A brief review of the estimated economic burden of sexually transmitted diseases in the United States: inflation-adjusted updates of previously published cost studies

Direct and Indirect Cost Savings From Sexually Transmitted Infection Testing, Treatment, and Counseling Among Foster Youth

BACKGROUND

Sexually transmitted infection (STI) prevention programs can decrease the economic burden of STIs. Foster youth have higher rates of STIs compared with their peers; however, information on direct costs and indirect costs averted by STI testing, treatment, and counseling among foster youth is lacking.

METHODS

This study used data from a comprehensive medical center for foster youth over a 3-year study period from July 2017 to June 2020. Direct and indirect costs averted by testing and treatment of chlamydia, gonorrhea, and syphilis, as well as HIV testing and counseling, were calculated based on formulas developed by the Centers for Disease Control and Prevention and adjusted for inflation.

RESULTS

Among the 316 youth who received medical services during this time, 206 were sexually active and tested for STIs and/or HIV. Among 121 positive STI test results, 64.5% (n = 78) were positive for chlamydia, 30.6% (n = 37) were positive for gonorrhea, and 5.0% (n = 6) were positive for syphilis. Treatment was provided to all. Overall, $60,049.68 in direct medical costs and $73,956.36 in indirect costs were averted.

CONCLUSIONS

Given the rates of STIs among this population and the economic benefit of STI treatment, it is imperative to continue to provide intensive and comprehensive, individualized sexual health care for foster youth. Traditional care management may miss the opportunity to prevent, identify, and treat STIs that comprehensive wraparound care can achieve. This study suggests that comprehensive wraparound care is a cost-effective way to identify, treat, and prevent STIs among foster youth.

The Estimated Direct Lifetime Medical Costs of Sexually Transmitted Infections Acquired in the United States in 2018

BACKGROUND

We estimated the lifetime medical costs attributable to sexually transmitted infections (STIs) acquired in 2018, including sexually acquired human immunodeficiency virus (HIV).

METHODS

We estimated the lifetime medical costs of infections acquired in 2018 in the United States for 8 STIs: chlamydia, gonorrhea, trichomoniasis, syphilis, genital herpes, human papillomavirus (HPV), hepatitis B, and HIV. We limited our analysis to lifetime medical costs incurred for treatment of STIs and for treatment of related sequelae; we did not include other costs, such as STI prevention. For each STI, except HPV, we calculated the lifetime medical cost by multiplying the estimated number of incident infections in 2018 by the estimated lifetime cost per infection. For HPV, we calculated the lifetime cost based on the projected lifetime incidence of health outcomes attributed to HPV infections acquired in 2018. Future costs were discounted at 3% annually.

RESULTS

Incident STIs in 2018 imposed an estimated $15.9 billion (25th-75th percentile: $14.9-16.9 billion) in discounted, lifetime direct medical costs (2019 US dollars). Most of this cost was due to sexually acquired HIV ($13.7 billion) and HPV ($0.8 billion). STIs in women accounted for about one fourth of the cost of incident STIs when including HIV, but about three fourths when excluding HIV. STIs among 15- to 24-year-olds accounted for $4.2 billion (26%) of the cost of incident STIs.

CONCLUSIONS

Incident STIs continue to impose a considerable lifetime medical cost burden in the United States. These results can inform health economic analyses to promote the use of cost-effective STI prevention interventions to reduce this burden.

Demand for Health Information on COVID-19 among Vietnamese

Due to the rapid spread of coronavirus, Vietnam introduced its first national partial lockdown on April 1st, 2020. The public relied on online sources, whether through official websites or phone-based applications, to acquire up-to-date health information, provide accurate instructions, and limit misinformation. This study aims to provide insight regarding the current level of awareness of the pandemic, and to identify associated factors in Vietnamese participants to recommend necessary interventions. A cross-sectional study was conducted using a web-based survey during the first week of the lockdown period. There were 341 observations collected using a snowball sampling technique. A Tobit multivariable regression model was used to identify factors associated with the demand for each category of health information. The most requested information was the latest updated news on the epidemic, followed by information about disease symptoms and updated news on the outbreak. The prevalence of diverse socioeconomic, demographic, and ethnic factors in Vietnam requires consideration of the specific health information needs of unique groups. Identifying group-specific demands would be helpful to provide proper information to fulfill each population group’s needs.

