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1.  Partner Services as Targeted HIV Screening—Changing the Paradigm 
Public Health Reports  2014;129(Suppl 1):50-55.
Objectives
The San Francisco Department of Public Health (SFDPH) has the goal of offering HIV partner services (PS) to all individuals newly diagnosed with HIV in San Francisco. However, measuring the potential impact of these services is challenging. Building on an existing syphilis partner notification program, we developed a framework for expanding and monitoring HIV PS in San Francisco.
Methods
We identified process and outcome measures to evaluate HIV PS in San Francisco, including the number of index patients interviewed, the proportion of named partners who had previously diagnosed HIV infection, the proportion of HIV-uninfected partners who tested through HIV PS, and the positivity rate among the partners tested. Results were recorded in a locally developed electronic surveillance and case-management system at SFDPH.
Results
We examined HIV PS data from 2005–2011. In 2011, 426 new HIV diagnoses were reported, and 178 were assigned for HIV PS; of these, 124 (69.7%) patients were successfully interviewed, naming a total of 109 sex partners. Of the named partners, 34 (31.2%) had been previously diagnosed with HIV. Among the remaining named partners not known to be HIV infected, 31 (32.3%) were tested, for a positivity of 22.6% (n=7). The proportion of HIV that was newly diagnosed by a provider who participated in the citywide HIV PS program increased from 15.4% in 2005 to 69.5% in 2011.
Conclusions
As HIV PS expand, locally relevant outcome measures are increasingly important. Using these criteria, HIV PS as a targeted screening activity resulted in the identification of newly diagnosed HIV cases.
PMCID: PMC3862989  PMID: 24385649
2.  Neisseria gonorrhoeae Strain with Reduced Susceptibilities to Extended-Spectrum Cephalosporins 
Emerging Infectious Diseases  2014;20(7):1211-1213.
The spread of Neisseria gonorrhoeae strains with reduced susceptibility to extended-spectrum cephalosporins is an increasing public health threat. Using Etest and multiantigen sequence typing, we detected sequence type 1407, which is associated with reduced susceptibilities to extended-spectrum cephalosporins, in 4 major populated regions in California, USA, in 2012.
doi:10.3201/eid2007.131396
PMCID: PMC4073858  PMID: 24964277
Neisseria gonorrhoeae; bacteria; antimicrobial resistance; reduced susceptibilities; extended-spectrum cephalosporins; cephalosporins; strain; ST1407; genogroups; California; United States
3.  Repeat Syphilis Among Men Who Have Sex With Men in California, 2002–2006: Implications for Syphilis Elimination Efforts 
Objectives
We examined rates of and risk factors for repeat syphilis infection among men who have sex with men (MSM) in California.
Methods
We analyzed 2002 to 2006 California syphilis surveillance system data.
Results
During the study period, a mean of 5.9% (range: 4.9%–7.1% per year) of MSM had a repeat primary or secondary (PS) syphilis infection within 2 years of an initial infection. There was no significant increase in the annual proportion of MSM with a repeat syphilis infection (P=.42). In a multivariable model, factors associated with repeat syphilis infection were HIV infection (odds ratio [OR] = 1.65; 95% confidence interval [CI] = 1.14, 2.37), Black race (OR = 1.84; 95% CI = 1.12, 3.04), and 10 or more recent sex partners (OR = 1.99; 95% CI = 1.12, 3.50).
Conclusions
Approximately 6% of MSM in California have a repeat PS syphilis infection within 2 years of an initial infection. HIV infection, Black race, and having multiple sex partners are associated with increased odds of repeat infection. Syphilis elimination efforts should include messages about the risk for repeat infection and the importance of follow-up testing. Public health attention to individuals repeatedly infected with syphilis may help reduce local disease burdens.
doi:10.2105/AJPH.2011.300383
PMCID: PMC3490561  PMID: 22095364
5.  Young Men’s Preferences for Sexually Transmitted Disease and Reproductive Health Services in San Francisco, California 
Sexually Transmitted Diseases  2012;39(6):421-423.
