Judith C. Shlay

Prediction of cervical intraepithelial neoplasia grade 2-3 using risk assessment and human papillomavirus testing in women with atypia on Papanicolaou smears

Objective To determine whether human papillomavirus (HPV) DNA testing and risk assessment can predict cervical intraepithelial neoplasia (CIN) 2–3 on biopsies in women with atypia on Papanicolaou smears. Methods One hundred ninety-five consenting women were referred for colposcopy because of atypia on Papanicolaou smears between September 1997 and April 1999. Before colposcopy, women completed risk assessments and had cervical swabs collected for HPV testing using the Hybrid Capture-II assay (Digene Corporation, Silver Spring, MD). Associations of demographic and clinical variables were assessed by χ2 analysis, and logistic regression was used to assess factors associated with CIN 2–3. The cost-effectiveness of routine colposcopy versus reflex HPV testing by either conventional or liquid-based Papanicolaou smear media was compared. Results Cervical intraepithelial neoplasia was diagnosed in 70 of 195 women (35.9%), 55 (28.2%) with CIN 1 and 15 (7.7%) with CIN 2–3. High-risk HPV types were detected in 31.3% of all subjects, 36.4% of those with CIN 1, and 93.3% of those with CIN 2–3. By logistic regression, CIN 2–3 was associated only with detection of high-risk HPV (odds ratio 110.08, 95% confidence interval 8.35, 999.00). The sensitivity of high-risk HPV for detecting CIN 2–3 was 93.3%, specificity 73.9%, positive predictive value 23.0%, and negative predictive value 99.3%. The cost of reflex HPV testing using conventional smear or liquid-based media was less than routine colposcopy (

Comparison of sexually transmitted disease prevalence by reported condom use: errors among consistent condom users seen at an urban sexually transmitted disease clinic.

4809 and

Promoting "dual protection" from pregnancy and sexually transmitted disease: a social ecological approach.

4308, respectively, versus

Initiating contraception in sexually transmitted disease clinic setting: a randomized trial.

4875 per case detected). Conclusions Triage based on HPV testing would result in referral of approximately 31% of patients to colposcopy and appears to be a sensitive and cost-effective alternative to colposcopy.

The effectiveness of a verbal opt-out system for human immunodeficiency virus screening during pregnancy

Background: The protective effect of condom use is controversial as a result of limited data. Goal: The goal of this study was to assess the association between condom use errors in consistent condom users and the prevalence of various sexually transmitted diseases (STDs). Study: We conducted a cross-sectional study of visits to an urban STD clinic between January 2001 and January 2003, by women, men who have sex with women (MSW), and men who have sex with men (MSM) by consistent condom users with or without a condom use error. Methods: Prevalence rates were calculated for gonorrhea, chlamydia, trichomonas, nongonococcal urethritis (NGU), and pelvic inflammatory disease. Rates were stratified by reported errors in condom use over the past 4 months for consistent users with adjusted odds ratios calculated by logistic regression. Results: Among 1973 consistent condom users with error information available, any condom use error was reported more commonly among women (57%) than MSW (48%), or MSM (P <0.001 for each comparison), with breakage being the most frequently reported error. Among MSW, having a condom use error was associated with gonorrhea (adjusted odds ratio [AOR], 5.53; 95% confidence interval [CI], 2.48–12.35), chlamydia (AOR, 3.19; 95% CI, 1.80–5.65), and NGU (AOR, 2.09; 95% CI, 1.45–3.01), whereas, for women and MSM, no associations were seen for any STD. Conclusions: Condom use errors were common among subjects reporting consistent condom use and for MSW, condom error was associated with a significant increased risk of STD. These data support the premise that correctness of condom use is an important methodologic issue in studies assessing condom effectiveness.

Predictors of contraceptive discontinuation in a sexually transmitted disease clinic population.

High rates of unintended pregnancy and sexually transmitted disease in women challenge health promotion to identify improvements in “dual protection” interventions. Findings from an exploratory qualitative study using a social ecological model identify causal, contextual, and intervening factors that influence dual protection. The study examined 48 U.S. women completing a sexually transmitted disease clinic process and focused on women at high risk of unwanted pregnancy and sexually transmitted disease. We frame findings from these interviews using social ecology to illustrate the levels where intervention to promote the concept of dual protection and associated behaviors might occur. Presenting findings within this framework offer an understanding of complex factors that influence dual protection and also present an opportunity to consider strategies for promoting dual protection that include interventions at the structural/environmental level, the social/interpersonal level, and the individual level.

Predicting pregnancy risk in women attending an STD clinic.

OBJECTIVE Our purpose was to determine the effectiveness of sexually transmitted disease (STD) clinic-initiated contraceptive care. STUDY DESIGN Nonpregnant women (n=877) attending an urban STD clinic using either no contraception or only condoms were randomly assigned to either an intervention (n=437) or control group (n=440). Both groups received condoms with spermicide and a referral list of primary care providers (PCP) for ongoing reproductive health care, and the intervention group also received enhanced contraceptive counseling, initial provision of contraception, and facilitated referral to a PCP. Outcomes measured at 4-, 8-, and 12-month follow-up were transition to a PCP, effective contraceptive use (ECU), interval pregnancy, and STD. RESULTS The median time to PCP transition was 79 days for the intervention group versus 115 days for the control group (P=.007). Rates of ECU were higher for the intervention group than for control group at the 4-month visit (50% vs 22%, P<.0001) as well as the 8-month visit, although in the intervention group ECU diminished over the course of the study. During follow-up, pregnancy outcomes were documented for 229 women (26.1%), for an overall pregnancy rate of 38.2 per 100 person-years of follow-up. Of the 159 pregnancies defined by patient self-report, 153 (96.2%) were described as unintended and 32 (20%) resulted in a therapeutic abortion. The pregnancy rate was 15% lower in the intervention (105/437, 24.0%) than the control group (124/440, 28.2%) (P=.16), but this difference was not statistically significant. CONCLUSION The intervention helped women transition to a PCP and initiate ECU but did not significantly reduce the pregnancy rate. More intensive interventions are needed to prevent unintended pregnancy in this high-risk population.

