2002 National STD Conference - Abstracts Referenced in Other Presentations/Findings of Interest

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Abstract 194: "Gonorrhea Prevalence and Co-infection with Chlamydia in Women Seen in Family Planning Clinics"

L Dicker, D Mosure, S Berman, W Levine, and Regional Infertility Prevention Program, Centers for Disease Control and Prevention, Atlanta, GA

Background: Gonorrhea (GC) is the second most commonly reported notifiable disease in the US. Data have not existed on the prevalence of GC in populations screened for both GC and chlamydia.

Objective: To describe the prevalence of gonorrhea and coinfection with chlamydia in women aged 15–24 years routinely screened in family planning clinics in 2000.

Methods: Data were analyzed on 527,818 tests on women aged 15–24 years screened for GC in 1,464 family planning clinics in 34 states in 2000. GC positivity (median and interquartile range [IQR]) and chlamydia positivity among women infected with GC were calculated by state and age group (15–19 and 20–24 years).

Results: The median state-specific GC positivity was 0.985% (IQR, 0.6–1.6%). For women 15–19 years the median GC positivity was 0.9% (IQR 0.7–2.1%); the median GC positivity in women 20–24 years was 0.8% (IQR, 0.5–1.2%). The median GC positivity was highest in the South (1.6%, IQR 0.9–2.0%) followed by the Midwest (0.9%, IQR 0.8–1.3%) and West (0.6%, IQR 0.5–0.8%), and lowest in the Northeast (0.45%, IQR 0.215–1.2%). Among the 20 states with at least 50 positive GC tests, median chlamydia positivity among those women infected with GC was 42.6% (IQR 39.1–45.2%); it was highest among those 15–19 years (45.6%. IQR 41.7–49.0%), compared with 20–24 years (36.6%, IQR 34.3–43.9%).

Conclusions: GC positivity is highest among women 15–19 years of age screened in family planning clinics; almost half of women aged 15–19 years with GC are also infected with chlamydia.

Implications for Programs: This analysis indicates the continued importance of testing for and presumptively treating chlamydia in those women infected with GC.

Implications for Research: Examination of risk factors associated with GC infection and co-infection with chlamydia is needed to assist in the development of effective gonorrhea screening criteria.

Learning Objectives: Participants should be able to describe the prevalence of GC and co-infection with chlamydia among young women screened in family planning clinics in the US.

Contact Information: National Center for HIV, STD and TB Prevention, Office of Communications: 404-639-8895

Abstract 297: "Preventive and Risk Behaviors Among Young Black Women Receiving STD Testing Services, Dallas, 1999–2001"

KM Sabin¹, G Secura¹, S Behel¹, D Shehan²

¹CDC, Atlanta, GA; ²University of Texas Southwestern Medical Center, Dallas, TX

Background: Recent studies suggest that African-American women are among the groups at highest risk for AIDS in the United States.

Objective: To measure preventive and risk behaviors among young minority women receiving STD-related services in family planning clinics.

Methods: We enrolled 306 women between the ages of 15–24 seeking routine or initial family planning services consecutively at three family planning clinics in Dallas between August 1999 and September 2000. Following informed consent, participants responded to a structured questionnaire. Gonorrhea and chlamydia infection were ascertained by Gen-Probe Combo Assay and confirmed with Gen-Probe individual DNA probe. Syphilis was tested for by RPR or VDRL and confirmed by MHATP. All tests were conducted during medical examinations on day of interview.

Results: Overall, 70% of women approached participated in the study. Reactive syphilis tests were returned by 1.6% of respondents; 14.7% were positive for chlamydia, and 5.2% were positive for gonorrhea. Overall, 57 women (18.6%) had at least one infection. Case-patients did not differ from uninfected persons by age, age of partner, condom use, self-reported STD history, or number of partners. HIV testing was accepted by 37.9% of women. Infected women were more likely to have a partner with a history of incarceration. Younger women (15–19) were twice as likely to have chlamydia as women 20–24.

Conclusion: Gonorrhea and chlamydia were common among young women receiving family planning services. Younger women were more likely to be infected with chlamydia and to have partners who had been incarcerated.

Implications for Program: Screening young women attending these clinics can reduce disease burden from STD. Ascertainment of incarceration history for sex partners may increase the number of infections identified.

