William C. Levine

Findings from STD screening of adolescents and adults entering corrections facilities: implications for STD control strategies.

Background Persons entering corrections facilities are at high risk for sexually transmitted diseases (STDs) because of risky sexual behavior and lack of access to routine screening. Goal The goal of the study was to develop a national picture of STD prevalence in this population. Study Design We analyzed information on age, race/ethnicity, urethral symptoms (men only), and test results for approximately 85,000 chlamydia, 157,000 gonorrhea, and 293,000 syphilis tests for persons entering 23 jails and 12 juvenile detention centers in 13 US counties from 1996 through 1999. Results At adult jails in nine counties, the median percentage of persons with reactive syphilis tests by county was 8.2% (range, 0.3–23.8%) for women and 2.5% (range, 1.0–7.8%) for men. At juvenile detention facilities in five counties, the median positivity for chlamydial infection was 15.6% (range, 8.0–19.5%) for adolescent girls and 7.6% (range, 2.8–8.9%) for adolescent boys; the median positivity for gonorrhea was 5.2% (range, 3.4–10.0%) for adolescent girls and 0.9% (range, 0.7–2.6%) for adolescent boys. Of adolescent boys testing positive for chlamydial infection at three juvenile facilities, approximately 97% did not report symptoms; of adolescent boys positive for gonorrhea, 93% did not report symptoms. Conclusion STD positivity among persons entering corrections facilities is high. Most chlamydial and gonococcal infections are asymptomatic and would not be detected without routine screening. Monitoring the prevalence of STDs in this population is useful for planning STD prevention activities in corrections facilities and elsewhere in the community.

Etiology of Genital Ulcers and Prevalence of Human Immunodeficiency Virus Coinfection in 10 US Cities

To determine the etiology of genital ulcers and to assess the prevalence of human immunodeficiency virus (HIV) infection in ulcer patients in 10 US cities, ulcer and serum specimens were collected from approximately 50 ulcer patients at a sexually transmitted disease clinic in each city. Ulcer specimens were tested using a multiplex polymerase chain reaction assay to detect Haemophilus ducreyi, Treponema pallidum, and herpes simplex virus (HSV); sera were tested for antibody to HIV. H. ducreyi was detected in ulcer specimens from patients in Memphis (20% of specimens) and Chicago (12%). T. pallidum was detected in ulcer specimens from every city except Los Angeles (median, 9% of specimens; range, 0%-46%). HSV was detected in >/=50% of specimens from all cities except Memphis (42%). HIV seroprevalence in ulcer patients was 6% (range by city, 0%-18%). These data suggest that chancroid is prevalent in some US cities and that persons with genital ulcers should be a focus of HIV prevention activities.

HIV prevalence in patients with syphilis, United States.

Background: Among persons with a sexually transmitted disease (STD), the proportion who are also infected with HIV is a major factor influencing the public health impact of that STD on HIV transmission. Goal: To assess HIV infection in persons with syphilis in the United States. Study Design: A systematic literature review was conducted of U.S. studies with HIV seroprevalence data in patients with syphilis. Results: Thirty studies were identified and analyzed. The median HIV seroprevalence in men and women infected with syphilis was 15.7% (interquartile range [IQR]: 13.6‐21.8%), among men was 27.5% (23.1‐29.6%), and among women was 12.4% (8.3‐20.5%). Median odds ratios for men and women, men only, and women only were 4.5, 8.5, and 3.3, respectively. Seroprevalences among men who have sex with men (MSM) and injecting drug users (IDU) ranged from 64.3‐90.0% and 22.5‐70.6%, respectively. Conclusions: Despite substantial variability, HIV seroprevalence is high among patients with syphilis in the United States, identifying them as a critical target group for HIV prevention efforts.

Estimated incidence and prevalence of genital Chlamydia trachomatis infections in the United States, 1996.

BACKGROUND AND OBJECTIVE Because genital Chlamydia trachomatis infections and their sequelae have a major impact on individuals and the health care system, it is important to periodically update estimates of chlamydia incidence and prevalence in the United States. STUDY DESIGN Chlamydia incidence and prevalence were estimated using: (1) a method based on estimates of population-specific chlamydia prevalence, and (2) a method based on the chlamydia-to-gonorrhea case rate ratio. RESULTS Using the prevalence-based method, point prevalence among persons 15 to 44 years of age was estimated to be 1.6 million chlamydial infections, and annual incidence, 2.4 million cases per year. Using a method based on the ratio of reported gonorrhea to chlamydia, incidence was estimated to be 2.8 million infections per year, and prevalence, 1.9 million. Adjustment for sensitivity of diagnostic tests yielded annual incidence estimates of 2.5 to 3.3 million infections. CONCLUSIONS Using two methods, we estimated the annual incidence of chlamydial infections in the United States among persons 15 to 44 years of age to be approximately 3 million infections. Critical data needed for more precise estimates include: sensitivity of current diagnostics, better data on infections in males, the current extent of underdetection and underreporting, and better data on duration of infection in men and women.

