2002 National STD Conference - Latebreaker Abstracts

Risk Factors for Neurosyphilis

CM Marra^1,2, CL Maxwell¹, SL Smith¹, SA Lukehart², AM Rompalo³, M Eaton⁴, BP Stoner⁵, DE Barker⁶, JJ Corbett⁷, M Augenbraun⁸, M Zajackowski⁹, C Raines³, J Nerad⁶, R Kee⁹, SH Barnett³

1Departments of Neurology and 2Medicine (Infectious Diseases), University of Washington School of Medicine, Seattle, WA; 3Department of Medicine, Johns Hopkins University, Baltimore, MD; 4Department of Medicine, Emory University, Atlanta, GA; 5Department of Medicine, Washington University, St. Louis, MO; 6Rush Medical College, Chicago, IL; 7Department of Neurology, University of Mississippi, Jackson, MS; 8Department of Medicine, SUNY-Downstate, Brooklyn, NY; 9Chicago Department of Health, Chicago, IL

Background: Treponema pallidum invades the central nervous system (CNS) early in infection. About 75% of patients clear CNS treponemes; those who do not are at risk for neurosyphils. It is difficult to predict which patients will progress to neurosyphilis.

Objective: Define clinical and laboratory features that identify patients with neurosyphilis.

Methods: Individuals with reactive serum treponemal and nontreponemal serological tests who had never been diagnosed or treated for neurosyphilis and who met the 1993 CDC guidelines for lumbar puncture underwent standardized medical history, neurological examination, venipuncture and lumbar puncture. Neurosyphilis was defined as CSF WBC count > 20 cells/uL or a reactive CSF-VDRL.

Results: Forty-three (18.0%) of 239 subjects had neurosyphilis. Neurosyphilis was not associated with syphilis stage, but was more common with serum RPR titer ≥1:32, even after controlling for HIV-1 status and stage of syphilis (P=0.002). Among HIV-1-infected subjects, taking into account serum RPR titer ≥ 1:32 and syphilis stage, neurosyphilis was more common with peripheral blood CD4 cell count ≤350 cells/uL (P=0.03). T. pallidum was identified in 14 CSF samples by reverse transcriptase polymerase chain reaction (RT-PCR). Serum RPR titer ≥ 1:32 and reactive CSF-VDRL were significantly more common (P=0.00002 and P=0.0002), and CSF WBC count was significantly higher (P=0.005) in RT-PCR-positive samples.

Conclusion: Serum RPR titer ≥ 1:32, regardless of stage or HIV-1 status, carries an increased risk of neurosyphilis. Among HIV-1-infected patients with syphilis, those with peripheral blood CD4 cell count ≤350 cells/uL are significantly more likely to have neurosyphilis.

Implications for Program/Policy: These results have direct relevance for the care of patients who are seen in STD clinics or in clinics where HIV-1 or syphilis is common.

Implications for Research: These finding support the contention that HIV-1-induced immune impairment may increase the risk of neurosyphilis. Further study of this issue is needed.

Measurable Learning Objectives: Participants will be able to discuss the clinical and laboratory features associated with neurosyphilis in patients with syphilis.

Factors Influencing the Acceptance of HSV 2 Antibody Testing Among Adolescents and Young Adults

KH Fife¹, W Tu¹, DI Bernstein², R Brady², F Biro², L Stanberry³, S.Rosenthal³, K Stone⁴, J Leichliter⁴, and GD Zimet¹

1Indiana University School of Medicine, Indianapolis, IN, 2Children’s Hospital Medical Center, Cincinnati, OH, 3University of Texas Medical Branch, Galveston, TX; 4Centers for Disease Control and Prevention, Atlanta, GA

Background: Recent availability of type-specific antibody tests for HSV 2 permits identification of individuals who are antibody positive, but have no symptoms of genital herpes. It is unclear who should undergo HSV 2 antibody testing and factors influencing test acceptance are unknown.

Objectives: To determine the factors associated with accepting or refusing HSV 2 antibody testing in adolescents and young adults.

Methods: Subjects attending an urban adolescent clinic, a large urban university, an urban STD clinic, and two urban/suburban primary care clinics were asked to complete a questionnaire regarding attitudes about STDs, personal sexual behavior, and attitudes about testing for genital herpes. The subjects were between the ages of 14 and 30 and had no history of genital herpes. After completing the questionnaire, subjects were offered free HSV 2 antibody testing and their acceptance or rejection of testing was noted.

Results: Complete information is available from 452 of the 520 subjects enrolled to date. HSV 2 testing was accepted by 272 subjects (60.2% acceptance rate). Factors that were positively associated with test acceptance included female gender (odds ratio (OR) 2.2), history of another STD (OR 7.4), perception of vulnerability (OR 1.2), and 2 or more of sex partners in the previous 6 months (OR 3.8). Only fear of needles (OR 0.92) was negatively associated with testing.

