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Annals of Internal Medicine | 2006

High Incidence of New Sexually Transmitted Infections in the Year following a Sexually Transmitted Infection: A Case for Rescreening

Thomas A. Peterman; Lin H. Tian; Carol Metcalf; Catherine Lindsey Satterwhite; C. Kevin Malotte; Nettie Deaugustine; Sindy M. Paul; Helene Cross; Cornelis A. Rietmeijer; John M. Douglas

Context The Centers for Disease Control and Prevention recommends that women treated for Chlamydia trachomatis infection return in 3 months for evaluation of reinfection. Contribution When data from the RESPECT-2 trial were used, these investigators found that among patients treated for sexually transmitted infections, 25.8% of women and 14.7% of men acquired 1 or more new infections with Chlamydia trachomatis, Neisseria gonorrhoeae, or Trichomonas vaginalis during 1 year of follow-up. Approximately 66% of reinfections were asymptomatic. Implications Successful treatment of incident cases of sexually transmitted infections is unlikely to eliminate a reservoir of infection in the community. Physicians need to perform ongoing surveillance on men and women and encourage lifestyle changes in patients with reinfection. The Editors In 1985, the Centers for Disease Control and Prevention (CDC) treatment guidelines recommended that persons infected with Neisseria gonorrhoeae should return for a test of cure to be sure that the antibiotics had cured the infection (1). With new medications, treatment failure became rare, and by 1989, the guidelines suggested testing 1 to 2 months after treatment to detect treatment failure and reinfection (2). By 1993, the guidelines stated only that a test of cure was not recommended for N. gonorrhoeae (3). Test of cure has been unnecessary for Chlamydia trachomatis after treatment with first-line drugs, but infections detected among women several months after treatment have suggested that rescreening might be effective for detecting reinfection (3). Recent studies have found that 11% to 15% of women treated for C. trachomatis were infected when retested 3 to 4 months after treatment, possibly due to treatment failure, reinfection from an untreated partner, or infection from a new partner (46). New infections are often asymptomatic. One study with scheduled follow-up visits found that 62% of new C. trachomatis infections in men and in women were asymptomatic or unrecognized and would therefore probably be missed without rescreening (7). Untreated C. trachomatis infections can persist for years (8) and put infected women at risk for complications of asymptomatic pelvic inflammatory disease (9). In addition, transmission from asymptomatic persons may be responsible for most new infections in a community (10). The CDC has recommended that health care providers consider advising women with diagnoses of C. trachomatis infection to have another C. trachomatis test in 3 monthsnot as a test of cure but as a test for reinfection (11). We wondered whether men might also benefit from retesting, whether retesting should be expanded to include persons with N. gonorrhoeae or Trichomonas vaginalis infections (12), and whether there were other factors that clinicians could use to recommend retesting. We analyzed data from a large prevention counseling trial (13) that included baseline and 4 scheduled follow-up visits of patients in 3 sexually transmitted disease (STD) clinics to determine the incidence of new sexually transmitted infections during the year after a visit to the clinics. Methods A multicenter randomized, controlled trial of HIV prevention counseling with a rapid HIV test or a standard HIV test (RESPECT-2) was conducted in 3 public STD clinics in Denver, Colorado; Long Beach, California; and Newark, New Jersey. Primary analyses and detailed methods are described elsewhere (13). Briefly, eligible clients were those who came to the clinics for a full diagnostic examination for sexually transmitted infections, were HIV-negative at enrollment, reported having vaginal or anal sex in the preceding 3 months, and were 15 to 39 years of age. At the initial visit, participants were counseled, examined, and tested for sexually transmitted infections and HIV infection. Outcomes were measured at 13-week intervals, scheduled 3, 6, 9, and 12 months from the date of enrollment. Before each follow-up visit, study staff mailed a reminder letter to each participant and made a reminder telephone call. When participants did not keep appointments, staff mailed additional reminder letters and made additional telephone calls to reschedule the visit as needed. Participants who were due for a study follow-up visit were screened for sexually transmitted infections and were interviewed if they visited the clinic any time from 1 week before the due date up to 12 weeks after the due date. Participants were given


Sexually Transmitted Diseases | 2005

Relative Efficacy of Prevention Counseling With Rapid and Standard HIV Testing: A Randomized, Controlled Trial (RESPECT-2)

Carol Metcalf; John M. Douglas; C. Kevin Malotte; Helene Cross; Beth Dillon; Sindy M. Paul; Suzanne M. Padilla; Lesley C. Brookes; Catherine A. Lindsey; Robert H. Byers; Thomas A. Peterman

25 for completing each follow-up visit. This amount was later increased to


Journal of Acquired Immune Deficiency Syndromes | 2011

HIV prevalence and risk practices among men who have sex with men in two South African cities.