Implications for Research: Prevention research needs to focus on increasing HIV test acceptance by young, urban black women.

Learning Objective: By the end of this session, participants will be able to describe STD related risk behaviors of young, urban black women in Dallas.

Contact Information: National Center for HIV, STD and TB Prevention, Office of Communications: 404-639-8895

Abstract 483: "Prevalence and Correlates of Chlamydia Trachomatis in Sexually Active African-AmericanAdolescent Females"

KM Williams¹, GM Wingood^1,3, RJ DiClemente^1,2,3, RA Crosby^1,2, D Hubbard McCree¹, A Liau¹, S Davies ⁴, K Harrington ⁵, EW Hook⁶, MK Oh⁴

¹Rollins School of Public Health, Department of Behavioral Sciences and Health Education, Atlanta, GA, ²Emory Center for AIDS Research, Atlanta, GA, ³Emory University School of Medicine, Department of Pediatrics, Division of Infectious Diseases, Epidemiology and Immunology, Atlanta, GA, ⁴School of Medicine, Department of Pediatrics, University of Alabama, Birmingham, AL, ⁵School of Public Health, Department of Health Behavior, University of Alabama, Birmingham, AL, ⁶School of Medicine, Department of Medicine, Division of Infectious Diseases, University of Alabama, Birmingham, AL

Background: Chlamydia trachomatis is the most common sexually transmitted bacterial pathogen in the United States and disproportionately affects African-American adolescents.

Objective: To determine the prevalence of C. trachomatis and to identify correlates of infection among African-American adolescent females.

Methods: Sexually active African-American adolescent females (N=522) completed a self-administered survey, structured interview, and provided vaginal swab specimens for laboratory assessment of STDs. The relationship between selected psychosocial, behavioral and biologically- confirmed STDs and C. trachomatis was assessed.

Results: The prevalence of C. trachomatis was 17.4%. Results of multiple logistic regression revealed that adolescents testing positive for C. trachomatis infection were significantly more likely to test positive for gonorrhea (OR = 5.0; p = .004); to report non-use of condoms with a steady partner (OR 2.4; p = .01); to be in shorter relationships (OR = 2.2; p = .02); and to perceive poorer parental monitoring (OR = 2.1; p = .03).

Conclusions: Study findings emphasize the need for assessing psychosocial factors, behavioral factors and the presence of other STDs when determining risk for C. trachomatis. Several of the constructs identified are particularly amenable to behavioral interventions.

Implications for Programs: These results will be useful in informing screening approaches to more reliably detect adolescents at higher risk for infection and provide useful information for the design of behavioral intervention programs aimed at decreasing risk for infection.

Implications for Research: Results of this analysis provide further information on the risk correlates of C. trachomatis, however additional research is needed to accurately isolate, quantify, and characterize the factors that enhance risk for C. trachomatis. Careful studies of the acquisition of C. trachomatis infections in relationship to specific psychosocial, behavioral, demographic and clinical factors are necessary to further investigate the current study findings.

Learning Objectives: Participants will be able to identify factors influencing risk for C. trachomatis infections among adolescent females.

Abstract 460: "Prevalence and Predictors of Human Papillomavirus Infection in HIV-Positive and Negative Women"

A Chaturvedi¹, A Gaffga², K Mire², J Dumestre², R Clark², P Braly², K Dunlap³, J Slavinsky¹, P Kissinger¹, M Hagensee²

¹ Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, ² Department of Medicine, Section of Infectious Diseases, Louisiana State University, New Orleans, LA, ³ Department of Obstetrics and Gynecology, Louisiana State University, New Orleans, LA,

Background: Histopathology of genital Human Papillomavirus (HPV) infection ranges from warts, to cervical cancer. Prevalence of individual genotypes largely depends on the population studied. Few studies have described prevalence and predictors of infection with individual genotypes in diverse populations.

Objectives: To describe the prevalence of individual genotypes, and cytological abnormalities and determine risk factors for infection with high-risk, low-risk and multiple HPV genotypes in HIV positive and negative women.

Methods: Cervical/vaginal swabs and Pap smears were collected from 727 women (109 low-risk, 422 high-risk and 196 HIV-positive women). HPV DNA was detected using the PGMY09/11consensus polymerase chain reaction (PCR) method and genotyped using the reverse line blot system. Sexual history and demographic characteristics were collected from a subset of women (N=363) and bivariate and multivariate analyses were performed.

