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1.  Correlates of Self-reported Pelvic Inflammatory Disease Treatment in Sexually Experienced Reproductive Age Women in the United States, 1995 to 2006–10 
Sexually transmitted diseases  2013;40(5):413-418.
Few studies have examined recent temporal trends in self-reported receipt of pelvic inflammatory disease (PID) treatment. We assessed trends in receipt of PID treatment and associated correlates using national survey data.
We used data from the National Survey of Family Growth, a multi-stage national probability survey of 15–44 year old women. We examined trends in self-reported receipt of PID treatment from 1995, 2002, to 2006–10. Additionally, we examined correlates of PID treatment in 1995 and 2006–10 in bivariate and adjusted analyses.
From 1995 to 2002, receipt of PID treatment significantly declined from 8.6% to 5.7% (p<.0001); however, there was no difference from 2002 to 2006–10 (5.0%, p=.16). In bivariate analyses, racial differences in PID treatment declined across time; in 2006–10, there was no significant difference between racial/ethnic groups (p=.22). Also in bivariate analyses, similar to 1995, in 2006–10, some of the highest reports of receipt of PID treatment were women who were 35–44 years old (5.6%), had an income less than 150% of poverty level (7.5%), had less than high school education (6.7%), douched (7.7%), had intercourse before age 15 (10.3%), and had 10 or more lifetime partners (8.0%). In adjusted analyses, differing from 1995, women at less than 150% of the poverty level were more likely (AOR=2.60, 95%CI 1.79–3.76) than women at 300% or more of the poverty level to have received PID treatment in 2006–10.
Receipt of PID treatment declined from 1995 to 2006–10 with the burden affecting women of lower socioeconomic status.
Data from a national probability sample of reproductive-aged women found a decrease in receipt of treatment for pelvic inflammatory disease from 1995 to 2006–10 but treatment was highest among women with a lower socioeconomic status.
PMCID: PMC5245165  PMID: 23588132
pelvic inflammatory disease; treatment; national data
2.  Prevalence and Correlates of Genital Infections Among Newly Diagnosed Human Immunodeficiency Virus–Infected Adults Entering Human Immunodeficiency Virus Care in Windhoek, Namibia 
Sexually transmitted diseases  2016;43(11):698-705.
Identifying and treating genital infections, including sexually transmitted infections (STI), among newly diagnosed human immunodeficiency virus (HIV)-infected individuals may benefit both public and individual health. We assessed prevalence of genital infections and their correlates among newly diagnosed HIV-infected individuals enrolling in HIV care services in Namibia.
Newly diagnosed HIV-infected adults entering HIV care at 2 health facilities in Windhoek, Namibia, were recruited from December 2012 to March 2014. Participants provided behavioral and clinical data including CD4+ T lymphocyte counts. Genital and blood specimens were tested for gonorrhea, Chlamydia, trichomoniasis, Mycoplasma genitalium, syphilis, bacterial vaginosis, and vulvovaginal candidiasis.
Among 599 adults, 56% were women and 15% reported consistent use of condoms in the past 6 months. The most common infections were bacterial vaginosis (37.2%), trichomoniasis (34.6%) and Chlamydia (14.6%) in women and M. genitalium (11.4%) in men. Correlates for trichomoniasis included being female (adjusted relative risk, [aRR], 7.18; 95% confidence interval [CI], 4.07–12.65), higher education (aRR, 0.58; 95% CI, 0.38–0.89), and lower CD4 cell count (aRR, 1.61; 95% CI, 1.08–2.40). Being female (aRR, 2.39; 95% CI, 1.27–4.50), nonmarried (aRR, 2.30; (95% CI, 1.28–4.14), and having condomless sex (aRR, 2.72; 95% CI, 1.06–7.00) were independently associated with chlamydial infection. Across all infections, female (aRR, 2.31; 95% CI, 1.79–2.98), nonmarried participants (aRR, 1.29; 95% CI, 1.06–1.59), had higher risk to present with any STI, whereas pregnant women (aRR, 1.16, 95% CI 1.03–1.31) were at increased risk of any STI or reproductive tract infection.
PMCID: PMC5206658  PMID: 27893600
4.  Field Evaluation of a Dual Rapid Immunodiagnostic Test for HIV and Syphilis infection in Peru 
Sexually transmitted diseases  2016;43(1):57-60.
Integrated prevention for HIV and syphilis is warranted because both syphilis and HIV infections have evidence-based, scalable interventions using current health care mechanisms. The advent of dual rapid point-of-care tests, single devices that can detect multiple infections using the same specimen, provides the opportunity to integrate the screening of syphilis into HIV programs, potentially increasing the numbers of people tested and allowing for same-day testing and treatment. The aim of this study was to evaluate the MedMira Multiplo Rapid TP/HIV Antibody Test (MedMira Inc, Halifax, Nova Scotia, Canada), a qualitative, rapid immunoassay that detects antibodies to T. pallidum and HIV.
