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Bole M, Khosropour CM, Glick SN, Barbee LA, Golden MR, Dhanireddy S, Dombrowski JC. Characterization of Patients Seeking Care at a Sexual Health Clinic Who Report Engaging in Exchange Sex. Sex Transm Dis 2022; 49:719-725. [PMID: 35797525 PMCID: PMC9481692 DOI: 10.1097/olq.0000000000001666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 06/23/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND People who exchange sex (PWES) for money or drugs are at increased risk for poor health outcomes and may be reluctant to engage in health services. METHODS We conducted a cross-sectional analysis of patients seen for new problem visits at the Public Health-Seattle and King County Sexual Health Clinic between October 2010 and March 2020 who reported exchanging sex for drugs or money in a computer assisted self-interview. We analyzed demographics; sexually transmitted infections (STIs), human immunodeficiency virus (HIV), and hepatitis C virus (HCV) history; and HIV preexposure prophylaxis (PrEP) use, stratified by gender. We compared characteristics of people who ever versus never exchanged sex using χ 2 tests and analyzed the visit reason and outcomes among PWES. RESULTS Among 30,327 patients, 1611 (5%) reported ever exchanging sex: 981 (61%) cisgender men, 545 (34%) cisgender women, and 85 (5%) transgender and gender diverse persons. Compared with people who never exchanged sex, PWES were more likely to report homelessness (29% vs 7%, P < 0.001), injection drug use (39% vs 4%, P < 0.001), prior STIs (36% vs 19%, P < 0.001), prior HIV diagnosis (13% vs 5%, P < 0.001), and prior HCV diagnosis (13% vs 2%, P < 0.001). People who exchange sex came to the clinic seeking STI tests (60%), HIV tests (45%), and care for STI symptoms (38%). Overall, 320 (20%) PWES were diagnosed with STIs, 15 (1%) were newly diagnosed with HIV, and 12 (1%) initiated PrEP at the visit. CONCLUSION People who exchange sex have complex barriers to care, and sexual health clinic visits present an opportunity to improve health services for this population.
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Affiliation(s)
| | | | - Sara N. Glick
- From the Departments of Medicine
- Public Health—Seattle and King County HIV/STD Program, Seattle, WA
| | - Lindley A. Barbee
- From the Departments of Medicine
- Public Health—Seattle and King County HIV/STD Program, Seattle, WA
| | - Matthew R. Golden
- From the Departments of Medicine
- Epidemiology, University of Washington
- Public Health—Seattle and King County HIV/STD Program, Seattle, WA
| | | | - Julia C. Dombrowski
- From the Departments of Medicine
- Epidemiology, University of Washington
- Public Health—Seattle and King County HIV/STD Program, Seattle, WA
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Ramchandani MS, Berzkalns A, Cannon CA, Dombrowski JC, Ocbamichael N, Khosropour CM, Barbee LA, Golden MR. A Demedicalized Model to Provide PrEP in a Sexual Health Clinic. J Acquir Immune Defic Syndr 2022; 90:530-537. [PMID: 35499503 PMCID: PMC9283215 DOI: 10.1097/qai.0000000000003005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 04/25/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Sexual health clinics (SHCs) serve large numbers of patients who might benefit from preexposure prophylaxis (PrEP). Integrating longitudinal PrEP care into SHCs can overburden clinics. We implemented an SHC PrEP program that task shifted most PrEP operations to nonmedical staff, disease intervention specialists (DIS). METHODS We conducted a retrospective cohort analysis of PrEP patients in an SHC in Seattle, WA, from 2014 to 2020 to assess the number of patients served and factors associated with PrEP discontinuation. Clinicians provide same-day PrEP prescriptions, whereas DIS coordinate the program, act as navigators, and provide most follow-up care. RESULTS Between 2014 and 2019, 1387 patients attended an initial PrEP visit, 93% of whom were men who have sex with men. The number of patients initiating PrEP per quarter year increased from 20 to 81. The number of PrEP starts doubled when the clinic shifted from PrEP initiation at scheduled visits to initiation integrated into routine walk-in visits. The percentage of visits performed by DIS increased from 3% in 2014 to 45% in 2019. Median duration on PrEP use was 11 months. PrEP discontinuation was associated with non-Hispanic black race/ethnicity [hazard ratio (HR) 1.34, 95% confidence interval (CI) 1.02 to 1.76], age <20 years (HR 2.17, 95% CI: 1.26 to 3.75), age between 20 and 29 years (HR 1.55, 95% CI: 1.06 to 2.28), and methamphetamine use (HR 1.98, 95% CI: 1.57 to 2.49). The clinic had 750 patients on PrEP in the final quarter of 2019. CONCLUSIONS A demedicalized SHC PrEP model that task shifts most operations to DIS can provide PrEP at scale to high priority populations.
