2002 National STD Conference - Latebreaker Poster Abstracts - LB1-LB11

LB1

Increasing Proportion of HSV-1 as a Cause of Genital Herpes Infection in College Students

CM Roberts¹, JR Pfister²

1University Health Services, University of Wisconsin-Madison; 2Wisconsin State Laboratory of Hygiene, University of Wisconsin-Madison

Background: HSV-1 is usually thought to cause less than 30% of genital herpes infections in the U.S. New reports indicate that the proportion of infections due to HSV-1 is increasing in some populations. Changing sexual practices including the use of condoms for vaginal intercourse and oral-genital sexual contact may contribute to this change.

Objectives: To determine the relative proportion of HSV-1 and HSV-2 as the cause of newly diagnosed genital herpes infections in a population of college students at a large public university, and to assess trends in the change of this proportion over time.

Methods: We reviewed data for all positive herpes viral cultures from genital specimens submitted to the same public health reference laboratory by a single student health service for the period 1993-2001 (n=483). Positive isolates were typed as either HSV-1 or HSV-2 using monoclonal antibodies. Analyses included comparisons of isolates by age group and sex.

Results: The proportion of newly diagnosed genital herpes infections due to HSV-1 increased from 29% in 1993 to 78% in 2001 (p<.001; linear trend, p<.001). HSV-1 was more common in females than males, but increases were noted for both sexes. HSV-1 was more common in persons age 16-21 than in persons age 22 or older.

Conclusions: HSV-1 has become the most common cause of new genital herpes infections in this population of college students and reflects a reversal of the usual HSV-1/HSV-2 ratio.

Implications for Policy: Serologic screening solely for HSV-2 may miss many genital herpes infections in young adult populations. Counseling messages for patients should emphasize the risk of oral sex as a mode of transmission for genital herpes.

Implications for Research: Epidemiologic research and vaccine development must incorporate the possibility of HSV-1 as a predominant cause of genital herpes infections in some populations.

Author Contact Information: Craig Roberts / Email: cmrober1@facstaff.wisc.edu

LB2

Effect of Endocervical Specimen Adequacy on Ligase Chain Reaction Detection of Chlamydia trachomatis

SJ Jirsa, RK Teske, JN Woods

State Hygienic Laboratory, University of Iowa, Iowa City, Iowa

Background: A number of studies have shown that the adequacy of endocervical specimens will affect the ability of tests, both antigen and nucleic acid detection, to detect Chlamydia trachomatis. However, controversy exists whether the sensitivity of nucleic acid amplification tests is influenced by specimen adequacy. Some believe that the sensitivity of NAATs is so great that a poorly collected specimen would contain sufficient C. trachomatis cells to generate a positive result. Many infected females might not be receiving proper treatment due to the lack of positive test results.

Objectives: Determine if the presence of endocervical cells or erythrocytes influence C. trachomatis positivity rates by LCR. Determine if a linear relationship exists between endocervical cells and C. trachomatis positivity by LCR.

Methods: Microscopic analysis was performed on 1633 endocervical specimens and compared with C. trachomatis results obtained by LCR.

Results: Of the 1633 specimens examined, 655 (40%) were found to contain one or more endocervical cells. The C. trachomatis positivity rate was 10.8% (71/655) among specimens containing endocervical cells, compared to 3.6% (35/978) among specimens lacking endocervical cells (P<0.0001). There was no linear trend between the C. trachomatis positivity rate and the number of endocervical cells (P=0.24). The C. trachomatis positivity rate was 5.4% (8/147) among specimens containing a high number of erythrocytes (>100 per high-powered field), compared to 6.6% (98/1486) among specimens containing less than 100 erythrocytes per high-powered field (P=0.59). These results show that the sensitivity of the Abbott C. trachomatis LCR test is affected by the presence of endocervical cells.

Implications for Programs: Periodic cytological evaluation of specimens is warranted to assess collection technique, and signal the initiation of collector training.

Implication for Research: Studies evaluating the effectiveness of various specimen adequacy screening and training programs need to be conducted.

