Community-based screening and treatment for STDs: results from a mobile clinic initiative

Increasing Access to Medical Care for Hispanic Women Without Insurance: A Mobile Clinic Approach

The purpose of this study was to describe the health status and barriers of people who sought care on a free mobile health clinic for women without insurance in California. Participants were 221 women who attended the Salud para Mujeres (Women's Health) mobile medical clinic between 2019 and 2021. Medical chart abstractions provided data on sociodemographic factors, medical history, barriers to care, depressive symptoms, and dietary factors. Anthropometric measure, blood pressure, and biomarkers of cardiometabolic disease risk were also abstracted. Participants were young adult (29.1 [SD 9.3] years), Hispanic (97.6%), farm-working (62.2%) women from Mexico (87.0%). Prevalent barriers to accessing (non-mobile) medical care included high cost (74.5%), language (47.6%), hours of operation (36.2%), and transportation (31.4%). The majority (89.5%) of patients had overweight (34.0%) or obesity (55.5%), and 27% had hypertension. Among those (n = 127) receiving a lipid panel, 60.3% had higher than recommended levels of low-density lipoprotein and 89% had lower than recommended levels of high-density lipoprotein. Point-of-care HbA1c tests (n = 133) indicated that 9.0% had diabetes and 24.8% had prediabetes. Over half (53.1%) of patients reported prevalent occupational exposure to pesticides and 19% had moderate to severe depressive symptoms. Weekly or more frequent consumption of sugar sweetened beverages (70.9%) and fast food (43.5%) were also prevalent. Mobile health units have potential for reaching women who face several barriers to care and experience major risk factors for cardometabolic disease. Findings suggest a compelling need to assure that Hispanic and Indigenous women and farmworkers have access to healthcare.

Achieving a Representative Sample of Asian Americans in Biomedical Research Through Community-Based Approaches: Comparing Demographic Data in the All of Us Research Program With the American Community Survey

BACKGROUND

Underrepresented persons are often not included in biomedical research. It is unknown if the general Asian American population is being represented in All of Us. The purpose of this study was to compare the Asian demographic data in the All of Us cohort with the Asian nationally representative data from the American Community Survey.

METHOD

Demographic characteristics and health literacy of Asians in All of Us were examined. Findings were qualitatively compared with the Asian data in the 2019 American Community Survey 1-year estimate.

RESULTS

Compared with the national composition of Asians, less All of Us participants were born outside the United States (64% vs 79%), were younger, and had higher levels of education (76% vs 52%). Over 60% of All of Us participants reported high levels of health literacy.

CONCLUSION

This study had implications for the development of strategies that ensure diverse populations are represented in biomedical research.

A systematic review and meta-analysis of the evidence for community-based HIV testing on men's engagement in the HIV care cascade

OBJECTIVE

Men with HIV are less likely than women to know their status, be on antiretroviral therapy, and be virally suppressed. This review examined men's community-based HIV testing services (CB-HTS) outcomes.

DESIGN

Systematic review and meta-analysis.

METHODS

We searched seven databases and conference abstracts through July 2018. We estimated pooled proportions and/or risk ratios (for meta-analyses) for each outcome using random effects models.

RESULTS

188 studies met inclusion criteria. Common testing models included targeted outreach (e.g. mobile testing), home-based testing, and testing at stand-alone community sites. Across 25 studies reporting uptake, 81% (CI: 75-86%) of men offered testing accepted it. Uptake was higher among men reached through CB-HTS than facility-based HTS (RR = 1.39; CI: 1.13-1.71). Over 69% (CI: 64-71%) of those tested through CB-HTS were men, across 184 studies. Across studies reporting new HIV-positivity among men (n = 18), 96% were newly diagnosed (CI: 77-100%). Across studies reporting linkage to HIV care (n = 8), 70% (CI: 36-103%) of men were linked to care. Across 57 studies reporting sex-disaggregated data for CB-HTS conducted among key populations, men's uptake was high (80%; CI: 70-88%) and nearly all were newly diagnosed and linked to care (95%; CI: 94-100%; and 94%; CI: 88-100%, respectively).

CONCLUSION

CB-HTS is an important strategy for reaching undiagnosed men with HIV from the general population and key population groups, particularly using targeted outreach models. When compared to facility-based HIV testing services, men tested through CB-HTS are more likely to uptake testing, and nearly all men who tested positive through CB-HTS were newly diagnosed. Linkage to care may be a challenge following CB-HTS, and greater efforts and research are needed to effectively implement testing strategies that facilitate rapid ART initiation and linkage to prevention services.

Barriers and facilitators to use of a mobile HIV care model to re-engage and retain out-of-care people living with HIV in Atlanta, Georgia

Novel strategies to re-engage and retain people living with HIV (PLWH) who are out of care are greatly needed. While mobile clinics have been used effectively for HIV testing and linkage, evidence guiding their use in providing HIV care domestically has been limited. To guide the development of a mobile HIV clinic (MHC) model as a strategy to re-engage and retain PLWH who are out of care, we aimed to explore stakeholder perceptions of barriers and facilitators to MHC implementation and use. From June 2019-July 2020, we conducted 41 in-depth interviews with HIV clinic providers, administrators, staff, legal authorities, and community advisory board members, PLWH, AIDS service organizations and city officials in Atlanta, Georgia, and domestic and international mobile health clinics to explore barriers and facilitators to use of MHCs. Interviews were transcribed, coded and thematically analysed. Barriers raised include potential for: breach of confidentiality with resulting heightened stigmatization, fractured continuity of care, safety concerns, staffing challenges, and low community acceptance of MHC presence in their locality. Participants provided suggestions regarding appropriate exterior design, location, timing, and co-delivery of non-HIV services that could facilitate MHC acceptance and address the concerns. In identifying key barriers and facilitators to MHC use, this study informs design and implementation of an MHC as a novel strategy for re-engaging and retaining PLWH who are out of care.

Impacts of Sexually Transmitted Disease/HIV Outreach Sites on the Effectiveness of Detecting New Infections in Baltimore City, 2015 to 2018

BACKGROUND

Effectiveness of sexually transmitted disease (STD)/HIV mobile van outreach programs has been shown to assist in identifying new cases of syphilis and HIV among high-risk populations. However, specific types of mobile outreach testing and their varying abilities to assist in STD/HIV case identification have not been thoroughly explored.

METHODS

We analyzed data from the Baltimore City Health Department syphilis and HIV testing intake interviews and subsequent laboratory results for clients at any of the 6 different Baltimore City Health Department mobile outreach testing setting types between 2015 and 2018. A total of 8098 syphilis and 7946 HIV testing encounters were included. Cross-tabulation and proportion estimates were used to obtain the volume of new syphilis and HIV diagnoses across the different mobile outreach testing setting types. Multivariable firth logistic regressions for rare events were used to obtain odds ratios for new syphilis diagnoses across the different mobile outreach setting categories.

RESULTS

Testing at street corners yielded the highest proportion of new syphilis cases (0.83%), whereas at community centers, it produced the highest proportion of new HIV cases (0.48%). The adjusted odds for new syphilis were 2.14 among street corners compared with community centers.

CONCLUSIONS

The findings indicated that street corners were the most successful at detecting new syphilis cases, whereas community centers were the most successful at detecting new HIV cases. However, because of the small number of new cases detected and low uptake per testing event between 2015 and 2018, STD/HIV mobile testing does not seem to be effective overall.

The potential of mobile health clinics in chronic disease prevention and health promotion in universal healthcare systems. An on-field experiment

BACKGROUND

Mobile health clinics (MHCs) are recognized to facilitate access to healthcare services, especially in disadvantaged populations. Notwithstanding that in Europe a wide-ranging background in mobile screening units for cancer is shared, evidences about MHCs targeting also at other non-communicable diseases (NCDs) in universal health coverage systems are scarce. The aim of this study was to describe the population attracted with a MHC initiative and to assess the potential of this tool in prevention and control of NCDs.

