Chlamydia screening of youth and young adults in non-clinical settings throughout California

Community Engagement and Venue-Based Sampling in Adolescent Male Sexually Transmitted Infection Prevention Research

OBJECTIVES

Middle adolescent males are a difficult group to recruit for community sexually transmitted infection (STI) prevention research. We describe a process of community engagement, and venue-based sampling of 14-17-year-old adolescent males, and compare rates of STIs and STI risk behaviors by venue.

METHODS

Community engagement consisted of (1) informational meetings with organizations; (2) participation in community meetings and events; (3) hiring community members as study personnel; and (4) an adolescent advisory board recruited from the community. Venues were identified and assessed at different times of the day and days of the week using a structured tool. At selected venues, males ages 14-17 years were invited to participate in a brief survey and provide a urine sample and an optional anal swab for DNA-based STI testing.

RESULTS

Venues were assessed (n = 249), and 31 were selected for recruitment, including parks, apartment complexes, community events, entertainment venues, a community school, and community programs for LGBT (gay, lesbian, bisexual, transgender) and adjudicated youth. We enrolled 667 participants, average age 15.7 years. Participants reported high rates of sexual and STI risk behaviors, but had low rates of STIs. These rates differed by venue, with more structured venues recruiting youth reporting fewer STI risk behaviors and less structured venues within the highest STI prevalence zip code recruiting youth reporting more STI risk behaviors.

CONCLUSION

Venue-based sampling is a feasible mechanism to target recruitment and enrollment adolescent males with high STI risk behaviors in community settings, with risk profiles varying by setting.

Trends in Chlamydia Screening, Test Positivity, and Treatment Among Females in California Juvenile Detention Facilities, 2003-2014

BACKGROUND

Juvenile detention facilities house adolescents at high risk for sexually transmitted diseases. Collaboration between health departments and juvenile detention authorities can provide routine, cost-efficient chlamydia screening and treatment to females with limited access to care. We describe trends in screening, positivity, treatment, and associated costs in a well-established juvenile detention chlamydia screening program.

METHODS

In the California Chlamydia Screening Project, juvenile detention facilities in 12 counties collected quarterly aggregate data on female census and line-listed chlamydia test results and treatment data from fiscal year (FY) 2003-2004 to FY 2013-2014. Trends in the proportion of females screened, positivity, and treatment by age, race/ethnicity, and facility volume were evaluated by Cochran-Armitage test. The median cost of the program per chlamydia positive identified was compared by facility in FY 2013-2014.

RESULTS

Data from 59,518 test records among juvenile females indicated high screening rates (75.1%-79.4%). Chlamydia positivity, although consistently high, decreased from 14.8% in 2003-2004 to 11.5% in 2013-2014 (P < 0.001). Documented treatment decreased (88.8% in 2005-2006 to 79.0% in 2013-2014, P < 0.001); of those treated, treatment within 7 days increased (80.1% in 2005-2006 to 88.8% in 2013-2014, P < 0.001). The median cost per chlamydia positive identified was $708 (interquartile range, $669-$894) and was lowest for facilities with high chlamydia positivity.

CONCLUSIONS

The California Chlamydia Screening Project demonstrated consistently high rates of chlamydia screening and positivity among adolescent females while keeping costs low for high-volume facilities. Further improvement in timely treatment rates remains a challenge for extending the impact of screening in this high-risk population.

Bacterial Sexually Transmitted Disease Screening Outside the Clinic--Implications for the Modern Sexually Transmitted Disease Program

BACKGROUND

The development of noninvasive nucleic acid amplification tests for chlamydia and gonorrhea has facilitated innovation in moving sexually transmitted disease (STD) screening to nonclinical settings. However, limited data are available to inform local STD programs on evidence-based approaches to STD screening in nonclinical settings in the United States.

METHODS

We conducted a systematic review of the literature published since 2000 related to chlamydia, gonorrhea, and syphilis screening in US correctional settings, bathhouses and sex venues, self-collected at-home testing, and other nonclinical sites.

RESULTS

Sixty-four articles met eligibility criteria and were reviewed. Although data on testing volume and positivity were available, there were scarce data on the proportion of new positives treated and the programmatic costs for the various screening programs. Screening in correctional settings identified a sizable amount of asymptomatic infections. The value and sustainability of screening in the other nonclinical settings examined was not clear from the published literature.

CONCLUSIONS

Local and state health departments should explore the development of sustainable jail and juvenile detention screening programs for STDs. Furthermore, local programs should pilot outreach and home-based STD screening programs to determine if they are identifying asymptomatic persons who would not have otherwise been found. Local programs are encouraged to present and publish their findings related to non-clinic-based screening to enhance the limited body of literature; data on the proportion of new infections treated and the local program costs are needed.

