Uptake of regular chlamydia testing by U.S. women: a longitudinal study

Sexually transmitted infection laboratory testing and education trends in US outpatient physician offices, 2009-2016

OBJECTIVE

To describe national rates of sexually transmitted infection (STI) testing and education overall and among patient subgroups in US outpatient physician offices from 2009 to 2016.

DESIGN

This was a cross-sectional study of the Centers for Disease Control and Prevention's National Ambulatory Medical Care Survey from 2009 to 2016. Data weights were applied to extrapolate to national estimates.

SETTING

Data were collected from a systematic random sample of outpatient physician office visits throughout USA. Physician office types include free standing clinics, private or group setting practices, centres offering community and mental health services, family planning clinics and health maintenance organisations/other prepaid clinics.

PARTICIPANTS

All sampled patient visits were eligible for inclusion and were assessed for the provision of STI prevention education and STI testing for chlamydia, gonorrhoea, hepatitis, human papillomavirus (HPV) and HIV.

RESULTS

Of 7.6 billion total visits, 123 million included an STI test. Hepatitis was the most commonly tested STI (9.12 per 1000), followed by chlamydia (6.67 per 1000), gonorrhoea (6.00 per 1000), HIV (5.40 per 1000) and HPV (5.03 per 1000). Testing rates for the three STIs measured for the entire 8-year period increased over time and peaked in 2015 compared with 2009: chlamydia (R2=0.36), HPV (R2=0.28) and HIV (R2=0.51). Testing was highest among women (21.93 per 1000), 15-24-year olds (46.04 per 1000), non-Hispanic blacks (37.33 per 1000) and those seen by obstetrics/gynaecology specialists (103.75 per 1000). STI prevention education was provided to 4.89 per 1000 patients and remained relatively unchanged from 2013 to 2016.

CONCLUSION

STI testing in outpatient physician offices increased over the study period but varied by patient characteristics and site of care. Few patients received STI prevention education, highlighting a potential gap in resource utilisation in these settings.

The Influence of Screening, Misclassification, and Reporting Biases on Reported Chlamydia Case Rates Among Young Women in the United States, 2000 Through 2017

BACKGROUND

National chlamydia case rate trends are difficult to interpret because of biases from partial screening coverage, imperfect diagnostic tests, and underreporting. We examined the extent to which these time-varying biases could influence reported annual chlamydia case rates.

METHODS

Annual reported case rates among women aged 15 through 24 years from 2000 through 2017 were obtained from the Centers for Disease Control and Prevention's National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention AtlasPlus tool. Estimates of reporting completeness, diagnostic test sensitivity and specificity, and screening coverage were derived from literature review and expert opinion. We adjusted annual reported case rates for incomplete reporting, imperfect diagnostic tests, and partial screening coverage through a series of corrections, and calculated annual adjusted case rates of correctly diagnosed chlamydia.

RESULTS

Adjusted chlamydia case rates among young women were higher than reported case rates throughout the study period. Reported case rates increased over the study period, but adjusted rates declined from 12,900 to 7900 cases per 100,000 person-years between 2000 and 2007. After 2007, adjusted case rates declined to 7500 cases per 100,000 person-years in 2017. Bias from partial screening coverage had a larger impact on case rate magnitude and trend shape than bias from imperfect diagnostic tests or underreporting.

CONCLUSIONS

Reported chlamydia case rates may be substantially lower than true chlamydia case rates because of incomplete reporting, imperfect diagnostic tests, and partial screening coverage. Because the magnitude of these biases has declined over time, the differences between reported and adjusted case rates have narrowed, revealing a sharp decline in adjusted case rates even as reported case rates have risen. The decline in adjusted case rates suggests that the rise in reported case rates should not be interpreted strictly as increasing chlamydia incidence, as the observed rise can be explained by improvements in screening coverage, diagnostic tests, and reporting.

Drassanes Exprés: a public and confidential testing service for asymptomatic STIs with same-day result notification

BACKGROUND

STIs are a major public health concern. Screening programmes for asymptomatic users are key components of STI control. Traditional limitations of screening programmes include low population coverage and delays in treatments, thus reducing the expected impact on STI control. In our centre, the normal time from test to results was 4 days, and 7 days until treatment was established.To reduce time to treatment and to increase population coverage, we developed 'Drassanes Exprés', a testing service for asymptomatic STIs. The objectives of this study were to provide a guide for the implementation of a service with these characteristics and to evaluate the results of this intervention.

METHODS

The Drassanes Exprés programme was launched in Spain on 07 November 2016 as a public, confidential and free-of-charge testing service for asymptomatic STIs, with same-day result notification. For this walk-in service, confidentiality was obtained by registering all information into the Laboratory Internal Software instead of the Electronic Patient Records. Samples were processed in a point-of-care laboratory and result notification was provided via mail or short message service.Information about workflow, screening protocols and result interpretation is detailed. Additionally, demographic characteristics, STI prevalence, and time from patients' sample collection to notification and treatment are analysed.

RESULTS

Between 07 November 2016 and 07 November 2019, 13 993 users attended the Drassanes Exprés screening programme. Of these, 0.5% were transgender people, 29.3% women, 45.2% men who have sex with men and 25.1% men who have sex with women. The median age was 31 years (range: 26-39 years). Overall, 14.6% of users tested positive for at least one STI. The most prevalent infection was Chlamydia trachomatis (8.3%), followed by Neisseria gonorrhoeae (5.7%), syphilis (1.8%), HIV (0.4%) and hepatitis C virus (0.2%). The median time from test to results was 2.4 hours (range: 2-3.1 hours). Of 2049 users diagnosed with an STI, treatment was achieved in 97.0% of cases; the average time to treatment was 2.0 days.

CONCLUSIONS

Drassanes Exprés is the first public programme for rapid, asymptomatic, STI screening and treatment in Spain. Assessing high-risk practices and providing confidentiality, easy access and rapid results/treatments are key elements in the development of STI screening programmes.

