Christina Schumacher

Extragenital Gonorrhea and Chlamydia Testing and Infection Among Men Who Have Sex With Men—STD Surveillance Network, United States, 2010–2012

BACKGROUNDnGonorrhea (GC) and chlamydia (CT) are the most commonly reported notifiable diseases in the United States. The Centers for Disease Control and Prevention recommends that men who have sex with men (MSM) be screened for urogenital GC/CT, rectal GC/CT, and pharyngeal GC. We describe extragenital GC/CT testing and infections among MSM attending sexually transmitted disease (STD) clinics.nnnMETHODSnThe STD Surveillance Network collects patient data from 42 STD clinics. We assessed the proportion of MSM attending these clinics during July 2011-June 2012 who were tested and positive for extragenital GC/CT at their most recent visit or in the preceding 12 months and the number of extragenital infections that would have remained undetected with urethral screening alone.nnnRESULTSnOf 21 994 MSM, 83.9% were tested for urogenital GC, 65.9% for pharyngeal GC, 50.4% for rectal GC, 81.4% for urogenital CT, 31.7% for pharyngeal CT, and 45.9% for rectal CT. Of MSM tested, 11.1% tested positive for urogenital GC, 7.9% for pharyngeal GC, 10.2% for rectal GC, 8.4% for urogenital CT, 2.9% for pharyngeal CT, and 14.1% for rectal CT. More than 70% of extragenital GC infections and 85% of extragenital CT infections were associated with negative urethral tests at the same visit and would not have been detected with urethral screening alone.nnnCONCLUSIONSnExtragenital GC/CT was common among MSM attending STD clinics, but many MSM were not tested. Most extragenital infections would not have been identified, and likely would have remained untreated, with urethral screening alone. Efforts are needed to facilitate implementation of extragenital GC/CT screening recommendations for MSM.

Social injecting and other correlates of high-risk sexual activity among injecting drug users in northern Vietnam

BACKGROUNDnSexual risk and STDs are relatively high among injecting drug users (IDUs) in Vietnam. We sought to determine characteristics of sexually active IDUs and correlates of high-risk sexual practices among IDUs in Bac Ninh province in northern Vietnam.nnnMETHODSnWe used data collected for a community-based cross-sectional pilot study to identify correlates of recent high-risk sex (>1 sex partner and inconsistent/no condom use in the past year). Factors associated with high-risk sex were identified using logistic regression.nnnRESULTSnAmong 216 sexually active male IDUs, one third (n=72) had engaged in high-risk sex within the last year. IDUs who reported injecting with others more frequently, having someone else inject their drugs at last injection, sharing needles or sharing any injection equipment were more likely to have reported recent high-risk sex. Factors independently associated with high-risk sexual activity were not injecting oneself [AOR: 2.22; 95% CI (1.09-4.51)], and sharing needles in the past 12 months [AOR: 2.57; 95% CI (1.10-5.99)].nnnCONCLUSIONSnIDUs who inject socially and IDUs who share needles are likely to engage in high-risk sexual behaviours and may serve as an important bridge group for epidemic HIV transmission in Vietnam. In addition to messages regarding the dangers of sharing needles and other injection equipment, preventive interventions among newly initiated IDUs should also focus on reducing sexual risk.

The Distribution of Sex Acts and Condom Use within Partnerships in a Rural Sub-Saharan African Population.

