Treatment Rates for Chlamydia trachomatis and Neisseria gonorrhoeae in a Metropolitan Area: Observational Cohort Analysis

BACKGROUND

Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) are the 2 most common sexually transmitted infections (STIs) in the United States. The Centers for Disease Control and Prevention regularly publishes and updates STI Treatment Guidelines. The purpose of this study was to measure and compare treatment rates for CT and GC among public and private providers.

METHODS

Data from multiple sources, including electronic health records and Medicaid claims, were linked and integrated. Cases observed during 2016-2020 were defined based on positive laboratory results. We calculated descriptive statistics and odd ratios based on characteristics of providers and patients, stratifying by public versus private providers. Univariate logistic regression models were used to examine the factors associated with recommended treatment.

RESULTS

Overall, we found that 82.2% and 63.0% of initial CT and GC episodes, respectively, received Centers for Disease Control and Prevention-recommended treatment. The public STI clinic treated more than 90% of CT and GC cases consistently across the 5-year period. Private providers were significantly less likely to treat first episodes for CT (79.6%) and GC (53.3%; P < 0.01). Other factors associated with a higher likelihood of recommended treatment included being male, being HIV positive, and identifying as Black or multiracial. Among GC cases, 10.8% received nonrecommended treatment; all CT cases with treatment occurred per guidelines.

CONCLUSIONS

Although these treatment rates are higher than previous studies, there remain significant gaps in STI treatment that require intervention from public health.

Underlying reasons for primary care visits where chlamydia testing was performed in the United States, 2019-2022

BACKGROUND

In the United States (US), most chlamydia cases are reported from non-STD clinics, and there is limited information focusing on the reasons for chlamydia testing in private settings. These analyses describe clinical visits to primary care providers where chlamydia testing was performed to help discern between screening and diagnostic testing for chlamydia.

METHODS

Using the largest primary care clinical registry in the US, the PRIME registry, chlamydia tests were identified using Current Procedural Terminology (CPT) procedure codes and categorized as either diagnostic testing for sexually transmitted infection (STI) related symptoms, screening for chlamydia, or "other", based on ICD-10 Evaluation and Management codes selected for visits.

RESULTS

Of 120,013 clinical visits with chlamydia testing between January 1, 2019 and December 31, 2022, 70.4% were women; 20.6% were with STI-related symptoms, 59.9% were for screening, and 19.5% for "other" reasons. Of those 120,013 clinical visits with chlamydia testing, the logit model showed that patients were significantly more likely to have STI-related symptoms if they were female than male, non-Hispanic black than non-Hispanic white, aged 15-24 years than aged ≥45 years, and resided in the South than in the Northeast.

CONCLUSION

It is important to know what proportion of chlamydial infections are identified through screening programs and to have this information stratified by demographics. The inclusion of lab results could further facilitate a better understanding of the impact of chlamydia screening programs on the identification and treatment of chlamydia in private office settings in the United States.

Predicting high quality of participation in adaptive snow-sports for individuals with disabilities: An exploratory study

OBJECTIVES

This exploratory study aimed to examine the individual, program and environmental (social and physical) characteristics which predict high quality of participation in adaptive snowsports for each dimension of the Quality of Participation in Parasport Framework (QPPF): autonomy, belongingness, mastery, challenge, engagement and meaning.

METHODS

A survey was completed by 133 individuals with disabilities or their representatives on each dimension of the QPPF in adaptive snowsports and on the factors impacting the quality of participation. Descriptive statistics were used to describe the study participants, and a multivariate logistic regression model was constructed for each dimension of the QPPF to evaluate the relative contribution of individual, snowsport-related, program and environmental factors to each dimension.

RESULTS

Individuals with disabilities in this study reported high quality of participation on all dimensions of the QPPF. The individual characteristics only predicted the QPPF dimension of challenge. However, the program and environmental characteristics such as equipment, number of instructors and barriers were robust predictors of quality of participation.

CONCLUSION

Overall, participants experienced high quality participation. Supporting the adaptive snowsports programs while reducing the barriers faced by people with disabilities should be a continued effort to promote quality of participation.

National Chlamydia Screening Rate in Young Sexually Active Women Using HEDIS Measures in the United States, 2011 to 2020

BACKGROUND

National guidelines recommend sexually active women younger than 25 years be screened annually for chlamydia. Our objective was to estimate the chlamydia screening rate of sexually active women aged 16 to 24 years from 2011 to 2020.

METHODS

We analyzed the chlamydia screening rates among sexually active women aged 16 to 24 years from 2011 to 2020 using the chlamydia measures in the Healthcare Effectiveness Data and Information Set data set. The annual national chlamydia screening rates were further stratified by census region and by patient age.

RESULTS

Chlamydia screening rates among sexually active women aged 16 to 24 years ranged from 55.0% to 61.8% in Medicaid health plans and from 46.9% to 52.4% in commercial health plans during 2011-2020. The Northeast consistently had the highest screening rates among 4 geographic regions. The chlamydia screening rate among sexually active women aged 16 to 24 years decreased from 2019 to 2020: from 61.8% to 57.9% in Medicaid plans and from 52.4% to 48.4% in commercial health plans. The number of sexually active women aged 16 to 24 years covered by commercial health plans decreased from 2019 to 2020, but the number covered by Medicaid increased from 2019 to 2020.

CONCLUSIONS

The chlamydia screening rates in the target population have increased little from 2011 to 2019. The decrease in chlamydia screening rates between 2019 and 2020 could be related to the COVID-19 pandemic and the reduced use of health services during that period. With recently suboptimal chlamydia screening rates in the United States, interventions of improving and assessing chlamydia screening rates are needed.

Sexually Transmitted Infection/Human Immunodeficiency Virus, Pregnancy, and Mental Health-Related Services Provided During Visits With Sexual Assault and Abuse Diagnosis for US Medicaid Beneficiaries, 2019

BACKGROUND

Centers for Disease Control recommends that the decision to provide sexually transmitted infection (STI)/human immunodeficiency virus (HIV) testing and presumptive treatment to patients who report sexual assault and abuse (SAA) be made on an individual basis.

METHODS

The 2019 Centers for Medicare & Medicaid Services national Medicaid data set was used. The SAA visits were identified by International Classification of Diseases 10th Revision Clinical Modification (O9A4 for pregnancy-related sexual abuse, T74.2 for confirmed sexual abuse, and Z04.4 for alleged rape). The initial SAA visit was defined as the patient's first SAA-related visit. Medical services were identified by International Classification of Diseases 10th Revision Clinical Modification codes, Current Procedural Terminology codes, and National Drug Code codes.

RESULTS

Of 55,113 patients at their initial SAA visits, 86.2% were female; 63.4% aged ≥13 years; 59.2% visited emergency department (ED); all STI/HIV tests were provided in ≤20% of visits; presumptive gonorrhea and chlamydia treatment was provided in 9.7% and 3.4% of visits, respectively; pregnancy test was provided in 15.7% of visits and contraception services was provided in 9.4% of visits; and diagnosed anxiety was provided in 6.4% of visits. Patients who visited ED were less likely to have STI testing and anxiety than those visited non-ED facilities, but more likely to receive presumptive treatment for gonorrhea, testing for pregnancy, and contraceptive services. About 14.2% of patients had follow-up SAA visits within 60 days after the initial SAA visit. Of 7821 patients with the follow-up SAA visits within 60 days, most medical services provided were chlamydia testing (13.8%), gonorrhea testing (13.5%), syphilis testing (12.8%), HIV testing (14.0%); diagnosed anxiety (15.0%), and posttraumatic stress disorder (9.8%).