LB3

Men with Regular Doctors Attending STD Clinics Have Similar Disease Burden to Those Who Do Not

JM Sizemore, Jr, Willa Sanders, DM Ennis, MD, EW Hook, III, MD

Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL

Background: In general, little is known about the determinants of male health seeking behaviors. More specifically, those studies that address these behaviors among men at high risk for sexually transmitted diseases (STD) have been conducted largely in the developing world.

Objectives: To examine demographic, sexual, and health seeking characteristics of male STD clinic attendees in a Southern urban setting.

Methods: In addition to receiving routine care, randomly selected men attending the Jefferson County Health Department STD Clinic were administered a comprehensive questionnaire regarding their demographic, sexual, and health care seeking characteristics. The men were stratified into two groups based on whether or not they reported having a “regular doctor.”

Results: 467 men were enrolled. 31% identified a regular doctor. These men were significantly more likely to be older (30.4 vs. 26.7 yrs.), be better educated (78 vs. 67% > grade 12), abstain from alcohol (23 vs. 14%), and would seek care for a “medical problem” at a private doctor’s office (52 vs. 9%) than those men without a regular physician. The two groups did not significantly differ in their past history of STD’s, prostitute exposure, illicit drug use nor their concurrent diagnoses of gonococcal urethritis, NGU, or all STDs diagnosed at the study visit.

Conclusions: Among male STD clinic attendees, identifying a regular physician does not seem to modify STD burden.

Implications for Programs/Policy: Public health STD clinics continue to play an important “safety net” role for STD care in men even if they have a regular healthcare provider, have health insurance, and would seek care for a “medical problem” at a private doctor’s office.

Implications for Research: Better understanding of why men with regular doctors seek STD care at public health clinics could improve patient-provider relationships.

Contact: JM Sizemore, Jr / Email: sizemore@uab.edu

LB4

Screening for Chlamydial Infection in a High-risk Male Population

S.M. Rogers¹, JM Zenilman²

1Research Triangle Institute, Washington DC; 2Johns Hopkins School of Medicine, Baltimore, MD

Background: Screening for chlamydial infections (CT) has focused largely on women since they are more likely to be asymptomatic than men and may experience more severe long-term health complications. Screening of men has been less common, in part because of the associated costs, and until recently, the need to obtain a urethral swab specimen.

Objectives: To estimate CT prevalence and evaluate screening criteria for CT infection among male STD clinic patients.

Methods: A cross-sectional study of 1127 patients (645 males) aged 15 to 39 years attending a STD clinic in Baltimore, MD from July 1999 through December 2001. Participants were tested for C. trachomatis and N. gonorrhoeae with urine-based ligase chain reaction assay and completed a detailed behavioral audio-CASI questionnaire.

Results: The prevalence of CT was 16.9% among males (13.9% among females, p=0.17). Levels of infection were highest among men aged 15-19 years (28.1%). CT was significantly associated with self-reported STD symptoms (dysuria or discharge within the past month) among males (21.5% v 12.3%, p=0.002), but not females (15.3% v 12.8%, p=0.4). However, recent symptoms were no longer associated with CT infection once males with a GC co-infection were excluded (11.2% v 10.4%, p=0.9). Among asymptomatic men, young age (<25 years), a new clinic patient, and 1+ new partners within the past 6 months were significantly associated with CT infection in multivariate analyses. Screening asymptomatic men with 1+ recent new partners would have detected 80% of infections while testing 62%.

Conclusions: Within this high-risk population, CT infection (symptomatic and asymptomatic) was at least as prevalent among men as women.

Implications for Policy: Routine screening strategies for men are needed to identify asymptomatic and presumably transmissible CT infections.

Implications for Research: Further research is needed to demonstrate the public health benefits to men and women of CT screening among high-risk male populations.

LB5

STD and HIV Services in Illinois County Jails

A McIntyre¹, A Studzinski², H Beidinger^3,4

1University of Illinois at Chicago School of Public Health, Division of Epidemiology and Biostatistics, Chicago, IL; 2Illinois Department of Public Health, STD Section, Springfield, IL; 3Centers for Disease Control and Prevention, Atlanta, GA; 4Chicago Department of Public Health, STD/HIV Prevention Program, Chicago, IL

Background: Jails present a unique opportunity to provide STD/HIV services to a medically underserved population. Any barriers to effectively implementing screening and treatment programs for detainees should be identified and minimized.