Recommendations for Providing Quality Sexually Transmitted Diseases Clinical Services, 2020

This report (hereafter referred to as STD QCS) provides CDC recommendations to U.S. health care providers regarding quality clinical services for sexually transmitted diseases (STDs) for primary care and STD specialty care settings. These recommendations complement CDC's Sexually Transmitted Diseases Treatment Guidelines, 2015 (hereafter referred to as the STD Guidelines), a comprehensive, evidence-based reference for prevention, diagnosis, and treatment of STDs. STD QCS differs from the STD Guidelines by specifying operational determinants of quality services in different types of clinical settings, describing on-site treatment and partner services, and indicating when STD-related conditions should be managed through consultation with or referral to a specialist. These recommendations might also help in the development of clinic-level policies (e.g., standing orders, express visits, specimen panels, and reflex testing) that can facilitate implementation of the STD Guidelines. CDC organized the recommendations for STD QCS into eight sections: 1) sexual history and physical examination, 2) prevention, 3) screening, 4) partner services, 5) evaluation of STD-related conditions, 6) laboratory, 7) treatment, and 8) referral to a specialist for complex STD or STD-related conditions.CDC developed the recommendations by synthesizing relevant, evidence-based guidelines and recommendations issued by other experts; reviewing current practice in the United States; soliciting Delphi ratings by subject matter experts on STD care in primary care and STD specialty care settings; discussing the scientific evidence supporting the proposed recommendations at a consultation meeting of experts and institutional stakeholders held November 20, 2015, in Atlanta, Georgia; conducting peer reviews of draft recommendations and supporting evidence; and discussing draft recommendations and supporting evidence during meetings of the CDC/Health Resources and Services Administration Advisory Committee on HIV, Viral Hepatitis, and STD Prevention and Treatment STD Work Group. These recommendations are intended to help health care providers in primary care or STD specialty care settings offer STD services at their clinical settings and to help the persons seeking care live safer, healthier lives by preventing and treating STDs and related complications.

Condom Use With Long-Acting Reversible Contraception vs Non-Long-Acting Reversible Contraception Hormonal Methods Among Postpartum Adolescents

IMPORTANCE

Increased use of long-acting reversible contraception (LARC; intrauterine devices [IUDs] and implants) has likely contributed to declining US teenage pregnancy and birth rates, yet sexually transmitted infection (STI) rates among teenagers remain high. While LARC methods are highly effective for pregnancy prevention, they, as with all nonbarrier methods, do not protect against STIs, including HIV. Studies of the general adolescent population suggest condom use is lower among LARC vs non-LARC hormonal methods users (birth control pill, contraceptive patch, vaginal ring, or injection). Despite the high use of LARC among postpartum teenagers, no studies have examined whether condom use differs by contraceptive method in this population.

OBJECTIVE

To compare condom use among sexually active postpartum teenagers using LARC vs those using non-LARC hormonal methods.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional analysis using 2012 to 2015 data from the Pregnancy Risk Assessment Monitoring System (PRAMS), a multisite and population-based surveillance system that collects data on maternal attitudes, behaviors, and experiences before, during, and shortly after pregnancy. We used data from 37 sites. Using multivariable survey-weighted logistic regression, we assessed the association of condom use by contraceptive methods. Participants were teenage mothers (≤19 years) with a recent live birth reporting LARC or non-LARC hormonal method use. Data were analyzed between March 2018 and April 2018.

MAIN OUTCOMES AND MEASURES

Condom use with LARC vs condom use with non-LARC hormonal methods.

RESULTS

Among the 5480 (weighted N = 245 847) postpartum teenage mothers in our sample, most were aged 18 to 19 years, unmarried, had current Medicaid coverage, were first-time mothers, had reported their pregnancy was unintended, and almost half were non-Hispanic white. Overall, condom use was reported by 28.8% of these teenagers. Users of LARC compared with non-LARC hormonal methods were half as likely to use condoms (17.8% vs 35.6%; adjusted prevalence ratio [aPR], 0.50; 95% CI, 0.41-0.60). Users of IUDs (15.1%) were less likely to report condom use than those using an implant (21.5%; aPR, 0.70; 95% CI, 0.51-0.98), patch, ring, or injection users (24.9%; aPR, 0.61; 95% CI, 0.47-0.79), and pill users (47.2%; aPR, 0.32; 95% CI, 0.25-0.40).

CONCLUSIONS AND RELEVANCE

Self-reported condom use was low overall among postpartum teenage mothers and lower among users of LARC vs non-LARC hormonal methods. Given the high rates of STIs among teenage mothers combined with higher use of LARC among postpartum teenaged mothers, interventions to promote condom use for STI/HIV prevention during the postpartum period are critically important.

Cost effectiveness of HIV and sexual reproductive health interventions targeting sex workers: a systematic review

Background

Sex workers have high incidences of HIV and other sexually transmitted diseases. Although, interventions targeting sex workers have shown to be effective, evidence on which strategies are most cost-effective is limited. This study aims to systematically review evidence on the cost-effectiveness of sexual health interventions for sex workers on a global level. It also evaluates the quality of available evidence and summarizes the drivers of cost effectiveness.