CONCLUSIONS

Current medical services during SAA visits for Medicaid patients are described in this evaluation. More collaboration with staff who handle SAA will improve SAA-related medical services.

Impact of the Early COVID-19 Pandemic on the Number of HIV Preexposure Prophylaxis Uses and the Proportion of Preexposure Prophylaxis Users Receiving Sexually Transmitted Infection Testing Services

BACKGROUND

With the potential impact of the COVID-19 pandemic on HIV preexposure prophylaxis (PrEP) care management, we assessed the number of PrEP users and sexually transmitted infection (STI) testing-eligible PrEP users, STI testing rates, and prevalence between prepandemic (January 1, 2018-March 31, 2020) and early-pandemic (April 1, 2020-September 30, 2020) periods.

METHODS

In this retrospective cohort study, a PrEP user for a given quarter is defined as either a previous PrEP user or a PrEP initiator who has at least 1-day coverage of tenofovir/emtricitabine in the given quarter. The STI testing-eligible PrEP users for a given quarter were defined as those persons whose runout date (previous dispense date + days of tenofovir/emtricitabine supply) was in the given quarter.

RESULTS

The quarterly number of PrEP users increased from the first quarter of 2018 to the first quarter of 2020 and then decreased in the second and third quarter of 2020. Among STI testing-eligible PrEP users who had ≤14 days between runout and next refill date, gonorrhea and chlamydia screening testing rates were 95.1% for prepandemic and 93.4% for early pandemic ( P = 0.1011). Among all STI testing-eligible PrEP users who were tested for gonorrhea and chlamydia, gonorrhea prevalence was 6.7% for prepandemic and 5.7% for early pandemic ( P = 0.3096), and chlamydia prevalence was 7.0% for prepandemic and 5.8% for early pandemic ( P = 0.2158).

CONCLUSIONS

Although the early COVID-19 pandemic resulted in lower numbers of PrEP users and PrEP initiators, individuals who remained continuous users of PrEP maintained extremely high rates of bacterial STI screening. With high STI prevalence among PrEP users, assessments of PrEP care management are continuously needed.

Findings From a Scoping Review: Presumptive Treatment for Chlamydiatrachomatis and Neisseria gonorrhoeae in the United States, 2006-2021

ABSTRACT

Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) are the 2 most common reported sexually transmitted infections in the United States. Current recommendations are to presumptively treat CT and/or GC in persons with symptoms or known contact. This review characterizes the literature around studies with presumptive treatment, including identifying rates of presumptive treatment and overtreatment and undertreatment rates. Of the 18 articles that met our inclusion criteria, 6 pertained to outpatient settings. In the outpatient setting, presumptive treatment rates, for both asymptomatic and symptomic patients, varied from 12% to 100%, and the percent positive of those presumptively treated ranged from 25% to 46%. Three studies also reported data on positive results in patients not presumptively treated, which ranged from 2% to 9%. Two studies reported median follow-up time for untreated, which was roughly 9 days. The remaining 12 articles pertained to the emergency setting where presumptive treatment rates, for both asymptomatic and symptomic patients, varied from 16% to 91%, the percent positive following presumptive treatment ranged from 14% to 59%. Positive results without presumptive treatment ranged from 4% to 52%. Two studies reported the percent positive without any treatment (6% and 32%, respectively) and one reported follow-up time for untreated infections (median, 4.8 days). Rates of presumptive treatment, as well as rates of overtreatment or undertreatment vary widely across studies and within care settings. Given the large variability in presumptive treatment, the focus on urban settings, and minimal focus on social determinants of health, additional studies are needed to guide treatment practices for CT and GC in outpatient and emergency settings.

Longitudinal Analysis of Electronic Health Information to Identify Possible COVID-19 Sequelae

Ongoing symptoms might follow acute COVID-19. Using electronic health information, we compared pre‒ and post‒COVID-19 diagnostic codes to identify symptoms that had higher encounter incidence in the post‒COVID-19 period as sequelae. This method can be used for hypothesis generation and ongoing monitoring of sequelae of COVID-19 and future emerging diseases.

Access to Healthcare and the Utilization of Sexually Transmitted Infections Among Homeless Medicaid Patients 15 to 44 Years of Age

Homelessness poses a direct threat to public health in the US as many individuals face debilitating health outcomes and barriers to adequate health care. Access to STI care for the homeless Medicaid population of USA has not been well-studied using administrative claims data. Our study aims to compare health services utilization, STI screening and diagnoses among people experiencing homelessness (PEH) vs. those who are non-PEH using ICD10 codes. We used 2019 MarketScan Medicaid claims data to analyze men and women aged 15-44 years with a diagnosis code for PEH (Z59.0), non-PEH (without Z59.0) and assessed their emergency department and outpatient visits and STI/HIV diagnoses and screening rates. We identified 5135 PEH men and 3571 PEH women among 1.3 million men and 2.1 million women in the 2019 US Medicaid database. PEH patients were more likely to have ED visits (94.80% vs 33.04%) and ≥ 20 outpatient clinic visits (60.29% vs 16.16%) than non-PEH patients in 2019. Higher diagnoses were observed for syphilis 1.57% (CI 1.32-1.86) vs 0.11% (CI 0.11-0.11), HIV 3.93% (CI 3.53-4.36) vs 0.41% (CI 0.41-0.42), chlamydia 1.94% (CI 1.66-2.25) vs 0.85% (CI 0.84-0.86) and gonorrhea 1.26% (CI 1.04-1.52) vs. 0.33% (CI 0.33-0.34) (p < 0.0001) among PEH compared to non-PEH. Among PEH, higher STI/HIV diagnoses rates indicate an increase in STI burden and suboptimal STI testing indicates an underutilization of STI services despite having a higher percentage of health care visits compared to non-PEH patients. Focused STI/HIV interventions are needed to address health care needs of PEH patients.

Impact of the COVID-19 Pandemic on Chlamydia and Gonorrhea Tests Performed by a Large National Laboratory-United States, 2019 to 2020

BACKGROUND

During the COVID-19 pandemic, disruptions were anticipated in the US health care system for routine preventive and other nonemergency care, including sexually transmitted infection care.

METHODS

Using a large national laboratory data set, we assessed the impact of the COVID-19 pandemic on the weekly numbers and percent positivity of chlamydia and gonorrhea tests ordered from the 5th week of 2019 to the 52nd week of 2020 in the United States. We compared weekly 2020 values for test volume, percent positive, and number of positives with the same week in 2019. We also examined the potential impact of stay-at-home orders for the month of April 2020.

RESULTS

Immediately after the declaration of a national emergency for COVID-19 (week 11, 2020), the weekly number of gonorrhea and chlamydia tests steeply decreased. Tests then rebounded toward the 2019 pre-COVID-19 level beginning the 15th week of 2020. The weekly percent positive of chlamydia and gonorrhea remained consistently higher in 2020. In April 2020, the overall number of chlamydia tests was reduced by 53.0% (54.1% in states with stay-at-home orders vs. 45.5% in states without stay-at-home orders), whereas the percent positive of chlamydia and gonorrhea tests increased by 23.5% and 79.1%, respectively.