We explored STD service preferences among 108 African-American adolescent males recruited from a high morbidity neighborhood. Participants largely preferred to seek care at traditional STD testing venues (86.5%) rather than non-traditional venues. Additionally, most males preferred receiving STD test results from a clinician (61.1%) rather than online (11.1%) or through email or text message (12.0%). These results highlight the need for continued strengthening of traditional public health clinics to ensure capacity to meet young men’s health needs and to improve outreach and access to traditional STD services for young men.
doi:10.1097/OLQ.0b013e318249d651
PMCID: PMC3355327  PMID: 22592826
STD; Screening; Chlamydia; Gonorrhea; Young men
6.  A Tale of Two Gonorrhea Epidemics: Results from the STD Surveillance Network 
Public Health Reports  2012;127(3):282-292.
Objective
An increasing proportion of gonorrhea in the United States is diagnosed in the private sector, posing a challenge to existing national surveillance systems. We described gonorrhea epidemiology outside sexually transmitted disease (STD) clinic settings.
Methods
Through the STD Surveillance Network (SSuN), health departments in the San Francisco, Seattle, Denver, Minneapolis, and Richmond, Virginia, metropolitan areas interviewed systematic samples of men and women reported with gonorrhea by non-STD clinic providers from 2006 through 2008.
Results
Of 2,138 interviews, 10.0% were from San Francisco, 26.4% were from Seattle, 25.2% were from Denver, 22.9% were from Minneapolis, and 15.5% were from Richmond. A total of 1,165 women were interviewed; 70.1% (815/1,163) were ≤24 years of age, 51.3% (598/1,165) were non-Hispanic black, and 19.0% (213/1,121) reported recent incarceration of self or sex partner. Among 610 men who have sex with only women, 50.9% were ≤24 years of age, 65.1% were non-Hispanic black, 14.1% reported incarceration of self or sex partner, and 16.7% reported anonymous sex. Among 363 men who have sex with men (MSM), 20.9% were ≤24 years of age, 61.6% were non-Hispanic white, 39.8% reported anonymous sex, 35.7% reported using the Internet to meet sex partners, and 12.1% reported methamphetamine use.
Conclusions
These data identified two concurrent gonorrhea epidemics in minority populations: a young, black, heterosexual epidemic with frequently reported recent incarceration, and an older, mostly white MSM epidemic with more frequently reported anonymous sex, Internet use to meet sex partners, and methamphetamine use.
PMCID: PMC3314072  PMID: 22547859
7.  Sexually Transmitted Disease Core Theory: Roles of Person, Place, and Time 
American Journal of Epidemiology  2011;174(1):81-89.
The authors’ purpose was to expand sexually transmitted disease core theory by examining the roles of person, place, and time in differentiating geographic core areas from outbreak areas. The authors mapped yearly census-tract-level syphilis rates for San Francisco, California, based on new primary and secondary syphilis cases reported to the San Francisco City sexually transmitted disease surveillance program between January 1, 1985, and December 31, 2007. SaTScan software (Information Management Services, Inc., Silver Spring, Maryland) was used to identify geographic clusters of significantly elevated syphilis rates over space and time. The authors graphed epidemic curves for 1) core areas, 2) outbreak areas, 3) neither core nor outbreak areas, and 4) noncore areas, where noncore areas included outbreaks, and stratified these curves according to demographic characteristics. Five clusters of significantly elevated primary and secondary syphilis rates were identified. A 5-year threshold was useful for differentiating core clusters from outbreak clusters. Epidemic curves for core areas, outbreak areas, neither core nor outbreak areas, and noncore areas were perfectly synchronized in phase trends and wavelength over time, even when broken down by demographic characteristics. Between epidemics, the occurrence of syphilis affected all demographic groups equally. During an epidemic, a temporary disparity in syphilis occurrence arose and a homogeneous core group of cases could be defined.
doi:10.1093/aje/kwr035
PMCID: PMC3159428  PMID: 21540320
disease outbreaks; epidemic model; geography; sexually transmitted diseases; spatial analysis; syphilis
8.  Trichomonas vaginalis Antimicrobial Drug Resistance in 6 US Cities, STD Surveillance Network, 2009–2010 
Emerging Infectious Diseases  2012;18(6):939-943.