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Affiliation(s)
- Meena S Ramchandani
- Department of Medicine, University of Washington, Seattle, WA
- HIV/STD Program, Public Health-Seattle & King County, Seattle, WA; and
| | - Anna Berzkalns
- HIV/STD Program, Public Health-Seattle & King County, Seattle, WA; and
| | - Chase A Cannon
- Department of Medicine, University of Washington, Seattle, WA
| | - Julia C Dombrowski
- Department of Medicine, University of Washington, Seattle, WA
- HIV/STD Program, Public Health-Seattle & King County, Seattle, WA; and
- Department of Epidemiology, University of Washington, Seattle, WA
| | | | | | - Lindley A Barbee
- Department of Medicine, University of Washington, Seattle, WA
- HIV/STD Program, Public Health-Seattle & King County, Seattle, WA; and
| | - Matthew R Golden
- Department of Medicine, University of Washington, Seattle, WA
- HIV/STD Program, Public Health-Seattle & King County, Seattle, WA; and
- Department of Epidemiology, University of Washington, Seattle, WA
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Tordoff DM, Barbee LA, Khosropour CM, Hughes JP, Golden MR. Derivation and Validation of an HIV Risk Prediction Score Among Gay, Bisexual, and Other Men Who Have Sex With Men to Inform PrEP Initiation in an STD Clinic Setting. J Acquir Immune Defic Syndr 2021; 85:263-271. [PMID: 32658131 DOI: 10.1097/qai.0000000000002438] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Clinicians and health departments would ideally undertake targeted efforts to promote HIV pre-exposure prophylaxis (PrEP) and frequent HIV testing using data-based criteria to identify populations at elevated risk for HIV. We developed an HIV risk prediction score for men who have sex with men (MSM) to identify individuals at substantial risk for HIV acquisition. METHODS We created a retrospective cohort of MSM who tested HIV-negative at the sexually transmitted disease clinic in Seattle, WA, from 2001 to 2015, and identified seroconversions using HIV surveillance data. We split the cohort randomly 2:1 into derivation and validation data sets, and used Cox proportional hazards to estimate the hazard of acquiring HIV associated with behavioral and clinical predictors, and the Akaike information criterion to determine which variables to retain in our model. RESULTS Among 16,448 MSM, 640 seroconverted over a 14.3-year follow-up period. The best prediction model included 13 variables and had an area under the receiver operating characteristic curve of 0.73 (95% confidence interval: 0.71 to 0.76), 76% sensitivity, and 63% specificity at a score cutoff ≥11. A simplified model restricted to 2011-2015 included 4 predictors [methamphetamine use, condomless receptive anal intercourse (CRAI), ≥10 partners, and current diagnosis or self-reported gonorrhea/syphilis in the past year]. This model, the Seattle PrEP Score, had an area under the receiver operating characteristic curve of 0.69 (95% confidence interval: 0.64 to 0.73), 62% sensitivity, and 70% specificity. One-year incidence was 0.5% for a score of 0, 0.7% for a score of 1, and 2.1% for scores ≥2. CONCLUSIONS The Seattle PrEP Score was predictive of HIV acquisition and could help clinicians and public health agencies identify MSM who could benefit from PrEP and frequent HIV testing.