CONCLUSIONS

To limit the impact of the pandemic on control of chlamydia and gonorrhea, public health officials and health care providers can assess measures put in place during the pandemic and develop new interventions to enable care for sexually transmitted infections to be delivered under pandemic and other emergency conditions. The assessment like this study is continuously needed.

Healthcare provider awareness of the recent FDA approval on first diagnostic tests for extragenital testing for chlamydia and gonorrhea

To assess healthcare provider awareness of the Food and Drug Administration (FDA) 2019 approval of nucleic acid amplification tests (NAAT) using extragenital specimens for chlamydia and gonorrhea, several questions were included in fall 2020 Porter Novelli's DocStyles survey, a US nationally representative semi-annual web-based survey of healthcare providers. There were 1502 respondents included in this study, 1000 family practitioners/internists as primary care physicians (PCPs), 251 obstetricians/gynecologists (OBs/GYNs), and 251 nurse practitioners/physician assistants (NP/PA). Awareness of this FDA approval was 34.3% overall and significantly varied by provider specialty: 45.0% for OB/GYN versus 23.5% for NP/PA, p < 0.01. OB/GYN had the lowest rate of ordering any extragenital gonorrhea and chlamydia tests in the past 12 months (31.6%) versus the other providers (ranging from 46.2% for NP/PA to 60.7% for PCP). The respondents were more likely to be aware of the FDA approval if they had ordered extragenital chlamydia or gonorrhea testing for men who have sex with men (MSM) than those who did not order the tests for MSM (72.3% versus 43.7%, p < 0.01). Of 1502 respondents, lack of reimbursement as a barrier to ordering extragenital tests for chlamydia and gonorrhea was most mentioned (16.6%) overall and did not significantly vary by provider's specialty. Further outreach is needed to educate healthcare providers on the changes in the FDA approval for extragenital gonorrhea and chlamydia testing so that they can provide comprehensive care to their patients and to reduce the potential for antimicrobial resistance.

STI/HIV Testing and Prevalence of Gonorrhea and Chlamydia Among Persons with Their Specified-Type Sex Partner

BACKGROUND

Previous studies have shown that sexually transmitted infections (STI) and human immunodeficiency virus (HIV) testing has varied, but STI prevalence was not estimated among patients during their health care visits in which a high-risk sexual partnership was documented. This study estimated gonorrhea, chlamydia, syphilis, and HIV testing rates and chlamydia and gonorrhea prevalence.

METHODS

From the de-identified commercial claims data of OptumLabs Data Warehouse, we identified men and women aged 15-60 years classified as having high-risk sexual relationships as diagnosis codes: Z72.51 for opposite-sex, Z72.52 for same-sex, and Z72.53 for same-and-opposite-sex relationships, stratified by gender, age group, region, type of health plan, and HIV status. We estimated STI testing rate and prevalence for chlamydia and gonorrhea among patients with high-risk sexual relationships. HIV testing was assessed only in high-risk sexual relationship patients without HIV.

RESULTS

Among 8.2 million females and 7.3 million males aged 15-60 years in the database from 2016 to 2019, 115,884 patients (0.7% of female, 0.8% of male) including 3,535 patients with HIV were diagnosed with high-risk sexual relationships. The testing rates for gonorrhea, chlamydia, syphilis, and HIV were 69.4% (confidence interval [CI]: 69.1-69.7), 68.9% (CI: 68.6-69.2), 43.4% (CI: 43.1-43.7), and 41.7% (CI: 41.4-42.0), respectively. Among patients with valid chlamydia and gonorrhea tests, 7.2% (CI: 7.0-7.5) and 2.6% (CI: 2.4-2.8) had positive chlamydia and gonorrhea test results, respectively, and varied by type of high-risk sexual relationship.

CONCLUSIONS

Our study findings of suboptimal STI screening among patient in high-risk sexual relationships are consistent with previous studies. Administrative records confirmed by lab results indicate a need for STI counseling, testing, and treatment among patients who are diagnosed with high-risk sexual relationships with same-sex, opposite-sex, or same-and-opposite sex partners.

Chlamydia trachomatis and Neisseria gonorrhoeae in Pregnancy: Trends in United States, 2010 to 2018

BACKGROUND

Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) case surveillance relies on reported positive laboratory results. Changes in reported cases may represent changes in testing practice or infection prevalence. This study evaluated changes over time for CT and NG positivity and testing rates of pregnant persons.

METHODS

Prenatal testing results from persons aged 16 to 40 years tested by a national reference clinical laboratory were analyzed for CT and NG testing and positivity from 2010 to 2018 (n = 3,270,610).

RESULTS

Testing rates increased among pregnant persons for CT (from 56.3% in 2010 to 64.1% in 2018, P < 0.001) and NG (from 55.6% to 63.2%, P < 0.001). Higher CT testing rates were found in Black non-Hispanic (adjusted odds ratio [AOR], 1.58; 95% confidence interval [CI], 1.57-1.60) and Hispanic (AOR, 1.19; 95% CI, 1.18-1.20) persons. NG and CT testing rates were virtually identical. Significant increasing trends in CT positivity were observed for each age group studied (P < 0.001 for all): 16-19 (from 11.7% to 13.0%), 20-24 (from 6.4% to 6.7%), 25-30 (from 1.9% to 2.4%), and 31-40 years (from 0.76% to 0.92%). Black non-Hispanic persons had the highest positivity for CT (AOR, 2.52; 95% CI, 2.46-2.57) and NG (AOR, 5.42; 95% CI, 5.05-5.82).

CONCLUSIONS

Testing and adjusted positivity for both CT and NG among pregnant persons increased from 2010 to 2018. Higher testing rates were observed in Black non-Hispanic and Hispanic persons (even in persons younger than 25 years), suggesting some testing decisions may have been based on perceived risk, in contrast to many guidelines recommending screening all pregnant persons younger than 25 years.

Syphilis testing adherence among women with livebirth deliveries: Indianapolis 2014-2016

BACKGROUND

The number of congenital syphilis (CS) cases in the United States are increasing. Effective prevention of CS requires routine serologic testing and treatment of infected pregnant women. The Centers for Disease Control and Prevention (CDC) recommends testing all pregnant women at their first prenatal visit and subsequent testing at 28 weeks gestation and delivery for women at increased risk.

METHODS

We conducted a cross-sectional cohort study of syphilis testing among pregnant women with a livebirth delivery from January 2014 to December 2016 in Marion County, Indiana. We extracted and linked maternal and infant data from the vital records in a local health department to electronic health records available in a regional health information exchange. We examined syphilis testing rates and factors associated with non-testing among women with livebirth delivery. We further examined these rates and factors among women who reside in syphilis prevalent areas.

RESULTS

Among 21260 pregnancies that resulted in livebirths, syphilis testing in any trimester, including delivery, increased from 71.7% in 2014 to 86.6% in 2016. The number of maternal syphilis tests administered only at delivery decreased from 16.6% in 2014 to 4.04% in 2016. Among women living in areas with high syphilis rates, syphilis screening rates increased from 79.6% in 2014 to 94.2% in 2016.

CONCLUSION

Improvement in prenatal syphilis screening is apparent and encouraging, yet roughly 1-in-10 women do not receive syphilis screening during pregnancy. Adherence to recommendations set out by CDC improved over time. Given increasing congenital syphilis cases, the need for timely diagnoses and prevention of transmission from mother to fetus remains a priority for public health.

