Christina M. Schumacher

Retreatment rates for uncomplicated gonorrhea infection: comparing ceftriaxone and azithromycin versus ceftriaxone and doxycycline.

Background The current recommended first-line regimen to treat gonorrhea is ceftriaxone in combination with either azithromycin or doxycycline. Azithromycin is the preferred second agent. We retrospectively measured and compared gonorrhea retreatment rates between patients receiving ceftriaxone plus azithromycin and those receiving ceftriaxone plus doxycycline. Methods Using data from public sexually transmitted disease clinics for patients treated for gonorrhea in Baltimore, Maryland, between January 2004 and December 2011, we measured time to retreatment from the date the ceftriaxone regimen was received. Censoring occurred on the earlier of 2 years posttreatment or March 31, 2012. Survival analysis methods were used to compare retreatment rates. Results One tenth (9.9%; n = 4457) of patients were retreated within 2 years. Treatment regimen was not related to time to retreatment (adjusted hazard ratio [aHR], 0.88; 95% confidence interval, 0.69–1.12). Patients receiving expedited partner therapy (EPT) were 45% less likely to be retreated (aHR, 0.55 [0.31–0.96]) compared with patients treated before EPT became available. A subanalysis among patients retested for gonorrhea within 90 and 30 days found retreatment rates of 18.8% (n = 91/485) and 13.5% (n = 19/140), respectively. The 90-day cohort showed no association with treatment regimen (aHR, 0.95 [0.55–1.65]); however, all of the retreated patients in the 30-day cohort had received the doxycycline regimen. Conclusions Gonorrhea retreatment was common, highlighting the need for rescreening and better partner therapies. The protective effect of EPT further underscores the need for effective oral therapies. Azithromycin may be preferable as the second agent to treat gonorrhea, although doxycycline seems to be a reasonable alternative.

Changes in demographics and risk behaviors of persons with early syphilis depending on epidemic phase.

Background: Syphilis incidence has been rising in the United States since 2000. Shifts in syphilis epidemic phases may be associated with changes between or within high-risk populations. Objectives/Goal: To determine whether shifts in syphilis epidemic phases are associated with changes between or within high-risk populations. Study Design: Using surveillance data collected from Baltimore, MD, 1994–2004, we retrospectively defined epidemic phases and compared epidemiologic profiles of syphilis cases infected during epidemic phase. Results: We defined 3 epidemic phases. The shift between hyperendemic and decline phases was not associated with demographic or behavioral changes among persons with syphilis. Compared to the decline phase, men infected with syphilis during the growth phase were 5 times [odds ratio (OR) 5.32 P <0.001] more likely to report having had sex with men (MSM) or women. Men and women infected during the growth phase were less likely to be >25 years of age (men: OR 0.60, P <0.001; women: OR 0.60, P <0.001), and more likely to be non-African American (men: OR 6.21 P <0.001; women: OR 7.76, P <0.001). Demographic trends persisted when we restricted the analysis to MSM and then restricted to young (age ≤25 years), non-IDU (injecting drug-using) women. Additionally, young, non-IDU women infected in the growth phase were significantly more likely to report ≥5 recent sex partners (OR 4.30, P <0.01) than those in the decline phase. Conclusions: We verified that the shift from a decline to growth phase in Baltimore was mostly because of increases in morbidity among non-African American MSM and young, non-IDU women with ≥5 recent sex workers. Although syphilis control activities have been targeted towards these groups, our analysis underscores the need for real-time investigation of potential tipping points to ensure interventions are properly focused at the beginning of any potential growth phase.

Reassessing a large-scale syphilis epidemic using an estimated infection date.