Understanding Primary Care Providers' Perceptions and Practices in Implementing Confidential Adolescent Sexual and Reproductive Health Services

PURPOSE

Substantial gaps exist between professional guidelines and practice around confidential adolescent services, including private time between health-care providers and adolescents. Efforts to provide quality sexual and reproductive health services (SRHS) require an understanding of barriers and facilitators to care from the perspectives of primary care providers working with adolescents and their parents.

METHODS

We conducted structured qualitative interviews with a purposive sample of pediatricians, family physicians, and nurse practitioners (n = 25) from urban and rural Minnesota communities with higher and lower rates of adolescent pregnancy. Provider interviews included confidentiality beliefs and practices; SRHS screening and counseling; and referral practices.

RESULTS

The analysis identified two key themes: (1) individual and structural factors were related to variations in SRH screening and counseling and (2) a wide range of factors influenced provider decision-making in initiating private time. A nuanced set of factors informed SRHS provided, including provider comfort with specific topics; provider engagement and relationship with parents; use of adolescent screening tools; practices, policies, and resources within the clinic setting; and community norms including openness with communication about sex and religious considerations regarding adolescent sexuality. Factors that shaped providers' decisions in initiating private time included adolescent age, developmental stage, health behaviors and other characteristics; observed adolescent-parent interactions; parent support for private time; reason for clinic visit; laws and professional guidelines; and cultural considerations.

CONCLUSIONS

Findings suggest opportunities for interventions related to provider and clinic staff training, routine communication with adolescents and their parents, and clinic policies and protocols that can improve the quality of adolescent SRHS.

Opposition to Pharmacist Contraception Services: Evidence for Rebuttal

Pharmacist contraception services are growing across the United States. Several states have authorized pharmacists to prescribe contraception, and the interest in other states continues to grow. Opposition to these practices exists and centers on discussions related to safety, training, cost, and fragmentation of care. We review these arguments and provide evidence refuting these concerns. Pharmacist-prescribed contraception increases access to care, and patients express interest in utilizing this service at the pharmacy. Pharmacists follow evidence-based recommendations. Counseling on preventative services and referral to other providers is part of contraception care by pharmacists. Training programs have been developed to equip both pharmacy students and pharmacists with the knowledge, skills, and tools needed to successfully provide these services. This article can serve as a guide for pharmacists and advocates when discussing pharmacist-prescribed contraception with policymakers, patients, and other healthcare professionals.

Temporal Patterns in Chlamydia Repeat Testing in Massachusetts

INTRODUCTION

National guidelines recommend test-of-cure for pregnant women and test-of-reinfection for all patients with chlamydia infections in order to interrupt transmission and prevent adverse sequelae for patients, partners, and newborns. Little is known about retesting and positivity rates, and whether they are changing over time, particularly in private sector practices.

METHODS

Electronic health record data on patients with chlamydia tests were extracted from three independent clinical practice groups serving ≅20% of the Massachusetts population. Records were extracted using the Electronic medical record Support for Public Health platform (esphealth.org). These data were analyzed for temporal trends in annual repeat testing rates by using generalized estimating equations after index positive chlamydia tests between 2010 and 2015 and for differences in intervals to first repeat tests among pregnant females, non-pregnant females, and males. Data extraction and analysis were performed during calendar years 2017 and 2018.

RESULTS

An index positive C. trachomatis result was identified for 972 pregnant female cases, 10,309 non-pregnant female cases, and 4,973 male cases. Test-of-cure 3-5 weeks after an index positive test occurred in 37% of pregnant females. Test-of-reinfection 8-16 weeks after an index positive test occurred in 39% of pregnant females, 18% of non-pregnant females, and 9% of males. There were no significant increases in test-of-cure or test-of-reinfection rates from 2010 to 2015. Among cases with repeat tests, 16% of pregnant females, 15% of non-pregnant females, and 16% of males had positive results.

CONCLUSIONS

Chlamydia test-of-cure and test-of-reinfection rates are low, with no evidence of improvement over time. There are substantial opportunities to improve adherence to chlamydia repeat testing recommendations.

Parent and Adolescent Attitudes Towards Preventive Care and Confidentiality

PURPOSE

Little is known about whether parents and adolescents agree in their attitudes towards preventive care, private time, and confidentiality for adolescent care.

METHODS

We surveyed a nationally representative sample of 1,209 13-18 year-old U.S. adolescents and their parents. Parent and adolescents attitudes towards preventive services, private time, and confidentiality were compared. Parent-youth dyad agreement was measured using Cohen's kappa and Spearman coefficients and modeled for association with demographic variables.

RESULTS

Parents are more likely than adolescents to think preventive services are important (71% vs. 48%; p < .001). Parent-youth attitudes were weakly to moderately correlated (Cohen's kappa coefficient = .22; p < .001). Parents and adolescents report similar ages for when teens should start having private time (median 16 years for both) and many think this age should be at 18, the legal age of adulthood). Fewer than half believe confidentiality should be provided for 10 services, ranging from routine care to abortion care (parents range: 12.8%-52.3%; adolescents: 24.0%-58.8%). While most adolescents agreed with their parents, teens were more likely to report wanting confidential access than parents. Older age, Hispanic ethnicity, having divorced parents and higher family income were associated with both adolescent/parent and adolescent endorsement of confidentiality.

CONCLUSIONS

Adolescents and parents generally agree about the importance of preventive services, private time, confidentiality, and what should and should not be confidential. On average, parents value clinical preventive services more than youth, and youth value confidentiality more than parents. Both believe private time should start at ages older than those recommended in clinical guidelines.

Community and clinic-based screening for curable sexually transmissible infections in a high prevalence setting in Australia: a retrospective longitudinal analysis of clinical service data from 2006 to 2009

Background In response to the high prevalence of sexually transmissible infections (STIs) in many central Australian Aboriginal communities, a community-wide screening program was implemented to supplement routine primary health care (PHC) clinic testing. The uptake and outcomes of these two approaches were compared.