Methods

A search of published articles until May 2018 was conducted. A search strategy consisted of key words, MeSH terms and other free text terms related to economic evaluation, sex workers and sexual and reproductive health (SRH) was developed to conduct literature search on Medline, Web of Science, Econlit and the NHS Economic Evaluation Database. The quality of reporting the evidence was evaluated using the CHEERS checklist and drivers of cost-effectiveness were reported.

Results

Overall, 19 studies met the inclusion criteria. The majority of the studies were based in middle-income countries and only three in low-income settings. Most of the studies were conducted in Asia and only a handful in Sub-Saharan Africa and Latin America. The reviewed studies mainly evaluated the integrated interventions, i.e. interventions consisted a combination of biomedical, structural or behavioural components. All interventions, except for one, were highly cost-effective. The reporting quality of the evidence was relatively good. The strongest drivers of cost-effectiveness, reported in the studies, were HIV prevalence, number of partners per sex worker and commodity costs. Furthermore, interventions integrated into existing health programs were shown to be most cost-effective.

Conclusion

This review found that there is limited economic evidence on HIV and SRH interventions targeting sex workers. The available evidence indicates that the majority of the HIV and SRH interventions targeting sex workers are highly cost-effective, however, more effort should be devoted to improving the quality of conducting and reporting cost-effectiveness evidence for these interventions to make them usable in policy making. This review identified potential factors that affect the cost-effectiveness and can provide useful information for policy makers when designing and implementing such interventions.

Electronic supplementary material

The online version of this article (10.1186/s12962-018-0165-0) contains supplementary material, which is available to authorized users.

The Role of Behavioral Counseling in Sexually Transmitted Disease Prevention Program Settings

BACKGROUND

Behavioral counseling for sexually transmitted disease (STD) prevention is recommended for persons at risk, and the body of evidence yields numerous interventions that have STD preventive efficacy. What is needed is a review of the subset of these interventions that could be feasible in clinical settings, especially settings in STD prevention programs.

METHODS

We reviewed existing systematic reviews of the literature and abstracted from them studies that fit the following criteria in that the interventions: (1) used no more than 60 minutes of contact time in 1 to 2 sessions, (2) were individual level and face to face, (3) took place in a clinical setting, (4) had STD outcomes available, (5) were based in the United States, (6) were peer reviewed, and (7) had a control group.

RESULTS

From 6 reviews (published 2006-2014) covering 91 studies, we found 13 analyses representing 11 intervention studies that fit the selection criteria. Of these 13, 5 returned lower STD rates in the intervention group at follow-up; one study reported a higher rate of STD in one subset of the intervention group (men who have sex with men). Studies with effects on STD at follow-up were quite similar to studies across populations, settings, and follow-up periods, although successful interventions were more likely to demonstrate behavioral effects as well (5/5 vs. 2/5 among 10 interventions measuring behavior change).

CONCLUSIONS

Counseling is likely to benefit some STD clinic attendees, although unlikely to benefit men who have sex with men. The balance of costs and benefits of implementing behavioral counseling in STD programs is unclear, but feasibility would be improved if behavioral counseling were implemented in the context of other prevention efforts. Because populations outside typical STD clinic settings could also benefit, programs may exercise a valuable role through partnerships.

Epidemiology of incident chlamydia and gonorrhoea infections and population attributable fractions associated with living in the inner-core of Winnipeg, Canada

Population attributable fractions help to convey public health significance of differential disease risk for chlamydia and gonorrhoea. Geographical residence serves as a useful proxy for complex processes creating ill health. Using population-based data, Poisson regression models were used to examine factors associated with chlamydia and gonorrhoea incidence. Population attributable fractions due to residency in the Winnipeg Health Region's inner-core were determined for chlamydia/gonorrhoea infections among 15-59-year olds (2005-2013), stratified by age group. For both chlamydia and gonorrhoea, it was found that the 15-24-year old age group had the highest incidence rates. There was also a stronger association between residency in the inner-core and incidence for gonorrhoea, compared to chlamydia. Overall, 24% (95% CI: 12-34%) of chlamydia infections were attributable to residency in the inner-core, compared to 46% (95% CI: 35-54%) for gonorrhoea ( p < .05). Within chlamydia/gonorrhoea, no statistically significant differences in population attributable fraction were observed by age group. The conclusion was that a concentration of efforts towards inner-core residents with gonorrhoea infections may result in a relatively larger decrease in incidence.