Laetitia C. Rispel; Carol Metcalf; Allanise Cloete; Reddy; Lombard C

50 in an attempt to improve retention rates. Participants were tested for C. trachomatis, N. gonorrhoeae, and T. vaginalis infections at enrollment, at each quarterly follow-up visit, and at other visits not related to the study that occurred during the 12-month follow-up period (interim visits). An incident sexually transmitted infection was defined as a positive laboratory result either preceded by a negative result for the same infection or detected more than 14 days after provision of antibiotics effective against that infection. Testing was done in the local laboratories used by each clinic. Tests for C. trachomatis and N. gonorrhoeae infections were done on urine specimens by using nucleic acid amplification tests. The sensitivity and specificity values from the package inserts for these tests are cited here; the exact values are difficult to establish because there is no gold standard for identifying infected patients (14). The Long Beach and Newark clinics used ligase chain reaction (LCx Uriprobe, Abbott Diagnostics Division, Abbott Park, Illinois); the sensitivity and specificity for C. trachomatis were 93.1% and 97.1%, respectively, and the sensitivity and specificity for N. gonorrhoeae were 97.5% and 98.3%, respectively (15, 16). The Denver clinic used polymerase chain reaction initially (Cobas Amplicor, Roche Diagnostic Systems, Inc., Branchburg, New Jersey); the sensitivity and specificity for C. trachomatis were 93.4% and 96.7%, respectively, and the sensitivity and specificity for N. gonorrhoeae were 97.1% and 98.1%, respectively (17, 18). Eighteen months later, however, this clinic changed to using strand displacement amplification (BDProbeTec ET, BD Diagnostic Systems, Sparks, Maryland); the sensitivity and specificity for C. trachomatis were 90.7% and 96.6%, respectively, and the sensitivity and specificity for N. gonorrhoeae were 96.0% and 98.8%, respectively) (19). Trichomonas vaginalis was cultured by using the InPouch TV test (BioMed Diagnostics Inc., San Jose, California) or modified Diamond medium as the culture medium. The sensitivity has been estimated at 82.4% for the InPouch TV test and 87.8% for Diamond medium; specificity for both culture methods is nearly 100% (20). Cultures were done by using vaginal swab specimens from women. At follow-up visits, vaginal swabs were collected by the participant (Denver and Long Beach) or by a clinician (Newark), depending on local clinic policy. Behavioral data were collected by using Audio Computer-Assisted Self-Interview technology at enrollment and at each scheduled study follow-up visit. For most questions, a uniform 3-month recall period was used, regardless of the time since the most recent study visit. Because previous work has shown that most new infections are asymptomatic, we limited our analysis to participants who returned for testing and therefore could be classified as infected or not infected. Return visits with testing and interviews were scheduled every 3 months, and most participants returned within 2 weeks of their scheduled time. However, some participants also returned before their scheduled visit because of concern about a possible infection. Those who returned early were tested for sexually transmitted infections and were told to return for their scheduled visit for the interview and repeated testing. All test results from interim visits between 2 interviews were associated with behaviors reported during the next scheduled interview after the interim tests. Study interviews were conducted the first time the participant returned during the scheduled follow-up time (visit 1, 84 to 174 days; visit 2, 175 to 265 days; visit 3, 266 to 356 days; and visit 4, 357 to 448 days). Test data from participants who missed interviews were grouped in the analysis with their next interview. We excluded data from visits that occurred after participants missed 2 consecutive follow-up interviews. Men who reported having sex with men in the baseline interview were also excluded because of the small sample size. Person-years at risk were calculated by using the time between interviews. Participants could contribute up to 4 intervals of observation. Those who had multiple infections with the same organism in the same interval were only counted as having 1 infection, but if an infection recurred in a different interval it was counted again. We looked for 2 types of risk factors for infection. First, we looked for characteristics that clinicians could identify during a clinic visit that might predict infection at a subsequent visit. These factors included demographic characteristics, past risk behaviors, and infections detected during that visit. Second, we looked at events that might occur during follow-up that would alert patients to a need to return for testing for sexually transmitted infections. These factors included acquiring a new partner or having sex with more than 1 partner. Multivariate analysis of factors associated with sexually transmitted infection included serial measures for each participant. We performed unconditional logistic regression using generalized estimating equations, which accounted for within-participant correlations of repeated measures (21). Because this method assumes that missing data are missing completely at random, we assessed the relationship between missing visits and response variables for all 2419 participants included in our stu