The Burden of and Trends in Pelvic Inflammatory Disease in the United States, 2006-2016

BACKGROUND

Pelvic inflammatory disease (PID) is an infection of the upper genital tract that has important reproductive consequences to women. We describe the burden of and trends in PID among reproductive-aged women in the United States during 2006-2016.

METHODS

We used data from 2 nationally representative probability surveys collecting self-reported PID history (National Health and Nutrition Examination Survey, National Survey of Family Growth); 5 datasets containing International Classification of Diseases, Ninth/Tenth Revision codes indicating diagnosed PID (Healthcare Utilization Project; National Hospital Ambulatory Medical Care Survey, emergency department component; National Ambulatory Medical Care Survey; National Disease Therapeutic Index; MarketScan); and data from a network of sexually transmitted infection (STI) clinics (Sexually Transmitted Disease Surveillance Network). Trends during 2006-2016 were estimated overall, by age group and, if available, race/ethnicity, region, and prior STIs.

RESULTS

An estimated 2 million reproductive-aged women self-reported a history of PID. Three of 4 nationally representative data sources showed overall declines in a self-reported PID history, and PID emergency department and physician office visits, with small increases observed in nearly all data sources starting around 2015.

CONCLUSIONS

The burden of PID in the United States is high. Despite declines in burden over time, there is evidence of an increase in recent years.

A New Call to Action to Combat an Old Nemesis: Addressing Rising Congenital Syphilis Rates in the United States

Congenital syphilis (CS) is on the rise in the United States and is a growing public health concern. CS is an infection with Treponema pallidum in an infant or fetus, acquired via transplacental transmission when a pregnant woman has untreated or inadequately treated syphilis. Pregnant women with untreated syphilis are more likely to experience pregnancies complicated by stillbirth, prematurity, low birth weight, and early infant death, while their children can develop clinical manifestations of CS such as hepatosplenomegaly, bone abnormalities, developmental delays, and hearing loss. One of the ways CS can be prevented is by identifying and treating infected women during pregnancy with a benzathine penicillin G regimen that is both appropriate for the maternal stage of syphilis and initiated at least 30 days prior to delivery. In this article we discuss many of the challenges faced by both public health and healthcare systems with regards to this preventable infection, summarize missed opportunities for CS prevention, and provide practical solutions for future CS prevention strategies.

Late Conditions Diagnosed 1-4 Months Following an Initial Coronavirus Disease 2019 (COVID-19) Encounter: A Matched-Cohort Study Using Inpatient and Outpatient Administrative Data-United States, 1 March-30 June 2020

BACKGROUND

Late sequelae of COVID-19 have been reported; however, few studies have investigated the time course or incidence of late new COVID-19-related health conditions (post-COVID conditions) after COVID-19 diagnosis. Studies distinguishing post-COVID conditions from late conditions caused by other etiologies are lacking. Using data from a large administrative all-payer database, we assessed type, association, and timing of post-COVID conditions following COVID-19 diagnosis.

METHODS

Using the Premier Healthcare Database Special COVID-19 Release (release date, 20 October 2020) data, during March-June 2020, 27 589 inpatients and 46 857 outpatients diagnosed with COVID-19 (case-patients) were 1:1 matched with patients without COVID-19 through the 4-month follow-up period (control-patients) by using propensity score matching. In this matched-cohort study, adjusted ORs were calculated to assess for late conditions that were more common in case-patients than control-patients. Incidence proportion was calculated for conditions that were more common in case-patients than control-patients during 31-120 days following a COVID-19 encounter.

RESULTS

During 31-120 days after an initial COVID-19 inpatient hospitalization, 7.0% of adults experienced ≥1 of 5 post-COVID conditions. Among adult outpatients with COVID-19, 7.7% experienced ≥1 of 10 post-COVID conditions. During 31-60 days after an initial outpatient encounter, adults with COVID-19 were 2.8 times as likely to experience acute pulmonary embolism as outpatient control-patients and also more likely to experience a range of conditions affecting multiple body systems (eg, nonspecific chest pain, fatigue, headache, and respiratory, nervous, circulatory, and gastrointestinal symptoms) than outpatient control-patients.

CONCLUSIONS

These findings add to the evidence of late health conditions possibly related to COVID-19 in adults following COVID-19 diagnosis and can inform healthcare practice and resource planning for follow-up COVID-19 care.

Sexually Transmitted Infection Testing and Prevalence Before and After Preexposure Prophylaxis Initiation Among Men Aged ≥18 Years in US Private Settings

BACKGROUND

The Centers for Disease Control and Prevention recommends initial and follow-up sexually transmitted infection (STI) and HIV testing when taking HIV preexposure prophylaxis (PrEP). We assessed frequencies of STIs and HIV testing and rates of STIs before and after PrEP initiation among men aged ≥18 years.

METHODS

We used the OptumLabs database for this cohort study. We measured STI/HIV testing rates and prevalence in 2 time intervals: (1) within 90 days before and on the date of PrEP initiation and (2) within 45 days of the 180th day after the date of PrEP initiation.

RESULTS

Of 4210 men who initiated PrEP in 2016 to 2017 and continuously used PrEP for ≥180 days, 45.7%, 45.7%, and 56.0% were tested for chlamydia, gonorrhea, and HIV, respectively, at the second time interval. These percentages were significantly lower than those at the first time interval (58.3%, 57.9%, and 73.5%, respectively; P < 0.01). Chlamydia and gonorrhea prevalence rates at the second time interval were 6.5% and 6.2%, respectively, versus 5.0% and 4.7%, respectively, at the first time interval. Most gonorrhea or chlamydia infections at the second time intervals seem to be new infections new infections.

CONCLUSIONS

Sexually transmitted infection/HIV testing for PrEP users in the real-world private settings is much lower than in clinical trials. High STI prevalence before and after PrEP initiation in this study suggests that patients taking PrEP have an increased risk of acquiring STI. Interventions to improve provider adherence for PrEP users are urgently needed.

Sexually Transmitted Infection/HIV Testing Among Medicaid/Children's Health Insurance Program-Insured Enrollees Aged 15 to 60 Years Who Were Diagnosed With High-Risk Sexual Behaviors With Their Opposite-Sex or Same-Sex Partners

BACKGROUND

There is a lack of information on high-risk sexual behaviors (HRSB) related to gender of sex partner and associated sexually transmitted infection (STI)/HIV testing among Medicaid enrollees.

METHODS

We used the 2016 Centers for Medicare & Medicaid Services Medicaid claims data to identify enrollees aged 15 to 60 years with HRSB by International Classification of Disease, Tenth Revision codes (Z72.51, Z72.52, and Z72.53). Enrollees diagnosed with HRSB were classified into 2 groups:(1) with same-sex partners and (2) with opposite-sex partners. The date when the initial diagnosis for HRSB was documented was used to define as the index date. We assessed chlamydia, gonorrhea, syphilis, and HIV testing on the index date, in the 6-month period before and after the index date (excluded the index date). HIV testing was limited to enrollees without documented HIV infection.