Azithromycin versus Doxycycline for Urogenital Chlamydia trachomatis Infection

BACKGROUND

Urogenital Chlamydia trachomatis infection remains prevalent and causes substantial reproductive morbidity. Recent studies have raised concern about the efficacy of azithromycin for the treatment of chlamydia infection.

METHODS

We conducted a randomized trial comparing oral azithromycin with doxycycline for the treatment of urogenital chlamydia infection among adolescents in youth correctional facilities, to evaluate the noninferiority of azithromycin (1 g in one dose) to doxycycline (100 mg twice daily for 7 days). The treatment was directly observed. The primary end point was treatment failure at 28 days after treatment initiation, with treatment failure determined on the basis of nucleic acid amplification testing, sexual history, and outer membrane protein A (OmpA) genotyping of C. trachomatis strains.

RESULTS

Among the 567 participants enrolled, 284 were randomly assigned to receive azithromycin, and 283 were randomly assigned to receive doxycycline. A total of 155 participants in each treatment group (65% male) made up the per-protocol population. There were no treatment failures in the doxycycline group. In the azithromycin group, treatment failure occurred in 5 participants (3.2%; 95% confidence interval, 0.4 to 7.4%). The observed difference in failure rates between the treatment groups was 3.2 percentage points, with an upper boundary of the 90% confidence interval of 5.9 percentage points, which exceeded the prespecified absolute 5-percentage-point cutoff for establishing the noninferiority of azithromycin.

CONCLUSIONS

In the context of a closed population receiving directly observed treatment for urogenital chlamydia infection, the efficacy of azithromycin was 97%, and the efficacy of doxycycline was 100%. The noninferiority of azithromycin was not established in this setting. (Funded by the National Institute of Allergy and Infectious Diseases; ClinicalTrials.gov number, NCT00980148.).

Epidemiology of Sexually Transmitted Infections Among Offenders Following Arrest or Incarceration

OBJECTIVES

We sought to estimate rates of sexually transmitted infections (STIs) among criminal offenders in the 1 year after arrest or release from incarceration.

METHODS

We performed a retrospective cohort study of risk of having a positive STI (chlamydia, gonorrhea, or syphilis) or incident-positive HIV test in the 1 year following arrest or incarceration in Marion County (Indianapolis), Indiana. Participants were 247,211 individuals with arrest or incarceration in jail, prison, or juvenile detention between 2003 and 2008.

RESULTS

Test positivity rates (per 100,000 and per year) were highest for chlamydia (2968) and gonorrhea (2305), and lower for syphilis (278) and HIV (61). Rates of positive STI and HIV were between 1.5 and 2.8 times higher in female than male participants and between 2.7 and 6.9 times higher for Blacks than Whites. Compared with nonoffenders, offenders had a relative risk of 3.9 for chlamydia, 6.6 for gonorrhea, 3.6 for syphilis, and 4.6 for HIV.

CONCLUSIONS

The 1-year period following arrest or release from incarceration represents a high-impact opportunity to reduce STI and HIV infection rates at a population level.

Chlamydia screening strategies and outcomes in educational settings: a systematic review

Chlamydia trachomatis (CT) screening programs have been established in educational settings in many countries during the past 2 decades. However, recent evidence suggests that high uptake of screening and management (treatment, partner notification, and retesting for reinfection) improves program effectiveness. We conducted a systematic review to understand the screening strategies, the extent of screening conducted, and uptake of management strategies in educational settings. Screening studies in educational settings were identified through a systematic search of published literature from 2005 to 2011. We identified 27 studies describing 30 screening programs in the United States/Canada (n = 10), Europe (n = 8), Australia/New Zealand (n = 5), and Asia (n = 4). Most studies targeted both male and female students (74%). Classroom-based strategies resulted in 21,117 testes overall (4 programs), followed by opportunistic screening during routine health examination (n = 13,470; 5 programs) and opportunistic screening at school-based health centers (n = 13,006; 5 programs). The overall median CT positivity was 4.7% (range, 1.3%-18.1%). Only 5 programs reported treatment rates (median, 100%; range, 86%-100%), 1 partner notification rate (71%), 1 retesting rate within a year of an initial CT diagnosis (47%), and 2 reported repeat positivity rates (21.1% and 26.3%). In conclusion, this systematic review shows that a variety of strategies have been used to screen large numbers of students in educational settings; however, only a few studies have reported CT management outcomes.