Such isolates should undergo drug susceptibility testing periodically to detect emerging resistance.
Nitroimidazoles (metronidazole and tinidazole) are the only recommended drugs for treating Trichomonas vaginalis infection, and previous samples that assessed resistance of such isolates have been limited in geographic scope. We assessed the prevalence of in vitro aerobic metronidazole and tinidazole resistance among T. vaginalis isolates from multiple geographic sites in the United States. Swab specimens were obtained from women who underwent routine pelvic examinations at sexually transmitted disease clinics in 6 US cities. Cultured T. vaginalis isolates were tested for nitroimidazole resistance (aerobic minimum lethal concentration [MLC] >50 µg/mL). Of 538 T. vaginalis isolates, 23 (4.3%) exhibited low-level in vitro metronidazole resistance (minimum lethal concentrations 50–100 µg/mL). No isolates exhibited moderate- to high-level metronidazole resistance or tinidazole resistance. Results highlight the possibility that reliance on a single class of antimicrobial drugs for treating T. vaginalis infections may heighten vulnerability to emergence of resistance. Thus, novel treatment options are needed.
doi:10.3201/eid1806.111590
PMCID: PMC3358158  PMID: 22608054
Trichomonas vaginalis; drug resistance; metronidazole resistance; tinidazole resistance; antimicrobial drug resistance; sexually transmitted diseases; protozoa; US cities
9.  Assessment of Geographic Information Systems and Data Confidentiality Guidelines in STD Programs 
Public Health Reports  2009;124(Suppl 2):58-64.
SYNOPSIS
Objective
Advancements in technology, such as geographic information systems (GIS), expand sexually transmitted disease (STD) program capacity for data analysis and visualization, and introduce additional confidentiality considerations. We developed a survey to examine GIS use among STD programs and to better understand existing data confidentiality practices.
Methods
A Web-based survey of eight to 22 questions, depending on program-specific GIS capacity, was e-mailed to all STD program directors through the National Coalition of STD Directors in November 2004. Survey responses were accepted until April 15, 2005.
Results
Eighty-five percent of the 65 currently funded STD programs responded to the survey. Of those, 58% used GIS and 54% used geocoding. STD programs that did not use GIS (42%) identified lack of training and insufficient staff as primary barriers. Mapping, spatial analyses, and targeting program interventions were the main reasons for geocoding data. Nineteen of the 25 programs that responded to questions related to statistical disclosure rules employed a numerator rule, and 56% of those used a variation of the “Rule of 5.” Of the 28 programs that responded to questions pertaining to confidentiality guidelines, 82% addressed confidentiality of GIS data informally.
Conclusions
Survey findings showed the increasing use of GIS and highlighted the struggles STD programs face in employing GIS and protecting confidentiality. Guidance related to data confidentiality and additional access to GIS software and training could assist programs in optimizing use of spatial data.
PMCID: PMC2775401
10.  Here Comes the SSuN: Early Experiences with the STD Surveillance Network 
Public Health Reports  2009;124(Suppl 2):72-77.
