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Oral, Symposium, and Workshop Abstracts - D

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D1

Linking STD and HIV Control Programs with Harm Reduction Strategies for Injection Drug Users

S Jenison¹, B Trigg¹, M Samuel²

1New Mexico Department of Health, Public Health Division; 2STD Control Branch, California Department of Health Services

Background: Since 1997, the New Mexico Department of Health has undertaken statewide implementation of harm reduction programs that include syringe exchange to reduce the transmission of HIV and hepatitis virus infections among injection drug users (IDUs), their sex partners and children. To date, approximately one quarter of New Mexico IDUs are enrolled in urban and rural community-based programs throughout the state. Within the last year, the New Mexico Legislature passed laws that permit syringe sales to IDUs in pharmacies and the use of naloxone by law enforcement agents and IDUs to treat heroin overdoses. These harm reduction activities provide unique access to a high-risk underserved population that facilitates a range of public health interventions including HIV testing, STD screening, hepatitis A and B vaccination and tuberculin skin testing.

Purpose: To discuss the public health opportunities, including STD screening and hepatitis vaccination, that are afforded by harm reduction programs.

Methods: In this workshop, we will describe the results of a street-based seroprevalence study among IDUs in New Mexico that indicated a low prevalence of HIV infection (<1%) and a high prevalence of hepatitis C infection (82%). The presenters will recount how these data were used to inform the New Mexico Legislature and Governor, resulting in the passage of laws that legalized syringe exchange, permitted syringe sales to IDUs in pharmacies, and limited the civil and criminal liability associated with the administration of opioid antagonists to treat heroin overdose. Participants will discuss public health interventions, including STD prevention and treatment, that could be offered to IDUs in the context of harm reduction programs.

Learning Objectives:

1. Describe the harm reduction strategy as it relates to public health interactions with IDUs.

2. Describe the range of public health interventions that can be offered to IDUs in the context of harm reduction programs.

Contact Information: Steve Jenison / Phone 505-476-3619 / stevej@doh.state.nm.us

D2

The Cost-Effectiveness of Jail-Based STD and HIV Prevention Programs and Their Impact on Inmate and Community Health

T Gift¹, B Varghese¹, J Kraut², D Beete³, H Beidinger¹, D Broussard³, T Conklin⁴, A McIntyre⁵, S Mier³, T Lincoln⁴, C Mugalla¹, R Tuthill⁶, K Irwin¹

1Centers for Disease Control and Prevention, Atlanta, GA, 2Northern Illinois University, DeKalb, IL, 3Cook County Jail, Chicago, IL, 4Hampden County Correctional Center, Ludlow, MA, 5University of Illinois at Chicago School of Public Health, Chicago, IL, 6University of Massachusetts-Amherst School of Public Health, Amherst, MA

Background and Rationale: Correctional facilities offer opportunities for HIV counseling and testing (CT) and STD testing and treatment for a sub-population at high risk for these infections. Partner notification (PN) services for inmates’ sex partners can provide a linkage to disease prevention in the community. Cost-effectiveness evaluation is one tool that can support resource allocation decisions. Inmates at HCCC are routinely screened for chlamydia, and are tested for gonorrhea if patient history, symptoms, or signs indicate elevated risk. They are offered serologic HIV CT. At CCJ, women are screened for syphilis with either routine or rapid RPR tests.

Objectives: To describe the process of data collection and the results of cost and cost-effectiveness analyses of jail-based HIV CT and STD testing programs.

Content: After a presentation describing the HIV CT and STD programs in place at HCCC, investigators will describe the process of data collection, analysis procedure, and results of cost and cost-effectiveness analyses of the HCCC HIV CT program, the HCCC STD screening and PN program, and the syphilis screening and PN program at CCJ.

Implications for Programs/Policy: This research will help quantify the costs of jail-based HIV CT and STD programs, identify key factors influencing their cost-effectiveness, and show what the impact is on community health of providing services to inmates’ sex partners. It will provide information useful to state and county correctional programs wishing to evaluate their existing programs or consider adopting new ones.

Implications for Research: Future studies should prospectively examine the cost-effectiveness of these screening approaches compared to targeted screening.

Learning Objectives:

1) Identify the key parameters influencing the cost-effectiveness of jail HIV CT and STD screening programs given the unique characteristics of incarcerated populations.

2) Quantify the impact on the cost-effectiveness of the jail screening programs of incorporating community health services (PN) into the analysis.

D3

Integrating Viral Hepatitis Prevention into STD/HIV Prevention Programs

J Buffington¹, K O’Connor¹, R Zimmerman², K Schlanger³, I Weisfuse³, R Gunn⁴

1Centers for Disease Control and Prevention, Atlanta, GA; 2Illinois Department of Public Health, Springfield, IL; 3New York City Department of Health, NY, NY; 4San Diego County Department of Health, San Diego, CA

Background and rationale: Viral hepatitis is a major public health problem in the United States. An estimated 120,000 new hepatitis B virus (HBV) and hepatitis C virus (HCV) infections occurred in 1998. Approximately 1.2 million Americans are chronically infected with HBV (primarily a sexually transmitted disease [STD]); an estimated three million are chronically infected with HCV (primarily blood borne; may be transmitted sexually). Integrating hepatitis prevention services into existing programs is an essential step towards prevention and control of these diseases.

