Moving upstream: ecosocial and psychosocial correlates of sexually transmitted infections among young adults in the United States

Sexually transmitted infection testing and diagnosis in adolescents and young adults with sickle cell disease

BACKGROUND

Sexually transmitted infections (STIs) are common and disproportionately affect Black adolescents and young adults (AYAs). Less is known about STIs among Black AYAs with chronic conditions, such as sickle cell disease (AYAs-SCD). This study compared STI testing and diagnosis between AYAs-SCD and their peers, overall and among STI-related encounters.

PROCEDURE

This retrospective, cross-sectional study used diagnosis and billing codes in the Pediatric Health Information System (PHIS) to identify inpatient and emergency department encounters from January 1, 2022 to May 31, 2023 among all AYAs 15-24 years and those with STI-related diagnoses (e.g., "cystitis"). STI testing and diagnosis rates were compared between AYAs-SCD, non-Black AYAs, and Black AYAs, controlling for age, sex, and encounter setting.

RESULTS

We identified 3602 AYAs-SCD, 177,783 Black AYAs, and 534,495 non-Black AYAs. AYAs-SCD were less likely to be tested for STIs than non-Black AYAs (odds ratio [OR] = 0.26; adj. p < .001) and Black AYAs (OR = 0.53; adj. p < .001). When tested, AYAs-SCD were more likely to be diagnosed with an STI than non-Black AYAs (OR = 2.39; adj. p = .006) and as likely as Black AYAs (OR = 0.67; adj. p = .15). Among STI-related encounters, AYAs-SCD were less likely to be tested than non-Black AYAs (OR = 0.18; adj. p < .001) and Black AYAs (OR = 0.44; adj. p < .001). No significant differences in STI diagnoses were found in this subset between AYAs-SCD and non-Black AYAs (OR = 0.32; adj. p = .28) or Black AYAs (OR = 1.07; adj. p = .99).

CONCLUSIONS

STI care gaps may disproportionately affect AYAs-SCD. STIs should be considered when evaluating symptomatic AYAs-SCD in acute settings. More research is needed to further contextualize STI care for AYAs-SCD.

Epidemiology of Chlamydia trachomatis and Repeat Positivity Following Detection in New York State

BACKGROUND

In New York State, excluding New York City, chlamydia remains a persistent health concern. Our aim was to characterize chlamydia epidemiology and identify groups at higher risk of repeat positivity to inform targeted public health interventions.

METHODS

We analyzed demographic and clinical data of laboratory-confirmed chlamydia cases in New York State from 2015 to 2019. Repeat positivity was defined as a second positive chlamydia test within 31 to 365 days of the initial positive test. We compared characteristics of individuals with single and repeat positivity and evaluated associations with repeat positivity using multivariable logistic regression models.

RESULTS

During the study period, 176 273 individuals were diagnosed with chlamydia, with 17 253 experiencing repeat positivity. Repeat positivity was more common among individuals assigned female at birth. Key predictors of repeat positivity among females included non-Hispanic Black (adjusted odds ratio [aOR]: 1.33; 95% confidence interval [CI], 1.27-1.40) race/ethnicity, ages 13 to 19 (aOR: 1.62; 95% CI, 1.55-1.69), prior sexually transmitted infection (STI) diagnosis (aOR: 1.24; 95% CI, 1.18-1.31), symptomatic examination (aOR: 1.07; 95% CI, 1.02-1.13), and county/community (aOR: 1.10; 95% CI, 1.05-1.15) or private/public (aOR: 1.18; 95% CI, 1.11-1.25) provider. Among males, predictors included non-Hispanic Black (aOR: 1.57; 95% CI, 1.45-1.70) race/ethnicity, ages 13 to 19 (aOR: 1.27; 95% CI, 1.17-1.38), HIV coinfection (aOR: 1.30; 95% CI, 1.10-1.54), prior STI diagnosis (aOR: 1.31; 95% CI, 1.20-1.43), extragenital infection site (aOR: 2.59; 95% CI, 2.27-2.95), symptomatic examination (aOR: 1.21; 95% CI, 1.12-1.31), and county/community health (aOR: 1.09; 95% CI, 1.02-1.17) provider.

CONCLUSIONS

Our findings provide valuable insights for sexual health interventions to prevent chlamydia transmission and recurrence. Prioritizing resources for prevention interventions and tailored sexual health promotion among non-Hispanic Black individuals is crucial. Additionally, targeted STI prevention efforts are needed for males who have sex with men and those initially diagnosed with extragenital infection. Research is warranted on STI prevention among people living with HIV or at high risk of HIV infection. Strengthening prevention strategies through Expedited Partner Therapy and sexual health education for individuals at risk of repeat positivity could enhance prevention efforts.

Sexual health variation among gang-involved youth in Washington state: Social ecological implications for research and practice

INTRODUCTION

Gang-involved youth experience greater disparities in sexual health compared to non-gang-involved youth. Yet, little is known about how and why sexual behaviors vary within the youth gang population. Developing relevant and effective service approaches requires an understanding of this variation and the environmental factors that influence patterns of sexual health risk.

METHODOLOGY AND RESULTS

Using latent class analysis, we identified four sexual behavior classes within a school-based sample of gang-involved youth in Washington State (N = 2060): Non-Sexually Active (54%), Limited Partners with Condom Use (14%), Multiple Partner with Sexting (19%), and High Sexual Vulnerability (13%). These classes were distinguished by age at sexual debut, number of sexual partners, condom use, and sexting. Interpersonal and macrosocial factors differentiated the classes, including multiform violence exposures, limited social support, and socioeconomic instability. We also found differences according to sexual identity and substance use.

DISCUSSION

Findings highlight the need for service approaches that are responsive to both the individual needs of gang-involved youth and the factors that shape their living environments. We discuss the implications for research and practice, including the potential utility of a harm reduction framework to promote sexual health and reduce disparities in the youth gang population.

Motivational interviewing to reduce risky sexual behaviors among at-risk male youth: A randomized controlled pilot study

BACKGROUND

Despite male youth taking more sexual risks that lead to unwanted partner pregnancy and/or sexually transmitted infections (STIs), research evaluating interventions for risky sex has focused almost exclusively on adolescent and adult females. With STIs among male youth on the rise, behavioral interventions that target risky sex among male youth are needed.

PURPOSE

A randomized controlled pilot study was conducted to examine the feasibility and acceptability of two manualized behavioral interventions for sexually active male youth.

METHODS

Sexually active at-risk male youth (N = 27) were recruited and randomized to receive one session of motivational interviewing (MI) or didactic educational counseling (DEC). Assessment interviews were conducted prior to and 3 months following the intervention session.

RESULTS

Support for the feasibility and acceptability of delivering behavioral interventions to reduce risky sexual behaviors among at-risk male youth was found. Compared to participants in DEC at follow-up, participants in MI reported having significantly fewer sexual encounters with casual partners, used substances at the time of sex significantly less often with all partners and casual partners, and reported fewer incidents of using substances at the time of sex without a condom with all partners. Conversely, participants who received MI used substances at the time of sex with main partners and used substances at the time of sex without a condom more often with main partners at follow-up compared to participants who received DEC.

CONCLUSIONS

Results of the pilot study support conducting a larger randomized controlled trial to examine treatment effects. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Factors associated with the diagnosis of depression in women followed in gynecological practices in Germany

BACKGROUND

There are many diagnoses in the field of gynecology that can severely impact the lives of patients and that are associated with an increased risk of developing depression. The goal of this study was to investigate which gynecological diagnoses are associated with depression.

METHODS

This retrospective case-control study based on the Disease Analyzer database (IQVIA) included 5893 women aged 18 years or older with depression and 5893 age-matched pairs followed in 256 gynecological practices in 2019 (index date). A multivariate logistic regression model was used to study the association between 33 pre-defined diagnoses documented within five years prior to the index date and depression diagnosis.

RESULTS

In total, 9 diseases were significantly associated with diagnosis of depression. The strongest association was observed for breast cancer (Odds Ratio (OR: 2.11 (95% Confidence Interval (CI): 1.76-2.52)), followed by female infertility (OR: 1.91 (95% CI: 1.48-2.47)), cancer of female genital organs excl. breast (OR: 1.87 (95% CI: 1.32-2.66)), and sexual dysfunction (OR: 1.63 (95% CI: 1.27-2.09). Other diseases that showed a significant association with depression included endometriosis, mastodynia, candidiasis, infections with a predominantly sexual mode of transmission, and urinary incontinence. Patients with a higher number of different disorders were more likely to be diagnosed with depression (ORs from 1.40 for two disorders to 2.38 for >6 disorders as compared to no disorders).

