Cornelis A. Rietmeijer

Young adults on the internet: Risk behaviors for sexually transmitted diseases and HIV

PURPOSE To examine the sexual behaviors and related risk factors for sexually transmitted diseases and HIV among young adults who seek sex partners on the Internet. METHODS Study staff recruited participants in online chat rooms, bulletin boards, and other online venues. A total of 4507 participants responded to a 68-item, self-administered, online survey of Internet sex-seeking practices. The survey solicited information on sexual behavior with partners found on the Internet; in addition, a parallel set of questions addressed sexual behaviors with partners found off the Internet. Of the respondents, 1234 (27.4%) were 18-24 years old. Of the young adults, 61% were male and 75% were white. Responses from young adults were compared to those received from older adults. In addition, responses from young adults who seek sex partners online were compared to responses from young adults who do not seek sex partners online. Analyses, including logistic regression, Chi-square tests, Students t-tests, and analyses of variance, focused on the difference between young and older adults, as well as the differences in sexual behavior with partners located online and offline. RESULTS Young adults who seek sex on the Internet report substantially different sexual behavior patterns than young adults who do not seek sex on the Internet. Young adults with online partners reported sexual behaviors similar to older respondents who used the Internet to find sex partners; however, older respondents were more likely than young adults to have been tested for sexually transmitted diseases and HIV. CONCLUSIONS Young adults who seek sex partners online may be at significantly greater risk for sexually transmitted diseases than their peers who do not seek sex partners online. These data point to an urgent need for online sexual health promotion.

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

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

Incidence and repeat infection rates of Chlamydia trachomatis among male and female patients in an STD clinic: implications for screening and rescreening.

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

Sex hustling, injection drug use, and non-gay identification by men who have sex with men: Associations with high-risk sexual behaviors and condom use

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

Effect of a Brief Video Intervention on Incident Infection among Patients Attending Sexually Transmitted Disease Clinics

Background Nucleic acid amplification tests permit widespread screening for Chlamydia trachomatis. However, the public health benefit of screening may be reduced by high chlamydia incidence and repeat infection rates. Goal To study chlamydia incidence and repeat infection among clients of a sexually transmitted disease (STD) clinic. Study Design A retrospective cohort study of all clients tested for chlamydia on two or more occasions during a 30-month period. Results Between January 1, 1997 and June 30, 1999, 3568 clients were tested on multiple occasions. Of these, 491 (13.8%) had positive test results at their first visit (baseline infections), and 385 (10.8%) had positive results at a subsequent visit (incident infections). The overall incidence was 11.7 per 100 person-years of follow-up evaluation (95% CI, 10.6–12.9). The incidence was significantly higher among those 25 years of age or younger (19.7/100 person-years; 95% CI, 17.3–22.2) than among older subjects (6.8/100 person-years, 95% CI, 5.7–7.9; relative hazard, 3.0; 95% CI, 2.5–3.7). The incidence of new infections among persons without a baseline infection was 10.0 per 100 person-years (95% CI, 8.8–11.2), whereas the incidence of repeat infections was 23.6 per 100 person-years (95% CI, 18.9–28.2; relative hazard, 2.4; 95% CI, 1.9–3.0), with repeat infections accounting for 26% of all incident infections. In the multivariate analysis, the factors associated with new infections included young age, black race, male gender, history of sexually transmitted disease, a new sex partner in the previous 30 days, and inconsistent condom use. The factors associated with repeat infection were younger age, nonuse of condoms, and no treatment after contact with a partner who had a diagnosis of chlamydia or a chlamydia-related condition, as measured at the initial visit. Conclusions Among clients making multiple visits to the clinic, repeat infection rates were significantly higher than new infection rates, likely because of reexposure to untreated partners. These findings point to the need for more effective strategies to prevent chlamydia infection, including enhanced partner management services and rescreening.