METHODS

Our MHC was set up in a railway wagon. Standard body measurements, finger-stick glucose, total cholesterol and blood pressure were recorded. Participants were asked about smoking, physical activity, diet, compliance to national cancer screening programmes and ongoing pharmacological treatment. One-to-one counselling was then provided.

RESULTS

Participants (n = 839) showed a higher prevalence of overweight/obesity, insufficient intake of vegetables, sedentary lifestyle, and a lower compliance to cancer screening compared with reference population. Our initiative attracted groups at higher risk, such as foreigners, men and people aged from 50 to 69. The proportion of newly diagnosed or uncontrolled disease exceeded 40% of participants for both hypertension and hypercholesterolemia (7% for diabetes). Adherence rate to counselling was 99.4%.

CONCLUSIONS

The MHC was effective in attracting hard-to-reach groups and individuals who may have otherwise gone undiagnosed. MHCs can play a complementary role also in universal coverage health systems, raising self-awareness of unreached population and making access to primary health care easier.

Venue-Based HIV-Testing: An Effective Screening Strategy for High-Risk Populations in Lima, Peru

Venue-based testing may improve screening efforts for HIV and syphilis, thereby reducing transmission. We offered onsite rapid dual HIV and syphilis testing at venues popular among MSM and/or transgender women in Lima, Peru. We used Poisson regression to calculate adjusted prevalence ratios (aPRs) for factors associated with each infection. Most (90.4%) of the 303 participants would test more frequently if testing was available at alternative venues. New cases of HIV (69) and syphilis infection (84) were identified. HIV was associated with recent sex work (aPR 1.11; 95% CI 1.02-1.22), sex with a partner of unknown serostatus (aPR 1.18; 95% CI 1.09-1.27), exclusively receptive anal sex role (aPR 1.16; 95% CI 1.03-1.30) or versatile sex role (aPR 1.17; 95% CI 1.06-1.30) compared to insertive. Syphilis was associated with reporting role versatility (aPR = 2.69; 95% CI 1.52-5.74). Sex work venues had higher syphilis prevalence 47% versus 28% in other venues, p value = 0.012. Venue-based testing may improve case finding.

Comparing neighborhood and state contexts for women living with and without HIV: understanding the Southern HIV epidemic

In the South, people living with HIV experience worse health outcomes than in other geographic regions, likely due to regional political, structural, and socioeconomic factors. We describe the neighborhoods of women (n = 1,800) living with and without HIV in the Women's Interagency HIV Study (WIHS), a cohort with Southern sites in Chapel Hill, NC; Atlanta, GA; Birmingham, AL; Jackson, MS; and Miami, FL; and non-Southern sites in Brooklyn, NY; Bronx, NY; Washington, DC; San Francisco, CA; and Chicago, IL. In 2014, participants' addresses were geocoded and matched to several administrative data sources. There were a number of differences between the neighborhood contexts of Southern and non-Southern WIHS participants. Southern states had the lowest income eligibility thresholds for family Medicaid, and consequently higher proportions of uninsured individuals. Modeled proportions of income devoted to transportation were much higher in Southern neighborhoods (Location Affordability Index of 28-39% compared to 16-23% in non-Southern sites), and fewer participants lived in counties where hospitals reported providing HIV care (55% of GA, 63% of NC, and 76% of AL participants lived in a county with a hospital that provided HIV care, compared to >90% at all other sites). Finally, the states with the highest adult incarceration rates were all in the South (per 100,000 residents: AL 820, MS 788, GA 686, FL 644). Many Southern states opted not to expand Medicaid, invest little in transportation infrastructure, and have staggering rates of incarceration. Resolution of racial and geographic disparities in HIV health outcomes will require addressing these structural barriers.

Expanding syphilis testing: a scoping review of syphilis testing interventions among key populations

INTRODUCTION

Syphilis is an important sexually transmitted infection (STI). Despite inexpensive and effective treatment, few key populations receive syphilis testing. Innovative strategies are needed to increase syphilis testing among key populations. Areas covered: This scoping review focused on strategies to increase syphilis testing in key populations (men who have sex with men (MSM), sex workers, people who use drugs, transgender people, and incarcerated individuals). Expert commentary: We identified many promising syphilis testing strategies, particularly among MSM. These innovations are separated into diagnostic, clinic-based, and non-clinic based strategies. In terms of diagnostics, self-testing, dried blood spots, and point-of-care testing can decentralize syphilis testing. Effective syphilis self-testing pilots suggest the need for further attention and research. In terms of clinic-based strategies, modifying default clinical procedures can nudge physicians to more frequently recommend syphilis testing. In terms of non-clinic based strategies, venue-based screening (e.g. in correctional facilities, drug rehabilitation centres) and mobile testing units have been successfully implemented in a variety of settings. Integration of syphilis with HIV testing may facilitate implementation in settings where individuals have increased sexual risk. There is a strong need for further syphilis testing research and programs.

Preventative health, diversity, and inclusion: a qualitative study of client experience aboard a mobile health clinic in Boston, Massachusetts

Background

There are approximately 2000 mobile health clinics operating in the United States. While researchers have established that mobile health clinics can be cost effective and improve outcomes, there is scant research examining the healthcare experience on a mobile health clinic from patients’ perspectives.

Methods

Data were gathered from interviews with 25 clients receiving care on a Boston-based mobile health clinic and analyzed using grounded theory methodology.

Results

Emerging patterns in the data revealed three relational and three structural factors most significant to participants’ experience of care on The Family Van. Relational factors include providers who 1) Communicate understandably, 2) Create a culture of respect and inclusivity, and 3) Are diverse with knowledge of the community. Structural factors include 1) A focus on preventative health and managing chronic disease, 2) Expeditious, free, and multiple services, and 3) Location.

Conclusions

The participant accounts in this report serve to expand on prior research exploring mobile health clinics’ role in patients’ healthcare, to more clearly define the most salient aspects of the mobile health clinic model for the patients they serve, and to give voice to patients too seldom heard in the academic literature.

Electronic supplementary material

The online version of this article (10.1186/s12939-017-0688-6) contains supplementary material, which is available to authorized users.

The scope and impact of mobile health clinics in the United States: a literature review

As the U.S. healthcare system transforms its care delivery model to increase healthcare accessibility and improve health outcomes, it is undergoing changes in the context of ever-increasing chronic disease burdens and healthcare costs. Many illnesses disproportionately affect certain populations, due to disparities in healthcare access and social determinants of health. These disparities represent a key area to target in order to better our nation's overall health and decrease healthcare expenditures. It is thus imperative for policymakers and health professionals to develop innovative interventions that sustainably manage chronic diseases, promote preventative health, and improve outcomes among communities disenfranchised from traditional healthcare as well as among the general population. This article examines the available literature on Mobile Health Clinics (MHCs) and the role that they currently play in the U.S. healthcare system. Based on a search in the PubMed database and data from the online collaborative research network of mobile clinics MobileHealthMap.org , the authors evaluated 51 articles with evidence on the strengths and weaknesses of the mobile health sector in the United States. Current literature supports that MHCs are successful in reaching vulnerable populations, by delivering services directly at the curbside in communities of need and flexibly adapting their services based on the changing needs of the target community. As a link between clinical and community settings, MHCs address both medical and social determinants of health, tackling health issues on a community-wide level. Furthermore, evidence suggest that MHCs produce significant cost savings and represent a cost-effective care delivery model that improves health outcomes in underserved groups. Even though MHCs can fulfill many goals and mandates in alignment with our national priorities and have the potential to help combat some of the largest healthcare challenges of this era, there are limitations and challenges to this healthcare delivery model that must be addressed and overcome before they can be more broadly integrated into our healthcare system.