CONCLUSION

A wide range of diseases documented in gynecologists' practices were associated with depression diagnosis. Understanding all of these associations may help gynecologists to refer women promptly to psychologists or psychiatrists who may help to manage depression in this population.

Horizons and Group Motivational Enhancement Therapy: HIV Prevention for Alcohol-Using Young Black Women, a Randomized Experiment

INTRODUCTION

Black women are at disproportionately greater risk for HIV and sexually transmitted infections than women of other ethnic/racial backgrounds. Alcohol use may further elevate the risk of HIV/sexually transmitted infection acquisition and transmission.

STUDY DESIGN

A random-assignment parallel-group comparative treatment efficacy trial was conducted with random assignment to 1 of 3 conditions.

SETTING/PARTICIPANTS

The sample comprised 560 Black or African American women aged 18-24 years who reported recent unprotected vaginal or anal sex and recent alcohol use. Participants were recruited from community settings in Atlanta, Georgia, from January 2012 to February 2014.

INTERVENTION

A Group Motivational Enhancement Therapy module was designed to complement a Centers for Disease Control and Prevention-designated evidence-based intervention (Horizons) to reduce sexual risk behaviors, alcohol use, and sexually transmitted infections, with 3 comparison groups: (1) Horizons + Group Motivational Enhancement Therapy intervention, (2) Horizons + General Health Promotion intervention, and (3) enhanced standard of care.

MAIN OUTCOME MEASURES

Outcome measures included safe sex (abstinence or 100% condom use); condom nonuse; proportion of condom use during sexual episodes; incident chlamydia, gonorrhea, and trichomonas infections; and problematic alcohol use measured by Alcohol Use Disorders Identification Test score. Treatment effects were estimated using an intention-to-treat protocol‒generalized estimating equations with logistic regression for binomial outcomes and Poisson regression for count outcomes. Analyses were conducted between October 2018 and October 2019.

RESULTS

Participants assigned to Horizons + Group Motivational Enhancement Therapy had greater odds of safe sex (AOR=1.45, 95% CI=1.04, 2.02, p=0.03), greater proportion of condom use (AOR=1.68, 95% CI=1.18, 2.41, p=0.004), and lower odds of condom nonuse (AOR=0.57, 95% CI=0.38, 0.83, p=0.004). Both interventions had lower odds of problematic alcohol use (Horizons: AOR=0.57, 95% CI=0.39, 0.85, p=0.006; Horizons + Group Motivational Enhancement Therapy: AOR=0.61, 95% CI=0.41, 0.90, p=0.01).

CONCLUSIONS

Complementing an evidence-based HIV prevention intervention with Group Motivational Enhancement Therapy may increase safer sexual behaviors and concomitantly reduce alcohol use among young Black women who consume alcohol.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT01553682.

Marijuana Use, Sexual Behaviors, and Prevalent Sexually Transmitted Infections Among Sexually Experienced Males and Females in the United States: Findings From the National Health and Nutrition Examination Surveys

BACKGROUND

Several national guidelines consider illicit drug use as an indication for testing and/or counseling for some sexually transmitted infections (STIs). The legal and social landscape of marijuana use is changing, and its relevance with STI risk is unclear.

METHODS

Sex-specific prevalence of T. vaginalis and/or C. trachomatis infection was examined by past-year marijuana use (no vs yes) among 2958 sexually experienced, 20- to 39-year-old participants of the 2013-2016 National Health and Nutrition Examination Surveys. Prevalence ratios (PRs) with 95% confidence intervals [CIs] were estimated by Poisson regression. Adjusted PRs (aPR) were estimated following propensity score covariate-adjustment accounting for sociodemographics, alcohol use, injection drug use, depression, and age at sexual debut.

RESULTS

Past-year marijuana use was reported by 27.3% and 36.3% of females and males, respectively. Male and female past-year marijuana users were more likely to have new and multiple sexual partners in the past year (P < 0.05). Past-year marijuana use was associated with prevalent C. trachomatis and/or T. vaginalis infection among females (7.4% vs. 2.9%; PR, 2.57 [95% CI, 1.62-4.07]) and males (4.0% vs. 1.1%; PR, 3.59 [95% CI, 1.96-6.58]), but this association was attenuated after propensity score covariate adjustment among females (aPR, 1.15 [95% CI, 0.72-1.83]) and males (aPR, 2.10 [95% CI, 0.88-5.02]). Additional adjustment for new or multiple sexual partners further attenuated the associations (aPRs, 1.02 [95% CI, 0.65-1.51] and 1.91 [95% CI, 0.82-4.47] for females and males, respectively).

CONCLUSIONS

Sexually transmitted infection prevalence was higher among persons with a past-year history of marijuana use; however, this association was not significant after accounting for measured confounders. Additional work is needed to characterize STI prevalence by the mode, duration, and frequency of marijuana use.

Profiles of Childhood Maltreatment: Associations with Sexual Risk Behavior during Adolescence in a Sample of Racial/Ethnic Minority Girls

This study examines associations between childhood maltreatment and developmental trajectories of sexual risk behaviors (SRBs) in a sample of 882 sexually active adolescent girls, predominantly Hispanic or Black, assessed every 6 months between 13 and 23 years. Latent profile analyses revealed four distinct maltreatment profiles: Low Maltreatment (76%), Moderate Emotional Neglect Only (15%), Severe Physical/Emotional Abuse (3%), and Severe Sexual Abuse (6%). Multilevel growth analyses showed the Moderate Emotional Neglect Only and Severe Sexual Abuse profiles exhibited more SRBs starting in late adolescence, and the Severe Sexual Abuse profile also exhibited a faster increase than the Low Maltreatment profile. Understanding heterogeneity within maltreated populations may have important implications for healthy sexual development.

Intimate Partner Violence, Anxiety, and Depression in Women with Sexually Transmitted Infections—A Hospital-based Case Control Study

Background:

Sexually transmitted infections (STIs) have complex relationship with mental health and intimate partner violence (IPV) causing community health concern among adolescents and young adults. Women encounter behavioral, psychological, and reproductive health consequences of violence affecting across their lifespan.

Aim:

To determine IPV anxiety and depression in women with STIs.

Methods and materials:

It is a hospital-based cross-sectional study. A total of 115 consecutive females between 18 and 45 years of age who attended STI clinic were enrolled. Sociodemographic details were collected by semi-structured pro forma. IPV was assessed by World Health Organization violence against women instrument; Hamilton Anxiety Rating Scale and Hamilton Depression Rating Scale were applied to assess severity of anxiety and depression.

Results:

Mean age of subjects was 31.21 ± 9.08 years. About 55% of the patients had history of IPV. Psychiatric comorbidities noted in 66% of patients. The odds of IPV were more with history of child abuse, suicidal ideation, and substance abuse in husband.

Conclusion:

IPV, anxiety, and depression in STI are in the primitive stage of validation due to associated stigma and lack of awareness. It is high time to divulge dormant triggering factors to protect vulnerable population. Current research should focus on education and women empowerment to prevent STI and mental health issues.

Delay in Seeking Health Care Services After Onset of Urethritis Symptoms in Men

BACKGROUND

Symptom awareness, behavioral factors, and other barriers associated with timely sexually transmitted infection (STI) health care provision in men is not well studied.

METHODS

Men attending an STI clinic answered a questionnaire regarding their symptoms, sexual behavior, and sociodemographic and behavioral characteristics. Characteristics of symptomatic men were compared between those who did and did not delay seeking health care services. Delayed care seeking was defined as clinic attendance longer than 7 days after symptoms, whereas early care seeking was defined as clinic attendance of 7 days or less.

RESULTS

Over a quarter (n = 43 [27.7%]) of men with urethritis symptoms (urethral discharge or dysuria) delayed seeking care for more than 7 days. Compared with men who sought treatment within 7 days, those that delayed care worried for longer periods that their symptoms were STI-related, were more likely to attempt self-treatment of STI symptoms, were more likely to continue engaging in sexual activity, and were less likely to use a condom during their last sexual encounter. Conversely, men that delayed care seeking were less likely to have urethral discharge on physical examination, to have 5 or more polymorphonuclear leukocytes, and to test positive for Neisseria gonorrhoeae. When compared with men that sought care earlier, men that delayed care seeking had fewer overall and new partners in the past 30 days.