Action Tweets Linked to Reduced County-Level HIV Prevalence in the United States: Online Messages and Structural Determinants

HIV is uncommon in most US counties but travels quickly through vulnerable communities when it strikes. Tracking behavior through social media may provide an unobtrusive, naturalistic means of predicting HIV outbreaks and understanding the behavioral and psychological factors that increase communities' risk. General action goals, or the motivation to engage in cognitive and motor activity, may support protective health behavior (e.g., using condoms) or encourage activity indiscriminately (e.g., risky sex), resulting in mixed health effects. We explored these opposing hypotheses by regressing county-level HIV prevalence on action language (e.g., work, plan) in over 150 million tweets mapped to US counties. Controlling for demographic and structural predictors of HIV, more active language was associated with lower HIV rates. By leveraging language used on social media to improve existing predictive models of geographic variation in HIV, future targeted HIV-prevention interventions may have a better chance of reaching high-risk communities before outbreaks occur.

Brief motivational intervention to reduce alcohol and HIV/sexual risk behavior in emergency department patients: A randomized controlled trial

OBJECTIVE

Given the prevalence of co-occurring risky sexual behavior and drinking among emergency department (ED) patients, we developed a motivational intervention (MI) to address both behaviors. This study tested efficacy of a single-session MI compared to brief advice (BA) for reducing heavy drinking and condomless sex in adult ED patients screening positive for both.

METHOD

We randomized 372 patients to MI (n = 184) or BA (n = 188). Alcohol and sex risk outcomes were assessed over 9 months.

RESULTS

Generalized estimating equations models analyzing 327 patients with follow-up data provided strong support for efficacy of this integrated alcohol and sex-risk MI. Compared to BA, and after controlling for baseline covariates, those in MI reported significantly fewer heavy drinking days, drinks per week, and were less likely to engage in excessive drinking over follow-up (all ps < .05). MI was also favored over BA for reducing sex risk. Compared to BA, those in MI reported significantly fewer days on which they engaged in condomless sex with casual partners, had lower odds of reporting any condomless sex with a casual partner, and reported fewer days of sex under the influence of alcohol/other drugs (all ps < .05).

CONCLUSION

This innovative MI was acceptable, feasible, and successfully delivered in 2 community hospitals and thus shows great promise for scalability and dissemination into complex health settings where newly insured at-risk individuals are likely to seek care. (PsycINFO Database Record

Student-Initiated Sexual Health Selective as a Curricular Tool

Introduction

Patients’ sexual health functioning is important for physicians in all fields of medicine to consider; however, this topic is lacking from almost half of U.S. medical school curricula.

Aims

This study aims to develop, implement, and assess the feasibility of a preliminary sexual health curriculum for medical students.

Methods

This Sexual Health Selective (SHS) was developed and implemented by a student and faculty champion for first year medical students. Its design incorporated a number of the guiding principles and recommendations from the 2012 Summit on Medical School Education in Sexual Health.

Main Outcome Measures

Feasibility was measured by limited-efficacy testing and participant acceptability of the SHS. Limited-efficacy testing was accomplished by conducting descriptive comparisons of responses to a sexual health attitudes and knowledge survey. These responses were compared between (i) participants vs. nonparticipants prior to the SHS, (ii) participants immediately after vs. participants prior to the SHS, (iii) participants 3 months after vs. participants prior to the SHS, and (iv) participants 3 months after vs. participants immediately after the SHS. Participant acceptability was assessed by asking qualitatively and quantitatively whether students enjoyed the SHS, found it beneficial to their learning, and would recommend it to their classmates.

Results

Immediately after the SHS and 3 months later, participants reported increased comfort and open-mindedness in their attitudes toward sexual health and demonstrated an increase in accurate knowledge about sexual health issues compared with baseline. Objective follow-up also revealed that most participants enjoyed the SHS, found it beneficial to their learning, and would recommend it to their classmates.

Conclusions

The 1-week SHS was successfully implemented through the teamwork of a medical student and faculty champion. It resulted in more accurate knowledge and more open attitudes toward sexual health among participating medical students. Potential benefits to undergraduate medical educators are reviewed.

Sexual health education in U.S. physician assistant programs

INTRODUCTION

Since the 1950s, sexual health education in medical schools has been evaluated and reported upon, but there has never been an assessment published about sexual health curricula in U.S. physician assistant (PA) programs.

AIM

The aim of this study was to gain better understanding of how PA programs cover sexual health topics.

METHODS

Between January and March 2014, 181 accredited PA programs received a mailed survey inquiring about their sexual health curriculum.

MAIN OUTCOME MEASURES

The survey assessed general sexual health topics; lesbian, gay, bisexual, transgender (LGBT) topics; teaching methods; and the amount of time spent on sexual health education.

