Screening Male Prisoners for Chlamydia trachomatis: Impact on Test Positivity Among Women From Their Neighborhoods Who Were Tested in Family Planning Clinics

HIV, Sexually Transmitted Infection, and Substance Use Continuum of Care Interventions Among Criminal Justice-Involved Black Men Who Have Sex With Men: A Systematic Review

BACKGROUND

Because Black men who have sex with men (BMSM) experience high rates of both HIV and incarceration relative to other groups, the various stages of criminal justice involvement may serve as important intervention points for addressing HIV and related conditions in this group. Although systematic reviews of HIV interventions targeting MSM in general and BMSM in particular exist, no review has explored the range and impact of HIV, sexually transmitted infection (STI), and substance use prevention and care continuum interventions focused on criminal justice-involved (CJI) populations.

OBJECTIVES

To describe the range and impact of published HIV, STI, and related substance use interventions for US-based CJI populations and to understand their relevance for BMSM.

SEARCH METHODS

We conducted systematic searches in the following databases: PubMed, MEDLINE, Cochrane, CINAHL, and PsycINFO, covering the period preceding December 1, 2016.

SELECTION CRITERIA

We selected articles in scientific publications involving quantitative findings for studies of US-based interventions that focused on CJI individuals, with outcomes related to sexual or substance use risk behaviors, HIV, or STIs. We excluded studies if they provided no demographic information, had minimal representation of the population of interest (< 30 African American or Black male or transgender participants), had study populations limited to those aged younger than 18 years, or were limited to evaluations of preexisting programs.

DATA COLLECTION AND ANALYSIS

We abstracted data from these articles on study design; years covered; study location; participant number, demographics, and sexual orientation (if available); criminal justice setting or type; health condition; targeted outcomes; and key findings. We scored studies by using the Downs and Black quality and bias assessment. We conducted linear regression to examine changes in study quality by publication year.

MAIN RESULTS

Fifty-eight articles met inclusion criteria, including 8 (13.8%) modeling or cost-effectiveness studies and 13 (22.4%) randomized controlled trials. Just 3 studies (5.2%) focused on sexual or gender minorities, with only 1 focused on BMSM. In most studies (n = 36; 62.1%), however, more than 50% of participants were Black. The most common intervention addressed screening, including 20 empirical studies and 7 modeling studies. Education-focused interventions were also common (n = 15) and usually employed didactic rather than skill-building approaches. They were more likely to demonstrate increases in HIV testing, knowledge, and condom-use intentions than reductions in sex- and drug-risk behaviors. Screening programs consistently indicated cost-effectiveness, including with BMSM. Care continuum interventions for people living with HIV showed mixed results; just 3 involved randomized controlled trials, and these interventions did not show significant differences compared with control conditions. A minority of programs targeted non-custody-based CJI populations, despite their constituting a majority of the CJI population at any given time.

AUTHORS' CONCLUSIONS

Screening CJI populations for HIV and other STIs is effective and cost-efficient and holds promise for reducing HIV in BMSM. Education-based and care provision interventions also hold promise for addressing HIV, STIs, mental health, and substance use in CJI populations. Additional empirical and modeling studies and results specific to sexual minorities are needed; their paucity represents a disparity in how HIV is addressed. Public Health Implications. HIV and STI screening programs focused on CJI populations should be a priority for reducing HIV risk and numbers of undiagnosed infections among BMSM. Funding agencies and public health leaders should prioritize research to improve the knowledge base regarding which care continuum intervention approaches are most effective for BMSM with criminal justice involvement. Developments in modeling approaches could allow researchers to simulate the impacts and costs of criminal justice involvement-related interventions that might otherwise be cost, time, or ethically prohibitive to study empirically.

Incorporation of Social Determinants of Health in the Peer-Reviewed Literature: A Systematic Review of Articles Authored by the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

OBJECTIVES

Social determinants of health (SDHs) are the complex, structural, and societal factors that are responsible for most health inequities. Since 2003, the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) has researched how SDHs place communities at risk for communicable diseases and poor adolescent health. We described the frequency and types of SDHs discussed in articles authored by NCHHSTP.

METHODS

We used the MEDLINE/PubMed search engine to systematically review the frequency and type of SDHs that appeared in peer-reviewed publications available in PubMed from January 1, 2009, through December 31, 2014, with a NCHHSTP affiliation. We chose search terms to identify articles with a focus on the following SDH categories: income and employment, housing and homelessness, education and schooling, stigma or discrimination, social or community context, health and health care, and neighborhood or built environment. We classified articles based on the depth of topic coverage as "substantial" (ie, one of ≤3 foci of the article) or "minimal" (ie, one of ≥4 foci of the article).

RESULTS

Of 862 articles authored by NCHHSTP, 366 (42%) addressed the SDH factors of interest. Some articles addressed >1 SDH factor (366 articles appeared 568 times across the 7 categories examined), and we examined them for each category that they addressed. Most articles that addressed SDHs (449/568 articles; 79%) had a minimal SDH focus. SDH categories that were most represented in the literature were health and health care (190/568 articles; 33%) and education and schooling (118/568 articles; 21%).