CONCLUSIONS

Our data suggest that over a quarter of men aware of STI symptoms delay seeking health services. Interventions that promote better patient understanding of the importance of symptom recognition and that facilitate timely access to care may provide new opportunities to reduce STI transmission.

Prevalence of Mycoplasma genitalium and Azithromycin-resistant Infections Among Remnant Clinical Specimens, Los Angeles

BACKGROUND

Mycoplasma genitalium is an important cause of bacterial sexually transmitted diseases. Diagnosis and susceptibility testing of M. genitalium are limited by the fastidious nature of the organism. Therefore, the prevalence of infection and azithromycin resistance are poorly studied.

METHODS

We conducted an exploratory study on remnant clinical specimens. We collected remnant DNA from consecutive urine samples and clinical swabs (cervical/vaginal, rectal, and pharyngeal) previously tested for Neisseria gonorrhoeae and Chlamydia trachomatis using the Cobas 4800 CT/NG assay (Roche Molecular Systems, Pleasanton, CA) between March-April 2017 from across the University of California, Los Angeles Health System. We then retrospectively tested all specimens with the ResistancePlus MG (550) kit, a molecular assay for the detection of M. genitalium and genetic mutations associated with azithromycin resistance.

RESULTS

Among 500 specimens, the prevalence of M. genitalium was 1.1% (95% confidence interval [CI], 0.04%-3.0%) in urine samples (n = 362), 17.4% (95% CI, 5.7%-39.6%) in rectal swabs (n = 23), and 1.9% (95% CI, 0.3%-7.3%) in cervical/vaginal swabs (n = 106). The prevalence of N. gonorrhoeae was 0.6% in urine samples and 4.3% in rectal swabs, whereas the prevalence of C. trachomatis was 2.2% in urine samples, 4.3% in rectal swabs and 3.8% in cervical/vaginal swabs. Of the 10 M. genitalium positive specimens, 8 (80.0%) had a mutation associated with azithromycin resistance.

CONCLUSIONS

The prevalence of M. genitalium infection in our population varied by anatomic site of infection. Most M. genitalium infections had at least 1 mutation associated with azithromycin resistance.

Gender and Race Informed Pathways From Childhood Sexual Abuse to Sexually Transmitted Infections: A Moderated Mediation Analysis Using Nationally Representative Data

PURPOSE

Although data suggest child sexual abuse is linked with increased risk of contracting asexually transmitted infection (STI), the mechanisms through which these experiences are connected remain understudied. Moreover, there is a need to explore how race/ethnicity and gender influence these processes.

METHODS

The present study examined the mediational pathways from child sexual abuse to risky sexual behavior to STIs and further evaluated the role of depressive symptomatology and nonmedical prescription drug use on the relationship between child sexual abuse and risky sexual behavior. In addition, race and gender were examined as moderators to account for potential different effects of these mechanisms on females and males and on different racial and ethnic groups. A nationally representative sample of 4,181 youth from the Add Health dataset was used.

RESULTS

Results from a moderated mediation model indicated risky sexual behavior partially mediated the pathway from child sexual abuse to STI contraction and depressive symptomatology and nonmedical prescription drug use partially mediated pathway from child sexual abuse to risky sexual behavior. Race and gender moderated the relationship between risky sexual behavior and STI contraction.

CONCLUSIONS

Findings underscore the need for STI prevention efforts among adolescents to focus on risk factors beyond risky sexual behaviors, such as childhood sexual abuse and mental health screening that includes depressive symptomatology and nonmedical prescription drug use. In addition, findings emphasize the need to further examine the different effects on different racial/ethnic and gender subgroups, particularly black women.

High-risk sexual behaviour in young people with mental health disorders

AIM

This study aimed to determine the prevalence of high-risk sexual behaviours, sequelae and associated factors in young people attending a youth mental health service.

METHODS

The study design was a cross-sectional survey of 103 young people aged between 15-25 years carried out across four specialist mental health clinics. A questionnaire on the sexual health of secondary level students was adapted for this study. Mental health symptomatology was assessed through the Brief Psychiatric Rating Scale (BPRS).

RESULTS

The mean age was 20.9 (SD ±2.8) years, with 50.5% being female, 41.7% male and 7.7% transgender. A total of 52.4% (N = 54) attended the psychosis [EPPIC] clinic; 15.6% (N = 16) attended the ultra-high risk for psychosis [PACE] clinic; 19.4% (N = 20) attended the personality disorders [HYPE] clinic; and 12.6% (N = 13) attended the mood clinic [YMC]. The mean BPRS score was 47.7 (SD ±12.2). A total of 77.7% of young people had previously been sexually active and of these, 37.5% did not use consistent contraception; 26.3% had been pregnant, of which 95.2% were unplanned. A total of 68.8% reported having been tested for sexually transmitted infections and 25.5% tested positive. The severity of symptoms or clinical characteristics were not associated with engagement in high-risk sexual behaviours.

CONCLUSIONS

These results indicate that young people with mental health disorders have high needs in regard to their sexual health, which could be addressed by incorporating sexual health referral pathways into early intervention services.

Evaluating the Impact of Housing Status on Gonorrhea and Chlamydia Screening in an HIV Primary Care Setting

INTRODUCTION

Gonorrhea and chlamydia (GC/CT) testing falls below recommended rates for people living with HIV (PLWH) in routine care. Despite evidence that homelessness and unstable housing (HUH) negatively impacts clinical outcomes for PLWH, little is known about GC/CT screening for HUH-PLWH in routine care.

METHODS

Using an observational cohort of PLWH establishing care at a large publicly funded HIV clinic in San Francisco between February 2013 and December 2014 and with at least 1 primary care visit (PCV) before February 2016, we assessed GC/CT testing for HUH (staying outdoors, in shelters, in vehicles, or in places not made for habitation in the last year) compared with stably housed patients. We calculated (1) the odds of having GC/CT screening at a PCV using logistic regression with random effects to handle intrasubject correlations and (2) the percent of time enrolled in clinical care in which patients had any GC/CT testing ("time in coverage") based on 180-day periods and using linear regression modeling.

RESULTS

Of 323 patients, mean age was 43 years, 92% were male, 52% were non-Latino white, and 46% were HUH. Homeless and unstably housed PLWH had 0.66 odds of GC/CT screening at a PCV than did stably housed patients (95% confidence interval, 0.44-0.99; P = 0.043). Time in coverage showed no difference by housing status (regression coefficient, -0.93; 95% confidence interval, -8.02 to 6.16; P = 0.80).

CONCLUSIONS

Homeless and unstably housed PLWH had 34% lower odds of GC/CT screening at a PCV, demonstrating a disparity in routine care provision, but similar time in coverage. More research is needed to effectively increase GC/CT screening among HUH-PLWH.

"Running Trains" and "Sexing-In": The Functions of Sex Within Adolescent Gangs

Gang members are exposed to unique sexual risks, yet little work has explored the influence of gang social norms. This study examines the functions and meanings of sex within gangs, with a specific focus on the ways in which sex is used to reinforce gang membership and norms, gender roles, and group cohesion. We conducted 58 semi-structured interviews with adolescent members of six gangs. Data were analyzed using thematic content analysis and constant comparative method in MAXQDA. Sexual risk behaviors within gangs are upheld and reinforced through unspoken norms and expectations. These high-risk sexual practices increase group cohesion and reinforce gender norms and power differences. Despite the prevalence of such practices, many gang members felt regret and remorse over their participation but noted it was just part of "the life." Our findings highlight the need for interventions to address the norms of the gang that reinforce sexual risk behavior.