Feasibility of providing sexually transmitted infection testing and treatment in off-campus, nonclinic settings for adolescents enrolled in a school-based research project

BACKGROUND

This study examined the acceptability and feasibility of using a biological outcome measure to evaluate a school-based sexuality education program. Confidential field-delivered sexually transmitted infection (STI) testing by nonmedical field staff and STI treatment by medically trained field staff was assessed in off-campus and off-clinic settings for adolescents enrolled in the trial.

METHODS

After parental and adolescent consent were obtained, a convenient time and location was identified to collect urine to test for chlamydia (Chlamydia trachomatis, CT), gonorrhea (Neisseria gonorrheae, NG), and trichomonas (Trichomonas vaginalis, TV) infection and to treat students with positive results.

RESULTS

A total of 391 of 1742 students had permission to participate (22%); 353 (90%) provided urine samples; 28 (8%) had positive test results: CT(18), NG(5), and TV(8). Testing and treatment occurred at home for 92% and 59% of students, respectively; on weekdays (for 69% and 96%, respectively) and between noon and 8 pm (for 76% and 88%, respectively). All students who tested positive were treated. Several lessons and strategies that may improve the likelihood that students will participate in field-delivered STI testing and treatment emerged.

CONCLUSION

STI testing and treatment are feasible for students enrolled in a school-based sexuality education program. However, obtaining parental consent may be challenging.

Adolescent criminal justice involvement and adulthood sexually transmitted infection in a nationally representative US sample

Criminal justice involvement (CJI) disrupts social and sexual networks, and sexually transmitted infections (STIs) thrive on network disruption. Adolescent CJI may be a particularly important determinant of STI because experiences during adolescence influence risk trajectories into adulthood. We used Wave III (2001-2002: young adulthood) of the National Longitudinal Study of Adolescent Health (N = 14,322) to estimate associations between history of adolescent (younger than 18 years) CJI and adult STI risk. Respondents who reported a history of repeat arrest in adolescence, adolescent conviction, and arrest both as an adolescent and an adult (persistent arrest) had between two to seven times the odds of STI (biologically confirmed infection with chlamydia, gonorrhea, or trichomoniasis) in adulthood and between two to three times the odds of multiple partnerships and inconsistent condom use in the past year in adulthood. In analyses adjusting for sociodemographic and behavioral factors, history of having six or more adolescent arrests was associated with more than five times the odds of STI (adjusted odds ratio (AOR) 5.44, 95 % confidence interval (CI) 1.74-17.1). Both adolescent conviction and persistent CJI appeared to remain independent correlates of STI (conviction: AOR 1.90, 95 % CI 1.02-3.55; persistent CJI: AOR 1.60, 95 % CI 0.99-2.57). Adolescents who have repeat arrests, juvenile convictions, and persist as offenders into adulthood constitute priority populations for STI treatment and prevention. The disruptive effect of adolescent CJI may contribute to a trajectory associated with STI in adulthood.

A systematic review and meta-analysis of the prevalence of chlamydia, gonorrhoea and syphilis in incarcerated persons

Communicable diseases are common in people who are incarcerated. We aimed to define the prevalence of chlamydia, gonorrhoea and syphilis in people who are incarcerated and to identify subgroups with the highest risk of infection. We searched for prevalence studies of chlamydia, gonorrhoea or syphilis in incarcerated populations. Pooled estimates were generated, and meta-regression was conducted. Random effects models yielded pooled prevalence estimates of 5.75% (95% confidence interval [CI] 5.01, 6.48) and 12.31% (95% CI 10.61, 14.01) for chlamydia in men and women, 1.4% (95% CI 1.09, 1.70) and 5.73% (4.76, 6.69) for gonorrhoea in men and women, and 2.45% (95% CI 2.08, 2.82) and 6.10% (95% CI 4.75, 7.46) for syphilis in men and women, respectively. Each infection was associated with female gender in meta-regression models. Chlamydia, gonorrhoea and syphilis are highly prevalent in these populations. Primary and secondary prevention efforts could improve individual and population health.

Reaching youth with out-of-facility HIV and reproductive health services: a systematic review

PURPOSE

Many young people, particularly those who are marginalized and most at risk for HIV and reproductive health-related problems, cannot or will not seek traditional facility-based health services. Policies and programs are being implemented to provide them with these health services in the community. We sought to review the effectiveness of such approaches in increasing HIV and reproductive health service use.

METHODS

A systematic literature review was undertaken to identify policies promoting or programs delivering HIV or reproductive health services in the community. We reviewed studies that evaluated uptake of services or commodities. Data from studies meeting inclusion criteria were qualitatively analyzed.

