Julia A. Schillinger

Patient-delivered partner treatment with azithromycin to prevent repeated Chlamydia trachomatis infection among women: A randomized, controlled trial

Background Repeated infection with Chlamydia trachomatis increases the risk for serious sequelae: pelvic inflammatory disease, ectopic pregnancy, infertility, and chronic pelvic pain. A substantial proportion of women treated for C trachomatis infection are reinfected by an untreated male sex partner in the first several months after treatment. Effective strategies to ensure partner treatment are needed. Goal The goal of the study was to determine whether repeated infections with C trachomatis can be reduced by giving women doses of azithromycin to deliver to male sex partners. Study Design A multicenter randomized controlled trial was conducted among 1787 women aged 14 to 34 years with uncomplicated C trachomatis genital infection diagnosed at family planning, adolescent, sexually transmitted disease, and primary care clinics or emergency or other hospital departments in five US cities. Women treated for infection were randomized to one of two groups: patient-delivered partner treatment (in which they were given a dose of azithromycin to deliver to each sex partner) or self-referral (in which they were asked to refer their sex partners for treatment). The main outcome measure was C trachomatis DNA detected by urine ligase chain reaction (LCR) or polymerase chain reaction (PCR) by 4 months after treatment. Results The characteristics of study participants enrolled in each arm were similar except for a small difference in the age distribution. Risk of reinfection was 20% lower among women in the patient-delivered partner treatment arm (87/728; 12%) than among those in the self-referral arm (106/726; 15%); however, this difference was not statistically significant (odds ratio, 0.80; 95% confidence interval, 0.62–1.05;P = 0.102). Women in the patient-delivered partner treatment arm reported high compliance with the intervention (82%). Conclusion Patient-delivered partner treatment for prevention of repeated C trachomatis infection among women is comparable to self-referral and may be an appropriate option for some patients.

Seroprevalence and Coinfection with Herpes Simplex Virus Type 1 and Type 2 in the United States, 1988–1994

Seroprevalence of and coinfection with herpes simplex virus type 1 (HSV-1) and type 2 (HSV-2) in the United States were analyzed by use of data from a nationally representative survey (National Health and Nutrition Examination Survey III, 1988-1994). Evidence was explored for possible protection by prior HSV-1 infection against infection and clinical disease with HSV-2. Overall, 27.1% of persons aged > or =12 years were seronegative for HSV-1 and HSV-2; 51.0% were seropositive for HSV-1 only, 5.3% for HSV-2 only, and 16.6% for both HSV-1 and HSV-2. The seroprevalence of HSV-2 was higher in persons with HSV-1 antibody. Approximately 76% of persons who had HSV-2 antibody also had HSV-1 antibody. Persons seropositive for HSV-2 only reported a history of genital herpes more frequently (16.2%) than persons seropositive for both HSV-1 and HSV-2 (5.9%). The seroprevalence of HSV-1 and age at infection may influence the epidemiology of clinical genital herpes, even if prior HSV-1 infection does not prevent HSV-2 infection.

Duration of untreated genital infections with Chlamydia trachomatis: a review of the literature.

Background: Estimates of the duration of untreated genital infections with Chlamydia trachomatis vary. Accurately estimating the distribution of the duration of infection would be useful in the counseling patients, and is essential when modeling the burden of chlamydial disease and the potential impact of prevention programs. Goal: The authors review the scientific literature to summarize what is known about the duration of genital chlamydial infection and the factors that affect it. Study Design: Literature review of animal and human studies. Results: Animal studies document a longer duration of infection in primates than in mice or guinea pigs. Although animals spontaneously become culture negative over time, numerous studies document persistent nonculture evidence of chlamydiae in the upper genital tract. Studies in which women have been serially cultured suggest that most untreated infections remain culture positive for more than 60 days. Small series report that some infections may persist for years. Most infections eventually become culture negative; however, nonculture evidence of chlamydiae often persist in women with negative cultures. The duration of chlamydial infection is reduced in animals previously exposed to chlamydiae and in older humans, suggesting that partial immunity may result from exposure. Data are inadequate to define the median duration of untreated infection or to derive a curve that describes the natural history of untreated genital chlamydial infections. Conclusion: Current data do not allow one to reliably estimate the duration of genital infections with C trachomatis. Systematic retesting could help to better define the duration of infection in patients who, against medical advice, delay treatment for genital chlamydial infections.

National seroprevalence and trends in herpes simplex virus type 1 in the United States, 1976-1994.