RESULTS

Of 50 million Medicaid enrollees aged 15 to 60 years, 1.2% were identified as enrollees with HRSB in 2016. Of those enrollees with HRSB, 2.7% were enrollees with same-sex partners and 0.71% had documented HIV infection. Chlamydia, gonorrhea, syphilis, and HIV testing rates were 82.4%, 81.9%, 33.2%, and 44.3%, respectively, at the index date. The chlamydia testing rate was ≥90% among enrollees who resided in the West compared with 53% to 61% across other regions. HIV testing was more likely among males and among those with same-sex partners. Sexually transmitted infection/HIV testing was <30% in the 6-month periods before and after the index date.

CONCLUSIONS

Among Medicaid enrollees with HRSB, STI/HIV testing varied regionally. Many enrollees were not tested for STI/HIV at the index visit in which they were identified as HRSB.

Chlamydia Screening Among Women Aged 15 to 44 Years Who Reported Anal Sex During the Past 12 Months in the United States, 2013 to 2017

ABSTRACT

Using the 2013-2017 National Survey of Family Growth, 37.6% of women with ≥1 anal sex partner in the last 12 months reported chlamydia testing at unspecified anatomic sites in the past 12 months. Women whose medical provider asked about type of sex (i.e., vaginal, oral, anal), compared with those whose provider did not, reported higher chlamydia testing.

Validation of International Classification of Diseases, Tenth Revision, Clinical Modification Codes for Identifying Cases of Chlamydia and Gonorrhea

BACKGROUND

While researchers seek to use administrative health data to examine outcomes for individuals with sexually transmitted infections (STIs), the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes used to identify persons with chlamydia and gonorrhea have not been validated. Objectives were to determine the validity of using ICD-10-CM codes to identify individuals with chlamydia and gonorrhea.

METHODS

We used data from electronic health records gathered from public and private health systems from October 1, 2015, to December 31, 2016. Patients were included if they were aged 13 to 44 years and received either (1) laboratory testing for chlamydia or gonorrhea or (2) an ICD-10-CM diagnosis of chlamydia, gonorrhea, or an unspecified STI. To validate ICD-10-CM codes, we calculated positive and negative predictive values, sensitivity, and specificity based on the presence of a laboratory test result. We further examined the timing of clinical diagnosis relative to laboratory testing.

RESULTS

The positive predictive values for chlamydia, gonorrhea, and unspecified STI ICD-10-CM codes were 87.6%, 85.0%, and 32.0%, respectively. Negative predictive values were high (>92%). Sensitivity for chlamydia diagnostic codes was 10.6%, and gonorrhea was 9.7%. Specificity was 99.9% for both chlamydia and gonorrhea. The date of diagnosis occurred on or after the date of the laboratory result for 84.8% of persons with chlamydia, 91.9% for gonorrhea, and 23.5% for unspecified STI.

CONCLUSIONS

Disease-specific ICD-10-CM codes accurately identify persons with chlamydia and gonorrhea. However, low sensitivities suggest that most individuals could not be identified in administrative data alone without laboratory test results.

Persistence With Human Immunodeficiency Virus Pre-exposure Prophylaxis in the United States, 2012-2017

BACKGROUND

Daily oral pre-exposure prophylaxis (PrEP) is highly effective in preventing human immunodeficiency virus (HIV) infection if used adherently throughout periods of HIV risk. We estimated PrEP persistence among cohorts of persons with commercial or Medicaid insurance.

METHODS

We analyzed data from the IBM MarketScan Research Database to identify persons aged 18-64 years who initiated PrEP between 2012 and 2017. We assessed PrEP persistence by calculating the time period that each person continued filling PrEP prescriptions until there was a gap in prescription fills > 30 days. We used Kaplan-Meier time-to-event methods to estimate the proportion of PrEP users who persisted with PrEP at 3, 6, and 12 months after initiation, and constructed Cox proportional hazards models to determine patient characteristics associated with nonpersistence.

RESULTS

We studied 11 807 commercially insured and 647 Medicaid insured persons with PrEP prescriptions. Commercially insured patients persisted for a median time of 13.7 months (95% confidence interval [CI], 13.3-14.1), compared to 6.8 months (95% CI, 6.1-7.6) among Medicaid patients. Additionally, female sex, younger age, residence in rural location, and black race were associated with shorter persistence. After adjusting for covariates, we found that female sex (hazard ratio [HR], 1.81 [95% CI, 1.56-2.11]) and younger age (18-24 years: HR, 2.38 [95% CI, 2.11-2.69]) predicted nonpersistence.

CONCLUSIONS

More than half of commercially insured persons who initiated PrEP persisted with it for 12 months, compared to a third of those with Medicaid. A better understanding of reasons for nonpersistence is important to support persistent PrEP use and to develop interventions designed for the diverse needs of at-risk populations.

Estimating Recommended Gonorrhea and Chlamydia Treatment Rate Using Linked Medical Claims, Prescription, and Laboratory Data in US Private Settings

BACKGROUND

The Centers for Disease Control and Prevention (CDC) recommends specific regimens for chlamydia and dual therapy for gonorrhea to mitigate antimicrobial-resistant gonorrhea in the CDC 2015 sexually transmitted disease treatment guidelines. Only limited studies examining adherence to these recommendations have been conducted at private practices in the United States.

METHODS

We used the OptumLabs Data Warehouse, a comprehensive, longitudinal data asset with deidentified persons with linked commercial insurance claims and clinical information, to identify persons aged 15 to 60 years who had valid nucleic acid amplification testing results demonstrating urogenital or extragenital gonorrhea or chlamydia in 2016 to 2018. We defined valid laboratory results as positive or negative. We then assessed the time of their first positive test result and the type of treatment within 30 days to determine if there was evidence in the claims record that the CDC-recommended treatment was provided. We defined presumed treatment if the date of treatment was before the date of the positive test result within 30 days.

RESULTS

Among 6476 patients with positive gonorrhea test results and 26,847 patients with positive chlamydia test results only, 34.8% and 64.2% had evidence of receiving the CDC-recommended therapy, respectively. Approximately 11.6% of patients with positive gonorrhea test results with recommended dual treatment and 7.1% of patients with positive chlamydia test results only with recommended chlamydia treatment were presumptively treated.

CONCLUSION

Analysis of treatment claims and medical records from private settings indicated low rates of recommended gonorrhea and chlamydia treatment. Validation of treatment claims is needed to support further quality of care interventions based on these data.

Performance improvement of wastewater treatment processes by application of machine learning

Improving wastewater treatment processes is becoming increasingly important, due to more stringent effluent quality requirements, the need to reduce energy consumption and chemical dosing. This can be achieved by applying artificial intelligence. Machine learning is implemented in two domains: (1) predictive control and (2) advanced analytics. This is currently being piloted at the integrated validation plant of PUB, Singapore's National Water Agency. (1) Primarily, predictive control is applied for optimised nutrient removal. This is obtained by application of a self-learning feedforward algorithm, which uses load prediction and machine learning, fine-tuned with feedback on ammonium effluent. Operational results with predictive control show that the load prediction has an accuracy of ≈88%. It is also shown that an up to ≈15% reduction of aeration amount is achieved compared to conventional control. It is proven that this load prediction-based control leads to stable operation and meeting effluent quality requirements as an autopilot system. (2) Additionally, advanced analytics are being developed for operational support. This is obtained by application of quantile regression neural network modelling for anomaly detection. Preliminary results illustrate the ability to autodetect process and instrument anomalies. These can be used as early warnings to deliver data-driven operational support to process operators.