The reference standard test for comparison to the T. pallidum component of the Multiplo TP/HIV Test was Treponema Pallidum Particle Agglutination assay. For the HIV component, the reference test included a 4th-generation enzyme immunoassay with a confirmatory Western blot test.
The sensitivity and specificity for the HIV antibody component were 93.8% (95% CI: 69.8%, 99.8%) and 100% (95% CI: 97.7%, 100%), respectively. The Treponema pallidum component of the test had a sensitivity of 81.0% (95% CI: 68.1%, 94.6%) and a specificity of 100% (95% CI: 97.6%, 100%).
Our study showed excellent performance of the HIV antibody component of the test and very good performance for the Treponema pallidum antibody component of the MedMira Multiplo Rapid TP/HIV Antibody Test, which should be considered to improve screening coverage. Use of effective dual tests will create improved access to more comprehensive care by integrating the screening of syphilis into HIV prevention programs.
PMCID: PMC4675040  PMID: 26650998
Dual test; HIV; syphilis; Treponema pallidum; point-of-care; diagnosis
5.  Relationship of estimated SHIV acquisition time points during the menstrual cycle and thinning of vaginal epithelial layers in pigtail macaques 
Sexually transmitted diseases  2015;42(12):694-701.
HIV acquisition in the female genital tract remains incompletely understood. Quantitative data on biological HIV risk factors, the influence of reproductive hormones, and infection risk are lacking. We evaluated vaginal epithelial thickness during the menstrual cycle in pigtail macaques (Macaca nemestrina). This model previously revealed increased susceptibility to vaginal infection during and following progesterone-dominated periods in the menstrual cycle.
Nucleated and non-nucleated (superficial) epithelial layers were quantitated throughout the menstrual cycle of 16 macaques. We examined the relationship with previously estimated vaginal SHIVSF162P3 acquisition time points in the cycle of 43 different animals repeatedly exposed to low virus doses.
In the luteal phase (days 17 to cycle end), the mean vaginal epithelium thinned to 66% of mean follicular thickness (days 1-16; p=0.007, Mann-Whitney test). Analyzing four-day segments, the epithelium was thickest on days 9-12, and thinned to 31% thereof on days 29-32, with reductions of nucleated and non-nucleated layers to 36 and 15% of their previous thickness, respectively. The proportion of animals with estimated SHIV acquisition in each cycle segment correlated with non-nucleated layer thinning (Pearson’s r = 0.7, p<0.05, linear regression analysis), but not nucleated layer thinning (Pearson’s r = 0.6, p=0.15).
These data provide a detailed picture of dynamic cycle-related changes in the vaginal epithelium of pigtail macaques. Substantial thinning occurred in the superficial, non-nucleated layer, which maintains the vaginal microbiome. The findings support vaginal tissue architecture as susceptibility factor for infection and contribute to our understanding of innate resistance to SHIV infection.
PMCID: PMC4646715  PMID: 26562699
HIV; animal model; reproductive immunology; hormonal contraception; infection risk
6.  Epidemiology of Human Papillomavirus (HPV) Detected in the Oral Cavity and Fingernails of Mid-Adult Women 
Sexually transmitted diseases  2015;42(12):677-685.
Oral and fingernail human papillomavirus (HPV) detection may be associated with HPV-related carcinoma risk at these non-genital sites and foster transmission to the genitals. We describe the epidemiology of oral and fingernail HPV among mid-adult women.
Between 2011–2012, 409 women aged 30–50 years were followed for 6 months. Women completed health and behavior surveys and provided self-collected oral, fingernail, and vaginal specimens at enrollment and exit for type-specific HPV DNA testing. Concordance of type-specific HPV detection across anatomic sites was described with kappa statistics. Using generalized estimating equations or exact logistic regression, we measured the univariate associations of various risk factors with type-specific oral and fingernail HPV detection.
Prevalence of detecting HPV in the oral cavity (2.4%) and fingernails (3.8%) was low compared to the vagina (33.1%). Concordance across anatomic sites was poor (kappa<.20 for all comparisons). However, concurrent vaginal infection with the same HPV type (OR=101.0;95%CI: 31.4–748.6) and vaginal HPV viral load (OR per one log10 viral load increase=2.2;95%CI:1.5–5.5) were each associated with fingernail HPV detection. Abnormal Pap history (OR=11.1;95%CI:2.8-infinity), lifetime number of male vaginal sex partners ≥10 (OR vs. 0–3 partners=5.0;95%CI:1.2-infinity), and lifetime number of open-mouth kissing partners ≥16 (OR vs. 0–15 partners=infinity;95%CI:2.6-infinity, by exact logistic regression) were each associated with oral HPV detection.