RESULTS

A total of 106 programs responded (59%). Ten programs offered a required, discrete course on human sexuality. The majority incorporated training into other coursework, which is consistent with most medical schools. LGBT topics were covered less thoroughly than the general sexual health topics. Total amount of time spent on sexual health topics varied widely among programs, from a minimum of 2-4 hours to a maximum of 60 hours, with a median of 12 hours.

CONCLUSIONS

PA programs in the United States appear to compare favorably with the training offered to medical students in regard to time spent on sexual health education. Transgender issues were least well-covered of all the topics queried.

Acceptability of home-based chlamydia and gonorrhea testing among a national sample of sexual minority young adults

CONTEXT

STDs are common among older adolescents and young adults; hence, STD screening is a public health priority. Home-based STD testing could be a strategy to improve screening rates, particularly among at-risk populations, including sexual minority (i.e., nonheterosexual) young adults.

METHODS

Data were collected from a national sample of 971 sexual minority young adults aged 18-26 through an online survey in the fall of 2013. Logistic regression analyses identified associations between respondents' characteristics and their willingness to use a home-based test for chlamydia and gonorrhea.

RESULTS

A greater proportion of men than of women were willing to use a home-based STD test (81% vs. 68%). Willingness was more likely among gay than among bisexual men, among men insured through their parents than among the uninsured and among those who had had two or more sexual partners in the past year than among those who had had fewer (adjusted odds ratios, 2.0-2.2). Among men, students were less likely than the employed to report willingness for home-based testing (0.4). Among women, willingness was more likely among those who reported at least two partners in the past year than among those who reported fewer (1.6). Overall, respondents' most common concerns about home-based STD testing regarded test accuracy, their ability to do the test correctly and their preference to see a doctor for testing.

CONCLUSIONS

Home-based STD testing may be a promising strategy for screening sexual minority young adults; understanding correlates of willingness and young adults' concerns may help inform self-testing programs.

Endorsement of compulsory HIV vaccination policy among populations at high risk of HIV exposure (LA VOICES)

Compulsory vaccination is a frequently implemented policy option for ensuring comprehensive vaccine coverage. Ongoing controversies around human papillomavirus vaccine dissemination, and suboptimal coverage, suggest the value of assessing acceptability of compulsory vaccinations-particularly among likely target populations-in advance of their public availability to support evidence-informed interventions. With the first HIV vaccine to demonstrate partial efficacy in a large-scale clinical trial, we examined individual characteristics and attitudes associated with support for compulsory HIV vaccination policy among a diverse, representative sample of adults attending probable HIV vaccine dissemination venues in a large urban county. Participants were recruited using three-stage probability sampling from likely venues for future HIV vaccine dissemination. We used Audio-CASI to administer a 60-min structured questionnaire. Items included endorsement of compulsory HIV vaccination policy, sociodemographic characteristics, injecting drug use, vaccine attitudes and perceived HIV risk. Among 1,225 participants (mean age = 36.8 years; 55.6 % males, 37.6 % non-English speaking Hispanic, 78.8 % heterosexual, 25.7 % injection drug users), almost half (48.2 %) endorsed a compulsory HIV vaccination policy. Non-English speaking Hispanics compared to whites, participants with less than high school education, higher positive vaccine attitude scores and higher perceived HIV risk were significantly more likely, and people who inject drugs significantly less likely to endorse compulsory HIV vaccination. Public health interventions to promote positive vaccine attitudes and accurate perceptions of HIV risk among vulnerable populations, and strategies tailored for people who inject drugs, may build support for compulsory HIV vaccination policy and promote broad HIV vaccine coverage.

Return on investment: a fuller assessment of the benefits and cost savings of the US publicly funded family planning program

Policy Points: The US publicly supported family planning effort serves millions of women and men each year, and this analysis provides new estimates of its positive impact on a wide range of health outcomes and its net savings to the government. The public investment in family planning programs and providers not only helps women and couples avoid unintended pregnancy and abortion, but also helps many thousands avoid cervical cancer, HIV and other sexually transmitted infections, infertility, and preterm and low birth weight births. This investment resulted in net government savings of $13.6 billion in 2010, or $7.09 for every public dollar spent.

CONTEXT

Each year the United States' publicly supported family planning program serves millions of low-income women. Although the health impact and public-sector savings associated with this program's services extend well beyond preventing unintended pregnancy, they never have been fully quantified.

METHODS

Drawing on an array of survey data and published parameters, we estimated the direct national-level and state-level health benefits that accrued from providing contraceptives, tests for the human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs), Pap tests and tests for human papillomavirus (HPV), and HPV vaccinations at publicly supported family planning settings in 2010. We estimated the public cost savings attributable to these services and compared those with the cost of publicly funded family planning services in 2010 to find the net public-sector savings. We adjusted our estimates of the cost savings for unplanned births to exclude some mistimed births that would remain publicly funded if they had occurred later and to include the medical costs for births through age 5 of the child.