Objectives: Timely ascertainment of syphilis cases is critical to initiating disease-control measures. Epidemic curves typically use the report date and may introduce lag-time bias into assessment. Goal: To reassess a large syphilis epidemic using an imputed infection date. Study: We compared 2 types of epidemic curves—1 based on report date and 1 on estimated infection date—using the large 1993–2003 Baltimore epidemic as our model. Results: In general, the shape of the report curves did not accurately reflect the shape of the corresponding infection curves during the growth period (period of largest increase in incidence); during the hyperendemic period (period of highest incidence), peaks in report curves did not follow peaks in the infection curve by the appropriate lag time. There was a tendency for reporting data to underestimate infections during the growth period and overestimate infections during the hyperendemic period. A sensitivity analysis showed similar trends regardless of the length of stage-specific incubation period used. Conclusions: Lag-time bias may be present when using epidemic curves based on report dates. Health departments should consider using an estimated infection date.

Sex Partner Meeting Places Over Time Among Newly HIV-Diagnosed Men Who Have Sex With Men in Baltimore, Maryland.

Background Sex partner meeting places may be important locales to access men who have sex with men (MSM) and implement targeted HIV control strategies. These locales may change over time, but temporal evaluations have not been performed. Methods The objectives of this study were to describe the frequency of report of MSM sex partner meeting places over time and to compare frequently reported meeting places in the past 5 years and past year among newly HIV-diagnosed MSM in Baltimore City, Maryland. Public health HIV surveillance data including partner services information were obtained for this study from the Baltimore City Health Department from May 2009 to June 2014. Results A total of 869 sex partner meeting places were reported, including 306 unique places. Bars/clubs (31%) and Internet-based sites (38%) were the most frequently reported meeting place types. Over the 5-year period, the percentage of bars/clubs decreased over time and the percentage of Internet-based sites increased over time. Among bars/clubs, 4 of 5 of those most frequently reported in the past 5 years were also most frequently reported in the most recent year. Among Internet-based sites, 3 of 5 of those most frequently reported in the past 5 years were also in the top 5 most frequently reported in the past year. Conclusion This study provides a richer understanding of sex partner meeting places reported by MSM over time and information to health departments on types of places to access a population at high risk for HIV transmission.

Neighborhoods at risk: Estimating risk of higher Neisseria gonorrhoeae incidence among women at the census tract level

Background The association between area-based social factors and sexually transmitted diseases has been demonstrated in numerous studies. Such associations have not previously been explored for their potential to quantify likelihood of higher transmission of gonorrhea in small geographic areas. Methods Aggregate census tract-level sociodemographic factors in 4 domains (demographics, educational attainment, household income, and housing characteristics) were merged with female gonorrhea incidence data from 113 counties in 10 US states. Multivariate models were constructed, and a tract-level composite gonorrhea risk index was calculated. This composite risk index was validated against gonorrhea incidence among women from 2 independent states. Results Seven tract-level factors were found to be most strongly correlated with female gonorrhea incidence: educational attainment, proportion of female headed households, annual household income below US

Investigation of Early Syphilis Trends Among Men Who Have Sex With Men to Identify Gaps in Screening and Case-finding in Baltimore City, Maryland

20,000, proportion of population non-Hispanic black, proportion of housing units currently vacant, proportion of population reporting moving in last year, and proportion of households that are nonfamily units. Composite index was highly correlated with female gonorrhea in the study area and validated with independent data. Conclusions Social factors predict gonorrhea incidence at the census tract level and identify small areas at risk for higher morbidity. These data may be used by health departments and health care practices to develop geographically based disease prevention and control efforts. This is especially useful because gonorrhea incidence data are not routinely available below the county level in many states.

Increases in the Rate of Neisseria gonorrhoeae Among Gay, Bisexual and Other Men Who Have Sex With Men—Findings From the Sexually Transmitted Disease Surveillance Network 2010–2015