Trends in the prevalence of chlamydial infections. The impact of community-wide testing.

Background: Evaluation of existing testing programs should guide the national effort to expand programs for the prevention of chlamydial infections. The Columbus (Ohio) Health Department instituted community‐wide testing for Chlamydia trachomatis in 1988. Goals: To assess trends in the prevalence of chlamydial infection, the coverage of screening, and concurrent trends in the prevalence of gonorrhea. Study Design: This was a cross‐sectional study of women 15 to 44 years of age tested for C. trachomatis at over 50 provider sites in Columbus, Ohio, from 1989 to 1992. Results: The prevalence of chlamydial infection among all women tested decreased by 33% from 1989 to 1992. Prevalence decreased least (19%) among black women 15 to 19 years of age, the group with the highest initial prevalence (20.2%), even though 42% of this population in the city was tested. Prevalence did not decrease at all among prenatal patients 15 to 19 years of age. For women tested for both gonorrhea and chlamydia, gonorrhea decreased by 39% during the 4‐year period. Conclusions: Screening appeared to have limited effect on the prevalence of chlamydial infection for groups with highest initial prevalence, despite the relatively high percentage of the population tested. Expanding screening programs to include men and instituting behavioral interventions may be necessary to reduce more rapidly the prevalence of chlamydia among these women.

Decline in sexually transmitted disease prevalence in female Bolivian sex workers: impact of an HIV prevention project.

Objective:To implement an HIV prevention intervention among female commercial sex workers (CSW), and to monitor key outcomes using routinely collected clinical and laboratory data. Design:Cross-sectional and longitudinal analysis of data from an open-enrollment cohort. Setting:One public sexually transmitted disease (STD) clinic and about 25 brothels in La Paz, Bolivia. Participants:A total of 508 female CSW who work at brothels and attend a public STD clinic. Intervention:Improved STD clinical care, supported by periodic laboratory testing, and behavioral interventions performed by a local non-governmental organization. Main outcome measures:Prevalence of gonorrhea, syphilis (reactive plasma reagin titer ≥ 1 : 16), genital ulcer disease, chlamydial infection, and trichomoniasis; self-reported condom use in the previous month; and HIV seroprevalence. Results:From 1992 through 1995, prevalence of gonorrhea among CSW declined from 25.8 to 9.9% (P < 0.001), syphilis from 14.9 to 8.7% (P = 0.02), and genital ulcer disease from 5.7 to 1.3% (P = 0.006); trends in prevalence of chlamydial infection and trichomoniasis were not significant. Self-reported condom use during vaginal sex in the past month increased from 36.3 to 72.5% (P < 0.001). In a multivariate analysis, condom use was inversely associated with gonorrhea [odds ratio (OR), 0.63; 95% confidence interval (CI), 0.41–0.97], syphilis (OR, 0.39; 95% CI, 0.23–0.64), and trichomoniasis (OR, 0.44; 95% CI, 0.32–0.71). In 1995, HIV seroprevalence among CSW was 0.1%. Conclusion:Effective prevention interventions for female CSW can be implemented through public services and non-governmental organizations while HIV rates are still low, and key outcomes can be monitored using data obtained from periodic screening examinations.

Screening women in jails for chlamydial and gonococcal infection using urine tests feasibility, acceptability, prevalence, and treatment rates

Background Women entering jails are at high risk for sexually transmitted diseases; however, screening for chlamydial and gonococcal infection is not routinely performed in most jails. New urine tests have made it easier to screen for these infections in nonclinical settings. Goal The feasibility and acceptability of urine-based screening for women entering jails and the prevalence of and treatment rates for chlamydial and gonococcal infections were determined. Study Design Women entering jails in Chicago, Illinois; Birmingham, Alabama; and Baltimore, Maryland, who signed consent forms were tested for chlamydial and gonococcal infection by means of the urine ligase chain reaction assay. Those testing positive were treated in jail; health department staff members attempted to contact those already released. Results Most women who were approached agreed to be tested (range, 87–98%, depending on city), and most of these women provided a specimen (range, 92–100%). Among 5364 women aged 16 to 75 years who were tested, the prevalence of chlamydial and gonococcal infections was high, especially among those <25 years of age (range, 15.3–21.5% for chlamydial infection and 8.2–9.2% for gonorrhea, depending on city). The majority of women testing positive were treated in jail or outside of jail (61–85%). Conclusions Screening women in jails for chlamydial and gonococcal infection with urine tests is feasible, is acceptable to most women, and leads to detection and treatment of many infections. Routine screening should reduce medical complications in this population and should prevent transmission in the community, given that many women are soon released.

