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

C1 - Feasibility of STD Control for HIV Prevention: Findings from 3 Southern US Cities

R Barnes¹, T Farley², A Rompalo³, and P Leone⁴

1CDC, Atlanta, GA; 2 Department of Community Health Sciences, Tulane University School of Public Health and Tropical Medicine; 3Baltimore City Health Dept; 4North Carolina Dept of Health and Human Services, Raleigh, NC

Background: Enhanced STD diagnosis and treatment have been shown to reduce HIV incidence by 42% in Tanzania. In comparison with Africa, the value of STD control for HIV prevention in the US is uncertain because characteristics of populations affected by STD and HIV epidemics are different, quality of and access to STD and HIV care is better, and incidence and prevalence of STD and HIV are generally lower. In 1998, the CDC-funded demonstration projects to assess the feasibility of STD control for HIV prevention in 3 US cities with high STD and HIV prevalence (New Orleans, Baltimore, and Raleigh).

Objectives: Describe methods and findings of the demonstration projects. Discuss implications for STD programs, policies, and research.

Content: Following an overview of the project goals, investigators from each site will describe: methods used to assess gaps in STD control, identify populations co-infected with STD and HIV, and develop feasible STD control strategies to reduce HIV transmission in clinical and community settings; findings about gaps, prevalence of co-infection, and intervention feasibility; experiences in implementing STD screening interventions in these settings.

CDC and site investigators will then discuss site-specific and general implications of the findings for STD programs, policy, and research.

Implications for Programs: This research will inform decisions about the feasibility of introducing STD and HIV screening in clinical and community settings where screening has not routinely been provided and enhancing screening in settings where screening is provided.

Implications for Research: Future research should explore:feasibility of expanding screening interventions in clinical and community settings and introducing screening in settings where STD and HIV may be prevalent (jails, shelters); prioritization of screening for specific STDs most common in HIV-infected or at-risk populations; optimal frequency for STD screening and counseling for high-risk and HIV-infected persons.

Learning Objectives:

1. Participants will be able to describe factors influencing feasibility of STD control for HIV prevention in the US.

2. Participants will be able to describe challenges to implementing or enhancing STD and HIV screening in settings that do and do not usually offer STD/HIV screening.

C2A - The Impact of Prostitution and Drugs on a Rural Syphilis Outbreak

EM Foust¹, PA Leone², RM Ashby¹, AL Oxendine³, CG Jones¹, JM Owen-O’Dowd¹

1North Carolina Department of Health and Human Services, HIV/STD Prevention and Care Branch, Raleigh, NC; 2University of North Carolina, School of Medicine, Chapel Hill, NC; 3Robeson County Health Department, Syphilis Elimination Project, Lumberton, NC

Background and Rationale: Robeson County, North Carolina has been experiencing an increase in syphilis since 1996. By 2000, the infectious syphilis rate was highest of any HMA in the nation. During that time, the proportion of cases declined from 73.8% among African-Americans to 41.4%, while increasing among Native Americans from 12.3% to 36.1%. Robeson County reported 133 cases of early syphilis in 2000 and reported 95 early syphilis cases through August 2001. Prostitution and/or drug use can be related to as many as 50% of the early syphilis cases in the county.

Purpose: To examine the role that prostitution and drugs played in the rural syphilis outbreak and strategies that are working to bring this multicultural epidemic under control.

Methods: In this workshop, we will discuss the difficulties encountered in working with prostitutes in a rural area with limited healthcare resources. Presenters will discuss the unique characteristics of this epidemic, including prostitutes known as “chicken-heads”, small truck stops, crack cocaine usage and addiction and rural “drug houses”. Photographs and videotapes will be used to help participants better visualize and understand the issues affecting Robeson County. The various methods of outreach and awareness building used with this multicultural population, from faith initiatives to pow-wows to working with weekly newspapers will also be explored. Presenters will also discuss the intensive intervention, SMART RIOT (Syphilis Makes Awareness Robeson’s Target for the Rapid Intervention Outreach Team), that began in May 2001 with the Robeson County Health Department and community members to decrease syphilis and increase awareness. The SMART RIOT included two weekend community outreaches. Intensive RIOT activities included increased case finding activities, syphilis screening, additional community outreach and education. The Branch, local health department and community are developing a long-range plan to further reduce syphilis and will work together toward syphilis elimination.

Learning Objectives: At the end of the workshop, participants will be able to:

1. Describe techniques that can be used to intervene in rural syphilis outbreaks.

2. Describe techniques to work with rural prostitutes and drug users.

3. Identify differences between rural and urban outbreaks.

Contact Information: Evelyn Foust / Phone 919-733-7301 / evelyn.foust@ncmail.net

C2B - Syphilis and Prostitution: A View from the Stroll

NL Winterbauer

University of Illinois, Chicago, IL

Background: Chicago has one of the highest rates of primary and secondary (P&S) syphilis in the nation. At 9.5 cases per 100,000 population, Chicago’s 1999 P&S rates were well above the Year 2000 objective, and both the Illinois and national rates. Case review in one high morbidity area (HMA) conducted from January–August 1999 revealed a strong relationship between syphilis, commercial sex work (CSW), and drug addiction. Ethnographic research was conducted to better understand these relationships.

Objective: To describe the context of syphilis transmission among street-level prostitutes in two HMAs in Chicago, particularly with regard to barriers to STD prevention and care.

Methods: Semi-structured, qualitative interviews with 57 street-level female prostitutes were combined with key informant interviews, and interactive-observations along prostitution strolls.

Results: Barriers to syphilis prevention and care included drug addiction, a police presence on prostitution strolls, which potentially limited condom use, minimal health knowledge, and a public health focus on disease, rather than health promotion.

Conclusions: The most obvious barrier to the prevention and care of syphilis and other STDs among street-level prostitutes in this study was drug addiction. A disease-specific public health response is of limited value in this high-risk group, among whom a harm reduction model may be more appropriate.

Implications for Programs/Policy: Programs seeking to reduce the STD burden associated with prostitution should consider interventions that shift the public health focus from treatment to prevention at the individual and structural levels.

Implications for Research: Syphilis and other STDs are risks inherently associated with prostitution. Future research should consider the: 1) societal level forces that structure prostitution and consequent health threats; and 2) feasibility and efficacy of aggressive outreach and street-level well-woman clinics that target prostitutes.

Learning Objective: Understand the structural and individual level factors that contribute to syphilis transmission among street-level prostitutes in Chicago.

C2C - Integrating Syphilis Elimination Efforts via STD/HIV Outreach, Radio Outreach, and Crisis Response Teams

M Allen, V Hartwell, R Lewis-Hardy, Y Holiday, C Perez-Espinoza, E Cameron, A Lomax, A Troutman, D Daniels

Background: In 2000, Georgia had 393 cases of primary and secondary syphilis. Currently, Georgia is ranked 6th in the nation; however, Fulton County (Atlanta) accounts for more than 50% of the syphilis morbidity in the state. The national rate of infectious syphilis is 30 times higher for African Americans than for Caucasian Americans. The Latino community had an increase among males.