RESULTS

Twenty studies met inclusion criteria, including 10 containing comparative data (e.g., before and after study or control study design). The studies generally demonstrated positive impact, although results varied across settings and approaches. The most successful approaches included mail-based chlamydia screening in the Netherlands, condom distribution via street outreach in Louisiana, home-based HIV counseling and testing in Malawi, and promotion of over-the-counter access to emergency contraception in various countries.

CONCLUSION

Overall, this review suggests that out-of-facility approaches can be important avenues to reach youth. Continued evaluation is necessary to better understand specific approaches that can successfully deliver health services.

Issues in gynecologic care for adolescent girls in the juvenile justice system

Incarcerated girls represent a captive audience, providing health care providers working in the juvenile justice system with a unique opportunity to intervene in this difficult to-reach population. Health care providers should promote and encourage healthy lifestyles with the aim of lowering their risk-taking behaviors, promote contraception and screen and treat sexually transmitted infections. For many delinquent girls this encounter represents their first contact with the medical care system as independent young women.It is important to encourage these girls to have a medical home and upon discharge from the facility, it is important to guarantee appropriate follow-up.

Patterns of chlamydia/gonorrhea positivity among voluntarily screened New York City public high school students

PURPOSE

Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) are common sexually transmitted infections that disproportionately affect adolescents. Annual screening for CT for sexually active female adolescents is recommended. In 2006, New York City began conducting CT/GC education, screening, and treatment in public high schools. We examine 3-year programmatic outcomes and the relationship between sexual activity, screening, and CT/GC positivity.

METHODS

We describe the epidemiology of students who screened and those infected with CT/GC. Univariate, bivariate, and multivariate logistic regression analyses were performed to assess relationships between sex, race/ethnicity, age, sexual activity, and screening status; and the relationship between sexually transmitted infection positivity and sexual activity.

RESULTS

Between July 2006 and June 2009, we educated 57,418 students and screened 27,353 (47.6%) for CT/GC; 1,736 (6.3%) students were reported to be infected with either organism. Students who screened positive were more likely to be females (8.9%), report black race (8.3%) and be ≥16 years of age (6.6%-9.7%). Screening rates were 70.6% for students who were sexually active, 27.9% for those who had never had sex, and 47.3% for those who did not respond to the sexual activity question; CT/GC positivity was 7.2%, 1.4%, and 6.1%, respectively.

CONCLUSIONS

Black, older adolescent females were most likely to screen positive for CT/GC in this population. A large proportion of students who did not answer the sexual activity question chose to screen for CT/GC and screened positive. School screening programs should offer screening to all students regardless of reported sexual activity. Programs should target females and older adolescents.

Home versus clinic-based specimen collection for Chlamydia trachomatis and Neisseria gonorrhoeae

Sexually transmitted infections (STIs) are a major public health concern that must be addressed with innovative screening methods to supplement traditional approaches. Home-based screening with self-collected urine or vaginal specimens is a highly feasible and acceptable method, and shows promise in improving STI screening rates in both men and women. Home collection kits have been offered in a variety of settings, with results ranging from very modest improvements in screening rates to 100-fold increases beyond the rates observed with clinic-based screening. This article describes and evaluates the effectiveness and limitations of various home screening strategies used for the detection of STIs.

Longitudinal examination of alcohol use: a predictor of risky sexual behavior and Trichomonas vaginalis among African-American female adolescents

BACKGROUND

Alcohol use has been linked to risky sexual practices among adolescents. However, limited research on alcohol use and risky sexual behavior has been conducted on African-American female adolescents. This study examined high quantity of alcohol as a longitudinal predictor of risky sexual behavior and sexually transmitted diseases (STDs) among African-American female adolescents, a high-risk population for STDs.

METHODS

Three hundred ninety-three adolescent females, 15 to 21 years, were assessed on sociodemographics, alcohol use, and risky sexual behaviors. Participants also provided 2 swab specimens that were assayed for STDs. High quantity of alcohol use was defined as ≥ 3 drinks in 1 sitting.

RESULTS

Binary generalized estimating equation models were conducted assessing the impact of alcohol use at baseline on risky sexual behavior and STDs over a 12-month period. Age, intervention group, and baseline outcome measures were entered as covariates. The results indicated that high quantity of alcohol use predicted positive TV test results, inconsistent condom use, high sexual sensation seeking, multiple sexual partners, sex while high on alcohol or drugs, and having anal sex over a 12-month follow-up period.

CONCLUSIONS

These findings suggest that HIV/STD-related behavioral interventions for African-American adolescents should discuss the link between alcohol and HIV/STD-risk behavior. A deeper understanding is paramount to the development of efficacious prevention programs at individual and community levels.