Applying core theory and spatial analysis to identify hepatitis C virus infection "core areas" in British Columbia, Canada

"Core areas" of transmission for bacterial sexually transmitted infections have been identified. However, it is unclear whether core areas apply to viral infections, such as hepatitis C virus (HCV). We used geographic mapping and spatial analysis to identify distinct core areas of HCV infection in British Columbia (BC) using the BC Hepatitis Testers Cohort (BC-HTC), 1990-2013. The BC-HTC includes all BC residents tested for HCV (~1.5 million; 1990-2013). Core HCV infection areas were identified spatially and temporally for five time periods (1990-1993, 1994-1998, 1999-2003, 2004-2008 and 2009-2013) through thematic mapping, Kernel Density Estimation, Hotspot analysis and cluster analysis at the Census dissemination area level in ArcGIS and SatScan. HCV infection core areas were consistently identified. HCV core areas expanded from the downtown of major cities in different regions of BC (Metro Vancouver, Vancouver Island, and Northern BC; 1990-1998), to smaller cities in Metro Vancouver and Interior BC (2000 onwards). Statistically significant clusters, or hotspots, were also observed for downtown Vancouver, Northern BC (Prince George) and Vancouver Island from 1990 to 2008 with expansion to other urban areas in Metro Vancouver from 1990-2013. Statistically significant clusters persisted after adjustment for injection drug use, number of HCV tests, age, sex, material and social deprivation. Persistence of areas with high HCV diagnoses rates in Vancouver and Prince George supports the theory of core areas of HCV transmission. Identification of core areas can inform prevention, care and treatment programme interventions and evaluate their impact over time.

Identifying Syndemics for Sexually Transmitted Infections Among Young Adults in the United States: A Latent Class Analysis

PURPOSE

Syndemic theory suggests that the convergence of social, environmental, and ecological factors can interact to exacerbate behavioral health problems and are often intensified by social conditions and disparities. This study used latent class analysis (LCA) to determine gender and racial/ethnic specific classes for sexually transmitted infection (STI) risk.

METHODS

LCA included 18 measured socioeconomic, depression, substance use, and sexual behavioral variables from 1,664 young adults ages 18-25 in the NHANES. Models were stratified by gender and then by race/ethnicity. Logistic regression determined associations between latent class membership and testing positive for one or more STIs (Chlamydia trachomatis, HIV or herpes simplex virus-II). For each stratified analysis, classes with the lowest probability of reported risk factors in the LCA were the reference groups.

RESULTS

Class 3 in females (highest probability of reporting both socioeconomic and behavioral factors) and class 3 in males (majority behavioral factors) had increased odds of STI (females: OR = 2.7, 95% CI 1.6-4.5; males: OR 2.5, 95% CI 1.3-4.6). By race for females, depression (highest in Hispanics), poverty, and less educated households (highest in blacks and Hispanics) were evident in classes associated with STI. Class 1 black males (majority behavioral factors) had a higher odds of STI compared with low risk white males (OR = 16.4 95% CI 3.7-72.0) However, no other associations were observed among males.

CONCLUSIONS

Risk patterns for STI differed by gender and race/ethnicity. Consistent with syndemic theory, effective STI interventions need to address socioeconomic factors and mental health rather than individual behaviors, particularly for minority women.

Associations of depression and anxiety symptoms with sexual behaviour in women and heterosexual men attending sexual health clinics: a cross-sectional study

Objective

To assess the association of symptoms of depression and anxiety with sexual risk behaviour and history, among women and heterosexual men attending genitourinary medicine (GUM) clinics.

Methods

Attitudes to and Understanding of Risk of Acquisition of HIV (AURAH) was a cross-sectional, self-administered questionnaire study recruited from 20 GUM clinics in England, 2013–2014. This analysis included women and heterosexual men. The prevalence of depression and anxiety symptoms was assessed. Modified Poisson regression was used to produce adjusted prevalence ratios (aPR) for the association of t demographic, socioeconomic and lifestyle factors with depression and anxiety, adjusted for gender, age, ethnicity, education level and study region. Among individuals reporting sex in the past 3 months, associations of depression and anxiety with sexual risk behaviour and history were assessed separately by gender, adjusted for age, ethnicity, study region, education and relationship status.

Results

Questionnaires were completed by 676 women and 470 heterosexual men. Depression symptoms were reported by 100 (14.8%) women and 33 men (7.0%). Anxiety symptoms were reported by 79 women (11.7%) and 21 men (4.5%). Among women reporting recent sex, those with depression symptoms were more likely to report condomless sex with a non-regular partner, aPR 1.38 (1.07–1.77) and recent condomless sex with two or more partners, 1.80 (1.25–2.59). Women with anxiety symptoms more likely to report recent condomless sex with two or more partners, 1.68 (1.13–2.50), low self-efficacy for condom use, 1.54 (1.02–2.31) and STI diagnosis in the last year 1.51 (1.04–2.20). Among heterosexual men reporting recent sex, depression and anxiety symptoms were associated with low self-efficacy with condom use, 2.32 (1.29–4.19) for depression and 2.23 (1.26–3.94) for anxiety, but not with measures of condomless sex.

Discussion

The associations between psychological symptoms and sexual risk behaviours highlight the importance of holistic assessment of need by both general and sexual health clinicians. We highlight the challenge in delivering holistic care associated with fragmentation of sexual health services.

Out of school female adolescent employment status and sexually transmitted infections (STIs) risk in Uganda: is it a plausible relationship?

BACKGROUND

High prevalence of Sexually Transmitted Infections (STIs) among adolescents is a serious public health concern. Although many factors are attributed to adolescents' risk of STI infections, the association between out of school adolescents' employment status and STIs has not been thoroughly explored in Uganda, yet many adolescents are known to be employed. Consequently, the extent to which adolescents' employment status may be a risk factor for unprotected sex and STIs among female adolescents is unclear. This study examines the association between female out of school adolescents' employment status and STI status using the Uganda Demographic and Health Survey (UDHS) data for 2016.

METHODS

Both descriptive and multilevel binary logistic regressions were used to analyse the data. The descriptive statistics provided an overview of the association between the two main variables while the multilevel binary logistic estimated the relationship between employment status and STI status, while controlling for other fixed factors and community random factors.

RESULTS

Compared to female adolescents who were not employed or not working, the odds of reporting positive STIs were significantly higher for female adolescents who were working but received no pay (1.801(95% CI = 1.105-2.936), were self-employed in agriculture (1.502 (95% CI = 1.003-2.250) and who did manual jobs (2.258(95% CI = 1.429-3.568) whether skilled or not. Likewise, female adolescents who had two or more lifetime sexual partners (11.679 (95% CI = 1.254-2.248) had significantly higher odds of reporting STIs than those who had only one lifetime sexual partner.

CONCLUSION

Out of school female adolescents who are employed in various types of low wage employments are at greater risk of exposure to STIs than their counterparts who do not work in Uganda. Instead of being a protective factor against the risk of STIs, their employment may expose them to risky sexual behaviour and STIs, given the vulnerabilities female adolescents who have dropped out of school tend to report. Therefore, the provision of decent employment opportunities for these females may provide an avenue for instructional scaffolding to build the life skills and empower these females so that they are better able to reduce their exposure to STIs.

Sexually Transmitted Infection Testing in Adolescents: Current Practices in the Hospital Setting

PURPOSE

Adolescents are disproportionately affected by sexually transmitted infections (STIs), and evidence supports expanding sexual health services to the hospital setting. Because STI testing practices in the hospital setting are poorly understood, we sought to describe current STI testing practices among adolescents seen in children's hospitals.

METHODS

We performed a retrospective analysis of adolescents (14-18 years old) from 45 children's hospitals in 2015-2016, excluding visits with a billing code for sexual abuse/assault. We calculated rates of STI testing and investigated differences in STI testing by patient and hospital characteristics using generalized linear mixed modeling.

RESULTS

Of the 541,714 adolescent encounters, 59,158 (10.9%) underwent STI testing. After adjusting for demographic characteristics, those with an STI test were more likely to be female (adjusted odds ratio [aOR] 1.61; 95% confidence interval [CI] 1.58-1.64), of non-Hispanic black race/ethnicity (aOR 1.20; 95% CI 1.17-1.23), or from the lowest median household income quartile (aOR 1.21; 95% CI 1.17-1.24). There was substantial inter-hospital variation in adjusted rates of STI testing (3%-24%), but strong correlation was observed between STI testing rates in the ED and inpatient settings within individual hospitals (adjusted R² .99).

CONCLUSIONS

Only one in ten adolescents seen in children's hospitals underwent STI testing with wide variation in testing patterns across hospitals. There are critical opportunities to increase adolescent STI testing in this setting. Our findings highlight potential disparities in STI testing rates and patterns that warrant further exploration from the patient, provider, and health system perspective.