Introduction In an HIV/AIDS epidemic driven primarily by heterosexual transmission, it is important to have an understanding of the human sexual behaviour patterns that influence transmission. We analysed the distribution and predictors of within-partnership sexual behaviour and condom use in rural Zimbabwe and generated parameters for use in future modelling analyses. Methods A population-based cohort was recruited from a household census in 12 communities. A baseline survey was carried out in 1998–2000 with follow-up surveys after 3 and 5 years. Statistical distributions were fitted to reported within-partnership numbers of total, unprotected and protected sex acts in the past two weeks. Multilevel linear and logistic regression models were constructed to assess predictors of the frequency of unprotected sex and consistent condom use. Results A normal distribution of ln(sex acts+1) provided the best fit for total and unprotected sex acts for men and women. A negative binomial distribution applied to the untransformed data provided the best fit for protected sex acts. Condom use within partnerships was predominantly bimodal with at least 88% reporting zero or 100% use. Both men and women reported fewer unprotected sex acts with non-regular compared to regular partners (men: 0.26 fewer every two weeks (95% confidence interval 0.18–0.34); women: 0.16 (0.07–0.23)). Never and previously married individuals reported fewer unprotected sex acts than currently married individuals (never married men: 0.64 (0.60–0.67); previously married men: 0.59 (0.50–0.67); never married women: 0.51 (0.45–0.57); previously married women: 0.42 (0.37–0.47)). These variables were also associated with more consistent condom use. Discussion We generated parameters that will be useful for defining transmission models of HIV and other STIs, which rely on a valid representation of the underlying sexual network that determines spread of an infection. This will enable a better understanding of the spread of HIV and other STDs in this rural sub-Saharan population.

Gonorrhea treatment practices in the STD Surveillance Network, 2010-2012.

Background Replacing oral treatments with ceftriaxone is a central component of public health efforts to slow the emergence of cephalosporin-resistant Neisseria gonorrhoeae in the United States; US gonorrhea treatment guidelines were revised accordingly in 2010. However, current US gonorrhea treatment practices have not been well characterized. Methods Six city and state health departments in Cycle II of the STD Surveillance Network (SSuN) contributed data on all gonorrhea cases reported in 101 counties and independent cities. Treatment data were obtained through local public health surveillance and interviews with a random sample of patients. Cases were weighted to adjust for site-specific sample fractions and for differential nonresponse by age, sex, and provider type. Results From 2010 to 2012, 135,984 gonorrhea cases were reported in participating areas, 15,246 (11.2%) of which were randomly sampled. Of these, 7,851 (51.5%) patients were interviewed. Among patients with complete treatment data, 76.8% received ceftriaxone, 16.4% received an oral cephalosporin, and 6.9% did not receive a cephalosporin; 51.9% of persons were treated with a regimen containing ceftriaxone and either doxycycline or azithromycin. Ceftriaxone treatment increased significantly by year (64.1% of patients in 2010, 79.3% in 2011, 85.4% in 2012; P = 0.0001). Ceftriaxone use varied widely by STD Surveillance Network site (from 44.6% to 95.1% in 2012). Conclusions Most persons diagnosed as having gonorrhea between 2010 and 2012 in the United States received ceftriaxone, and its use has increased since the release of the 2010 Centers for Disease Control and Prevention STD Treatment Guidelines.

Patient-Reported Expedited Partner Therapy for Gonorrhea in the United States: Findings of the STD Surveillance Network 2010-2012.

Background Expedited partner therapy (EPT) has been shown to prevent reinfection in persons with gonorrhea and to plausibly reduce incidence. The Centers for Disease Control and Prevention recommends EPT as an option for treating sex partners of heterosexual patients. Few studies that examine how the reported use of this valuable intervention differs by patient and provider characteristics and by geography across multiple jurisdictions in the United States are currently available. Methods Case and patient interview data were obtained for a random sample of reported cases from 7 geographically disparate US jurisdictions participating in the Sexually Transmitted Disease (STD) Surveillance Network. These data were weighted to be representative of all reported gonorrhea cases in the 7 study sites. Patient receipt of EPT was estimated, and multivariate models were constructed separately to examine factors associated with receipt of EPT for heterosexuals and for men who have sex with men. Results Overall, 5.4% of patients diagnosed and reported as having gonorrhea reported receiving EPT to treat their sex partners. Heterosexual patients were more likely to have received EPT than men who have sex with men at 6.6% and 2.6% of patients, respectively. Receipt of EPT did not vary significantly by race, Hispanic ethnicity, or age for either group, although significant variation was observed in different provider settings, with patients from family planning/reproductive health and STD clinic settings more likely to report receiving EPT. Jurisdiction variations were also observed with heterosexual patients in Washington State most likely (35.5%), and those in New York City, Connecticut, and Philadelphia least likely to report receiving EPT (<2%). Conclusions With the exception of one jurisdiction in the STD Surveillance Network actively promoting EPT use, patient-reported receipt of the intervention remains suboptimal across the network. Additional efforts to promote EPT, especially for patients diagnosed in private provider and hospital settings, are needed to realize the full potential of this valuable gonorrhea control intervention.