While our findings support HPV DNA deposition or autoinoculation between anatomic sites in mid-adult women, the rarity of HPV in the oral cavity and fingernails suggests that oral/fingernail HPV does not account for a significant fraction of HPV in genital sites.
PMCID: PMC4646722  PMID: 26562696
human papillomavirus; women; oral; fingernail
7.  Trends in Genital Warts in the Era of HPV Vaccination 
Sexually transmitted diseases  2015;42(12):669-670.
PMCID: PMC4648687  PMID: 26560967
8.  High rate of β-globin DNA detection validates self-sampling in HSV shedding studies 
Sexually transmitted diseases  2015;42(12):705-709.
Self-sampling is a convenient, feasible and acceptable way of collecting genital specimens, but the veracity of reported self-collection is difficult to verify. We investigated whether a host gene, β-globin, can be used to confirm adequacy of self-collected mucosal and skin genital specimens in studies of genital HSV infection.
HSV-2 seropositive adults self-collected daily anogenital and oral swabs. Mucosal samples were tested for HSV DNA using a real-time quantitative PCR assay. A real time Taqman PCR detecting the β-globin gene was used to quantify host cells.
One hundred twelve participants collected 5559 genital and 2002 oral swabs. Sixty (54%) were women, 65% were HSV-2 seropositive, and 35% were HSV-1 & HSV-2 seropositive by Western blot. β-globin DNA was detected in 99% and 93% of swabs obtained from women and men, respectively. The quantity of β-globin DNA detected was significantly higher when HSV was present in genital swabs in women (0.1 log10 copies/mL; p=0.001) and in men (0.6 log10 copies/mL; p<0.001), but not in oral swabs in women (0.2 log10 copies/mL; p=0.08) or men (0.0 log10 copies/mL; p=0.70).
Human β-globin DNA detection rate was high, and the quantity obtained significantly increased with genital, but not oral HSV shedding. The high rate of β-globin DNA detection is consistent with high adherence to study procedures in longitudinal studies of genital herpes shedding.
PMCID: PMC4803496  PMID: 26562701
Self-sampling; HSV; β-globin; DNA; PCR
9.  Factors Associated With Recent Human Immunodeficiency Virus Testing Among Men Who Have Sex With Men in Puerto Rico, National Human Immunodeficiency Virus Behavioral Surveillance System, 2011 
Sexually transmitted diseases  2016;43(6):346-352.
Annual human immunodeficiency virus (HIV) testing is considered a key strategy for HIV prevention for men who have sex with men (MSM). In Puerto Rico, HIV research has primarily focused on injection drug use, yet male-to-male sexual transmission has been increasing in recent years.
Cross-sectional data from the National HIV Behavioral Surveillance system collected in 2011 in San Juan, Puerto Rico, were analyzed to identify factors associated with HIV testing in the past 12 months (recent testing).
Overall, 50% of participants were tested recently. In the multivariate analysis, testing recently was associated with having multiple partners in the past 12 months (adjusted prevalence ratio [aPR] [≥4 vs 1 partner] = 1.5; 95% confidence interval [95% CI], 1.2–2.0), visiting a health care provider in the past 12 months (aPR, 1.4; 95% CI, 1.04–1.8), and disclosing male-male attraction/sex to a health care provider (aPR< 1.4; 95% CI, 1.1–1.7).
Human immunodeficiency virus testing was suboptimal among MSM in San Juan. Strategies to increase HIV testing among MSM may include promoting HIV testing for all sexually active MSM including those with fewer partners, increasing utilization of the healthcare system, and improving patient-provider communication.
PMCID: PMC5114708  PMID: 27200518
10.  Sexual partnership patterns among South African adolescent girls enrolled in HPTN 068: measurement challenges and implications for HIV/STI transmission 
Sexually transmitted diseases  2015;42(11):612-618.
Estimates of sexual partnership durations, gaps between partnerships, and overlaps across partnerships are important for understanding sexual partnership patterns and developing interventions to prevent transmission of HIV/STIs. However, a validated, optimal approach for estimating these parameters, particularly when partnerships are ongoing, has not been established.
We assessed four approaches for estimating partnership parameters using cross-sectional reports on dates of first and most recent sex and partnership status (ongoing or not) from 654 adolescent girls in rural South Africa. The first, commonly used, approach assumes all partnerships have ended, resulting in underestimated durations for ongoing partnerships. The second approach treats reportedly ongoing partnerships as right-censored, resulting in bias if partnership status is reported with error. We propose two “hybrid” approaches, which assign partnership status to reportedly ongoing partnerships based on how recently girls last had sex with their partner. We estimate partnership duration, gap length, and overlap length under each approach using Kaplan-Meier methods with a robust variance estimator.