METHODS

Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) community and clinic screening data for Aboriginal people aged 15-34 years, 2006-2009, were used. Regression analyses assessed predictors of the first test occurring in the community screen, positivity and repeat testing.

RESULTS

A total of 2792 individuals had 9402 tests (median: four per person) over 4 years. Approximately half of the individuals (54%) were tested in the community and clinic approaches combined, 29% (n=806) in the community screen only and 18% (n=490) in the clinic only. Having the first test in a community screen was associated with being male and being aged 15-19 years. There was no difference between community and clinic approaches in CT or NG positivity at first test. More than half (55%) of individuals had a repeat test within 2-15 months and of these, 52% accessed different approaches at each test. The only independent predictor of repeat testing was being 15-19 years.

CONCLUSIONS

STI screening is an important PHC activity and the findings highlight the need for further support for clinics to reach young people. The community screen approach was shown to be a useful complementary approach; however, cost and sustainability need to be considered.

Sustained Reduction in Chlamydia Infections Following a School-Based Screening: Detroit, 2010-2015

We describe school-based screening events in four Detroit, Michigan public high schools. To examine trends, we analyzed Chlamydia trachomatis data from 2010 to 2015. Prevalence of C. trachomatis decreased significantly (P < .01): from 10.24% to 6.27%. Future school-based screening events may bring about similar results if the program is instituted in a high-prevalence area and can achieve high student participation.

Laboratory Screening for Children Entering Foster Care

OBJECTIVES

To determine the prevalence of medical illness detected by laboratory screening in children entering foster care in a single, urban county.

METHODS

All children entering foster care in a single county in Ohio were seen at a consultation foster care clinic and had laboratory screening, including testing for infectious diseases such as HIV, hepatitis B, hepatitis C, syphilis, and tuberculosis as well as for hemoglobin and lead levels.

RESULTS

Over a 3-year period (2012-2015), laboratory screening was performed on 1977 subjects entering foster care in a consultative foster care clinic. The prevalence of hepatitis B, hepatitis C, syphilis, and tuberculosis were all found to be <1%. There were no cases of HIV. Seven percent of teenagers entering foster care tested positive for Chlamydia. A secondary finding was that 54% of subjects were hepatitis B surface antibody-negative, indicating an absence of detected immunity to the hepatitis B virus.

CONCLUSIONS

Routine laboratory screening for children entering foster care resulted in a low yield. Targeted, rather than routine, laboratory screening may be a more clinically meaningful approach for children entering foster care.

Future prospects for new vaccines against sexually transmitted infections

PURPOSE OF REVIEW

This review provides an update on the need, development status, and important next steps for advancing development of vaccines against sexually transmitted infections (STIs), including herpes simplex virus (HSV), Neisseria gonorrhoeae (gonorrhea), Chlamydia trachomatis (chlamydia), and Treponema pallidum (syphilis).

RECENT FINDINGS

Global estimates suggest that more than a million STIs are acquired every day, and many new and emerging challenges to STI control highlight the critical need for development of new STI vaccines. Several therapeutic HSV-2 vaccine candidates are in Phase I/II clinical trials, and one subunit vaccine has shown sustained reductions in genital lesions and viral shedding, providing hope that an effective HSV vaccine is on the horizon. The first vaccine candidate for genital chlamydia infection has entered Phase I trials, and several more are in the pipeline. Use of novel technological approaches will likely see viable vaccine candidates for gonorrhea and syphilis in the future. The global STI vaccine roadmap outlines key activities to further advance STI vaccine development.

SUMMARY

Major progress is being made in addressing the large global unmet need for STI vaccines. With continued collaboration and support, these critically important vaccines for global sexual and reproductive health can become a reality.

Status of vaccine research and development of vaccines for Chlamydia trachomatis infection

Genital infection with Chlamydia trachomatis, a gram-negative obligate intracellular bacterium, is the most common bacterial sexually transmitted infection globally. Ascension of chlamydial infection to the female upper genital tract can cause acute pelvic inflammatory disease, tubal factor infertility, ectopic pregnancy, and chronic pelvic pain. Shortcomings of current chlamydia control strategies, especially for low- and middle-income countries, highlight the need for an effective vaccine. Evidence from animal models, human epidemiological studies, and early trachoma vaccine trials suggest that a C. trachomatis vaccine is feasible. Vaccine development for genital chlamydial infection has been in the preclinical phase of testing for many years, but the first Phase I trials of chlamydial vaccine candidates are underway, and scientific advances hold promise for additional candidates to enter clinical evaluation in the coming years. We describe the clinical and public health need for a C. trachomatis vaccine, provide an overview of Chlamydia vaccine development efforts, and summarize current vaccine candidates in the development pipeline.

Parent and Adolescent Interest in Receiving Adolescent Health Communication Information From Primary Care Clinicians

PURPOSE

Patient-centered health care recognizes that adolescents and parents are stakeholders in adolescent health. We investigate adolescent and parent interest in receiving information about health topics and parent-teen communication from clinicians.

METHODS

Ninety-one parent-adolescent dyads in one practice completed individual interviews. Items assessed levels of interest in receiving health and health communication information from the adolescent's doctor about 18 topics, including routine, mental health, sexual health, substance use, and injury prevention issues. Analyses tested differences between parents and adolescents, within-dyad correlations, and associations with adolescent gender and age.

RESULTS

Most parents were female (84%). Adolescents were evenly divided by gender; 36 were aged 12-13 years, 35 were aged 14-15 years, and 20 were aged 16-17 years. Adolescent race reflected the practice population (60% black; 35% white). The vast majority of parents and adolescents reported moderate or high levels of interest in receiving information about all 18 health issues and information to increase parent-teen communication about these topics. Parents' interest in receiving information varied by adolescent age when the expected salience of topics varied by age (e.g., acne, driving safety), whereas adolescents reported similar interest regardless of age. Adolescent gender influenced parent and adolescent interest. Level of interest in receiving information from doctors within adolescent-parent pairs was not significantly correlated for one-half of topics.