Acceptability and feasibility of self-sampling for the screening of sexually transmitted infections in cabana privacy shelters

Screening for sexually transmitted infections (STIs) outside of traditional health-care facilities is limited by the privacy needed for sample collection. We explored the acceptability of privacy shelters for the self-collection of genital swabs and tested the use of privacy shelters during mobile STI screening. Attendees ≥14 years old at two outdoor community events completed a questionnaire that assessed participant characteristics, health-care access, and rating of acceptability of self-collecting penile or vaginal swabs in a privacy shelter and four other private spaces: portable restroom, health van, home, and doctor's office. A privacy shelter was used during mobile STI screening. The majority (65%) of the 95 participants reported that using a privacy shelter was somewhat or very acceptable. No participant characteristics or health-care access factors were associated with the acceptability of privacy shelters. Women rated a privacy shelter more acceptable than a portable restroom or health van. Men rated a privacy shelter more acceptable than a portable restroom. During mobile STI screening, all 13 men and women who requested STI testing used the privacy shelter for self-sampling. Rating of acceptability before and after privacy shelter use was the same. Privacy shelters may enable STI screening without using a building or vehicle for sample collection.

Web-Based HIV Testing in Abruzzo, Italy: Analysis of 15-Month Activity Results

Undiagnosed cases of HIV infection in developed countries are estimated at 20-30% of individuals living with HIV. Web-based strategies may represent a new approach to easier, wider, and unrestricted access to early testing. The Abruzzo Region, Italy, developed a Web-based tool to recruit persons at high risk of HIV and other sexually transmitted infections (STIs). At the Website www.failtestanchetu.it , browsers found information on STIs (HIV, hepatitis B and C, and syphilis), a structured questionnaire called "risk calculator" to assess one's own risk behaviors and direct booking of their test at one of six sites throughout the region. The Website was advertised on local media and in pharmacies, high schools, sports facilities, and factories. Between February 1, 2014, and May 31, 2015, about 6000 users visited the Website; 3046 people attended a visit for counseling on risk behaviors, signs, or symptoms of STIs and accepted blood drawing for HIV, hepatitis B Virus (HBV), hepatitis C Virus (HCV), and syphilis tests. Fifty-eight (1.90%) subjects were positive for HCV, 56 (1.84%) for HBsAg, 90 (2.95%) for Treponema pallidum antibodies, and 28 (0.92%) for HIV. Ninety-two percent of HIV-positive patients were successfully linked to care. Late presenters were less frequent in this sample than in the population diagnosed with HIV in Italy in 2014. An overall 7% proportion of HIV, HBV, HCV, and syphilis-unaware cases were all transferred to care, with the exception of three people. HIV seropositivity among testers was higher than 2/1000, the cost-effectiveness threshold suggested for effective testing. Therefore, our Web-based unrestricted and free access methodology appears worth further and wider evaluation.

Adapting the Get Yourself Tested Campaign to Reach Black and Latino Sexual-Minority Youth

BACKGROUND

Culturally appropriate efforts are needed to increase sexually transmitted disease (STD) testing and care among Black and Latino sexual-minority youth, who are at high risk for STDs. Get Yourself Tested, a national testing campaign, has demonstrated success among youth, but it has yet to be assessed for relevance or impact among this population.

METHOD

This effort included (1) formative and materials-testing research through focus groups; (2) adaptation of existing Get Yourself Tested campaign materials to be more inclusive of Black and Latino sexual-minority youth; (3) a 3-month campaign in four venues of New York City, promoting STD testing at events and through mobile testing and online and social media platforms; (4) process evaluation of outreach activities; and (5) an outcome evaluation of testing at select campaign venues, using a preexperimental design.

RESULTS

During the 3-month campaign period, the number of STD tests conducted at select campaign venues increased from a comparable 3-month baseline period. Although testing uptake through mobile vans remained low in absolute numbers, the van drew a high-prevalence sample, with positivity rates of 26.9% for chlamydia and 11.5% for gonorrhea. This article documents the process and lessons learned from adapting and implementing a local campaign for Black and Latino sexual-minority youth.

Church-Based HIV Screening in Racial/Ethnic Minority Communities of California, 2011-2012

Community-based human immunodeficiency virus (HIV) testing at religious congregations has been proposed as a potentially effective way to increase screening among disproportionately affected populations, such as those self-identifying as African American and Latino. Although congregations may provide reach into these communities, the extent to which church-based HIV testing alleviates access barriers, identifies new cases, and reaches people at increased risk for HIV is not well documented. We examined the results of an HIV testing program that was conducted as part of a larger intervention aimed at reducing HIV stigma at five churches in Los Angeles County, California, in 2011-2012. HIV screening identified one positive result in 323 tests but reached a substantial proportion of people who had not been tested before, including many who lacked health insurance. Although this approach may not be an efficient way to identify cases of previously unknown HIV infection, it could help achieve universal testing goals.

Mobile clinics for women's and children's health

BACKGROUND

The accessibility of health services is an important factor that affects the health outcomes of populations. A mobile clinic provides a wide range of services but in most countries the main focus is on health services for women and children. It is anticipated that improvement of the accessibility of health services via mobile clinics will improve women's and children's health.

OBJECTIVES

To evaluate the impact of mobile clinic services on women's and children's health.

SEARCH METHODS

For related systematic reviews, we searched the Database of Abstracts of Reviews of Effectiveness (DARE), CRD; Health Technology Assessment Database (HTA), CRD; NHS Economic Evaluation Database (NHS EED), CRD (searched 20 February 2014).For primary studies, we searched ISI Web of Science, for studies that have cited the included studies in this review (searched 18 January 2016); WHO ICTRP, and ClinicalTrials.gov (searched 23 May 2016); Cochrane Central Register of Controlled Trials (CENTRAL), part of The Cochrane Library. www.cochranelibrary.com (including the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register) (searched 7 April 2015); MEDLINE, OvidSP (searched 7 April 2015); Embase, OvidSP (searched 7 April 2015); CINAHL, EbscoHost (searched 7 April 2015); Global Health, OvidSP (searched 8 April 2015); POPLINE, K4Health (searched 8 April 2015); Science Citation Index and Social Sciences Citation Index, ISI Web of Science (searched 8 April 2015); Global Health Library, WHO (searched 8 April 2015); PAHO, VHL (searched 8 April 2015); WHOLIS, WHO (searched 8 April 2015); LILACS, VHL (searched 9 April 2015).

SELECTION CRITERIA

We included individual- and cluster-randomised controlled trials (RCTs) and non-RCTs. We included controlled before-and-after (CBA) studies provided they had at least two intervention sites and two control sites. Also, we included interrupted time series (ITS) studies if there was a clearly defined point in time when the intervention occurred and at least three data points before and three after the intervention. We defined the intervention of a mobile clinic as a clinic vehicle with a healthcare provider (with or without a nurse) and a driver that visited areas on a regular basis. The participants were women (18 years or older) and children (under the age of 18 years) in low-, middle-, and high-income countries.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the titles and abstracts of studies identified by the search strategy, extracted data from the included studies using a specially-designed data extraction form based on the Cochrane EPOC Group data collection checklist, and assessed full-text articles for eligibility. All authors performed analyses, 'Risk of bias' assessments, and assessed the quality of the evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

MAIN RESULTS

Two cluster-RCTs met the inclusion criteria of this review. Both studies were conducted in the USA.One study tested whether offering onsite mobile mammography combined with health education was more effective at increasing breast cancer screening rates than offering health education only, including reminders to attend a static clinic for mammography. Women in the group offered mobile mammography and health education may be more likely to undergo mammography within three months of the intervention than those in the comparison group (55% versus 40%; odds ratio (OR) 1.83, 95% CI 1.22 to 2.74; low certainty evidence).A cost-effectiveness analysis of mammography at mobile versus static units found that the total cost per patient screened may be higher for mobile units than for static units. The incremental costs per patient screened for a mobile over a stationary unit were USD 61 and USD 45 for a mobile full digital unit and a mobile film unit respectively.The second study compared asthma outcomes for children aged two to six years who received asthma care from a mobile asthma clinic and children who received standard asthma care from the usual (static) primary provider. Children who receive asthma care from a mobile asthma clinic may experience little or no difference in symptom-free days, urgent care use and caregiver-reported medication use compared to children who receive care from their usual primary care provider. All of the evidence was of low certainty.