Objectives: (1) Provide accessible and timely client centered counseling, screening, and treatment services in high morbidity areas and potential re-emergence areas. (2) Provide free HIV and syphilis testing in conjunction with Radio One, the largest African American owned and operated broadcast company in the nation. (3) Collaborate with community based organizations in high morbidity areas to increase testing and provide education.

Methods: The Mobile Unit was used in areas of high syphilis incidence to provide education and intervention through screening and early detection. Radio One initiated Operation WAVE (the War Against the Virus is Escalating) a community outreach program, to increase HIV testing in African American communities by giving concert tickets as incentives for testing.

Results: To date (September 2001), approximately 250 people have been screened for Syphilis, HIV, and TB. From March 2001–September 2001, (8) people tested positive for HIV, (12) people tested positive for syphilis, and (8) had positive PPD tests.

Conclusions: Free testing in resource poor communities with high disease morbidity is essential to syphilis elimination efforts. Collaboration with non-health agencies; i.e., Radio One allows the community to receive the prevention message through public service announcements.

Implications for Programs/ Policy: Free screening in high morbidity areas should be a fundamental to community outreach programs.

Implications for Research: The outreach efforts in Georgia (Fulton County) could serve as a model for other syphilis elimination programs.

Learning Objectives: To demonstrate the use of strengthen community involvement and organizational partnerships in high morbidity areas and the Latino community.

C2D - Syphilis Elimination in South Carolina: Finding Local Solutions to Local Problems

C Wright, B Gaddist

South Carolina African American HIV/AIDS Council, Columbia, SC

Background: South Carolina currently ranks 5^th nationally in infectious syphilis. African Americans represented 17.1 cases compared to the national average of 2.6 cases per 100,000. In an effort to reduce the incidence of syphilis in South Carolina, the SC Department of Health and Environmental Control contracted the SC African American HIV/AIDS Council (SCAAHAC), a non-profit, 501(c)(3) organization, to explore ideas and strategies to involve communities to create “local solutions to local problems.”

Objective: To provide participants with a description of strategies and methods used to create local syphilis elimination coalitions within two rural counties in South Carolina.

Methods: Presenters will describe the coordination of the needs assessment using information from the CDC’s National Plan to Eliminate Syphilis. Using the methods of the Health Belief Model, local syphilis elimination coalitions were organized and included local citizens. Lancaster and Greenwood counties were ranked 1^st and 2^nd respectively for syphilis cases per 100,000 population in 1998. These coalitions were comprised mostly of local citizens who had no background in health.

Results: Two local syphilis elimination coalitions comprised of approximately 30 citizens from two counties in South Carolina were founded. These county coalitions completed community plans of action based upon local needs assessment data collected during the contract period, FY 2000. During FY 2001, these local syphilis elimination coalitions implemented their plans of action toward elimination of syphilis.

Conclusions: Community input in health care issues, even STD prevention, can prove beneficial for the entire community.

Implications for Programs: Organizing community coalitions can be beneficial to assist in STD/HIV prevention. Dissemination of STD/HIV/AIDS information, the development of culturally competent programs of intervention, and adoption of attitudes/beliefs that enhance community involvement must include models that promote true community partnerships.

Implications for Research: Future monitoring of cases and surveillance should determine the impact of syphilis elimination coalition activities. Strategies for integrating similar coalitions into high incidence counties should be explored.

Learning Objectives: Participants will be able to describe methods of organizing local citizens to become proactive in STD prevention.

Contact Information: Cynthia Wright / Phone 803-254-6644 / WAANYAA@aol.com

C2E - Use of Street Intercept Interviews to Assess Most “At-Risk” Population Recall of a Multimedia Syphilis Elimination Campaign

VA Caine¹, C Langley¹, A Goldsmith², DR Black³, J Arno¹, D DiOrio Rekas⁴, J Burks-Craig², DC Coster⁵

1Marion County Health Department and Indiana University School of Medicine, Indianapolis, IN; 2Marion County Health Department, Indianapolis, IN; 3Purdue University, West Lafayette, IN; 4Centers for Disease Control, Atlanta, GA and New Jersey STD Program, Trenton, NJ; 5Utah State University, Logan, UT

Background: In 1999, Marion County (Indianapolis) reported the highest number of syphilis cases in the nation. A community coalition, “Stamp Out Syphilis,” was formed to develop and implement a culturally sensitive public awareness campaign, including radio, television, print, outdoor, and public transit advertising. Focus groups were used to test and revise multimedia materials.

Objective: To determine the ability of those in Marion County’s four highest morbidity ZIP Codes to recall syphilis elimination information from the campaign.

Method: A street-intercept survey was conducted from May–November 2000 and randomly administered to 479 persons.

Results: There were 331 (69.1%) respondents who provided a spontaneous recall response about what they saw or heard related to syphilis. Significantly more respondents who heard or saw the multimedia campaign took action to get tested, treated, or to use condoms more often (n = 77, 23.37%) versus those who did not hear or see the intervention, but took action anyway (n = 6, 4.1%), c² (1, N = 479) = 26.34, p <.0001. The percentage who report taking action is 4.6–7.6 times greater than the standard 3-5% increase in sales reported in the literature for a successful marketing campaign.

Conclusions: The multimedia campaign appears to be associated with positive health behaviors to reduce

syphilis. The campaign seems effective for the most at-risk populations identified by a cluster map.

Implications for Programs/Policy: Multimedia campaigns should be considered as a viable public health strategy in addition to other conventional strategies used to motivate the public to take appropriate health actions to eliminate syphilis. It is important to identify the medium most effective for different respondents.

Implications for Research: More data are needed pertaining to the length of time to conduct a syphilis campaign and how often to change the content of the campaign.

Learning Objectives:

The audience will:

1) Identify the components of the multimedia syphilis elimination campaign.

2) Understand the measurement instrument and results.

3) Gain knowledge about how to design multimedia campaigns for the most “at-risk” populations.

C2F - Using E-mail as an Investigative Tool in Syphilis Case Management

M Bender, A Gerard, W Clothier, B Wills-Hooks, M Goldberg

City of Philadelphia, Department of Public Health, STD Control Program, Philadelphia, PA

Background: Philadelphia is experiencing a significant increase in primary and secondary (P&S) syphilis among men who have sex with men (MSM). Through September 15, 2001, MSM P&S cases increased 250% (+10 cases) when compared to the 4 cases reported during the same period in 2000. Through active provider referral case management activities, two cases identified anonymous sex partners met through Internet chat rooms who could only be contacted using an e-mail address.

