Roxanne P. Kerani

Trichomonas vaginalis Antimicrobial Drug Resistance in 6 US Cities, STD Surveillance Network, 2009–2010

Such isolates should undergo drug susceptibility testing periodically to detect emerging resistance.

Extragenital Gonorrhea and Chlamydia Testing and Infection Among Men Who Have Sex With Men—STD Surveillance Network, United States, 2010–2012

BACKGROUND Gonorrhea (GC) and chlamydia (CT) are the most commonly reported notifiable diseases in the United States. The Centers for Disease Control and Prevention recommends that men who have sex with men (MSM) be screened for urogenital GC/CT, rectal GC/CT, and pharyngeal GC. We describe extragenital GC/CT testing and infections among MSM attending sexually transmitted disease (STD) clinics. METHODS The STD Surveillance Network collects patient data from 42 STD clinics. We assessed the proportion of MSM attending these clinics during July 2011-June 2012 who were tested and positive for extragenital GC/CT at their most recent visit or in the preceding 12 months and the number of extragenital infections that would have remained undetected with urethral screening alone. RESULTS Of 21 994 MSM, 83.9% were tested for urogenital GC, 65.9% for pharyngeal GC, 50.4% for rectal GC, 81.4% for urogenital CT, 31.7% for pharyngeal CT, and 45.9% for rectal CT. Of MSM tested, 11.1% tested positive for urogenital GC, 7.9% for pharyngeal GC, 10.2% for rectal GC, 8.4% for urogenital CT, 2.9% for pharyngeal CT, and 14.1% for rectal CT. More than 70% of extragenital GC infections and 85% of extragenital CT infections were associated with negative urethral tests at the same visit and would not have been detected with urethral screening alone. CONCLUSIONS Extragenital GC/CT was common among MSM attending STD clinics, but many MSM were not tested. Most extragenital infections would not have been identified, and likely would have remained untreated, with urethral screening alone. Efforts are needed to facilitate implementation of extragenital GC/CT screening recommendations for MSM.

Comparative geographic concentrations of 4 sexually transmitted infections.

OBJECTIVES We measured and compared the concentration of primary and secondary syphilis, gonorrhea, chlamydial infection, and genital herpes in a large county with urban, suburban, and rural settings. METHODS We geocoded sexually transmitted infections reported to King County, Washington health department in 2000-2001 to census tract of residence. We used a model-based approach to measure concentration with Lorenz curves and Gini coefficients. RESULTS Syphilis exhibited the highest level of concentration (estimated Gini coefficient = 0.68, 95% confidence interval [CI] = 0.64, 0.78), followed by gonorrhea (estimated Gini coefficient=0.57; 95% CI=0.54, 0.60), chlamydial infection (estimated Gini coefficient = 0.45; 95% CI = 0.40, 0.43), and herpes (estimated Gini coefficient=0.26; 95% CI=0.22, 0.29). CONCLUSIONS Geographically targeted interventions may be most appropriate for syphilis and gonorrhea. For less-concentrated infections, control strategies must reach a wider portion of the population.

Rising rates of syphilis in the era of syphilis elimination.

Objective: The objective of this study was to assess the impact of syphilis control activities in King County, Washington. Study Design: We calculated rates of early syphilis and trends in numbers of persons tested and diagnosed through screening and partner notification from 1998 to 2005. Results: Early syphilis cases increased from 38 in 1998 to 188 in 2005 with 92% occurring among men who have sex with men (MSM). Our health department conducted public awareness campaigns, increased publicly financed syphilis screening among MSM by 179%, and intensified partner notification efforts. Despite these efforts, the prevalence of syphilis among screened populations was only 1.1%, and 71% syphilis cases were diagnosed after seeking care for symptoms. The proportion of cases diagnosed through screening and partner notification did not significantly change during the evaluation period. Early syphilis incidence among MSM more than doubled between 2003 and 2005. Conclusions: New, innovative approaches to syphilis control are needed.

HIV among African-born persons in the United States: a hidden epidemic?

Background:Although a large proportion of HIV diagnoses in Western Europe occur in African-born persons, analyses of US HIV surveillance data do not routinely assess the proportion of diagnoses occurring in African-born US residents. Objective:To determine the percentage of newly reported HIV diagnoses occurring in African-born persons in selected areas of the United States with large African-born immigrant populations. Methods:We collated and analyzed aggregate data on persons diagnosed with HIV in 2003-2004 and reported to HIV surveillance units in the states of California, Georgia, Massachusetts, Minnesota, and New Jersey and in King County, Washington; New York City; and the portion of Virginia included in the Washington, DC, metropolitan area. Results:African-born persons accounted for 0.6% of the population and 3.8% of HIV diagnoses in participating areas (HIV diagnoses range: 1%-20%). Across all areas, up to 41% of diagnoses in women (mean: 8.4%, range: 4%-41%) and up to 50% of diagnoses in blacks (mean: 8.0%, range: 2%-50%) occurred among African-born individuals. Conclusions:In some areas, classifying HIV cases among foreign-born blacks as occurring in African Americans dramatically alters the epidemiological picture of HIV. Country of birth should be consistently included in local and national analyses of HIV surveillance data.