AUTHORS' CONCLUSIONS

The paucity of evidence and the restricted range of contexts from which evidence is available make it difficult to draw conclusions on the impacts of mobile clinics on women's and children's health compared to static clinics. Further rigorous studies are needed in low-, middle-, and high-income countries to evaluate the impacts of mobile clinics on women's and children's health.

Readiness to Implement HIV Testing in African-American Church Settings

HIV and AIDS continue to impact Black Americans at disproportionately high rates. Promotion of HIV testing and linkage to care is a national health imperative for this population. As a pillar in the Black community, the Black Church could have a significant impact on the promotion of HIV testing within their churches and surrounding communities. Churches, however, have varied levels of involvement in testing. Furthermore, little is known about how to assess a church's readiness to integrate HIV testing strategies into its mission, much less how to promote this practice among churches. This qualitative study used interviews and focus groups with pastors and church leaders from four churches with varying levels of involvement in HIV testing to identify key stages in the progression of toward church-based HIV testing and linkage to care. Findings showed that churches progressed through levels of readiness, from refusal of the possibility of HIV interventions to full integration of HIV testing and linkage to care within the church.

Predictors identifying those at increased risk for STDs: a theory-guided review of empirical literature and clinical guidelines

SummarySexually transmitted diseases (STDs) are leading causes of substantial morbidity worldwide. Identification of risk factors for estimating STD risk provides opportunities for optimising service delivery in clinical settings, including improving case finding accuracy and increasing cost-efficiency by limiting the testing of low-risk individuals. The current study was undertaken to synthesise the evidence supporting commonly cited chlamydia and gonorrhoea risk factors. The level of empirical support for the following predictors was strong/moderate: age, race/ethnicity, multiple lifetime sexual partners, sex with symptomatic partners and concurrent STD diagnosis. The following predictors had weak evidence: socio-economic status, transactional sex, drug/alcohol use, condom use and history of STD diagnosis. The most frequently listed predictors among nine clinical guidelines were younger age and multiple sexual partners; the least consistently listed predictor was inconsistent condom use. We found reasonably good concordance between risk factors consistently listed in the recommendations and predictors found to have strong empirical support in the literature. There is a need to continue building the evidence base to explicate the mechanisms and pathways of STD acquisition. We recommend periodic reviews of the level of support of predictors included in clinical guidelines to ensure that they are in accordance with empirical evidence.

Expanding sexually transmitted infection screening among women and men engaging in transactional sex: the feasibility of field-based self-collection

Routine screening is a key component of sexually transmitted infection (STI) prevention and control; however, traditional programmes often fail to effectively reach men and women in hidden communities. To reduce prevalence, we must understand the programmatic features that would encourage utilization of services among asymptomatic individuals. Using incentivized snowball sampling, 44 women and men recently engaging in transactional sex were recruited (24 women, 20 men); median age 37 years. Respondents were offered the opportunity to collect genital, oropharyngeal and rectal samples for STI testing and completed a face-to-face interview about their experience with self-obtained sampling. Interviews were analysed using qualitative methods. Participants were unaware of potential risk for STI, but found self-sampling in non-clinical settings to be acceptable and preferable to clinic-based testing. All participants collected genital specimens; 96% and 4% collected oropharyngeal and rectal specimens, respectively. The burden of disease in this population was high: 38% tested positive for at least one STI. We detected multiple concomitant infections. Incorporating field collection of self-obtained samples into STI control programmes may increase utilization among high-risk populations unlikely to access clinic-based services. High infection rates indicate that individuals engaging in transactional sex would benefit from, and be responsive to, community-based self-sampling for STI screening.

Self-collected versus clinician-collected sampling for sexually transmitted infections: a systematic review and meta-analysis protocol

BACKGROUND

Three meta-analyses and one systematic review have been conducted on the question of whether self-collected specimens are as accurate as clinician-collected specimens for STI screening. However, these reviews predate 2007 and did not analyze rectal or pharyngeal collection sites. Currently, there is no consensus on which sampling method is the most effective for the diagnosis of genital chlamydia (CT), gonorrhea (GC) or human papillomavirus (HPV) infection. Our meta-analysis aims to be comprehensive in that it will examine the evidence of whether self-collected vaginal, urine, pharyngeal and rectal specimens provide as accurate a clinical diagnosis as clinician-collected samples (reference standard).

INCLUSION AND EXCLUSION CRITERIA

Eligible studies include both randomized and non-randomized controlled trials, pre- and post-test designs, and controlled observational studies.

SEARCH STRATEGY

The databases that will be searched include the Cochrane Database of Systematic Reviews, Web of Science, Database of Abstracts of Reviews of Effects (DARE), EMBASE and PubMed/Medline.

DATA COLLECTION AND ANALYSIS

Data will be abstracted independently by two reviewers using a standardized pre-tested data abstraction form. Heterogeneity will be assessed using the Q2 test. Sensitivity and specificity estimates with 95% confidence intervals as well as negative and positive likelihood ratios will be pooled and weighted using random effects meta-analysis, if appropriate. A hierarchical summary receiver operating characteristics curve for self-collected specimens will be generated.

DISCUSSION

This synthesis involves a meta-analysis of self-collected samples (urine, vaginal, pharyngeal and rectal swabs) versus clinician-collected samples for the diagnosis of CT, GC and HPV, the most prevalent STIs. Our systematic review will allow patients, clinicians and researchers to determine the diagnostic accuracy of specimens collected by patients compared to those collected by clinicians in the detection of chlamydia, gonorrhea and HPV.

Bringing testing to the people - benefits of mobile unit HIV/syphilis testing in Lima, Peru, 2007-2009

Mobile unit (MU) HIV testing is an alternative method of providing healthcare access. We compared demographic and behavioural characteristics, HIV testing history and HIV prevalence between participants seeking testing at a MU vs. fixed clinic (FC) in Lima, Peru. Our analysis included men and transgender women (TW) in Lima aged ≥ 18 years old seeking HIV testing at their first visit to a community-based MU or FC from October 2007 to November 2009. HIV testing history, HIV serostatus and behavioural characteristics were analysed. A large percentage of MU attendees self-identified as transgender (13%) or heterosexual (41%). MU attendees were more likely to engage in transactional sex (24% MU vs. 10% FC, p < 0.001), use alcohol/drugs during their last sexual encounter (24% MU vs. 20% FC, p < 0.01) and/or be a first-time HIV tester (48% MU vs. 41% FC, p < 0.001). MU HIV prevalence was 9% overall and 5% among first-time testers (49% in TW and 11% in men who have sex with men [MSM] first-time testers). MU testing reached large numbers of at-risk (MSM/TW) populations engaged in unsafe sexual behaviours, making MU outreach a worthy complement to FC testing. Investigation into whether MU attendees would otherwise access HIV testing is warranted to determine the impact of MU testing.