In vitro evaluations of condoms with and without nonoxynol 9 as physical and chemical barriers against chlamydia trachomatis, Herpes simplex virus type 2, and human immunodeficiency virus

Objective: To explore differences in demographic characteristics, risk practices, and preventive behaviors among subgroups of men who have sex with men (MSM), including gay‐ and non‐gay‐identified MSM, MSM who inject drugs, and those engaging in sex hustling. Design: A secondary analysis of cross‐sectional data collected through interviewer‐administered questionnaires in a purposive sample of MSM. Setting: Gay bars, bath houses, adult video arcades, and outdoor cruising areas in Denver and Long Beach. Participants: Men who reported oral or anal sex with another man in the past year with oversampling of non‐gay‐identified MSM. Results: Of 1,290 MSM, 417 (32%) did not gay‐identify, 86 (7%) were drug injectors, and 117 (9%) were hustlers. Of drug‐injecting MSM, 55% reported sex hustling and 40% of hustlers reported injection drug use. Hustling was associated with higher number of partners, more frequent anal sex with men and women, and less frequent condom use during anal sex with occasional male partners. Hustlers and drug‐injecting MSM used condoms less consistently during vaginal intercourse with female partners than did other MSM. Conclusions: Among MSM, subgroups at particularly high risk for HIV can be identified. Although these subgroups may be relatively small, they may be important epidemiologic links to the larger MSM and heterosexual communities and warrant focused behavioral interventions to prevent the further spread of HIV.

Risks and benefits of the internet for populations at risk for sexually transmitted infections (STIs): results of an STI clinic survey.

Background Sexually transmitted disease (STD) prevention remains a public health priority. Simple, practical interventions to reduce STD incidence that can be easily and inexpensively administered in high-volume clinical settings are needed. We evaluated whether a brief video, which contained STD prevention messages targeted to all patients in the waiting room, reduced acquisition of new infections after that clinic visit. Methods and Findings In a controlled trial among patients attending three publicly funded STD clinics (one in each of three US cities) from December 2003 to August 2005, all patients (n = 38,635) were systematically assigned to either a theory-based 23-min video depicting couples overcoming barriers to safer sexual behaviors, or the standard waiting room environment. Condition assignment alternated every 4 wk and was determined by which condition (intervention or control) was in place in the clinic waiting room during the patients first visit within the study period. An intent-to-treat analysis was used to compare STD incidence between intervention and control patients. The primary endpoint was time to diagnosis of incident laboratory-confirmed infections (gonorrhea, chlamydia, trichomoniasis, syphilis, and HIV), as identified through review of medical records and county STD surveillance registries. During 14.8 mo (average) of follow-up, 2,042 patients (5.3%) were diagnosed with incident STD (4.9%, intervention condition; 5.7%, control condition). In survival analysis, patients assigned to the intervention condition had significantly fewer STDs compared with the control condition (hazard ratio [HR], 0.91; 95% confidence interval [CI], 0.84 to 0.99). Conclusions Showing a brief video in STD clinic waiting rooms reduced new infections nearly 10% overall in three clinics. This simple, low-intensity intervention may be appropriate for adoption by clinics that serve similar patient populations. Trial registration: http://www.ClinicalTrials.gov (#NCT00137670).

Increases in gonorrhea and sexual risk behaviors among men who have sex with men: A 12-year trend analysis at the Denver Metro Health Clinic

Simulated in vitro intercourse conditions demonstrated that unlubricated latex condoms provide an effective physical barrier to high concentrations of Chlamydia trachomatis, herpes simplex virus type 2, and human immunodeficiency virus. However, since condoms can be damaged after manufacturing inspection and prior to use, latex condoms alone should not be perceived as absolute protection against STDs. Nonoxynol 9 used in conjunction with condoms provided additional, yet still not foolproof, protection against the three viruses.

