Latebreakers - 2004 STD Prevention Conference

Latebreaker Abstracts

Syphilis Outbreak in Southwestern Idaho — 2002-2003

K Carter1,3, J Bartschi1, C Christiansen2, J Tripp2, P Harris2, C Hahn1

1Idaho Division of Health, Office of Epidemiology and Food Protection, Boise, ID; 2Southwest District Health Department, Caldwell, ID; 3Centers for Disease Control and Prevention, EPO/DAPHT/State Branch, Atlanta, GA

Background: Syphilis can facilitate HIV infection and cause stillbirth, blindness, and dementia. Recently in the United States, syphilis outbreaks among men who have sex with men (MSM) have been reported. We describe a syphilis outbreak in which heterosexual men, pregnant women, and no MSMs were reported.

Methods: Syphilis cases were defined by using CDC/CSTE case definitions. Standard CDC interview forms were used with case–patients and partners. Data were entered into STD*MIS and analyzed in EpiInfo™ version 3.01.

Results: The number of reported syphilis cases in Idaho during 2002–2003 was 64 compared with 22 during 2000–2001. Thirty-four (53%) of these 64 cases were early syphilis; 12 (19%) were detected during incarceration. Characteristics of the 64 case–patients were male, 34 (53%); age (yrs) 14–83 (median:26.5); ethnicity, 36 (54%) Hispanic, 21 (33%) non–Hispanic, 7 (11%) unknown; known pregnant at diagnosis, 12 (40%) of 30 females; residence in Southwest Health District, 29 (45.3%), including 21 early syphilis cases of which 17 (81%) were among Hispanics. The most frequently reported risk factor was sex with the opposite sex (25 (78%) of 32 responses from 24 case–patients). No sex partners of the same sex were reported.

Conclusions: An outbreak of syphilis predominately among heterosexual Hispanics is ongoing in Idaho. We recommended enhanced syphilis screening at prenatal care for young Hispanic females in southwestern Idaho and for inmates upon intake at correctional institutions. Follow-up of infants born to syphilis reactors is tracked by the health department. Outreach to Hispanics in southwestern Idaho to encourage prenatal care, syphilis awareness and testing, and safer sex practices is ongoing.

Implications for Programs, Policy, and Research: Syphilis prevention programs should include culturally and linguistically appropriate outreach to heterosexual, Hispanic populations. Research is needed to develop and evaluate such tools for outreach to affected communities.

Syphilis Among Men Who Have Sex With Men: Limitations of Traditional Case and Partner Services, San Diego County, CA

RA Gunn1,2, A Maroufi2, TA Peterman1

1Centers for Disease Control and Prevention, Atlanta, GA; 2Health and Human Services Agency, San Diego, CA

Background: Traditional syphilis control focuses on the prompt identification and treatment of infectious cases (primary and secondary [P&S] stage) and preventive treatment of sex partners. Anecdotal reports suggest this approach may not be very effective among men who have sex with men (MSM).

Objective: To determine the stage at diagnosis, the duration of the infectious period, and the outcome of partner services for MSM with P&S syphilis in San Diego County, 2002 – 2003.

Methods: The infectious period was defined as the number of days from onset of symptoms until treatment; for secondary stage cases, 21 days were added to the period to account for estimated primary stage infectious days.

Results: During the 2 years, 147cases of P&S syphilis were reported; 111 (76%) were MSM. Compared to heterosexual men, MSM cases were 40% less likely to be diagnosed in the primary stage (33% [37/111] vs. 53% [7/13], RR = 0.6, 95% CI = 0.4, 1.1, p = 0.25). Among MSM, those reporting receptive anal intercourse were 50% less likely to be diagnosed in the primary stage (26% [21/82] vs. 55% [16/29], RR = 0.5, 95% CI = 0.3, 0.8, p < 0.01). The mean infectious period for MSM was 36 days. MSM reported a total of 1190 sex partners (mean 11 per case) during the interview period but provided contact locating information for only 199 (17%); 34 (31%) of MSM named no contacts. Results of partner services will be reported.

Conclusion: Among MSM, the long duration of infectiousness and the low percentage of sex partners receiving partner services, very likely limits the community level effectiveness of the traditional approach.

Implications for Program and Research: The effectiveness of other approaches, such as symptom recognition (through education of MSM and clinical care providers), frequent serologic screening, and behavioral interventions should be evaluated.