Home compared with clinic-based screening for sexually transmitted infections: a randomized controlled trial

OBJECTIVE

To determine whether home-based screening for sexually transmitted infections results in a higher sexually transmitted infection screening rate compared with clinic-based screening in participants using long-acting reversible contraception.

METHODS

We performed a randomized clinical trial of women using long-acting reversible contraception methods in the Contraceptive CHOICE Project (n=558). Participants were randomly assigned to home-based testing (swabs mailed to the participant's home) or clinic-based testing. Self-collected vaginal swabs were tested for Chlamydia trachomatis and Neisseria gonorrhoeae using strand displacement analysis. We estimated the relative risk (RR) of screening by group using Poisson regression with robust error variance.

RESULTS

The randomization groups were similar at baseline, except for marital status; the clinic group had more never-married women (62.0% compared with 51.6%), and the home group had more divorced women (12.1% compared with 5.6%, P=.007). Women in the home group were more likely to self-report screening compared with women in the clinic group in the multivariable analysis (56.3% compared with 32.9%; RR 1.7; 95% confidence interval [CI] 1.4-2.0). When analyzed by tests received or documented in medical records, similar results were obtained (56.3% compared with 25.0%; RR 2.2; 95% CI 1.7-2.7). Women who completed screening had higher levels of education and were more likely to receive public assistance compared with those who did not complete screening.

CONCLUSION

Long-acting reversible contraception users randomized to sexually transmitted infection screening at home were more likely to complete screening than those randomized to traditional clinic-based screening. Home-based screening may be useful in women using long-acting reversible contraceptive methods who may not present for regular screening.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.gov, NCT01184157.

Home screening compared with clinic-based screening for sexually transmitted infections

OBJECTIVE

To estimate completion rate and acceptability of home screening for sexually transmitted infections (STIs) compared with clinic-based screening in a prospective cohort study.

METHODS

The first 462 women enrolled in the Contraceptive Choice Project were screened at the 12-month follow-up for Chlamydia trachomatis and Neisseria gonorrhoeae using strand displacement analysis of self-collected vaginal swabs. In a telephone interview, participants were given a choice of no-cost screening with swabs mailed to the participant's home (home-based) or screening that was available at area family planning clinics without an appointment (clinic-based). The clinic-based group also included women who elected to screen with their regular provider according to the clinician's normal practice. We analyzed the rates of screening, including patient preference and the proportion of completed tests by testing method.

RESULTS

Women were more likely to choose to screen for STIs at home than at a clinic or with their own medical provider (75.7% compared with 16.1% compared with 8.2%, P<.001). Women choosing clinic testing were more likely to be African American than those choosing home testing. African-American women constituted 42% of the clinic group compared with 28% of the home group (relative risk [RR] 1.63, 95% confidence interval [CI] 1.14-2.31). The groups did not differ in other demographic characteristics, STI risk factors, or access to health care. Overall, 228 women (56.6%) completed screening. Women who chose home-based testing were more likely to complete a test compared with all clinic-based testers (64.6% compared with 31.6%, RR 2.04, 95% CI 1.51-2.76).

CONCLUSION

Women overwhelmingly preferred to screen for STIs at home. Future interventions to increase screening rates in young women should consider alternative screening strategies such as home-based or patient-controlled testing.

LEVEL OF EVIDENCE

II.

Relative efficiency of chlamydia screening in non-clinical settings in two California counties

We examined the relative efficiency of non-clinical sites to screen for chlamydia in youth and young adults. Chlamydia screening targeting youth (under 30 years of age) was performed at non-clinical sites in high-morbidity neighbourhoods of two California counties. Venues were subdivided into community outreach, schools, parenting centres and drug treatment/correctional facilities. Relative efficiency was estimated with multivariate Poisson regression using incidence of chlamydia per person-hours labour adjusting for strategy and county. Among the 1514 youths screened, the overall prevalence of chlamydia was 5.5%. By venue, the highest prevalence was in drug treatment/correction facilities at 11.1% followed by parenting centres at 6.3%, community outreach at 4.9% and schools at 4.6%. Drug treatment/correctional facilities were the most labour time efficient at 9.9 person-hours per chlamydia case. Schools and parenting centres had the lowest cost per screen at 0.9 person-hours per screen. Adjusted relative labour time efficiency (chlamydia cases per paid person-hour) was significantly higher in schools, 2.0 (95% confidence interval [CI] 1.0-4.2), parenting centres, 3.2 (95% CI 1.6-6.6) and drug treatment/correctional facilities, 2.9 (95% CI 1.0-7.8), compared with community outreach. In conclusion, parenting centres and drug treatment centres and correctional facilities are the most efficient venues for chlamydia screening.

