Matthew Hogben

Social Determinants and Sexually Transmitted Disease Disparities

Social determinants of health play an important role in sexually transmitted disease (STD) transmission and acquisition; consequently, racial and ethnic disparities among social determinants are influences upon disparities in STD rates. In this narrative review, we outline a general model showing the relationship between social determinants and STD outcomes, mediated by epidemiologic context. We then review 4 specific social determinants relevant to STD disparities: segregation, health care, socioeconomics and correctional experiences, followed by 2 facets of the resultant epidemiologic context: core areas and sexual networks. This review shows that disparities exist among the social determinants and that they are related to each other, as well as to core areas, sexual networks, and STD rates. Finally, we discuss the implications of our review for STD prevention and control with particular attention to STD program collaboration and service integration.

Partner notification for HIV and STD in the United States: low coverage for gonorrhea, chlamydial infection, and HIV.

Background Little is known about the scope of current public health partner-notification (PN) activities in the United States. Goal The goal of the study was to define what PN services U.S. health departments provide in areas with high STD/HIV-related morbidity. Study Design The study involved a survey of STD program staff members in U.S. areas with the highest reported rates of infectious syphilis, gonorrhea, chlamydia, and HIV in 1998. Results Staff members of 60 (77%) of 78 health departments provided data. PN interviews were conducted with 7583 (89%) of 8492 cases of syphilis, 23,097 (17%) of 139,287 cases of gonorrhea, and 26,487 (12%) of 228,210 cases of chlamydia. In areas with mandatory HIV reporting, 4375 (52%) of 8328 persons infected with HIV were interviewed for PN. Conclusions Except for patients with syphilis, public health PN services affect only a minority of persons with STD or HIV infection in high-morbidity areas of the United States.

Patient-delivered partner therapy for sexually transmitted diseases as practiced by U.S. physicians.

Objective: The objective of this study was to estimate how many U.S. physicians practice patient-delivered partner therapy (PDPT), which is the practice of giving patients diagnosed with curable sexually transmitted infections medication to give to their sex partners. Study: The authors conducted a national survey of physicians in specialties that diagnose the majority of sexually transmitted diseases in the United States. Results: A total of 3011 physicians diagnosed at least 1 case of either gonorrhea or chlamydial infection in the preceding year. For gonorrhea and chlamydial infection, 50% to 56% reported ever using PDPT; 11% to 14% reported usually or always doing so. Obstetricians and gynecologists and family practice physicians more often used PDPT than internists, pediatricians, and emergency department physicians. Clinicians who collected sex partner information, as well as those who saw more female and white patients, used PDPT most often. Conclusions: PDPT is widely but inconsistently used throughout the United States and is typically provided to a minority of persons.

Are All of Your Students Represented in Their Textbooks? A Content Analysis of Coverage of Diversity Issues in Introductory Psychology Textbooks

Introductory psychology is the gateway course for further study in psychology for minority as well as majority group members. We examined text and photographs in 28 introductory textbooks published between 1990 and 1992 for coverage of diversity issues (e.g., minority group members and lesbian and gay lifestyles). Although women are not a minority in the population, we also included an analysis of gender issues. Results indicated that diversity-related content in 1990s textbooks is limited, although more extensive than in older textbooks. Analysts of content as a function of gender of author(s) revealed that female authors covered some diversity issues to a significantly greater extent than male authors or mixed-gender coauthors. Regarding photographs, Latinos/Latinas and women were significantly underrepresented. Implications of these findings for college students, instructors, authors, and publishers are discussed.

Disinhibition and risk compensation: scope, definitions, and perspective.