Pap Smear Screening in an Urban STD Clinic: Yield of Screening and Predictors of Abnormalities

OBJECTIVE: We sought to evaluate the use of human immunodeficiency virus (HIV) screening during pregnancy in a health care system using the verbal opt-out method, in which HIV screening was recommended during all pregnancies and women were given an opportunity to refuse testing. METHODS: This was a retrospective cohort study of pregnancies resulting in delivery from 1998 through 2001 at Denver Health Medical Center, an urban public hospital. The main outcome measure was the proportion of documented HIV screening within 9 months before the delivery date. RESULTS: Of 12,221 pregnancies resulting in delivery, HIV screening was completed in 12,000 (98.2%, 95% confidence interval 97.9–98.4%). Of the 221 women not screened for HIV, only 24 (10.9% of those not screened, 0.2% of all women in the study) were documented as refusing HIV testing. Patients not screened for HIV presented late in pregnancy, a median of 1 day before delivery, compared with a median of 176 days for those who were screened (P < .001). CONCLUSION: A verbal opt-out system was very effective in promoting HIV screening during pregnancy. Late presentation in pregnancy was associated with not having HIV screening performed. LEVEL OF EVIDENCE: II-3

Association between Provision of Initial Family Planning Services and Unintended Pregnancy among Women Attending an STD Clinic

CONTEXT Women who attend sexually transmitted disease (STD) clinics are at high risk for unintended pregnancy. Little information is available, however, on the rates of discontinuation of effective contraceptive method use among this population. METHODS As part of a study on contraceptive services offered by an STD clinic in Denver, 406 clients who accepted these services in 1996-1999 were interviewed about their contraceptive practice, experience of side effects and method-use problems at baseline and at four, eight and 12 months of follow-up. Multivariate survival analysis was used to assess predictors of discontinuation of effective contraceptive use. RESULTS Twenty-nine percent of women discontinued use by the end of one year. Coxproportional hazards models show that compared with women who reported no method-use problems, those who experienced one problem were three times as likely (hazard ratio, 3.0) to discontinue effective use, and women who had at least two problems were five times as likely (5.0) to discontinue use. The experience of side effects with either a past or a current method, however, was not associated with the risk of discontinuation. Furthermore, women who reported risky sexual behavior in the year before enrollment were significantly less likely to discontinue effective method use (hazard ratio, 0.4), as were women who were covered by medical insurance or who gained such coverage during a follow-up interval (hazard ratio, 0.5 for each). CONCLUSIONS In this study population of STD clinic users, method-use problems appear to be a more fundamental issue for contraceptive compliance than the pastor current experience of side effects. The unexpected association between method-use problems and the risk of discontinuation needs to be further delineated so that effective interventions addressing these problems can be developed and implemented.

Comparison of sexually transmitted disease prevalence by reported level of condom use among patients attending an urban sexually transmitted disease clinic.

Background Although sexually transmitted disease (STD) clinics focus mainly on STD treatment and prevention, women attending these clinics are also at high risk for pregnancy. Goal To evaluate the relationship between certain demographic and behavioral characteristics and the probability of pregnancy in women attending an urban STD clinic. Study Design Non-contraceptive-using women in an STD clinic–initiated randomized controlled contraception study (n = 877) were interviewed at baseline, and incident pregnancies within 1 year of enrollment were measured. Association between baseline demographic and behavioral characteristics with incident pregnancy was assessed by chi-square analysis, and logistic regression was used to assess factors associated with an incident pregnancy. Results Among the 673 women (76.7%) for whom follow-up pregnancy information was available, 220 (32.7%) incident pregnancies occurred within 1 year. By logistic regression controlling for study assignment, incident pregnancy was associated with age ≤19 years (odds ratio [OR], 2.8; 95% CI: 1.5–5.2), previous abortion (OR, 3.1; 95% CI: 1.7–5.4), frequency of sexual encounters of at least once a week (OR, 1.8; 95% CI: 1.2–2.6), and having a chlamydial infection at the time of enrollment (OR, 1.8; 95% CI: 1.0–3.2). With a combination of demographic and behavioral characteristics correlated by univariate analysis with incident pregnancy (i.e., age ≤19 years, nonwhite race, high school/general equivalency diploma or less education, previous pregnancy, no use of birth control with last intercourse, sex at least once a week, previous abortion, ≥3 partners within the past month, and <17 years of age at first pregnancy), the cumulative risk of pregnancy with 6 or more of the 9 characteristics was 51%, compared with 25.6% for women with ≤5 characteristics. Conclusion For this STD clinic population, a combination of demographic and behavioral characteristics was useful when combined for identifying a subgroup of women at higher risk for subsequent pregnancy. Targeted intervention by STD care providers should include the provision for both pregnancy and STD prevention counseling.