Providing sexually transmitted disease education and risk assessment to disengaged young men through community outreach

This study describes a community outreach project designed to increase access to reproductive health services to young African American men living in low-income urban neighborhoods. The project examined the effectiveness of providing community-based outreach and health education on increasing sexually transmitted disease (STD) screening. Outreach workers provided STD education and risk assessment in community settings, including street corners, parks, schools, and community centers. Data were recorded on outreach contacts, including client demographics, health education topics covered, and risk assessment results. Outreach workers conducted 9,701 contacts in a 176-week period. Most contacts (89%) were with African Americans, and most (84%) were with young men between 15 and 20 years old. Outreach workers discussed each health education item in their protocol at least 85% of the time and each risk assessment item at least 90% of the time. The majority of contacts (94%) reported being sexually active. Compared with the year prior to the project, actual STD testing of the target population doubled at the project clinics. This study suggests that going beyond traditional clinic-based testing to reach young, disenfranchised males constitutes a promising approach to reducing racial disparities in STD infections.

Determining risk markers for gonorrhea and chlamydial infection and reinfection among adolescents in public high schools

BACKGROUND

In response to high adolescent rates of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC), Philadelphia began screening in all public high schools in 2003.

METHODS

Data from 14,862 students who tested more than once in the Philadelphia High School STD Screening Program (PHSSSP) during the 2002-2006 school years were analyzed for factors associated with CT and GC infection. Multivariable Cox proportional hazards models and logistic regression models were constructed to identify characteristics associated with measured STD rates. A secondary analysis assessed short-term reinfection rates among participants retesting within the same school year.

RESULTS

In the primary analysis, over multiple years, the unadjusted female CT/GC rate was more than double that in males (6.0 vs. 2.4 cases per 100 person-years, respectively). Among students with a baseline positive, males had a higher rate than females (19.9 vs. 17.7 cases per 100 person-years, respectively). Among students with a positive test result, 13.6% were reinfected within the same school year. Females with named partners not treated had a higher reinfection rate than all others (85.5 vs. 40.1-45.2 cases per 100 person-years, respectively).

CONCLUSIONS

Clinicians and screening programs that offer STD testing to urban high school students, regardless of gender, should encourage those with a prior STD history to test more frequently. Clinicians should work with infected patients, especially females, to ensure their partners are treated.

Screening for Chlamydia trachomatis and Neisseria gonorrhoeae among adolescents in Family Court, Philadelphia, Pennsylvania

OBJECTIVES

To evaluate the use of the Family Court System as a venue for screening adolescents, especially males for sexually transmitted diseases (STD).

GOAL

To identify, treat, and describe the prevalence of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) infections among adolescents on probation under the jurisdiction of the Family Court System of Philadelphia from April 2004 through December 2006.

STUDY DESIGN

We analyzed data from the first several years of this program, which offered education and voluntary noninvasive screening for CT and GC to adolescents adjudicated delinquent and placed on probation through the Family Court of Philadelphia.

RESULTS

Between April 1, 2004 and December 31, 2006, 2270 adolescents were counseled about STDs, of whom 1605 voluntarily submitted a urine specimen for STD testing. Among the 1594 unique individuals with a valid test result, 13.9% (44 of 317) of females, 7.0% (90 of 1277) of males, and 8.4% overall (134 of 1594) were found to be positive for either or both STD. In total, treatment was confirmed for 93.3% (84/90) of males and 100% (44/44) of females testing positive.

CONCLUSIONS

Noninvasive STD testing was well accepted by adolescents in the Family Court System. Over several years of study, infection rates were found to be persistently high in both males and females. The Family Court is an effective venue to identify and treat adolescent males and females with chlamydia and/or gonorrhea infection.

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.

Sexually transmitted infection among adolescents receiving special education services

BACKGROUND

To estimate the relative risk of sexually transmitted infections (STIs) among children identified as having learning disabilities through the special education system.

METHODS

This cross-sectional study used special education data and Medicaid data from Philadelphia, Pennsylvania, for calendar year 2002. The sample comprised 51,234 Medicaid-eligible children, aged 12-17 years, 8015 of whom were receiving special education services. Claims associated with diagnoses of STIs were abstracted, and logistic regression was used to estimate the odds of STI among children in different special education categories.

RESULTS

There were 3% of males and 5% of females who were treated for an STI through the Medicaid system in 2002. Among females, those in the mental retardation (MR) category were at greatest risk (6.9%) and those in the emotionally disturbed or "no special education" category at lowest risk (4.9% each). Among males, STIs were most prevalent among those classified as mentally gifted (6.7%) and lowest among those in the MR category (3.0%). In adjusted analyses, males with specific learning disabilities and females with MR or who were academically gifted were at excess risk for STIs.