WITH MANY CHANGES, INCLUDING advances in health, comes speculation about the possible damaging and unintended consequences of introducing change. In many preventive interventions, unintended consequences follow a particular form called disinhibition or risk compensation. As typically understood, these concepts are operationalized via individuals who, once feeling protected against 1 health risk, engage in other risky behavior that puts them at risk for the same or other health problems. For example, commentary from the 1960s and 1970s cited effective STD treatment as a risk for increased sexual behavior.1 As well, recent debate over mandatory human papillomavirus vaccinations for school entry has brought similar fear that young women might subsequently feel free from concern about the cancer-causing disease and have more unprotected sex with more partners at an earlier age.2–4 In this issue of Sexually Transmitted Diseases, Greg et al. present data from a HIV prevention trial testing the safety and efficacy of oral tenofivir for women in Ghana,5 which we will use to prompt some thoughts about the differences between disinhibition and risk compensation and their scope and relationship to intervention. First, we note there are important conceptual differences between disinhibition and risk compensation with different implications for intervention strategies. Disinhibition derives from psychological terminology; it occurs when people stop trying to avoid risk to themselves or others. Probably the most widely known examples in sexual behavior are centered around the disinhibiting effects of alcohol; an inebriated person may be sexually incautious or aggressive because he or she no longer “cares” about the risk of sexual exposure.6,7 Other examples are drawn from people who feel they cannot avoid a harm and then no longer even try to do so.8 In both examples, the outcome is behavioral disinhibition through lack of caring, although the causes (alcohol vs. perception of unavoidable risk) are very different. Risk compensation, on the other hand, is best understood from a more cognitive perspective. The term applies to those whose diminished susceptibility via a given preventive intervention permits them to increase other risk behaviors. Although both terms are often used interchangeably in the literature, what we have defined as risk compensation is the most common source of concern for those conducting interventions. Guest et al.’s analysis of HIV preexposure prophylaxis in this issue5 is a good starting point to examine these phenomena more closely because the women in the trial, largely sex workers, (a) had high potential for disinhibition via greatly elevated–“unavoidable”–risk of HIV acquisition and (b) high potential for risk compensation via their economic motive for sex. Specifically, the authors examined changes in risk behavior among HIV negative, sexually active women after enrollment in the trial, with data gathered across up to 12 visits over the course of 6 months. For the purposes of these analyses, Guest et al. stratified the sample by baseline sexual risk characteristics (most risky 25% vs. all others); as both control and intervention arm participants took a pill daily, changes in risk would not easily be attributed to knowing one was on antiretroviral prophylaxis. They found that participants reported decreases in unprotected sex, with the steepest declines among women categorized (via number of partners and proportion of unprotected sex acts) in the highest risk group. Through qualitative interviews with a subset of the women, the authors were able to attribute decreased risk behavior at least partly to counseling accompanying the drug regimen. All this is good news about “changes in sexual behavior.” The intervention provides another demonstration that most members of groups whose sexual health prospects have become more assured do not subsequently attempt to damage said prospects: that is, no widespread risk compensation was seen. Similarly, penicillin “preexposure prophylaxis” for syphilis, tested in Louisiana between 1997 and 1999, and a review of sexual behavior for HIV positive people on antiretroviral therapy yielded the same conclusions.9,10 Inference about disinhibition is more indirect, although the results are consistent with reduced disinhibition as the women’s protective behaviors increased with the advent of the preventive intervention. As with risk compensation, the qualitative data were supportive of such inferences but without ruling out alternative explanations. We do not suggest that risk compensation and disinhibition are always negligible effects in interventions. If one lesson seems to be that neither disinhibition nor risk compensation is a widespread, Correspondence: Matthew Hogben, PhD, Mail Stop E-44, Centers for Disease Control and Prevention, Atlanta, GA 30333. E-mail: mhogben@ cdc.gov. Received for publication August 1, 2008, and accepted September 19, 2008. From the Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia Sexually Transmitted Diseases, December 2008, Vol. 35, No. 12, p.1009–1010 DOI: 10.1097/OLQ.0b013e31818eb752 Copyright

HIV partner notification in the United States: a national survey of program coverage and outcomes.