CONCLUSIONS

Parents and adolescents want health care professionals to help them learn and talk about a wide range of adolescent health topics. Feasible primary care interventions that effectively improve parent-teen health communication, and specific adolescent health outcomes are needed.

Screening for asymptomatic urogenital Chlamydia trachomatis infection at a large Dublin maternity hospital: results of a pilot study

BACKGROUND

There are currently no Irish guidelines on screening for Chlamydia trachomatis infection in pregnancy. Prevalence rates in the antenatal population are not known which has prevented the development of screening recommendations for this group.

AIMS

The objective of this study was to determine the prevalence of asymptomatic urogenital C. trachomatis infection in young women attending for care at a large maternity hospital.

METHODS

All patients aged 25 years and under attending the Hospital between December 2011 and December 2013 were offered screening for urogenital C. trachomatis infection. Nucleic acid amplification testing of the C. trachomatis cryptic plasmid was performed on either endocervical swabs or first void urine samples.

RESULTS

There were 2687 women tested for C. trachomatis infection, 83.4 % (2241/2687) through the antenatal clinics, 7.1 % (193/2687) through the gynaecology clinic, and 9.4 % (253/2687) through the emergency department. The rate of a positive test result was 5.6 % (151/2687) overall. The rates in women ages 16-18, 19-21 and 22-25 years were 9.1 % (31/340), 6.5 % (50/774) and 4.4 % (69/1561), respectively. A positive test result was more likely in those who were unemployed (p = 0.04), those who were Irish (p = 0.03) and those who were unmarried (p < 0.01). There were no cases of neonatal C. trachomatis infection in babies born to mothers who were screened in early pregnancy.

CONCLUSIONS

The prevalence rate of detected C. trachomatis infection was 5.6 % in the study population. Screening of antenatal patients may have a role in preventing vertical transmission of infection to the neonate.

School-Based Sexually Transmitted Disease Screening: Review and Programmatic Guidance

School-based sexually transmitted disease (STD) screening (SBSS) was designed to provide chlamydia and gonorrhea testing, treatment, and counseling to adolescents in a school setting to overcome some of the difficulties of screening in this population. To inform STD control programs and other entities on decision making about potentially implementing this intervention, we reviewed existing published and gray literature on SBSS from 1998 to 2014. Although they are work-intensive to establish, school-based STD screening programs are a feasible and cost-effective way of testing large numbers of male and female adolescents for chlamydia and gonorrhea, and to provide counseling and treatment to almost all those who are found infected. School-based STD screening programs do not seem to reduce prevalence in either the school or the general adolescent population, although there are currently relatively few studies on large-scale SBSS. More research in this field is needed.

Cost-effectiveness of Chlamydia vaccination programs for young women

A successful vaccine could be a cost-effective addition to current screening practices.

We explored potential cost-effectiveness of a chlamydia vaccine for young women in the United States by using a compartmental heterosexual transmission model. We tracked health outcomes (acute infections and sequelae measured in quality-adjusted life-years [QALYs]) and determined incremental cost-effectiveness ratios (ICERs) over a 50-year analytic horizon. We assessed vaccination of 14-year-old girls and catch-up vaccination for 15–24-year-old women in the context of an existing chlamydia screening program and assumed 2 prevaccination prevalences of 3.2% by main analysis and 3.7% by additional analysis. Estimated ICERs of vaccinating 14-year-old girls were $35,300/QALY by main analysis and $16,200/QALY by additional analysis compared with only screening. Catch-up vaccination for 15–24-year-old women resulted in estimated ICERs of $53,200/QALY by main analysis and $26,300/QALY by additional analysis. The ICER was most sensitive to prevaccination prevalence for women, followed by cost of vaccination, duration of vaccine-conferred immunity, and vaccine efficacy. Our results suggest that a successful chlamydia vaccine could be cost-effective.

Incidence and predictors of annual chlamydia testing among 15-29 year olds attending Aboriginal primary health care services in New South Wales, Australia

BACKGROUND

For the past two decades, chlamydia has been the most commonly notified infectious disease among young people (15-29 year olds) in Australia, the United States of America and the United Kingdom and rates have increased annually in these three countries. In Australia, rates of chlamydia are three times higher in Aboriginal compared with non-Aboriginal people. Australian sexually transmissible infection guidelines recommend annual chlamydia testing for 15-29 year old females and males. This analysis will examine the incidence and predictors of annual chlamydia testing in 15-29 year olds attending four Aboriginal Community Controlled Health Services (ACCHS) in Australia.

METHODS

From 2009-2011, attendance and chlamydia testing data were extracted from the patient system to calculate the number and proportion of 15-29 year olds that were tested for chlamydia and that tested positive for chlamydia by gender (male, female), age-group (15-19, 20-24, 25-29 years), Aboriginal status (Aboriginal, non-Aboriginal people) and by the four ACCHSs sites (1, 2, 3 and 4). A cohort was created to calculate the incidence rate per 100 person-years (PY) and predictors of an annual chlamydia test (a test within 12-months of a previous test/visit) by the above factors using Cox regression. Unadjusted and adjusted hazard ratios (AHR) and their 95 % confidence intervals (CIs) and p-values were calculated with significance at p < 0.05.

RESULTS

From 2009-2011, there were 2896 individuals who attended the four ACCHSs. Overall , 17 % (22 % of females and 10 % of males) were tested for chlamydia and 9 % tested positive (8 % of females and 14 % of males). The median time to an annual chlamydia test was 10.7 months. The cohort included 2318 individuals. Overall the incidence rate of an annual chlamydia test was 9.1 per 100 PY (11.6 in females and 5.8 in males). Predictors of an annual chlamydia test were being female (AHR: 1.7, 95 % CI: 1.2-2.2, p < 0.01), being 15-19 years old (AHR: 1.6, 95 % CI: 1.1-2.3, p < 0.01) and attending ACCHS site 2 (AHR: 3.8, 95 % CI: 1.8-8.0, p < 0.01).