Acceptability of a mobile health unit for rural HIV clinical trial enrollment and participation

Few rural minorities participate in HIV clinical trials. Mobile health units (MHUs) may be one strategy to increase participation. We explored community perceptions of MHU acceptability to increase clinical trial participation for rural minorities living with HIV/AIDS. We conducted 11 focus groups (service providers and community leaders) and 35 interviews (people living with HIV/AIDS). Responses were analyzed using constant comparative and content analysis techniques. Acceptable MHU use included maintaining accessibility and confidentiality while establishing credibility, community ownership and control. Under these conditions, MHUs can service rural locations and overcome geographic barriers to reaching major medical centers for clinical trials.

Knowledgeable Neighbors: a mobile clinic model for disease prevention and screening in underserved communities

The Family Van mobile health clinic uses a "Knowledgeable Neighbor" model to deliver cost-effective screening and prevention activities in underserved neighborhoods in Boston, MA. We have described the Knowledgeable Neighbor model and used operational data collected from 2006 to 2009 to evaluate the service. The Family Van successfully reached mainly minority low-income men and women. Of the clients screened, 60% had previously undetected elevated blood pressure, 14% had previously undetected elevated blood glucose, and 38% had previously undetected elevated total cholesterol. This represents an important model for reaching underserved communities to deliver proven cost-effective prevention activities, both to help control health care costs and to reduce health disparities.

Future chlamydia screening preferences of men attending a sexually transmissible infection clinic

BACKGROUND

Despite years of public health efforts, Chlamydia trachomatis remains a highly prevalent disease suggesting that current control strategies are not sufficient. Asymptomatic men with chlamydial infections are under-identified and probably play an important role in sustaining the epidemic. Novel methods of actively screening asymptomatic men are needed to reduce the prevalence of chlamydia. This formative study explored the features of a sexually transmissible infection (STI) control program that would encourage annual testing among men.

METHODS

Using semi-structured interviews and focus group discussions, we explored issues related to health seeking behaviours and preferences for STI screening among men recruited from a public health STI clinic.

RESULTS

All 29 participants acknowledged the expertise of clinic staff and most men preferred speaking with a provider over using electronic informational resources. The clinic was the preferred venue for future screening, followed by self-collected home sampling with clinic drop-off. Men expressed a preference for receiving results via the telephone rather than electronic options, and preferred personalised reminders for future STI screening.

CONCLUSIONS

In this sample, there was high interest in utilising the expertise of STI clinic personnel and less in non-clinical options. While this may be due to recruiting from an STI clinic, the data serves as a reminder that service provision must be responsive to the needs of potential users. Our findings suggest that future non-clinic based screening strategies may require an initial educational component to address concerns about confidentiality and sample quality in order to be acceptable.

Provision of HIV counseling and testing services at five community-based organizations among young men of color who have sex with men

In the context of monitoring and improving CDC-funded HIV prevention programs, we describe HIV tests and infections, provision of results, previous HIV tests, and risk behaviors for young (aged 13-29) men of color who have sex with men who received HIV tests at five community-based organizations. Of 1,723 tests provided, 2.1% were positive and 75.7% of positives were previously unaware of their infection. The highest positivity rate was among men aged 25-29 (4.7%). Thirty-four percent of tests were provided to men who were tested for the first time. Over half the tests (53.2%) were provided to men who reported sex with a person of unknown HIV status, and 34% to men who reported sex with an anonymous partner. Continued and more focused prevention efforts are needed to reach and test young men of color who have sex with men and to identify previously undiagnosed HIV infections among this target population.

Choice of Rapid HIV testing and entrance into care in Baltimore City sexually transmitted infections clinics

Point-of-service (POS) HIV testing in sexually transmitted infection (STI) clinics is one public health strategy to increase knowledge of serostatus and to facilitate entry into care. Variation has been reported in clients' views of test reliability and rates of test acceptance. Our objective was to characterize STI clinic patients' choice of POS versus conventional testing (enzyme-linked immunosorbant assay [ELISA] followed by Western blot, with results in 1 week) in Baltimore, Maryland (a high-prevalence city) when both were offered (May through August 2008), then to compare rates of engaging in care. Odds ratios (OR) with 95% confidence intervals (CI) described factors associated with test type choice, as well as HIV test type with entrance into care. The overall prevalence of HIV among testers was 1.1% (60/5101). Those reporting receptive anal sex (OR 1.4; 95% CI 1.1-1.7), illicit drug use (OR 1.3; 95% CI 1.0-1.6), or an HIV-positive sexual contact (OR 1.5; 95% CI 1.0-2.2) were more likely to choose POS testing, as were those who had been tested for HIV previously (OR 1.3; 95% CI 1.1-1.5). Hispanics were less likely to choose POS testing (OR 0.6; 95% CI 0.4- 0.7). Entry into care was low in both categories of test takers (52% in POS testers versus 42% in conventional testers, p = 0.58). Patients at the highest risk for HIV preferred POS testing in STI clinics. Strengthening linkage to care is important for optimizing outcomes of HIV-positive patients presenting to STI clinics.

Prevalence and associated factors for Chlamydia trachomatis infection among undocumented immigrants in a primary care facility in Geneva, Switzerland: a cross-sectional study

Chlamydia trachomatis infection (CTI) is the most frequent sexually transmitted infection in western countries. Its prevalence in undocumented immigrants, a rapidly growing vulnerable population, remains unknown. We aimed to document the prevalence of CTI and associated factors at the primary health care level. This cross-sectional study included all undocumented immigrants attending a health care facility in Geneva, Switzerland. Participants completed a questionnaire and were tested for CTI by PCR assay. Three-hundred thirteen undocumented immigrants (68.4% female, mean age 32.4 (SD 8) years) agreed to participate. CTI prevalence was 5.8% (95% CI 3.3-8.4). Factors associated with higher prevalence were age ≤25 (OR 3.9, 95% CI 1.3-12.2) and having had two or more sexual partners during the precedent year (OR 4.5, 95% CI 1.5-13.7). Prevalence and associated factors for infection in this vulnerable population were comparable with other populations in Western countries. Our findings support the importance of facilitating access to existing screening opportunities in particular to individuals at higher risk.

Knowledge of Chlamydia trachomatis among men and women approached to participate in community-based screening, Scotland, UK

Background

Poor awareness and knowledge of Chlamydia trachomatis could be a barrier to uptake of screening. This study aimed to determine the level of awareness and knowledge of chlamydia among young people who were being approached in a variety of community settings and offered opportunistic screening.

Methods

Men and women aged 16-24 years were approached in education, health and fitness, and workplace settings and invited to complete a self-administered questionnaire then provide a urine sample for chlamydia testing. Follow-up semi-structured interviews with 24 respondents were carried out after test results were received.

Results

363 questionnaires were completed (43.5% from men). Whilst awareness of chlamydia was high, knowledge decreased as questions became increasingly focussed so that around half of respondents were unaware of the asymptomatic nature of chlamydia infections. Men's knowledge of symptoms was consistently lower than women's, with most men failing to identify unusual discharge as a symptom in men (men 58.3%, female 45.8%, p = 0.019); fewer men knew unusual discharge was a symptom among women (men 65.3% female 21.4%, p < 0.001). The asymptomatic nature of the infection resonated with respondents and was the commonest piece of information they picked up from their participation in the study.

Conclusions

Despite scientific gains in understanding chlamydia infection, public understanding remains limited. Greater efforts are required to translate scientific evidence to the public. An improvement in knowledge may maximise gains from interventions to improve detection.

Immigrant women's experiences of receiving care in a mobile health clinic

AIM

This paper is a report of a study of the experiences of Portuguese-speaking immigrant women who used a mobile health clinic for their reproductive health care.

BACKGROUND

Upon arrival in Canada, immigrant women often are in better health than their Canadian-born counterparts; however, this health status tends to deteriorate over time. One reason for this change is limited access to services.