CONCLUSIONS

This assessment serves as a baseline measurement of inclusion of SDH topics from NCHHSTP authors in the literature and creates a methodology that can be used in future assessments of this topic.

Interventions to Increase Male Attendance and Testing for Sexually Transmitted Infections at Publicly-Funded Family Planning Clinics

PURPOSE

We assessed the impact of staff, clinic, and community interventions on male and female family planning client visit volume and sexually transmitted infection testing at a multisite community-based health care agency.

METHODS

Staff training, clinic environmental changes, in-reach/outreach, and efficiency assessments were implemented in two Family Health Center (San Diego, CA) family planning clinics during 2010-2012; five Family Health Center family planning programs were identified as comparison clinics. Client visit records were compared between preintervention (2007-2009) and postintervention (2010-2012) for both sets of clinics.

RESULTS

Of 7,826 male client visits during the time before intervention, most were for clients who were aged <30 years (50%), Hispanic (64%), and uninsured (81%). From preintervention to postintervention, intervention clinics significantly increased the number of male visits (4,004 to 8,385; Δ = +109%); for comparison clinics, male visits increased modestly (3,822 to 4,500; Δ = +18%). The proportion of male clinic visits where chlamydia testing was performed increased in intervention clinics (35% to 42%; p < .001) but decreased in comparison clinics (37% to 33%; p < .001). Subgroup analyses conducted among adolescent and young adult males yielded similar findings for male client volume and chlamydia testing. The number of female visits declined nearly 40% in both comparison (21,800 to 13,202; -39%) and intervention clinics (30,830 to 19,971; -35%) between preintervention and postintervention periods.

CONCLUSIONS

Multilevel interventions designed to increase male client volume and sexually transmitted infection testing services in family planning clinics succeeded without affecting female client volume or services.

Infectious Diseases and the Criminal Justice System

The United States leads the world in incarceration, which disproportionately affects disadvantaged individuals, including those who are mentally ill, poor, homeless and racial minorities. Incarceration is disruptive to families and communities and contributes to health disparities in sexually transmitted infections (STIs) and human immunodeficiency virus (HIV). The objective of this grand rounds is to review (1) the epidemiology of incarceration in the United States, (2) the social factors which contribute to high rates of STIs in incarcerated individuals and (3) the HIV care cascade in incarcerated and recently released individuals. Routine screening and treatment for STIs and HIV in the criminal justice system can identify many new infections and has the potential to both improve individual outcomes and reduce transmission to others. Increased collaboration between the department of health and department of corrections, as well as partnerships between academic institutions and the criminal justice system, have the potential to improve outcomes in this vulnerable population.

Sexually Transmitted Disease Prevention Policies in the United States: Evidence and Opportunities

Policies are an important part of public health interventions, including in the area of sexually transmitted disease (STD) prevention. Similar to other tools used in public health, policies are often evaluated to determine their usefulness. Therefore, we conducted a nonsystematic review of policy evidence for STD prevention. Our review considers assessments or evaluations of STD prevention-specific policies, health care system policies, and other, broader policies that have the potential to impact STD prevention through social determinants of health. We also describe potential policy opportunity in these areas. It should be noted that we found gaps in policy evidence for some areas; thus, additional research would be useful for public health policy interventions for STD prevention.

How do changes in the population tested for chlamydia over time affect observed trends in chlamydia positivity? Analysis of routinely collected data from young women tested for chlamydia in family planning clinics in the Pacific Northwest (USA), between 2003 and 2010

Background The proportion of chlamydia tests that are positive (positivity) is dependent on the population tested and the test technology used. The way in which changes in these variables might affect trends in positivity over time is investigated.

METHODS

Data from 15- to 24-year-old women tested for chlamydia in family planning clinics participating in the Infertility Prevention Project in the Pacific Northwest, United States (USA Public Health Service Region X) during 2003-2010 (n=590557) were analysed. Trends in positivity and in test, demographic and sexual behaviour variables were identified. Unadjusted and adjusted trends in chlamydia positivity were calculated using logistic regression.

RESULTS

The proportion of tests carried out using nucleic acid amplification tests (NAATs) increased dramatically during the analysis period in two states. Smaller changes in demographic and behavioural characteristics were seen. Controlling for test technology used had the largest effect on the trend in testing positive per year, leading to a fall in the calculated odds ratio of testing positive from 1.06 to 1.02 in Oregon, and from 1.07 to 1.02 in Idaho. Controlling for other variables had minimal effect on chlamydia positivity trends.

CONCLUSIONS

Changes in NAAT use had a large effect on observed trends in chlamydia positivity over time in the two states where NAATs were introduced during the analysis period. While trends in chlamydia positivity may be a useful metric for monitoring chlamydia burden, it is important to consider changes in test type when interpreting these data.