Objective: The objective of this study was to define the scope and case-finding success of HIV partner notification (PN) in the United States. Study: The authors conducted an analysis of PN data from metropolitan areas >500,000 reporting ≥200AIDS cases in 2001. Results: Data were collected from 28 (72%) of 39 eligible jurisdictions. In 22 jurisdictions with reportable HIV, health departments interviewed 32% of 20,353 persons with newly reported HIV. Among 6394 sex or needle-sharing partners, 19% had been previously HIV-diagnosed; 10% tested HIV-positive; 32% tested HIV-negative; and 39% were not notified, denied previous HIV diagnosis and refused HIV testing, or outcome was unknown. Health departments interviewed 13.8 persons to identify 1 new case of HIV (range, 1.0–196). Areas in which larger proportions of AIDS cases occurred among men who have sex with men reported less success identifying new cases of HIV through PN. Conclusions: HIV PN programs identify new cases of HIV but have variable success and affect a minority of persons reported with HIV.

Comparison of methods to increase repeat testing in persons treated for gonorrhea and/or chlamydia at public sexually transmitted disease clinics.

Background: Retesting 3 to 4 months after treatment for those infected with chlamydia and/or gonorrhea has been recommended. Goal: We compared various methods of encouraging return for retesting 3 months after treatment for chlamydia or gonorrhea. Study: In study 1, participants were randomly assigned to: 1) brief recommendation to return, 2) intervention 1 plus

A Randomized Controlled Trial for Reducing Risks for Sexually Transmitted Infections Through Enhanced Patient-Based Partner Notification

20 incentive paid at return visit, or 3) intervention 1 plus motivational counseling at the first visit and a phone reminder at 3 months. In study 2, participants at 1 clinic were randomly assigned to 4) intervention 1, 5) intervention 1 plus phone reminder, or 6) intervention 1 plus motivational counseling but no telephone reminder. Results: Using multiple logistic regression, the odds ratios for interventions 2 and 3, respectively, compared with intervention 1 were 1.2 (95% confidence interval [CI], 0.6–2.5) and 2.6 (95% CI, 1.3–5.0). The odds ratios for interventions 5 and 6 compared with intervention 4 were 18.1 (95% CI, 1.7–193.5) and 4.6 (95% CI, 0.4–58.0). Conclusions: A monetary incentive did not increase return rates compared with a brief recommendation. A reminder phone call seemed to be the most effective method to increase return.

Internet partner notification: another arrow in the quiver.

OBJECTIVES We sought to assess the effectiveness of approaches targeting improved sexually transmitted infection (STI) sexual partner notification through patient referral. METHODS From January 2002 through December 2004, 600 patients with Neisseria gonorrhoeae or Chlamydia trachomatis were recruited from STI clinics and randomly assigned to either a standard-of-care group or a group that was counseled at the time of diagnosis and given additional follow-up contact. Participants completed an interview at baseline, 1 month, and 6 months and were checked at 6 months for gonorrhea or chlamydial infection via nucleic acid amplification testing of urine. RESULTS Program participants were more likely to report sexual partner notification at 1 month (86% control, 92% intervention; adjusted odds ratio [AOR] = 1.8; 95% confidence interval [CI] = 1.02, 3.0) and were more likely to report no unprotected sexual intercourse at 6 months (38% control, 48% intervention; AOR = 1.5; 95% CI = 1.1, 2.1). Gonorrhea or chlamydial infection was detected in 6% of intervention and 11% of control participants at follow-up (AOR = 2.2; 95% CI = 1.1, 4.1), with greatest benefits seen among men (for gender interaction, P = .03). CONCLUSIONS This patient-based sexual partner notification program can help reduce risks for subsequent STIs among urban, minority patients presenting for care at STI clinics.