CONCLUSIONS

This analysis highlights that opportunistic STI testing strategies are needed to increase annual chlamydia testing in young people; especially males.

Estimating chlamydia screening coverage: a comparison of self-report and health care effectiveness data and information set measures

BACKGROUND

Population-based surveys (self-report) and health insurance administrative data (Healthcare Effectiveness Data and Information Set [HEDIS]) are used to estimate chlamydia screening coverage in the United States. Estimates from these methods differ, but few studies have compared these 2 indices in the same population.

METHODS

In 2010, we surveyed a random sample of women aged 18 to 25 years enrolled in a Washington State-managed care organization. Respondents were asked if they were sexually active in last year and if they tested for chlamydia in that time. We linked survey responses to administrative records of chlamydia testing and reproductive/testing services used, which comprise the HEDIS definition of the screened population and the sexually active population, respectively. We compared self-report and HEDIS using 3 outcomes: (1) sexual activity (gold standard = self-report), (2) any chlamydia screening (no gold standard), and (3) within-plan chlamydia screening (gold standard = HEDIS).

RESULTS

Of 954 eligible respondents, 377 (40%) completed the survey and consented to administrative record linkage. Chlamydia screening estimates for HEDIS and self-report were 47% and 53%, respectively. The sensitivity and specificity of HEDIS to define sexually active women were 84.8% (95% confidence interval [CI], 79.6%-89.1%) and 63.5% (95% CI, 52.4%-73.7%), respectively. Forty percent of women had a chlamydia test in their administrative record, but 53% self-reported being tested for chlamydia (κ = 0.35); 19% reported out-of-plan chlamydia testing. The sensitivity of self-reported within-plan chlamydia testing was 71.3% (95% CI, 61.0%-80.1%); the specificity was 80.6% (95% CI, 72.6%-87.2%).

CONCLUSIONS

The Healthcare Effectiveness Data and Information Set does not accurately identify sexually active women and may underestimate chlamydia testing coverage. Self-reported testing may not be an accurate measure of true chlamydial testing coverage.

Social factors associated with readiness for sexual activity in adolescents: a population-based cohort study

Various factors are associated with sexual activity in adolescence and it is important to identify those that promote healthy and adaptive romantic and sexual development. The objectives of this study were to describe rates of early sexual intercourse (before 16 years) and sexual readiness in adolescence and to assess the extent to which these were social patterned. We prospectively studied nearly 5,000 15-year-olds from the Avon Longitudinal Study of Parents and Children, a UK birth cohort. Between 2006 and 2008, female and male participants answered a computer assisted interview about romantic and sexual behaviors in the last year. Predictors of sexual intercourse and readiness for sexual intercourse were examined across a range of sociodemographic measures. Overall, 17.7% (95% CI 16.7%, 18.9%) of participants reported having had sexual intercourse in the last year, with more girls than boys reporting sexual experience (risk ratio 1.30, 95% CI 1.15, 1.47). Of these, one-third of both male and female were classed as unready because they were unwilling, lacking in autonomy, felt regret or had not used contraception. There was strong evidence of social patterning for sexual activity with higher rates for young people from poorer homes, with lower social class, and with younger, less educated mothers. In contrast, among 860 young people who had had sexual intercourse, there was no clear evidence of associations between social factors and sexual readiness. The lack of social patterning in sexual readiness supports the provision of comprehensive education to develop life skills for adolescents across all social groups.

A new approach to estimating trends in chlamydia incidence

OBJECTIVES

Directly measuring disease incidence in a population is difficult and not feasible to do routinely. We describe the development and application of a new method for estimating at a population level the number of incident genital chlamydia infections, and the corresponding incidence rates, by age and sex using routine surveillance data.

METHODS

A Bayesian statistical approach was developed to calibrate the parameters of a decision-pathway tree against national data on numbers of notifications and tests conducted (2001-2013). Independent beta probability density functions were adopted for priors on the time-independent parameters; the shapes of these beta parameters were chosen to match prior estimates sourced from peer-reviewed literature or expert opinion. To best facilitate the calibration, multivariate Gaussian priors on (the logistic transforms of) the time-dependent parameters were adopted, using the Matérn covariance function to favour small changes over consecutive years and across adjacent age cohorts. The model outcomes were validated by comparing them with other independent empirical epidemiological measures, that is, prevalence and incidence as reported by other studies.

RESULTS

Model-based estimates suggest that the total number of people acquiring chlamydia per year in Australia has increased by ∼120% over 12 years. Nationally, an estimated 356 000 people acquired chlamydia in 2013, which is 4.3 times the number of reported diagnoses. This corresponded to a chlamydia annual incidence estimate of 1.54% in 2013, increased from 0.81% in 2001 (∼90% increase).

CONCLUSIONS

We developed a statistical method which uses routine surveillance (notifications and testing) data to produce estimates of the extent and trends in chlamydia incidence.

Rate of repeat diagnoses in men who have sex with men for Chlamydia trachomatis and Neisseria gonorrhoeae: a retrospective cohort study

Background Sexually transmissible infections (STIs) have increased rapidly among men who have sex with men (MSM). One of the most effective strategies to control STIs is partner notification. Inadequate partner notification may be associated with high rates of repeat diagnoses with STIs. The aim of this study is to estimate and compare the rate of chlamydia and gonorrhoea infection following primary infection to the overall clinic rate. Methods: A retrospective cohort analysis of MSM attending the Melbourne Sexual Health Clinic was conducted. For both infections, the overall incidence and that following diagnosis and treatment was calculated. Results: Of the 13053 MSM, the incidence of diagnoses for chlamydia and gonorrhoea was 8.5 (95% CI: 8.2–8.9) and 6.2 (95% CI: 5.9–6.5) per 100 person-years, respectively. Seventy per cent of chlamydia and 64% of gonorrhoea cases were retested at 10–365 days after diagnosis and treatment. Following diagnosis and treatment of chlamydia, the rate ratio in these individuals in the first quarter was 16- and 8-fold higher for chlamydia and gonorrhoea, respectively, compared with the background incidence of diagnoses. Similarly, following diagnosis and treatment of gonorrhoea, the rate ratio in these individuals in the first quarter was 18- and 10-fold higher for gonorrhoea and chlamydia, respectively. Conclusions: These data suggest that approximately half of MSM who test positive for chlamydia or gonorrhoea within 90 days after an initial infection represent contact with either a previous sexual partner or member of the same sexual network, the remainder representing the particularly high STI risk for these MSM.