Objective: To develop a protocol to use e-mail as an investigative tool.

Methods: The Philadelphia STD Program developed and implemented a protocol to notify sex partners of their exposure to syphilis when only their e-mail addresses were known. The Disease Intervention Specialist (DIS) staff interviewed patients to obtain all available locating information for their partners consistent with existing provider referral syphilis case management protocols. All DIS, clinical, and support staff were informed of DIS efforts to locate partners via Internet addresses to insure proper responses to calls when they telephoned in response to e-mail. E-mail letters sent to partners included carefully crafted subject lines to entice them to open it. An option was given to the partner to seek evaluation (and treatment) from their doctor.

Results: One investigation utilizing e-mail resulted in a 60% (3/5) response from partners, suspects, and associates; one partner was epidemiologically treated. A second investigation resulted in responses from 40% (2/5) of the suspects and associates identified through the Internet; both were not infected.

Conclusion: E-mail can be an effective investigative tool in syphilis case management.

Implication for Programs: Programs should implement protocols to pursue high-risk individuals through the Internet.

Implications for Research: Internet sites could be used as an assessment tool to collect behavioral data from individuals who visit adult websites. Data could be analyzed to improve the effectiveness of e-mail as an investigative tool.

Learning Objectives: Participants will be able to utilize the handout from the Philadelphia STD Control Program to develop and implement a protocol for their local program.

C3A - Distribution of Trichomonas vaginalis Infection in Females at High Risk for STI

B Van Der Pol¹, JA Williams¹, R Di Clemente²; JR Murphy³, L O’Donnell⁴; T Perrino³, D Pugatch⁶; Project SHIELD Collaborators²

1Indiana University School of Medicine, Indianapolis, IN; 2Emory University , Atlanta, GA; 3RTI, Int., Washington, DC; 4Education Development Center, Newton, MA; University of Miami, Miami, FL; 5Miriam Hospital, Brown University, Providence, RI; 6Center for Mental Health Services, Rockville, MD

Background: Trichomonas vaginalis (TV) has been implicated as a risk factor in the spread of HIV.

Objective: To better understand the epidemiology of infection with TV in women at high risk for acquisition of HIV.

Methods: Women enrolled in a longitudinal study carried out at 7 study sites, were tested at baseline for chlamydia (CT), gonorrhoeae (GC) and TV using PCR. Enrollment was based on high-risk behaviors. Inclusion criteria at adult oriented study sites included additional risk-taking behaviors beyond those required at sites targeting adolescents.

Results: A total of 693 subjects were tested from the adolescent population (POP-1) and 1039 from the adult population (POP-2). The mean ages were 19.3 and 35.4 from POP-1 & POP-2, respectively (P<.001). Although the majority of subjects in both populations were African American (AA), 54.5 and 57.7%, the overall racial distribution was different between the two study groups (P<.001). The prevalence of TV (7.5 and 24.1% in POP-1 and POP-2, respectively) and CT (12.4 and 5.3%) were also different between the 2 populations (both P<.001), but GC (2.3 & 2.2%) was not. Among both of the populations age, race, and CT infection were significant predictors of TV infection (all P<.03).

Conclusions: Rates of TV were high in the populations studied. When controlling for other STI (CT & GC) and race, risk for infection with TV increases with age in 2 different populations, both at high-risk for HIV acquisition.

Program/Policy Implications: Consideration should be given to age-variable risk factors, such as TV infection, when designing HIV intervention programs. Because of the high prevalence of TV in some women at risk for HIV, TV screening may be useful.

Research Implications: Further research into the epidemiology of TV and its potential role in the spread of HIV is needed. Surveillance of TV in high-risk populations may help identify additional risk factors which can be used to target interventions.

Learning Objectives: By the end of this session participants will be able to discuss the basic epidemiology of TV infection in women at high-risk for STI & HIV.

C3B - The Role of Mycoplasma genitalium in Nongonococcal Urethritis

DH Martin, L Mena, TF Mroczkowski, X Wang

Louisiana State University Health Sciences Center, New Orleans, LA and the City of New Orleans’ Delgado Clinic

Background: Mycoplasma genitalium (Mg) was first isolated from men with urethritis in 1983. However, difficulty in cultivating the organism inhibited evaluation of its true pathogenic potential and epidemiology until the recent development of PCR assays. Recent studies have provided data that more strongly link Mg to urethritis in men. We report here the results of our recent work with this organism in men with urethritis and in asymptomatic controls.

Objective: To determine the association of Mg with urethritis in New Orleans.

Methods: Men older than 16 years presenting to the New Orleans STD clinic with urethritis were enrolled. Urine and urethral swab specimens were obtained. Frozen urine specimens obtained from men previously enrolled in a study of asymptomatic urethral infections were used as controls. Chlamydia trachomatis (Ct) and Neiserria gonorrhoeae (Ng) were detected in urine using DNA amplification and Mg was detected following a published PCR protocol.

Results: Ninety-seven men with urethritis and 184 asymptomatic men were available for analysis. Demographically the two groups were similar. Infection rates for Mg in men negative for Ct and Ng were as follows: symptomatic 8/32 (25%) and asymptomatic 10/143 (7%) (P<.01) Co-infection rates of Mg among men with Ct and Ng urethritis were 35% and 14%, respectively. Symptomatic men with Mg resembled those with Ct in that both groups were younger than the Ng cases and were more likely to present with a milder form of urethritis.

Conclusions: Mycoplasma genitalium is independently associated with NGU in New Orleans though there is a high co-infection rate between Ct and Mg. Clinically Mg and Ct urethritis present similarly.

Implications for Programs: None as yet.

Implications for Research: Studies are needed in women. If Mg causes genital tract inflammatory disease in women many of the same complications seen in women with Ct and Ng infections could be associated with this organism.

Learning Objectives: Participants will understand the potential for Mg to be a significant STD pathogen.

Contact Information: David H. Martin/ phone 504-568-5031 / dhmartin@lsuhsc.edu

C3C - Mycoplasma genitalium is Associated with Mucopurulent Cervicitis

L Manhart^1,2, K Holmes^1,2, S Dutro1, C Stevens¹, C Critchlow¹, D Eschenbach³, P Totten²

University of Washington, Seattle, WA: Departments of 1Epidemiology, 2Medicine, and 3Obstetrics and Gynecology

Background: Although mucopurulent cervicitis (MPC) is often associated with Neisseria gonorrhoeae (GC) or Chlamydia trachomatis (CT), many cases have no known etiology. Mycoplasma genitalium is associated with male nongonococcal urethritis (NGU), suggesting it may also be associated with MPC.

Objectives: Determine if M. genitalium is associated with MPC. Identify risk factors for infection.