Results: Overall, HPV prevalence was 39.6%. Prevalence of high-risk, low-risk and multiple HPV types was 35.1%, 14.0% and 17.5% respectively. The most prevalent genotypes were MM7 and 53 in HIV+ women and types 16 and 52 in the HIV- women. After adjusting for age, race, number of recent sex partners and history of STDs, women aged <25 years and HIV+ women had a greater prevalence of any HPV infection, any high-risk type and multiple types. After adjusting for infection with multiple types, HPV types 16,35,39,52,and 56 were significantly associated with prevalence of abnormal Pap smears.

Conclusions: Prevalence was significantly higher in HIV+ and younger women with different genotypes being prevalent in different populations.

Implications for Programs: Prevention programs for genital HPV infection should target younger and HIV+ populations. The utilization of the line blot assay to follow the natural history of individual HPV genotypes and identify multiple infections may lead to improved cancer screening strategies.

Implications for Research: Longitudinal studies describing disease progression of individual genotypes in diverse populations would contribute to current vaccine strategies.

Learning Objectives: By the end of this sessionparticipants will be able to identify: 1. Prevalent genotypes in different populations and 2. Populations at risk for HPV infections.

Contact Information: Anil Chaturvedi/phone: 504-568-4369/achatur@tulane.edu

Abstract 72: "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; ² Department 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

Abstract 274: "Condoms Protect Men and Women Against Herpes Simplex Virus Type 2 (HSV-2) Acquisition"

A Wald, A Langenberg, E Kexel, A Izu, R Ashley, L Corey

University of Washington, Seattle, WA; Chiron Corp., Emeryville, CA

Background: The efficacy of condom use against HSV-2 has been shown for women but not for men. This study investigated condom use and other behavioral risk factors for the acquisition of HSV-2 among persons attending sexually transmitted disease (STD) clinics.

Objective: To measure the efficacy of condom use against HSV-2 acquisition.

Methods: A cohort of 1862 HSV-2 susceptible persons with ≥4 sexual partners or ≥1 STD in the past year was followed for 18 months to evaluate the efficacy of a candidate HSV-2 vaccine. Demographic and behavioral information were collected at enrollment and throughout the study and blood tested for HSV-2 antibody.

Results: One hundred eighteen (6.4%) persons acquired HSV-2, for an overall rate of 5.2/100 person years (p-y). The rates for women and men were similar, 5.7 vs. 5.1/100 p-y. In multivariate models, frequency of sexual activity, HR = 1.11 (95%CI: 1.04, 1.2) and STD in the year prior to study, HR = 1.31 (95%CI: 1.01, 1.71) were associated with increased risk of HSV-2. Use of condoms for more than 65% of sex acts offered significant protection against HSV-2 acquisition for men, HR = 0.56 (95% CI: 0.33, 0.97) as well as for the total population, HR = 0.58 (95%CI: 0.37, 0.92). The degree of protection was comparable in women, HR = 0.66 (95%CI: 0.30,1.46), heterosexual men, HR = 0.59 (95%CI: 0.32, 1.08), and men who have sex with men, HR = 0.42 (95%CI: 0.12, 1.49).

Conclusions: Condoms protect men and women against HSV-2 acquisition.

Implications for Programs: People should be counseled to use condoms to prevent HSV-2 acquisition and transmission.

Implications for Research: Studies of HSV-2 acquisition and condom use in other populations would be useful; interventions to increase condom use for prevention of HSV acquisition and transmission should be assessed.

Learning Objectives: Participants will be able to describe risk factors for HSV-2 acquisition and the role of condoms in protecting against HSV-2.

Contact Information: Anna Wald / 206-720-4340 /annawald@u.washington.edu

Abstract 90: "Cost-Effectiveness of Universal Screening for Gonorrhea and Chlamydia Among Inmates in United States Jails"

J Kraut¹, A Haddix², R Greifinger³, K Irwin⁴

¹Northern Illinois University, DeKalb, IL; ²Rollins School of Public Health, Atlanta, GA; ³Bromeen Group, New Rochelle, NY; ⁴Centers for Disease Control and Prevention, Atlanta, GA

Background: Although the value of STD screening in jails is now widely recognized, the most effective and cost-effective implementation strategies must be identified. Universal screening shortly after intake has been proposed as one effective strategy to decrease morbidity and transmission of gonorrhea and chlamydia.