A randomized controlled trial of the effects of a brief intervention to increase chlamydia and gonorrhea testing uptake among young adult female emergency department patients

OBJECTIVES

The objective of this study was to test the effect of a brief educational and counseling intervention on increasing the uptake of free testing for Chlamydia trachomatis (chlamydia) and Neisseria gonorrhea (gonorrhea) among young female emergency department (ED) patients. Women are particularly vulnerable to more serious consequences of these infections due to asymptomatic presentation. Increased testing is important to detect, treat, and halt the spread of these infections among asymptomatic women.

METHODS

This was a randomized controlled trial. Research assistants (RAs) approached female patients in two EDs. Eligible patients were between 18 and 35 years of age, who reported having sex with males, but were not attending the ED for either treatment of sexually transmitted infection (STI) or testing for possible STI exposure. Participants responded to survey questions about their lifetime and past 3-month substance use, number of recent sexual partners, condom use, and perception of risks for chlamydia and gonorrhea infections. Following the survey, the RAs randomized participants into study control or treatment arms. Each treatment arm participant received a brief educational/counseling intervention from the RA. The brief intervention focused on the woman's personal risks for chlamydia and gonorrhea and condoms attitudes and usage. As the primary outcome of this study, participants were offered free urine tests for chlamydia and gonorrhea infection postintervention or post-survey completion, depending on group assignment.

RESULTS

A total of 171 women completed the baseline assessment and were offered chlamydia and gonorrhea testing. The mean (±SD) age was 26 (±4.76) years, 18% were Hispanic, and 12% were Spanish-speaking only. The brief intervention that was offered to increase these women's awareness of their STI risk did not result in increased acceptance of testing; 48% in the brief intervention group accepted testing (95% confidence interval [CI] = 32% to 64%) versus 36% in the control group (95% CI = 19% to 53%). In a multivariable logistic regression, only self-identifying as being Hispanic was associated with greater willingness to be tested. Of the asymptomatic women tested (n = 71), five tested positive for chlamydia. This represents a positivity rate of 7%. There were no positive test results for gonorrhea. Women who reported high-risk factors for STI, such as younger age (≤25 years), having sex in the past 90 days without using condoms, identified substance use, or previous STI, were not more likely to accept the offer of chlamydia and gonorrhea testing.

CONCLUSIONS

The brief intervention used in this study did not increase the uptake of testing for chlamydia and gonorrhea infections in this sample, in comparison to receiving no intervention. Although Hispanic women were more likely to accept chlamydia and gonorrhea testing, it is concerning that those women who report STI risk factors were not more likely to accept the offer of chlamydia and gonorrhea testing. Future research should focus on the refinement of an intervention protocol to focus on prior STI and lack of condom use to increase the uptake of testing among this high-risk group.

Cumulative risk of chlamydial infection among young women in Florida, 2000-2011

PURPOSE

Chlamydia trachomatis is a very common infection among young women in the United States; information on cumulative risk of infection is limited. We sought to estimate the cumulative risk of chlamydial infection for young women.

METHODS

We measured cumulative risk of reported chlamydial infection for 14- to 34-year-old women in Florida between 2000 and 2011 using surveillance records and census estimates. We calculated reported infections per woman, analyzed first infections to get cumulative risk, and calculated risk of repeat infection over the 12-year period.

RESULTS

There were 457,595 infections reported among 15- to 34-year-old women. Reports increased annually from 25,390 to 51,536. Nineteen-year-olds were at highest risk with 5.1 infections reported per 100 women in 2011. There were 341,671 different women infected. Among women aged 14-17 years in 2000, over 20% had at least one infection reported within 12 years, and among blacks, this risk was over 36%, and that underestimates risk because 18% of cases were missing race/ethnicity information. Repeat infections were common. Among 53,109 with chlamydia at the age of 15-20 years during 2000-2003, 36.7% had additional infections reported by 2011.

CONCLUSIONS

More than one out of five women in Florida was reported as having chlamydia during her young-adult years; risk was highest for black women. True infection risks were likely much higher because many infections were not diagnosed or reported. Young women who had chlamydia were very likely to get reinfected. Rates of infection remain high despite years of screening. More information is needed on how to prevent chlamydial infection.

Toward global prevention of sexually transmitted infections (STIs): the need for STI vaccines

An estimated 499 million curable sexually transmitted infections (STIs; gonorrhea, chlamydia, syphilis, and trichomoniasis) occurred globally in 2008. In addition, well over 500 million people are estimated to have a viral STI such as herpes simplex virus type 2 (HSV-2) or human papillomavirus (HPV) at any point in time. STIs result in a large global burden of sexual, reproductive, and maternal-child health consequences, including genital symptoms, pregnancy complications, cancer, infertility, and enhanced HIV transmission, as well as important psychosocial consequences and financial costs. STI control strategies based primarily on behavioral primary prevention and STI case management have had clear successes, but gains have not been universal. Current STI control is hampered or threatened by several behavioral, biological, and implementation challenges, including a large proportion of asymptomatic infections, lack of feasible diagnostic tests globally, antimicrobial resistance, repeat infections, and barriers to intervention access, availability, and scale-up. Vaccines against HPV and hepatitis B virus offer a new paradigm for STI control. Challenges to existing STI prevention efforts provide important reasons for working toward additional STI vaccines. We summarize the global epidemiology of STIs and STI-associated complications, examine challenges to existing STI prevention efforts, and discuss the need for new STI vaccines for future prevention efforts.