FINDINGS

In 2010, care provided during publicly supported family planning visits averted an estimated 2.2 million unintended pregnancies, including 287,500 closely spaced and 164,190 preterm or low birth weight (LBW) births, 99,100 cases of chlamydia, 16,240 cases of gonorrhea, 410 cases of HIV, and 13,170 cases of pelvic inflammatory disease that would have led to 1,130 ectopic pregnancies and 2,210 cases of infertility. Pap and HPV tests and HPV vaccinations prevented an estimated 3,680 cases of cervical cancer and 2,110 cervical cancer deaths; HPV vaccination also prevented 9,000 cases of abnormal sequelae and precancerous lesions. Services provided at health centers supported by the Title X national family planning program accounted for more than half of these benefits. The gross public savings attributed to these services totaled approximately $15.8 billion-$15.7 billion from preventing unplanned births, $123 million from STI/HIV testing, and $23 million from Pap and HPV testing and vaccines. Subtracting $2.2 billion in program costs from gross savings resulted in net public-sector savings of $13.6 billion.

CONCLUSIONS

Public expenditures for the US family planning program not only prevented unintended pregnancies but also reduced the incidence and impact of preterm and LBW births, STIs, infertility, and cervical cancer. This investment saved the government billions of public dollars, equivalent to an estimated taxpayer savings of $7.09 for every public dollar spent.

Formative research for the development of an interactive web-based sexually transmitted disease management intervention for young women

Sexually transmitted diseases are common among young women and effective self-management is foundational to improving health outcomes and preventing negative sequelae. Advances in technology create the opportunity for innovative delivery methods of self-management interventions. However, it is essential to conduct formative research with the target population to identify both the needs and the preferences for the content and delivery method of a sexually transmitted disease self-management intervention prior to intervention development. Eight focus groups were conducted with 35 young women between 18 and 24 years of age. We found that young women strongly support the use of a Web-based intervention to provide sexually transmitted disease self-management guidance. Women were interested in receiving comprehensive management information from the perspective of both clinicians and other women who have experienced a sexually transmitted disease. There was a clear interest in incorporating new media into the Web-based intervention to allow for communication with providers as well as to create opportunities for social networking between women. This formative research provides critical information about the content and delivery method of a self-management intervention and gives direction for intervention development that is inclusive of varying types of new media to allow for connectivity among users, their peers, and clinicians.

Costs of adverse events among patients with HIV infection treated with nonnucleoside reverse transcriptase inhibitors

OBJECTIVES

The aim of the study was to assess the incidence and costs of adverse events (AEs) among patients with HIV infection treated with nonnucleoside reverse transcriptase inhibitors (NNRTIs) from the health care system perspective.

METHODS

US medical and pharmacy claims during 2004-2009 were examined to select adult new NNRTI users with HIV infection. The incidence of selected AEs and time to occurrence were assessed during the first year. Episodes of care for each AE were identified using claims associated with AE management. For each AE, a propensity score model was used to match patients with an AE to those without (1:4) based on the propensity of having an AE. Mean total health care costs, AE-associated costs and incremental costs per episode, and annual total health care costs per patient were calculated.

RESULTS

Of the 2548 NNRTI-treated patients, 29.3% experienced AEs. The incidence ranged from 0.4 episodes/1000 person-years for suicide/self-injury to 14.9 episodes/1000 person-years for dizziness, 49.8 episodes/1000 person-years for depression and 150.3 episodes/1000 person-years for lipid disorder. The mean AE-associated cost (duration) per episode ranged from $586 (88 days) for lipid disorder to $975 (33 days) for rash, $2760 (73 days) for sleep-related symptoms and $4434 (41 days) for nausea/vomiting. The mean incremental cost per episode ranged from $1580 for rash to $2032 for lipid disorder, $8307 for sleep-related symptoms and $12 833 for nausea/vomiting. During the 12 months following NNRTI initiation, the mean annual total health care cost was $27 299 (efavirenz: $26 185; other NNRTIs: $34 993) and AE-associated costs were $608 (efavirenz: $554; other NNRTIs: $979) among all NNRTI users.

CONCLUSIONS

With treatment increasing patient survival, comparisons of therapeutic regimens should consider treatment-associated AEs. Findings from this study could be informative for clinicians and payers in managing HIV infection with NNRTIs.

Productivity costs of nonviral sexually transmissible infections among patients who miss work to seek medical care: evidence from claims data

BACKGROUND

Productivity losses can arise when employees miss work to seek care for sexually transmissible infections (STIs). We estimated the average productivity loss per acute case of four nonviral STIs: chlamydia, gonorrhoea, syphilis and trichomoniasis.

