in this analysis. Community-level HIV stigmatizing attitudes and disclosure concerns were associated with higher odds of self-reported STDs (adjusted odds ratio = 2.07; 95% confidence interval: 1.55 to 2.77; adjusted odds ratio = 2.95; 95% confidence interval: 1.51 to 5.58). Compared with men, community-level HIV stigmatizing attitudes among women were a stronger driver of self-reported STDs (interaction P = 0.07). Gender modified the association between community-level HIV disclosure concerns and both recent and consistent condom usage (interaction P = 0.03 and P = 0.002, respectively). Community-level HIV disclosure concerns among women were observed to be a driver of risky sex and self-reported STDs.

CONCLUSIONS

This study shows that community-level HIV stigma may be a driver for risky sex and self-reported STDs, particularly among women. Our findings suggest that community-held stigmatizing beliefs and HIV disclosure concerns among women might be important targets for HIV stigma reduction interventions.

Sexually transmitted infections: challenges ahead

WHO estimated that nearly 1 million people become infected every day with any of four curable sexually transmitted infections (STIs): chlamydia, gonorrhoea, syphilis, and trichomoniasis. Despite their high global incidence, STIs remain a neglected area of research. In this Commission, we have prioritised five areas that represent particular challenges in STI treatment and control. Chlamydia remains the most commonly diagnosed bacterial STI in high-income countries despite widespread testing recommendations, sensitive and specific non-invasive testing techniques, and cheap effective therapy. We discuss the challenges for chlamydia control and evidence to support a shift from the current focus on infection-based screening to improved management of diagnosed cases and of chlamydial morbidity, such as pelvic inflammatory disease. The emergence and spread of antimicrobial resistance in Neisseria gonorrhoeae is globally recognised. We review current and potential future control and treatment strategies, with a focus on novel antimicrobials. Bacterial vaginosis is the most common vaginal disorder in women, but current treatments are associated with frequent recurrence. Recurrence after treatment might relate to evidence that suggests sexual transmission is integral to the pathogenesis of bacterial vaginosis, which has substantial implications for the development of effective management approaches. STIs disproportionately affect low-income and middle-income countries. We review strategies for case management, focusing on point-of-care tests that hold considerable potential for improving STI control. Lastly, STIs in men who have sex with men have increased since the late 1990s. We discuss the contribution of new biomedical HIV prevention strategies and risk compensation. Overall, this Commission aims to enhance the understanding of some of the key challenges facing the field of STIs, and outlines new approaches to improve the clinical management of STIs and public health.

A Multigroup, Longitudinal Study of Truant Youths, Marijuana Use, Depression, and STD-Associated Sexual Risk Behavior

Truant youth are likely to engage in a number of problem behaviors, including sexual risky behaviors. Previous research involving non-truant youth has found sexual risk behaviors to be related to marijuana use and depression, with differential effects for male and female youth. Using data collected in a NIDA funded, prospective intervention project, results are reported of a male-female, multi-group, longitudinal analysis of the relationships among truant youth baseline sexual risk behavior, marijuana use, and depression, and their sexual risk behavior over four follow-up time points. Results indicated support for the longitudinal model, with female truants having higher depression scores, and showing stronger relationships between baseline depression and future engagement in sexual risk behavior, than male truants. Findings suggest that incorporating strategies to reduce depression and marijuana use may decrease youth sexual risk behavior.

Alcohol and marijuana use in pathways of risk for sexually transmitted infection in white and black adolescent females

BACKGROUND

Some types of sexually transmitted infection (STI) have higher prevalence in females than males, and among black, relative to white, females. Identifying mechanisms of STI risk is critical to effective intervention. The authors tested a model in which alcohol and marijuana use serve as mediating factors in the associations between depression and conduct problems with sexual risk behavior (SRB) and STI in adolescent females.

METHODS

The Pittsburgh Girls Study is a longitudinal observational study of females who have been followed annually to track the course of mental and physical health conditions. The 3 oldest cohorts (N = 1750; 56.8% black, 43.2% white) provided self-reports of substance use, depression and conduct problems, SRB, and STI at ages 16-18. A path model tested alcohol and marijuana use at age 17 as mechanisms that mediate the associations of depression and conduct problems at age 16 with SRB and STI at age 18.