Conclusions: There is interest in HSV 2 antibody testing in a variety of clinical settings and the factors associated with acceptance of testing are the same as those that place the individual at risk of exposure to genital herpes.

Implications for Programs/Policy: If offered without charge, testing for HSV 2 antibody in clinical settings would be accepted by those at greatest risk.

Implications for Research: We will examine the impact of a positive HSV 2 antibody on a person without recognized genital herpes.

Learning Objective: by the end of the session, participants will be able to list at least two demographic or behavioral factors that are associated with acceptance of HSV 2 antibody testing and one factor that is associated with refusal of HSV 2 antibody testing.

Human Papillomavirus Infection Among Men Attending an STD Clinic

S Baldwin¹, S Redmond¹, D Wallace¹, M Papenfuss¹, M Abrahamsen¹, J Hallum², A Giuliano¹

1Arizona Cancer Center, University of Arizona, Tucson, AZ; 2HIV/STD Control Program, Pima County Health Department, Tucson, AZ

Background: HPV is the main etiologic agent of anogenital cancers including cervical cancer. Little is known about the prevalence and natural history of HPV in men.

Objectives: To identify prevalence of HPV and risk factors for infection among men attending an STD clinic.

Methods: Participants completed a questionnaire that assessed sociodemographic factors and sexual history. Following routine STD exam, clinicians collected a penile skin swab for HPV DNA analysis, which was conducted using PCR.

Results: Penile skin test results were available for 349 men, of which 31.8% were HPV positive. Of these, 12.6% had oncogenic type HPV, 13.8% had non-oncogenic HPV only, 10% tested positive for unknown types, and 6.6% had infection with multiple types. Prevalence was highest in men ages 18-24 (30.7%) and ages 40-70 (29.0%). In univariate analyses, HPV was significantly associated with Hispanic ethnicity, increased frequency of sexual intercourse, history of gonorrhea or genital warts, and diagnosis of genital warts at the clinic visit. HPV was inversely associated with education, circumcision, and 3 measures of condom use. Independent predictors of HPV detection were current genital warts and increased frequency of intercourse during the previous 3 months, while circumcision, sexual monogamy, use of condom at last anal intercourse, and no history of anal intercourse were protective against HPV.

Conclusions: HPV infection among high-risk men is common, but characteristics of male infection differ from what has been described in females. Analysis reveals a broad distribution of HPV types in men, and classic risk factors for HPV infection in women do not apply.

Implications for Programs/Policy: If risk factors for HPV in men are confirmed by other studies, public health efforts to stem the spread of HPV could include efforts to promote condom use and monogamy.

Implications for Research: More studies are needed.

Learning Objectives: By the end of this presentation, participants will understand the importance of studying HPV in men. They will be able to describe the prevalence and risk factors for HPV in the population studied.

The National Pharmaceutical Stockpile and the STD Prevention Program Professional – A National Security Relationship

DE Adcock and R Havlak

National Pharmaceutical Stockpile Program, Centers for Disease Control and Prevention

Background: The events of September 11, 2001, and the anthrax attacks of October and November, proved that the threat of international terrorism on U.S. soil is no longer an abstraction. The effects of this reality on public health, in general, and the STD Prevention Program professional, in particular, could be profound.

Objectives: In a terrorism event, the objective will be to save as many lives as possible and protect the health of U.S. citizens who come into harm’s way.

Methods: The CDC National Pharmaceutical Stockpile (NPS) is among the responses to a terrorism event, especially an attack using biological or chemical weapons.

Results: Effective management and use of life-saving NPS assets requires people from the affected area who can gather vital data from treating facilities, can help move medical materiel efficiently to multiple sites across the community, and can skillfully fill essential roles in possibly the largest and most complex mass treatment effort ever undertaken in their community.

Conclusions: STD Professionals, by virtue of their knowledge of area treating facilities and how to efficiently navigate their area, and their skills at filling multiple roles in post-exposure prophylaxis Distribution Sites, could make them valuable assets in several phases of the effective management and use of the NPS. Implications: It is prudent for STD Professionals to study and understand the possible roles they could play in the effective management and use of the NPS, a valuable national security resource should a terrorism event ever occur in their community.

Measurable Learning Objective: By the end of the presentation, and review of the handout material, participants will be able to identify components of the National Pharmaceutical Stockpile to which they might make a professional contribution should this National Security asset ever deploy locally due to a terrorist or other event threatening the lives and health of the citizenry.

Author Contact Information: David E. Adcock / Phone: 770-488-4564 / Email: dea1@cdc.gov,

Once is Not Enough: Re-Screening Sexually Transmitted Disease (STD) Clinic Patients in Six Months to Detect New, Unrecognized STDs

O. Bolu¹, C. Lindsey¹, T. Peterman¹, M. Kamb¹,G. Bolan², J. Zenilman³, J. Douglas⁴, K Malotte⁵, J. Rogers⁶, for the Project RESPECT study group.