Narrative Review: Sexually Transmitted Diseases and Homeless Youth-What Do We Know About Sexually Transmitted Disease Prevalence and Risk?

BACKGROUND

Homelessness affects an estimated 1.6 million US youth annually. Compared with housed youth, homeless youth are more likely to engage in high-risk behaviors, including inconsistent condom use, multiple sex partners, survival sex, and alcohol/drug use, putting them at increased sexually transmitted disease (STD) risk. However, there is no national estimate of STD prevalence among this population.

METHODS

We identified 10 peer-reviewed articles (9 unique studies) reporting STD prevalence among homeless US youth (2000-2015). Descriptive and qualitative analyses identified STD prevalence ranges and risk factors among youth.

RESULTS

Eight studies reported specific STD prevalence estimates, mainly chlamydia, gonorrhea, and syphilis. Overall STD prevalence among homeless youth ranged from 6% to 32%. STD rates for girls varied from 16.7% to 46%, and from 9% to 13.1% in boys. Most studies were conducted in the Western United States, with no studies from the Southeast or Northeast. Youths who experienced longer periods of homelessness were more likely to engage in high-risk sexual behaviors. Girls had lower rates of condom use and higher rates of STDs; boys were more likely to engage in anal and anonymous sex. Additionally, peer social networks contributed to protective effects on individual sexual risk behavior.

CONCLUSIONS

Sexually transmitted disease prevalence estimates among homeless youth fluctuated greatly by study. Sexually transmitted disease risk behaviors are associated with unmet survival needs, length of homelessness, and influence of social networks. To promote sexual health and reduce STD rates, we need better estimates of STD prevalence, more geographic diversity of studies, and interventions addressing the behavioral associations identified in our review.

Gender Differences in the Path From Sexual Victimization to HIV Risk Behavior Among Homeless Youth

Experiencing sexual victimization prior to becoming homeless is common among homeless youth and is associated with increased HIV risk behavior. This study examined mediating variables that underlie this association, adding to the understanding of gender differences in these paths. Participants were homeless youth in Los Angeles recruited through service access centers who completed a computerized self-administered interview in English or Spanish using an iPad. Findings indicate a high presence of sexual victimization across both genders. Female participants experienced posttraumatic stress disorder and subsequent engagement with exchange sex, whereas male participants were primarily involved in substance use risk pathways. Results indicate paths in the association between sexual victimization and HIV risk behavior differ between male and female homeless youth. Gender-specific, mental-health-informed interventions targeting sexual risk reduction are warranted.

Lifetime Sexual Assault and Sexually Transmitted Infections Among Women Veterans

OBJECTIVE

Women veterans report a high prevalence of sexual assault. Unfortunately, there are limited data on the reproductive health sequelae faced by these women. Our objective was to evaluate the association between completed lifetime sexual assault (LSA) and sexually transmitted infections (STIs) among a cohort of women veterans, adjusting for sexual risk behaviors.

MATERIALS AND METHODS

We conducted a retrospective study among women veterans aged 51 years or younger who enrolled for care at two Veterans Administration (VA) healthcare sites between 2000 and 2008. Participants completed a telephone interview assessing reproductive health and sexual violence history. We compared the frequencies of past STI diagnoses among those who had and had not experienced LSA. We used logistic regression to assess the effect of sexual assault with history of an STI diagnosis after adjusting for age, sexual risk behaviors, and substance abuse treatment.

RESULTS

Among 996 women veterans, a history of STIs was reported by 32%, including a lifetime history of gonorrhea (5%), chlamydia (15%), genital herpes infection (8%), and human papillomavirus infection (15%), not mutually exclusive; 51% reported LSA. Women with a history of LSA were significantly more likely to report a history of STIs (unadjusted odds ratio [OR] 1.91, 95% confidence interval [CI] 1.45-2.50; adjusted OR 1.49, 95% CI 1.07-2.08).

CONCLUSIONS

Women veterans who have experienced LSA are at increased risk for lifetime STI diagnoses. To adequately address the reproductive health needs of the growing population of women veterans, STI risk assessments should include queries of military service and LSA histories.

Age at migration, family instability, and timing of sexual onset

This study builds on and extends previous research on nativity variations in adolescent health and risk behavior by addressing three questions: (1) whether and how generational status and age at migration are associated with timing of sexual onset among U.S. adolescents; (2) whether and how family instability mediates associations between nativity and sexual debut; and (3) whether and how these associations vary by gender. We find that first- and second-generation immigrant youth initiate sexual activity later than native youth. Foreign-born youth who migrate after the start of adolescence exhibit the latest sexual onset; boys' sexual behavior is particularly sensitive to age at migration. Parental union stability is protective for first- and second-generation youth, especially boys; however, instability in co-residence with parents accelerates sexual debut for foreign-born girls, and dilutes protections from parental marital stability. Use of a non-English language at home delays sexual onset for immigrant girls, but not boys.

Antiretroviral medication treatment for all HIV-infected individuals: a protocol using innovative multilevel methodologies to evaluate New York City's universal ART policy among problem substance users

BACKGROUND

The intersection of HIV-related health outcomes and problem substance use has been well documented. New York City continues to be a focal point of the U.S. HIV epidemic. In 2011, the NYC Department of Health and Mental Hygiene (NYC DOHMH) issued a recommendation that all HIV infected individuals should be offered antiretroviral therapy (ART) regardless of CD4 cell count or other indicators of disease progression. This policy is based in the concept of "treatment as prevention," in which providing ART to people living with HIV (PLWH) greatly reduces the likelihood of HIV transmission, while also improving individual health. The "ART for ALL" (AFA) study was designed to inform modifications to and identify gaps in the implementation of universal ART, and specifically to help guide allocation of resources to obtain local policy goals for increasing viral suppression among PLWH who have problem substance use.

METHODS/DESIGN

The AFA Study is informed by two complementary frameworks: Glasgow and colleagues' RE-AIM model, a multi-level framework developed to guide the evaluation of implementation of new policies, and Bronfrenbrenner's ecological systems model, which conceptualizes the bi-directional interplay between people and their environment. Using multi-level data and mixed methods, the primary aims of the AFA Study are to assess rates of viral load suppression, using the NYC HIV Surveillance Registry, within 12 months of HIV diagnosis with (a) yearly cohorts of high-risk-to-transmit, difficult-to-treat, substance using patients recruited from NYC Sexually Transmitted Disease clinics and a large detoxification unit and (b) yearly cohorts of all newly HIV diagnosed people in NYC. Further goals include (c) recruiting cross-sectional samples of HIV/AIDS service providers to assess ART initiation with problem substance users and d) examining geographic factors that influence rates of viral load suppression. An Implementation Collaborative Board meets regularly to guide study procedures and interpret results.

DISCUSSION

The AFA Study has the unique strength of accessing and analyzing data at multiple levels using mixed methodology, taking advantage of NYC DOHMH biomedical surveillance data. If successful, others may benefit from lessons learned to inform local and state policies to improve the health of PLWH and further reduce HIV transmission.

Developing Measures of Pathways that May Link Macro Social/Structural Changes with HIV Epidemiology

Macro-social/structural events ("big events") such as wars, disasters, and large-scale changes in policies can affect HIV transmission by making risk behaviors more or less likely or by changing risk contexts. The purpose of this study was to develop new measures to investigate hypothesized pathways between macro-social changes and HIV transmission. We developed novel scales and indexes focused on topics including norms about sex and drug injecting under different conditions, involvement with social groups, helping others, and experiencing denial of dignity. We collected data from 300 people who inject drugs in New York City during 2012-2013. Most investigational measures showed evidence of validity (Pearson correlations with criterion variables range = 0.12-0.71) and reliability (Cronbach's alpha range = 0.62-0.91). Research is needed in different contexts to evaluate whether these measures can be used to better understand HIV outbreaks and help improve social/structural HIV prevention intervention programs.