Evaluation of a population-based program of expedited partner therapy for gonorrhea and chlamydial infection

AS WE LOOK AT THE EVER-INCREASING technological innovation in public health, one of the authors recalls the suspicion with which a nameless health department treated e-mail in the late 1990s, something akin to how the Luddites felt about the horseless carriage. Times have changed, however, and innovation in partner management for STD and HIV has expanded to the Internet.1,2 In this issue of Sexually Transmitted Diseases, Mimiaga and colleagues surveyed men who have sex with men (MSM) using an online site to meet sex partners.3 Given the high rates of anonymous and semianonymous sex that results from online-initiated encounters, sometimes the only means of contacting those partners subsequently is through the Internet, assessed in Mimiaga’s article via e-mail. Results from Mimiaga et al.3,4 clarify some basic points about partner notification with MSM. They found high overall acceptability of partner notification via e-mail across respondents: 92%. This is a similar finding to acceptance of partner notification among MSM in surveys of in-person patient referral or health department involvement,5 and reminds us that partner notification is about as widely acceptable as a concept among MSM as among other partitions of society.6 Partner notification effectiveness with MSM is also comparable to that for heterosexual patients, albeit if judged by traditional indices of effectiveness. A review of partner notification efforts among cities with largely MSM-driven syphilis outbreaks in the early 2000s found proportions of partners notified and brought to treatment that were similar to statistics for the population at large.7 A specific comparison of syphilis partner notification with MSM patients compared to heterosexual male patients in Georgia found almost identical yields for partner notification in each group.8 The differences between MSM and heterosexual men lie in the proportion of total partners claimed: MSM claimed more partners overall and more partners for whom no in-person investigation could be started.7,8 For these partners especially, innovations in contact methods such as e-mail are sorely needed. Roughly two-thirds of respondents in Mimiaga et al. reported that they would use the health department to send notification e-mails to some or all partners, while a little under a quarter reported they would notify all of their partners on their own.3 Substantial preference existed for patient referral of main partners versus health department referral of other partners. HIV-infected men were less enamored of health department-based notification than were uninfected men, with 29% preferring to notify all their partners themselves, versus 21% of uninfected men. Those HIVinfected men and men with other prior STD experience were less inclined to involve health departments in partner notification reminds one of the history of STD/HIV stigma and, as the authors conclude, points to the need for carefully calibrated and marketed partner notification efforts. For that matter, many HIV-infected men are likely comfortable enough with disclosure to view notifying partners as perfectly manageable without health department help. Not that too much should be made of the differences between responses from infected and uninfected men: responses were never more than 8% points apart, so the general portrait holds for each group. Health departments certainly have an interest in some level of involvement with e-mail notification in particular and Internetbased partner notification (IPN) in general, although the level and nature of that involvement is an evolving story. For HIV infection, this means bringing people to vital long-term care, so the relative efficiency of notification methods in case-finding has serious implications for infected people. How relevant “offline” partner notification evaluations are to online models is hard to say, but one Colorado program evaluation in which patients had a choice of health department or patient-led referral with health department referral as a back-up showed that patient referral yielded only about a fifth of all notifications.9 Interestingly, in the above evaluation, health department investigators were able to find partners who the patient had chosen to notify, but not done so (90% or more of partners were notified eventually, regardless of whether the patient has chosen patient referral or health department referral as the first option). Thus, the health department was able to offer a choice of notification strategies to infected patients without reducing the effectiveness of their infection control efforts. One hopes that this approach can be applied via the Internet; it involves the patient and the health department in a collaborative venture in which each party at least implicitly recognizes the stake the other holds in partner notification and subsequent management. The Colorado data were collected in 1988; if patients and public health could collaborate in that era of the HIV epidemic, they certainly ought to be able to do so now. Other recent data have shown that electronic partner notification appears to be less efficient in bringing people to care than inperson efforts.10 In a Texas evaluation, partners of persons infected Correspondence: Matthew Hogben, PhD, or Rachel Kachur, MPH, Centers for Disease Control and Prevention, Mail Stop E-44, Atlanta, GA 30333. E-mail: mhogben@cdc.gov, rkachur@cdc.gov. Received for publication December 3, 2007, and accepted December 3, 2007. Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia Sexually Transmitted Diseases, February 2008, Vol. 35, No. 2, p.117–118 DOI: 10.1097/OLQ.0b013e31816408dd Copyright