Journal of Public Health Policy | 2011

You become afraid to tell them that you are gay: health service utilization by men who have sex with men in South African cities.

Laetitia C. Rispel; Carol Metcalf; Allanise Cloete; Julia Moorman; Vasu Reddy

Background: Two risk-reduction counseling sessions can prevent sexually transmitted diseases (STDs); however, return rates for test results are low. Study: A randomized, controlled trial compared rapid HIV testing and counseling in 1 visit with standard HIV testing and counseling in 2 visits. Main outcomes were STDs (gonorrhea, chlamydia, trichomoniasis, syphilis, HIV) within 12 months. Participants were 15- to 39-year-old STD clinic patients in Denver, Long Beach, and Newark. STD screening and questionnaires were administered every 3 months. Results: Counseling was completed by 1632 of 1648 (99.0%) of the rapid-test group and 1144 of 1649 (69.4%) of the standard-test group. By 12 months, STD was acquired by 19.1% of the rapid group and 17.1% of the standard group (relative risk [RR], 1.11; confidence interval [CI], 0.96–1.29). STD incidence was higher in the rapid-test group than in the standard-test group among men (RR, 1.34; CI, 1.06–1.70), men who had sex with men (RR, 1.86; 95% CI, 0.92–3.76), and persons with no STDs at enrollment (RR, 1.21; 95% CI, 0.99–1.48). Behavior was similar in both groups. Conclusions: Counseling with either test had similar effects on STD incidence. For some persons, counseling with standard testing may be more effective than counseling with rapid testing.


Sexually Transmitted Diseases | 2008

Heterosexual anal sex activity in the year after an STD clinic visit.

Lin H. Tian; Thomas A. Peterman; Guoyu Tao; Lesley C. Brooks; Carol Metcalf; C. Kevin Malotte; Sindy M. Paul; John M. Douglas

Background:In South Africa, information on HIV among men who have sex with men (MSM) is limited, and HIV prevention programs for men MSM are not widely available, despite global evidence that MSM are at substantial risk for HIV infection. The Johannesburg/eThekwini Mens Study was conducted during 2008 to provide information on HIV among MSM in Johannesburg and Durban. Methods:MSM aged 18 years or older were recruited using respondent-driven sampling. Participants completed a questionnaire and provided finger-prick blood specimens for anonymous HIV testing in a laboratory. Results:From July to December 2008, 285 MSM were recruited in Johannesburg (n = 204) and Durban (n = 81). Participants had a median age of 22 years and were predominantly black Africans (88.3%). The HIV prevalence was 49.5% [95% confidence interval (CI): 42.5% to 56.5%] in Johannesburg and 27.5% [95% CI: 17.0% to 38.1%] in Durban. HIV infection was associated with gay identification [adjusted odds ratio (aOR): 8.4; 95% CI: 3.7 to 19]. Factors in the previous year that were associated with HIV infection included receptive unprotected anal intercourse [aOR 4.3; 95% CI: 2.4 to 7.6]; sex with a person known to be HIV positive [aOR: 2.3; 95% CI: 1.1 to 4.9]; and a sexually transmitted infection diagnosis [aOR 2.4; 95% CI: 1.1 to 5.2]. Conclusions:HIV prevalence among MSM in Johannesburg and Durban is considerably higher compared with men in the general population. There is an urgent need to establish national HIV surveillance among MSM and to expand the availability of HIV prevention programs for MSM.