SYNOPSIS
In 2005, the Centers for Disease Control and Prevention established the STD Surveillance Network (SSuN), a sentinel surveillance system comprising local, enhanced sexually transmitted disease (STD) surveillance systems that follow common protocols. The purpose of SSuN is to improve the capacity of national, state, and local STD programs to detect, monitor, and respond rapidly to trends in STDs through enhanced collection, reporting, analysis, visualization, and interpretation of clinical, behavioral, and geographic information obtained from a geographically diverse sample of individuals diagnosed with STDs. To demonstrate the utility of a national sentinel surveillance network, this article reviews the lessons learned from the first three years of SSuN, which, through its enhanced gonorrhea and genital warts sentinel surveillance projects, has proved to be a useful adjunct to routine STD surveillance in the U.S. that can be expanded into other areas of STD public health interest.
PMCID: PMC2775403
11.  The Free Condom Initiative: Promoting Condom Availability and Use in New York City 
Public Health Reports  2009;124(4):481-489.
SYNOPSIS
In 2005, the New York City Department of Health and Mental Hygiene (DOHMH) made free condoms available to organizations through a Web-based ordering system. In 2006, we interviewed managers and patrons about free condom availability, acquisition, and use in venues where people at high risk for human immunodeficiency virus congregate. DOHMH condom distribution increased from 5.8 million in 2004 to 17.3 million in 2006. Overall, managers reported making condoms available at 76% (309/409) of high-priority venues, but only at 40% of gay bars. Among patrons who saw free condoms, 80% (280/351) reported taking them; 73% (205/280) of those who reported taking them also reported using them. A simple, Web-based ordering system dramatically increased condom distribution. In the venues we sampled, the majority of patrons acquired and used free condoms when available and visible, suggesting that increasing free condom availability may increase use. Special efforts are needed to ensure availability at gay bars.
PMCID: PMC2693161  PMID: 19618784
12.  Racial/ethnic and sexual behavior disparities in rates of sexually transmitted infections, San Francisco, 1999-2008 
BMC Public Health  2010;10:315.
Background
Racial/ethnic minorities and men who have sex with men (MSM) represent populations with disparate sexually transmitted infection (STI) rates. While race-specific STI rates have been widely reported, STI rates among MSM is often challenging given the absence of MSM population estimates. We evaluated the race-specific rates of chlamydia and gonorrhea among MSM and non-MSM in San Francisco between 1999-2008.
Methods
2000 US Census data for San Francisco was used to estimate the number of African-American, Asian/Pacific Islander, Hispanic, and white males. Data from National HIV Behavioral Surveillance (NHBS) MSM 1, conducted in 2004, was used to estimate the total number of MSM in San Francisco and the size of race/ethnic sub-populations of MSM. Non-MSM estimates were calculated by subtracting the number of estimated MSM from the total number of males residing in San Francisco. Rates of MSM and non-MSM gonorrhea and chlamydia reported between 1999 and 2008 were stratified by race/ethnicity. Ratios of MSM and non-MSM rates of morbidity were calculated by race/ethnicity.
Results
Between 1999-2008, MSM accounted for 72% of gonorrhea cases and 51% of chlamydia cases. Throughout the study period, African-American MSM had the highest chlamydia rate with 606 cases per 100,000 in 1999 increasing to 2067 cases per 100,000 in 2008. Asian/Pacific Islander MSM consistently had the lowest rate among MSM with1003 cases per 100,000 in 2008. The ratio of MSM/non-MSM for chlamydia was highest among whites 11.6 (95% CI: 8.8-14.4) and Asian/Pacific Islanders 8.6 (95% CI: 6.2-11), and lowest among African-Americans 1.53 (95% CI: 1.2-1.9) and Hispanics 4.43 (95% CI: 2.8-6.0). Gonorrhea rates were similar for African-American, white, and Hispanic MSM between 2137-2441 cases per 100,000 in 2008. Asian/Pacific Islander MSM had the lowest gonorrhea rate with 865 cases per 100,000 in 2008. The ratio of MSM/non-MSM for gonorrhea was highest among whites 11.6 (95% CI: 8.8-14.4) and Asian/Pacific Islanders 8.6 (95% CI: 6.2-11), and lowest among African-Americans 1.53 (95% CI: 1.2-1.9) and Hispanics 4.43 (95% CI: 2.8-6.0).