Methods: From 1984–86, randomly selected women attending Seattle’s STD clinic were enrolled in a study of the microbial etiology of STD syndromes. Subjects underwent a standardized interview and pelvic examination. GC, CT, Trichomonas vaginalis (TV), and herpes simplex virus (HSV) were assessed by culture, and bacterial vaginosis (BV) by Amsel’s criteria. Cervical secretions transferred to filter paper and stored at -20℃ were tested for M. genitalium by PCR.

Results: M. genitalium was detected in 50 (7.0%) of 719 women, of whom only 14 were co-infected with cervical GC or CT. After adjusting for age, GC, CT, HSV, and TV, women with MPC (either visible yellow mucopus or >30 PMNs/HPF) were three times more likely than women without MPC to have M. genitalium (OR = 2.9, 95% CI 1.52–5.49). M. genitalium was associated with >2 new partners in the past 30 days (OR = 3.3 [1.18–9.53]), smoking (OR = 2.7 [1.28–5.65]), proliferative phase of menstrual cycle (OR = 2.6 [1.34–4.89]), frequent douching (OR 2.5 [1.08–5.60]), and history of miscarriage (OR = 2.4 [1.00–5.79]). It was negatively associated with age (OR = 0.9 per year; [0.81–0.95]), history of cunnilingus (OR = 0.4 [0.22–0.86]), and BV (OR = 0.4 [0.19–0.97]).

Conclusions: M. genitalium was independently associated with MPC, as has also been demonstrated with NGU and endometritis.

Implications for Programs/Policy: With confirmation of these results, M. genitalium should be considered a possible cause of MPC.

Implications for Research: Confirmatory studies are needed, as are studies of antimicrobial susceptibility, impact of therapy, evaluation of sex partners, and role in pregnancy and perinatal morbidity.

Learning Objectives: By the end of this session, participants will be able to explain the association between M. genitalium and mucopurulent cervicitis and describe risk factors associated with M. genitalium infection in women.

C3D - Promiscuous Sexual Activity is Associated with Bacterial Vaginosis in Young Women Who Douche

MK Oh, J Schwebke, J Merchant, P Brown, R Desmond, M Jones, H Weiss

University of Alabama at Birmingham, Birmingham, AL

Background: Vaginal douching has been linked to bacterial vaginosis (BV). However, the mechanism of this association is unclear.

Purpose: To determine correlates of BV in adolescent and young women who douche.

Methods: Study participants were 144 young women 14–21 years of age, who douche regularly and are participants of an on-going douching intervention study. Baseline data included Hx of douching, sexual behaviors, gynecologic events and STD Hx. All participants were tested for C. trachomatis (CT) and N. gonorrhoeae (GC) by LCR, T. vaginalis by culture, HSV type 2 serology, and BV (by Nugent’s criteria). Data from 62 (42.5%) who had BV at baseline were compared with those who did not, using the Chi-square test and two-sample t-tests to determine factors associated with BV.

Results: Mean age of 144 participants was 18.7 ± 1.9 yrs, age at sexual debut was 15.0 ± 1.7 yrs, 21% had more than one sex partner in the past 3 months, 33% were on hormonal birth control, 52% reported condom use with the last sex, and 42% had a history of STD and 26% a history of BV. Mean age at first douche was 15.8 ± 1.9 yrs, 44% reported douching more than once a month, 32% douched within the last week. Positive rates were 14% for CT, 5% GC, 7% T. vaginalis and, 22% HSV type 2 serology. Those who had BV (n = 62), compared with those who did not, were more likely to report multiple partners in last 3 months (p=.02; OR = 2.78) and were more likely to have GC infection (p=.02; OR = 3.66). Frequent douching and recent douching were not among the significant correlates of BV in this study participants.

Conclusion: BV in douching women may indicate existence of other high-risk sexual behavior.

Implications for Programs/Policy: Management of women with bacterial vaginosis should include assessment for high risk sexual behavior and testing for bacterial STDs.

Implications for Research: Research examining effects of vaginal douching must account for confounding high-risk sexual behaviors.

Learning Objectives: The participants will become aware that the association between vaginal douching and bacterial vaginosis remains unresolved.

Contact Information: MK Oh, mkoh@uab.edu, 205-934-8770

C3E - Risk Factors for Bacterial Vaginosis and Relationship with STDs in Adolescents

EH Koumans¹, LE Markowitz¹, A Pierce¹, MK Sawyer², J Papp¹, E Unger¹, C Black¹

1Centers for Disease Control and Prevention, Atlanta, GA; 2Emory University, Atlanta, GA

Background: Bacterial vaginosis (BV) has been associated with STDs, although risk factors for this condition are not well understood.

Objective: To investigate the relationship between BV and chlamydial, gonococcal, and trichomonal infections and determine risk factors for BV in a cross sectional study of adolescents.

Methods: Demographics, sexual risk factors, condom and douching use were determined at an initial visit. A Chlamydia trachomatis (CT) or Neisseria gonorrhoeae (NG) infection was defined as two or more nucleic acid amplification tests positive in urine, cervical, or vaginal samples or growth in culture; Trichomonas vaginalis (TV) infection was detected using wet mount or Affirm VP; BV was determined using Nugent’s criteria.

Results: Among 137 adolescent women enrolled to date, median age was 17 years (range 12–19), 93% were black, 92% were in school, 92% had one or more sex partners in the previous 90 days, and 46% had BV. Compared to women without BV, those with BV had a higher prevalence of CT (22% vs 44%, p=.009), NG (4% vs 13%, p=.06), and trichomoniasis (6% vs 19%, p=.04). Women who douched (52% vs 32%), had vaginal sex more than 7 times in the last 90 days (58% vs 41%), were current smokers (25% vs 9%), and had a sex partner more than 1.5 years older (63% vs 44%) were significantly more likely to have BV. In multivariate analysis, after adjusting for number of sex acts and age difference of partner, only douching (OR = 2.1, 95% CI: 1–4.2) and current smoking (OR = 2.9, 95% CI: 1.1–8.1) remained significantly associated with BV.

Conclusions: In this small cross-sectional study, BV was associated with recent douching and smoking. In addition, women with BV were more likely to have CT, NG, or TV. Further prospective studies are needed to define the relationships between vaginal infections and douching.

Implications for Programs: Young women with BV have a higher prevalence of other STDs.

Implications for Research: Increased research on the cause, course, and prevention of BV is needed.

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

C3F - Randomized Trial of Douching and Pelvic Inflammatory Disease

KJ Rothman, DP Funch, T Alfredson, J Brady, NA Dreyer

Ingenix Pharmaceutical Services, Epidemiology Division, Newton, MA

Background: Several studies have reported that use of vaginal douche products is associated with increased risk for pelvic inflammatory disease (PID). Most cases of PID are believed to result from a sexually transmitted infection (STI), and risk factors for STI are also risk factors for PID. Many of these factors are also associated with vaginal douching, and thus confound the association between douching and PID. Controlling this confounding is difficult, because it is difficult to measure accurately risk factors for sexual activity.