Positive and Negative Aspects of Relationship Quality and Unprotected Sex among Young Women

The aim of this study was to examine both positive and negative aspects of relationship quality in relation to condom use. Sexually active young women aged 14-18 years (n=111; 34% non-white) were recruited from community clinics and schools in the Midwest USA and provided data via an online survey. The number of unprotected sex acts in the past month with the most recent male partner was regressed on relationship quality with that partner, adjusting for demographics and other characteristics. Negative relationship quality was associated with a greater number of unprotected sex acts among women reporting a low level of positive relationship quality and among women taking hormonal/IUD contraception. Positive relationship quality was associated with unprotected sex among women who reported multiple partners in the past month. Both positive and negative aspects of relationship quality may confer risk for unprotected sex. This risk appears modified by patterns of contraceptive use and other sexual behaviours. Health professionals may be more effective in promoting condom use if they ask questions about both positive and negative aspects of young people's relationship quality and tailor their conversations based on the responses received.

Condom deserts: geographical disparities in condom availability and their relationship with rates of sexually transmitted infections

BACKGROUND

Identifying predictors that contribute to geographical disparities in sexually transmitted infections (STIs) is necessary. This study assesses the spatial relationship between condom availability to locations of STIs in order to better understand these geographical disparities.

OBJECTIVES

We conducted a condom availability audit among potential condom-selling establishments. New gonorrhoea and chlamydia cases in 2011 (n=6034) and HIV infection cases from 2006 to 2011 (n=565) were collected by census tract in St Louis, Missouri. 829 potential condom-selling establishments participated in the condom availability audit in St Louis City; 242 of which sold condoms.

RESULTS

A negative linear relationship exists between condom vendors and cases of gonorrhoea and chlamydia, after adjusting for concentrated disadvantage and free condom locations. Higher concentrated disadvantage, higher proportions of convenience vendors and free locations were associated with higher rates of HIV.

CONCLUSIONS

This study was conducted to provide evidence that lack of condom availability is associated with STI rates, and likely is an integral component to influencing the subjective norms surrounding condom use and STI rates. Condom distribution interventions may be addressing availability needs and social norms, yet are more likely to be effective when placed in locations with the highest STI rates.

Childhood lead exposure and sexually transmitted infections: New evidence

INTRODUCTION

The adverse health effects of lead exposure in children are well documented and include intellectual and behavioral maladies. Childhood lead exposure has also been linked to impulsive behaviors, which, in turn, are associated with a host of negative health outcomes including an increased risk for sexually transmitted infections (STI). The purpose of this study was to assess the association of lead exposure with STI rates across census tracts in St. Louis City, Missouri.

METHODS

Incident cases of gonorrhea and chlamydia (GC) during 2011 were identified from the Missouri Department of Health and Senior Services and aggregated by census tract. We also geocoded the home address of 59,645 children >72 months in age who had blood lead level tests performed in St. Louis City from 1996 to 2007. Traditional regression and Bayesian spatial models were used to determine the relationship between GC and lead exposure while accounting for confounders (condom and alcohol availability, crime, and an index of concentrated disadvantage).

RESULTS

Incident GC rates were found to cluster across census tracts (Moran's I=0.13, p=0.006). After accounting for confounders and their spatial dependence, a linear relationship existed between lead exposure and GC incidence across census tracts, with higher GC rates occurring in the northern part of St. Louis City

CONCLUSIONS

At the census-tract level, higher lead exposure is associated with higher STI rates. Visualizing these patterns through maps may help deliver targeted interventions to reduce geographic disparities in GC rates.

Association Between Cumulative Psychosocial Risk and Cervical Human Papillomavirus Infection Among Female Adolescents in a Free Vaccination Program

OBJECTIVE

This study investigated the association of cervical human papillomavirus (HPV) infection with cumulative psychosocial risk reflecting family disadvantage, psychological distress, and unhealthy lifestyle.

METHODS

The sample (N = 745) comprised sexually active female adolescent patients (12-19 yr), primarily ethnic minorities, enrolled in a free HPV vaccination program. Subjects completed questionnaires and provided cervical swabs for HPV DNA testing. Unweighted and weighted principal component analyses for categorical data were used to derive multisystemic psychosocial risk indices using 9 indicators: low socioeconomic status, lack of adult involvement, not attending high school/college, history of treatment for depression/anxiety, antisocial/delinquent behavior, number of recent sexual partners, use of alcohol, use of drugs, and dependency risk for alcohol/drugs. The association between cervical HPV (any type, high-risk types, vaccine types) assayed by polymerase chain reaction and self-reported number of psychosocial risk indicators was estimated using multivariable logistic regression.

RESULTS

Subjects had a median of 3 psychosocial risk indicators. Multiple logistic regression analyses showed associations with unweighted and weighted number of psychosocial indicators for HPV any type (adjusted odds ratio [aOR] = 1.1; 95% confidence interval [CI], 1.0-1.2), with the strongest associations between weighted drug/alcohol use, drug/alcohol dependency risk, and antisocial/delinquent behavior and detection of HPV vaccine types (aOR = 1.5; 95% CI, 1.1-2.0) independent of number of recent sexual partners and vaccine dose (0-3).

CONCLUSION

Increased HPV infections including HPV vaccine types were associated with greater number of psychosocial risk indicators even after controlling for demographics, sexual behavior, history of chlamydia, and vaccine dose.

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

Background

The success of chlamydia screening programmes relies on their ability to effectively target those with greatest need. Young people from disadvantaged backgrounds may be at greater need for chlamydia screening, but existing evidence on the variation of prevalence with social position is inconclusive. We carried out a systematic review to examine variation in chlamydia prevalence in populations and possible sources of this variation.

Methods

Studies were eligible if they reported chlamydia prevalence derived from population-based samples that included young people aged 15–24 years from Europe, North America or Australia. Systematic searches of the following databases were undertaken from their inception to November 2014: MEDLINE, Embase, Web of Science and PsychINFO. There were no restrictions by language or publication date. Independent screening for eligibility and data extraction were carried out by two reviewers. Where possible, data were pooled in a meta-analysis using a random effects model. Heterogeneity was further investigated using meta-regression techniques.

Results

Of 1248 unique titles and abstracts and 263 potentially relevant full texts, 29 studies were eligible for inclusion. There was relatively strong evidence that disadvantaged young people had an increased risk of having a chlamydia infection across multiple measures of disadvantage, including lower educational attainment (OR 1.94, 95 % CI: 1.52 to 2.47), lower occupational class (OR 1.49, 95 % CI: 1.07 to 2.08) and residence in deprived areas (OR 1.76, 95 % CI: 1.15 to 2.71) with an overall OR of 1.66 (95 % CI: 1.37 to 2.02). Socioeconomic disadvantage was associated with chlamydia infection in both men and women. There was weaker evidence that prevalence estimates also varied by gender and age.

Conclusions

This review provides evidence of a consistent association between socioeconomic disadvantage and higher risk of Chlamydia infection. This association may reflect a number of factors including social variation in engagement with Chlamydia control programmes. Chlamydia screening could therefore reduce or increase health inequalities, depending on service provision and uptake by different socioeconomic groups.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-2069-7) contains supplementary material, which is available to authorized users.

Replication of a whole school ethos-changing intervention: different context, similar effects, additional insights

BACKGROUND

Whole school, ethos-changing interventions reduce risk behaviours in middle adolescence, more than curriculum-based approaches. Effects on older ages are not known. We set out to replicate one of these interventions, Australia's Gatehouse Project, in a rural Canadian high school.

METHODS

A guided, whole school change process sought to make students feel more safe, connected, and valued by: changes in teaching practices, orientation processes, professional development of staff, recognition and reward mechanisms, elevating student voice, and strategies to involve greater proactivity and participation. We conducted risk behaviour surveys in grades 10 to 12 before the intervention and 2 years afterwards, and social network analyses with the staff. Changes in health and health risk behaviours were assessed using chi-square. Interactions between the intervention and gender and between the intervention and school engagement were assessed using interaction terms in logistic regression models. Changes in the density of relationships among staff were tested with methods analogous to paired t-tests.

RESULTS

Like Gatehouse, there was no statistically significant reduction in depressive symptoms or bullying, though the trend was in that direction. Among girls, there was a statistically significant decrease in low school engagement (45% relative reduction), and decreases in drinking (46% relative reduction), unprotected sex (61% relative reduction) and poor health (relative reduction of 73%). The reduction in drinking matched the national trend. Reductions in unprotected sex and poor health went against the national trend. We found no statistically significant changes for boys. The effects coincided with statistically significant increases in the densities of staff networks, indicating that part of the mechanism may be through relationships at school.