Median partnership duration and overlap length varied considerably across approaches (from 368 to 1,024 days and 168 to 409 days, respectively), but gap length was stable. Lifetime prevalence of concurrency ranged from 28% to 33%, and at least half of gap lengths were shorter than 6 months, suggesting considerable potential for HIV/STI transmission.
Estimates of partnership duration and overlap lengths are highly dependent on measurement approach. Understanding the effect of different approaches on estimates is critical for interpreting partnership data and utilizing estimates to predict HIV/STI transmission rates.
PMCID: PMC4608257  PMID: 26462185
11.  Community-Based Screening for Cervical Cancer: A Feasibility Study of Rural Appalachian Women 
Sexually transmitted diseases  2015;42(11):607-611.
To describe women’s comfort levels and perceptions about their experience self-collecting cervico-vaginal swabs for HPV testing; to determine whether nurse-guided patient navigation increases the odds of women receiving a traditional Pap test after HPV screening; and to test the hypothesis that women testing positive for oncogenic HPV would be more likely to have a subsequent Pap test than those testing negative.
400 women were recruited from eight rural Appalachian counties, in 2013 and 2014. After completing a survey, women were provided instructions for self-collecting a cervico-vaginal swab. Specimens were tested for 13 oncogenic HPV types. Simultaneously, women were notified of their test results and offered initial navigation for Pap testing. Chart-verified Pap testing within the next six months served as the endpoint.
Comfort levels with self-collection were high: 89.2% indicated they would be more likely to self-collect a specimen for testing, on a regular basis, compared to Pap testing. Thirty women (7.5%) had a follow-up Pap test. Women receiving added nurse-guided navigation efforts were significantly less likely to have a subsequent test (P = .01). Women testing positive for oncogenic HPV were no more likely than those testing negative to have a subsequent Pap test (P = .27). Data were analyzed in 2014.
Rural Appalachian women are comfortable self-collecting cervico-vaginal swabs for HPV testing. Further, efforts to re-contact women who have received an oncogenic HPV test result and an initial navigation contact may not be useful. Finally, testing positive for oncogenic HPV may not be a motivational factor for subsequent Pap testing.
PMCID: PMC4608378  PMID: 26462184
Cervical cancer screening; HPV testing; self-collection; Appalachia; rural
12.  Differing identities, but comparably high HIV and bacterial sexually transmitted disease burdens, among married and unmarried men who have sex with men in Mumbai, India 
Sexually transmitted diseases  2015;42(11):629-633.
Although HIV incidence has declined in India, men and transgender women who have sex with men (MSM) continue to have high rates of HIV and STD. Indian MSM face substantial pressures to marry and have families, but the HIV/STD burden among married Indian MSM is not well-characterized.
A diverse sample of Indian MSM was recruited through respondent driven sampling (RDS). Independent variables that produced a p-value of 0.10 or less were then added to a multivariable logistic regression model.
Most of the 307 MSM (95 married, and 212 unmarried) recruited into the study were less than 30, and less than 1/3 had more than a high school education. Almost two thirds of the married men had children, compared to 1.4% of the unmarried men (p<0.001). The numbers of condomless anal sex acts did not differ by marriage status. Although unmarried MSM more often identified themselves as “kothi” (receptive role), their rates of HIV or bacterial STD were similar to married MSM, with 14.3% being HIV-infected. The RDS-adjusted prevalence of any bacterial STD was 18.3% for married MSM and 20% for unmarried MSM (NS). Participants reported high levels of psychological distress, with 27.4% of married and 20.1% of unmarried MSM reporting depressive symptoms (NS).
MSM in Mumbai had high rates of HIV, STD and behavioral health concerns. Clinicians need to become more comfortable in eliciting sexual histories so that they can identify MSM who need HIV/STD treatment and/or prevention services.
PMCID: PMC4610131  PMID: 26462187
men who have sex with men; sexually transmitted infections; HIV; India
13.  Condom Use Errors and Problems: A Comparative Study of HIV-Positive Versus HIV-Negative Young Black MSM 
Sexually transmitted diseases  2015;42(11):634-636.
To describe self-reported frequencies of selected condom use errors and problems among young (ages 15–29) Black MSM (YBMSM) and to compare the observed prevalence of these errors/problems by HIV serostatus.
Between September 2012 October 2014, electronic interview data were collected from 369 YBMSM attending a federally supported STI clinic located in the southern U.S. Seventeen condom use errors and problems were assessed. Chi-square tests were used to detect significant differences in the prevalence of these 17 errors and problems between HIV-negative and HIV-positive men.