Sexually Transmitted Diseases | 2007

Changes in Sexual Behavior and STD Prevalence Among Heterosexual STD Clinic Attendees: 1993-1995 Versus 1999-2000

Catherine Lindsey Satterwhite; Mary L. Kamb; Carol Metcalf; John M. Douglas; C. Kevin Malotte; Sindy M. Paul; Thomas A. Peterman

We describe the utilization of health services by men who have sex with men (MSM) in South African cities, their perceptions of available health services, and their service preferences. We triangulated data from 32 key informant interviews (KIIs), 18 focus group discussions (FGDs) with MSM in four cities, and a survey of 285 MSM in two cities, recruited through respondent-driven sampling in 2008. FGDs and KIIs revealed that targeted public health sector programs for MSM were limited, and that MSM experienced stigma, discrimination, and negative health worker attitudes. Fifty-seven per cent of the survey participants had used public health services in the previous 12 months, and 69 per cent had no private health insurance, with no difference by HIV status. Despite these findings, South Africa is well placed to take the lead in sub-Saharan Africa in providing responsive and appropriate HIV services for MSM.


Sexually Transmitted Diseases | 2008

Risk factors for prevalent and incident trichomonas vaginalis among women attending three sexually transmitted disease clinics

Donna J. Helms; Debra J. Mosure; Carol Metcalf; John M. Douglas; C. Kevin Malotte; Sindy M. Paul; Thomas A. Peterman

Objectives: To describe heterosexual anal sex activity during a year and to identify factors associated with heterosexual anal sex and condom use during anal sex. Methods: Secondary analysis of data from a trial conducted in 3 public sexually transmitted disease (STD) clinics. Patients described sexual behaviors every 3-months for the year. Logistic regression models with generalized estimating equations were used to include multiple observations for each subject. Results: Two thousand three hundred fifty-seven heterosexual subjects reported on 6611 3-month intervals that included 9235 partnerships. About 18.3% of subjects had anal sex in a particular 3-month interval and 39.3% in the year. About 23.5% of subjects had anal sex in at least two 3-month intervals in the year. Anal sex was associated with having more sex acts, 2 or more sex partners, unprotected vaginal sex, and a main partner. For anal sex in the past 3 months, 27.3% of subjects consistently used condoms, and 63% of subjects never used condoms. Consistent condom use for anal sex was associated with having consistent condom use for vaginal sex, 2 or more partners, and anal sex with casual or new partner. Conclusion: STD clinic patients were commonly engaged in heterosexual anal sex, and most of them never used condoms during anal sex. Patients who had anal sex tended to also engage in other risk behaviors that put them at risk of STD/human immunodeficiency virus. Clinicians should ask about anal sex, appropriately examine and test patients who have had anal sex, and recommend condom use for both anal and vaginal sex.


Sexually Transmitted Diseases | 2005

Efficacy of a booster counseling session 6 months after HIV testing and counseling: a randomized, controlled trial (RESPECT-2).

Carol Metcalf; C. Kevin Malotte; John M. Douglas; Sindy M. Paul; Beth Dillon; Helene Cross; Lesley C. Brookes; Nettie Deaugustine; Catherine A. Lindsey; Robert H. Byers; Thomas A. Peterman

Objective: To examine trends in sex behaviors and STD prevalence over time among heterosexual STD clinic populations from 3 urban STD clinics in the United States. Study Design: Cross-sectional analysis comparing baseline data on risk (self-reported) and STDs (laboratory defined) from 2 randomized controlled trials evaluating counseling efficacy conducted about 5 years apart, Project RESPECT (1993–1995) and RESPECT-2 (1999–2000). Results: The participants from RESPECT (n = 2457) and RESPECT-2 (n = 3080) were demographically similar. However, the proportion of participants reporting any unprotected anal sex was much higher in RESPECT-2 (women: 7% vs. 18%; men: 7% vs. 17%). Also, substantially more participants reported a new sex partner in RESPECT-2 (women: 43% vs. 61%; men: 54% vs. 72%). In addition, more women reported 2 or more partners (37% vs. 48%) and a partner with another concurrent sex partner (19% vs. 32%). Slightly more women and men in RESPECT-2 reported 2 protective behaviors, having an HIV test and any condom use; however, consistent condom use did not differ. Conversely, the proportion of participants with bacterial STDs (chlamydia, gonorrhea, or syphilis) was much lower in RESPECT-2 (women: 24% vs. 18%; men: 38% vs. 24%). Conclusions: Despite substantial promotion of safer sex behaviors over the past decade, many risk behaviors were stable over time, and some behaviors, such as unprotected anal sex, appeared substantially higher. Even in the absence of widespread behavior change, the prevalence of common bacterial STDs appeared to have decreased appreciably.