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Affiliation(s)
| | - Lindley A Barbee
- Medicine, University of Washington, Seattle, WA.,Public Health-Seattle & King County HIV/STD Program, Seattle, WA; and
| | - Christine M Khosropour
- Departments of Epidemiology.,Public Health-Seattle & King County HIV/STD Program, Seattle, WA; and
| | - James P Hughes
- Department of Biostatistics, University of Washington, Seattle, WA
| | - Matthew R Golden
- Departments of Epidemiology.,Medicine, University of Washington, Seattle, WA.,Public Health-Seattle & King County HIV/STD Program, Seattle, WA; and
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Siegler AJ, Mehta CC, Mouhanna F, Giler RM, Castel A, Pembleton E, Jaggi C, Jones J, Kramer MR, McGuinness P, McCallister S, Sullivan PS. Policy- and county-level associations with HIV pre-exposure prophylaxis use, the United States, 2018. Ann Epidemiol 2020; 45:24-31.e3. [PMID: 32336655 DOI: 10.1016/j.annepidem.2020.03.013] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 03/18/2020] [Accepted: 03/27/2020] [Indexed: 12/15/2022]
Abstract
PURPOSE HIV pre-exposure prophylaxis (PrEP) is highly efficacious, and yet most individuals indicated for it are not currently using it. To provide guidance for health policymakers, researchers, and community advocates, we developed county-level PrEP use estimates and assessed locality and policy associations. METHODS Using data from a national aggregator, we applied a validated crosswalk procedure to generate county-level estimates of PrEP users in 2018. A multilevel Poisson regression explored associations between PrEP use and (1) state policy variables of Medicaid expansion and state Drug Assistance Programs (PrEP-DAPs) and (2) county-level characteristics from the U.S. Census Bureau. Outcomes were PrEP per population (prevalence) and PrEP-to-need ratio (PnR), defined as the ratio of PrEP users per new HIV diagnosis. Higher levels of PrEP prevalence or PnR indicate more PrEP users relative to the total population or estimated need, respectively. RESULTS Our 2018 county-level data set included a total of 188,546 PrEP users in the United States. Nationally, PrEP prevalence was 70.3/100,000 population and PnR was 4.9. In an adjusted model, counties with a 5% higher proportion of black residents had 5% lower PnR (rate ratio (RR): 0.95, 95% confidence interval (CI): 0.93, 0.96). Similarly, counties with higher concentration of residents uninsured or living in poverty had lower PnR. Relative to states without Medicaid expansion or PrEP-DAPs, states with only one of those programs had 25% higher PrEP prevalence (RR: 1.25, 95% CI: 1.09, 1.45), and states with both programs had 99% higher PrEP prevalence (RR: 1.99, 95% CI: 1.60, 2.48). There was a significant linear trend across the three policy groups, and similar findings for the relation between PnR and the policy groups. CONCLUSIONS In a data set comprising approximately 80% of PrEP users in the United States, we found that Medicaid expansion and PrEP-DAPs were associated with higher PrEP use in states that adopted those policies, after controlling for potential confounders. Future research should identify which components of PrEP support programs have the most success and how to best promote PrEP among groups most impacted by the epidemic. States should support the admirable health decisions of their residents to get on PrEP by implementing policies that facilitate access.
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Affiliation(s)
- Aaron J Siegler
- Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, GA.
| | - C Christina Mehta
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Farah Mouhanna
- Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, GA; Department of Epidemiology, Milken Institute School of Public Health, The George Washington University, Washington, DC
| | | | - Amanda Castel
- Department of Epidemiology, Milken Institute School of Public Health, The George Washington University, Washington, DC
| | - Elizabeth Pembleton
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Chandni Jaggi
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Jeb Jones
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Michael R Kramer
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Pema McGuinness
- Department of Epidemiology, Gilead Sciences, Foster City, CA, 94404
| | | | - Patrick S Sullivan
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
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STD Partner Services to Monitor and Promote HIV Pre-exposure Prophylaxis Use Among Men Who Have Sex With Men. J Acquir Immune Defic Syndr 2019; 80:533-541. [PMID: 30649032 DOI: 10.1097/qai.0000000000001952] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Men who have sex with men (MSM) with bacterial sexually transmitted diseases (STDs) are at elevated risk of HIV. We evaluated the integration of pre-exposure prophylaxis (PrEP) referrals into STD partner services (PS) for MSM. SETTING King County, Washington. METHODS Disease Intervention Specialists (DIS) in King County attempt to provide PS to all MSM with early syphilis and, as resources allow, MSM with gonorrhea or chlamydia. Our health department defines MSM with any of the following as at high HIV risk: early syphilis, rectal gonorrhea, methamphetamine/poppers use, sex work, or an HIV-unsuppressed partner. DIS offer high-risk MSM referral to our STD Clinic for PrEP and other MSM referral to community providers. In 2017, we interviewed a random sample of MSM offered referrals in 2016 to assess PrEP initiation after PS. RESULTS From August 2014 to August 2017, 7546 cases of bacterial STDs were reported among HIV-negative MSM. DIS provided PS to 3739 MSM, of whom 2055 (55%) were at high risk. DIS assessed PrEP use in 1840 (90%) of these men, 895 (49%) of whom reported already using PrEP. DIS offered referrals to 693 (73%) of 945 MSM not on PrEP; 372 (54%) accepted. Among 132 interviewed for the random sample, men who accepted referrals at initial interview were more likely to report using PrEP at follow-up (32/68 = 47%) than those who did not (12/64 = 19%) (P = 0.0006). An estimated 10.4% of all interviewed MSM initiated PrEP following PS-based referral. CONCLUSIONS Integrating PrEP referrals into STD PS is an effective population-based strategy to link MSM at high HIV risk to PrEP.
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Patient Disengagement From an HIV Preexposure Prophylaxis Program in a Sexually Transmitted Disease Clinic. Sex Transm Dis 2019; 45:e62-e64. [PMID: 29485544 DOI: 10.1097/olq.0000000000000823] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Among 307 patients enrolled in an HIV preexposure prophylaxis (PrEP) program in the Public Health-Seattle & King County STD Clinic, 52 patients (17%) did not fill their PrEP prescription and 40% of those who started PrEP discontinued it at least once within 12 months.