Management of Pelvic Inflammatory Disease in Selected US Sexually Transmitted Disease Clinics: Sexually Transmitted Disease Surveillance Network, January 2010–December 2011

Background Pelvic inflammatory disease (PID) remains an important source of preventable reproductive morbidity, but no recent studies have singularly focused on US sexually transmitted disease (STD) clinics in relationship to established guidelines for diagnosis and treatment. Methods Of the 83,076 female patients seen in 14 STD clinics participating in the STD Surveillance Network, 1080 (1.3%) were diagnosed as having PID from 2010 to 2011. A random sample of 219 (20%) women were selected, and medical records were reviewed for clinical history, examination findings, treatment, and diagnostic testing. Our primary outcomes were to evaluate how well PID diagnosis and treatment practices in STD clinic settings follow the Centers for Disease Control and Prevention (CDC) treatment guidelines and to describe age group–specific rates of laboratory-confirmed Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) in patients clinically diagnosed as having PID in the last 12 months, inclusive of the PID visit. Results Among the 219 women, 70.3% of the cases met the CDC treatment case definition for PID, 90.4% had testing for CT and GC on the PID visit, and 68.0% were treated with a CDC-recommended outpatient regimen. In the last 12 months, 95.4% were tested for CT or GC, and positivity for either organism was 43.9% in women aged 25 years or younger with PID, compared with 19.4% of women older than 25 years with PID. Conclusions Compliance with CDC guidelines was documented for many of the women with PID, though not all. Our findings underscore the need for continued efforts to optimize quality of care and adherence to current guidance for PID management given the anticipated expertise of providers in these settings.

P3.212 Young Persons and Men Who Have Sex with Men Are More Likely to Have Had an Early Syphilis Diagnosis Shortly Before or After an HIV Diagnosis

Background High rates of HIV co-infection have been observed in recent syphilis epidemics, and persons diagnosed with HIV and early syphilis (ES) within a short period of time may be an appropriate focus for targeted HIV control strategies. Targeted control strategies seek to prevent HIV transmission by focusing specifically on those most likely to transmit, i.e., high viral load or concurrent STIs. To implement targeted HIV control in Baltimore, Maryland, we sought to characterise persons newly diagnosed with HIV who also received an ES diagnosis. Methods Using retrospective public health surveillance data of newly diagnosed HIV cases reported to the Baltimore City Health Department from 2009 to 2011, we measured the proportion of persons with ES diagnoses. Chi-square tests were used to assess differences in age (> = 30 vs. < 30), gender, and sexual orientation by infection (HIV only vs. ES-HIV). Results Of the 811 persons with newly diagnosed HIV, 104 (12.8%) also received at least one ES diagnosis between 2009 and 2011, 95% of whom were male. Compared to persons receiving only an HIV diagnosis, persons receiving both HIV and ES diagnoses were more likely to be younger (35.8% vs. 69.2%, p < 0.001, respectively) and men who have sex with men (MSM) (24.3% vs. 62.5%, p < 0.001, respectively). When controlling for sexual orientation, younger age was significantly associated with ES among men who have sex with women (MSW) (28.0% vs. 64.7%, p < 0.01, respectively) and females (25.9% vs. 80.0%, p = 0.02, respectively); however, among MSM, age was no longer statistically significant (62.8% vs. 70.8%, p = 0.25, respectively). Conclusions A substantial proportion of persons newly diagnosed with HIV were also recently infected with syphilis, with young age strongly associated with ES among non-MSM. In addition to MSM, women and MSW under 30 years old may be appropriate foci for targeted control.