1Division HIV/AIDS Prevention, CDC, Atlanta, Georgia; 2San Francisco Health Department; 3Baltimore City Health Department & Johns Hopkins University; 4Denver Public Health, Colorado Department of Health and Environment; 5Long Beach Health Department and California State University; 6New Jersey Health Department (Trenton) & Newark STD Clinic

Background: STD clinic clients are at risk for subsequent STDs, which may be unrecognized, untreated, and contribute to STD transmission. We investigated whether scheduled follow-up visits would help detect unrecognized STDs.

Objectives: Assess the importance of scheduling follow-up visits for STD clinic clients.

Methods: We analyzed data collected during a 1993—1996 5-city counseling trial for STD clinic clients. At baseline, 4328 participants were randomly assigned to return for scheduled 6-month (161-219 days after baseline) STD exam; 1430 were not scheduled. All participants could return anytime they had STD symptoms. To estimate STDs that would have been missed if clients were not scheduled for 6-month follow-up (unrecognized STDs), we subtracted new STDs in the unscheduled group (multiplied by 3.026 to adjust for group-size at baseline) from new STDs in the scheduled group. STDs diagnosed before the 6-month period were not counted. Similar calculations were done to identify predictors of unrecognized STDs.

Results: During scheduled clients the 6-month period, 2722 (63%) clients and 95 (7%) unscheduled returned. A total of 214 clients (202 scheduled, 12 unscheduled) had ≥1 new STD: 60% chlamydia, 27% gonorrhea, 8% chlamydia and gonorrhea, 4% syphilis, and 1% other. Thus, 202-(12x3.026)=166 scheduled clients who returned (6%) would not have had their STD diagnosed had they not been scheduled for follow-up. Unrecognized STDs were more common among clients with baseline STD (12%) vs. no baseline STD (4%) (P<0.00003), and age ≤25 years (8%) vs. >25 (5%) (P<0.001), but did not differ by gender. Unrecognized STDs among clients with baseline STD were lowest in Denver (6%), highest in San Francisco (11%) and Newark (18%).

Conclusions: Clients with baseline STDs should return for 6-month follow-up exam because many will have new, unrecognized infections. Implications for programs / policy: Schedule follow-up for clients with baseline STD. Implications for Research: Demonstration projects could evaluate infection rates for clients returning for follow-up.

Randomized Controlled Trial of HIV Counseling with Rapid and Standard HIV Testing (RESPECT-2)

Metcalf CA¹, Cross H², Dillon BA¹, Douglas JM Jr.³, Malotte CK⁴, Young PA⁵, Lindsey CA¹, Peterman TA¹

1Centers for Disease Control and Prevention; 2New Jersey Department of Health and Senior Services; 3Denver Public Health; 4California State University Long Beach; 5NOVA Research Company

Background: Project RESPECT found that HIV testing with 2 sessions of prevention counseling can prevent more STDs than HIV testing with information alone. In practice, many patients do not return for their HIV test result and 2nd counseling session. We compared rapid HIV testing with all counseling in one visit with standard HIV testing and 2 counseling sessions 1 week apart for efficacy at preventing STDs.

Methods: Consenting STD clinic patients in 3 US cities were randomized to receive either a rapid or standard HIV test. Participants were interviewed and screened for chlamydia, gonorrhea, and trichomoniasis at baseline and every 3 months for 1 year, and for HIV and syphilis at baseline and 12 months. We did an intention to treat analysis.

Results: 3,293 participants were enrolled and followed-up for 12 months. Data are pending for 14.2% of participants. Over 95% of the rapid test group received their test result compared to 67.7% of the standard test group. Preliminary data show 22% more new STDs in the rapid test group by the 6-month visit (12.6%) compared to the standard test group (10.3%) (relative risk [RR] 1.22; 95% confidence interval [CI] 1.01–1.48; p=0.04). By the 12-month visit, there were 12% more new STDs since baseline in the rapid test group (18.8%) compared to the standard test group (16.9%) (RR 1.12; CI 0.96–1.29; p=0.14).

Conclusion: More patients received their HIV test result using a rapid HIV test than a standard HIV test. Preliminary results indicate that the standard 2-visit counseling was associated with fewer new STDs. Differences in STD rates between groups decreased over time.

Implications for Programs: Return rate, and the relative importance of promoting knowledge of HIV status versus preventing STDs need to be considered in choosing HIV test type.

Implications for Research: Preliminary results need to be confirmed once data submission is complete.

Measurable Learning Objectives: By the end of this session participants will be able to discuss the relative advantages of using a standard HIV test or a rapid HIV test for counseling and testing in STD clinic settings