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Comparison of Algorithms to Triage Patients to Express Care in a Sexually Transmitted Disease Clinic. Sex Transm Dis 2019; 45:696-702. [PMID: 29634599 DOI: 10.1097/olq.0000000000000854] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The ideal approach to triaging sexually transmitted disease (STD) clinic patients between testing-only express visits and standard visits with clinician evaluation is uncertain. METHODS In this cross-sectional study, we used classification and regression tree analysis to develop and validate the optimal algorithm for predicting which patients need a standard visit with clinician assessment (i.e., to maximize correct triage). Using electronic medical record data, we defined patients as needing a standard visit if they reported STD symptoms, received any empiric treatment, or were diagnosed as having an infection or syndrome at the same visit. We considered 11 potential predictors for requiring medical evaluation collected via computer-assisted self-interview when constructing the optimized algorithm. We compared test characteristics of the optimized algorithm, the Public Health-Seattle and King County STD Clinic's current 13-component algorithm, and a simple 2-component algorithm including only presence of symptoms and contact to STD. RESULTS From October 2010 to June 2015, 18,653 unique patients completed a computer-assisted self-interview. In the validation samples, the optimized, current, and simple algorithms appropriately triaged 90%, 85%, and 89% of patients, respectively. The optimized algorithm had lower sensitivity for identifying patients needing standard visits (men, 94%; women, 93%) compared with the current algorithm (men, 95%; women, 98%), as did the simple algorithm (men, 91%; women, 93%). The optimized, current, and simple algorithms triaged 31%, 23%, and 33% of patients to express visits, respectively. CONCLUSIONS The overall performance of the statistically optimized algorithm did not differ meaningfully from a simple 2-component algorithm. In contrast, the current algorithm had the highest sensitivity but lowest overall performance.
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8
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Rietmeijer CA. Improving care for sexually transmitted infections. J Int AIDS Soc 2019; 22 Suppl 6:e25349. [PMID: 31468743 PMCID: PMC6715945 DOI: 10.1002/jia2.25349] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Accepted: 06/21/2019] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Rising rates of reported sexually transmitted infections (STIs) in the US and Europe are a public health priority and require a public health response. The diagnosis and treatment of STIs have been the cornerstone of STI control and prevention for many decades and, historically, publicly funded STI clinics have played a central role in the provision of STI care. Innovations in non-invasive diagnostic techniques, especially nucleic acid amplification tests in the mid-1990s, have facilitated the expansion of STI testing and treatment outside traditional STI clinics, including primary care, family planning, school-based health, outreach, corrections, emergency departments and HIV prevention and care settings. As a result, the continued need for categorical STI clinics has been debated. In this Commentary, we discuss how practice can be improved at each level of STI care. DISCUSSION STI practice improvement plans should be tailored to the strengths of each care setting. Thus, in primary care, the focus should be on improving STI screening rates, the provision of hepatitis B and human papillomavirus vaccines and, in jurisdictions where this is legal, expedited partner therapy for gonorrhoea and chlamydia. Extragenital (pharyngeal and rectal) testing for gonorrhoea and chlamydia should be available in settings serving populations more vulnerable to STI acquisition at these anatomical sites, including men who have sex with men. In family planning settings with a mostly female patient population, there are opportunities to serve male partners with both contraceptive and STI services. STI screening rates can also be improved in other settings serving populations at increased risk for STIs, including school-based clinics, emergency departments, correctional health facilities and providers of HIV care and prevention. These improvements are predominantly logistical in nature and not dependent on extensive STI clinical expertise. While some providers in these settings may have the clinical knowledge and skills to evaluate symptomatic patients, many do not, and STI speciality clinics must be available for consultation and referral and evolve from "safety net" providers of last resort to STI centres of excellence. CONCLUSIONS A tailored practice improvement plan can be envisioned to achieve an optimally functioning STI care continuum.