The recall period was the past 90 days. The overall mean number of errors/problems was 2.98 (sd=2.29). The mean for HIV-negative men was 2.91 (sd=2.15) and the mean for HIV-positive men was 3.18 (sd=2.57). These means were not significantly different (t=1.02, df=367, P=.31). Only two significant differences were observed between HIV-negative and HIV-positive men. Breakage (P = .002) and slippage (P = .005) were about twice as likely among HIV-positive men. Breakage occurred for nearly 30% of the HIV-positive men compared to about 15% among HIV-negative men. Slippage occurred for about 16% of the HIV-positive men compared to about 9% among HIV-negative men.
A need exists to help YBMSM acquire the skills needed to avert breakage and slippage issues that could lead to HIV transmission. Beyond these two exceptions, condom use errors and problems were ubiquitous in this population regardless of HIV serostatus. Clinic-based intervention is warranted for these young men, including education about correct condom use and provision of free condoms and long-lasting lubricants.
PMCID: PMC4610153  PMID: 26462188
Condoms; young men; sexually transmitted diseases; sexual behavior
14.  Vaginal self-sampling for HPV infection as a primary cervical cancer screening tool in a Haitian population 
Sexually transmitted diseases  2015;42(11):655-659.
Human papillomavirus (HPV) testing as primary cervical cancer screening has not been studied in Caribbean women. We tested vaginal self-collection versus physician cervical sampling in a population of Haitian women.
Participants were screened for high-risk HPV with self-performed vaginal and clinician-collected cervical samples using Hybrid Capture 2 assays (Qiagen, Gaithersburg, Maryland). Women positive by either method then underwent colposcopy with biopsy of all visible lesions. Sensitivity and positive predictive value were calculated for each sample method compared to biopsy results, with kappa statistics performed for agreement. McNemar’s tests were performed for differences in sensitivity at ≥ cervical intraepithelial neoplasia (CIN)-I and ≥ CIN-II.
Of 1845 women screened, 446 (24.3%) were HPV-positive by either method, including 105 (5.7%) only by vaginal swab and 53 (2.9%) only by cervical swab. Vaginal and cervical samples were 91.4% concordant (κ= 0.73 [95% CI: 0.69 – 0.77], p < 0.001). Overall, 133 HPV-positive women (29.9%) had CIN-I, while 32 (7.2%) had ≥ CIN-II. The sensitivity of vaginal swabs was similar to cervical swabs for detecting ≥ CIN-I (89.1% vs 87.9%, respectively, p=0.75) lesions and ≥ CIN-II disease (87.5% vs 96.9%, p=0.18). Eighteen of 19 cases of CIN-III and invasive cancer were found by both methods.
HPV screening via self-collected vaginal swabs or physician-collected cervical swabs are feasible options in this Haitian population. The agreement between cervical and vaginal samples was high, suggesting vaginal sample-only algorithms for screening could be effective for improving screening rates in this under-screened population.
PMCID: PMC4610156  PMID: 26462192
Cervical cancer; human papillomavirus; HPV self-sampling; Haiti
15.  Creative contributory contests (CCC) to spur innovation in sexual health: Two cases and a guide for implementation 
Sexually transmitted diseases  2015;42(11):625-628.
Sexual health campaigns are often designed “top-down” by public health experts, failing to engage key populations. Using the power of crowdsourcing to shape a “bottom-up” approach, this note describes two creative contributory contests (CCC) to enhance sexual health campaigns. We provide guidance for designing CCCs to improve HIV and other STD testing.
PMCID: PMC4610177  PMID: 26462186
HIV; STD; community engagement; contest; innovation
16.  HIV Testing, HIV Positivity, and Linkage and Referral Services in Correctional Facilities in the United States, 2009–2013 
Sexually transmitted diseases  2015;42(11):643-649.
Because of health disparities, incarcerated persons are at higher risk for multiple health issues, including HIV. Correctional facilities have an opportunity to provide HIV services to an underserved population. This article describes Centers for Disease Control and Prevention (CDC)–funded HIV testing and service delivery in correctional facilities.
Data on HIV testing and service delivery were submitted to CDC by 61 health department jurisdictions in 2013. HIV testing, HIV positivity, receipt of test results, linkage, and referral services were described, and differences across demographic characteristics for linkage and referral services were assessed. Finally, trends were examined for HIV testing, HIV positivity, and linkage from 2009 to 2013.
Of CDC-funded tests in 2013 among persons 18 years and older, 254,719 (7.9%) were conducted in correctional facilities. HIV positivity was 0.9%, and HIV positivity for newly diagnosed persons was 0.3%. Blacks accounted for the highest percentage of HIV-infected persons (1.3%) and newly diagnosed persons (0.5%). Only 37.9% of newly diagnosed persons were linked within 90 days; 67.5% were linked within any time frame; 49.7% were referred to partner services; and 45.2% were referred to HIV prevention services. There was a significant percent increase in HIV testing, overall HIV positivity, and linkage from 2009 to 2013. However, trends were stable for newly diagnosed persons.