Objectives: To evaluate the level of STD/HIV services provided in Illinois county jails, identify barriers to the provision of services, assess willingness to increase services, and compare results with county-level surveillance data.

Methods: The Illinois and Chicago Departments of Public Health and the University of Illinois at Chicago School of Public Health collaborated to design a survey tool. This survey about STD and HIV services was administered to medical personnel at the 91 county jails in Illinois.

Results: 78% (71/91) of Illinois jails completed the survey. Respondents were Medical Personnel (31%), Jail Administrators (35%), Security Personnel (21%), and Local Health Department (LHD) Personnel (13%). 85% (60/71) have a relationship with the LHD (personnel, funding). 48% (34/71) of facilities provide STD testing and 52% (37/71) provide HIV testing. 86% (61/71) provide HIV/AIDS medical care on demand. Barriers to providing STD/HIV services: none (34%), cost (39%), and limited staff time (17%). If assistance from the state or local health department was offered, 58% would be interested in increasing STD/HIV services.

Conclusions: Collaborations between local health departments and jails will likely enable smaller facilities to offer a wider range of services to detainees and facilitate important post-release, community-based linkages for STD/HIV services.

Implications for Programs: Demand for STD/HIV services varies dramatically between facilities; thus, collaborations between local health departments and jails should be strongly encouraged in order to develop the most efficient and effective programming for each site.

Implications for Research: County-level surveillance data may help direct STD/HIV prevention and education programs as well as provide important information about the value of implementing services at county jails.

Learning Objectives: Participants will be able to describe the importance of public health and corrections collaborations, as well as how to assemble, implement, and analyze a useful survey tool for collecting STD/HIV services information at county jails and how to integrate existing surveillance data with survey results.

Contact Information: Anne McIntyre / Email: amcint1@uic.edu

LB6

An Economic Evaluation of a School-Based Sexually Transmitted Disease Screening Program

G Burstein

Centers for Disease Control and Prevention, Atlanta, GA

Background: A school-based chlamydia screening program was implemented in eight New Orleans public high schools.

Goal of this study: To assess the incremental cost-effectiveness of a shift from no school screening to the school-based screening program.

Study design: A decision-analysis model was constructed to compare costs and cases of expected pelvic inflammatory disease (PID) between the school-based screening scenario and a no school-based screening scenario. Cost-effectiveness was quantified and measured as cost per case of PID prevented.

Results: Under base-case assumptions, at an intervention cost of $86,449, the school screening program prevented an estimated 38 cases of PID compared to no school-based screening and saved $119,423 costs in treating PID and its sequelae, resulting in savings of $1,517 per case of PID prevented. Results remained cost saving over a reasonable range of model parameter estimates.

Conclusions: The New Orleans school-based chlamydia screening program was cost-effective and cost-saving, and could be cost-effective in other settings. School-based screening programs of this type are likely to be a cost-effective use of public funds and can reduce the burden of sexually transmitted diseases (STDs) among adolescents.

Implications for programs/policy: A school-based chlamydia screening and treatment program can be a cost-effective chlamydia control strategy by preventing the development of sequelae and saving future health care costs. Policy makers should routinely consider incorporating school-based chlamydia screening programs as part of an STD control strategy to efficiently reduce the burden of STDs among our nation’s youth.

Implications for research: More research is needed on the probability of PID developing from an untreated chlamydia infection, the cost of treating a case of PID and its sequelae, and the likelihood of adolescents receiving STD services. In the future school-based STD screening programs should collect program cost data so that more cost-effectiveness evaluations can be conducted.

LB7

Partner Notification: Survey of Health Departments in High Morbidity Areas

MR Golden^1,2, M Hogben³, HH Handsfield^1,2, JS St. Lawrence³, JJ Potterat, KK Holmes¹

1Center for AIDS and STD, University of Washington, Public Health –Seattle & King County; 2Division of STD Prevention; 3CDC, Seattle, WA

Background: Little is known about the scope of partner notification (PN) services offered by health departments in the United States.

Objective: To define what PN services U.S. health departments provide in areas with high STD/HIV morbidity.

Methods: Surveys regarding PN practices were sent to STD program managers in the 78 U.S. health departments serving areas with the highest reported rates of infectious syphilis, gonorrhea, chlamydia, and AIDS in 1998.