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Affiliation(s)
- Cornelis A Rietmeijer
- Rietmeijer ConsultingDenverCOUSA
- Colorado School of Public HealthUniversity of ColoradoDenverCOUSA
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9
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Pearson WS, Spicknall IH, Cramer R, Jenkins WD. Medicaid Coverage of Sexually Transmitted Disease Service Visits. Am J Prev Med 2019; 57:51-56. [PMID: 31128954 PMCID: PMC6724212 DOI: 10.1016/j.amepre.2019.02.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 02/14/2019] [Accepted: 02/15/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Chlamydia and gonorrhea are the most commonly reported notifiable infections in the U.S., with direct medical costs for the treatment of these infections exceeding $700 million annually. Medicaid currently covers approximately 80 million low-income Americans, including a high percentage of racial and ethnic minorities. Studies have shown that racial and ethnic minority populations, particularly those with low SES, are at an increased risk of acquiring a sexually transmitted disease. Therefore, as Medicaid expands, there will likely be a greater demand for sexually transmitted disease services in community-based physician offices. To determine demand for these services among Medicaid enrollees, this study examined how often Medicaid was used to pay for sexually transmitted disease services received in this setting. METHODS This study combined 2014 and 2015 data from the National Ambulatory Medical Care Survey and tested for differences in the proportion of visits with an expected payment source of Medicaid when sexually transmitted disease services were and were not provided. All analyses were conducted in October 2018. RESULTS During 2014-2015, an estimated 25 million visits received a sexually transmitted disease service. Medicaid paid for a greater percentage of sexually transmitted disease visits (35.5%, 95% CI=22.5%, 51.1%) compared with non-sexually transmitted disease visits (12.1%, 95% CI=10.8%, 13.6%). Logistic regression modeling, controlling for age, sex, and race of the patient, showed that visits covered by Medicaid had increased odds of paying for a sexually transmitted disease service visit (OR=1.97, 95% CI=1.12, 3.46), compared with other expected payment sources. CONCLUSIONS Focusing sexually transmitted disease prevention in Medicaid populations could reduce sexually transmitted disease incidence and resulting morbidity and costs.
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Affiliation(s)
- William S Pearson
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia.
| | - Ian H Spicknall
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Ryan Cramer
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Wiley D Jenkins
- Department of Population Science and Policy, Southern Illinois University School of Medicine, Springfield, Illinois
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Meyerson BE, Davis A, Reno H, Haderxhanaj LT, Sayegh MA, Simmons MK, Multani G, Naeyaert L, Meador A, Stoner BP. Existence, Distribution, and Characteristics of STD Clinics in the United States, 2017. Public Health Rep 2019; 134:371-378. [PMID: 31112071 PMCID: PMC6598148 DOI: 10.1177/0033354919847733] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Studies of sexually transmitted disease (STD) clinics have been limited by the lack of a national list for representative sampling. We sought to establish the number, type, and distribution of STD clinics and describe selected community characteristics associated with them. METHODS We conducted a 2-phased, multilevel, online search from September 2014 through March 2015 and from May through October 2017 to identify STD clinics in all 50 US states and the District of Columbia. We obtained data on clinic name, address, contact information, and 340B funding status (which requires manufacturers to provide outpatient drugs at reduced prices). We classified clinics by type. We also obtained secondary county-level data to compare rates of chlamydia and HIV, teen births, uninsurance and unemployment, and high school graduation; ratios of primary care physician to population; health care costs; median household income; and percentage of population living in rural areas vs nonrural areas. We used t tests to examine mean differences in characteristics between counties with and without STD clinics. RESULTS We found 4079 STD clinics and classified them into 10 types; 2530 (62.0%) clinics were affiliated with a local health department. Of 3129 counties, 1098 (35.1%) did not have an STD clinic. Twelve states had an STD clinic in every county, and 34 states had ≥1 clinic per 100 000 population. Most STD clinics were located in areas of high chlamydia morbidity and where other surrogate needs were greatest; rural areas were underserved by STD clinics. CONCLUSIONS This list may aid in more comprehensive national studies of clinic services, STD clinic adaptation to external policy changes (eg, in public financing or patient access policy), and long-term clinic survival, with special attention to clinic coverage in rural areas.
