Katherine Ahrens

Molecular Epidemiology of Syphilis-San Francisco, 2004-2007

We describe the molecular epidemiology of syphilis in San Francisco (SF) using Treponema pallidum specimens obtained from patients examined at the SF municipal sexually transmitted diseases clinic during 2004-2007. Of 69 specimens, 52 (75%) were subtype 14d9. Single subtype predominance might reflect a closely linked sexual network in SF.

Using surveillance data to monitor entry into care of newly diagnosed HIV-infected persons: San Francisco, 2006–2007

BackgroundLinkage to care after HIV diagnosis is associated with both clinical and public health benefits. However, ensuring and monitoring linkage to care by public health departments has proved to be a difficult task. Here, we report the usefulness of routine monitoring of CD4 T cell counts and plasma HIV viral load as measures of entry into care after HIV diagnosis.MethodsSince July 1, 2006, the San Francisco Department of Public Health (SFDPH) incorporated monitoring initial primary care visit into standard HIV public health investigation for newly diagnosed HIV-infected patients in select clinics. Entry into care was defined as having at least one visit to a primary HIV care provider after the initial diagnosis of HIV infection. Investigators collected reports from patients, medical providers, laboratories and reviewed medical records to determine the date of the initial health care visit after HIV diagnosis. We identified factors associated with increased likelihood of entering care after HIV diagnosis.ResultsOne -hundred and sixty new HIV-infected cases were diagnosed between July 1, 2006 and June 30, 2007. Routine surveillance methods found that 101 of those cases entered HIV medical care and monitoring of CD4 T cell counts and plasma HIV viral load confirmed entry to care of 25 more cases, representing a 25% increase over routine data collection methods. We found that being interviewed by a public health investigator was associated with higher odds of entry into care after HIV diagnosis (OR 18.86 [1.83–194.80], p = .001) compared to cases not interviewed. Also, HIV diagnosis at the San Francisco county hospital versus diagnosis at the county municipal STD clinic was associated with higher odds of entry into care (OR 101.71 [5.29–1952.05], p < .001).ConclusionThe time from HIV diagnosis to initial CD4 T cell count, CD4 T cell value and HIV viral load testing may be appropriate surveillance measures for evaluating entry into care, as well as performance outcomes for local public health departments HIV testing programs. Case investigation performed by the public health department or case management by clinic staff was associated with increased and shorter time to entry into HIV medical care.

HIV partner notification outcomes for HIV-infected patients by duration of infection, San Francisco, 2004 to 2006.

Background:The San Francisco Department of Public Health conducts HIV third-party partner notification in the following populations based on standard Centers for Disease Control and Prevention (CDC) guidelines: (1) persons with acute and nonacute incident HIV infection tested at the municipal sexually transmitted disease (STD) clinic and the county hospital and (2) all county residents with early syphilis and long-standing HIV infection. Methods:We reviewed routinely collected demographic and partner notification outcome data among acute and nonacute cases between 2004 and 2006 and among long-standing cases between July 2005 and December 2006. Outcomes were examined among the 3 case types. Results:Most acute (n = 30), nonacute (n = 398), and long-standing cases (n = 335) occurred in gay/bisexual men (89%), and most case-patients were interviewed (80%). In acute and nonacute cases, 13% of partners tested for HIV were newly identified as HIV-infected. The number of patients interviewed per new HIV infection identified was 25 for acute cases, 21 for nonacute cases, and 39 for long-standing cases; however, half of recent new HIV infections were identified among partners of long-standing patients. Few patients or partners refused partner notification services. Conclusions:Partner notification was acceptable and successfully identified new HIV infections. Other jurisdictions should consider implementing or expanding partner notification for HIV infection. More evaluation is needed of the effectiveness of partner notification among HIV-infected persons with other STDs.

High prevalence of gonococcal and chlamydial infection in men who have sex with men with newly diagnosed HIV infection: an opportunity for same-day presumptive treatment.

Background:The increasing use of point-of-care HIV tests in sexually transmitted disease (STD) clinics allows for rapid identification of patients with newly diagnosed HIV infection who may also be at risk for more common sexually transmitted infections. Positive point-of-care HIV test results might be used to identify and provide presumptive treatment to patients who are likely to be coinfected with gonorrhea (GC) and chlamydia (CT). Methods:Data from 6864 STD clinic visits by men who have sex with men (MSM) with no history of HIV infection and an HIV antibody test at that visit were analyzed. Results from rectal, pharyngeal, and urine nucleic acid amplification tests were used to calculate the prevalence of infection with GC and CT. Results:MSM with newly diagnosed HIV infection were more likely than HIV-uninfected MSM to be infected with GC (25.9% [53 of 205] vs. 10.9% [728 of 6659]; P < 0.001) and CT (18.5% [38 of 205] vs. 7.8% [518 of 6659]; P < 0.001). Conclusions:GC and CT are common in MSM with newly diagnosed HIV infection at an STD clinic. In this population, a positive point-of-care HIV test result is a useful risk marker for untreated gonococcal and chlamydial infections and provides a justification for presumptive GC and CT treatment.