Objectives: To explore strategies for, share experience and barriers to integrating hepatitis prevention activities into existing programs; to track activities; to explore mechanisms for outreach to high risk populations; to measure the impact of integration on existing services.

Content: Experience in Illinois, San Diego, and New York City on integrating hepatitis prevention into existing programs will be presented. Strategies for outreach to high-risk populations, integration, evaluation, and tracking of counseling, testing, vaccination, and medical management services, and measurement of the impact of services on existing programs will be discussed.

Implications for Programs/Policy: Integration into existing programs of activities to prevent and control hepatitis among persons at high risk for multiple infections (HIV, STDs, hepatitis) makes good public health sense. However, limited experience exists as to the feasibility, efficacy, and effectiveness of integrated services. Activities presented will provide much-needed information in support of program integration and setting of policy to support integration of services to persons at risk for multiple diseases.

Implications for Research: Program evaluation and outcomes research (both disease and behavioral) are critical to efforts to integrate services for prevention and control of blood borne and sexually transmitted diseases. Planning for this research must be integral to integration activities, as public health settings with limited resources need to determine the most efficient and cost-effective ways to provide services to at-risk populations.

Learning Objectives:

1) By the end of the session, participants will be able to describe strategies to and identify barriers against integrating viral hepatitis prevention activities into existing STD programs; 2) By the end of the session, participants will be able to describe key factors in targeting and reaching persons at high risk for hepatitis infection who may benefit from integrated service delivery.

Contact Information: Joanna Buffington / Phone 404-371-5293 / jbuffington@cdc.gov

D4

Using Agency-Specific and Community-wide Needs Assessments for Improving Integrated and Teen-Friendly Sexual and Reproductive Health Services for Adolescents

V Loo¹, C Brindis², B Allen³, J Wasserheit⁴, N Adler⁵, G Bolan¹

1Sexually Transmitted Disease Prevention and Control Branch, California Department of Health Services, Berkeley, CA; 2Institute for Health Policy Studies, University of California–San Francisco; 3Division of AIDS & Communicable Disease, Department of Public Health, Alameda County, CA; 4Division of STD Prevention, National Center for HIV, STD, and TB Prevention, CDC, Atlanta, GA; 5Department of Psychiatry, School of Medicine, University of California–San Francisco

Background: National guidelines recommend integrated service delivery and teen-friendliness as strategies for improving adolescents’ utilization of sexually transmitted disease (STD), HIV, and family planning services. A guidebook for putting these recommendations into action was developed through a case-study of current service models implemented by adolescent providers in Alameda County, California.

Purpose: This workshop will assist health agency staff, program administrators, and community groups assess the needs and assets of both clinical and primary prevention sexual and reproductive health services currently available to adolescents they serve. The workshop will also demonstrate how to use the assessment to plan next steps for achieving more integrated and teen-friendly programs.

Methods (Instructional Approach): Steps for conducting both individual program and community-level assessments will be reviewed. Special topics include: organizing a collaborative effort around program assessment, determining a program’s current level of teen friendliness and integration, implementing routine risk assessments, developing strong referral linkages, collecting provider and client feedback in a confidential manner. Using findings from a sample program assessment, facilitators will lead participants through exercises simulating the process of summarizing findings of a program assessment and planning next steps. A portion of the workshop time will be spent discussing implementation in the context of participants’ specific programs or communities. Copies of the guidebook will be distributed to participants at the workshop.

Learning Objectives: By the end of the workshop, participants will be able to plan a needs assessment of individual program or community-wide services; select and administer appropriate assessment tools; interpret assessment results through group discussion; identify doable next steps and create action plans to achieve service delivery goals.

D5A

Discord, Discordance and Concurrency in New Partnerships

LN Drumright¹, PM Gorbach², KK Holmes³

1University of California – San Diego, School of Medicine; 2University of California – Los Angeles, School of Public Health; 3University of Washington, Center for AIDS and STD Research

Background: Sexual links between high and low STD prevalence groups and concurrency contribute to STD transmission.

Objective: Determine associations between STDs, concurrency and commitment at the partnership level.

Methods: Ninety-six individuals presenting for care at STD and family planning (FP) clinics in San Diego and their new partners (N = 192) underwent audio computer-assisted interviews, were tested for gonorrhea and chlamydial infection by ligase chain reaction, for trichomoniasis by culture (InPouch), and had medical records reviewed. First sex in partnerships occurred in the past three months. Recent STD infection and discordance were analyzed using chi-squared and logistic regression at the partnership level.