METHOD

Data collection during 2004 and 2005 involved individual interviews with seven Portuguese-speaking women who received care in a mobile health clinic in Toronto, Canada, and with four clinic care providers. Non-participant observation of the interaction between clients and care providers was also conducted. Interviews conducted in Portuguese were translated into English and transcribed, along with those conducted in English. Interview transcripts were read and re-read in the context of observational notes to develop codes. Emerging codes were grouped together to develop subcategories and categories.

FINDINGS

Participants' experiences of accessing and receiving care in the mobile health clinic were shaped by their perceptions of health, which included physical, mental, social and spiritual aspects, and their pre- and postmigration care experiences. As an alternative model of care delivery, the mobile health clinic was perceived by participants to address their care needs and to help overcome postmigration barriers by providing accessible, holistic, and linguistically and culturally appropriate care.

CONCLUSION

Mobile health clinics should be considered as an alternative care delivery model for immigrant women who may be at a disadvantage because of their socio-economic, cultural, and racialized statuses.

Field collection of rectal samples for sexually transmitted infection diagnostics among men who have sex with men

Rectal sexually transmitted infections (STIs) are common in men at risk for urethral infections with these pathogens, particularly men who have sex with men (MSM). However, for those individuals not regularly seen by a clinician, screening for rectal STI is not currently a widespread option. Qualitative data and samples (i.e. self-obtained rectal specimens) were collected from 75 MSM in a variety of venues. Upon completion of the rectal self-sampling, each participant completed a brief interview regarding their overall experience with the process. Participants reported an overall high level of acceptability and comfort-level involved with self-sampling for rectal STI. Of the majority of men who agreed to provide a rectal self-sample, all reported that they would provide a sample again in the future. However, many men also appreciated the interaction with a health-care provider that a clinical setting offered. In conclusion, self-sampling is a feasible and acceptable option when offered to MSM in a range of community-based venues. Further research is needed to determine which combinations of STI testing and treatment methods (including self-sampling) are most appropriate for diverse groups of men.

Taking It to the Pews: a CBPR-guided HIV awareness and screening project with black churches

Utilizing a community-based participatory research (CBPR) approach is a potentially effective strategy for exploring the development, implementation, and evaluation of HIV interventions in African American churches. This CBPR-guided study describes a church-based HIV awareness and screening intervention (Taking It to the Pews [TIPS]) that fully involved African American church leaders in all phases of the research project. Findings from the implementation and evaluation phases indicated that church leaders delivered TIPS Tool Kit activities on an ongoing basis (about twice a month) over a 9-month period. TIPS church members were highly exposed to TIPS activities (e.g., 91% reported receiving HIV educational brochures, 84% heard a sermon about HIV). Most (87%) believed that the church should talk about HIV, and 77% believed that the church should offer HIV screening. These findings suggest that implementing an HIV intervention in Black church settings is achievable, particularly when a CBPR approach is used.

Staff strategies for improving HIV detection using mobile HIV rapid testing

This paper examines the performance of 13 mobile testing units (MTUs) and rapid HIV testing technology in Los Angeles County as reflected in the relationship between the cognitive strategies used by MTU staff regarding instructions to clients about picking up their test results and returning for test results, and following up with those clients who did not return, and the spatial distribution of MTUs and AIDS rates in 2003. Maps were created using geographic information systems (GIS) data on 93 MTU testing locations and 2003 AIDS cases data. MTU staff (N = 45) were interviewed and several themes were identified. MTU testing locations were clustered near high AIDS rate areas. Staff reports were obtained on 24 clients in the past 6 months who received HIV-negative test results and 24 clients during the same time period who received HIV-positive test results. Staff strategies that were used included keeping clients with them while rapid test results were being processed and adjusting to clients' schedules when arranging for picking up test results. Some staff used tangible incentives such as vouchers for area businesses to encourage preliminary HIV-positive clients to return for confirmatory test results. Staff also sought to convince clients who preliminarily tested HIV-positive to convert from anonymous to confidential testing in order to facilitate clients' linkage to treatment. The GIS findings and client risk data support the Centers for Disease Control and Prevention policy of implementing MTUs and rapid testing in large urban communities with high AIDS rates.

Chlamydia trachomatis positivity rates among men tested in selected venues in the United States: a review of the recent literature

The cost-effectiveness of screening men for Chlamydia trachomatis depends in part on the prevalence of chlamydia in the screened population and the ease with which screening programs can be implemented. Screening in venues with high rates of chlamydia positivity among men may therefore be an important adjunct to chlamydia control. To evaluate the recent US literature on chlamydia positivity in chlamydia screening programs among asymptomatic men in nonsexually transmitted disease clinic settings, we reviewed published articles between 1995 and June 2007, using PubMed as the primary search tool. Articles were abstracted and positivity rates summarized by type of venue, race/ethnicity, age group, and US region. The overall median positivity rate was 5.1%. The highest rates were observed among men tested in juvenile (7.9%) and adult (6.8%) detention facilities, among blacks (6.7%), the 15 to 19 years old (6.1%) and 20 to 24 years old (6.5%) age groups, and among men screened in the southern United States (6.4%). Chlamydia rates among men are high in certain venues, particularly correctional settings, but also depend on the demographic composition of the target population and location. Programs considering male chlamydia screening programs should conduct pilot programs to assess chlamydia positivity as well as feasibility and cost in target venues.

Cost-effectiveness of screening strategies for Chlamydia trachomatis using cervical swabs, urine, and self-obtained vaginal swabs in a sexually transmitted disease clinic setting

BACKGROUND

We evaluated the cost-effectiveness of Chlamydia screening strategies that use different methods of specimen collection: cervical swabs, urines, and self-obtained vaginal swabs.

METHODS

A decision analysis was modeled for a hypothetical cohort of 10,000 per year of women attending sexually transmitted disease (STD) clinics. Incremental cost-effectiveness of 4 screening strategies were compared: 1) Endocervical DNA probe test (PACE2, Gen-Probe), 2) Endocervical AC2 (Aptima Combo 2, Gen-Probe), 3) Self-Obtained Vaginal AC2, and 4) Urine AC2. Sensitivities of the vaginal, urine, and cervical AC2 tests were derived from 324 women attending STD clinics. The primary outcome was cases of pelvic inflammatory disease prevented. The model incorporated programmatic screening and treatment costs and medical cost savings from sequelae prevented.

RESULTS

Chlamydia prevalence in the sampled population was 11.1%. Sensitivities of vaginal, urine, and cervical AC2 were 97.2%, 91.7%, and 91.7%, respectively. The sensitivity of the DNA probe was derived from the literature and estimated at 68.8%. The self-obtained vaginal AC2 strategy was the least expensive and the most cost-effective, preventing 17 more cases of pelvic inflammatory disease than the next least expensive strategy.

CONCLUSIONS

Use of a vaginal swab to detect Chlamydia in this STD clinic population was cost-saving and cost-effective.

Polysubstance use and HIV/STD risk behavior among Massachusetts men who have sex with men accessing Department of Public Health mobile van services: implications for intervention development

Polysubstance use has been posited to be a significant contributor to excess burden of HIV disease among men who have sex with men (MSM). The current study investigated polysubstance use and sexual risk among men who utilize Massachusetts Department of Public Health (MDPH) van services (such as HIV, chlamydia, gonorrhea, or syphilis testing; Hepatitis A and B vaccinations) at venues targeting MSM. Participants (n = 214) completed a one-time, cross-sectional survey via an audio computer-assisted self-interview (ACASI) in English or Spanish between June 2007 and September 2007. Fifteen percent of the overall sample did not know their HIV status; 11% reported polysubstance use (concurrent use of three or more: poppers, ecstasy, GHB, cocaine, crystal methamphetamine, Viagra) during sex in the 12 months prior to study enrollment. Polysubstance users were more likely to be HIV infected (odds ratio [OR] = 4.62; p = 0.03) and to have a history of one or more sexually transmitted diseases (STDs; OR = 4.74; p = 0.03) relative to participants who did not report polysubstance use during sex. After controlling for covariates of age, race/ethnicity, education level, insurance status, sexual orientation, STD history, HIV status, and depression, multivariable logistic regression analyses revealed that polysubstance users were 9 times more likely to have reported unprotected anal (insertive or receptive) sex in the 12 months prior to study enrollment (adjusted OR = 9.53; p = 0.007) compared to nonpolysubstance-using MSM. Polysubstance users lacked access to care (21% were uninsured) and the overwhelming majority (96%) were first time users of mobile health van services. Accessible outreach services for MSM such as mobile van services need to include drug screening and interventions that triage men into treatment programs; year-round availability of van services is warranted.