CONCLUSIONS

The finding that children with learning disabilities are at similar or greater risk for contracting STIs as other youth suggests the need to further understand their risk behaviors and the potential need to develop prevention programs specific to their learning needs.

Prevalence of Chlamydia trachomatis and associated risk factors in women inmates admitted to a youth offenders institute in the UK

The aim of the study was to estimate the prevalence of Chlamydia trachomatis genital infections in young women inmates aged 17-21 located on the Youth Offenders Institute of HMP Holloway. The study consisted of a questionnaire and a urine sample for analysis. A health advisor administered a questionnaire to establish sociodemographic profile, sexual history and illicit drug use. C. trachomatis was diagnosed using a nucleic acid amplification test. Overall, the prevalence of C. trachomatis was 13.2%. Drug use was common with 41.2% using crack cocaine and 17.3% using intravenous heroin. A majority (80.2%) reported not using condoms during the last sexual encounter and 62.6% had a history of a previous pregnancy. Over half (53.3%) had a previous sexually transmitted infection (STI) screening and 74.7% had never been previously diagnosed with a STI. Sexual health programmes in prisons should include screening as well as education about STI risk reduction and drug prevention.

Chlamydia trachomatis reinfection rates among female adolescents seeking rescreening in school-based health centers

BACKGROUND

Chlamydia trachomatis (CT) infections are common among adolescents attending high and middle schools. The study objective was to determine the reinfection rates of CT for females attending school-based health centers.

METHODS

Adolescents attending school-based health centers who reported they were sexually active were screened for CT using nucleic acid amplification tests on cervical or urine samples. Between 1996 and 2003, 10,609 female students were tested. The overall annual prevalence for unduplicated students in a calendar year ranged from 15.1% to 19.5%. Reinfection was defined as a positive test result occurring between 30 and 365 days after an initial positive result.

RESULTS

There were 897 female students who tested positive for CT and returned for at least 1 subsequent test between 30 and 365 days later. Of these, 236 had 1 or more subsequent positive tests for a cumulative incidence of reinfection in 1 year of 26.3% (95% confidence interval = 23.4-29.2%). Young age at first infection was significantly associated with increased risk of subsequent infection (P <0.01). Across sites, the cumulative incidence of reinfection in these female students ranged from 14.3% to 38.9%.

CONCLUSIONS

The chlamydia cumulative incidence of reinfection in these female adolescents attending high and middle schools was high and supports the Centers for Disease Control and Prevention recommendation to screen adolescents frequently, especially those with a history of a previous chlamydia infection.

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.

Prevalence of Chlamydia in young men in the United States from newly implemented universal screening in a national job training program

OBJECTIVE

The objective of this study was to examine chlamydia prevalence and its risk factors from the first universal screening in socioeconomically disadvantaged young men.

GOAL

The goal of this study was to evaluate the need for universal screening in young men.

STUDY DESIGN

We calculated chlamydia prevalence by demographic and geographic characteristics from 51,478 men aged 16 to 24 years who were screened from July 2003 to December 2004.

RESULTS

Overall, chlamydia prevalence was 8.2%. Only 2.4% of the young men had sexually transmitted disease symptoms. Blacks had the highest prevalence (13.0%), whereas non-Hispanic whites had the lowest (3.1%). Men who smoked marijuana had a significantly higher prevalence compared with those who did not (11.9% vs. 6.4%). Men who used cocaine or PCP also had a significantly higher chlamydia prevalence compared with those who did not. Men who lived in the southern region of the United States had the highest prevalence.

CONCLUSIONS

Chlamydial infection is highly prevalent among socioeconomically disadvantaged young men. Young men entering the National Job Training Program represent an important population for screening.

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 incarcerated adolescents

PURPOSE OF REVIEW

The objectives of this review are to summarize recent developments in the epidemiology of sexually transmitted disease in incarcerated adolescents and to review screening and treatment recommendations for sexually transmitted disease in juvenile corrections facilities.

RECENT FINDINGS

The introduction of non-invasive, urine-based nucleic acid-amplification tests for chlamydia and gonorrhea has led to a dramatic increase in the ability to screen for chlamydia and gonorrhea in non-traditional settings, including corrections facilities. The prevalence of chlamydia and gonorrhea has been uniformly high in incarcerated adolescents. The prevalences of chlamydia and gonorrhea in adolescents aged 18-19 years incarcerated in adult corrections facilities were higher than those incarcerated in juvenile facilities. The prevalence was higher in incarcerated adolescent women than adolescent men and in black adolescents than non-black adolescents. Screening for chlamydia in incarcerated adolescents has been shown to be a cost-effective strategy for preventing adverse health consequences. Syphilis prevalence in incarcerated adolescents is relatively low. Hepatitis B is relatively common among incarcerated adolescents.