Uptake and Population-Level Impact of Expedited Partner Therapy (EPT) on Chlamydia trachomatis and Neisseria gonorrhoeae: The Washington State Community-Level Randomized Trial of EPT

Background Expedited partner therapy (EPT), the practice of treating the sex partners of persons with sexually transmitted infections without their medical evaluation, increases partner treatment and decreases gonorrhea and chlamydia reinfection rates. We conducted a stepped-wedge, community-level randomized trial to determine whether a public health intervention promoting EPT could increase its use and decrease chlamydia test positivity and gonorrhea incidence in women. Methods and Findings The trial randomly assigned local health jurisdictions (LHJs) in Washington State, US, into four study waves. Waves instituted the intervention in randomly assigned order at intervals of 6–8 mo. Of the state’s 25 LHJs, 24 were eligible and 23 participated. Heterosexual individuals with gonorrhea or chlamydial infection were eligible for the intervention. The study made free patient-delivered partner therapy (PDPT) available to clinicians, and provided public health partner services based on clinician referral. The main study outcomes were chlamydia test positivity among women ages 14–25 y in 219 sentinel clinics, and incidence of reported gonorrhea in women, both measured at the community level. Receipt of PDPT from clinicians was evaluated among randomly selected patients. 23 and 22 LHJs provided data on gonorrhea and chlamydia outcomes, respectively. The intervention increased the percentage of persons receiving PDPT from clinicians (from 18% to 34%, p < 0.001) and the percentage receiving partner services (from 25% to 45%, p < 0.001). Chlamydia test positivity and gonorrhea incidence in women decreased over the study period, from 8.2% to 6.5% and from 59.6 to 26.4 per 100,000, respectively. After adjusting for temporal trends, the intervention was associated with an approximately 10% reduction in both chlamydia positivity and gonorrhea incidence, though the confidence bounds on these outcomes both crossed one (chlamydia positivity prevalence ratio = 0.89, 95% CI 0.77–1.04, p = 0.15; gonorrhea incidence rate ratio = 0.91, 95% CI .71–1.16, p = 0.45). Study findings were potentially limited by inadequate statistical power, by the institution of some aspects of the study intervention outside of the research randomization sequence, and by the fact that LHJs did not constitute truly isolated sexual networks. Conclusions A public health intervention promoting the use of free PDPT substantially increased its use and may have resulted in decreased chlamydial and gonococcal infections at the population level. Trial Registration ClinicalTrials.gov NCT01665690

Failure of serosorting to protect African American men who have sex with men from HIV infection.

Background: Serosorting is the practice of choosing sex partners or selectively using condoms based on a sex partners perceived HIV status. The extent to which serosorting protects African American (AA) and Hispanic men who have sex with men (MSM) is unknown. Methods: We analyzed data collected from MSM sexually transmitted diseases clinic patients in Seattle, WA, 2001–2010. Men were asked about the HIV status of their anal sex partners in the prior year and about their condom use with partners by partner HIV status. We defined serosorters as MSM who had unprotected anal intercourse (UAI) only with partners of the same HIV status, and compared the risk of testing HIV positive among serosorters and men who reported having UAI with partners of opposite or unknown HIV status (ie, nonconcordant UAI). We used generalized estimating equations to evaluate the association of serosorting with testing HIV positive. Results: A total of 6694 MSM without a prior HIV diagnosis were tested during 13,657 visits; 274 men tested HIV positive. Serosorting was associated with a lower risk of testing HIV positive than nonconcordant UAI among white MSM (2.1 vs. 4.5%, odds ratio [OR]: 0.45, 95% confidence interval [CI]: 0.34–0.61), but not AA MSM (6.8 vs. 6.0%, OR: 1.1, 95% CI: 0.57–2.2). Among Hispanics, the risk of testing HIV positive was lower among serosorters than men engaging in nonconcordant UAI, though this was not significant (4.1 vs. 6.0%, OR: 0.67, 95% CI: 0.36–1.2). Conclusions: In at least some AA MSM populations, serosorting does not seem to be protective against HIV infection.