Should asymptomatic men be included in chlamydia screening programs? Cost-effectiveness of chlamydia screening among male and female entrants to a national job training program

OBJECTIVE

To compare the cost-effectiveness of various chlamydia screening strategies within a population of male and female youth entering a national job training program.

STUDY DESIGN

Cost-effectiveness analysis of various chlamydia screening strategies among a cohort of 4000 female and male New England job training students. Strategies for women include (a) no screening, (b) universal endocervical DNA probe screening, (c) universal urine based NAAT screening, and (d) universal endocervical NAAT screening. Strategies for men include (a) no screening, (b) selective urine NAAT screening of leukocyte esterase (LE)-positive urines, and (c) universal urine-based NAAT screening.

RESULTS

Universal endocervical NAAT screening of women and universal urine NAAT screening of men were the most effective and cost-effective strategies individually and in combination. Endocervical NAAT screening of women prevented 23 more cases of PID and saved $27,000 more than endocervical DNA probe screening. Likewise, universal urine NAAT screening of men prevented 21 more cases of PID in their female partners and saved $16,000 more than selective urine NAAT screening of LE positive men.

CONCLUSIONS

Use of a sensitive NAAT to screen both men and women for chlamydia upon entry to a National Job Training Program is cost-effective, cost-saving, and provides a public health opportunity to substantially reduce chlamydia infections among youth at risk for sexually transmitted diseases.

The feasibility of recruiting young men in rural areas from community football clubs for STI screening

OBJECTIVE

To investigate the feasibility of recruiting young men from rural football clubs for screening for sexually transmitted infections (STIs).

METHODS

Young men aged 16 to 29 were recruited from four football clubs outside of metropolitan areas in Victoria, Australia, and completed a questionnaire about sexual activity, knowledge and history of STIs, and alcohol and drug use, and provided a urine sample for STI testing.

RESULTS

One hundred and eight participants completed the questionnaire and 92 (85.2%) also provided a urine sample. More than 90% of eligible players present at the clubs on the night of the study participated. Eighty-seven participants (80.6%) had ever had penetrative sex, with 33 (39.3%) reporting a new sexual partner in the past three months. Among those who had ever had sex, the prevalence of chlamydia was 3.9% (95% Cl 0.8-11.0). While the majority of participants visited their doctor in the past year (78.7%) and were comfortable with the idea of an annual STI screen, few had ever discussed sex or STIs with their doctor or had a previous STI test.

CONCLUSION

Young men from rural areas may be at considerable risk of STIs and many have not been previously tested. However, most are willing to participate in screening programs and the high participation rate achieved in this pilot project demonstrates the potential for screening to be successfully extended into non-medical settings such as sporting clubs.

IMPLICATIONS

Young people at risk of STIs can be successfully recruited for STI screening from community settings.

Use of a community mobile health van to increase early access to prenatal care

OBJECTIVE

To examine whether the use of a community mobile health van (the Lucile Packard Childrens Hospital Women's Health Van) in an underserved population allows for earlier access to prenatal care and increased rate of adequate prenatal care, as compared to prenatal care initiated in community clinics.

METHODS

We studied 108 patients who initiated prenatal care on the van and delivered their babies at our University Hospital from September 1999 to July 2004. One hundred and twenty-seven patients who initiated prenatal care in sites other than the Women's Health Van, had the same city of residence and source of payment as the study group, and also delivered their babies at our hospital during the same time period, were selected as the comparison group. Gestational age at which prenatal care was initiated and the adequacy of prenatal care - as defined by Revised Graduated Index of Prenatal Care Utilization (RGINDEX) - were compared between cases and comparisons.

RESULTS

Underserved women utilizing the van services for prenatal care initiated care three weeks earlier than women using other services (10.2 +/- 6.9 weeks vs. 13.2 +/- 6.9 weeks, P = 0.001). In addition, the data showed that van patients and non-van patients were equally likely to receive adequate prenatal care as defined by R-GINDEX (P = 0.125).

CONCLUSION

Women who initiated prenatal care on the Women's Health Van achieved earlier access to prenatal care when compared to women initiating care at other community health clinics.

Gonorrhea prevention and clinical care in the private sector: lessons learned and priorities for quality improvement

We reviewed literature on gonorrhea prevention and clinical care in the private sector, the setting where most gonorrhea cases in the United States are now diagnosed. Although most private-sector health settings had a low prevalence of gonorrhea (0.1-2.5%), some private emergency departments and specialty clinics that serve a large number of high-risk or infected patients had prevalences ranged from 1.7% to 11.0%. Studies of diverse settings and populations suggest that, in general, diagnostic testing of symptomatic patients (69-83%), appropriate treatment (61-100%), and case reporting (64-94%) are delivered more commonly than risk assessment for asymptomatic patients (15-28%), routine screening of pregnant women (31-77%), risk-reduction counseling (35-78%), and sex partner management (0-82%). To sustain the recent declines in gonorrhea incidence in the United States, private-sector providers and health systems must continue to offer gonorrhea prevention and clinical services and consider implementing interventions to improve delivery of risk assessment, risk-reduction counseling, and partner management services.

Identifying likely syphilis transmitters: implications for control and evaluation

BACKGROUND/OBJECTIVES

Persistence of syphilis in communities may be maintained by relatively small groups of high-risk persons centrally placed among a larger group with low to moderately risky behavior. We sought to determine which control strategies identified particularly high-risk, early-stage syphilis cases considered to have high prevention value.

METHODS

In 2 cities with recent heterosexual outbreaks, data were abstracted for early syphilis cases from 1997 through 2002. Disease stage and number of sex partners were used to create an index to estimate the relative likelihood and magnitude of future transmission had the case not been treated. We estimated the relative transmission potential for each stage of syphilis (primary = 4.3, secondary = 2.5, and early-latent = 1.0) and multiplied by the number of reported partners to determine a prevention value score. Cases scoring >10 were considered high prevention value. Cases were stratified by the method used to detect the case.

RESULTS

Of 1,700 female early syphilis cases, 174 (10%) were high value. Cases were identified by private physicians (28% of all female cases and 16% of high-value cases), jails (19% of all, 40% of high-value cases), partner notification (16% of all, 10% of high-value cases), sexually transmitted disease (STD) clinic (9% of all, 13% of high-value cases), and the emergency room (8% of all, 4% of high-value cases). Of 1,851 male cases, 228 (12%) were high value. Cases were identified by jails (27% of all male cases and 14% of high-value cases), STD clinic (21% of all, 47% of high-value), private physicians (17% of all, 17% of high-value), partner notification (14% of all, 11% of high-value), and the emergency room (6% of all, 14% of high-value).

CONCLUSIONS

Private physicians identified the most female cases; however, jail screening identified the most high-prevention-value female cases. Jail screening identified the most male cases; however, the STD clinic (self-referred) identified the most high-prevention-value cases. Partner notification identified relatively few high-value cases.