Objectives: We studied the relation between douching and PID using a design that minimizes confounding by sexual activity risk factors.

Methods: We conducted a randomized field trial, comprising women age 18–34, recruited through 59 clinics or research centers in 24 states. Eligible women were regular users of a douche product and recently treated for a bacterial STI. Women were randomly assigned to use either a newly designed douche product or a soft cloth towelette. During the 12 months of follow-up, participants returned every 2 months to receive more products, return diary forms recording menses and product use, and reply to questions on sexual activity, changes in the number of sex partners, STIs, other concurrent illnesses, and symptoms that might correspond to PID. Women who reported symptoms consistent with PID were referred to a physician for a clinical evaluation.

Results: The analysis comprised 1827 women, 870 assigned to the douche group and 957 to the wipe group. During the 12 months following enrollment, we found 41 cases of PID, 20 (2.3%) and 21 (2.2%) in the douche and wipe groups respectively. In an intent-to-treat analysis, the risk ratio was 1.05, with a 95% CI of 0.57–1.9. We found similar results using an on-protocol analysis.

Conclusions: There was little or no increase in risk of PID related to douching.

Implications for Policy: These findings do not have any implication for a change in current policy regarding douche products.

Implications for Research: Replicating the study would reduce the residual uncertainty of the effect estimate.

Learning Objectives: Participants will be able to describe the relation between the use of a douche product and the risk of pelvic inflammatory disease, unconfounded by risk factors for pelvic inflammatory disease that are associated with douching.

Author contact information:

Kenneth J. Rothman / Phone 617-244-1200 / KRothman@epidemiology.com,

C4A - Working Effectively with Native Communities to Prevent and Control Sexually Transmitted Diseases (STDs)

L Shelby¹, James Cheek¹, R Pacheco¹, S Jackson², L Foster³, A Oxendine⁴, D Morgan⁵, T Peterson⁶, Slinkey⁷, Jones⁸, Peyton⁹, and E Howard¹⁰

1Indian Health Service National Epidemiology Program. Albuquerque, New Mexico; 2Northwest Portland Area Indian Health Board. Portland, Oregon; 3Navajo Nation Department of Social Hygiene. Gallup, New Mexico; 4Robeson County Health Department. Lumberton, North Carolina; 5South Dakota STD Program. Pierre, South Dakota; 6Montana STD Program. Helena, Montana; 7Belcourt Indian Health Service Hospital. Belcourt, North Dakota; 8Choctaw Nation Health Center, Philadelphia, Mississippi; 9Mississippi State Department of Health; 10Phoenix Indian Medical Center. Phoenix, Arizona

Background and Rationale: STDs are among several disease conditions that have disproportionately affected Native communities. The 1999 CDC STD Surveillance Report shows AI/ANs had the second highest case rates of syphilis, gonorrhea, and chlamydia of any racial/ethnic group in the US. STD control in Native American communities, however, is challenging and complex. Barriers to STD control include a fragmented and under-funded health care delivery system, facilities located in geographically remote and isolated areas, variable relationships with states, and ill-defined roles of public health jurisdictions between tribes, states, and federal agencies. Many public heath professionals are unfamiliar with the Indian health care system and culturally appropriate intervention strategies.

Objective: Intervention strategies needed to reduce STD rates in the AI/AN population are unique in many ways. This workshop presents an overview of challenges and successes in STD control, and strategies to enhance and improve STD interventions in Native American communities.

Content: A panel of tribal, state, and federal STD specialists will discuss topics including national STD trends in AI/AN populations, the Indian health care system, gaps in resources and public health activities, and traditional Indian health practices and beliefs. The panel will also discuss how to build strong partnerships among Tribes, States and other agencies, engage tribal leaders in STD control, and mobilize Native communities to eliminate syphilis. The workshop format will consist of a series of short presentations from each panelist moderated by the Indian Health Service National STD Program Director. The panel presentations will be followed by a question and answer period.

Learning Objectives: By the end of this session, participants will be able to:

1. Describe the Indian health care system, STD trends in AI/AN populations, and challenges in STD control in Indian County.

2. Describe strategies to build strong partnerships between tribes, states, and other agencies.

3. Describe culturally appropriate STD interventions for Native American communities.

Contact Information: Laura Shelby / 505-248-4395 / laura.shelby@mail.ihs.gov

C5 - Screening Males for Chlamydial Infection—Do We Have the Data to Guide Program?

JA Schillinger¹, T Gift¹, JM Marrazzo², J Ellen³, C Gaydos³, N Willard³, C Rietmeijer⁴, CK Kent⁵, L Markowitz¹

1Centers for Disease Control and Prevention, Atlanta, GA; 2University of Washington, Seattle, WA; 3Johns Hopkins University School of Medicine, Baltimore, MD; 4Denver Public Health, Denver, CO; 5San Francisco Department of Public Health, San Francisco, CA

Background and Rationale: Screening asymptomatic men at high risk for Chlamydia trachomatis (Ct) using urine-based testing in non-traditional settings may be a cost-effective way of preventing Ct and its sequalae among women. Many state and local STD control programs are interested in introducing urine-based Ct screening for asymptomatic males but lack experience with screening outside traditional clinical settings (i.e., public health, family planning, or STD clinics). For an ongoing evaluation of the feasibility, acceptability and cost effectiveness of screening asymptomatic men for Ct, urine Ct-testing is being offered to men in non-traditional, non-clinical venues in four US cities (Baltimore, Denver, San Francisco, Seattle); 12,000 men have been screened, and partner services provided to Ct-infected men.

Objectives: (1) To present data from 2 years of screening to describe the benefits and challenges of screening men in venues where the primary mission is not STD services; (2) To review data needed to determine the cost effectiveness of screening males.

Content: Investigators will describe the implementation and maintenance of a male screening program, including identification of, and collaboration with non-traditional venues, integration of male screening into venue activities, and issues related to service delivery, partner notification, and associated costs. They will present data to estimate the effectiveness of different approaches and the yield at different venue types. Models for school-, and for jail-based screening will be described, with presentation of data on acceptance rates for testing, volume of testing, Ct prevalence, proportion of positives treated, and partner notification activities. A closing presentation will outline issues individual programs may wish to consider before undertaking male screening, and will highlight data needed to assess the cost effectiveness of male screening and issues which should be addressed before male screening guidelines can be developed.

Implications for Programs/Policy: STD and Infertility Prevention Programs may use information presented to guide decision-making about screening asymptomatic males.

Implications for Research: The symposium will identify gaps in knowledge and data needed to assess the effectiveness, and programmatic appropriateness of male screening.