METHODS

We extracted outpatient claims from 2001-2005 MarketScan databases using International Classification Disease ver. 9 (ICD-9) codes. We linked claims with their absence records in the Health and Productivity Management database by matching enrolee identifiers and the service dates from the claims such that our final data included only those who were absent because they were sick and were diagnosed with an STI on the day of their visit. To ensure that the visit was for the STIs being examined, we restricted the criteria to records with the specified ICD-9 codes only, excluding claims with other codes. We estimated the average number of hours absent and multiplied it by the mean hourly wage rate including benefits ($29.72 in 2011 United States dollars) to estimate the average productivity loss per case.

RESULTS

The average productivity losses per case were: $262 for chlamydia, $197 for gonorrhoea, $419 for syphilis and $289 for trichomoniasis. There were no significant differences between males and females.

CONCLUSIONS

Among those who take sick leave to seek care, productivity losses associated with treating nonviral STIs may be higher than their estimated direct medical costs. These productivity cost estimates can help to quantify the overall STI burden, and inform cost-effectiveness analyses of prevention and control efforts.

The estimated direct medical cost of selected sexually transmitted infections in the United States, 2008

BACKGROUND

Millions of cases of sexually transmitted infections (STIs) occur in the United States each year, resulting in substantial medical costs to the nation. Previous estimates of the total direct cost of STIs are quite dated. We present updated direct medical cost estimates of STIs in the United States.

METHODS

We assembled recent (i.e., 2002-2011) cost estimates to determine the lifetime cost per case of 8 major STIs (chlamydia, gonorrhea, hepatitis B virus, human immunodeficiency virus (HIV), human papillomavirus, genital herpes simplex virus type 2, trichomoniasis and syphilis). The total direct cost for each STI was computed as the product of the number of new or newly diagnosed cases in 2008 and the estimated discounted lifetime cost per case. All costs were adjusted to 2010 US dollars.

RESULTS

Results indicated that the total lifetime direct medical cost of the 19.7 million cases of STIs that occurred among persons of all ages in 2008 in the United States was $15.6 (range, $11.0-$20.6) billion. Total costs were as follows: chlamydia ($516.7 [$258.3-$775.0] million), gonorrhea ($162.1 [$81.1-$243.2] million), hepatitis B virus ($50.7 [$41.3-$55.6] million), HIV ($12.6 [$9.5-$15.7] billion), human papillomavirus ($1.7 [$0.8-$2.9] billion), herpes simplex virus type 2 ($540.7 [$270.3-$811.0] million), syphilis ($39.3 [$19.6-$58.9] million), and trichomoniasis ($24.0 [$12.0-$36.0] million). Costs associated with HIV infection accounted for more than 81% of the total cost. Among the nonviral STIs, chlamydia was the most costly infection.

CONCLUSIONS

Sexually transmitted infections continue to impose a substantial cost burden on the payers of medical care in the United States. The burden of STIs would be even greater in the absence of STI prevention and control efforts.

Optimizing the scientific yield from a randomized controlled trial (RCT): evaluating two behavioral interventions and assessment reactivity with a single trial

Randomized controlled trials (RCTs) remain the gold standard for evaluating intervention efficacy but are often costly. To optimize their scientific yield, RCTs can be designed to investigate multiple research questions. This paper describes an RCT that used a modified Solomon four-group design to simultaneously evaluate two, theoretically-guided, health promotion interventions as well as assessment reactivity. Recruited participants (N = 1010; 56% male; 69% African American) were randomly assigned to one of four conditions formed by crossing two intervention conditions (i.e., general health promotion vs. sexual risk reduction intervention) with two assessment conditions (i.e., general health vs. sexual health survey). After completing their assigned baseline assessment, participants received the assigned intervention, and returned for follow-ups at 3, 6, 9, and 12 months. In this report, we summarize baseline data, which show high levels of sexual risk behavior; alcohol, marijuana, and tobacco use; and fast food consumption. Sexual risk behaviors and substance use were correlated. Participants reported high satisfaction with both interventions but ratings for the sexual risk reduction intervention were higher. Planned follow-up sessions, and subsequent analyses, will assess changes in health behaviors including sexual risk behaviors. This study design demonstrates one way to optimize the scientific yield of an RCT.

Considerations for national public health leadership in advancing sexual health

Nations across the globe face significant public heath challenges in optimizing sexual health, including reducing human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), sexually transmitted infections (STIs), unintended pregnancies, and sexual violence, and mitigating the associated adverse social and economic impacts. In response, some countries have implemented national strategies and other efforts focused on promoting more holistic and integrated approaches for addressing these syndemics. This article describes opportunities for national leadership to use a more holistic approach to improve the sexual health of individuals and communities.