CONCLUSIONS

A non-specific, risk protective intervention in the social environment of the school had a significant impact on a cluster of risk behaviours for girls. Results were remarkably like reports from similar school environment interventions elsewhere, albeit with different behaviours being affected. It may be that this type of intervention activates change processes that interact highly with context, impacting different risks differently, according to the prevalence, salience and distribution of the risk and the interconnectivity of relationships between staff and students. This requires further exploration.

Targeting Structural Change for HIV Prevention: A Process and Tool for Community Application

To address the persistent HIV epidemic in the United States, prevention efforts are focusing on social determinants related to HIV risk by targeting systems and structures, such as organizational and institutional policies, practices and programs, and legislative and regulatory approaches to modify features of the environment that influence HIV risk. With limited evidenced-based examples, communities can benefit from strategic planning resources that help them consider developing structural-level changes that target root causes of HIV risk. In this article, we present the Connect to Protect® project that outlines a process and a tool to move from general ideas to specific structural changes. Examples from 14 coalitions are also provided. Using the process and tools presented here can provide a launching pad for other coalitions seeking to build an HIV prevention agenda and for practitioners seeking to incorporate structural changes for community health promotion.

Social-, age- and gender differences in testing and positive rates for Chlamydia trachomatis urogenital infection - a register-based study

BACKGROUND

Chlamydia trachomatis is suspected of causing female infertility. It is the most widespread sexually transmitted infection with an estimated general prevalence of ~5-10% with a peak in younger individuals. C. trachomatis infection is more prevalent among lower social classes.

OBJECTIVE

In this study, the association between age, gender, social status and testing and positive rates is investigated in the age group 15-24 years.

DESIGN

Case-control study linked to data from Statistics Denmark.

METHODS

Data from the Department of Microbiology, Hvidovre University Hospital, Copenhagen were used and included 21887 people tested by general practitioners (GPs) and 3177 people tested at a venereological clinic. The age range was 15-24 years in 2011. These data were linked with the parental educational status delivered by Statistics Denmark, which also delivered a matched control group. The data were analysed using a case-control design.

RESULTS

Testing was more frequent in the following groups: age range 20-24 years, females and patients with higher parental educational status. About 87.3% of patient had been tested by GPs. Positive rates were highest among males at the general practice constituting 17.1% versus females 10.6%, younger individuals and patients with lower parental educational status.

CONCLUSIONS

The C. trachomatis testing pattern and positive rates highlight a need for a greater focus on males, younger patients and individuals with a lower social status.

Sex-Related Alcohol Expectancies Among African American Women Attending an Urban STI Clinic

African American women are disproportionately affected by human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) and sexually transmitted infections (STIs). Alcohol use is a significant risk factor for HIV/STI acquisition. Sex-related alcohol expectancies (SRAEs) may partially account for alcohol-related risky sexual behaviors. Using qualitative interviews we explored the link between alcohol use and risky sex among 20 African American women attending an STI clinic who had consumed four or more alcoholic drinks per drinking day (binge drinking) and/or reported vaginal or anal sex while under the influence of alcohol. Four SRAEs emerged, which we named drink for sexual desire, drink for sexual power, drink for sexual excuse, and drink for anal sex. While the desire SRAE has been documented, this study identified three additional SRAEs not currently assessed by expectancy questionnaires. These SRAEs may contribute to high-risk sex when under the influence of alcohol and suggests the importance of developing integrated alcohol-sexual risk reduction interventions for high-risk women.

Understanding the link between early sexual initiation and later sexually transmitted infection: test and replication in two longitudinal studies

PURPOSE

Age at sexual initiation is strongly associated with sexually transmitted infections (STI); yet, prevention programs aiming to delay sexual initiation have shown mixed results in reducing STI. This study tested three explanatory mechanisms for the relationship between early sexual debut and STI: number of sexual partners, individual characteristics, and environmental antecedents.

METHODS

A test-and-replicate strategy was employed using two longitudinal studies: the Seattle Social Development Project (SSDP) and Raising Healthy Children (RHC). Childhood measures included pubertal age, behavioral disinhibition, and family, school, and peer influences. Alcohol use and age of sexual debut were measured during adolescence. Lifetime number of sexual partners and having sex under the influence were measured during young adulthood. Sexually transmitted infection diagnosis was self-reported at age 24. Early sex was defined as debut at <15 years. Path models were developed in SSDP evaluating relationships between measures, and were then tested in RHC.

RESULTS

The relationship between early sex and STI was fully mediated by lifetime sex partners in SSDP, but only partially in RHC, after accounting for co-occurring factors. Behavioral disinhibition predicted early sex, early alcohol use, number of sexual partners, and sex under the influence, but had no direct effect on STI. Family management protected against early sex and early alcohol use, whereas antisocial peers exacerbated the risk.

CONCLUSIONS

Early sexual initiation, a key mediator of STI, is driven by antecedents that influence multiple risk behaviors. Targeting co-occurring individual and environmental factors may be more effective than discouraging early sexual debut and may concomitantly improve other risk behaviors.

"I Don't Have a Problem With It, But Other Guys Do": An Exploration of Condom Negotiation among Young Black Men Who Have Sex with Men in the South

Condom negotiation among young Black men who have sex with men in the Southern United States was explored using the theory of reasoned action. Fifty-four (18- to 29-year-old) males participated in nine focus group interviews. Discussions elicited condom use and negotiation attitudes, beliefs and social norms. Positive personal attitudes (respect of self, personal health concerns) and high negotiation self-efficacy was emphasized. Conversely, social norms revealed non-prioritized condom use behavior. Divergence between individual and community indicates theoretical models targeting sexual communication must address external factors (social, economic, political context), which intersects with individual intentions, attitudes to influence HIV prevalence in this community.

Sexual risk behavior in young adulthood: broadening the scope beyond early sexual initiation

A robust link between early sexual initiation and sexual risk-taking behavior is reported in previous studies. The relationship may not be causal, however, as the effect of common risk factors is often not considered. The current study examined whether early initiation was a key predictor of risky sexual behavior in the 20s and 30s, over and above co-occurring individual and environmental factors. Data were drawn from the Seattle Social Development Project, a longitudinal panel of 808 youth. Early predictors (ages 10 to 15) and sexual risk taking (ages 21 to 24 and 30 to 33) were assessed prospectively. Early sexual initiation (before age 15) was entered into a series of probit regressions that also included family, neighborhood, peer, and individual risk factors. Although a positive bivariate relation between early sexual initiation and sexual risk taking was observed at both ages, the link did not persist when co-occurring risk factors were included. Behavioral disinhibition and antisocial peer influences emerged as the strongest predictors of sexual risk over and above early sexual initiation. These results suggest that early sexual initiation must be considered in the context of common antecedents; public health policy aimed at delaying sexual intercourse alone is unlikely to substantially reduce sexual risk behavior in young adulthood.

Socioeconomic disparities in sexually transmitted infections among young adults in the United States: examining the interaction between income and race/ethnicity

BACKGROUND

There is considerable evidence of racial/ethnic patterning of sexually transmitted infection (STI) risk in the United States. There is also evidence that poorer persons are at increased STI risk. Evidence regarding the interaction of race/ethnicity and income is limited, particularly nationally at the individual level.

METHODS

We examined the pattern of socioeconomic gradients in STI infection among young people in a nationwide US study and determined how these gradients varied by race/ethnicity. We estimated the cumulative diagnosis prevalence of chlamydia, gonorrhea, or trichomoniasis (via self-report or laboratory confirmation) for young adults (ages, 18-26 years old) Hispanics and non-Hispanic whites, blacks, and others across income quintiles in the Add Health data set. We ran regression models to evaluate these relationships adjusting for individual- and school-level covariates.

RESULTS

Sexually transmitted infection diagnosis was independently associated with both racial/ethnic identity and with low income, although the racial/ethnic disparities were much larger than income-based ones. A negative gradient of STI risk with increasing income was present within all racial/ethnic categories, but was stronger for nonwhites.

CONCLUSIONS

Both economic and racial/ethnic factors should be considered in deciding how to target STI prevention efforts in the United States. Particular focus may be warranted for poor, racial/ethnic minority women.