Feasibility and yield of screening Urine for Chlamydia trachomatis by polymerase chain reaction among high-risk male youth in field-based and other nonclinic settings : A new strategy for sexually transmitted disease control

Background The Internet is increasingly used for the recruitment of sex partners, potentially leading to increased risks for sexually transmitted infections (STIs). Less is known about the use of the Internet as a resource for STI education and prevention. Goal To evaluate the use of the Internet for sex-seeking and STI information purposes by clients of a large STI clinic. Study Design A 10-item survey was conducted among clients of the Denver Metro Health (STI) Clinic who visited the clinic for a new problem between September 2000 and May 2001. Results Among 4741 clients surveyed, 2159 (45.5%) had Internet access. Of these, 138 (6.4%) reported to have gone on-line with the specific purpose of finding a sex partner and 146 (6.8%) reported having sex with a partner they found over the Internet. Internet sex-seeking was more common among men who have sex with men (MSM; 77/269, or 28.6%) than among men who have sex with women (MSW; 52/1176, or 4.4%;P < 0.0001) and higher among MSW than among women (9/714, or 1.3%;P < 0.001). The Internet was accessed by 604 persons (28.0%) to find information on STIs. Of these, 65.1% did so for general STI information, 36.3% for information on HIV, 25.7% for information on genital herpes, 22.4% for information on chlamydia, 21.7% for information on HPV, 19.9% for information on gonorrhea, 16.1% for information on syphilis, and 9.3% for other information. Of persons seeking sex, 54.4% accessed the Internet for STI information, compared to 26.2% of persons not seeking sex (P < 0.0001). Conclusions Among STI clinic clients in Denver, nearly half have access to the Internet. Sex-seeking appears to be most prevalent among MSM. Internet use for STI information is common among those with Internet access and even more widespread among those who access the Internet to seek sex. Research is needed to develop and evaluate Internet-based STI-prevention interventions.

Internet-based Screening for Sexually Transmitted Infections To Reach Nonclinic Populations in the Community: Risk Factors for Infection in Men

Background Recent increases in rates of sexually transmitted diseases (STDs) and decreases in safe sex behaviors among men who have sex with men (MSM) in several American and European cities have been noted by researchers. It has been suggested that these trends are the result of perceptions that HIV/AIDS is less serious because of the availability of highly active antiretroviral therapy (HAART). Goal The goal of the study was to examine trends in STD rates and risk behaviors among MSM and men who have sex with women (MSW) visiting a public STD clinic in Denver and to determine whether there is an ecological association with the availability of HAART. Study Design This is a two-part retrospective analysis of male visits to the Denver Metro Health Clinic (DMHC). The first part describes gonorrhea and early (primary and secondary) syphilis trends among MSM between 1982 and 2001. For the second part, data were grouped into two 6-year time periods to represent pre-HAART and post-HAART time frames, 1990 to 1995 and 1996 to 2001. Results Gonorrhea and early syphilis cases among MSM declined precipitously between 1982 and 1988 and then stabilized at low rates. The proportion of male visits to the clinic made by MSM decreased from 14.1% in 1990 to 7.2% in 1995 and then increased to 13.0% in 2001. Gonorrhea positivity rates among MSM increased after 1995 and were significantly higher in the period 1996 to 2001 (12.9%) than in the period 1990 to 1995 (8.1%; P < 0.0001). Conversely, gonorrhea rates among MSW dropped from 11.2% in the first period to 6.9% in the second (P < 0.0001). Among MSM known to be HIV-infected, gonorrhea rates increased from 11.6% in the first time period to 24.0% in the second period (P < 0.0001). Reports of anal sex among MSM increased from 64.4% to 70.9% (P < 0.0001). Reporting more than one sex partner increased for MSM from 65.2% to 70.3% (P < 0.0001), but it significantly decreased from 52.6% to 46.2% for MSW (P < 0.0001). No or inconsistent condom use increased from 60.9% to 63.0% for MSM (P = NS) and decreased from 85.1% to 82.4% among MSW (P < 0.0001). Conclusions These trends appear to reflect a change toward higher risk-taking behaviors among MSM but not MSW since the time HAART became available and raise concerns about the potential for increased HIV transmission in this group.