Results: Overall, in 22% of partnerships one or both partners had STD in past 6 months, including 35% of partnerships discordant vs. 13% concordant by number of lifetime partners (P=0.02); 33% discordant vs. 14% concordant for considering partnership dissolution (discord) (P=0.03); and 36% of partnerships in which one or both reported other partners (concurrency) vs. 17% of those non-concurrent (P=0.05). In multivariate analysis stratified by clinic, partnerships with STD were significantly more likely discordant by ethnicity (OR = 3.3); number of lifetime partners (OR = 5.3); discordant for considering partnership dissolution (OR = 4.1); and more likely to report concurrency at onset (OR = 3.5). Education discordance and condom use were not associated with STD.

Conclusions: At the partnership level, partnership discordance by ethnicity and number of lifetime partners were associated with STDs in new partnerships, possibly representing bridging between different sexual networks. Concurrency at first sex and discordance in commitment may also be markers for increased STD risk.

Implications for Programs: Data on partnership characteristics from young heterosexuals attending STD and FP clinics may help identify those with STD.

Implications for Research: Studies examining the relationships of STD and partnership patterns may contribute to understanding STD transmission and sexual networks.

Learning Objectives: Ability to describe patterns of risk for STDs in new partnerships.

Contact Information: Lydia N. Drumright / Phone 619-692-8091 / ldrumright@ucsd.edu

D5B

Geographic Bridges for Importation of STD in the Seattle Metropolitan Area: Barbarians at the Gates

RP Kerani¹, MR Golden^1,2, WLH Whittington¹, HH Handsfield^1,2, KK Holmes¹

1University of Washington, Seattle, WA; 2Public Health–Seattle and King County, Seattle, WA

Background: Importation may be an important contributor to persistence of bacterial STD in populations with low STD endemicity.

Objectives: To describe potential importers of gonorrhea and chlamydial infection.

Methods: Heterosexuals with gonorrhea or chlamydial infection were interviewed about demographics and partnership characteristics, including the residences of up to nine sex partners (SP) encountered during the preceding 60 days. Geographic bridges were defined as infected persons with >1 SP residing within and >1 SP residing outside of the Seattle metropolitan area (SMA). Among bridges, characteristics of partnerships involving partners living within and outside of the SMA were also compared.

Results: Of 2294 persons interviewed, 224 (10%) reported >1 partner from outside the SMA, and 107 (5%) were classified as geographic bridges. In multivariate analyses, bridges were more likely than other infected persons to be employed full-time (OR = 2.1, 95% CI: 1.2–3.5), white (OR = 1.6, 1.1–2.5), live in high socioeconomic status areas (SES: OR = 1.9, 1.3–3.0), report concurrent partners (OR = 2.0, 1.4–3.4), and believe their SPs had other partners (OR = 4.7, 2.8–7.9). Bridges reported that their partners from outside of Seattle, compared to local partners, were more often one-time partners, less likely to be persons they expected to have sex with again, and more often the suspected source of their infection. Bridges also reported being less able to contact distant partners.

Conclusions: High-risk partnerships outside of Seattle were especially common among persons of higher SES and may be important in maintaining STD endemicity.

Implications for Programs/Policy: In regions with low rates of bacterial STD, further reductions in prevalence may be dependent on improved disease control in areas with higher STD prevalence. Geographic restrictions on partner notification may be a barrier to effective disease control.

Implications for Research: Studies defining the contribution of STD importation to maintenance of endemic infection are warranted.

Learning Objectives: Participants will be able to describe the characteristics of potential importers of bacterial STD in the Seattle Metropolitan Area.

D5C

STD Prevention: The Female as Health-Communicator and Risk-Manager

M Vega

University of California, Berkeley, CA

Background: Sexually transmitted diseases are socially transmitted diseases in as far as sexual behavior is social. Behavioral changes that not only minimize physical risks, but take into account social components of transmission, represent the greatest hope for controlling the spread of STDs. Precautionary behavior such as condom use generally requires negotiating with a sexual partner.

Objective: In order to illuminate the operative social processes, we need to take into account: (1) The specific interpersonal dynamics of dyadic behavior—including power differentials, and (2) The relationship type. Based on research suggesting individuals maintain interpersonal scripts guiding behavior, a study was conducted to investigate how condom use, communication about condom use, and subsequent emotions are scripted in heterosexual relationships.

Method: One hundred eighty-eight undergraduates read one of four possible vignettes depicting different heterosexual dating relationships (one-night stand; first date; just physical; committed). The vignette promptly ends after the couple begins to kiss. Thus, respondents “filled in the gaps” based on perceived interpersonal scripts. Condom use was hypothesized to be scripted as occurring in less intimate relationships (one-night stand; first date). The female was posited to be the health communicator because of her role as sexual “gatekeeper.”

Results: Contrary to hypotheses, condom use is perceived as occurring throughout relationships. However, condom use communication is not perceived as occurring right before sex—including a one-night stand. Furthermore, women are perceived as the ones to initiate said communication across all relationships. Respondents, in open-ended accounts, indicate women have the potential to “lose the most” consequently holding women responsible as the health communicator—reinforcing a notion that safe sex is a female concern. Furthering this notion is the perception that the male is happy when not using a condom. The results indicate a female “gatekeeping” script.