Objective: Examine the cost-effectiveness of universal gonorrhea and chlamydia screening of inmates on intake as compared with the commonstrategy of presumptive treatment (without laboratory testing) of symptomatic inmates.

Methods: Decision analysis models were developed to estimate the cost-effectiveness of pathogen-specific screening strategies for men and women. Analyses were based on hypothetical cohorts of 10,000 inmates. Parameter estimates were drawn from literature and expert opinion. We evaluated the costs and benefits to the health system (including jails), specifically, cases of pelvic inflammatory disease (PID) prevented by screening women and cases of potentially infectious acute infections detected by screening men.

Results: At chlamydia prevalence rates of 8% or more, universally screening female inmates was cost saving in terms of cases of pelvic inflammatory disease (PID) averted. At gonorrhea prevalence rates of 6% or more, universally screening women was considered cost-effective because it cost the health system ~$1,700 to prevent a case of PID. At chlamydia prevalence rates of 4% or more, universally screening men was considered cost-effective because it cost ~$1,950 to detect an acute, potentially infectious case. Universally screening men for gonorrhea was not cost-effective.

Conclusions: At prevalence levels typical of many jails, universal screening at intake for these STDs is cost-effective, and for chlamydia in women, would save money. Jail screening programs may provide STD services to high-risk persons with limited access to care elsewhere.

Implications for Programs/Policy: Universal screening for chlamydia and gonorrhea at intake is a cost-effective strategy that should be considered in jails with high prevalence of these STDs.

Implications for Research: Additional cost-effectiveness analyses of other jail STD-screening strategies should be evaluated.

Learning Objectives: Participants will be able to identify relevant costs and benefits of jail-screening programs and allow them to evaluate jail screening in their community.

Contact Information: Julie R. Kraut/Phone: (815) 753-2436/E-mail: jkraut@niu.edu

Abstract 83: "Potential Impact of the National Plan to Eliminate Syphilis on HIV Incidence Rates Among African-Americans"

HW Chesson¹, SD Pinkerton², R Voigt¹, GW Counts¹

¹Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA; ²Center for AIDS Intervention Research, Medical College of Wisconsin, Milwaukee, WI

Background: African-Americans are disproportionately affected by syphilis and HIV/AIDS. Because syphilis can facilitate the transmission of HIV (through increased infectiousness of HIV-infected persons and/or increased susceptibility of HIV-uninfected persons), an effective syphilis elimination program in the United States could decrease HIV incidence.

Objective: To estimate the number and cost of new, syphilis-attributable HIV cases in African-Americans in 1999.

Methods: We used a simplified model of HIV transmission. Based on the number of reported syphilis cases and estimates of HIV and syphilis co-infection rates, we estimated the number of partnerships consisting of HIV-discordant African-Americans in which at least one partner had infectious syphilis. Using estimates of the probability of HIV transmission in such partnerships, we estimated how many new cases of HIV resulted from these partnerships as compared with how many new HIV cases would have been expected had syphilis not been present. We calculated the cost of these syphilis-attributable cases using published estimates of the discounted lifetime direct medical treatment cost per case of HIV ($195,000 in 1996 dollars).

Results: In 1999, an estimated 896 new cases of HIV in African-Americans could be attributed to the facilitative effects of syphilis. These 896 cases (602 women, 294 men) represent approximately 3 to 8 percent of all new cases of HIV in African-Americans in 1999.

Conclusions: A successful syphilis elimination program could reduce HIV incidence and the disproportionate burden of HIV/AIDS on the African-American community. This reduction in HIV incidence could save $175 million in future HIV costs, suggesting that a national syphilis elimination program likely would pay for itself.

Implications for Programs: Syphilis prevention can be a cost-effective tool for HIV prevention.

Implications for Research: More complex transmission models could be used to estimate the long-term effects of syphilis prevention on HIV incidence.

Learning Objectives: Participants will learn the basic components and methodology of this simplified transmission model, and will be able to evaluate the potential effect of syphilis elimination on HIV incidence for a wide range of populations.

Contact Information: National Center for HIV, STD, and TB Prevention, Office of Communications: 404-639-8895