Objectives: The objectives of this study were to estimate national seroprevalence of herpes simplex virus type 1 (HSV-1), describe trends in seroprevalence, and examine correlates of infection. Goal: The goal of this study was to measure the burden of HSV-1 infection in the U.S. population. Study: We tested serum samples for HSV-1 antibody and analyzed questionnaire data collected for the second and third National Health and Nutrition Surveys (NHANES II, 1976–80; NHANES III, 1988—94). Seroprevalence estimates were weighted to represent the total U.S. population. Results: At the time of NHANES III, two thirds (68%) of the U.S. population 12 years and older had HSV-1 antibody. Prevalence increased with age and varied by race/ethnicity; the majority of persons in all race/ethnic groups were HSV-1-seropositive by age 30. Overall, the national seroprevalence of HSV-1 decreased nonsignificantly by 2% in the years between NHANES II and III; decreases in HSV-1 seroprevalence in some population subgroups were balanced by increases in other groups. Conclusions: There was no overall change in the seroprevalence of HSV-1 in the U.S. population between NHANES II and III.

Men who have sex with men have a 140-fold higher risk for newly diagnosed HIV and syphilis compared with heterosexual men in New York City.

ObjectivesTo describe the population of men who have sex with men (MSM) in New York City, compare their demographics, risk behaviors, and new HIV and primary and secondary (P&S) syphilis rates with those of men who have sex with women (MSW), and examine trends in infection rates among MSM. DesignPopulation denominators and demographic and behavioral data were obtained from population-based surveys during 2005–2008. Numbers of new HIV and P&S syphilis diagnoses were extracted from city-wide disease surveillance registries. MethodsWe calculated overall, age-specific and race/ethnicity-specific case rates and rate ratios for MSM and MSW and analyzed trends in MSM rates by age and race/ethnicity. ResultsThe average prevalence of male same-sex behavior during 2005–2008 (5.0%; 95% CI: 4.5 to 5.6) differed by both age and race/ethnicity (2.3% among non-Hispanic black men; 7.4% among non-Hispanic white men). Compared with MSW, MSM differed significantly on all demographics and reported a higher prevalence of condom use at last sex (62.9% vs. 38.3%) and of past-year HIV testing (53.6% vs. 27.2%) but also more past-year sex partners. MSM HIV and P&S syphilis rates were 2526.9/100,000 and 707.0/100,000, each of which was over 140 times MSW rates. Rates were highest among young and black MSM. Over 4 years, HIV rates more than doubled and P&S syphilis rates increased 6-fold among 18-year-old to 29-year-old MSM. ConclusionsThe substantial population of MSM in New York City is at high risk for acquisition of sexually transmitted infections given high rates of newly diagnosed infections and ongoing risk behaviors. Intensified and innovative efforts to implement and evaluate prevention programs are required.

An Outbreak of Syphilis in Alabama Prisons: Correctional Health Policy and Communicable Disease Control

OBJECTIVES After syphilis outbreaks were reported at 3 Alabama State mens prisons in early 1999, we conducted an investigation to evaluate risk factors for syphilis infection and describe patterns of syphilis transmission. METHODS We reviewed medical, patient interview, and prison transfer records and documented sexual networks. Presumptive source cases were identified. Odds of exposure to unscreened jail populations and transfer from other prisons were calculated for case patients at 1 prison. RESULTS Thirty-nine case patients with early syphilis were identified from 3 prisons. Recent jail exposure (odds ratio [OR] = 8.0, 95% confidence interval [CI] = 0.3, 158.7, P = .14) and prison transfer (OR = 32.0, 95% CI = 1.6, 1668.1, P < .01) were associated with being a source case patient. CONCLUSIONS Probable sources of syphilis introduction into and transmission within prisons included mixing of prisoners with unscreened jail populations, transfer of infected inmates between prisons, and multiple concurrent sexual partnerships. Reducing sexual transmission of disease in correctional settings is a public health priority and will require innovative prevention strategies.

HIV Incidence Among Men With and Those Without Sexually Transmitted Rectal Infections: Estimates From Matching Against an HIV Case Registry

BACKGROUND Sexually transmitted bacterial rectal infections are objective markers of HIV risk behavior. Quantifying HIV risk among men who have sex with men (MSM) who have had these infections can inform prevention efforts. We measured HIV risk among MSM who have and those who have not been diagnosed with rectal Chlamydia trachomatis (CT) and/or rectal Neisseria gonorrhoeae (GC). METHODS HIV incidence among a cohort of 276 HIV-negative MSM diagnosed with rectal CT and/or GC in New York City sexually transmitted disease (STD) clinics was compared to HIV incidence among HIV-negative MSM without these infections. Matches against the citywide HIV/AIDS registry identified HIV diagnoses from STD clinics, and by other providers. Cox proportional hazards models were used to explore factors associated with HIV acquisition among MSM with rectal infections. RESULTS HIV-negative MSM with rectal infections (>70% of which were asymptomatic) contributed 464.7 person-years of follow-up. Among them, 31 (11.2%) were diagnosed with HIV, of whom 14 (45%) were diagnosed by non-STD clinic providers. The annual HIV incidence was significantly higher among MSM with rectal infections (6.67%; 95% confidence interval [CI], 4.61%-9.35%) than among MSM without rectal infections (2.53%; 95% CI, 1.31%-4.42%). Black race (hazard ratio, 4.98; 95% CI, 1.75-14.17) was associated with incident HIV among MSM with rectal CT/GC. CONCLUSIONS One in 15 MSM with rectal infections was diagnosed with HIV within a year, a higher risk than for MSM without rectal infections. Such data have implications for screening for rectal STD, and may be useful for targeting populations for risk-reduction counseling and other HIV prevention strategies, such as preexposure prophylaxis.