Implications for Research: This research recognizes the importance of incorporating aspects of social interaction into understanding sexual health behavior. Specifically, the impact of social context on risky decision-making, such as whether or not to use a condom.

Implications for Programs/Policy: By gaining a better understanding of these sexual scripts, one can try to address these scripts in intervention programs. One such intervention may involve airing more condom negotiation strategies aimed at men to relieve women from being the sole “risk manager.” An understanding of these interpersonal scripts can lead to safe-sex messages that resonate with target audiences.

D5D

Evaluation of Field Delivered Therapy for Individuals with Uncomplicated Chlamydial or Gonococcal Infections

V Davila, CK Kent, J Chaw, L Fischer, J Klausner, DIS staff

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

Background: In March 1999, in order to facilitate treatment, SFDPH implemented a protocol for Disease Intervention Specialists (DIS) to deliver single dose therapy in the field (FDT) to individuals with chlamydia or gonorrhea and their partners.

Objective: To evaluate FDT for individuals with uncomplicated chlamydia or gonorrhea.

Methods: FDT was performed under the medical license of our program director, and was offered to persons reluctant to return for treatment of uncomplicated chlamydia or gonorrhea. For those who agreed to FDT, DIS assessed the client’s behavior, provided HIV/STD prevention education, provided azithromycin 1 gm, cefixime 400 mg, or both depending upon the diagnosis, provided information about the medication and potential complications, and had the client read and sign a consent form. We also followed-up with partners and gave them the option of FDT. We compared the proportion of persons brought to treatment before FDT became available (1998) with the proportion brought to treatment after the first full calendar year of implementation (2000).

Results: In 1998, 56.7% (261/460) of those assigned for treatment follow-up were brought to treatment, while in 2000 it increased to 74.6% (478/641) (P<.01). Since its inception, 14% (191/1384) of clients followed-up for treatment received FDT. Those accepting FDT were significantly more likely to be female, <25 years, African-American or heterosexual (all P values <.05). The majority (80%) of those treated by FDT had chlamydia. Between March 1999 and September 2001, there were no reported complications from FDT.

Conclusions: FDT is feasible to implement and appears to be effective in enhancing treatment follow-up, especially for those at greatest risk for adverse sequelae young women.

Implications for Program: FDT may assist other programs in increasing treatment follow-up of difficult to motivate individuals.

Implications for Research: FDT should be evaluated in other communities.

Learning Objectives:

1. Participants will be able to describe basic components of implementing FDT.

2. Participants will be able to describe a method for evaluating FDT.

D5E

Cost Effectiveness of Patient-Delivered Partner Treatment Compared to Partner Referral for Chlamydial Infections in Women

JA Schillinger, MR Sternberg, T Gift

Centers for Disease Control and Prevention, Atlanta, GA

Background: To interrupt disease transmission and prevent re-infection, treatment must be provided to the male sex partners of women with Chlamydia trachomatis (Ct) infection. Patient-delivered partner treatment (PDTx) is a strategy of providing Ct-infected women with medication to deliver to their male partners as treatment for Ct.

Objectives: To compare the cost effectiveness of PDTx for Ct infection to partner referral (PR), the standard practice for managing the male sex partners of Ct-infected women in the US.

Methods: The cost effectiveness of 3 strategies was compared using decision analysis: 1) PDTx provided for all partners 2) PR for all partners, and 3) Selective-PDTx (PDTx provided only to partners not expected to seek care, PR was provided to all others). The outcome of interest was pelvic inflammatory disease (PID). Costs were estimated from the health-care perspective and that of a single clinic (which excludes PID costs). Probability and cost parameters were derived from medical literature, industry data, and a recently completed trial comparing PDTx to PR.

Results: In a hypothetical cohort of 1000 women, a similar number of cases of PID resulted under each of the partner management strategies (~85 cases). Men’s concurrent female partners added approximately 25 cases of PID to each of the strategies. From the health care perspective PDTx provided a cost saving of at most 10% compared to PR. PDTx was least expensive (~$33) from a single clinic perspective, with cost savings approaching 20%. PDTx provided treatment to 15% more Ct-infected men than either PR or Selective-PDTx.

Conclusions: PDTx provides limited savings, and leads to treatment for substantially more infected men than does PR.

Implications for Programs/Policy: STD control programs may consider PDTx a cost effective strategy.

Implication for Research: Future studies should measure male partners’ compliance with patient-delivered medication, examine effectiveness of PDTx for gonorrhea, and study effectiveness of PDTx with male index patients.

Learning Objectives: Participants should be able to: 1) describe the three strategies presented, 2) outline key assumptions in the decision analysis, and 3) discuss some of the reasons the three strategies yielded similar results.