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Affiliation(s)
- Beth E. Meyerson
- Department of Applied Health Science, Indiana University School of Public Health–Bloomington, Bloomington, IN, USA
- Rural Center for AIDS/STD Prevention, Indiana University, Bloomington, IN, USA
| | - Alissa Davis
- Columbia University School of Social Work, New York, NY, USA
| | - Hilary Reno
- Division of Infectious Disease, Department of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Laura T. Haderxhanaj
- Department of Applied Health Science, Indiana University School of Public Health–Bloomington, Bloomington, IN, USA
- Rural Center for AIDS/STD Prevention, Indiana University, Bloomington, IN, USA
| | - M. Aaron Sayegh
- Department of Epidemiology and Biostatistics, Indiana University School of Public Health–Bloomington, Bloomington, IN, USA
| | - Megan K. Simmons
- Department of Applied Health Science, Indiana University School of Public Health–Bloomington, Bloomington, IN, USA
- Rural Center for AIDS/STD Prevention, Indiana University, Bloomington, IN, USA
| | - Gurprit Multani
- Department of Applied Health Science, Indiana University School of Public Health–Bloomington, Bloomington, IN, USA
- Rural Center for AIDS/STD Prevention, Indiana University, Bloomington, IN, USA
| | - Lindsey Naeyaert
- Department of Applied Health Science, Indiana University School of Public Health–Bloomington, Bloomington, IN, USA
- Rural Center for AIDS/STD Prevention, Indiana University, Bloomington, IN, USA
| | - Audra Meador
- Department of Applied Health Science, Indiana University School of Public Health–Bloomington, Bloomington, IN, USA
- Rural Center for AIDS/STD Prevention, Indiana University, Bloomington, IN, USA
| | - Bradley P. Stoner
- Departments of Anthropology and Medicine, Washington University in St. Louis, St. Louis, MO, USA
- St. Louis STD/HIV Prevention Training Center, St. Louis, MO, USA
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Rao DW, Carr J, Naismith K, Hood JE, Hughes JP, Morris M, Goodreau SM, Rosenberg ES, Golden MR. Monitoring HIV Preexposure Prophylaxis Use Among Men Who Have Sex With Men in Washington State: Findings From an Internet-Based Survey. Sex Transm Dis 2019; 46:221-228. [PMID: 30870322 PMCID: PMC7687921 DOI: 10.1097/olq.0000000000000965] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Many state and local health departments now promote and support the use of HIV preexposure prophylaxis (PrEP), yet monitoring use of the intervention at the population level remains challenging. METHODS We report the results of an online survey designed to measure PrEP use among men who have sex with men (MSM) in Washington State. Data on the proportion of men with indications for PrEP based on state guidelines and levels of awareness, interest, and use of PrEP are presented for 1080 cisgender male respondents who completed the survey between January 1 and February 28, 2017. We conducted bivariate and multivariable logistic regression to identify factors associated with current PrEP use. To examine patterns of discontinuation, we conducted Cox proportional hazards regression and fit a Kaplan-Meier curve to reported data on time on PrEP. RESULTS Eighty percent of respondents had heard of PrEP, 19% reported current use, and 36% of men who had never used PrEP wanted to start taking it. Among MSM for whom state guidelines recommend PrEP, 31% were taking it. In multivariable analysis, current PrEP use was associated with older age, higher education, and meeting indications for PrEP use. Our data suggest that 20% of PrEP users discontinue within 12 months, and men with lower educational attainment were more likely to discontinue. CONCLUSIONS Despite high levels of use, there is significant unmet need for PrEP in Washington. Our experience indicates that Internet surveys are feasible and informative for monitoring PrEP use in MSM.
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Affiliation(s)
- Darcy White Rao
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Jason Carr
- Infectious Disease Assessment Unit, Disease Control and Health Statistics, Washington State Department of Health, Olympia, Washington, USA
| | - Kelly Naismith
- Infectious Disease Assessment Unit, Disease Control and Health Statistics, Washington State Department of Health, Olympia, Washington, USA
| | - Julia E. Hood
- Public Health – Seattle and King County HIV/STD Program, Seattle, WA, USA
| | - James P. Hughes
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Martina Morris
- Department of Statistics, University of Washington, Seattle, Washington, USA
- Department of Sociology, University of Washington, Seattle, Washington, USA
| | - Steven M. Goodreau
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- Department of Anthropology, University of Washington, Seattle, Washington, USA
| | - Eli S. Rosenberg
- Department of Epidemiology and Biostatistics, University at Albany School of Public Health, State University of New York, Rensselaer, NY
| | - Matthew R. Golden
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- Public Health – Seattle and King County HIV/STD Program, Seattle, WA, USA
- School of Medicine, University of Washington, Seattle, Washington, USA
- Center for AIDS and STD, University of Washington, Seattle, Washington, USA
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12
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Abstract
PURPOSE OF REVIEW Syphilis continues to cause morbidity and mortality worldwide. While syphilis infection is easily identifiable and treatable, rates of syphilis infection continue to increase among select populations in high-income countries and remain at endemic levels in low- and middle-income counties. RECENT FINDINGS World Health Organization recommended strategies have led to the dual elimination of mother-to-child transmission of syphilis and HIV in several countries, however outbreaks among select populations need to be adequately addressed. SUMMARY Continued vigilance and investment is needed to address syphilis worldwide. The epidemiology of syphilis differs in high-income and low- and middle-income counties.