Learning Objectives:

1) By the end of the session participants will be able to discuss different approaches to male screening, to outline some of the advantages and disadvantages of different approaches, and to describe factors which could influence the yield of a male screening program undertaken in their jurisdiction.

2) By the end of the session participants will be able to discuss the kinds of data which are needed to evaluate the advisability of screening males in different venues in their jurisdiction, as well as some of the data which are still needed to judge the cost-effectiveness of screening asymptomatic males for chlamydia.

C6A - Evaluation of Gonorrhea Screening in Family Planning Settings: California 2000

CK Kent¹, M Brammeier², G Bolan², N Casas³, M Funabiki³, P Blackburn⁴

1San Francisco Department of Public Health, STD Prevention and Control Services; 2California Department of Health Services, STD Prevention and Control Branch; 3California Family Health Council; 4Center for Health Training, Oakland, CA

Background: Chlamydia screening of women by nucleic acid amplification testing is cost-effective at a prevalence of 4% or higher. There are no published reports examining the cost-effectiveness of gonorrhea screening.

Objective: To evaluate gonorrhea screening of women in family planning settings in order to better target screening.

Methods: Gonorrhea and chlamydia test results, symptom status, age and ethnicity were examined for 2000 data from 29 California sentinel family planning clinics.

Results: The observed gonorrhea prevalence was 0.9% (257/28,590), while chlamydia prevalence was 4.9% (1,497/30,568). Gonorrhea prevalence was significantly higher among women with symptoms, with concurrent chlamydial infection, who were younger than 25 years, or who were African-American (all P-values <.01). Women with symptoms and/or chlamydia had an observed gonorrhea prevalence of 2.3% (155/6,716). Seventy-six percent (21,874/28,590) of women tested for gonorrhea had neither symptoms nor chlamydia, and the observed gonorrhea prevalence among these women was 0.5% (98/21,324). Among women with neither symptoms nor chlamydia, the observed prevalence among those less than 25 years was 0.6% (61/10,130), and among African-Americans it was 1.2% (44/3,776). The positive predictive value for an observed prevalence of 0.9% (the overall prevalence among those tested) would be only 43% for a test with sensitivity of 95.0% and specificity of 99.5%.

Conclusions: Diagnostic testing for gonorrhea based on symptoms and chlamydial infection may be more appropriate in California family planning settings than screening with no clinical indication, even among women less than 25 years. Performing only diagnostic testing could reduce current testing by 75%. While human costs of false positives are difficult to quantify, they are important to consider in establishing screening guidelines.

Implications for Programs: Tremendous resources may be needlessly devoted to current gonorrhea screening practices.

Implications for Research: Cost/prevention effectiveness analyses of gonorrhea screening should be continued and performed in other settings.

Learning Objectives:

1. Participants will be able to describe a simple way to evaluate gonorrhea screening.

2. Participants will understand the importance of positive predictive value in low prevalence populations.

C6B - Utility of the Urethral Gram Stain Among Asymptomatic Male STD Clinic Attendees

AS Palakkathodi¹, CA Lindsey ¹, TA Peterman¹, JM Zenilman², CK Malotte³, M Iatesta^1,4, ML Kamb¹

1Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA; 2Baltimore City Health Department and John Hopkins University, Baltimore, MD; 3Long Beach Health Department and California State University, Long Beach, CA; 4New Jersey Health Department, Trenton, NJ

Background: A urethral Gram stain (UGS) is done in many STD clinics as a quick and inexpensive means of identifying gonorrhea (GC) and chlamydia (CT) urethritis in males. UGS enables treatment during the clinic visit, preventing further transmission and loss to follow-up.

Objective: To assess the utility of UGS for identifying and treating GC and CT among male STD clinic patients with and without signs or symptoms of urethritis.

Methods: We used baseline clinical data collected 7/93–9/96 from 3 STD clinics participating in an HIV/STD counseling trial. Participating males had a genital examination, UGS, GC culture, and CT tests (urine PCR plus urethral culture or EIA). UGS was considered positive for GC if there were Gram negative intracellular diplococci, and positive for non-gonococcal urethritis (which is treated as CT) if there were >5 white blood cells per high-power field (and no GC). We estimated the sensitivity of UGS and calculated cases detected per 100 UGS performed among males with and without signs or symptoms of urethritis.

Results: Among all 1275 males, lab testing after UGS confirmed GC in 285 (22%) and CT in 220 (17%). Among 790 males with signs or symptoms of urethritis, UGS detected 236 (85%) of 277 GC and 158 (93%) of 170 CT cases; and there were 50 cases of GC or CT detected per 100 UGS. Among 485 males without signs or symptoms, UGS detected 3 (38%) of 8 GC and 11 (22%) of 50 CT cases; and there were 3 cases of GC or CT detected per 100 UGS.

Conclusion: One case of GC or CT was detected for every 33 UGS in males without signs or symptoms of urethritis in these clinics, suggesting that UGS should be done using the swab routinely taken for GC culture. GC culture and CT tests detected many infections missed by UGS and should also be done for asymptomatic men.

Implications for Programs: UGS, GC culture, and especially CT tests are important for all males visiting STD clinics.

Learning Objectives: By the end of this presentation, participants should be informed of the utility and practicality of urethral Gram staining in males attending STD clinics regardless of signs or symptoms of urethritis.

C6C - Effects of the Transition to Chlamydia Nucleic Acid Amplification Testing in a Public Health Screening Program

RA McDonald, J Pfister

Wisconsin State Laboratory of Hygiene, Madison, WI

Background: Nucleic acid amplification tests (NAAT) offer a significant improvement in the diagnosis of Chlamydia (Ct) and gonorrhea (GC) infections. Increased sensitivity and the options of urine testing and dual testing of a single specimen allow for expansion into non-traditional screening settings, and the detection of more infections.

Objectives: To assess effects of the transition from non-amplified Ct testing to NAAT in a public health screening program.

Methods: Ct and GC testing data from females attending 64 Wisconsin family planning clinics from January through June 2000 (n = 13,752 using EIA) were compared with the same period in 2001 (n = 13,851 using NAAT).

Results: Overall Ct positivity increased from 6.3% to 7.2% (+14.3%), but the increase was much higher in low prevalence clinics (3.4% to 5.7%; +67.7%) than in high-prevalence clinics (8.9% to 9.0%; +1.1). In the low prevalence clinics, lower-risk clients yielded larger increases in positivity (2.9% to 4.7%; +62.1%), than those with symptoms or history of STD contact (11.5% to 13.4%; +16.5%). In 2001, GC requests increased by 16.3%, and 2.6% of testing was performed on urine specimens.

Conclusions: While the overall increased Ct positivity using NAAT is consistent with previous data, the large increases among lower-risk clients accentuate the unacceptably low sensitivity of the EIA for screening in this population. Increases in GC testing and testing of urine specimens resulted from the new capabilities afforded by NAAT.