D5F

Training Sex Workers as Disease Prevention and Health Promotion and Maintenance Educators

J Breyer³, C Cloniger III¹, D Cohan², T Knutson³

1San Francisco Department of Public Health (SFDPH), San Francisco, CA; 2University of California, San Francisco, San Francisco, CA; 3St. James Infirmary (SJI), San Francisco, CA

Background: Based on its health needs assessment data San Francisco’s St. James Infirmary (SJI), the nation’s first occupational health and safety clinic for sex workers, has begun an innovative program to train sex workers as HIV/ STD risk assessment/ reduction counselors, and, sexual and general health promotion/ maintenance educators.

Objectives: To decrease HIV/STD sexual risk taking, increase knowledge of and access to age and risk appropriate disease prevention screenings and immunizations, and promote and facilitate overall improved health among sex workers in San Francisco

Methods: SJI staff self selected for inclusion in the training program, which was conducted by SJI-affiliated medical staff in conjunction with the San Francisco Department of Public Health, Division of STD Prevention & Control, as well as other local agencies. Educational sessions included standard programs for HIV risk assessment and risk reduction counseling and testing, the CDC STD modules, and national and local health care maintenance guidelines.

Results: Seven sex worker staffers of St. James Infirmary have enrolled in the program and have begun utilizing their skills with sex worker clients during clinic visits and outreach activities.

Conclusions: Sex workers can be trained to provide HIV/STD risk assessment and risk reduction counseling and general health care promotion and maintenance education to their colleagues.

Implications for Research: Additional studies would be useful in assessing actual decreases in morbidity and increases in health promotive behaviors among sex workers exposed to the peer educators.

Implications for Programs/Policy: As demonstrated in the cross-cultural health care literature, interventions which spring from the communities they seek to target are likely to have greater impact on disease prevention and health maintenance than those arising outside the community.

Learning Objectives: Understand how community based health initiatives in collaboration with public health agencies may help bridge gaps in health care to communities outside the mainstream of service delivery.

Contact Information: Charles Cloniger / Phone 415-487-5556 / Charles_cloniger@dph.sf.ca.us

D6A

Utilization and Quality of STD Services in Managed Care Organizations: A Synthesis of Recent Research

K Irwin¹, W Lafferty², ER Brown³, N Pourat³, M Stiffman⁴, D Magid⁵, S Ratelle⁶, R Platt⁷, D Yokoe⁷, G Tao¹, L Anderson¹, E Patterson¹, W Kassler⁸

1Centers for Disease Control, Atlanta, GA; 2University of Washington, Seattle, WA; 3University of California, Los Angeles, CA; 4HealthPartners, Minneapolis, MN; 5Kaiser Colorado, Denver, CO; 6Massachusetts Department of Public Health, Jamaica Plain, MA; 7Harvard Medical School, Boston, MA; 8New Hampshire Department of Health and Human Services, Concord, NH

Background: Managed care organizations (MCOs) now provide most STD care in the US. However, little is known about the utilization and quality of STD care in MCOs.

Objective: To review the results of CDC-sponsored research on STD care delivered in commercial and Medicaid MCOs from 1997–2001.

Methods: CDC-sponsored intramural and extramural projects addressed the delivery of STD risk assessment, screening, diagnostic testing, treatment, risk reduction counseling, and partner services. Data from medical claims and records, surveys of MCO clinicians and policies, and surveys of the privately insured adults were analyzed.

Results: Only 27% of privately insured adults and 47% of adolescents in three Medicaid MCOs had sexual risk assessment during routine checkups. In three Medicaid MCOs, <28% of sexually active adolescents were screened for chlamydia. In another 31 Medicaid MCOs, only 55% of clinicians reported screening adolescents for chlamydia. Only 50% of pregnant women insured by >100 commercial MCOs were screened for syphilis. In two commercial MCOs, >25% of clinicians reported that finding time or staff for risk assessment, counseling, and partner services was problematic. Among 21 Medicaid MCOs, <60% had policies to notify health departments about partner services. In three commercial staff-model MCOs, >86% of men with symptomatic urethritis were tested and treated with CDC-recommended antibiotics, and >93% of chlamydial infections and genital warts were treated with CDC-recommended treatments.

Conclusion: Substantial improvement in risk assessment, screening, counseling, and partner services is needed in both commercial and Medicaid MCOs. Diagnostic testing and treatment appear adequate in several commercial MCOs.

Implications for Programs/Policy: Interventions to improve STD care should focus on risk assessment, screening, counseling, and partner services.

Implications for Research: More research on actual and perceived barriers to STD care is needed, especially in network-model MCOs that dominate the commercial market and in Medicaid MCOs that serve high risk populations.

Learning Objectives: Participants will be able to identify barriers to STD care that can guide intervention development in MCOs.

Contact Information: Kathleen Irwin / Phone 404-639-8979 / kli1@cdc.gov

D6B

Women’s Health Care Utilization Following an STD Diagnosis

S Wilson¹, N Brown¹, M Manos², W Leyden², V Chin², D Levin², P Braverman³, S Shapiro², P Lavori⁴

1Palo Alto Medical Foundation Research Institute; 2Kaiser Permanente Medical Group, Inc.; 3St. Christopher’s Hospital for Children; 4Stanford University

Background: STDs have been linked to subsequent infertility, increased risk of cervical cancer, complications in pregnancy, and increased risk of HIV. Relatively little is known about patterns of near-term health care utilization (HCU) subsequent to an STD diagnosis.