The consistency of relative incidence rates of nonviral sexually transmissible infections from health insurance claims and surveillance data, 2005-10

BACKGROUND

Given the growing popularity of administrative data for health research, information on the differences and similarities between administrative data and customary data sources (e.g. surveillance) will help to inform the use of administrative data in the field of sexually transmissible infections (STIs). The objective of this study was to compare the incidence rates of three nonviral STIs from a large health insurance administrative database (MarketScan) with surveillance data.

METHODS

We computed and compared STI rates for 2005-10 from MarketScan and national surveillance data for three major nonviral STIs (i.e. chlamydia (Chlamydia trachomatis), gonorrhoea (Neisseria gonorrhoeae) and syphilis (Treponema pallidum)). For administrative data, we assessed the sensitivity of the rates to enrollee inclusion criteria: continuous (≥320 member-days) versus all enrollees. Relative rates were computed for 5-year age groups and by gender.

RESULTS

The administrative database rates were significantly lower (P<0.01) than those in the national surveillance data, except for syphilis in females. Gonorrhoea and syphilis rates based on administrative data were significantly lower (P<0.01) for all enrollees versus continuous enrollees only. The relative STI rates by age group from the administrative data were similar to those in the surveillance data.

CONCLUSIONS

Although absolute STI rates in administrative data were lower than in the surveillance data, relative STI rates from administrative data were consistent with national surveillance data. For gonorrhoea and syphilis, the estimated rates from administrative data were sensitive to the enrollee inclusion criteria. Future studies should examine the potential for administrative data to complement surveillance data.

Building a web-based tool to support clinical decisions in the control of Chlamydia trachomatis and Neisseria gonorrhoeae infections

Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) are the agents of two common, sexually transmitted diseases afflicting women in the United States (http://www.cdc.gov). We designed a novel web-based application that offers simple recommendations to help optimize medical outcomes with CT and GC prevention and control programs. This application takes population groups, prevalence rates, parameters for available screening assays and treatment regimens (costs, sensitivity, and specificity), as well as budget limits as inputs. Its output suggests optimal screening and treatment strategies for selected at-risk groups, commensurate with the clinic's budget allocation. Development of this tool illustrates how a clinical informatics application based on rigorous mathematics might have a significant impact on real-world clinical issues.

Screening and treating Chlamydia trachomatis genital infection to prevent pelvic inflammatory disease: interpretation of findings from randomized controlled trials

We critically reviewed randomized controlled trials evaluating chlamydia screening to prevent pelvic inflammatory disease (PID) and explored factors affecting interpretation and translation of trial data into public health prevention. Taken together, data from these trials offer evidence that chlamydia screening and treatment is an important and useful intervention to reduce the risk of PID among young women. However, the magnitude of benefit to be expected from screening may have been overestimated based on the earliest trials. It is likely that chlamydia screening programs have contributed to declines in PID incidence through shortening prevalent infections, although the magnitude of their contribution remains unclear. Program factors such as screening coverage as well as natural history factors such as risk of PID after repeat chlamydia infection can be important in determining the impact of chlamydia screening on PID incidence in a population. Uptake of chlamydia screening is currently suboptimal, and expansion of screening among young, sexually active women remains a priority. To reduce transmission and repeat infections, implementation of efficient strategies to treat partners of infected women is also essential. Results of ongoing randomized evaluations of the effect of screening on community-wide chlamydia prevalence and PID will also be valuable.

Is out-of-pocket cost a barrier to receiving repeat tests for chlamydia and gonorrhoea?

We aimed to examine whether out-of-pocket (OOP) costs associated with chlamydia (CT) and gonorrhoea (GC) screening tests is a barrier to receiving CT/GC re-screening and follow-up annual screening. A major health insurance claims database 2006-2010 was used for analysis. The date of first CT/GC diagnosis was used as the index date, and OOP costs at index date for screening tests were retrieved. A re-screening test and an annual screening were defined as tests that occurred within 90-180 days and 181-395 days of the index date, respectively. Re-screening rates were 11.7% and 10.9% and annual screening rates were 24.7% and 23.7% for CT and GC cases, respectively. Compared with the CT patients without OOP expenses, those with OOP expenses of $30 or higher had significantly reduced likelihood of receiving re-screening and annual screening. Similar results were found for GC patients. We concluded that OOP costs serve as a significant barrier to re-screening and annual screening.

Reproductive health preventive screening among clinic vs. over-the-counter oral contraceptive users

BACKGROUND

Interest is growing in moving oral contraceptives over-the-counter (OTC), although concerns exist about whether women would continue to get preventive health screening.

STUDY DESIGN

We recruited cohorts of US-resident women who obtained oral contraceptives from US family planning clinics (n=532) and OTC from pharmacies in Mexico (n=514) and interviewed them four times over 9 months. Based on self-reports of having a Pap smear within 3 years or ever having had a pelvic exam, clinical breast exam and testing for sexually transmitted infections (STIs), we assessed the prevalence of preventive screening using Poisson regression models.

RESULTS

The prevalence of screening was high for both groups (>88% for Pap smear, pelvic exam and clinical breast exam and >71% for STI screening), while the prevalence ratios for screening were higher for clinic users, even after multivariable adjustment.

CONCLUSIONS

Results suggest that most women would obtain reproductive health preventive screening if oral contraceptives were available OTC, and also highlight the need to improve access to preventive screening for all low-income women.