Gonorrhea testing, morbidity, and reporting using an integrated sexually transmitted disease registry in Indiana: 2004-2016

Surveillance of gonorrhea (GC), the second most common notifiable disease in the United States, depends on case reports. Population-level data that contain the number of individuals tested in addition to morbidity are lacking. We performed a cross-sectional analysis of data obtained from individuals tested for GC recorded in a sexually transmitted disease (STD) registry in the state of Indiana. Descriptive statistics were performed, and a Poisson generalized linear model was used to evaluate the number of individuals tested for GC and the positivity rate. GC cases from a subset of the registry were compared to CDC counts to determine the completeness of the registry. A total of 1,870,811 GC tests were linked to 627,870 unique individuals. Individuals tested for GC increased from 54,334 in 2004 to 269,701 in 2016; likewise, GC cases increased from 2,039 to 5,997. However, positivity rate decreased from 3.75% in 2004 to 2.22% in 2016. The difference in the number of GC cases captured by the registry and those reported to the CDC was not statistically significant (P = 0.0665). Population-level data from an STD registry combining electronic medical records and public health case data may inform STD control efforts. In Indiana, increased testing rates appeared to correlate with increased GC morbidity.

Syphilis Testing among Men Who Have Had Rectal Gonorrhea and Chlamydia Tests, United States

The Centers for Disease Control and Prevention (CDC) recommends syphilis screening at least annually for sexually active men who have sex with men (MSM). The objective of this study is to assess the frequency of MSM testing for syphilis and how syphilis test results compared with results of rectal gonorrhea and chlamydia tests. In collaboration with a large US commercial laboratory, we identified men aged 15-60 years who had rectal chlamydia or gonorrhea tests during 09/01/2013-09/30/2015 as presumed MSM. We classified MSM as having current or past syphilis if during the study period they had (1) either a reactive qualitative non-treponemal test or at least a 1:1 quantitative non-treponemal test, and (2) they had a reactive treponemal test. Of 52,771 MSM, 14.3% had no syphilis testing, 4.8% had only treponemal testing (37.8% were reactive), 63.2% had only non-treponemal testing (2.0% were reactive), and 17.7% had both non-treponemal and treponemal testing (86.6% had current or past syphilis). Of those MSM who had reactive qualitative non-treponemal tests, at least 90% had no quantitative non-treponemal tests. Current or past syphilis was more common among MSM with positive rectal gonorrhea or chlamydia tests (24.1%) than MSM with negative rectal gonorrhea and chlamydia tests (13.0%, p < 0.005). Of MSM with any syphilis testing during 09/01/2013-09/30/2014, 64.8% also had annual repeat testing. Syphilis testing in general and repeat syphilis testing were frequent but suboptimal among MSM. It is important to continually monitor syphilis for MSM, especially for those MSM who had rectal chlamydia or gonorrhea infection.

Infrequent Testing of Women for Rectal Chlamydia and Gonorrhea in the United States

Background

Anal sex is a common sexual behavior among women that increases their risk of acquiring rectal infection with Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC).

Methods

We estimated the frequency and positivity of rectal CT and GC tests for women aged 15-60 years performed by a large US commercial laboratory between November 2012 and September 2015. We also estimated the frequency and positivity of pharyngeal and genital specimens also performed on the same date. Among women with a positive CT or GC result, we estimated the frequency and positivity of recommended repeat testing within 12 months.

Results

Of 5499 women who had rectal CT and GC tests, positivity was 10.8%. On the same date, approximately 80% also had genital CT tests, genital GC tests, and pharyngeal GC tests, while 40% had pharyngeal CT tests. Rectal CT or GC infection was associated with genital CT or GC infection, but 46.5% of rectal CT and GC infections would not have been identified with genital testing alone. Among women with a rectal CT or GC infection, only 20.0% had a recommended repeat rectal test. Of those who had a repeat test, 17.7% were positive.

Conclusions

Testing women for rectal CT and GC was infrequent, but positive tests were often found in women with negative genital tests. Most women with positive rectal tests were not retested. Interventions are needed to increase extragenital CT and GC testing of at-risk women.

Corrigendum to: Significant difference in HEDIS annual chlamydia testing rates between women who had given birth and those who had not among young Medicaid women

We used the 2013 Medicaid Analytic eXtract (MAX) database to estimate chlamydia testing rates separately for sexually active women aged 15-25 years who had, or had not, given birth in 2013. Approximately 9.2% of sexually active women aged 15-25 years gave birth in 2013. The Healthcare Effectiveness Data Information Set (HEDIS) annual chlamydia testing rate was significantly higher among women who had given birth than women who had not in 2013 (59.7 vs 29.4%, P<0.05). Our findings suggest a need for more research to understand how differences in population mix changes and preventive screening practices for pregnant and non-pregnant women affect publicly reported chlamydia screening rates.

Laboratory Testing of a Cohort of Commercially Insured Users of HIV Preexposure Prophylaxis in the United States, 2011-2015

To ensure the health and safety of persons taking antiretroviral medication as preexposure prophylaxis (PrEP) against human immunodeficiency virus (HIV) infection, Centers for Disease Control and Prevention guidelines recommend initial and follow-up laboratory testing. We assessed the rates of recommended testing, using a commercial insurance claims database. Before taking PrEP, 45% of users were tested for HIV, 55% for syphilis, 43% for chlamydia/gonorrhea, and 38% for hepatitis B, and 31% had their creatinine level measured. By 6 months after PrEP initiation, 38% were tested for HIV, 49% for syphilis, and 39% for chlamydia/gonorrhea, and 37% had their creatinine level measured. Although laboratory testing was less frequent than recommended, testing rates increased over the study period.

Young Adults' Access to Insurance Through Parents: Relationship to Receipt of Reproductive Health Services and Chlamydia Testing, 2007-2014

PURPOSE

Adolescents' concerns about confidential service receipt have been linked to avoidance of sexual and reproductive healthcare. Healthcare system changes allowing young adults to remain on a parent's health insurance plan up to age 26 may have extended these concerns to young adults. This study examines: (1) The association between the relationship of young women to primary health plan policy holder (parent or self) on receipt of reproductive health services and chlamydia screening. (2)Changes, over time, in the proportion of young women who are parentally- versus self-insured.

METHODS

Cross-sectional analysis of commercially insured young women (18-25) enrolled ≥330days in health plans included in the Truven Health MarketScan commercial claims and encounters database (2007-2014).

RESULTS

Between 2010 and 2014, the proportion of parentally-insured young women increased significantly across all age groups (AOR = 4.32, CI = 4.29, 4.33). Compared to self-insured young women, parentally-insured young women were less likely to receive a reproductive health service (AOR = .66, CI = .66, .67) and sexually active parentally-insured young women were less likely to receive chlamydia testing (AOR = .75, CI = .75, .76) using their parent's insurance.

CONCLUSIONS

Young women who are insured through a parent are less likely to receive reproductive health services or chlamydia testing using their parent's insurance, which could suggest that concerns about confidential receipt of health services may result in missed care. Various policies, including those related to explanation of benefits sent to a plan policy holder outlining services received, may affect the receipt of confidential healthcare by young adults.

Low HIV testing rates among US women who report anal sex and other HIV sexual risk behaviors, 2011-2015

OBJECTIVE

In 2016, 19% of HIV diagnoses were in women. About 40% of HIV infections in women aged 18-34 years have been attributed to anal sex, suggesting that women who report high risk behaviors such as anal sex might benefit from HIV testing and prevention with preexposure prophylaxis (PrEP). In this analysis, we estimated HIV testing rates among women who reported anal sex.