Rapid Emergence of Gonococcal Fluoroquinolone Resistance in Men Who Have Sex With Men in King County, Washington

WLH Whittington1, MR Golden1,2, KK Winterscheid1, SA Wang3, KK Holmes1, HH Handsfield1,2

1Department of Medicine, University of Washington, 2Public Health—Seattle & King County, Seattle, WA; 3Centers for Disease Control and Prevention, Atlanta, GA

Background: Fluoroquinolone resistance in Neisseria gonorrhoeae is prevalent in many parts of the Pacific Rim. From 1995-2001, fluoroquinolone resistant gonococci caused <1% of reported cases of gonorrhea in King County. Sporadic cases (1.6% of 506 isolates tested) were identified during 2002, but rates rose in 2003.

Objectives: To describe prevalence and trends in gonococcal fluoroquinolone resistance in 2003.

Methods: Ciprofloxacin susceptibilities were determined by disk diffusion and agar dilution susceptibility tests on gonococci recovered by public and private clinical laboratories. Ciprofloxacin resistance was defined by a minimum inhibitory concentration (MIC) of >1 mg/ml.

Results: Throughout January-April 2003, 0/110 gonococcal isolates were ciprofloxacin resistant. During May-June, 4 infections in men (3 heterosexual) were caused by ciprofloxacin resistant gonococci and routine susceptibility testing of all isolates was implemented July 1. During July-September and October-December, 3.8% (6/159) and 16.5% (22/133) of isolates were ciprofloxacin resistant, respectively (P<0.05). All isolates with disk diffusion zone diameters <21 mm yielded MICs >1 mg/ml. From July through December, prevalence was similar among persons attending the Public Health STD Clinic (12%) and other facilities (10%). Three distinct phenotypes were identified and ciprofloxacin MICs were 4-16 mg/ml for 86% of isolates from these 28 infections. Decreased susceptibility to tetracycline and azithromycin was observed in 80% of ciprofloxacin resistant isolates. Almost all (27/28) infected persons were male. Among persons attending the STD Clinic, resistance was more common among men who have sex with men (MSM, 22%) than among heterosexual men and women (3%, OR 8.6, 95% CI 1.8-80.6).

Conclusions: Fluoroquinolone resistance emerged rapidly among persons with gonorrhea in Seattle during 2003; cases have been predominately identified in MSM. Local gonorrhea treatment recommendations were modified and fluoroquinolones are no longer recommended.

Implications for Programs, Policy and/or Research: Timely use of susceptibility tests permits appropriate local tailoring of gonorrhea treatment recommendations.

Partner Impairment of Safe Sex Behavior by Women Participating in a Randomized, Controlled STD/HIV Prevention Trial

A Holden1, R Shain1, J Piper1, J Korte1, S Perdue2, J Champion3

1University of Texas Health Science Center at San Antonio, OB Gyn; 2University of Texas Health Science Center at San Antonio, Microbiology; 3University of Texas Health Science Center at San Antonio, School of Nursing

Background: A controlled, randomized trial of a cognitive/behavioral intervention significantly reduced STD reinfection for one year among 477 participating women by reducing high-risk sexual behavior. Using detailed information about each woman’s sexual partners, we identified 78 men (8.7%), referred to as “players”, who had sex with more than one participant; 46 women (9.6%) were involved. Significantly, women partnered to these men experienced 34% of all infections during follow-up.

Objective: To determine if and the extent to which sexual contact with these men impacted the practice of safer sex.

Methods: We conducted chi-square and logistic regression analysis to assess the relationship between having sex with these men and the failure to practice safe sex. We also utilized chi-square analysis to identify those elements of the safer sex variable (no condom use with a casual partner, or problematic condom use in conjunction with 5 or more unprotected acts in the past 3 months) that were most affected.

Results: Women partnered to “players” were significantly more likely to practice unsafe sex (OR = 2.3, C.I. 1.6 - 3.5, p < .02). Specifically, they were more likely to never use condoms with him during sex (OR = 1.8, C.I. 1.0 - 3.5, p < .08). Of those who used condoms, more were likely to experience problems (OR = 2.9, C.I. 1.6-5.5, p < .01). These problems included, for example, slippage, breakage, improper coverage of the penis, and his removal of the condom prior to coitus. Finally, women partnered to these men were more likely than other women to report that their partners had “a lot” of influence over them (51.2% vs 38.5%, p=.07).