Implications for Programs/Policy: Detection of more infections necessitates increased efforts in treatment and partner services, and could possibly exceed capacity for follow-up. Higher testing costs, expansion of screening programs using urine specimens, and increased concomitant GC testing may also require additional resource allocation.

Implications for Research: Further investigation into the characteristics of previously undetected positives, particularly among lower-risk individuals, may allow targeting NAAT to settings where impact will be highest.

Learning Objectives: By the end of this session, participants will be able to identify potential effects of using nucleic acid amplification tests for chlamydia beyond simple increases in positivity, and to discuss possible impact to screening programs.

C6D - Self-collected Vaginal Specimens for the Detection of Multiple Sexually Transmitted Infections in Adolescent Detainees

CM Holland¹, HC Wiesenfeld², PJ Murray³

1The Ohio State University College of Medicine and Public Health, Children’s Hospital, Columbus, OH; 2University of Pittsburgh Medical School, Magee-Women’s Hospital, Pittsburgh, PA; 3University of Pittsburgh Medical School, Children’s Hospital of Pittsburgh, Pittsburgh, PA

Background: STIs are prevalent among teenage women in juvenile detention centers, where widespread screening with pelvic exams is often not feasible. Polymerase chain reaction (PCR) performed on self-collected vaginal specimens (“self-testing”) is a sensitive, specific alternative to endocervical testing for several organisms. Few studies have described the acceptability of this method to teenage women.

Objective: To describe the use and acceptability of self-testing for the diagnosis of Neisseria gonorrhoeae,

Chlamydia trachomatis, and Trichomonas vaginalis in a juvenile detention facility.

Methods: One hundred thirty-three female detainees (ages 12–17 years) underwent STI screening using self-testing. PCR was used to test each specimen for the three infections. Endocervical testing was performed at the discretion of a physician performing a routine intake physical, independent of the study. The number of infections diagnosed by routinely offering self-testing was compared to the number diagnosed using standard clinical practices. Subjects completed anonymous, self-administered questionnaires to assess acceptability.

Results: Twenty-four percent of sexually active subjects had one or more infections diagnosed by self-testing: 11.3% had C. trachomatis, 8.5% had N. gonorrhoeae, and 11.7% had T. vaginalis. Only 30% of subjects with infections had pelvic exams while detained, therefore 70% of girls with infections would have been missed in the absence of the self-testing option. Self-testing was acceptable to 95% of subjects; 81% preferred self-testing to pelvic exams.

Conclusions: STI testing using self-collected vaginal specimens is highly acceptable to adolescents, and can dramatically increase the detection rate for these three treatable infections when pelvic exams are not universally performed.

Implications for Programs: Self-testing for multiple STIs should be considered in settings where endocervi-cal testing is not feasible due to lack of time, appropriate facilities, or providers.

Implications for Research: Further research may compare self-testing to urine testing to determine relative sensitivities, specificities, and acceptability of these two less invasive methods.

Learning Objectives: Participants will be able to identify a potential role for STI testing using self-collected vaginal specimens, and to describe adolescents’ acceptability of this testing method compared to other methods.

Contact Information: Cynthia Holland / Phone 614-722-2458 / hollandc@pediatrics.ohio-state.edu

C6E - Evaluation of HIV Rapid Diagnostic Devices

NL Michael, H Zahwa, M Robb, J Malia

Div Retrovirology, Walter Reed Army Inst of Research, Washington, DC

Background: Point-of-care, rapid HIV testing can reduce HIV transmission by increasing the number of individuals who know their HIV serostatus thereby reducing transmission risk behaviors. This testing is also a cost-effective method for serodiagnosis in resource poor environments.

Objectives: To identify rapid HIV diagnostic devices with high sensitivity, specificity, and low cost that are suitable for field use.

Methods: Retrospective studies of blood product test devices were evaluated with large numbers of archived sera with known reactivity by conventional HIV EIA and Western blot technology.

Results: Six HIV test devices were tested using panels of approximately 11,000 pedigreed sera with a 1:10 ratio of seropositive to seronegative samples. None of these test devices are currently approved for diagnostic use by the U.S. FDA but are in various states of evaluation by the FDA. These devices, Determine HIV (Abbott Laboratories), Multispot (Bio-Rad Laboratories), UniGold (Trinity Laboratories), OraQuick HIV 1/2 test (OraSure Technologies, Inc.), InstantScreen (GAIFAR), and Hemastrip (Saliva Diagnostic Systems) were all highly sensitive, specific, and suitable for field use. The performance of tests can vary with the population tested. Combinations of these tests achieved similar diagnostic accuracy to conventional HIV serology.

Conclusions: Simple and accurate HIV rapid test devices are being produced by multiple manufacturers with serious intent to pursue FDA licensure. This corporate intent should be highly encouraged by public health agencies to allow the future development of HIV testing algorithms with FDA approved devices.

Implications for Programs: Programs that serve point of care populations in resource poor settings will benefit from FDA licensed rapid HIV test devices.

Implications for Research: Test algorithms need to be developed for different populations based on performance and feasibility of execution.

Learning Objectives: Participants will be able to describe benefits and costs associated with rapid versus conventional HIV screening tests.

Contact Information: Nelson Michael / Phone 301-251-5000 / nmichael@hivresearch.org

C6F - Rapid HIV Testing in an Emergency Department

K Kroc¹, S Kendrick^1,2,3, D Withum⁴, E Couture², S Miller², B Zagorski², B Branson⁴, R Weinstein^1,2,3

1CORE Center, Chicago, IL; 2Cook County Hospital, Chicago, IL; 3Rush Medical College, Chicago, IL; 4Center for Disease Control, Atlanta, GA

Methods: SUDS^® HIV-1 test was offered to ED patients ages 18–60 beginning in June 2001. Known HIV+ patients were excluded. Health educators actively encouraged RT, obtained informed consent, and performed all counseling, phlebotomy, and RT.

Background: Many patients use the Emergency Department (ED) for primary care, including STD treatment. Historically, the Cook County Hospital ED has referred patients seeking conventional HIV testing (CT) to ambulatory care clinics or to the CORE Center STD Screening Clinic (CORE). The ED began CT in January 2001 and through May, 56 patients had received CT in the ED and 18% (10/56) reported to the CORE STD clinic or other hospital sites to receive their test results.

Objectives: To determine if point-of-care, rapid HIV testing (RT) is feasible in a large urban hospital ED.

Results: For the RT period June through August 2001, 82% (1717/2099) of patients were eligible, 24% (410/1717) accepted RT. Twelve (2.9%) new HIV infections were identified. 98% (405/410) of patients received results and post-test counseling within 90 minutes of pretest counseling.