Healthy Penis: San Francisco's Social Marketing Campaign to Increase Syphilis Testing among Gay and Bisexual Men

The authors describe the development, implementation, and evaluation of their innovative social marketing campaign.

The acceptability and feasibility of the Positive Reinforcement Opportunity Project, a community-based contingency management methamphetamine treatment program for gay and bisexual men in San Francisco

Abstract The Positive Reinforcement Opportunity Project (PROP) was a pilot program developed to build on the efficacy of contingency management (CM) using positive reinforcement to address the treatment needs of gay and bisexual men currently using crystal methamphetamines (meth). It was hypothesized that a version of CM could be implemented in San Francisco that was less costly than traditional treatment methods and reached gay and other MSM using meth who also engaged in highrisk sexual activity. Of the 178 men who participated in PROP from December 2003 to December 2005, many self-reported behaviors for acquiring and spreading sexually transmitted diseases including HIV infection. During the initial intake, 73% reported high-risk sexual behavior in the prior three months, with 60% reporting anal receptive and/or insertive sex without condoms. This report describes the implementation of PROP and suggest both its limitations and potential strengths. Initial findings suggest that PROP was a useful and low cost substance use treatment option that resulted in a 35% 90-day completion rate, which is similar to graduation rates from traditional, more costly treatment options. Further evaluation of the limited data from three- and six-month follow-up of those who completed PROP is currently ongoing.

Evaluation of a New Point-of-Care Serologic Assay for Herpes Simplex Virus Type 2 Infection

Herpes simplex virus type 2 infection is one of the most common sexually transmitted diseases. Because presentation is often atypical or subclinical, serologic testing is necessary for diagnosis, treatment, and counseling. In an urban clinic that specializes in the treatment of sexually transmitted disease, a new point-of-care rapid serologic test was compared with enzyme-linked immunosorbent assay or Western blot for the detection of herpes simplex virus type 2. With use of an enzyme-linked immunosorbent assay index cutoff value of 1.1, the rapid test was found to have a sensitivity of 97%, a specificity of 98%, a positive predictive value of 92%, and a negative predictive value of 99%. Increasing the cutoff index value to 3.5 increased the test sensitivity to 100%.

Predictors of incident herpes simplex virus type 2 infections in young women at risk for unintended pregnancy in San Francisco

BackgroundYoung women receiving family planning services are at risk for both unintended pregnancy and herpes simplex virus type 2 (HSV-2) infection.MethodsWe performed a secondary analysis using data from a previously published randomized controlled trial evaluating access to emergency contraception on reproductive health outcomes. Women aged 15 to 24 years were recruited from two Planned Parenthood clinics and two community health clinics in San Francisco. Demographic information and sexual history were obtained by interview. HSV-2 seropositivity was determined by fingerstick blood test. New pregnancies were measured by self-report, urine testing and medical chart review. Subjects were evaluated for incident HSV-2 infection and pregnancy at a 6-month follow-up appointment. Women who were pregnant or intending to become pregnant at enrolment were excluded.ResultsAt enrolment 2,104 women were screened for HSV-2 and 170 (8.1%) were seropositive. Eighty-seven percent of initially seronegative women completed the study (n = 1,672) and 73 (4.4%) became HSV-2 seropositive. HSV-2 seroincidence was 7.8 cases per 100 person-years. One hundred and seventeen women (7%) became pregnant and 7 (6%) of these had a seroincident HSV-2 infection during the study. After adjustment for confounders, predictors of incident HSV-2 infection were African American race and having multiple partners in the last six months. Condom use at last sexual encounter was protective.ConclusionHSV-2 seroincidence and the unintended pregnancy rate in young women were high. Providers who counsel women on contraceptive services and sexually transmitted infection prevention could play an expanded role in counselling women about HSV-2 prevention given the potential sequelae in pregnancy. The potential benefit of targeted screening and future vaccination against HSV-2 needs to be assessed in this population.

Trends in the use of sexually transmitted disease diagnostic technologies in California, 1996-2003.