Conclusions
For all racial/ethnic groups in San Francisco, MSM carried a substantially higher burden of STIs compared to non-MSM except among African-American men. These racial and sexual behavior disparities warrant further public health attention and resources.
doi:10.1186/1471-2458-10-315
PMCID: PMC2903517  PMID: 20525397
13.  Exploring the relationship between sexually transmitted diseases and HIV acquisition by using different study designs 
Background
It is hypothesized that sexually transmitted diseases (STDs) increase the risk of HIV acquisition. Yet, difficulties establishing an accurate temporal relation and controlling confounders have obscured this relationship. In an attempt to overcome prior methodologic shortcomings, we explored the use of different study designs to examine the relationship between STDs and HIV acquisition.
Methods
Acutely HIV-infected patients were included as cases and compared to 1) HIV-uninfected patients (matched case-control), 2) newly diagnosed, chronically HIV-infected patients (infected analysis), and 3) themselves at prior clinic visits when they tested HIV-negative (case-crossover). We used t-tests to compare the average number of STDs and logistic regression to determine independent correlates and the odds of acute HIV infection.
Results
Between October 2003 and March 2007, 13,662 male patients who had sex with men were tested for HIV infection at San Francisco's municipal STD clinic and 350 (2.56%) HIV infections were diagnosed. Among the HIV-infected patients, 36 (10.3%) cases were identified as acute. We found consistently higher odds of having had an STD within the 12 months (matched case-control, OR 5.2 [2.2-12.6]; infected analysis, OR 1.4 [1.0-2.0]; case-crossover, OR 1.3 [0.5-3.1]) and 3 months (matched case-control, OR 34.5 [4.1-291.3]; infected analysis, OR 2.3 [1.1-4.8]; case-crossover OR 1.8 [0.6-5.6]) prior to HIV testing among acutely HIV-infected patients. We found higher odds of acute HIV infection among patients with concurrent rectal gonorrhea (17.0 [2.6 - 111.4], p<0.01) or syphilis (5.8 [1.1 - 32.3], p=0.04) when compared to those HIV-uninfected.
Conclusions
Acute HIV infection was associated with a recent or concurrent STD, particularly rectal gonorrhea, among men at San Francisco's municipal STD clinic. Given the complex relationship between STDs and HIV infection, no single design will appropriately control for all the possible confounders; studies using complementary designs are required.
PMCID: PMC2680242  PMID: 19367993
14.  Trichomonas vaginalis Infection and Associated Risk Factors in a Socially-Marginalized Female Population in Coastal Peru 
Objective. The epidemiology of Trichomonas vaginalis infection among sexually active socially-marginalized women in three urban, coastal Peruvian cities was examined in order to quantify the prevalence of trichomonas infection and identify associated risk factors. Methods. We conducted a cross-sectional, venue-based study of women from socially-marginalized populations in three coastal Peruvian cities. Results. Among the 319 women enrolled, the overall prevalence of trichomonal infection was 9.1% (95% CI, 5.9%–12.3%). The mean age was 26.3 years, and 35.5% reported having had unprotected intercourse with nonprimary partners and 19.8% reported two or more sex partners in the last three months. Trichomonal infection was associated with increased number of sex partners (PR 2.5, 95% CI 1.4–4.6) and unprotected sex with nonprimary partner in the last three months (PR 2.3, 95% CI 1.1–4.9). Conclusions. A moderately high prevalence of trichomonal infection was found among women in our study. Trichomonal infection was associated with unprotected sex and multiple sex partners. Efforts to control the continued spread of trichomonal infection are warranted.
doi:10.1155/2009/752437
PMCID: PMC2704012  PMID: 19584943
15.  Using surveillance data to monitor entry into care of newly diagnosed HIV-infected persons: San Francisco, 2006–2007 
BMC Public Health  2009;9:17.