Conclusion: Women partnered with men who have proven sexual relationships with other women are less likely to practice safe sex, primarily absence of or incorrect condom use. They are also more vulnerable to his control.

Implications for Programs, Policy, and/or Research: Intervention attempts to reduce risky sexual behavior among women who interact with extremely high-risk men may need to address issues involving how to identify these men, how to avoid involvement with them, or increased acquisition of communication and related skills by program participants. Further, programs may need to incorporate specialized components to increase efficacy of identification and treatment of male partners of women at risk for disease transmission.

Remnants of the Tuskegee Syphilis Study Effects on University Freshmen: Yet a Possible Barrier to Research Participation?

CB Spivey, T Simpson, MK Oh, T Vazin1, K Gunn1

Univ Alabama at Birmingham and 1Alabama State Univ, Montgomery, AL

Background: African Americans’ distrust of the biomedical community has been attributed to the Tuskegee Study. Assessing perceived barriers to participation in biomedical research will illuminate the impact of the Tuskegee Study.

Methods: A cross-sectional survey was administered during freshmen orientation at a Historically Black University Sept-Oct 2003.

Results: A total of 691 students participated in the survey (57% female, 95% AA). When asked about the impact of the Tuskegee Study as a possible barrier to participation in biomedical research, 35% reported that it was very important, 33% reported that it was somewhat important, 14% reported it was unimportant, and 17% of those surveyed “never heard of it”. Alabama students were more likely than non-Alabama students to report the study as being very important to participation in research (X = 11.0; p-value = .01). Females were more likely to report the study as being very important than males (X= 22.42; p-value = .001), whereas males were more likely to cite the study as not being important. Students citing confidentiality as being highly important were significantly more likely to report the Tuskegee Study as being very important in their decision to participate in research (X= 34.39; p-value= .000). Likewise, those students in which confidentiality was not of concern were less likely to have heard of the Tuskegee Study. Students reporting mistrust of researchers were more likely to report the Tuskegee Study as being very important in their decision to participate in research (X= 62.1; p-value= .000). Trusting researchers were less likely to be an issue among students unfamiliar with the Tuskegee Study. Students citing lack of interest as a very important barrier were more likely to report the Tuskegee Study as being very important (X= 51.65; p-value= .000).

Conclusion: Study findings indicate that the Tuskegee Study still continues to be one of the pervading factors, within the African American community, influencing individual interest in participating in biomedical research. A.11 Philadelphia, Pennsylvania March 8-11, 2004 2004 National STD Prevention Conference

Implications for Programs, Policy, and/or Research: This study brought into focus the correlation of possible barriers precluding students’ willingness to participate in biomedical research. Programs seeking to increase minority participation in biomedical research should address these and related barriers.

Parental Receptiveness to a Hypothetical HPV Vaccine

AJ Lenar, EL Anderson, A Carpico, M Wentworth, K Connolly

Merck & Company, Inc., West Point, PA

Background: Human Papillomavirus (HPV) infection is the most common sexually-transmitted viral diseases worldwide. Overall, 50%-75% of sexually active men and women contract genital HPV infection at some point in their lives.1

Objective: To assess quantitatively parental acceptance of an HPV vaccine for adolescents if one were available.

Methods: An internet-based survey was administered to 2,050 parents of female adolescents, 9-17 years of age. In order to obtain a representative sample, quotas were set for Hispanic and African-American parents. Data were analyzed using cumulative logistic regression to examine factors influencing parental acceptance.

Results: Data demonstrated a majority (71%) of parents were generally unaware of a relationship between HPV and cervical cancer. Despite an initial lack of knowledge, when presented with epidemiological data regarding the disease, 62% percent of all parents said they would get their daughters vaccinated before their 18th birthday if a vaccine were available. Most of the remainder was unsure, rather than opposed to vaccination. Fewer than five percent of parents said that they would leave the decision up to their daughters, upon turning 18. The receptiveness hierarchy was most closely associated with protective attitudes towards children (OR = 9.70, p<.0001). Social values and perceptions regarding sexual debut influenced parental receptiveness, but to a lesser extent. In addition, a strong physician recommendation increases overall parental receptiveness to 79%, a change of 17%.

Conclusions: Most parents were unaware of a relationship between HPV and cervical cancer. Once they received information regarding the disease, parents of adolescent girls were receptive to vaccinating their daughters if a vaccine became available. Receptiveness increases with a strong physician recommendation.