Objectives: To quantify HCU for new/recurrent STDs and other relevant Ob/Gyn and mental health problems in the 18-months subsequent to an STD diagnosis.

Methods: Using a prospective cohort design, we compared HCU between 18–45 year old female Kaiser Foundation Health Plan members diagnosed with an STD (n = 1,205) and a medical-center-and-age group-matched sample of women seen for a non-STD diagnosis (n = 4,820), with/without controlling for pregnancy status and chronic disease status.

Results: An STD diagnosis was associated with significantly higher rates of office visits for cervical dysplasia (RR = 1.66), dyspareunia/pelvic pain/PID (RR = 1.67), abnormal bleeding (RR = 1.31), high risk/complicated/ectopic pregnancy (RR = 1.48), and behavioral/mental health problems (RR = 1.26), as well as for STDs (RR = 3.84), candidiasis (RR = 1.96), and vaginitis (RR = 2.39), compared with women seen for a non-STD diagnosis.

Conclusions: Detrimental sequelae of STDs are reflected in substantially elevated near-term HCU following an STD diagnosis.

Implications for Programs/Policy: This evidence further justifies aggressive efforts to prevent STD infections.

Implications for Research: The present results can be useful in defining HCU end-points and planning sample size in STD prevention intervention trials.

Learning Objectives: By the end of this session, participants will be able to describe the health care utilization pattern of women (ages 18–45) diagnosed with an STD.

D6C

Re-infection With Chlamydia trachomatis in a Large Northern California HMO: Implications for Screening

M Kang¹, J Chow¹, T Dunn², K Deosaransingh², S Black², G Bolan¹

1California Department of Health Services; 2Kaiser Permanente Medical Care Program of Northern California, Berkeley, CA

Background: Women with recurrent Chlamydia trachomatis (CT) infection experience more serious disease sequelae than those infected once. While annual screening of young women is recommended, re-screening of chlamydia infected women is not.

Objectives: This analysis examines rates of, and factors associated with, recurrent chlamydia among females seeking care through a large health maintenance organization (HMO).

Methods: From July 1, 1999, to June 15, 2001, all CT or gonorrhea (GC) laboratory records for females ages 10 and over were merged with clinic encounter data. Test positivity and re-infection were analyzed by age and time since initial infection. Tests less than 30 days apart or more than 11 months from initial infection were excluded from analysis.

Results: Among women tested, (N = 203,071) 2.7% (5504) were positive at least once for CT and 65% of positives were retested within the study. Of women retested within 11 months, 15% became re-infected (395/2604). Median time to re-infection was 4.2 months (range 1 to 11). Of women aged 10 to 19, 19% were re-infected compared to 14% of 20 to 25 year olds and 8% of women over 26. Over half of reinfections occurred before 5 months and more than 75% occurred by 7 months. Re-infection was associated with younger age, high morbidity, county or residence, and infection with GC during follow-up. Effects of age were modified by county morbidity. For CT positives in high morbidity counties, hazard ratio (HR) per year younger was 1.11 (95% confidence interval [CI] 1.07–1.15).

Conclusions: Women infected with CT, particularly young women in high prevalence areas, and women with GC infection, require more frequent screening to detect prevalent recurrent infections.

Implications for Programs/Policy: These data support recommendations to re-screen women infected with chlamydia. Screening recommendations should reflect the characteristics of the population that is being screened. Re-screening of women who have had a chlamydia infection within 4 to 6 months of their initial positive test would identify more than half of women re-infected, and could prevent sequelae associated with multiple infections.

Implications for Research: This study was based on a review of administrative databases. In order to create evidenced based screening guidelines, studies of re-infection should be performed in a variety of geographic and clinic settings. Information from a prospective active cohort of participants would also help to understand the factors associated with reinfection and with return for testing.

Learning Objectives: Participants will be able to describe the association of age, gonorrhea, and prevalence with repeat chlamydia infection. Participants will also be able to discuss implications of re-infection for screening policies.

Contact Information: Mi-Suk Kang / Phone 510-883-6644 / mkang@dhs.ca.gov

D6D

Beyond Knowledge: Integrating the Sexual History Taking Literature to Improve Provider Practices

K Farber, H Bauer, G Bolan

California Department of Health Services Sexually Transmitted Disease Control Branch, Berkeley, CA

Background: Routine sexual risk assessment in primary care enables appropriate STD screening and risk reduction counseling. Studies of primary care clinicians’ practices, however, continue to show sporadic and cursory sexual history taking. While study authors attribute barriers to providers’ lack of knowledge about STDs and sexuality, research suggests that increased awareness alone rarely changes practice patterns. Integrating findings from the sexual history taking literature can lead to innovative ways of addressing the barriers to sexual history taking.