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Affiliation(s)
- Noah Kojima
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, 90095
| | - Jeffrey D Klausner
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, 90095
- Fielding School of Public Health, University of California Los Angeles, Los Angeles, 90024
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13
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Dize L, Barnes P, Barnes M, Hsieh YH, Marsiglia V, Duncan D, Hardick J, Gaydos CA. Performance of self-collected penile-meatal swabs compared to clinician-collected urethral swabs for the detection of Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, and Mycoplasma genitalium by nucleic acid amplification assays. Diagn Microbiol Infect Dis 2016; 86:131-5. [PMID: 27497595 PMCID: PMC5028267 DOI: 10.1016/j.diagmicrobio.2016.07.018] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 06/23/2016] [Accepted: 07/19/2016] [Indexed: 11/28/2022]
Abstract
Men were enrolled in a study to assess the performance and acceptability of self-collected penile meatal swabs as compared to clinician-collected urethral swabs for sexually transmitted infections (STIs). We expected penile-meatal swabs to perform favorably to urethral swabs for Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), Trichomonas vaginalis (TV), and Mycoplasma genitalium (MG) detection by nucleic acid amplification assays (NAATs). Of 203 swab pairs tested; for CT, penile-meatal swab sensitivity was 96.8% and specificity was 98.8%. NG sensitivity and specificity were 100% and 98.9%, respectively. For TV, sensitivity was 85.0% and specificity was 96.7%. For MG sensitivity and specificity were 79.3% and 99.4%, respectively. No significant statistical differences between sample type accuracy (CT: P=0.625; NG: P=0.248; TV: P=0.344; and MG: P=0.070) existed. Most men, 90.1%, reported self-collection of penile-meatal swabs as "Very Easy" or "Easy". Self-collected penile-meatal swabs appeared acceptable for NAAT STI detection and an acceptable collection method by men.
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Affiliation(s)
- Laura Dize
- Johns Hopkins University, Division of Infectious Diseases, Baltimore, MD.
| | - Perry Barnes
- Johns Hopkins University, Division of Infectious Diseases, Baltimore, MD
| | - Mathilda Barnes
- Johns Hopkins University, Division of Infectious Diseases, Baltimore, MD
| | - Yu-Hsiang Hsieh
- Johns Hopkins University, Department of Emergency Medicine, Baltimore, MD
| | | | | | - Justin Hardick
- Johns Hopkins University, Division of Infectious Diseases, Baltimore, MD
| | - Charlotte A Gaydos
- Johns Hopkins University, Division of Infectious Diseases, Baltimore, MD; Johns Hopkins University, Department of Emergency Medicine, Baltimore, MD
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14
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Mehtani NJ, Schumacher CM, Johnsen LE, Khaldun JS, Chaulk CP, Ghanem KG, Jennings JM, Page KR. Continued Importance of Sexually Transmitted Disease Clinics in the Era of the Affordable Care Act. Am J Prev Med 2016; 51:364-7. [PMID: 27242080 PMCID: PMC4992609 DOI: 10.1016/j.amepre.2016.04.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 04/08/2016] [Accepted: 04/08/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Following the 2014 expansions of Medicaid and private health insurance through the Affordable Care Act, municipal sexually transmitted disease (STD) clinics-which have historically served predominantly uninsured patients-have been threatened with budget cuts nationwide. This study was conducted to evaluate the impact of the insurance expansions on the demand for STD clinic services. METHODS The proportion of total incident sexually transmitted infections in Baltimore City that were diagnosed at STD clinics was compared between 2013 and 2014, and a multivariate analysis was conducted to determine factors associated with diagnosis at an STD clinic. Analyses were conducted in July 2015. RESULTS There was no change in the overall proportion of sexually transmitted infection diagnoses made at STD clinics from 2013 to 2014 (relative rate, 1.03; 95% CI=0.95, 1.11). Hispanic ethnicity, black race, male sex, and age >24 years were associated with an increased likelihood of STD clinic utilization (p<0.0001). CONCLUSIONS Despite the Affordable Care Act's insurance expansion measures, the demand for STD clinics remained stable. These safety net clinics serve patients likely to face barriers to accessing traditional health care and their preservation should remain a priority.
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Affiliation(s)
- Nicky J Mehtani
- Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | | | - Luke E Johnsen
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | - Khalil G Ghanem
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jacky M Jennings
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kathleen R Page
- Johns Hopkins University School of Medicine, Baltimore, Maryland
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15
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Hoover KW, Parsell BW, Leichliter JS, Habel MA, Tao G, Pearson WS, Gift TL. Continuing Need for Sexually Transmitted Disease Clinics After the Affordable Care Act. Am J Public Health 2015; 105 Suppl 5:S690-5. [PMID: 26447908 DOI: 10.2105/ajph.2015.302839] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We assessed the characteristics of sexually transmitted disease (STD) clinic patients, their reasons for seeking health services in STD clinics, and their access to health care in other venues. METHODS In 2013, we surveyed persons who used publicly funded STD clinics in 21 US cities with the highest STD morbidity. RESULTS Of the 4364 STD clinic patients we surveyed, 58.5% were younger than 30 years, 72.5% were non-White, and 49.9% were uninsured. They visited the clinic for STD symptoms (18.9%), STD screening (33.8%), and HIV testing (13.6%). Patients chose STD clinics because of walk-in, same-day appointments (49.5%), low cost (23.9%), and expert care (8.3%). Among STD clinic patients, 60.4% had access to another type of venue for sick care, and 58.5% had access to another type of venue for preventive care. Most insured patients (51.6%) were willing to use insurance to pay for care at the STD clinic. CONCLUSIONS Despite access to other health care settings, patients chose STD clinics for sexual health care because of convenient, low-cost, and expert care. Policy Implication. STD clinics play an important role in STD prevention by offering walk-in care to uninsured patients.