Predictors of sexually transmitted infection in Australian women: evidence from the Australian Longitudinal Study on Women's Health

This longitudinal study examined characteristics of women diagnosed with sexually transmitted infections (STI) for the first time in their later 20s and early 30s. Participants were 6,840 women (born 1973-1978) from the Australian Longitudinal Study on Women's Health. Women aged 18-23 years were surveyed in 1996 (S1), 2000 (S2), 2003 (S3), and 2006 (S4). There were 269 women reporting an STI for the first time at S3 or S4. Using two multivariable logistic regression analyses (examining 18 predictor variables), these 269 women were compared (1) with 306 women who reported an STI at S2 and (2) with 5,214 women who never reported an STI across the four surveys. Women who reported an STI for the first time at S3 or S4 were less likely to have been pregnant or had a recent Pap smear compared to women reporting an STI at S2. Women reporting a first STI at S3 or S4 were less likely to have been pregnant or had a recent Pap smear compared to women reporting an STI at S2. Women were more likely to report an STI for the first time at S3 or S4 compared to women not reporting an STI at any survey if they were younger, unpartnered, had a higher number of sexual partners, had never been pregnant, were recently divorced or separated, and reported poorer access to Women's Health or Family Planning Centres at S2. These findings demonstrate the value of longitudinal studies of sexual health over the life course beyond adolescence.

Exposure to Different Types of Violence and Subsequent Sexual Risk Behavior among Female STD Clinic Patients: A Latent Class Analysis

OBJECTIVE

Diverse forms of violence, including childhood maltreatment (CM), intimate partner violence (IPV), and exposure to community violence (ECV), have been linked separately with sexual risk behaviors. However, few studies have explored multiple experiences of violence simultaneously in relation to sexual risk-taking, especially in women who are most vulnerable to violent experiences.

METHODS

Participants were 481 women (66% African American, M_age = 27 years) attending a publicly-funded STD clinic who reported on their past and current experiences with violence and their current sexual risk behavior. We identified patterns of experience with violence using latent class analysis (LCA) and investigated which combinations of experiences were associated with the riskiest sexual outcomes.

RESULTS

Four classes of women with different experiences of violence were identified: Low Violence (39%), Predominantly ECV (20%), Predominantly CM (23%), and Multiply Victimized (18%). Women in the Multiply Victimized and Predominantly ECV classes reported the highest levels of sexual risk behavior, including more lifetime sexual partners and a greater likelihood of receiving STD treatment and using substances before sex.

CONCLUSIONS

Women with different patterns of violent experiences differed in their sexual risk behavior. Interventions to reduce sexual risk should address violence against women, focusing on experiences with multiple types of violence and experiences specifically with ECV. Additional research is needed to determine the best ways to address violence in sexual risk reduction interventions.

The problem with the phrase women and minorities: intersectionality-an important theoretical framework for public health

Intersectionality is a theoretical framework that posits that multiple social categories (e.g., race, ethnicity, gender, sexual orientation, socioeconomic status) intersect at the micro level of individual experience to reflect multiple interlocking systems of privilege and oppression at the macro, social-structural level (e.g., racism, sexism, heterosexism). Public health's commitment to social justice makes it a natural fit with intersectionality's focus on multiple historically oppressed populations. Yet despite a plethora of research focused on these populations, public health studies that reflect intersectionality in their theoretical frameworks, designs, analyses, or interpretations are rare. Accordingly, I describe the history and central tenets of intersectionality, address some theoretical and methodological challenges, and highlight the benefits of intersectionality for public health theory, research, and policy.

A prospective study of the psychosocial impact of a positive Chlamydia trachomatis laboratory test

BACKGROUND

Few data exist on potential harms of chlamydia screening. We assessed the psychosocial impact of receiving a positive Chlamydia trachomatis test result.

METHODS

We prospectively studied women ≥16 years of age undergoing chlamydia testing in 2 Midwestern family planning clinics. We surveyed women at baseline and about 1 month after receiving test results, using 9 validated psychosocial scales/subscales and chlamydia-specific questions. Changes in scale scores were calculated for each woman. Mean percent changes in scores for chlamydia-positive and -negative women were compared using a t test.

RESULTS

We enrolled 1807 women (response rate, 84%). Of the 1688 women with test results, 149 (8.8%) tested positive. At follow-up, chlamydia-positive women (n = 71) had a 75% increase in anxiety about sexual aspects of their life on the Multidimensional Sexual Self-Concept Questionnaire (P < 0.001), significantly greater than the 26% increase among 280 randomly selected chlamydia-negative women (P = 0.02). There were no differences for the other 8 scales/subscales, including general measures of anxiety, depression, and self-esteem. Chlamydia-positive women were more likely than chlamydia-negative women to be "concerned about chlamydia" (80% vs. 40%, P < 0.001) and to report breaking up with a main partner (33% vs. 11%, P < 0.001) at follow-up. Women testing positive reported a range of chlamydia-specific concerns.

CONCLUSIONS

Chlamydia-positive women had significant increases in anxiety about sex and concern about chlamydia, but did not have marked changes in more general measures of psychosocial well-being about 1 month after diagnosis. Chlamydia diagnoses were associated with some disruption of relationships with main partners. Chlamydia-specific concerns may guide counseling messages to minimize psychosocial impact.

Bridging the gap between individual-level risk for HIV and structural determinants: using root cause analysis in strategic planning

HIV prevention efforts have expanded beyond individual-level interventions to address structural determinants of risk. Coalitions have been an important vehicle for addressing similar intractable and deeply rooted health-related issues. A root cause analysis process may aid coalitions in identifying fundamental, structural-level contributors to risk and in identifying appropriate solutions. For this article, strategic plans for 13 coalitions were analyzed both before and after a root cause analysis approach was applied to determine the coalitions' strategic plans potential impact and comprehensiveness. After root cause analysis, strategic plans trended toward targeting policies and practices rather than on single agency programmatic changes. Plans expanded to target multiple sectors and several changes within sectors to penetrate deeply into a sector or system. Findings suggest that root cause analysis may be a viable tool to assist coalitions in identifying structural determinants and possible solutions for HIV risk.

Associations of discrimination and violence with smoking among emerging adults: differences by gender and sexual orientation

INTRODUCTION

Lesbian, gay, and bisexual (i.e., sexual minority) populations have higher smoking prevalence than their heterosexual peers, but there is a lack of empirical study into why such disparities exist. This secondary analysis of data sought to examine associations of discrimination and violence victimization with cigarette smoking within sexual orientation groups.

METHODS

Data from the Fall 2008 and Spring 2009 National College Health Assessments were truncated to respondents of 18-24 years of age (n = 92,470). Since heterosexuals comprised over 90% of respondents, a random 5% subsample of heterosexuals was drawn, creating a total analytic sample of 11,046. Smoking status (i.e., never-, ever-, and current smoker) was regressed on general (e.g., not sexual orientation-specific) measures of past-year victimization and discrimination. To examine within-group differences, two sets of multivariate ordered logistic regression analyses were conducted: one set of models stratified by sexual orientation and another set stratified by gender-by-sexual-orientation groups.

RESULTS

Sexual minorities indicated more experiences of violence victimization and discrimination when compared with their heterosexual counterparts and had nearly twice the current smoking prevalence of heterosexuals. After adjusting for age and race, lesbians/gays who were in physical fights or were physically assaulted had higher proportional odds of being current smokers when compared with their lesbian/gay counterparts who did not experience those stressors.

CONCLUSIONS

When possible, lesbian/gay and bisexual groups should be analyzed separately, as analyses revealed that bisexuals had a higher risk profile than lesbians/gays. Further research is needed with more nuanced measures of smoking (e.g., intensity), as well as examining if victimization may interact with smoking cessation.

Incorporating geospatial capacity within clinical data systems to address social determinants of health

Linking electronic health record (EHR) systems with community information systems (CIS) holds great promise for addressing inequities in social determinants of health (SDH). While EHRs are rich in location-specific data that allow us to uncover geographic inequities in health outcomes, CIS are rich in data that allow us to describe community-level characteristics relating to health. When meaningfully integrated, these data systems enable clinicians, researchers, and public health professionals to actively address the social etiologies of health disparities.This article describes a process for exploring SDH by geocoding and integrating EHR data with a comprehensive CIS covering a large metropolitan area. Because the systems were initially designed for different purposes and had different teams of experts involved in their development, integrating them presents challenges that require multidisciplinary expertise in informatics, geography, public health, and medicine. We identify these challenges and the means of addressing them and discuss the significance of the project as a model for similar projects.