Objective: To identify barriers to sexual history taking, underlying factors, and intervention opportunities.

Methods: A systematic review of 20 studies (13 provider surveys, 3 program evaluations, 2 chart reviews, and 2 observational studies) of sexual risk assessment practices, barriers, and/or provider interventions among U.S. primary care clinicians published 1990–2001 was conducted. Barriers most consistently identified through provider surveys were selected, and all articles were searched for factors associated with those barriers.

Results: The most consistently cited barriers were: (1) lower priority given to STD prevention, relating to an acute care emphasis and the devaluation of sexual health and behavioral interventions; (2) provider discomfort due to awkwardness with sexual language, concern for patient privacy, and perceived social risks; (3) inadequate provider training, particularly a lack of skills, tools, and behavior change guidance; and (4) lack of time, relating to insufficient reimbursement and the perceived complexity of sexual history taking. Provider interventions that demonstrated techniques and allowed clinicians to practice skills were more effective than purely didactic interventions.

Conclusions: This review suggests that provider barriers go beyond knowledge to include professional culture and reimbursement issues, along with needs for skills-based training, risk assessment tools, and guidance through the behavior change process.

Implications for Programs/Policy: Clinical and continuing education programs that reinforce prevention priorities, model sexual history taking techniques and language, and incorporate behavior change interventions may be more effective than didactic approaches. Strategies that address reimbursement barriers, such as billing codes for risk assessment and risk reduction counseling, may also promote sexual history taking.

Implications for Research: Researchers should develop and validate clear, brief risk assessment tools and evaluate interventions for their impact on behavior change and skills development.

Learning Objectives: By the end of this presentation, participants will be able to identify the top four barriers to sexual history taking in primary care, describe underlying factors, and evaluate educational and structural interventions.

Contact Information: Katy Farber / kfarber@dhs.ca.gov

D6E

Physician Practices for Syphilis Screening and Case Management: A Comparison of High Morbidity, Potential Re-emergent and Low Morbidity Areas

JS Leichliter, SP Williams, G Counts

Centers for Disease Control and Prevention, Atlanta, GA

Background: Effective elimination of syphilis is dependent upon many factors including the screening of at-risk individuals and the reinforcement of prevention practices. The purpose of this presentation is to describe the syphilis screening and prevention practices of a sample of US physicians who practice in high morbidity (HMA), potential re-emergent (PRA) and low morbidity (LMA) areas.

Objectives: To describe the differences in syphilis screening and case management between US physicians in areas of diverse syphilis morbidity.

Methods: From 5/99–1/00, 4,226 US physicians completed a survey examining physicians’ STD prevention and control practices (e.g. screening, patient counseling, partner notification). The sample consisted of public (13%) and private physicians (87%), with three-quarters of respondents male and 81% white. Physicians were practicing for an average of 18 years with 43 hours per week in direct patient care (0 = 98 patients/week). Chi-squares and ANOVAs were utilized.

Results: PRA physicians reported significantly higher syphilis screening rates compared to HMA and LMA physicians for males (53 vs. 29 and 27%), non-pregnant females (62 vs. 34 and 28%) and pregnant females (65 vs. 57 and 54%), respectively. Generally, PRA physicians also reported providing patient counseling and partner notification significantly more often than HMA and LMA physicians. PRA physicians nearly “always” told patients to use condoms and believed that it was “very worthwhile” to encourage patient referral. Demographic and practice differences between HMA, PRA and LMA physicians will also be discussed.

Conclusions: PRA physicians engaged in more syphilis screening and reinforcement of prevention practices than their counterparts in HMAs and LMAs.

Implications for Program/Policy: Private and public physicians in HMAs and PRAs should be included in enhanced syphilis elimination efforts.

Implications for Research: Findings can contribute to the development of interventions that target private and public physicians delivering STD prevention and care.

D6F

Physicians’ Actions Following the Diagnosis of a Bacterial STD: Results from a National Survey

DH McCree, N Liddon, M Hogben, JS St Lawrence

Centers for Disease Control and Prevention, Atlanta, GA

Background: Research shows that brief interventions by physicians following STD diagnosis can reduce further STD risk. However, relatively little is known about what actions physicians currently take following diagnosis.

Objectives: To describe the reported actions that physicians take after diagnosing gonorrhea, chlamydia or syphilis and to determine if these actions differ across the three STDs.

Methods: A random national sample of 7,300 physicians (70% response rate) practicing in five medical specialties providing care for 85% of the STDs reported in the United States responded to 12 questions. Physicians reported how often they engaged in counseling patients about prevention methods and treatment, and partner follow-up choices. Mean differences across STDs were examined using the General Linear Model function of SPSS and an exploratory factor analysis was conducted to generate coherent themes.