A randomized, controlled trial of inSPOT and patient-delivered partner therapy for gonorrhea and chlamydial infection among men who have sex with men

Background: The efficacy of patient-delivered partner therapy (PDPT) and inSPOT, a web-based partner notification service, in increasing partner treatment and/or notification among men who have sex with men (MSM) has not been evaluated. Methods: We enrolled MSM with chlamydia and/or gonorrhea in a randomized, controlled trial with the following 4 arms: inSPOT, PDPT, combined inSPOT and PDPT (inSPOT/PDPT), and standard partner management. Men were offered enrollment when contacted for partner services. Participants completed baseline and follow-up interviews approximately 2 weeks apart. Results: We offered enrollment to 393 eligible MSM, of whom 75 (19%) enrolled and 318 (81%) declined enrollment. The study was halted early due to low enrollment. Among the 75 enrollees, 53 (71%) completed baseline and follow-up interviews. Of these 53 men, 13, 10, 17, and 13 were assigned to the PDPT, inSPOT, inSPOT/PDPT, and standard arms, respectively; participants provided information about 186 partners. The number of partners treated per original patient was 2.33 in the PDPT arm and 1.52 in the non-PDPT arms. PDPT assignment increased the mean number of partners treated per original patient by 54% (ratio of means = 1.54, 95% confidence interval: 1.01–2.34), after adjustment for inSPOT assignment. Among 27 men assigned to inSPOT or inSPOT/PDPT, 1 (4%) used inSPOT to notify ≥1 partner. inSPOT did not affect partner notification, but decreased partner human immunodeficiency virus testing (ratio of means: 0.42, 95% confidence interval: 0.18–0.99). Conclusions: PDPT may increase partner treatment among MSM. Few MSM appear to be willing to use inSPOT to notify their sex partners. Traditional randomized trials of partner notification strategies may not be feasible among MSM.

Comprehensive assessment of sociodemographic and behavioral risk factors for Mycoplasma genitalium infection in women.

Background: Neisseria gonorrhoeae and Chlamydia trachomatis are characterized by different risk factors, thus control strategies for each also differ. In contrast, risk factors for Mycoplasma genitalium have not been well characterized. Methods: Between 2000 and 2006, 1090 women ages 14 to 45 attending the Public Health-Seattle & King County Sexually Transmitted Diseases Clinic in Seattle, WA, underwent clinical examination and computer-assisted survey interview. M. genitalium was detected by transcription mediated amplification from self-obtained vaginal swab specimens. C. trachomatis and N. gonorrhoeae were detected by culture from cervical swab specimens. Results: Prevalent M. genitalium infection was detected in 84 women (7.7%), C. trachomatis in 63 (5.8%), and N. gonorrhoeae in 26 (2.4%). Age <20 and nonwhite race were associated with increased risk for all 3 organisms. In addition, risk for M. genitalium was higher for women with a black partner (adjusted odds ratio [AOR]: 3.4; 95% confidence interval = 1.83–6.29), those never married (AOR: 2.6; 1.08–6.25), using Depo-Provera (AOR: 2.3; 1.19–4.46), and smoking (AOR: 1.7; 1.03–2.83). Drug use, history of STI in the past year, ≤high school education, meeting and having intercourse the same day, anal sex, douching, and hormonal contraception were associated with N. gonorrhoeae or C. trachomatis, but not with M. genitalium. Number of partners was not associated with any of the 3 organisms. Conclusions: The limited number of risk factors for prevalent infection common to all 3 pathogens suggests that M. genitalium may circulate in different sexual networks than N. gonorrhoeae or C. trachomatis. The predominance of sociodemographic risk factors for M. genitalium, rather than high-risk sexual behaviors, suggests broad-based testing may be the most effective control strategy.

Spatial bridges for the importation of gonorrhea and chlamydial infection.

A study of heterosexuals with gonorrhea and/or chlamydial infection in King County, Washington, found that 5.2% of study participants had both local and geographically distant sex partners in the 60 days before diagnosis. Individuals who served as spatial bridges were of higher socioeconomic status and older than other patients. Background Sexual mixing between distant geographic areas (spatial bridging) is important in the spread of antimicrobial resistance and new sexually transmitted disease pathogens. Goal The goal was to define the extent of sexual mixing between persons with gonorrhea or chlamydial infection in King County, Washington, and persons outside the Seattle area, and to identify characteristics of persons and partnerships associated with spatial bridging. Methods Patients contacted for purposes of partner notification were interviewed regarding demographics, sexual behavior, and the characteristics of their sex partners. Results Of 2912 participants, 150 (5.2%) were spatial bridgers. Bridgers were of higher socioeconomic status than nonbridgers and more often reported concurrent partnerships. Over a 39-month period, bridgers and potential bridgers linked King County with 35 states and 13 foreign countries. Conclusion Spatial bridging could represent an important channel of transmission between geographic areas. These results highlight the need for linkage of prevention efforts across geographic boundaries.