STUDY DESIGN

We analyzed data from the 2011-2015 National Survey of Family Growth to estimate the proportion of sexually active, nonpregnant US women aged 15-44 years who had an HIV test within the past year, stratified by those who reported anal sex and other risk factors, including ≥2 sexual partners, condomless sex with a new partner or multiple partners, gonorrhea in the past year, or any history of syphilis.

RESULTS

Overall, 7.9 million of 42.4 million sexually active, nonpregnant US women (18.7%) reported an HIV test within the past year. Among 42.4 million sexually active women, 9.0 million (20.1%) reported they had anal sex in the past year. Among these 9.0 million women, 19.2% reported that their providers asked about their type of intercourse, and 20.1% reported an HIV test within the past year. Overall, HIV testing was higher among women who reported anal sex and reported that their providers asked about type of sex than those whose provider did not ask (37.8% vs 15.9%; P < .001). HIV testing in the past year was higher for women with other risk behaviors compared with anal sex, ranging from 35.8% to 47.2%.

CONCLUSION

Overall, HIV testing rates within the past year were low among women with sexual behaviors that increase their risk of acquiring HIV and especially low among those who reported anal sex. Early detection and treatment of HIV, and HIV prevention with PrEP, are effective health services that protect women's health and well-being but that can be offered only based on HIV testing results. Women's health care providers are uniquely poised to assess risk for acquiring HIV, including taking a sexual history that asks about anal sex, and performing HIV testing to identify women who need HIV treatment or might benefit from PrEP.

Significant difference in HEDIS annual chlamydia testing rates between women who had given birth and those who had not among young Medicaid women

We used the 2013 Medicaid Analytic eXtract (MAX) database to estimate chlamydia testing rates separately for sexually active women aged 15-25 years who had, or had not, given birth in 2013. Approximately 9.2% of sexually active women aged 15-25 years gave birth in 2013. The Healthcare Effectiveness Data Information Set (HEDIS) annual chlamydia testing rate was significantly higher among women who had given birth than women who had not in 2013 (59.7 vs 29.4%, P<0.05). Our findings suggest a need for more research to understand how differences in population mix changes and preventive screening practices for pregnant and non-pregnant women affect publicly reported chlamydia screening rates.

Increase in Urgent Care Center Visits for Sexually Transmitted Infections, United States, 2010-2014

During 2010–2014, urgent care centers saw a ≈2-fold increase in the number of visits for chlamydia and gonorrhea testing and a >3-fold increase in visits by persons with diagnosed sexually transmitted infections. As urgent care becomes more popular, vigilance is required to ensure proper management of these diseases.

Utilization pattern of other preventive services during the US Medicare annual wellness visit

Annual wellness visit (AWV) was introduced for Medicare patients in 2011 to help patients stay healthy. The object of this study is to assess whether AWV have an impact on the use of other preventive services in the eligible population. Medicare claims for the full sample of beneficiaries who were continuously enrolled in fee-for-service Medicare in 2013 and 2014 were analyzed. The association between AWV and three other preventive services (depression screening [DPS], influenza virus vaccine [IVV], and sexually transmitted infection screening [STI]) were assessed. In addition, the utilization pattern of these three preventative services at AWV visit by the calendar month when beneficiaries had an AWV service was also assessed. Of 28 million eligible Medicare beneficiaries, 16.0% had AWV in 2014. The patients who had AWV had a significantly higher percentage of three preventive services than those who had no AWV: 63.8% vs. 41.6% in IVV, 4.9% vs. 0.5% in DPS, and 2.3% vs. 1.8% in STI. The percentages of beneficiaries who received IVV during an AWV visit varied significantly by calendar month: from < 0.1% in June to 36.8% in October. AWV is associated with increased use of other preventive services. In addition, the association is significantly affected by type of other preventive services that may be highly related with seasonal factors.

Updated Estimates of Ectopic Pregnancy among Commercially and Medicaid-Insured Women in the United States, 2002-2013

OBJECTIVES

To update trends in the rates of ectopic pregnancy, to compare rates of ectopic pregnancy between commercially insured and Medicaid-insured women, and to assess the differences in rates of ectopic pregnancy by different measures of ectopic pregnancy.

METHODS

We analyzed data from 2002 to 2013 using the Truven Health MarketScan Commercial and Medicaid Claims Database. We limited the study population to women aged 15 to 44 years with any pregnancy in each year. Pregnancy and ectopic pregnancy were identified by clinical services with diagnostic or procedural codes. Ectopic pregnancy was measured in two ways: diagnosed and treated compared with diagnosed only; pregnancy was measured in two ways: any pregnancy compared with pregnancy with delivery.

RESULTS

We did not observe a substantial trend in the rate of ectopic pregnancy from 2002 to 2013. The rate of diagnosed and treated ectopic pregnancy substantially increased by age: 0.29% in women aged 15 to 19 years and 0.89% in women aged 40 to 44 years among the commercially insured population and 0.23% and 0.85% among the Medicaid-insured population, respectively. The rate of ectopic pregnancy also varied by the different methodologies used to estimate rates.

CONCLUSIONS

The rate of ectopic pregnancy is relatively low and stable for women of reproductive age in the United States. Our findings highlight that it is important to clearly define the numerator and denominator in the measure of ectopic pregnancy rates.

An Integrated Surveillance System to Examine Testing, Services, and Outcomes for Sexually Transmitted Diseases

Despite laws that require reporting of sexually transmitted diseases (STDs) to governmental health agencies, integrated surveillance of STDs remains challenging. Data and information about testing are fragmented from information on treatment and outcomes. To overcome this fragmentation, data from multiple electronic systems spanning clinical and public health environments were integrated to create an STD surveillance registry. Electronic health records, disease case records, and birth registry records were linked and then stored in a de-identified, secure server for use by health officials and researchers. The registry contains nearly 6 million tests for 628,138 individuals over a 12-year period. The registry supports efforts to understand the epidemiology of STDs as well as health services and outcomes for those diagnosed with STDs. Specialized disease registries hold promise for collaboration across clinical and public health domains to improve surveillance efforts, reduce health disparities, and increase prevention efforts at the local level.

Rectal Infection With Neisseria gonorrhoeae and Chlamydia trachomatis in Men in the United States

BACKGROUND

 Centers for Disease Control and Prevention guidelines recommend at least annual rectal screening of men who have receptive anal intercourse for Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT). Only limited national data are available on the prevalence of rectal GC and CT infection among US men.

METHODS

 In collaboration with a large US commercial laboratory, we estimated positivity of the first rectal GC and CT test ("index" test) in men aged 15-60 years tested between January 2013 and May 2015. We estimated the frequency and positivity of pharyngeal or urine specimens tested for GC and CT on the index date, and the frequency and positivity of repeat rectal testing or any follow-up testing at any anatomic site after the index date.

RESULTS

 Of 52 063 tested men aged 15-60 years, approximately 6.1% were positive for GC only, 8.3% for CT only, and 2.7% for both GC and CT on their index date. On that date, 86.5% had either urine or pharyngeal specimens collected, and 56.1% had both specimens collected. Pharyngeal GC infection was highly associated with rectal GC infection. Follow-up testing after 12 months ranged from 42.4% among uninfected men to 56.7% among infected men on the index date. Positivity was at least 5.7% in rectal GC, rectal CT, or pharyngeal GC at their last test.