Extensive Genetic Diversity, Unique Population Structure and Evidence of Genetic Exchange in the Sexually Transmitted Parasite Trichomonas vaginalis

Background Trichomonas vaginalis is the causative agent of human trichomoniasis, the most common non-viral sexually transmitted infection world-wide. Despite its prevalence, little is known about the genetic diversity and population structure of this haploid parasite due to the lack of appropriate tools. The development of a panel of microsatellite makers and SNPs from mining the parasites genome sequence has paved the way to a global analysis of the genetic structure of the pathogen and association with clinical phenotypes. Methodology/Principal Findings Here we utilize a panel of T. vaginalis-specific genetic markers to genotype 235 isolates from Mexico, Chile, India, Australia, Papua New Guinea, Italy, Africa and the United States, including 19 clinical isolates recently collected from 270 women attending New York City sexually transmitted disease clinics. Using population genetic analysis, we show that T. vaginalis is a genetically diverse parasite with a unique population structure consisting of two types present in equal proportions world-wide. Parasites belonging to the two types (type 1 and type 2) differ significantly in the rate at which they harbor the T. vaginalis virus, a dsRNA virus implicated in parasite pathogenesis, and in their sensitivity to the widely-used drug, metronidazole. We also uncover evidence of genetic exchange, indicating a sexual life-cycle of the parasite despite an absence of morphologically-distinct sexual stages. Conclusions/Significance Our study represents the first robust and comprehensive evaluation of global T. vaginalis genetic diversity and population structure. Our identification of a unique two-type structure, and the clinically relevant phenotypes associated with them, provides a new dimension for understanding T. vaginalis pathogenesis. In addition, our demonstration of the possibility of genetic exchange in the parasite has important implications for genetic research and control of the disease.

Sexual Behaviors and Sexual Violence: Adolescents With Opposite-, Same-, or Both-Sex Partners

OBJECTIVE: To describe sexual behaviors, sexual violence, and sexual identity among a population-based sample of adolescents according to the sex of their sex partners, considering separately those with partners of both sexes. METHODS: From the 2005–2007 New York City Youth Risk Behavior Surveys, 3805 male and 3456 female adolescents reported having had sex and the sex of their sexual contacts. Subgroups were constructed: only opposite-sex partners; only same-sex partners; and partners of both sexes (both-sex partners). Weighted prevalence, risk behaviors (eg, using drugs/alcohol with sex), and sexual identity among subgroups were described. RESULTS: Similar numbers of sexually active male (3.2%) and female adolescents (3.2%) reported only same-sex behavior, but fewer male than female adolescents reported both-sex partners (3.7% vs 8.7%; P < .001). Male adolescents with both-sex partners reported a higher prevalence of sexual risk behaviors than male adolescents with only opposite-sex or only same-sex partners. Female adolescents with both-sex or only same-sex partners reported a higher prevalence of risk behaviors than female adolescents with only opposite-sex partners. Adolescents with both-sex partners reported a marked prevalence of dating violence and forced sex. Many adolescents with only same- or both-sex partners (38.9%) self-identified as straight. CONCLUSIONS: Of sexually active adolescents, 9.3% reported a same-sex partner, a higher estimate than other published rates. Those who reported both male and female partners reported behaviors that placed them at risk for sexually transmitted infections (STIs), including HIV. Pediatricians and school health providers must inquire about behaviors, not identity, to determine STI risk, and STI education should be appropriate for youth with same-sex partners.

The program cost and cost-effectiveness of screening men for Chlamydia to prevent pelvic inflammatory disease in women.

Background: Because men transmit Chlamydia trachomatis to women, screening men to prevent pelvic inflammatory disease in women may be a viable strategy. However, the cost-effectiveness of this approach requires careful assessment. Methods: Data from a demonstration project and longitudinal study that examined screening men for chlamydia were applied to a compartment-based transmission model to estimate the cost-effectiveness of screening men for chlamydia compared with alternative interventions, including expanded screening of women and combining disease investigation specialist–provided partner notification with screening. Cases of pelvic inflammatory disease and quality-adjusted life years lost were the primary outcome measures. A male screening program that screened 1% of men in the population annually was modeled. Results: A program targeting high-risk men for screening (those with a larger number of partners in the previous year than the general population and a higher chlamydia prevalence) was cost saving compared with using equivalent program dollars to expand screening of lower-risk women. Combining partner notification with male screening was more effective than screening men alone. In sensitivity analyses, the male program was not always cost saving but averaged