Timing of progression from Chlamydia trachomatis infection to pelvic inflammatory disease: a mathematical modelling study

BACKGROUND

Pelvic inflammatory disease (PID) results from the ascending spread of microorganisms from the vagina and endocervix to the upper genital tract. PID can lead to infertility, ectopic pregnancy and chronic pelvic pain. The timing of development of PID after the sexually transmitted bacterial infection Chlamydia trachomatis (chlamydia) might affect the impact of screening interventions, but is currently unknown. This study investigates three hypothetical processes for the timing of progression: at the start, at the end, or throughout the duration of chlamydia infection.

METHODS

We develop a compartmental model that describes the trial structure of a published randomised controlled trial (RCT) and allows each of the three processes to be examined using the same model structure. The RCT estimated the effect of a single chlamydia screening test on the cumulative incidence of PID up to one year later. The fraction of chlamydia infected women who progress to PID is obtained for each hypothetical process by the maximum likelihood method using the results of the RCT.

RESULTS

The predicted cumulative incidence of PID cases from all causes after one year depends on the fraction of chlamydia infected women that progresses to PID and on the type of progression. Progression at a constant rate from a chlamydia infection to PID or at the end of the infection was compatible with the findings of the RCT. The corresponding estimated fraction of chlamydia infected women that develops PID is 10% (95% confidence interval 7-13%) in both processes.

CONCLUSIONS

The findings of this study suggest that clinical PID can occur throughout the course of a chlamydia infection, which will leave a window of opportunity for screening to prevent PID.

Effectiveness of yearly, register based screening for chlamydia in the Netherlands: controlled trial with randomised stepped wedge implementation

OBJECTIVE

To evaluate the effectiveness of register based, yearly chlamydia screening.

DESIGN

Controlled trial with randomised stepped wedge implementation in three blocks.

SETTING

Three regions of the Netherlands: Amsterdam, Rotterdam, and South Limburg.

PARTICIPANTS

317 304 women and men aged 16-29 years listed on municipal registers at start of trial.

INTERVENTION

From March 2008 to February 2011, the Chlamydia Screening Implementation programme offered yearly chlamydia screening tests. Postal invitations asked people to use an internet site to request a kit for self collection of samples, which would then be sent to regional laboratories for testing. Treatment and partner notification were done by the general practitioner or at a sexually transmitted infection clinic.

MAIN OUTCOME MEASURES

Primary outcomes were the percentage of chlamydia tests positive (positivity), percentage of invitees returning a specimen (uptake), and estimated chlamydia prevalence. Secondary outcomes were positivity according to sex, age, region, and sociodemographic factors; adherence to screening invitations; and incidence of self reported pelvic inflammatory disease.

RESULTS

The participation rate was 16.1% (43 358/269 273) after the first invitation, 10.8% after the second, and 9.5% after the third, compared with 13.0% (6223/48 031) in the control block invited at the end of round two of the intervention. Chlamydia positivity in the intervention blocks at the first invitation was the same as in the control block (4.3%) and 0.2% lower at the third invitation (odds ratio 0.96 (95% confidence interval 0.83 to 1.10)). No substantial decreases in positivity were seen after three screening rounds in any region or sociodemographic group. Among the people who participated three times (2.8% of all invitees), positivity fell from 5.9% to 2.9% (odds ratio 0.49 (0.47 to 0.50)).

CONCLUSIONS

There was no statistical evidence of an impact on chlamydia positivity rates or estimated population prevalence from the Chlamydia Screening Implementation programme after three years at the participation levels obtained. The current evidence does not support a national roll out of this register based chlamydia screening programme.

TRIAL REGISTRATION

NTR 3071 (Netherlands Trial Register, www.trialregister.nl).

Factors associated with screening for sexually transmitted infections

OBJECTIVE

The purpose of this study was to determine predictors of the completion of free annual sexually transmitted infection screening among sexually active young women of ≤ 25 years old.

STUDY DESIGN

We analyzed survey data from 2607 sexually active women who were enrolled in the Contraceptive CHOICE Project, a prospective cohort study. We evaluated demographic characteristics, sexual risk behaviors, relationship characteristics, and contraceptive methods. Receipt of a home- or clinic-based test kit within 56 days of the 12-month survey constituted a completed screen. A multivariable model to predict screening completion was created with the use of Poisson regression with robust error variance.

RESULTS

Fifty-seven percent of the women completed the screening. Screening completion was associated most strongly with a college education or higher (adjusted relative risk, 1.2; 95% confidence interval, 1.1-1.3) and home-based testing (adjusted relative risk, 1.3; 95% confidence interval, 1.2-1.5).

CONCLUSION

Free and home-based testing increased screening rates among young women. To meet annual testing guidelines, the availability and use of home-based testing kits should increase.

STD and HIV testing behaviors among black and Puerto Rican young adults

CONTEXT

Given the high rates of infection among urban young adults, STD and HIV testing promotion is a public health priority. To inform future testing efforts, lifetime and recent testing behaviors of this population within casual and serious relationships should be better understood.

METHODS

Data from a 2007-2008 study conducted in select neighborhoods in Hartford and Philadelphia were used to examine self-reported STD and HIV testing behaviors and attitudes among 483 sexually active black and Puerto Rican young adults aged 18-25. Multivariate ordered logit regression analyses were conducted to assess characteristics associated with lifetime number of STD tests.

RESULTS

More than eight in 10 participants reported having been tested for STDs, and a similar proportion for HIV, most of them multiple times. Nineteen percent had ever had an STD diagnosis. A majority-86%-perceived their risk of STD infection in the next year as "not at all likely." Sixty-one percent of those in serious relationships reported that both partners had been tested, compared with 25% of those in casual relationships. Characteristics associated with higher lifetime number of STD tests were being female (odds ratio, 2.2), being from Philadelphia (2.5), being black (1.5), having lived with two or more serious partners (1.7) and having ever received an STD diagnosis (2.3).

DISCUSSION

Despite their risks, participants did not perceive themselves to be at risk of STDs. However, they did report testing repeatedly. Testing was highly acceptable, particularly within serious relationships. Questions about the timing of testing initiation and repeat testing merit attention for the benefits of widespread testing to be fully realized.