Cost-effectiveness of screening men in Maricopa County jails for chlamydia and gonorrhea to avert infections in women

BACKGROUND

Chlamydia and gonorrhea infections can lead to serious and costly sequelae in women, but sequelae in men are rare. In accordance with the Centers for Disease Control and Prevention guidelines, female jail inmates in Maricopa County (Phoenix area), Arizona, are screened for these infections. Owing to lack of evidence of screening benefits in men, male inmates are tested and treated based on symptoms only.

METHODS

We developed a probabilistic simulation model to simulate chlamydia and gonorrhea infections in Maricopa County jail male inmates and transmissions to female partners per year. We estimated the cost-effectiveness of screening as the cost per infection averted. Costs were estimated from the perspective of the Maricopa County Department of Public Health and the Correctional Health Services.

RESULTS

Compared with symptom-based testing and treating strategy, screening male arrestees of all ages and only those 35 years or younger yielded the following results: averted approximately 556 and 491 cases of infection in women at a cost of approximately US $1240 and $860 per case averted, respectively, if screened during physical examination (between days 8 and 14 from entry to jail), and averted approximately 1100 and 995 cases of infections averted at a cost of US $1030 and $710 per infection averted, respectively, if screened early, within 2 to 3 days from entry to jail.

CONCLUSIONS

Screening of male inmates incurs a modest cost per infection averted in women compared with symptom-based testing. Screening in correctional settings can be used by public health programs to reduce disease burden, sequelae, and associated costs.

Advances in sampling and screening for chlamydia

Chlamydia is the most commonly diagnosed bacterial sexually transmitted infection in the developed world, with diagnosis rates continuing to increase each year. As chlamydia is largely asymptomatic, screening and treatment is the main way to detect cases and reduce transmission. Recent advances in self-collected specimens and laboratory tests has made chlamydia screening easier to implement as well as possible in nonclinical settings. This review will discuss new approaches to specimen collection and how these have expanded opportunities for reaching target populations for chlamydia screening. Furthermore, it will discuss how advanced molecular microbiological methods can be used with self-collected specimens to further our knowledge of the epidemiology of chlamydia and the dynamics of transmission.

Investigating the potential public health benefit of jail-based screening and treatment programs for chlamydia

Observational studies have found mixed results on the impact of jail-based chlamydia screen-and-treat programs on community prevalence. In the absence of controlled trials or prospectively designed studies, dynamic mathematical models that incorporate movements in and out of jail and sexual contacts (including disease transmission) can provide useful information. We explored the impact of jail-based chlamydia screening on a hypothetical community's prevalence with a deterministic compartmental model focusing on heterosexual transmission. Parameter values were obtained from the published literature. Two analyses were conducted. One used national values (large community); the other used values reported among African Americans--the population with the highest incarceration rates and chlamydia burden (small community). A comprehensive sensitivity analysis was carried out. For the large-community analysis, chlamydia prevalence decreased by 13% (from 2.3% to 2.0%), and based on the ranges of parameter values (including screening coverage of 10%-100% and a postscreening treatment rate of 50%-100%) used in the sensitivity analysis, this decrease ranged from 0.1% to 58%. For the small-community analysis, chlamydia prevalence decreased by 54% (from 4.6% to 2.1%). Jail-based chlamydia screen-and-treat programs have the potential to reduce chlamydia prevalence in communities with high incarceration rates. However, the magnitude of this potential decrease is subject to considerable uncertainty.

Association between enhanced screening for Chlamydia trachomatis and Neisseria gonorrhoeae and reductions in sequelae among women

PURPOSE

Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) are typically asymptomatic, but, if untreated, can lead to sequelae including pelvic inflammatory disease (PID) and ectopic pregnancy. The objective was to describe trends of these sequelae in Philadelphia after implementing citywide screening in a high-morbidity population (>6% positivity).

METHODS

In this ecologic study, which used data from 1996 to 2007, multivariable linear regression analysis was used to assess the association between the number of annual CT/GC screening tests by gender and the number of women aged 14-30 years hospitalized for PID or ectopic pregnancy. A standardized hospitalization database provided the number of admissions with a discharge diagnosis of PID or ectopic pregnancy. Positive CT/GC laboratory results reported by hospitals and emergency departments (EDs) were used as a proxy for outpatient PID.

RESULTS

Between 1996 and 2007, CT/GC screening increased by 188%, whereas declines were noted in hospitalized PID cases (36%, -173 cases), ectopic pregnancy (38%, -119 cases), and ED-diagnosed CT/GC cases (39%, -727 cases). Screening 10,000 females for CT/GC corresponded with 26.1 fewer hospitalized PID cases (95% confidence interval 11.2-41.1), whereas screening 10,000 males corresponded to 10.4 (95% CI: 2.6-18.2) fewer cases. Although male screening was not significantly associated with ectopic pregnancy, screening 10,000 females was associated with 28.6 fewer ectopic pregnancies (95% CI: 7.4-49.8).

CONCLUSIONS

This ecologic analysis found a correlation between large-scale CT/GC screening in a high-morbidity population and reductions in hospitalized PID, ectopic pregnancies, and ED-diagnosed CT/GC.