RESULTS

Race was involved in 2 risk pathways. In one pathway, white females reported greater alcohol use, which was associated with greater SRB. In another pathway, black females reported earlier sexual onset, which was associated with subsequent SRB. Public assistance use was independently associated with early sexual onset and STI. SRB, but not substance use, mediated the association of depression and conduct problems with STI.

CONCLUSIONS

Differences by race in pathways of risk for SRB and STI, involving, for example, alcohol use and early sexual onset, were identified for young white and black females, respectively. Depression and conduct problems may signal risk for SRB and STI in young females, and warrant attention to improve health outcomes.

Chlamydia trachomatis Genital Infections

Etiology, transmission and protection: Chlamydia trachomatis is the leading cause of bacterial sexually transmitted infection (STI) globally. However, C. trachomatis also causes trachoma in endemic areas, mostly Africa and the Middle East, and is a leading cause of preventable blindness worldwide. Epidemiology, incidence and prevalence: The World Health Organization estimates 131 million new cases of C. trachomatis genital infection occur annually. Globally, infection is most prevalent in young women and men (14-25 years), likely driven by asymptomatic infection, inadequate partner treatment and delayed development of protective immunity. Pathology/Symptomatology: C. trachomatis infects susceptible squamocolumnar or transitional epithelial cells, leading to cervicitis in women and urethritis in men. Symptoms are often mild or absent but ascending infection in some women may lead to Pelvic Inflammatory Disease (PID), resulting in reproductive sequelae such as ectopic pregnancy, infertility and chronic pelvic pain. Complications of infection in men include epididymitis and reactive arthritis. Molecular mechanisms of infection: Chlamydiae manipulate an array of host processes to support their obligate intracellular developmental cycle. This leads to activation of signaling pathways resulting in disproportionate influx of innate cells and the release of tissue damaging proteins and pro-inflammatory cytokines. Treatment and curability: Uncomplicated urogenital infection is treated with azithromycin (1 g, single dose) or doxycycline (100 mg twice daily x 7 days). However, antimicrobial treatment does not ameliorate established disease. Drug resistance is rare but treatment failures have been described. Development of an effective vaccine that protects against upper tract disease or that limits transmission remains an important goal.

Chlamydia diagnosis rate in England in 2012: an ecological study of local authorities

OBJECTIVES

Local authorities (LAs) in England commission chlamydia screening as part of the National Chlamydia Screening Programme. It is recommended that LAs achieve a chlamydia diagnosis rate of ≥2300 cases per 100 000 population aged 15-24. We describe national patterns in attainment of the chlamydia diagnosis rate recommendation and possible implications of using it to measure LA-level performance.

METHODS

We used publicly available data sets from England (2012) to explore the association between LAs attaining the recommended chlamydia diagnosis rate and population size, socioeconomic deprivation, test setting and sex.

RESULTS

We used data from 1 197 121 recorded chlamydia tests in females and 564 117 in males. The chlamydia diagnosis rate recommendation was achieved by 22% (72/324) of LAs overall (43% female population; 8% male population). LAs in the highest deprivation quintile were more likely to reach the recommendation than those in the least-deprived quintile for both sexes (women: unadjusted prevalence ratio (UPR) 7.43, 95% CI 3.65 to 15.11; men: UPR 7.00, 95% CI 1.66 to 29.58). The proportion of tests performed in genitourinary medicine clinics was negatively associated with attainment of the recommended diagnosis rate (UPR 0.95, 0.93 to 0.97).

CONCLUSIONS

Chlamydia diagnosis rate recommendations that reflect local area deprivation (as a proxy for disease burden) may be more appropriate than a single national target if the aim is to reduce health inequalities nationally. We suggest LAs monitor their chlamydia diagnosis rate, test coverage and test positivity across a range of measures (including setting and sex) and pre/post changes to commissioned services. Critical evaluation of performance against the recommendation should be reflected in local commissioning decisions.