Gonorrhea in the United States, 1981-1996. Demographic and geographic trends.

Objective: To describe demographic and geographic trends in gonorrhea incidence in the United States from 1981 through 1996. Study Design: We analyzed aggregate gonorrhea cases reported to the Centers for Disease Control and Prevention by the 50 states, District of Columbia, and 63 large cities. Annual incidence rates (cases/100,000 persons) were calculated. Results: Between 1981 and 1996, the incidence of reported gonorrhea decreased 71.3%, from 431.5 to 124.0 cases/100,000. However, rates among blacks were 35 times higher than rates among whites in 1996 (684.6 versus 19.4) compared with 11 times higher in 1981 (1,894.3 versus 164.3). Among women of all races, 15 to 19 year olds had the highest rates (716.6 in 1996), whereas among men, 20 to 24 year olds had the highest rates (512.9 in 1996). Southern states had higher rates than other regions. Conclusions: Large segments of the population, including adolescents, young adults, and blacks, continue to have high rates of gonococcal infection; prevention programs and health care providers should address the needs of these groups.

A pilot study of the prevalence of chlamydial infection in a national household survey

Background: The prevalence of Chlamydia trachomatis genital infection in the United States population is unknown. Using a new urine test for C. trachomatis, we conducted a pilot survey as part of the National Health and Nutrition Examination Survey III (NHANES III). Goal: To determine whether the prevalence of chlamydial infection in a convenience sample of NHANES participants was high enough to justify testing for C. trachomatis in a national survey. Study Design: NHANES III, conducted from 1988 to 1994, was based on a stratified multistage probability sample of the United States population. Non‐Hispanic blacks and Mexican‐Americans were oversampled. Using the ligase chain reaction assay for C. trachomatis, we tested urine from participants 12 to 39 years of age from 10 of the 89 sites of NHANES III. The prevalence of infection was calculated by racial or ethnic group. Results: We tested 1,144 study participants, of whom 65% were female, 30% were non‐Hispanic blacks, and 30% were Mexican‐American. Prevalence was higher for non‐Hispanic blacks (7%) than for Mexican‐Americans (3%) and non‐Hispanic whites (2%). Prevalence was higher for women than men in non‐Hispanic blacks (7% vs. 6%), Mexican‐Americans (5% vs. 2%), and non‐Hispanic whites (2% vs. 1%). In 15‐ to 19‐year‐old women, prevalence was 13% in non‐Hispanic blacks, 11% in Mexican‐Americans, and 5% in non‐Hispanic whites. Conclusion: The prevalence of C. trachomatis genital infection was high enough to suggest that a reliable national prevalence estimate could be obtained in a national probability sample survey.

Maternal and congenital syphilis in Bolivia, 1996: prevalence and risk factors

OBJECTIVES The present study was carried out in seven maternity hospitals to determine the prevalence of maternal syphilis at the time of delivery and the associated risk factors, to conduct a pilot project of rapid syphilis testing in hospital laboratories, to assure the quality of syphilis testing, and to determine the rate of congenital syphilis in infants born to women with syphilis at the time of delivery--all of which would provide baseline data for a national prevention programme in Bolivia. METHODS All women delivering either live-born or stillborn infants in the seven participating hospitals in and around La Paz, El Alto, and Cochabamba between June and November 1996 were eligible for enrolment in the study. FINDINGS A total of 61 out of 1428 mothers (4.3%) of live-born infants and 11 out of 43 mothers (26%) of stillborn infants were found to have syphilis at delivery. Multivariate analysis showed that women with live-born infants who had less than secondary-level education, who did not watch television during the week before delivery (this was used as an indicator of socioeconomic status), who had a previous history of syphilis, or who had more than one partner during the pregnancy were at increased risk of syphilis. While 76% of the study population had received prenatal care, only 17% had syphilis testing carried out during the pregnancy; 91% of serum samples that were reactive to rapid plasma reagin (RPR) tests were also reactive to fluorescent treponemal antibody-absorption (FTA-ABS) testing. There was 96% agreement between the results from local hospital laboratories and national reference laboratories in their testing of RPR reactivity of serum samples. Congenital syphilis infection was confirmed by laboratory tests in 15% of 66 infants born to women with positive RPR and FTA-ABS testing. CONCLUSION These results indicate that a congenital syphilis prevention programme in Bolivia could substantially reduce adverse infant outcomes due to this disease.