South African Medical Journal | 2009

Assessing missed opportunities for the prevention of mother-to-child HIV transmission in an Eastern Cape local service area

Laetitia C. Rispel; Karl Peltzer; Nancy Phaswana-Mafuya; Carol Metcalf; Latasha Treger

Goal: Trichomonas vaginalis is the most common nonviral sexually transmitted infection in the United States and may be associated with adverse birth outcomes and may also increase susceptibility to or transmissibility of human immunodeficiency virus. The purpose of this analysis is to describe the epidemiology of T. vaginalis in Sexually Transmitted Disease clinics and characterize the risk factors associated with prevalent and incident T. vaginalis within the same population. Methods: We analyzed data from visits occurring during February 1999–December 2001 from 3 sexually transmitted disease clinics in Newark, NJ; Long Beach, CA; and Denver, CO. Data were analyzed from 1462 women aged 15 to 39 years who were tested by culture at their initial visit for T. vaginalis, and for 1269 women with at least 1 follow-up visit. Risk factors for prevalent infections at baseline and incident infections among treated or previously uninfected women were assessed. Results: At baseline, 13.0% of the women had a prevalent infection; risk factors included the following: older age (≥20 years), black race, having less than 12 years of education, and having a concurrent chlamydial infection. At follow-up, 4.6% of women had an incident infection; risk factors included the following: older age (35–39 years), black race, having a concurrent chlamydial infection, having had multiple sexual partners in the 3 months before incident infection, and having had T. vaginalis at the visit before their incident infection. Conclusions: T. vaginalis incidence is high in women. Risk factors for prevalent and incident infection are similar. T. vaginalis was associated with older age in women, unlike other sexually transmitted infections.


Sahara J-journal of Social Aspects of Hiv-aids | 2015

‘We keep her status to ourselves’: Experiences of stigma and discrimination among HIV-discordant couples in South Africa, Tanzania and Ukraine

Laetitia C. Rispel; Allanise Cloete; Carol Metcalf

Background: HIV counseling prevents sexually transmitted diseases (STDs), with most of the benefit accumulating in the first 6 months. Study: The authors conducted a multicenter, randomized, controlled trial of a 20-minute additional (booster) counseling session 6 months after HIV counseling compared with no additional counseling for prevention of STDs (gonorrhea, chlamydia, trichomoniasis). Participants were 15- to 39-year-old STD clinic patients in Denver, Long Beach, and Newark. Results: Booster counseling was completed by 1120 (67.8%) of 1653 assigned to receive it. An incident STD during the 6 to 12 months after initial counseling (and within the 6 months after scheduled booster counseling) was detected in 141 of 1653 (8.5%) participants in the booster counseling group and 144 of 1644 (8.8%) in the no-booster group (relative risk, 0.97; 95% confidence interval, 0.78–1.22). Three months after booster counseling, sexual risk behaviors were reported less frequently by the booster group than the no-booster group. Conclusions: Booster counseling 6 months after HIV testing and counseling reduced reported sexual risk behavior but did not prevent STDs.

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Dive into the Carol Metcalf's collaboration.

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Sindy M. Paul

New Jersey Department of Health and Senior Services

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Emmanuel Fajardo

Médecins Sans Frontières

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Helen Bygrave

Médecins Sans Frontières

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C. Kevin Malotte

California State University

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John M. Douglas

Centers for Disease Control and Prevention

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Thomas A. Peterman

Centers for Disease Control and Prevention

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Daniela Garone

Médecins Sans Frontières

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Laetitia C. Rispel

University of the Witwatersrand

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Tom Ellman

Médecins Sans Frontières

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Allanise Cloete

Human Sciences Research Council

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