SUMMARY

The high prevalence of chlamydia in incarcerated adolescents and gonorrhea in incarcerated adolescent women suggests that screening of these populations should be a priority. The reasons for the higher prevalence of chlamydia and gonorrhea in young adults aged 18-19 years incarcerated in selected adult corrections facilities compared with those incarcerated in juvenile facilities should be investigated. Hepatitis B virus vaccination in juvenile correction facilities is recommended to prevent and control the transmission of this disease.

Chlamydial Infections Among Female Adolescents Screened in Juvenile Detention Centers in Washington State, 1998???2002

OBJECTIVE

The objective of this study was to assess trends in Chlamydia trachomatis positivity and associated risk factors among detained female adolescents.

GOAL

The goal of this study was to determine trends in prevalence of chlamydia among detained female adolescents.

STUDY DESIGN

We retrospectively reviewed risk factor data and chlamydia results collected by providers during 1998-2002 at four large juvenile detention centers in Washington State that routinely screen female adolescents for C. trachomatis.

RESULTS

Of 3,593 tests, a total of 493 (13.7%) were positive for chlamydia. High chlamydia positivity was sustained throughout the 5-year period (range, 12.5-15.0%) with no statistically significant trends in positivity. Independent risk factors for chlamydial infection included report of more than one sex partner in the previous 60 days (adjusted odds ratio [OR] = 1.56, 95% confidence interval [CI] = 1.19-2.04) and previous chlamydial infection within 12 months (adjusted OR = 1.87, 95% CI = 1.45-2.40).

CONCLUSIONS

Efforts are needed to promote chlamydia screening programs in juvenile detention centers because these sites have access to high-risk sexually active female adolescents.

Chlamydia trachomatis Testing Patterns and Prevalence of Genital Chlamydial Infection Among Young Men and Women in Central Norway 1990–2003: A Population-Based Registry Study

OBJECTIVE

The study objective was to investigate Chlamydia trachomatis (CT) testing patterns, prevalence, and incidence among men and women in Sør-Trøndelag county, central Norway, 1990-2003.

GOAL

The goal of this study was to obtain data for recommendations regarding CT screening.

STUDY DESIGN

Laboratory data on CT tests for persons 15 to 24 years old were retrieved and analyzed.

RESULTS

Four percent of men and 44% of women had been CT tested at least once by the age of 20. By the age of 25, 44% of men and 84% of women had been tested. Prevalence at first test was at its peak in 2000-2002 (men: 15-19 years 18%, 20-24 years 23%; women: 15-19 years 11%, 20-24 years 9%). Incidence estimates were higher for persons with a positive first test than for persons with a negative first test.

CONCLUSIONS

More men and more female teenagers need to be tested. Repeat testing is particularly important among people who have been diagnosed with CT.

Diagnostic Tests for Chlamydial and Gonorrheal Infections

Chlamydia trachomatis and Neisseria gonorrhoeae are the two most prevalent bacterial sexually transmitted infections reported in the United States. The purpose of this article is to review the various tests available for diagnosing C. trachomatis and N. gonorrhoeae. The nucleic acid amplification tests are preferred owing to their high sensitivity and specificity and use on specimens obtained noninvasively. Non-amplified non-culture tests, such as the DNA probe test, remain a choice for settings in which nucleic acid amplification tests are not available or affordable. Culture is recommended for use on conjunctival, oropharyngeal, and rectal specimens and in cases of suspected abuse. In addition, for gonorrhea, culture is recommended when screening in populations with a low prevalence of infection. Point-of-care tests are limited by low sensitivity and should be used for only populations unlikely to return for follow-up.

Innovative Approaches to the Prevention and Control of Bacterial Sexually Transmitted Infections

Bacterial STI continues to be a major problem in developed nations. Research and evolving standards of public health practice are cause for optimism and concern. Innovations in case-finding and treatment, particularly the application of NAATs to test for chlamydial infection in nonclinical settings, are successes that merit more widespread application. EPT, selective STI screening in men, and rescreening are all promising, but are not yet in widespread use and may face significant operational barriers. To date, public health efforts to alter sexual behavior, at least through specific interventions, are more discouraging. Although some behavioral interventions have been effective, none has been widely instituted. Moreover, the likelihood that existing behavioral interventions will be widely applied seems remote. Future research efforts in this area will need to focus less on proof-of-concept efficacy trials and more on developing and testing sustainable, cost-effective interventions that focus on those at greatest risk and that can be scaled-up within the existing public health infrastructure.