CONCLUSIONS

 This analysis of a large number of male rectal specimens tested for GC and CT suggest that routine testing and timely repeat rectal GC and CT testing should be prioritized among men who report receptive rectal sex.

Evaluating the Quality of Sexual Health Care Provided to Adolescents in Medicaid Managed Care: A Comparison of Two Data Sources

This study compares 2 data sources to evaluate the quality of sexual health care provided to adolescents in Medicaid managed care: (a) Medicaid encounter data and (b) medical record data. Data from 1998 for 1112 adolescent enrollees came from 3 Seattle-area managed care organizations (MCOs): a group model health maintenance organization, an independent practice association, and a clinic network. Quality of care was tracked by estimating within-MCO chlamydia testing rates for sexually active female enrollees. Rates varied dramatically depending on which data source was used. Logistic regression models indicated substantially less difference between MCOs when analysis was based on data from the 2 sources combined than when based on either data source alone. Study results did not support the use of Medicaid encounter data as a sole data source for evaluating quality of adolescent sexual health care, despite the cost savings this would represent. However, encounter data, used as an adjunct to medical record review, may increase the reliability of quality evaluations.

Willingness to Use Health Insurance at a Sexually Transmitted Disease Clinic: A Survey of Patients at 21 US Clinics

OBJECTIVES

To survey patients of publicly funded sexually transmitted disease (STD) clinics across the United States about their willingness to use health insurance for their visit.

METHODS

In 2013, we identified STD clinics in 21 US metropolitan statistical areas with the highest rates of chlamydia, gonorrhea, and syphilis according to Centers for Disease Control and Prevention surveillance reports. Patients attending the identified STD clinics completed a total of 4364 surveys (response rate = 86.6%).

RESULTS

Nearly half of the insured patients were willing to use their health insurance. Patients covered by government insurance were more likely to be willing to use their health insurance compared with those covered by private insurance (odds ratio [OR] =  3.60; 95% confidence interval [CI] = 2.79, 4.65), and patients covered by their parents' insurance were less likely to be willing to use their insurance compared with those covered by private insurance (OR = 0.72; 95% CI = 0.52, 1.00). Reasons for unwillingness to use insurance were privacy and out-of-pocket cost.

CONCLUSIONS

Before full implementation of the Affordable Care Act, privacy and cost were barriers to using health insurance for STD services.

PUBLIC HEALTH IMPLICATIONS

Barriers to using health insurance for STD services could be reduced through addressing issues of stigma associated with STD care and considering alternative payment sources for STD services.

Novel poly (ADP-ribose) polymerase inhibitor, AZD2281, enhances radiosensitivity of both normoxic and hypoxic esophageal squamous cancer cells

Radiotherapy plays an important role in the treatment of esophageal squamous cell carcinoma (ESCC). However, the outcome of radiotherapy in ESCC remains unsatisfactory because esophageal squamous cancer cells, particularly those under hypoxic condition, exhibit radioresistance. The aim of this study was to determine whether or not AZD2281, a potent poly (ADP-ribose) polymerase (PARP) inhibitor, could enhance the radiation sensitivity of two ESCC cell lines, namely ECA109 and TE13. The radiosensitizing effect of AZD2281 was evaluated on the basis of cell death, clonogenic survival and tumor xenograft progression. AZD2281 alone was slightly toxic to ESCC cell lines. Apoptosis was increased and clonogenic survival was decreased in both cell lines when AZD2281 was combined with ionizing radiation (IR) under normoxic condition. AZD2281 enhanced IR-induced apoptosis to a more significant level under chronic hypoxic condition (0.2% O(2), 48 hour) than under normoxic condition. AZD2281 also slightly enhanced clonogenic cell death under chronic hypoxic condition compared with that under normoxic condition. This result could be associated with increased radiation-induced DNA double-strand breaks (DSB), decreased DSB repair and increased apoptosis of ESCC cells. Furthermore, homologous recombination (HR) protein Rad51 expression and focus formation were decreased in ESCC cells exposed to moderate chronic hypoxic condition (0.2% O(2), 48 hour); this result indicated that chronic hypoxic ESCC cells were HR deficient, possibly causing contextual synthetic lethality with PARP inhibitor in radiation sensitization. AZD2281 was also a radiation sensitizer in ESCC tumor xenograft models. Hence, in vitro and in vivo findings provide evidence that AZD2281 potently sensitizes ESCC cells to X-ray irradiation. The selective cell killing of HR-defective hypoxic cells contributes to radiosensitization by PARP inhibitor in ESCC cells under hypoxic condition.

Continuing Need for Sexually Transmitted Disease Clinics After the Affordable Care Act

OBJECTIVES

We assessed the characteristics of sexually transmitted disease (STD) clinic patients, their reasons for seeking health services in STD clinics, and their access to health care in other venues.

METHODS

In 2013, we surveyed persons who used publicly funded STD clinics in 21 US cities with the highest STD morbidity.

RESULTS

Of the 4364 STD clinic patients we surveyed, 58.5% were younger than 30 years, 72.5% were non-White, and 49.9% were uninsured. They visited the clinic for STD symptoms (18.9%), STD screening (33.8%), and HIV testing (13.6%). Patients chose STD clinics because of walk-in, same-day appointments (49.5%), low cost (23.9%), and expert care (8.3%). Among STD clinic patients, 60.4% had access to another type of venue for sick care, and 58.5% had access to another type of venue for preventive care. Most insured patients (51.6%) were willing to use insurance to pay for care at the STD clinic.

CONCLUSIONS

Despite access to other health care settings, patients chose STD clinics for sexual health care because of convenient, low-cost, and expert care. Policy Implication. STD clinics play an important role in STD prevention by offering walk-in care to uninsured patients.

Circumcision of privately insured males aged 0 to 18 years in the United States

BACKGROUND

Male circumcision confers protection against HIV, sexually transmitted infections, and urinary tract infections. Compared with circumcision of postneonates (>28 days), circumcision of neonates is associated with fewer complications and usually performed with local rather than general anesthesia. We assessed circumcision of commercially insured males during the neonatal or postneonatal period.

METHODS

We analyzed 2010 MarketScan claims data from commercial health plans, using procedural codes to identify circumcisions performed on males aged 0 to 18 years, and diagnostic codes to assess clinical indications for the procedure. Among circumcisions performed in the first year of life, we estimated rates for neonates and postneonates. We estimated the percentage of circumcisions by age among males who had circumcisions in 2010, and the mean payment for neonatal and postneonatal procedures.

RESULTS

We found that 156,247 circumcisions were performed, with 146,213 (93.6%) in neonates and 10,034 (6.4%) in postneonates. The neonatal circumcision rate was 65.7%, and 6.1% of uncircumcised neonates were circumcised by their first birthday. Among postneonatal circumcisions, 46.6% were performed in males younger than 1 year and 25.1% were for nonmedical indications. The mean payment was $285 for a neonatal and $1885 for a postneonatal circumcision.

CONCLUSIONS

The large number of nonmedical postneonatal circumcisions suggests that neonatal circumcision might be a missed opportunity for these boys. Delay of nonmedical circumcision results in greater risk for the child, and a more costly procedure. Discussions with parents early in pregnancy might help them make an informed decision about circumcision of their child.