BackgroundSyphilis incidence is increasing across the United States among men who have sex with men (MSM). Early latent (EL) versus primary and secondary (P&S) syphilis may be an indicator of delayed diagnosis and increased opportunity for transmission. To inform syphilis control strategies and identify potential gaps in case finding, we described recent syphilis trends among MSM and compared characteristics of syphilis cases by diagnosis stage. MethodsWe used public health surveillance data on P&S and EL syphilis diagnoses reported to the Baltimore City Health Department between 2009 and 2015. Differences across diagnosis stage were assessed using Cochran-Armitage and &khgr;2 tests. ResultsBetween 2009 and 2015, Baltimore City Health Department received 2436 reports of P&S and EL diagnoses. The majority (61%) of reports were among MSM, among whom 86% were black and 67% were human immunodeficiency virus (HIV)-infected. During this period, P&S and EL syphilis increased by 85% and 245%, respectively (P < 0.0001). MSM with EL versus P&S syphilis were similarly likely to be Black, more likely to be older (P < 0.05), HIV coinfected (P < 0.001), and diagnosed in private health care settings (P < 0.0001), but less likely to report multiple (P < 0.001) and anonymous sex partners (P < 0.001). ConclusionsIn Baltimore City, syphilis diagnoses, particularly EL diagnoses, are increasing rapidly and are concentrated among Black HIV-infected MSM. Significant gaps in identifying MSM with P&S syphilis may exist, specifically among HIV-infected MSM, and those diagnosed in private health care settings. Strategies to address these gaps may include local guidelines and provider education to screen MSM more frequently than CDC currently recommends and regardless of HIV status or risk.

A Pilot Study to Increase the Efficiency of HIV Outreach Testing Through the Use of Timely and Geolocated HIV Viral Load Surveillance Data

Background Inequalities in Neisseria gonorrhoeae (gonorrhea) burden by sexual minority status in the United States are difficult to quantify. Sex of sex partner is not routinely collected for reported cases. Population estimates of men who have sex with men (MSM) necessary to calculate case rates have not been available until recently. For these reasons, trends in reported gonorrhea rates among MSM have not been described across multiple jurisdictions. Methods We estimated of the number of MSM cases reported in 6 jurisdictions continuously participating in the STD Surveillance Network 2010–2015 based on interviews with a random sample of cases. Data were obtained for Baltimore, Philadelphia, New York City, San Francisco, California (excluding San Francisco), and Washington State. Estimates of the MSM, heterosexual male (MSW) and female populations were obtained from recently published estimates and census data. Case rates and rate-ratios were calculated comparing trends in reported cases among MSM, heterosexual males and women. Results The proportion of male gonorrhea cases among MSM varied by jurisdiction (range: 20% to 98%). Estimated MSM rate increased from 1369 cases per 100,000 in 2010 to 3435 cases per 100,000 in 2015. Between 2010 and 2015, the MSM-to-Women gonorrhea rate ratio increased from 13:1 to 24:1, and the MSM-to-MSW gonorrhea rate ratio increased from 16:1 to 31:1. Conclusions Estimated gonorrhea rate among MSM increased in a network of 6 geographically diverse US jurisdictions. Estimating the size of this population, determining MSM among reported cases and estimating rates are essential first steps for better understanding the changing epidemiology of gonorrhea.

Modeling a Syphilis Outbreak Through Space and Time Using the Bayesian Maximum Entropy Approach

Background Eliminating HIV transmission in a population necessitates identifying population reservoirs of HIV infection and subgroups most likely to transmit. HIV viral load is the single most important predictor of HIV transmission. The objective of this analysis was to evaluate whether a public health practice pilot project based on community viral load resulted in increases in the proportion of time spent testing in high viral load areas (process measure) and 3 outcome measures—the number and percent of overall HIV diagnoses, new diagnoses, and high viral load positives—in one mid-Atlantic US city with a severe HIV epidemic. Methods The evaluation was conducted during three, 3-month periods for 3 years and included the use of community viral load, global positioning system tracking data, and statistical testing to evaluate the effectiveness of the pilot project. Results The proportion of time spent outreach testing in high viral load areas (69%–84%, P < 0.001) and the overall number and percent of HIV positives ((60 (3%) to 127 (6%), P < 0.001) significantly increased for 3 years. The number and percent of new diagnoses (3 (0.1%) to 6 (0.2%)) and high viral load positives (5 (0.2%) to 9 (0.4%)) increased, but the numbers were too small for statistical testing. Discussion These results suggest that using community viral load to increase the efficiency of HIV outreach testing is feasible and may be effective in identifying more HIV positives. The pilot project provides a model for other public health practice demonstration projects.