Objective: To describe trends in STD diagnostic test volume and test technology in California from 1996 to 2003. Study: A self-administered survey was mailed annually to licensed clinical laboratories in California that performed STD testing. Data were collected on volume and diagnostic test type for chlamydia, gonorrhea, syphilis, chancroid, HIV, hepatitis B, herpes simplex virus (HSV), and human papilloma virus (HPV). Data were analyzed for trends over time. Results: Response rates ranged from 77% to 99% per survey year. The total number of chlamydia, gonorrhea, and syphilis tests increased from 8.1 to 9.3 million annually. The proportion of chlamydia and gonorrhea tests performed using nucleic acid amplification testing increased from 5% to 66% and from 1% to 59%, respectively. Gonorrhea culture testing decreased from 42% to 10% of all gonorrhea tests. HIV test volume increased from 2.4 to 3.1 million tests. Newer technology tests for HSV and HPV were less common but increased in use. Nonpublic health laboratories conducted over 90% of all STD testing. Conclusions: Analyzing trends in diagnostic technologies enhances our understanding of the epidemiology of STDs and monitoring laboratory capacity and practices facilitates implementation of STD control activities.

Increased Knowledge of Safe and Appropriate Penicillin Injection After Viewing Brief Instructional Video Titled How to Inject Bicillin LA

B instructional videos have an increasingly important role in clinician education.1,2 Because of declines in primary and secondary syphilis incidence in the years from 1990 to 2000, many currently practicing clinicians may not be familiar with the use of penicillin G benzathine injectable suspension.3 Syphilis incidence, however, has increased substantially since 2000, and more clinicians with limited experience in syphilis management are treating patients newly diagnosed with syphilis.4,5 The 2006 Centers for Disease Control Sexually Transmitted Disease Treatment Guidelines advise that the early stages of syphilis, including primary, secondary, and early latent, are effectively treated with a 1-time injection of appropriately administered intramuscular penicillin G benzathine 2.4 million units (MU) [Bicillin LA (long-acting) (King Pharmaceuticals, Bristol, TN)].6,7 Given the Centers for Disease Control recommendations regarding the treatment of early syphilis, it is imperative that providers be trained in the indications for, and appropriate use of, intramuscular penicillin G benzathine. Also, reports of inadvertent misuse of Bicillin CR to treat syphilis, suggest a need for improved education regarding the appropriate treatment of early syphilis.8 To address this need for clinician education, a 5-minute instructional digital video, “How to Inject Bicillin LA,” was produced in partnership between the San Francisco Department of Public Heath and King Pharmaceuticals, Inc. The video was designed to be viewed by clinicians with diverse backgrounds, as the experience of prescribing physicians, may differ significantly from the experience of nurses who administer the injections. The video addressed a number of topics regarding the safe and appropriate injection of penicillin G benzathine to treat early syphilis. A single dose of Bicillin LA 2.4 million units via deep intramuscular injection is the recommended treatment for adults.6 Bicillin LA is available in single use syringes in 1-, 2-, and 4-ml sizes, containing the equivalent of 600,000, 1,200,000, and 2,400,000 units, respectively, of penicillin G benzathine.9 The video recommends that the total dose be given in 2 injections, 1 in each buttock. The potential for confusion between Bicillin LA and Bicillin CR is also emphasized, as Bicillin CR is not indicated for the treatment of syphilis.8 Bicillin LA is contraindicated in any person with a history of penicillin allergy, as it has been estimated that there is a prevalence of 0.002% fatal and 0.7% to 10% nonfatal anaphylactic reactions to penicillin.10 Given the risk of allergic reactions, it is recommended that patients be observed for 20 to 30 minutes after injection. There are reports of serious adverse reactions to inadvertent intravascular injection. Therefore, the video demonstrates appropriate intramuscular injection technique.11 The video also describes the potential for fever, headache, and fatigue in the first 24 hours after injection, associated with the Jarisch Herxheimer reaction.7 To evaluate whether viewing the video was associated with an increase in syphilis treatment and penicillin G benzathine administration knowledge, we surveyed clinicians attending a STD educational symposium in San Francisco in October 2007. The symposium participants consisted of a diverse group of 164 clinicians, including physicians, nurses, and medical assistants. Before viewing the video, participants self-administered an optional, anonymous, 5 questions multiple-choice pretest evaluation. After viewing the video, the participants were asked to answer the same 5 questions again, as a posttest evaluation. A total of 151 (92%) of the seminar participants completed both the preand posttest evaluations. The 5 questions regarding the administration of Bicillin LA for the treatment of syphilis were: