2002 National STD Conference - Oral, Symposium, and Workshop Abstracts - B

B1A - Increases in Sexually Transmitted Diseases among Men Who Have Sex with Men: A Need for New Prevention and Research Strategies

C McLean¹, S Blank^1,2, R Bronzan¹, G DeSimone³, H Calvet⁴, C Ciesielski^1,5, K Mayer⁶

1Centers for Disease Control and Prevention, Atlanta, GA; 2New York City Department of Health; 3Whitman Walker Clinic, Washington D.C.; 4Long Beach Department of Health and Human Services, Long Beach, CA; 5Chicago Department of Public Health, Chicago, IL; 6Fenway Community Health Center, Boston, MA, Brown University, Providence, RI, and Miriam Hospital, Providence, RI.

Background: Recent reports from outbreak investigations and behavioral surveys suggest a decline in safer sex practices among men who have sex with men (MSM). Some MSM are participating in high-risk sexual behaviors that place them at increased risk for sexually transmitted diseases (STDs) and HIV infection. While primary and secondary syphilis rates have declined almost 90% in the last decade, large outbreaks of syphilis have occurred in several U.S. cities among MSM.

Objective: To examine recent patterns and discuss programmatic issues involved in increases in STD infection and sexual risk behaviors among MSM in multiple U.S. cities and to discuss implications for future prevention and research efforts.

Content: Epidemiologic data from and descriptions of programmatic responses to recent investigations of increases in syphilis in Los Angeles, New York City, and Miami will be discussed. Additionally, results will be presented from centers in Long Beach, Washington D.C., Boston, and Chicago, participating in the Monitoring Trends in Prevalence of STDs, Tuberculosis, and HIV Risk Behaviors among MSM Project. Analyses will describe rates of STDs among both HIV infected and uninfected MSM, review trends over time, and also examine risk behaviors in these populations.

Implications for Programs/Policy: Interventions are necessary that address rising rates of STDs, and perhaps HIV, among MSM. Continued monitoring of STDs among MSM across the U.S. is critical for evaluating trends in sexual practices as well as the impact of prevention efforts.

Implications for Research: Findings from these populations highlight the need for further research on the determinants and dynamics of risk-behavior among MSM.

Learning Objectives:

By the end of this session, participants will be able

1) To describe the epidemiology of recent STD increases among MSM

2) To understand the implications of high STD morbidity among MSM for STD and HIV programs. 3) To understand programmatic approaches utilized to address these recent increases

Contact information: Catherine McLean / Phone 404-639-8467 / cvm9@cdc.gov

B1B - Sexually Transmitted Diseases, HIV Testing, and HIV Risk Behaviors Among Men Who Have Sex with Men Seeking Care at Howard Brown Health Center

CA Ciesielski^1,2, J Flynn³, C McLean²

1Chicago Department of Public Health, Chicago, IL; 2Centers for Disease Control and Prevention, Atlanta, GA; 3Howard Brown Health Center, Chicago, IL

Background: There has been a resurgence of gonorrhea (GC) and syphilis among men who have sex with men (MSM), as well as decreasing use of condoms during receptive anal intercourse (RAI).

Objectives: To prospectively monitor the prevalence of STDs, HIV, and risk behaviors in MSM clients of Howard Brown Health Center (HBHC).

Methods: Medical charts were abstracted for all MSM who attended HBHC’s primary care and STD clinics (including bathhouse screening) between 1/1/00 and 12/31/00.

Results: Included in the analysis were 1,283 MSM. Sixty-four (10%) of 653 men tested were infected with CT, 108 (17%) of 622 had GC, and 15 (2%) of 644 had infectious syphilis. Comparing MSM with and without STDs, 39% vs 26%, respectively, reported RAI in the past 60 days, and 20% vs 13% reported sex in bathhouses (p<.05). Of those reporting RAI, 40% vs 54% reported always using condoms; 49% vs 20% sometimes did, and 25% vs 26% reported never using condoms (p=.03). While 74% of MSM with STDs had been HIV tested, only 31% of those without STDs had been (p<.001). Of those with STDs, 16% of those tested were HIV infected, compared to 19% of MSM without STDs (p>.05). However, of those with syphilis, 40% were HIV infected.

Conclusion: These data identify a relatively high prevalence of STDs among the MSM presenting for medical care and STD screening. Of particular concern is the HIV prevalence among those with STDs, indicating recent unsafe sexual activities among these men.

Implications for Programs: Continued monitoring of STDs and high risk behaviors among MSM is critical to evaluate trends in sexual practices and the impact of prevention efforts in this high risk population in Chicago.

Implications for Research: These data highlight the urgent need for behavioral studies to identify more effective prevention methods for MSM.

Learning Objectives:

1) To identify the extent of the STD morbidity among MSM clients of Howard Brown Health Center

2) To understand the implications of high STD morbidity among MSM for STD program 3) To recognize the research implications of high STD morbidity among MSM

B1C - Patterns of STD Infection, HIV Coinfection, and Risk-Behavior Among MSM at a Boston Community Health Center

SA Golub¹, K Mayer^{1, 2, 3}, W Lo¹, D Cohen¹

1Fenway Community Health, Boston, MA; 2Brown University, Providence, RI; 3Miriam Hospital, Providence, RI

Background: Several recent reports have documented alarming increases in sexually transmitted infection rates among men who have sex with men (MSM), and a corresponding decline in safer sex practices. After years of successful prevention efforts, this trend may portend a resurgence of HIV infection in the MSM community. Fenway Community Health is a freestanding clinic that follows the largest population of MSM in Boston, and provides primary care to more than 1,000 people living with HIV.

Objectives: To examine recent patterns of STD infection, STD/HIV co-infection, and sexual risk-taking behavior among a group of MSM diagnosed with syphilis or gonorrhea in a Boston community health center.

Methods: A retrospective chart review was conducted, including all MSM who tested positive for gonorrhea, syphilis, or chlamydia in 1999 and 2000. Four types of variables were extracted: 1) demographics; 2) visit variables; 3) clinical variables; and 4) behavioral variables. Analyses included univariate descriptives and both bivariate and multivariate comparisons.

Results: Gonorrhea rates have tripled to more than 100 cases per year, since the mid 1980s. The twelve cases of syphilis diagnosed last year are the largest number in over a decade. Analyses revealed differences in demographic patterns by type of STD and infection site. For example, over 75% of new syphilis cases occurred among MSM ages 30–39, while both rectal and pharyngeal gonorrhea were most common among MSM under 30. Analyses also revealed important findings in patterns of sexual behavior; for example, 21% reported that they were infected through contact with their regular sexual partner. Finally, at least 20% of STD cases occurred among HIV-positive individuals.

Conclusions: Gonorrhea and syphilis have significantly increased in recent years at Fenway Community Health. Different patterns of STD infection and risk behavior are occurring among MSM of different age groups and among HIV-positive and negative populations.

Implications for Programs/Policy: Additional interventions are needed to address rising rates of STD infection in the MSM community.

Implications for Research: This study points to the need for further research on the determinants and dynamics of risk-behavior among MSM.

Learning Objectives: By the end of this session, participants will be able to describe key findings from this analysis, and explain demographic and behavioral dynamics that are potentially important to future prevention efforts in the MSM community.

B2 - How Community, Corrections, Neighboring Jurisdictions, and Surveillance Have Worked Together to Contain an Outbreak of Syphilis in Baltimore City

J Michaud^1,2, S Johnson^1,2, K Robinson^1,2, S Tulloch³, E Reams¹, G Olthoff¹, R Vogel¹, G Baker¹, J Leber⁴, J Ellen²

1Baltimore City Health Department, Baltimore, MD; 2Johns Hopkins University School of Medicine, Baltimore MD; 3Maryland State Department of Health and Mental Hygiene, Baltimore MD; 4Anne Arundel County Department of Health, Anne Arundel County, MD

Background and Rationale: Following guidelines and recommendations developed by the Centers for Disease Control and Prevention (CDC), the Baltimore City Health Department (BCHD) developed a Syphilis Elimination Plan (SEP) in 1999 in collaboration with members of the community and other local agencies. BCHD has subsequently developed an integrated approach to syphilis elimination that includes: an expanded surveillance system based on the location syphilis cases report meeting their sex partners, collaborative efforts with community based organizations (CBOs) and community health centers (CHCs), and close coordination with nearby jurisdictions and the corrections system.

Objectives: To present Baltimore City’s SEP as a model for an integrated approach to syphilis elimination in an urban high morbidity area that includes a data-driven research base, expanded surveillance, corrections, and community participation. The application of this approach to an actual outbreak of syphilis will be presented.

Content: Presenters will summarize the research base supporting the importance of “risk space” in syphilis intervention efforts, and present geographic and risk data collected through expanded surveillance and will also explain how the data were used to identify an outbreak of syphilis in Baltimore. The important roles of CBOs, CHCs, and corrections to the outbreak response will be discussed, and results of the successful rapid-response outreach and screening effort will be presented.

Implications for Programs: This presentation will demonstrate how a local STD program successfully integrated an expanded surveillance system, community groups, and correction in controlling a local syphilis outbreak. A similar integrated approach may make a significant impact on other programs’ ability to reduce syphilis morbidity toward the ultimate goal of elimination.

Implications for Research: Future research and evaluation projects must monitor the success of the geographic risk space data driven approach and its utility for public health STD interventions. Further strategies for including the community in STD control efforts, especially syphilis elimination, should be explored.

Learning Objectives:

1. Participants will be able to describe how to integrate the efforts the community, corrections, and surrounding jurisdictions into a health department’s syphilis elimination effort 2. Participants will be able to outline the usefulness of collecting information about geographic risk space and how it can be a key determinant for the syphilis rapid-response effort.

B3A - Core Concepts for Hepatitis Education

L Gilbert, K Ford, D Bergmire-Sweat

American Social Health Association (ASHA)

Background: Viral hepatitis prevention messages are confusing because of viral type, natural history, transmission and sequelae differences. Further, content standards do not exist and, although many educational materials exist, few have been evaluated.

Objectives: This study was designed to develop consensus “core concepts” (essential topics for hepatitis educational materials) from recognized experts; to develop data collection and scoring tools; to collect and rate educational materials; and, to identify concepts most often excluded from educational materials.

Methods: Using the Delphi Technique, 26 experts were asked to identify ten essential concepts for patients and for providers and then to rank order them. Concepts scoring higher than the median were retained. From these, a scoring tool and scale were developed and used to rate the comprehensiveness of educational materials. Further analysis revealed which concepts were most often included and excluded from materials.

Results: Eleven experts recommended 97 and 100 core concepts for providers and patients, respectively. These were collapsed into four categories: epidemiology, vaccine, and clinical management and health behavior/health education issues. Second round rankings (n=12) were averaged to determine consensus scores. 87 final core concepts were used to rate over 400 hepatitis brochures, fact sheets, Web sites, and videos; scores ranged from 0 to 70%.

Conclusions: Confusing, complex information can be simplified to include essential concepts. Most existing materials excluded many of the core concepts. Few materials existed for providers.

Implications for Programs: Results provide guidelines for designing, tailoring and evaluating comprehensive hepatitis educational messages.

Implications for Research: Methods were effective in gathering consensus core concepts and rating materials. What is needed is replication with patient and provider samples. Combining all recommendations will yield a standard from which hepatitis materials can be developed and/or evaluated.

Learning Objectives:

At the end of this session, participants will be able to: 1. Understand how the Delphi Technique can be used to achieve consensus opinion among experts, 2. Describe how core concepts were developed, 3. Describe how hepatitis educational materials were rated, and, 4. Identify concepts frequently missing from hepatitis A, B and C educational materials for patients.

Contact Information: Lisa Gilbert / Phone 919-361-4809 / lisgil@ashastd.org

B3B - Hepatitis B Screening and Vaccine Referral Program in an STD Clinic

J Subiadur, J Landrigan, F Judson, M Bedell, J Douglas

Denver Public Health, Denver, CO

Background: A well-coordinated approach to prevention of hepatitis B virus (HBV) infection among young adults has not yet been developed in the U.S.

Objectives: To evaluate HBV acceptance and completion of free immunization in an STD clinic.

Methods: Clinicians were asked to complete a screening form regarding past experience with and current interest in HBV immunization. Patients eligible for free immunization (gay/bisexual men, injection drug users, and high risk heterosexuals) were referred to the adjacent Immunization Clinic. From 8/99–7/00, clients were reminded to return for subsequent doses via letter or telephone. Subsequently, there was no active reminder system.

Results: From 8/99–4/01, of 12,694 eligible persons visiting the STD clinic, 5519 (43%) were screened; of these, 1517 (27%) had been previously vaccinated. Of the remaining 4002, 1545 (39%) declined, 1294 (32%) agreed but never presented for vaccine, and 1163 (29%) received a first dose. Overall, 446/1163 (38%) clients received a second dose within 60 days of the first dose. Through 11/01, of the 937 receiving their first dose <12 months earlier (e.g. before 11/00), 257 (27%) clients completed the 3-dose immunization series. In bivariate analysis, factors associated with return for second doses included older age (<25: 28%, >25: 44%, p<.001), ethnicity (non-Hispanic white: 42%, non-white: 34%, p<.01), and reminders (present 45%, absent 30%). In a multivariate model, reminder system (OR = 2.0, 95% CI: 1.5–2.6, p<.001), white race (OR = 1.5; 95% CI: 1.1–2.1, p<.05) and age (OR = 1.04 for each year of age; 95% CI: 1.02–1.06, p<.0001) were each independently associated with higher return rates.

Conclusions: Approximately 30% of persons offered free HBV vaccine will present to an adjacent clinic for a first dose. Follow up with subsequent doses varies by demographic factors and can be influenced by simple reminder systems.

Implications for Programs: Offering hepatitis B vaccination as part of routine STD clinic visits is an effective way to vaccinate high risk persons.

Implications for Research: Studies on methods to improve compliance with follow up doses are warranted.

Learning Objectives: The participant will understand how the Denver Public Health STD clinic began screening for interest in HBV vaccination and implemented a vaccination program.

Contact Information: Julie Subiadur, RN / Phone 303-436-7183 / jsubiado@dhha.org

B3C - Investigation of a Cluster of Acute Hepatitis C Virus (HCV) Infections in Injecting Drug Users (IDU), Minnesota, 2001

L Mercedes¹, T Heymans², J Saavedra², J Martimo³, C Hooker⁴

1Immunization, Tuberculosis and International Health Section, Minnesota Department of Health, Minneapolis, MN; 2STD & HIV Section, Minnesota Department of Health, Minneapolis, MN; 3St. Louis County Public Health Department, Duluth, MN; 4Hennepin County Community Health Department, Hopkins, MN

Background: Diagnosis of acute HCV infection is challenging because it is rarely symptomatic; conversely, chronically infected persons can exhibit symptoms. For acute HCV cases reported to the Minnesota Department of Health (MDH), IDU is the most commonly identified risk factor. In April 2001, 3 cases of HCV infection were reported to MDH by a plasma center in northeastern Minnesota. These cases were donors £31 years of age who had recently documented asymptomatic seroconversions; they later developed symptoms. In June, a Twin Cities local health department (LHD) reported 2 symptomatic acute HCV cases; both cases were IDUs with potential connection to northeastern Minnesota. In July, a tribal health clinic reported a symptomatic acute HCV case in an IDU residing on an Indian reservation in northern Minnesota. MDH hepatitis surveillance staff reviewed the HCV database and identified additional cases for further investigation, based on possible demographic links to this cluster.

Objectives: To interview cases for needle-sharing and sexual partner services, find links between cases, make referrals for hepatitis A and B testing and vaccination, and provide education.

Methods: MDH disease intervention specialists and LHD staff employed discreet field investigation tactics to locate cases and conduct interviews.

Results: Seven of 8 confirmed acute HCV cases admitted to initiating IDU with needle sharing in the previous year; 5 were interviewed. Two plasma donors were sexual partners. Six partner relationships and 25 suspects were identified. Cluster interviews identified a social network of needle-sharing and sex partners residing on a reservation, 6 of whom were previously reported to MDH as HCV infected.

Conclusions: Hepatitis intervention and prevention services can be provided to high-risk and hard-to-reach HCV cases to identify pockets of need.

Implications for Programs/Policy: Combining existing surveillance, immunization and HIV/STD program resources for viral hepatitis interventions can be effective.

Implications for Research: Continue to locate additional IDU clusters for co-infection intervention/prevention studies.

Learning Objectives: By the end of this session, participants will be able to identify key factors for incorporating HCV in routine STD/HIV case investigation.

Contact Information: tim.heymans@health.state.mn.us and jessie.saavedra@health.state.mn.us

B3D - HPV Infection and Abnormal Cytology in a High Risk Adolescent Population

EH Koumans¹, TA Tarkowski¹, MK Sawyer², A Pierce¹, CM Black¹, J Papp¹, LE Markowitz¹, ER Unger¹

1Centers for Disease Control and Prevention, Public Health Service, US Department of Health and Human Services, Atlanta, GA; 2Emory University, Atlanta, GA

Background: Susceptibility to HPV and its complications, such as cervical dysplasia, may be increased when initial exposure occurs at a young age.

Objective: To determine prevalence of abnormal cytology and HPV, and risk factors for HPV in adolescents.

Methods: Sexually active adolescent females (12–19 years) attending a primary care clinic were enrolled. Behavioral data were obtained by interviews. Exfoliated cervical cells were collected and placed in PreservCyt media for ThinPrep^TM Pap test (Cytyc Corp). Material remaining was tested for HPV using PCR and typed using a reverse line blot assay (Roche Diagnostics).

Results: The study population (n = 313) was predominantly African American (96%), median age 16.9 years (range, 12.8-19.9), with recent onset of sexual activity (2.3 median years). The median number of sex partners was 4 (range 1–50) with maximum age difference of partners ranging from 1–43 years (median 3). Overall, 20% had ASCUS, 15% LSIL, and 1% HSIL. HPV prevalence was 64% (201). Among those with HPV, 101 (50%) had multiple types (range 2-7 types). Adolescents with abnormal cytology had higher prevalence of HPV (54.4% in normal, 66.7% in ASCUS and 91% in LSIL, p=0.001) and higher prevalence of multiple types (41% in normal, 45% in ASCUS, 74% in LSIL, p=.002). HPV was associated with marijuana use, current douching, sex abuse, greater number of sex partners, greater years of sexual activity, and age difference of sex partner. In multivariate analyses, number of sex partners (2–3, OR = 2.9 [95% CI: 1.4–6.2]; 4–7, OR = 4.1 [95% CI: 2.0-8.7]; > 8, OR = 6.5 [95% CI: 2.6-16]), current douching (OR = 2.2 [1.3–3.8]), and age difference of partner(s) (>1.5 yrs OR = 2.2 [1.3–3.7]) remained significantly associated with HPV.

Conclusions: HPV infection, infection with multiple types, and abnormal cytology were common in this population. In addition to previously described risk factors, douching was a significant risk factor for HPV.

Implications for Programs: Understanding of HPV epidemiology will be important for programs as HPV prevention interventions develop.

Implications for Research: Prospective follow-up of this population is needed to evaluate factors associated with HPV incidence and persistence.

Learning Objectives: By the end of the session, participants should be able to describe risk factors for BV and the association of BV with other STD.

B3E - Impact of Knowledge of Herpes Simplex Virus Type II Serostatus on STD Clinic Patients

K Kroeger¹, R Knaup², M Williams², B Stoner¹

1Washington University School of Medicine, St. Louis, MO; 2Department of Health, St. Louis County, MO

Background: This survey examined patient reactions to a positive serological test for HSV-2.

Objective: To assess the psychosocial and behavioral impact of serological screening for herpes on patients who test positive.

Methods: Five hundred consecutive STD clinic patients received serological screening for HSV-2 antibodies. Patients who tested positive were contacted a few weeks after receiving test results and asked to participate in a survey of how people feel about their diagnosis. Forty-three patients agreed to participate in a 15-minute telephone interview. No incentives were paid.

Results: Patients felt surprise (90.7%), disbelief (60.5%), fear of rejection (69.7%) and worry about infecting someone else (81.4%). Most people (74.4%) did not recall prior symptoms; but all (100.0%) agreed it was important to know they had herpes. More respondents agreed it would be difficult to tell a new partner they had herpes (68.8%) than a current partner (32.6%). Most people (86.0%) agreed they would use condoms more often; 37.3% would likely use condoms to protect partners but not disclose they had herpes. Almost half (44.2%) would likely tell a friend about their diagnosis; but only 37.2% would tell a parent, a family member (27.9%); or attend a support group (23.3%).

Conclusions: Patients want to know if they have herpes but there are significant psychological and behavioral issues associated with receiving a diagnosis through routine serological screening. Patients may feel disbelief and lack emotional support. Those who use condoms but do not disclose may believe they are preventing transmission of HSV-2 when this is not necessarily the case.

Implications for Programs: Patients who undergo routine screening for herpes should receive pre and post test counseling. Program managers must weigh the costs/benefits of implementing routine screening because counseling issues are complex and labor-intensive.

Implications for Research: Research is needed to develop appropriate counseling and educational messages and to assess costs/benefits of implementing routine HSV-2 screening in resource poor settings.

Contact Information: Karen Kroeger / kkroeger@im.wustl.edu

B3F - Testing Asymptomatic Individuals for Herpes Simplex Virus Type 2: Psychosocial Implications

KR Turner, CK Kent, T Miyai, JD Klausner

STD Prevention and Control Services, San Francisco Department of Public Health, San Francisco, CA

Background: Eighty percent of persons infected with herpes simplex virus type 2 (HSV-2) are unaware of their infection. There is concern that diagnosing previously unrecognized HSV-2 infection will result in psychosocial distress.

Objectives: To assess the psychosocial impact of a positive HSV-2 diagnosis among asymptomatic individuals attending a municipal sexually transmitted disease clinic in San Francisco.

Methods: Participants without a history of genital herpes were tested for HSV-2 and completed baseline and two follow-up interviews. A modified mental health inventory and sexual self-concept questionnaire assessed psychosocial distress. We examined changes in psychosocial scores among seropositives and seronegatives over time. At the first follow-up interview a herpes quality of life (HQoL) instrument was administered in seropositives only.

Results: We enrolled 201 individuals: 83% were male, 60% were white, 38% were men who have sex with men, and the median age was 32 years. HSV-2 results were available for 165 individuals; 34 (21%) were infected with HSV-2, and 142 (86%) completed their first follow-up interview. There were no significant changes in mental health scores from baseline to first follow-up interview in seropositive or seronegative persons. At the first follow-up interview, HSV-2 seropositives had slightly more negative attitudes towards sex than seronegatives (p<.06). Seropositives thought genital herpes was less traumatic at the first follow-up interview than they did at baseline (p<.01). Seventy-eight percent of seropositives scored in the top quartile on the HQoL instrument, indicating good quality of life.

Conclusions: Testing persons for HSV-2 infection who have no history of genital herpes does not appear to cause substantial short-term psychosocial morbidity.

Implications for Programs/Policy: The psychosocial impact of a serologic HSV-2 diagnosis may not be a barrier to implementing HSV-2 testing.

Implications for Research: Additional studies are needed to further explore psychosocial issues and serologic herpes testing.

Learning Objectives: Participants will be able to describe the psychosocial impact of a positive HSV-2 diagnosis among persons with previously unrecognized genital herpes infection.

B4 - HIV/AIDS and STD Prevention Among Migrant Farmworkers and their Families: A Replicable Model

M González

The Farmworker Justice Fund, Inc.

Background: It is estimated that there are approximately 4.8 million farmworkers in the United States. In addition, the Commission to Prevent Infant Mortality estimates the rate of infection among farmworkers to be 10 times higher than the national average, as well as high incidences of STDs. These rates can be contributed in large part to the lack of information that exists among this population, especially that which is culturally and linguistically appropriate.

Purpose: Educate migrant and seasonal farmworker communities with reference to HIV/AIDS) and other Sexually Transmitted Diseases and promote early detection, early treatment.

Method: This session will present the use of promotores de salud (lay health workers) to educate their families and peers in a culturally and linguistically appropriate manner. Using 120 men, women, and youth in six US-Mexico border communities to provide peer education we will demonstrate methods used by promotores to reach their intended population (over 20,000); describe collaborative efforts with other health service providers, strategies used to make others aware of importance of programs such as this and discuss barriers.

Learning Objectives: By the end of this session participants will be able to comprehend working/living condition of migrant and seasonal farmworkers, enabling them to list how these affect their risk of HIV/AIDS, STDs. They should also be able to offer some insight as to how to better their lack of health services. Participants will be informed of collaborative efforts between promotores and other health service providers, serving to bridge the cultural gap that many times exist between public health providers and the farmworker community.

Contact Information: Myrtelina González / Phone 202-776-1757 / mgonzalez@nclr.org

B5A - Early Incident STI in Adolescent Women

B Van Der Pol, BE Batteiger, DP Orr, JD Fortenberry

Indiana University School of Medicine, Indianapolis, Indiana

Background: Screening of young women for chlamydial (CT) infection is driven by HEDIS requirements, while none exist for gonorrhoeae (GC) or trichomonas (TV).

Objective: To learn about the incidence and course of these infections in adolescent women.

Methods: Young women enrolled in a 27-month study of sexual behaviors provided weekly self-obtained vaginal samples and daily dairies during up to five 12-week collection periods. Before and after the weekly field sampling, women had a clinic-based exam. Testing was by PCR, and all infections were treated in clinic before and/or after collection periods. Incident infection was any positive test during a 12-week period if the initial clinic visit was negative.

Results: From 102 subjects with 196 collection periods, 67 episodes (27 CT, 9 TV, and 31 GC) were identified. More GC (12; 38.7%) than CT (5; 14.8%) or TV (0) were identified from only one weekly sample (p<.05). Two CT and 1 GC episodes (4% of all episodes) occurred among subjects with no reported sex during the period. Of the remaining 64 episodes, 27 (42.2%) were also detected at follow-up: 17/25 CT (68%), 5/9 TV (55.6%) and 7/30 GC (23.3%).

Conclusions: Incident infections are common in this cohort. Some CT & GC episodes consisted of a single positive sample. Screening following the 12-week period identified only 23–68% of infected subjects.

Implications for Programs/Policy: Many incident infections were not detected at follow-up. Some may represent intermittent shedding, self-limited infection or exposure without active infection; nevertheless, the number of incident infections in the US may be severely underestimated.

Implications for Research: There is a need for improved diagnostic tools and development of cues for health-seeking behaviors to facilitate more effective screening. The significance of positive tests at a single sampling period needs further investigation.

Learning Objectives: By the end of this session participants will be able to discuss the occurrence of incident STI in urban adolescent women

B5B - Gonorrhea Drips on in California

MC Samuel¹, V Loo¹, D Gilson¹, D Kodagoda², S Coulter¹, G Bolan¹

1California Department of Health Services, Sexually Transmitted Disease Control Branch, Berkeley, CA; 2Los Angeles Department of Health Services, Sexually Transmitted Disease Program

Background: Gonorrhea (GC) is the second most frequently reported sexually transmitted disease in California and in the United States. It is a serious public health problem and is an indicator of the occurrence of behaviors that are risk factors for other STDs, including HIV. Increases in GC have recently been noted throughout the world, including in the United States.

Objectives: To describe the epidemiology of GC in California, with emphasis on increases in observed cases.

Methods: Data are from California’s case-based STD surveillance system. Trends in GC by time period, age, gender, and race/ethnicity were assessed using descriptive statistics and graphical methods.

Results: From 1980 through 1999, GC cases decreased 91%, from 574.1 to 54.8 per 100,000 population. The rate increased in 2000 to 62.7, and continued to rise in 2001. In the first half of 2001, 11,632 cases were reported, up 33% from the 8,773 reported in the same period in 1999. Comparing these time periods, increases in GC were seen in both men (39% increase) and women (26%); in all racial/ethnic categories; in all age groups; and in 78% (32 of 41) of California’s health jurisdictions that reported >2 cases in 2001. Of these jurisdictions, 59% reported increases in male cases and 71% in female cases. The increase in GC was directly correlated with age, with the lowest increase in the <20 year-old age group (23%) and the largest increase in the 40+ age group (48%). While African Americans have the highest rate of GC in California, they experienced a lower increase (14%) than any other group. Los Angeles, which accounted for 41% of the reported cases in 2001, experienced increases in all demographic categories, including a 67% increase in male cases and a 45% increase in female cases.

Conclusions: GC is increasing in California in all demographic categories. Particularly large increases are seen in the oldest age groups and in men. Enhanced surveillance and screening is required to determine key factors responsible for this increase.

Implications for Programs/Policy: Renewed attention to gonorrhea control is required because of the increases in cases observed in California, the United States, and elsewhere. Focused efforts, targeting groups with the highest rates and largest increases are needed.

Implications for Research: Enhanced surveillance is needed to determine the associations of specific behavioral, laboratory, and other factors with the observed increase in gonorrhea. This activity was recently initiated in California and is needed in other areas.

Learning Objectives: By the end of this session, participants will be able to describe the epidemiology of gonorrhea in California, and highlight the groups where the increase in gonorrhea is greatest.

B5C - Comparing HIV and Gonorrhea/Chlamydia Co-morbidity on a Mobile Van-Based Clinic

R Vogel¹, S Bonu², T Liang², M Ward³, JM Ellen²

1Baltimore City Health Department, Baltimore, MD; 2Johns Hopkins University School of Medicine, Baltimore, MD; 3AIDS Administration, Maryland Department of Health and Mental Hygiene, Baltimore, MD

Background: The Ujima Demonstration Project, funded by the CDC and implemented by Baltimore City Health Department, is a mobile van-based clinic providing HIV/STD services to at-risk clients in designated neighborhoods of Baltimore City.

Objectives: To determine the co-morbidity of HIV and gonorrhea/chlamydia infection in clients utilizing van-based HIV/STD services, and to assess program implications of co-morbidity.

Methods: Analysis was done of clients utilizing services on the mobile clinic between November 2000 and July 2001. Both bivariate and multivariate analyses were performed to determine the association between clients’ demographic and risk factors and HIV and gonorrhea/chlamydia test results.

Results: Among 686 clients tested for HIV and/or gonorrhea/chlamydia, 43 (6.85%) clients tested positive for HIV and 28 (5.6%) tested positive for gonorrhea and/or chlamydia. Only one client tested positive for both HIV and gonorrhea/chlamydia. Bivariate analysis revealed that HIV positive clients were more likely to be: older than 30 years (OR = 13.0, 95% CI: 1.8–95.1), MSM (OR = 8.9, 95% CI: 1.9–41.6), and IDUs (OR = 5.2, 95% CI: 2.6–10.1); and gonorrhea/chlamydia positive clients were more likely to report symptoms as reasons for visit (OR = 3.4, 95% CI: 1.4–8.1) and less likely to be older than 30 years (OR = 0.1, 95% CI: 0.06–0.3). Multivariate analysis demonstrated that HIV positive clients were more likely to be older than 30 years, MSM, IDUs; and gonorrhea/chlamydia positive clients less likely to be older than 30 years, MSM, and IDUs.

Conclusions: Low co-morbidity and differences in demographic and risk factors were noted in clients testing positive for HIV and gonorrhea/chlamydia with significant program implications.

Implications for Programs: Van-based mobile clinics catering to clients in areas with high prevalence of HIV related to IDU risk behavior may find low gonorrhea/chlamydia co-morbidity.

Implications for Research: Cost-effective analysis of van-based HIV/STD services in areas with different HIV epidemics—IDU, MSM, etc—may be a key determinant for more appropriate allocation of resources.

Learning Objectives: Participants will gain an understanding of determinants related to implementation of mobile van-based HIV/STD services, demographic and behavioral risk aspects of co-morbidity for HIV and gonorrhea/chlamydia, and program-related initiatives.

Contact Information: Sekhar Bonu / Phone 410-502-7623