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Affiliation(s)
- Karen W Hoover
- Karen W. Hoover, Jami S. Leichliter, Melissa A. Habel, Guoyu Tao, William S. Pearson, and Thomas L. Gift are with the Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Bradley W. Parsell is with the National Opinion Research Center, Chicago, IL
| | - Bradley W Parsell
- Karen W. Hoover, Jami S. Leichliter, Melissa A. Habel, Guoyu Tao, William S. Pearson, and Thomas L. Gift are with the Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Bradley W. Parsell is with the National Opinion Research Center, Chicago, IL
| | - Jami S Leichliter
- Karen W. Hoover, Jami S. Leichliter, Melissa A. Habel, Guoyu Tao, William S. Pearson, and Thomas L. Gift are with the Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Bradley W. Parsell is with the National Opinion Research Center, Chicago, IL
| | - Melissa A Habel
- Karen W. Hoover, Jami S. Leichliter, Melissa A. Habel, Guoyu Tao, William S. Pearson, and Thomas L. Gift are with the Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Bradley W. Parsell is with the National Opinion Research Center, Chicago, IL
| | - Guoyu Tao
- Karen W. Hoover, Jami S. Leichliter, Melissa A. Habel, Guoyu Tao, William S. Pearson, and Thomas L. Gift are with the Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Bradley W. Parsell is with the National Opinion Research Center, Chicago, IL
| | - William S Pearson
- Karen W. Hoover, Jami S. Leichliter, Melissa A. Habel, Guoyu Tao, William S. Pearson, and Thomas L. Gift are with the Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Bradley W. Parsell is with the National Opinion Research Center, Chicago, IL
| | - Thomas L Gift
- Karen W. Hoover, Jami S. Leichliter, Melissa A. Habel, Guoyu Tao, William S. Pearson, and Thomas L. Gift are with the Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Bradley W. Parsell is with the National Opinion Research Center, Chicago, IL
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16
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Evaluation of pooled ocular and vaginal swabs by the Cepheid GeneXpert CT/NG assay for the detection of Chlamydia trachomatis and Neisseria gonorrhoeae compared to the GenProbe Aptima Combo 2 Assay. Diagn Microbiol Infect Dis 2014; 81:102-4. [PMID: 25497459 DOI: 10.1016/j.diagmicrobio.2014.11.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Revised: 11/19/2014] [Accepted: 11/20/2014] [Indexed: 11/20/2022]
Abstract
Ocular swabs from Tanzania were tested for Chlamydia trachomatis (CT), and self-collected vaginal swabs collected through a home collection program, iwantthekit.org, were tested for Neisseria gonorrhoeae and CT to evaluate Cepheid GeneXpert for the use of pooling multiple specimens before testing. GeneXpert shows to be a promising test for pooling.
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17
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Fairley CK, Hocking JS. Sexual health in Indigenous communities. Med J Aust 2012; 197:597-8. [DOI: 10.5694/mja12.11448] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2012] [Accepted: 10/23/2012] [Indexed: 11/17/2022]
Affiliation(s)
| | - Jane S Hocking
- School of Population Health, University of Melbourne, Melbourne, VIC
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18
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Eugene JM, Hoover KW, Tao G, Kent CK. Higher yet suboptimal chlamydia testing rates at community health centers and outpatient clinics compared with physician offices. Am J Public Health 2012; 102:e26-9. [PMID: 22698048 DOI: 10.2105/ajph.2012.300744] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
To assess chlamydia testing in women in community health centers, we analyzed data from national surveys of ambulatory health care. Women with chlamydial symptoms were tested at 16% of visits, and 65% of symptomatic women were tested if another reproductive health care service (pelvic examination, Papanicolaou test, or urinalysis) was performed. Community health centers serve populations with high sexually transmitted disease rates and fill gaps in the provision of sexual and reproductive health care services as health departments face budget cuts that threaten support of sexually transmitted disease clinics.
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Affiliation(s)
- Jeffrey M Eugene
- Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention (CDC), Atlanta, GA 30333, USA
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