Predictors of repeat Chlamydia trachomatis and/or Neisseria gonorrhoeae infections among African-American adolescent women

BACKGROUND

Young African-American women have the highest rates of Chlamydia trachomatis and Neisseria gonorrhoeae in the USA. The objective was to identify baseline predictors of repeat chlamydia and/or gonorrhoea infections among African-American adolescent women.

METHODS

Sociodemographic, psychosocial and behavioural data were collected at baseline and every 6 months for 2 years from 701 African-American women (14-20 years) enrolled in an HIV prevention trial. Vaginal swabs were self-collected at each visit and assayed for chlamydia and gonorrhoea using DNA amplification. Among participants testing positive for chlamydia and/or gonorrhoea at baseline, logistic regression analyses assessed baseline predictors of repeat infection.

RESULTS

Of 618 (88%) participants with ≥1 follow-up assessment, 123 (20%) had a positive chlamydia and/or gonorrhoea test result at baseline; 49 (40%) had a repeat infection during the study period. Of those with a repeat infection, 30 (61%) were positive at one follow-up visit, 18 (37%) at two visits and 1 (2%) at three follow-up visits. Controlling for age and intervention condition, impulsivity (AOR: 1.71, p=0.018) was associated with an increased likelihood, and having a boyfriend (AOR: 0.21, p=0.006) was associated with a decreased likelihood of repeat infection.

CONCLUSIONS

Repeat chlamydia and/or gonorrhoea infections are common among African-American adolescent women. Among young African-American women who test positive for chlamydia and/or gonorrhoea, tailored interventions for more impulsive adolescents and those not in a relationship may reduce risk of repeat infections. Given the high numbers of repeat infections after receipt of an evidence-based intervention, enhanced screening and treatment services for young men may be warranted.

CLINICAL TRIALS REGISTRATION

http://www.clinicaltrials.gov (NCT00279799).

Costs and effectiveness of neonatal male circumcision

OBJECTIVE

To evaluate the expected change in the prevalence of male circumcision (MC)-reduced infections and resulting health care costs associated with continued decreases in MC rates. During the past 20 years, MC rates have declined from 79% to 55%, alongside reduced insurance coverage.

DESIGN

We used Markov-based Monte Carlo simulations to track men and women throughout their lifetimes as they experienced MC procedure-related events and MC-reduced infections and accumulated associated costs. One-way and probabilistic sensitivity analyses were used to evaluate the impact of uncertainty.

SETTING

United States.

PARTICIPANTS

Birth cohort of men and women.

INTERVENTION

Decreased MC rates (10% reflects the MC rate in Europe, where insurance coverage is limited).

OUTCOMES MEASURED

Lifetime direct medical cost (2011 US$) and prevalence of MC-reduced infections.

RESULTS

Reducing the MC rate to 10% will increase lifetime health care costs by $407 per male and $43 per female. Net expenditure per annual birth cohort (including procedure and complication costs) is expected to increase by $505 million, reflecting an increase of $313 per forgone MC. Over 10 annual cohorts, net present value of additional costs would exceed $4.4 billion. Lifetime prevalence of human immunodeficiency virus infection among males is expected to increase by 12.2% (4843 cases), high- and low-risk human papillomavirus by 29.1% (57 124 cases), herpes simplex virus type 2 by 19.8% (124 767 cases), and infant urinary tract infections by 211.8% (26 876 cases). Among females, lifetime prevalence of bacterial vaginosis is expected to increase by 51.2% (538 865 cases), trichomoniasis by 51.2% (64 585 cases), high-risk human papillomavirus by 18.3% (33 148 cases), and low-risk human papillomavirus by 12.9% (25 837 cases). Increased prevalence of human immunodeficiency virus infection among males represents 78.9% of increased expenses.

CONCLUSION

Continued decreases in MC rates are associated with increased infection prevalence, thereby increasing medical expenditures for men and women.

Controlling the HIV/AIDS epidemic: current status and global challenges

This review provides an overview of the current status of the global HIV pandemic and strategies to bring it under control. It updates numerous preventive approaches including behavioral interventions, male circumcision (MC), pre- and post-exposure prophylaxis (PREP and PEP), vaccines, and microbicides. The manuscript summarizes current anti-retroviral treatment options, their impact in the western world, and difficulties faced by emerging and resource-limited nations in providing and maintaining appropriate treatment regimens. Current clinical and pre-clinical approaches toward a cure for HIV are described, including new drug compounds that target viral reservoirs and gene therapy approaches aimed at altering susceptibility to HIV infection. Recent progress in vaccine development is summarized, including novel approaches and new discoveries.