Identification of newly diagnosed persons in correctional facilities has remained stable from 2009 to 2013. Correctional facilities seem to be reaching blacks, likely due to higher incarceration rates. The current findings indicate that improvements are needed in HIV testing strategies, service delivery during incarceration, and linkage to care postrelease.
PMCID: PMC4773196  PMID: 26462190
17.  HIV/STI Prevention Messaging: Targeting Root Causes of Sexual Risk Behavior 
Sexually transmitted diseases  2016;43(2):71-77.
Sexual risk behaviors (SRB) often lead to sexually transmitted infections (STI), yet little is known about what drives SRB and whether this differs by gender.
Participants (n=920; 75% Caucasian) were drawn from the Raising Healthy Children study, enrolled in 1993 and 1994 in grades 1-2 and followed through age 24/25. Lifetime STI diagnosis was defined by self-report or seropositivity for Chlamydia trachomatis or herpes simplex virus 2. Multivariable models assessed individual (social skills, behavioral disinhibition) and environmental factors (family involvement, school bonding, antisocial friends) predictive of STI diagnosis as mediated by 3 proximal SRB (sex under the influence of drugs or alcohol, condom use, lifetime number of sex partners).
Twenty-five percent of participants had ever had an STI. All SRB differed by gender (p<0.001), and females were more likely to have had an STI (p<0.001). Behavioral disinhibition and antisocial friends in adolescence were associated with more SRB for both genders, whereas social skills were associated with less SRB in females, but more in males. Considering SRB, individual, and environmental factors together, lifetime number of sex partners (ARR=1.04per partner; 95%CI 1.03-1.05) and inconsistent condom use (ARR=1.10per year; 95%CI 1.04-1.16) were associated with increased risk of STI whereas social skills was associated with decreased risk of STI (ARR=0.84; 0.75-0.93). Behavioral disinhibition appeared to drive SRB, but family involvement mitigated this in several cases.
Adolescent environmental influences and individual characteristics drive some SRB and may be more effective targets for STI/HIV prevention interventions than proximal risk behaviors.
Graphical abstract
Longitudinal data demonstrated that potentially modifiable adolescent environmental and individual characteristics may drive sexual risk behavior and risk for sexually transmitted infections.
PMCID: PMC5087127  PMID: 26760178
sexually transmitted disease; STD; intervention; prevention; behavior; substance abuse
18.  Impact of a Routine, Opt-Out HIV Testing Program on HIV Testing and Case Detection in North Carolina Sexually-Transmitted Disease Clinics 
Sexually transmitted diseases  2014;41(6):395-402.
The impact of routine, opt-out HIV testing programs in clinical settings is inconclusive. The objective of this study was to estimate the impact of an expanded, routine HIV testing program in North Carolina sexually transmitted disease (STD) clinics on HIV testing and case detection.
Adults aged 18–64 who received an HIV test in a North Carolina STD clinic July 1, 2005 through June 30, 2011 were included in this analysis, dichotomized at the date of implementation on November 1, 2007. HIV testing and case detection counts and rates were analyzed using interrupted time series analysis, and Poisson and multilevel logistic regression.
Pre-intervention, 426 new HIV-infected cases were identified from 128,029 tests (0.33%), whereas 816 new HIV-infected cases were found from 274,745 tests post-intervention (0.30%). Pre-intervention, HIV testing increased by 55 tests per month (95% confidence interval [CI]: 41, 72), but only 34 tests per month (95% CI: 26, 42) post-intervention. Increases in HIV testing rates were most pronounced in females and non-Hispanic whites. A slight pre-intervention decline in case detection was mitigated by the intervention (mean difference [MD]=0.01; 95% CI: −0.02, 0.05). Increases in case detection rates were observed among females and non-Hispanic blacks.
The impact of a routine HIV screening in North Carolina STD clinics was marginal, with the greatest benefit among persons not traditionally targeted for HIV testing. The use of a pre-intervention comparison period identified important temporal trends that otherwise would have been ignored.
PMCID: PMC5056640  PMID: 24825338
routine HIV testing; STD clinic; intervention analysis
19.  Chlamydia and Gonorrhea in HIV-infected Pregnant Women and Infant HIV Transmission 
Sexually transmitted diseases  2015;42(10):554-565.
Sexually transmitted infections (STIs) such as Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) can lead to adverse pregnancy and neonatal outcomes. STI prevalence and its association with HIV mother-to-child transmission (MTCT) were evaluated in a sub-study analysis from a randomized, multi-center clinical trial.