Assessing the feasibility of harm reduction services for MSM: the late night breakfast buffet study

BACKGROUND

Despite the leveling off in new HIV infections among men who have sex with men (MSM) in San Francisco, new evidence suggests that many recent HIV infections are linked with the use of Methamphetamine (MA). Among anonymous HIV testers in San Francisco, HIV incidence among MA users was 6.3% compared to 2.1% among non-MA users. Of particular concern for prevention programs are frequent users and HIV positive men who use MA. These MSM pose a particular challenge to HIV prevention efforts due to the need to reach them during very late night hours.

METHODS

The purpose of the Late Night Breakfast Buffet (LNBB) was to determine the feasibility and uptake of harm reduction services by a late night population of MSM. The "buffet" of services included: needle exchange, harm reduction information, oral HIV testing, and urine based sexually transmitted infection (STI) testing accompanied by counseling and consent procedures. The study had two components: harm reduction outreach and a behavioral survey. For 4 months during 2004, we provided van-based harm reduction services in three neighborhoods in San Francisco from 1-5 a.m. for anyone out late at night. We also administered a behavioral risk and service utilization survey among MSM.

RESULTS

We exchanged 2000 needles in 233 needle exchange visits, distributed 4500 condoms/lubricants and provided 21 HIV tests and 12 STI tests. Fifty-five MSM enrolled in the study component. The study population of MSM was characterized by low levels of income and education whose ages ranged from 18-55. Seventy-eight percent used MA in the last 3 months; almost 25% used MA every day in the same time frame. Of the 65% who ever injected, 97% injected MA and 13% injected it several times a day. MA and alcohol were strong influences in the majority of unprotected sexual encounters among both HIV negative and HIV positive MSM.

CONCLUSION

We reached a disenfranchised population of MA-using MSM who are at risk for acquiring or transmitting HIV infection through multiple high risk behaviors, and we established the feasibility and acceptability of late night harm reduction for MSM and MSM who inject drugs.

Chlamydia trachomatis infections in multi-ethnic urban youth: a pilot combining STI health education and outreach testing in Rotterdam, Netherlands

BACKGROUND/OBJECTIVES

Testing for Chlamydia trachomatis (Ct) is less accepted in people of non-Dutch ethnicity than Dutch people. We offered additional Ct and gonorrhoea testing through our outreach sexually transmitted infections (STI) prevention programme to determine whether this intervention strategy is feasible and efficient.

METHODS

Outreach workers offered test kits to women and men aged 15-29 years, in group and street settings and in a vocational training school. Demographic and behavioural data and characteristics of non-responders were assessed. DNA was isolated (using the MagNA Pure LC system) from urine and tested using the Cobas Amplicor test.

RESULTS

Among sexually active people, the test rate differed by venue (groups 80% (74/93), school 73% (49/67), street 17% (49/287); p<0.001). There was no difference in test rate between group and school settings by gender or ethnicity. Ct positivity was 14.5% (25/172); women 20.2% (20/99) versus men 6.8% (5/73); p = 0.01. Ct positivity was highest at school (24.5% (12/49)) and among Surinamese/Antillean people (17.5% (14/80)). Treatment rate of index cases and current partners was 100% and 78%, respectively.

CONCLUSIONS

We found a high acceptance of chlamydia testing in group and school settings in both men and women of non-Dutch ethnicity. The prevalence indicates that we have accessed high risk people. Outreach testing and is feasible and most efficient in school and group settings. School screening may have an impact on community prevalence of Ct infections.

Sexually transmitted diseases in older adults

Health professionals are frequently reluctant to recognize or investigate the sexuality of their older patients. Thus, sexual health may never be addressed, even among older adults who come into frequent contact with health care professionals. As the dominant culture continues to shift toward a more realistic view of aging that supports the expression of sexuality among older adults, evaluation of sexual health will become a critical component of comprehensive assessment of the geriatric patient. This article reviews the clinical features and management of common sexually transmitted diseases in the older adult.

Unmet need for recommended preventive health services among clients of California syringe exchange programs: implications for quality improvement

BACKGROUND

Comprehensive preventive services are recommended for injection drug users (IDU), including screening tests, vaccinations, risk reduction counseling, and sterile syringes. Syringe exchange programs (SEP) may facilitate receipt of preventive services by IDUs, but whether SEP clients receive recommended preventive care is not known. We examined use of recommended preventive services by clients of 23 SEPs throughout California.

METHODS

Five hundred and sixty SEP clients were recruited from 23 SEPs throughout California between March and September 2003. Receipt of 10 recommended preventive services and source of care (SEP versus non-SEP providers) was ascertained from client interviews.

RESULTS

On average, SEP clients received only 13% of recommended preventive services and 49% of clients received none of the recommended services. Of services that were received, 76% were received from SEPs. In multivariate analysis, use of drug treatment and more frequent SEP visits were associated with receipt of recommended preventive services by clients.

CONCLUSIONS

SEPs are often the only source of preventive care for their IDU clients. Still, SEP clients fail to receive most recommended preventive services. Interventions to increase use of preventive services and improve the quality of preventive care received by IDUs, such as increased access to drug treatment and SEPs, are needed.

Control of syphilis outbreaks in men who have sex with men: the role of screening in nonmedical settings

OBJECTIVE

To quantify the scope and yield of targeted syphilis screening in nonmedical settings in 7 US cities affected by recent syphilis outbreaks among men who have sex with men (MSM).

METHODS

Data were collected from syphilis screening activities targeting MSM between 1999 and 2004, conducted in bathhouses or other commercial sex venues, MSM-oriented bars, mobile vans, and other nonmedical settings by the public health departments of Chicago, Houston, Miami/Fort Lauderdale, Los Angeles, NY, and San Francisco.

RESULTS

Of 14,143 syphilis screening tests (STS) conducted during community outreach campaigns at a variety of MSM oriented venues, 132 (0.9%) new cases of syphilis were identified. One hundred five (0.8%) new cases of early syphilis were found, including 23 cases of symptomatic syphilis. Screening in jails produced the highest prevalence of early syphilis (1.3%, 51 cases/3853 STS), followed by sex venues, including bathhouses (1.2%, 29 cases/2511 STS).

CONCLUSIONS

These data suggest that even nontraditional, highly targeted screening programs conducted during outbreak situations do not detect many persons with syphilis, even though many of the screening venues were locations where men with syphilis met their sex partners. The low prevalence of infectious syphilis identified during these screening events suggests that the direct impact of these programs on decreasing syphilis transmission may be negligible. However, the secondary benefits, such as increasing awareness of syphilis and prompting earlier treatment due to symptom recognition, may be substantial.

Community based syphilis screening: feasibility, acceptability, and effectiveness in case finding

OBJECTIVES

To investigate the feasibility and acceptability of implementing community based syphilis screening using different sample collection techniques, and its effectiveness in screening at-risk populations and identifying new syphilis cases.

METHODS

Two phases of syphilis screening were conducted in venues frequented by men who have sex with men (MSM). Phase 1 used venepuncture and phase 2 a validated saliva test. Evaluation used quantitative data from testers, venues and the local genitourinary medicine (GUM) clinic, and qualitative data from venue and programme staff.

RESULTS

1090 MSM were tested over 7 weeks. 62% of testers had not attended a GUM clinic in the past year. 64% of testers reported > or = 2 sexual contacts in the past 90 days and 11% reported > or = 10. Similar diagnosis rates were recorded for phase 1 (1.4%) and phase 2 (1.8%). There was greater uptake of testing with the saliva test in saunas during phase 2.

CONCLUSIONS

Syphilis screening in gay venues is feasible and acceptable to at-risk MSM, and reaches a group not routinely accessing GUM services. The low case detection for syphilis suggest this approach, while unlikely to contain outbreaks, may be more useful if combined with screening for other sexually transmitted infections and effective health promotion strategies.