Results: Staff from 60 (77%) of the 78 selected health departments completed the survey. Of 8492 cases of syphilis reported in participating jurisdictions, 7583 (89%) were interviewed for PN. HIV was reportable in 41 (68%) of 60 jurisdictions. Of the 8328 persons reported with HIV in those areas, 4375 (52%) were interviewed for PN. Only 19 (32%) health departments routinely provided PN to patients with gonorrhea diagnosed outside of public health clinics, and only 14 (23%) provided PN to non-public health patients with chlamydial infection. In the areas served by survey respondents, 23,097 (17%) of 139,287 reported cases of gonorrhea and 26,487 (12%) of 228,210 reported cases of chlamydial infections were interviewed for PN. The most commonly reported barriers to improved PN services were insufficient staff and funding.

Conclusions: Except for syphilis, only a minority of persons with reportable STD/HIV in high morbidity areas of the U.S receive PN services.

Implications for Programs: Increased funding is probably necessary and may be sufficient to provide PN services to all newly diagnosed cases of HIV in the U.S. Feasible levels of funding alone are not likely to be sufficient to provide universal public health PN services to persons with gonorrhea and chlamydial infection. STD programs need to devise new, more efficient mechanisms to ensure partner treatment for these STDs.

Implications for Research: New approaches to PN for gonorrhea and chlamydial infection are needed.

LB8

Incidence of Primary and Secondary Syphilis among HIV Infected Men in San Francisco, 2001

W Wong^1,2, C Kent¹, R Kohn¹, J Klausner¹

1STD Prevention and Control Services, San Francisco Department of Public Health (SFDPH), San Francisco, CA; 2Centers for Disease Control and Prevention (CDC), Atlanta, GA

Background: In 2001, there was a 157% increase of reported cases of primary and secondary (P&S) syphilis in San Francisco from the previous year. Ninety-eight percent of cases were among men and 64% were HIV infected. Based on surveillance data, we estimated the incidence of P&S syphilis among HIV infected men was 525.3 cases per 100,000.

Objective: To determine incidence of P&S syphilis in a sample of HIV infected men to validate surveillance findings.

Methods: From 9/15 to 12/15/2001, clinicians providing HIV care to men seen at 10 SFDPH affiliated clinics were asked to order a serum Venereal Disease Research Laboratory (VDRL) assay with every test of quantitative HIV viral load (VL). Seroreactive VDRL tests were confirmed using Treponema Pallidum Particle Agglutination (TP-PA). We evaluated all persons with confirmed reactive VDRL tests for syphilis. We calculated an estimate of the annual incidence and 95% confidence intervals (CI) of P&S syphilis.

Results: Of 1154 VL submitted from the selected clinics, 532 (46.1%) were accompanied by VDRL serologies. Syphilis serology results were obtained on 429 men; and two men had P&S syphilis. The median age of screened men was 39 years (range 23-63) and the majority were white (52%). The annual incidence of P&S syphilis in this sample of HIV infected men was 1864.8 (95% CI 312 to 3,064) cases per 100,000.

Conclusions: The rate of P&S syphilis in this sample of HIV infected men was high. While our calculated incidence from this sample was imprecise, it was comparable with surveillance data incidence estimates.

Implications for Program / Policy: HIV infected men are at high risk for infection with syphilis and prevention programs targeting this population are indicated.

Implications for Research: Additional strategies to independently validate syphilis surveillance systems are needed.

Learning Objectives: Participants will be able to evaluate the incidence of P&S syphilis in HIV infected men.

LB9

Babes in Boystown: Responding to a Syphilis Outbreak Among MSM in Chicago

Y Cruz¹, D Broussard^1,2, M Vazquez-Perez¹, J Johnson-Norwood¹

1Chicago Department of Public Health; 2Centers for Disease Control and Prevention

Background: In August 2001, the Chicago Department of Public Health (CDPH) discovered evidence of an outbreak of early syphilis among MSM. Case management records revealed a link between the outbreak and anonymous sex in bathhouses and other public sex environments along Chicago’s north shore.

Objectives: The objective was to reach clients where they were. The response had to be immediate, culturally sensitive, and innovative in order to reach the population and intervene in ongoing transmission.