Implications for Programs, Policy, and/or Research: Other research suggests that the physicians would respond favorably to an HPV vaccine if one were available and would be most likely to offer a personal recommendation to their older adolescent patients.2 Efforts may be needed to increase parental awareness of HPV.

1CDC, Tracking the Hidden Epidemics 2000,
2Physician Quantitative Study, Merck Vaccine Division, December 2003.

B2G Physician Attitudes and Receptiveness to STD Vaccines

A Carpico, E Anderson, AJ Lenar, M Wentworth, K Connolly

Merck & Company, Inc., West Point, PA

Background: Human papillomavirus (HPV) is a very common sexually transmitted disease (STD) among young, sexually active people. An estimated 20 million people in the United States currently have genital HPV infections.1

Objective: To assess quantitatively the prevalence of sexual risk discussions among physicians and their female adolescent patients, 9-18 years of age and to assess physician’s attitudes towards vaccines for STDs, including an HPV vaccine if one were available.

Methods: An internet-based survey was conducted with 642 physicians (309 pediatricians and 333 family practitioners) from the American Medical Association (AMA) master file. Quotas were set for physician specialty, gender, region, and type of practice, in order to obtain a representative sample of physicians.

Results: Over 50% of physicians reported having sexual risk discussions with their female adolescent patients, 9- 18 years of age. These discussions occurred more frequently with older patients. Forty-three percent of physicians reported that they strongly believe vaccines against STDs are important for their 9-12 year old patients; these physicians were more likely to strongly recommend an HPV vaccine if one were available. Among almost all physicians (73%), parental resistance to an HPV vaccine if one were available was considered an extremely, very, or somewhat important barrier to vaccination.

Conclusions: Many physicians reported discussing the risks of sexual activity with their adolescent patients; some physicians were more proactive than others. While many physicians considered vaccines against STDs important, parental resistance was perceived by physicians as a significant barrier to vaccinating their adolescent patients.

Implications for Programs, Policy, and/or Research: Other research suggests that many parents would be generally receptive to an HPV vaccine if one were available and a strong physician recommendation increases their receptivity.2 In this study, many physicians perceived parental resistance as a large barrier. It appears that there is a knowledge gap between physicians and parents that needs to be closed in order to reduce misconceptions about STD vaccination.

Learning Objectives: By the end of the session, participants will learn about the prevalence of sexual risk discussions among physicians and their 9-18 year old patients. In addition, participants will be able to describe physician attitudes regarding STD vaccines for their adolescent patients.

1CDC, Tracking the Hidden Epidemics 2000,
2Parent Quantitative Study, Merck Vaccine Division, December 2003.

C5G Lessons Learned: Sexual Health Social Marketing in Retail Pharmacies

S Cohen

Pharmacy Access Partnership, Public Health Institute, San Francisco, CA

Background: With direct pharmacy access to emergency contraception in California, there are opportunities for pharmacies to a play stronger role in STI prevention. Consumer awareness of the family planning category, including condoms, is limited as products are not actively promoted and educational materials are not widely provided. In some pharmacies condoms are difficult to locate as they are placed in a “feminine hygiene” aisle. Piloting traditional pharmacy marketing strategies applied to the family planning product category is a new direction for pharmacy retailers.

Objectives: Reinforce consumer’s decision to seek/use OTC family planning products. Increase consumer educational opportunities for STI prevention. Increase public awareness of pharmacist services

Methods: During 2003, Pharmacy Access Partnership worked with pharmacies and public health stakeholders to create and pilot educational and promotional materials for retail pharmacy settings. Materials include signs, posters, shelf talkers, coupon bag stuffers, and brochures. Selected pharmacies in California including major chain stores were recruited to pilot materials.

Results: Approximately 100 pharmacies committed to piloting materials. This presentation highlights lessons learned in developing materials and describes implementation challenges and evaluation of using pharmacies to increase consumer education around STIs.

Conclusions: By prominently grouping OTC contraceptive supplies with educational materials, pharmacies have the opportunity to better meet consumer needs and play a more active role in STI prevention.

Implications for Programs, Policy, and/or Research: As pharmacies are part of the health care system that people interact with most, they serve as an important place to deliver STI prevention education.

Learning Objectives: By the end of the session, participants will be able to (1) recognize the role pharmacies can plan in promoting the prevention of STIs (2) understand the implementation challenges in promoting sexual health education in a retail store environment.