Results: For all three STDs, most physicians reported instructing patients to abstain from sex during treatment, to use condoms, and to inform their sexual partners of their exposure. Item mean differences and factor analyses revealed that, for syphilis, physicians were less likely to treat the patient presumptively and to give the patient medication for their partners; and more likely to collect partner information, to follow up with the patient to see if the partner was referred for treatment and to send patient information to the health department.

Conclusions: Physicians appear more willing to regard syphilis as a STD requiring special attention for public health follow-up.

Implications for Program/Policy: Programs should reinforce physicians’ policy of reporting syphilis diagnoses. Given the recent upswing in chlamydia rates and the flattening out of previous gonorrhea rate decreases, STD programs should facilitate increased partner follow-up for these two STDs.

Implications for Research: Questions include why physicians treat syphilis differently from chlamydia/gonorrhea, and what program changes produce better sex partner follow-up.

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

1) Described the counseling practices of physicians in the sample following the diagnosis of chlamydia, gonorrhea, and syphilis.

2) Discuss how these practices differed across the three STDs.

3) Discuss reasons why practices varied for the three STDs.

D7

Multi-level Interventions to Improve Adolescent Health and Prevent STD Infection

K Ethier¹, P Dittus¹, K Vandevanter²

1Centers for Disease Control and Prevention, Atlanta, GA; 2Columbia University, New York, NY

Background and Rationale: In order to be fully effective in improving the health of our adolescents, we must also change important aspects of their social context. For example, their communication with parents, STD screening by health care providers, and social norms in their communities can impact adolescent health behavior in important ways. Moving beyond adolescent-focused, individual interventions to higher-level and even multi-level approaches to adolescent health promotion and STD prevention provides a new paradigm in research, program and policy.

Objectives: The proposed symposium will: (1) establish the need to move toward higher- and multi-level interventions; (2) review current work on interventions with parents, health care providers, communities, neighborhoods and schools to improve adolescent health; and (3) discuss multi-level interventions for adolescents, the current state of this field and further research directions.

Content: Five presentations will be included. The first will provide and overview and rationale for higher- and multi-level interventions. The second, third and fourth presentations will provide the current state of the field and future directions in the areas of (1) parent, (2) health care provider and (3) community, neighborhood, and school interventions to improve adolescent health. The final presentation will focus on multi-level interventions.

Implications for Programs/Policy: Including the social context of the adolescent in health promotion and STD prevention will require field personnel to broaden their approach to prevention for adolescents. This symposium will provide an important overview regarding the current state of this field.

Implications for Research: The proposed symposium presents a new research paradigm for adolescent health promotion and STD prevention. As such it presents the need for increased collaboration among researchers with differing areas of expertise, the development of new research methodologies, and the utilization of cutting edge data analytic techniques.

Learning Objectives: By the end of this session, participants will be able to describe and discuss the potential of multi-level interventions to improve health and prevent STD infection among adolescents.

D8

Changing Trends in Nationally Notifiable Sexually Transmitted Diseases in the United States

H Weinstock, J Heffelfinger, L Newman, S Wang, K Fox, D Mosure, S Berman, O Devine

Centers for Disease Control and Prevention, Atlanta, GA

Background and Rationale: Although national surveillance data for syphilis, gonorrhea, and chlamydia show that these sexually transmitted diseases (STDs) have generally declined during the 1990s, recent data suggest a slowing in these decreases, and in some areas of the country and among some populations, increases are occurring.

Objectives: To describe the latest trends for each of the three major notifiable STDs using nationally reported surveillance data and to describe the program and policy implications of the changing epidemiology of these diseases.

Content: This symposium will include presentations on each of the major notifiable STDs. Progress towards syphilis elimination in the US will be described, highlighting areas where recent increases have occurred. The presentation on gonorrhea will describe those areas of the US where gonorrhea is increasing and the latest trends in antimicrobial resistance. Also discussed will be recommendations from an external consultation to review priorities for federal and local gonorrhea prevention activities and research. Trends in chlamydia case reports and prevalence-monitoring data will also be presented, including findings from the Regional Infertility Prevention Program.

Implications for Programs/Policy: The changing epidemiology of STDs informs how and where the Syphilis Elimination, Gonorrhea Control, and the Infertility Prevention Programs may direct resources and efforts.

Implications for Research: These changes highlight priorities for research, including the identification of reasons for and interventions to address recent increases in STDs among men who have sex with men, factors fueling syphilis outbreaks in other populations, identification of more effective methods for gonorrhea control, and better understanding of factors explaining increases in chlamydia prevalence.

Learning objectives:

1. Describe the latest trends in syphilis, gonorrhea, and chlamydia in the United States.

2. Describe successes and challenges in the efforts toward syphilis elimination and recent recommendations for research, programs, and policy for gonorrhea control.

Implications for Programs: Appropriate CT screening guideline implementation requires further provider education to modify clinical practice. Absent guideline adherence and changing to more sensitive and costly screening measures will likely increase CT prevalence with concomitant increased program costs. Ongoing quality assurance should address guideline adherence.

Implications for Research: Future research should focus on site- or provider-specific benchmarks and feedback to improve CT screening rates in a young adult