Methods: CDPH established a multi-agency Outbreak Response Team to offer prevention education and syphilis screening when these venues were at their busiest, between 10 p.m. and 3 a.m. A key strategy was to partner with agencies with well-respected ties to Chicago’s gay community.

CDPH partnered with nine CBOs. Press releases in the gay/mainstream press kicked off the effort. Accompanied by a mobile health unit, volunteers from the Outbreak Response Team conducted outreach in bathhouses, bars, and along the street where there was heavy foot traffic between these various venues. The volunteers gave out condoms, lubricants, and literature. They educated clients about the symptoms of syphilis as few knew that a rash could be a symptom. Volunteers also provided syphilis testing in the bathhouses and on the mobile unit.

Results: In fifty days, 1,030 individuals were tested and 23 new cases of syphilis were discovered. Though not a focus of the effort, nine new HIV cases were identified, primarily in young African-American men.

Conclusions: This outbreak response, using a multi-agency model, was effective in reaching large numbers of MSM in an environment in which ongoing transmission was occurring.

Implications for Programs/Policies: This presentation will assist other programs in responding to outbreaks among MSM.

Learning Objectives: To provide programs with a model to combat syphilis transmission among MSM. To learn the benefits and obstacles of offering services in public sex environments.

LB10

Shining a Light on Syphilis: a Community-led New Year’s Eve Social Marketing Campaign for Men Who Have Sex with Men

H Rotblatt¹, T Ford²

1L.A. County DHS STD Program, Los Angeles, CA; 2AIDS Healthcare Foundation, Los Angeles, CA

Background: LA County (LAC) experience a resurgence of syphilis among men who have sex with men (MSM) in 2001. A 2000 MSM outbreak seemed to decline after DHS and community agency interventions, including a two-month media campaign. After the 2001 resurgence, LAC DHS planned a new media effort, in partnership with 6 community organizations. The first part of the campaign launched in December 2001, to forestall significant transmission around New Year’s eve, as in 1999 and 2000.

Objectives: To reduce syphilis transmission during the New Year’s period by increasing awareness and syphilis testing among high-risk MSM.

Methods: The campaign was coordinated by AIDS Healthcare Foundation, a leading HIV service provider to MSM. Better World Advertising developed campaign ideas and materials. Decisions were made by committee involving 6 ethnically diverse MSM-serving agencies. DHS case data helped guide campaign elements. Materials were collaboratively shared with San Francisco.

Results: The selected theme was designed to contrast with typical gay-press ads, and included a novelty item to integrate the campaign with the holiday party atmosphere at key venues. Ads were placed in 5 magazines and 1 website; 12,000 English and 4,000 Spanish packets, with palm cards and the novelty item, were distributed to venues. Assessment results of campaign impact, including hotline calls, will be presented.

Conclusions: A substantial, timely social marketing effort for MSM was successfully created through DHS-community organization and inter-organization collaboration.

Implications for Programs/Policy: The December campaign involved collaboration between government and community agencies, including resolution of divergent views and priorities. This process, and the innovative media solutions generated, may aid other localities in addressing syphilis/HIV/STDs among MSM.

Implications for Research: Assessment of campaign impact will be discussed.

Measurable Learning Objectives: Session participants will be able to: 1) describe three advantages of a community-led social marketing campaign; 2) describe the group process and key parameters used to develop campaign ideas and materials; 3) discuss two issues in developing this social marketing campaign for MSM on syphilis and how these were resolved; 4) discuss the importance of inter-regional collaboration, such as was done with San Francisco, in syphilis prevention among MSM.

LB11

Behavioral Risk Assessment Data Collected From Sexually Transmitted Disease (STD) Clinics and Syphilis Counseling Records

A Studzinski, R Zimmerman, S Holmes, C Rabins

Illinois Department of Public Health STD Section, Springfield, IL

Background: Behavioral risk factor information is important for identifying STD risk groups and behaviors and for targeting intervention programs. In 2000, the Illinois Department of Public Health (IDPH) STD Section began collecting risk assessment surveys (RASs) from all STD clinics in Illinois (excluding Chicago) as well as syphilis behavioral risk assessments (BRAs) on all clients counseled for early syphilis. During the period January through August 2001, 19,867 RASs and 64 Syphilis BRAs were received.