Background
Linkage to care after HIV diagnosis is associated with both clinical and public health benefits. However, ensuring and monitoring linkage to care by public health departments has proved to be a difficult task. Here, we report the usefulness of routine monitoring of CD4 T cell counts and plasma HIV viral load as measures of entry into care after HIV diagnosis.
Methods
Since July 1, 2006, the San Francisco Department of Public Health (SFDPH) incorporated monitoring initial primary care visit into standard HIV public health investigation for newly diagnosed HIV-infected patients in select clinics. Entry into care was defined as having at least one visit to a primary HIV care provider after the initial diagnosis of HIV infection. Investigators collected reports from patients, medical providers, laboratories and reviewed medical records to determine the date of the initial health care visit after HIV diagnosis. We identified factors associated with increased likelihood of entering care after HIV diagnosis.
Results
One -hundred and sixty new HIV-infected cases were diagnosed between July 1, 2006 and June 30, 2007. Routine surveillance methods found that 101 of those cases entered HIV medical care and monitoring of CD4 T cell counts and plasma HIV viral load confirmed entry to care of 25 more cases, representing a 25% increase over routine data collection methods. We found that being interviewed by a public health investigator was associated with higher odds of entry into care after HIV diagnosis (OR 18.86 [1.83–194.80], p = .001) compared to cases not interviewed. Also, HIV diagnosis at the San Francisco county hospital versus diagnosis at the county municipal STD clinic was associated with higher odds of entry into care (OR 101.71 [5.29–1952.05], p < .001).
Conclusion
The time from HIV diagnosis to initial CD4 T cell count, CD4 T cell value and HIV viral load testing may be appropriate surveillance measures for evaluating entry into care, as well as performance outcomes for local public health departments' HIV testing programs. Case investigation performed by the public health department or case management by clinic staff was associated with increased and shorter time to entry into HIV medical care.
doi:10.1186/1471-2458-9-17
PMCID: PMC2633266  PMID: 19144168
16.  Cocaine- and opiate-related fatal overdose in New York City, 1990–2000 
BMC Public Health  2007;7:31.
Background
In New York City (NYC), the annual mortality rate is higher for accidental drug overdoses than for homicides; cocaine and opiates are the drugs most frequently associated with drug overdose deaths. We assessed trends and correlates of cocaine- and opiate-related overdose deaths in NYC during 1990–2000.
Methods
Data were collected from the NYC Office of the Chief Medical Examiner (OCME) on all fatal drug overdoses involving cocaine and/or opiates that occurred between 1990–2000 (n = 8,774) and classified into three mutually exclusive groups (cocaine only; opiates-only; cocaine and opiates). Risk factors for accidental overdose were examined in the three groups and compared using multinomial logistic regression.
Results
Overall, among decedents ages 15–64, 2,392 (27.3%) were attributed to cocaine only and 2,825 (32.2%) were attributed to opiates-only. During the interval studied, the percentage of drug overdose deaths attributed to cocaine only fell from 29.2% to 23.6% while the percentage of overdose deaths attributed to opiates-only rose from 30.6% to 40.1%. Compared to New Yorkers who fatally overdosed from opiates-only, fatal overdose attributed to cocaine-only was associated with being male (OR = 0.71, 95% CI 0.62–0.82), Black (OR = 4.73, 95% CI 4.08–5.49) or Hispanic (OR = 1.51, 95% CI 1.29–1.76), an overdose outside of a residence or building (OR = 1.34, 95% CI 1.06–1.68), having alcohol detected at autopsy (OR = 0.50, 95% CI 0.44–0.56) and older age (55–64) (OR = 2.53 95% CI 1.70–3.75)).
Conclusion
As interventions to prevent fatal overdose become more targeted and drug specific, understanding the different populations at risk for different drug-related overdoses will become more critical.
doi:10.1186/1471-2458-7-31
PMCID: PMC1839087  PMID: 17349051

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