The network structure of sex partner meeting places reported by HIV-infected MSM: Opportunities for HIV targeted control

Baltimore, Maryland ranks among U.S. cities with the highest incidence of HIV infection among men who have sex with men (MSM). HIV screening at sex partner meeting places or venues frequented by MSM with new diagnoses and/or high HIV viral load may reduce transmission by identifying and linking infected individuals to care. We investigated venue-based clustering of newly diagnosed MSM to identify high HIV transmission venues. HIV surveillance data from MSM diagnosed between October 2012-June 2014 and reporting ≥1 sex partner meeting place were examined. Venue viral load was defined according to the geometric mean viral load of the cluster of cases that reported the venue and classified as high (>50,000 copies/mL), moderate (1500-50,000 copies/mL), and low (<1500 copies/mL). 143 MSM provided information on ≥1 sex partner meeting place, accounting for 132 unique venues. Twenty-six venues were reported byxa0>xa01 MSM; of these, a tightly connected cluster of six moderate viral load sex partner meeting places emerged, representing 66% of reports. Small, dense networks of moderate to high viral load venues may be important for targeted HIV control among MSM.

P3.45 Identifying health care settings for prep delivery to msm at high risk for hiv acquisition

Introduction Syphilis rates among MSM are increasing sharply in urban areas across the U.S. MSM with syphilis are at high risk for acquiring HIV, and may be an important subgroup to increase awareness and delivery of pre-exposure prophylaxis (PrEP). Key, however, is identifying access points to this population. Our objective was to determine health care settings where syphilis positive and HIV negative (vs. HIV positive) MSM were diagnosed to prioritise and tailor to settings for PrEP delivery. Setting: A mid-Atlantic U.S. city which has seen a 102% increase in early (primary, secondary and early latent) syphilis among MSM from 2009–2015. Methods We analysed routinely collected public health surveillance data on MSM diagnosed with early syphilis reported to a city health department between 2009–2015. We compared diagnosing provider information by HIV status overall and in 2015 using Chi-squared tests. Results Of the 1,495 MSM diagnosed with early syphilis between 2009–2015, the majority was aged ≥ 25 years (73%), African American (86%) and HIV co-infected (67%). Overall, 52% were diagnosed in private health care settings, and 25% were diagnosed in publically funded sexually transmitted infection (STI) clinics. Early syphilis positive/HIV negative MSM were more likely than HIV positive MSM to receive a syphilis diagnosis in STI clinics (38% vs. 19% p=<0.0001) and Emergency Departments (EDs) or Urgent Care Centres (UCC) (12% vs. 8% p<0.0001) and less likely to be diagnosed by private providers (33% vs. 61%, p<0.0001). Among the 268 MSM diagnosed with early syphilis in 2015, HIV negative MSM (n=44) were as likely as HIV positive MSM (n=224) to receive a syphilis diagnosis in STI clinics (27% vs. 16%, p=0.06), more likely to be diagnosed in EDs/UCCs (20% vs. 10%, p=0.03) and less likely to be diagnosed by private providers (36% vs. 66%, p<0.0001). Conclusions EDs/UCCs and are important access points for MSM at high risk for HIV but sites may change over time. Efforts by the city health department to increase PrEP delivery at these sites are being initiated.

Public Health Detailing to Increase Routine HIV Screening in Baltimore, Maryland: Satisfaction, Feasibility, and Effectiveness

The objective of this study was to evaluate the satisfaction with, and the feasibility and effectiveness of, a public health detailing project focused on increasing routine human immunodeficiency virus (HIV) screening of people aged 13-64 by primary care providers working in areas of Baltimore City, Maryland, with high rates of HIV transmission (defined as a mean geometric viral load of ≥1500 copies/mL per census tract). In public health detailing, trained public health professionals (ie, detailers) visit medical practice sites to meet with providers and site staff members, with the intention of influencing changes in clinical practice policy and/or behavior. During 2014, detailers made personal visits and gave HIV Testing Action Kits containing maps, educational and guideline documents, and resource lists to 166 providers and office managers at 85 primary care sites. At follow-up, 88 of 91 (96.7%) providers and 37 of 38 (97.4%) clinic managers were very satisfied or satisfied with the project. Of the 79 sites eligible at follow-up (ie, those that had not closed or merged with another practice), 76 (96.2%) had accepted at least 1 HIV Testing Action Kit, and 67 of 90 (74.4%) providers had increased their HIV screening. Public health detailing projects can be used to educate and support providers, establish relationships between providers and local health departments, and disseminate public health messages.