Objective: Describe behavioral risk factors reported by STD clinic clients and clients counseled for early syphilis using linked databases.

Methods: 1) All STD clinic clients complete a behavioral risk assessment survey (RAS). Clinic staff affix to the form a bar code for the client’s STD laboratory tests conducted by the three IDPH laboratories. The RASs are forwarded to the STD Section on a weekly basis. Utilizing Teleforms software, RAS data are electronically scanned, verified and downloaded into an MSAccess database. The section receives daily, electronic line-listed testing data from the IDPH laboratories. The RAS and laboratory databases are linked utilizing the unique laboratory identification (bar code) number.

2) Local health department counselors complete a behavioral risk assessment form (BRA) on each client counseled for early syphilis. The forms are submitted to the STD Section with the syphilis interview record (IR) within one week of the counseling session. The IRs and syphilis BRAs are entered into an MSAccess database and linked by a unique control number.

Results: This procedure provides the STD Section with extensive behavioral data for STD clinic patients and clients counseled for early syphilis. By linking the databases, risk assessment data can be generated by diagnosis, selected time periods, and client demographics. Responses from infected clients can be compared to those with a negative test for gonorrhea or chlamydia. Behavioral data collected from syphilis patients can be analyzed separately. STD clinic attendance data by client demographics and diagnosis also can be generated.

Conclusions: Collection of electronic line-listed behavioral data linked to laboratory results provides a flexible system for analysis of behavioral data that can be used to target STD intervention programs.

Implications for Programs/Policy: Collection and analysis of STD behavioral data will assist syphilis elimination efforts by providing information that will help to identify population groups at increased risk for STDs and behaviors that put clients at risk of acquiring an STD.

Implications for Research: The data presented are a compilation of descriptive findings. Further analysis is needed to assess which findings are statistically significant.

Presenting Author Contact Information: Alice Studzinski / Phone: 217-782-2747 / Fax: 217-524-5443 / Email: astudzin@idph.state.il.us

LB12

Randomized Controlled Trial of Relapse Prevention (“Booster”) Counseling (RESPECT-2).

Metcalf CA¹, Dillon BA¹, DeAugustine N², Douglas JM³, Paul SM⁴, Young PA⁵, Lindsey CA¹, Peterman TA¹

1Centers for Disease Control and Prevention; 2Long Beach Department of Health and Human Services; 3Denver Public Health; 4New Jersey Department of Health and Senior Services; 5NOVA Research Company

Background: Project RESPECT found that HIV testing with 2 sessions of prevention counseling prevented more STDs than HIV testing with information alone, but that the effect waned over time. We assessed whether a “booster” counseling session 6 months after HIV testing and counseling would further prevent STD.

Methods: Consenting STD clinic patients in 3 US cities were randomized to receive either a rapid or a standard HIV test. At baseline, half the participants in each group were further randomized to receive “booster” counseling 6 months later. Participants were interviewed and screened for chlamydia, gonorrhea, and trichomoniasis at baseline and every 3 months for 1 year. We did an intention to treat analysis.

Results: 3,293 participants were enrolled and followed-up for 12 months. Data are pending for 14.2% of participants. 70.1% of the no booster group and 71.0% of the booster counseling group visited at 6-months when the booster session was given. Preliminary data show that between the 6- and 9-month visits, 4.6% of the no booster group and 5.0% of the booster group developed a new STD (relative risk [RR] 1.09; 95% confidence interval [CI] 0.80–1.47; p=0.60). By the 12-month visit, 8.7% of the no booster group and 8.9% of the booster group had developed a new STD since the 6-month visit (RR 1.03; CI 0.83–1.28; p=0.80).

Conclusion: Preliminary results indicate that an additional counseling session 6 months after HIV testing and counseling had no effect on the incidence of new STDs over the following 6 months.

Implications for Programs: The introduction of an additional counseling session 6 months after initial HIV counseling and testing would not be an effective means of further preventing STDs in STD clinic patients.

Implications for Research: Further research is needed to develop more effective behavioral interventions for preventing STDs in STD clinic patients.

Measurable Learning Objectives: By the end of this session participants will be able to discuss the effect of an additional counseling session 6 months after HIV testing and counseling on STD incidence over the following 6 months.