Conclusions: Point-of-care RT is feasible and accepted by a subset of ED patients. RT improves client receipt of HIV test results.

Implications for Programs/Policy: STD prevention programs should consider establishing linkages with EDs to foster HIV testing. EDs should consider using RT to reduce the need for additional follow up and increase client receipt of results.

Implications for Research: Reasons for the relatively low test acceptance rate in ED require further study. Studies to evaluate use of candidate simple, quick HIV rapid tests capable of reducing test turn around time in ED settings are warranted.

C7 - Crossing the Cultural Divide: A Non-deficit Approach to STD Prevention Practices

G Lara

Children’s Hospital of MI, Detroit

Background and Rationale: Cultural sensitivity, diversity, and similar terms are frequently espoused values of public service and non-profit organizations. Approaches to expressing these values vary widely. Sexually transmitted diseases disproportionately burden cultural minorities challenging those working in STD prevention to be culturally sensitive as they reach out to their targeted clientele. Yet, the tools to carry out their work under guidance of these values are typically very limited. Good intentions often fall short of success in dealing with the complexity of interactions between staff and clients of different cultures. When these cultural barriers are not overcome, all subsequent STD prevention efforts can fail. As the populations affected by STDs has grown more and more culturally diverse, so has the need to utilize highly effective methods to bridge cultural differences.

Purpose: The purpose of this workshop is to instruct participants in the non-deficit approach to service delivery for STD prevention. Emphasis will be on more effectively reaching and serving populations at risk for STDs though their assets rather than their problems. Additional focus will be on bridging cultural differences between organizational partners working together on STD prevention efforts.

Methods: In this workshop, participants will be introduced to the basic tenets of a non-deficit approach. Participants will learn about the importance of critical thinking based on investment in asking questions versus making assumptions about the meaning of the communication behaviors of others. Video case scenarios will be used to stimulate discussion. Additional case examples focused on STD prevention practices will be utilized.

Contact Information: Guadalupe Lara, MSW, CSW / Phone 313-745-0382 / glara@msn.com

C8 - The OASIS Project: Diverse Activities Utilizing & Integrating Surveillance Data for a More Comprehensive STD Program

D Thomas¹, J Beall², M Kang³, J Lisbin³, R Hamm⁴, Y Tang⁵, M Stenger⁶, J Ellen⁷

1Centers for Disease Control & Prevention, Atlanta, GA; 2Indiana State Health Department, Indianapolis, IN; 3California State Health Department, Sacramento, CA; 4Missouri Department of Health, Jefferson City, MO; 5Massachusetts Department of Health, Boston, MA; 6Washington State Health Department, Olympia, WA; 7Johns Hopkins University School of Medicine, Baltimore, MD

Background and Rationale: Health departments routinely collect a large amount of surveillance data. However, few resources have been provided to promote the integrated interpretation and use of these data. Since 1998 CDC has provided such resources through the OASIS Project (Outcome Assessment through Systems of Integrated Surveillance). This project encourages collaboration among surveillance units and analyses of the extent of co-morbidity among STDs, HIV, AIDS, TB, and adverse reproductive outcomes. Sites are also encouraged to integrate behavioral data, utilize new technological tools, and involve local community members in the analysis and interpretation of the data.

Objective: To describe diverse activities being conducted by the OASIS project and how they are enhancing STD programs.

Content: This symposium includes presentations from six OASIS sites demonstrating their use of surveillance data and describing integration of surveillance activities and activities involving community partners. These projects will show how these efforts can benefit programs and clients by taking a more holistic approach in the analyses of the data. Indiana will examine STD and HIV co-infection rates before and after a syphilis outbreak. California will describe the association of chlamydia infection and adverse reproductive outcomes based upon matching cases and birth certificate data. California will also identify factors contributing to the discrepancy between trends of birth and chlamydia rates among African American adolescent girls. Missouri will describe a proposed study intended to determine demographic, behavioral, and psychological factors predictive of continued risky behaviors. Massachusetts will demonstrate how HIV case registries that collect data without names can yet be useful for program planning. Washington will share the results of their HIV and STD registry match and their involvement with the local community planning group. Baltimore will present an inventory of community based interventions and a map of the communities they target.

Implications for Program/Policy: This project will describe several data integration activities and their potential utility for enhancing STD programs.

Implications for Research: Future research should evaluate the success of these integrated programs and the impact on their local communities.

Learning Objectives:

1. By the end of this session, participants will be able to describe multiple approaches to integrating relevant data.

2. By the end of this session, participants will be able to describe examples of how integrated surveillance can benefit STD programs.

Contact: Dorotha Love Thomas / 404-639-8425 / dit1@cdc.gov

C9 - Expanding the Armamentarium: How Do We Get Non-Condom Prevention Tools?

A Forbes¹, D Arrindel², J Moore³, K Whaley⁴

1Global Campaign for Microbicides; 2American Social Health Association; 3California Family Health Council; 4Johns Hopkins University, ReProtect and Epicyte, Inc.

Background and Rationale: Because of cultural norms, domestic violence, economic dependence, drug use and other factors, millions of women can’t always insist on condom use. Consistent condom use is also problematic for some men who have sex with men, as the recent changes in STD incidence clearly indicate. Microbicides—products that can be used vaginally or rectally to reduce STD risk—have the potential to enhance community STD prevention efforts substantially. Overcoming the barriers that are slowing and impeding development of these new tools is, therefore, is an important policy challenge in STD prevention.

Purpose: To provide an overview of what microbicides are, how they work and what factors are delaying and impeding microbicide research and development. To examine the demonstrable, but largely latent, public demand for microbicides that exists nationally and globally. To consider why that demand is not yet reflected in commensurate levels of public and private sector investment in microbicide research. To explore how STD prevention professionals can foster public education about, and support for, microbicides research and why such community involvement is essential at this time.

Methods: In this workshop, we will explore the need for non-condom prevention tools and consider the impact that adding microbicides to the existing STD prevention armamentarium could have. Presenters from various sectors of the STD prevention field (family/women’s health, research, commercial, public health and community organizing) will discuss their perspectives on this issue and how they are working to involve their various constituencies in microbicide advocacy. Participants will have ample opportunity to question, respond and discuss the role microbicides might play in their own STD prevention work in the future, as well as their thoughts regarding the need for collective microbicide advocacy at this time.

Learning Objectives: At the end of this session, participants will be able to:

1. Summarize the types of topical microbicide candidate products currently in the research pipeline and how they will work

2. Identify the barriers to expedited microbicide research and development and the ways in which microbicide advocates are working to overcome those barriers 3. Discuss the impact that microbicides could have on current disease prevention efforts and why advocating for their development constitutes a new policy challenge in STD prevention.

Contact Information: Anna Forbes / Phone: 610-649-8113 / aforbes@critpath.org