Urine samples from HIV-infected pregnant women collected at the time of labor and delivery were tested using polymerase chain reaction (PCR) testing for the detection of CT and NG (Xpert® CT/NG, Cepheid, Sunnyvale, CA). Infant HIV infection was determined by HIV DNA PCR at 3 months.
Of the 1373 urine specimens, 249 (18.1%) were positive for CT and 63 (4.6%) for NG; 35 (2.5%) had both CT and NG detected. Among 117 cases of HIV MTCT (8.5% transmission) the lowest transmission rate occurred among infants born to CT and NG uninfected mothers (8.1%) as compared to those infected with only CT (10.7%) and both CT and NG (14.3%), (p = 0.04). Infants born to CT-infected mothers had almost a 1.5-fold increased risk for HIV acquisition (OR 1.47, 95% CI 0.9–2.3, p=0.09).
This cohort of HIV-infected pregnant women are at high risk for infection with CT and NG. Analysis suggests that STIs may predispose to an increased HIV MTCT risk in this high risk cohort of HIV-infected women.
PMCID: PMC4571193  PMID: 26372927
maternal to child transmission; HIV; pregnancy; chlamydia; gonorrhea; sexually transmitted infections
20.  Sex partner meeting places over time among newly HIV diagnosed men who have sex with men (MSM) in Baltimore, Maryland 
Sexually transmitted diseases  2015;42(10):549-553.
Sex partner meeting places may be important locales to access men who have sex with men (MSM) and implement targeted human immunodeficiency virus (HIV) control strategies. These locales may change over time, but temporal evaluations have not been performed.
The objectives of this study were to describe the frequency of report of MSM sex partner meeting places over time, and to compare frequently reported meeting places in the past five years and past year among newly HIV diagnosed MSM in Baltimore City, Maryland. Public health HIV surveillance data including partner services information was obtained for this study from the Baltimore City Health Department from May 2009 to June 2014.
869 sex partner meeting places were reported, including 306 unique places. Bars/clubs (31%) and internet-based sites (38%) were the most frequently reported meeting place types. Over the five year period, the percentage of bars/clubs decreased over time and the percentage of internet-based sites increased over time. Among bars/clubs, 4/5 of those most frequently reported in the past five years were also most frequently reported in the most recent year. Among internet-based sites, 3/5 of those most frequently reported in the past five years were also in the top five most frequently reported in the past year.
This study provides a richer understanding of sex partner meeting places reported by MSM over time and information to health departments on types of places to access a population at high risk for HIV transmission.
PMCID: PMC4571287  PMID: 26372926
men who have sex with men; HIV; sex partner meeting places; HIV transmission; HIV control
21.  Barriers to Bacterial STI Testing of HIV-Infected Men who have Sex with Men Engaged in HIV Primary Care 
Sexually transmitted diseases  2015;42(10):590-594.
Approximately 15% of HIV-infected MSM engaged in HIV primary care have been diagnosed with an STI in the past year, yet STI testing frequency remains low.
We sought to quantify STI testing frequencies at a large, urban HIV care clinic, and to identify patient- and provider-related barriers to increased STI testing. We extracted laboratory data in aggregate from the electronic medical record to calculate STI testing frequencies (defined as the number of HIV-infected MSM engaged in care who were tested at least once over an 18-month period divided by the number of MSM engaged in care). We created anonymous surveys of patients and providers to elicit barriers.
Extra-genital gonorrhea and chlamydia testing were low (29%–32%), but the frequency of syphilis testing was higher (72%). Patients frequently reported high-risk behaviors, including drug use (16.4%) and recent bacterial STI (25.5%), as well as substantial rates of recent testing (>60% in prior 6 months). Most (72%) reported testing for STI in HIV primary care, but one-third went elsewhere for “easier” (42%), anonymous (21%) or more frequent (16%) testing. HIV primary care providers lacked testing and treatment knowledge (25–32%), and cited lack of time (68%), discomfort with sexual history taking and genital exam (21%), and patient reluctance (39%) as barriers to increased STI testing.
STI testing in HIV care remains unacceptably low. Enhanced education of providers, along with strategies to decrease provider time and increase patient ease and frequency of STI testing, are needed.
PMCID: PMC4576720  PMID: 26372931
gonorrhea; chlamydia; syphilis; STI testing; HIV care; barriers to STI testing
22.  Would Targeting Increase Efficiency of Syphilis Partner Services Programs?—Data From New York City, Philadelphia, Texas, and Virginia 
Sexually transmitted diseases  2014;41(6):407-412.
Targeted partner notification (PN), or limiting PN to groups in which efforts are most successful, has been suggested as a potentially cost-effective alternative to providing PN for all syphilis case-patients. The purpose of this study was to identify index case characteristics associated with highest yield partner elicitation and subsequent case finding to determine whether some groups could be reasonably excluded from PN efforts.
We examined index case characteristics and PN metrics from syphilis case management records of 4 sexually transmitted disease control programs—New York City, Philadelphia, Texas, and Virginia. Partner elicitation was considered successful when a case-patient named 1 or more partners during interview. Case finding was considered successful when a case-patient had 1 or more partners who were tested and had serologic evidence of syphilis exposure. Associations between case characteristics and proportion of pursued case-patients with successful partner elicitation and case finding were evaluated using χ2 tests.
Successful partner elicitation and new case finding was most likely for index case-patients who were younger and diagnosed at public sexually transmitted disease clinics. However, most characteristics of index case-patients were related to success at only a few sites, or varied in the direction of the relationship by site. Other than late latent case-patients, few demographic groups had a yield far below average.
If implemented, targeted PN will require site-specific data. Sites may consider eliminating PN for late latent case-patients. The lack of demographic groups with a below average yield suggests that sites should not exclude other groups from PN.
PMCID: PMC5024550  PMID: 24825340
24.  Anal Intercourse among Young Heterosexuals in Three US STD Clinics 
Sexually transmitted diseases  2009;36(4):193-198.
To examine factors associated with heterosexual anal intercourse (AI).
Between 2001 and 2004, 890 heterosexual adults aged 18-26 attending public STD clinics in Seattle, New Orleans and St Louis were interviewed using CASI and tested for sexually transmitted infections (STI) Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium, Trichomonas vaginalis, and genital herpes (HSV-2). Characteristics associated with AI were identified using logistic regression.
Overall 289 (32%) reported ever having had AI, 201 (26.5%) reported AI with at least one of their last three partners and 17% reported AI with their last partner. Fewer females than males reported condom use at last AI (24% vs. 47%, p<0.001). Ever having AI was associated with sex on the same day as meeting a partner (AOR 3.5 [95% CI 1.94-6.15]), receiving money for sex (AOR 3.3 [1.40-7.75]), and >3 lifetime sex partners (AOR 2.2 [1.17-4.26]) among women, and sex on the same day as meeting a partner (AOR 2.0 [1.28-3.14]) and paying for sex (AOR 1.8 [1.00-3.15]) among men. AI with the last partner was associated with sex toy use (AOR 5.3 [2.35-12.0]) and having concurrent partners (AOR 2.3 [1.18-4.26]) among men, and with sex within a week of meeting (AOR 2.7 [1.21-5.83]), believing the partner was concurrent (AOR 2.6 [1.38-4.83]), and partnership duration >3 months (AOR 3.2 [1.03-10.1]) among women. Prevalent STI was not associated with AI.
Many young heterosexuals attending STD clinics reported AI, which was associated with other sexual risk behaviors, suggesting a confluence of risks for HIV infection.
PMCID: PMC5019823  PMID: 19265740
Heterosexual Anal intercourse; STDs; Young Adults; Sexual Partnerships
25.  Heterogeneity of HIV prevalence among the sexual networks of Black and White MSM in Atlanta: illuminating a mechanism for increased HIV risk for young Black MSM 
Sexually transmitted diseases  2015;42(9):505-512.
Studying the heterogeneity and correlates of HIV risk in the sexual networks of Black and White MSM may help explain racial disparities in HIV-infection.
Black and White MSM were recruited as seeds using venue-based time sampling, and provided data regarding their recent sex partners. We used chain referral methods to enroll seeds’ recent sex partners; newly enrolled partners in turn provided data on their recent sex partners, some of whom later enrolled. Data about unenrolled recent sex partners obtained from seeds and enrolled participants were also analyzed. We estimated the prevalence of HIV in sexual networks of MSM and assessed differential patterns of network HIV risk by the race of the seed.
The mean network prevalence of HIV in sexual networks of Black MSM (n=117) was 36% compared to 4% in networks of White MSM (n=78) (P<0.0001). Sexual networks of unemployed Black MSM had a higher prevalence of HIV than their employed counterparts (51% vs. 29%, P=0.007). The networks of HIV-negative Black MSM seeds aged 18–24 had a network prevalence of 9% compared to 2% among those aged 30 or older. In networks originating from a Black HIV-positive seed, the prevalence ranged from 63% among those aged 18–24 to 80% among those 30 or older.
The high prevalence of HIV in the networks of HIV-negative young Black MSM demonstrates a mechanism for the increased HIV incidence observed in this age group. More research is needed into how age and socioeconomic factors shape sexual networks and HIV risk.
PMCID: PMC4536576  PMID: 26267877
sexual partners; homosexual men; HIV seroprevalence; sexual behavior; socioeconomic factors; epidemiology

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