Access to health services and sexually transmitted infections in a cohort of relocating African American public housing residents: an association between travel time and infection

Adolescent Trichomonas vaginalis in a High-burdened Region of the Southern United States

BACKGROUND

We evaluated the clinical management and risk factors for Trichomonas vaginalis-positive adolescents in upstate South Carolina.

METHODS

An Epic electronic medical record report was generated to identify any physician-ordered T. vaginalis test from February 2016 to December 2017 for patients aged 12 to 18 years within the Prisma Health Upstate system. Utilizing a case-control study design of patients with a documented T. vaginalis diagnostic result, we reviewed records of patients with physician-ordered T. vaginalis tests for demographics, clinical disease course, sexually transmitted infection test results, treatment order and dosage, infection risk factors, comorbidities, pregnancy term, and neonatal birth outcomes.

RESULTS

Of 789 male and female adolescents with physician-ordered T. vaginalis tests, 44% had a documented result. Of those with a document test result, 13% were T. vaginalis positive. Cases (n = 45) and randomly selected negative controls (n = 45) were all girls. Cases were more likely to be African American, symptomatic, and present with vaginal discharge, pain, and vulvar itch. T. vaginalis patients were more likely to have documented histories of chlamydia (P < 0.0001) and gonorrhea (P = 0.0191), with 18% having concurrent triple infections (T. vaginalis, chlamydia, and gonorrhea). All 26 pregnant girls with T. vaginalis delivered full-term, healthy infants.

CONCLUSIONS

We identified a disproportionally high burden of T. vaginalis infection, with an alarmingly high rate of triple infections, among a population of suspected high-risk adolescents. Our results indicate the need to clarify infection prevalence, develop pediatrician-focused education campaigns, and elucidate potentially modifiable risk factors for these high-risk patients.

Estimated Impact of Screening on Gonorrhea Epidemiology in the United States: Insights From a Mathematical Model

The burden of gonorrhea infections in the United States is high. There are marked disparities by race/ethnicity and sexual orientation. We quantified the impact of screening and treatment on gonorrhea rates in the US population aged 15 to 39 years for the period 2000 to 2015 and estimated the impact that alternative screening strategies might have had over the same period.

METHODS

We developed a national-level transmission model that divides the population by race/ethnicity, preferred gender of sex partners, age, gender, and sexual activity level. We compared our fitted model ("base case") to 4 alternative strategies: (i) no screening, (ii) full adherence to current screening guidelines, (iii) annual universal screening, or (iv) enhanced screening in groups with the highest infection burden. Main outcomes were incidence, infections averted, and incidence rate ratios by race/ethnicity. Mean values and 95% credible intervals were calculated from 1000 draws from parameter posterior distributions.

RESULTS

The calibrated model reproduced observed trends in gonorrhea, including disparities in infection burden by race/ethnicity. We estimated that screening for gonorrhea from 2000 to 2015 averted 30% (95% credible intervals, 18-44%) of total infections that would otherwise have occurred. All alternative active screening strategies were estimated to further reduce, but not eliminate, gonorrhea infections relative to the base case, with differential impacts on the subpopulations of interest.

CONCLUSIONS

Our model results suggest that screening has reduced gonorrhea incidence in the US population. Additional reductions in infection burden may have been possible over this period with increased screening, but elimination was unlikely.

Public Housing Relocations and Relationships of Changes in Neighborhood Disadvantage and Transportation Access to Unmet Need for Medical Care

INTRODUCTION

Cross-sectional research suggests that neighborhood characteristics and transportation access shape unmet need for medical care. This longitudinal analysis explores relationships of changes in neighborhood socioeconomic disadvantage and trans- portation access to unmet need for medical care.

METHODS

We analyzed seven waves of data from African American adults (N = 172) relocating from severely distressed public housing complexes in Atlanta, Georgia. Surveys yielded individual-level data and admin- istrative data characterized census tracts. We used hierarchical generalized linear models to explore relationships.

RESULTS

Unmet need declined from 25% pre-relocation to 12% at Wave 7. Post-relocation reductions in neighborhood disadvantage were inversely associated with reductions in unmet need over time (OR = 0.71, 95% CI = 0.51-0.99). More frequent transportation barriers predicted unmet need (OR = 1.16, 95% CI = 1.02-1.31).

CONCLUSION

These longitudinal findings support the importance of neighborhood environments and transportation access in shaping unmet need and suggest that improvements in these exposures reduce unmet need for medical care in this vulnerable population.

Contextual Predictors of Injection Drug Use Among Black Adolescents and Adults in US Metropolitan Areas, 1993-2007

OBJECTIVES

We sought to determine whether contextual factors shape injection drug use among Black adolescents and adults.

METHODS

For this longitudinal study of 95 US metropolitan statistical areas (MSAs), we drew annual MSA-specific estimates of the prevalence of injection drug use (IDU) among Black adolescents and adults in 1993 through 2007 from 3 surveillance databases. We used existing administrative data to measure MSA-level socioeconomic status; criminal justice activities; expenditures on social welfare, health, and policing; and histories of Black uprisings (1960-1969) and urban renewal funding (1949-1974). We regressed Black IDU prevalence on these predictors by using hierarchical linear models.

RESULTS

Black IDU prevalence was lower in MSAs with declining Black high-school dropout rates, a history of Black uprisings, higher percentages of Black residents, and, in MSAs where 1992 White income was high, higher 1992 Black income. Incarceration rates were unrelated.

CONCLUSIONS

Contextual factors shape patterns of drug use among Black individuals. Structural interventions, especially those that improve Black socioeconomic security and political strength, may help reduce IDU among Black adolescents and adults.

Childhood lead exposure and sexually transmitted infections: New evidence

INTRODUCTION

The adverse health effects of lead exposure in children are well documented and include intellectual and behavioral maladies. Childhood lead exposure has also been linked to impulsive behaviors, which, in turn, are associated with a host of negative health outcomes including an increased risk for sexually transmitted infections (STI). The purpose of this study was to assess the association of lead exposure with STI rates across census tracts in St. Louis City, Missouri.

METHODS

Incident cases of gonorrhea and chlamydia (GC) during 2011 were identified from the Missouri Department of Health and Senior Services and aggregated by census tract. We also geocoded the home address of 59,645 children >72 months in age who had blood lead level tests performed in St. Louis City from 1996 to 2007. Traditional regression and Bayesian spatial models were used to determine the relationship between GC and lead exposure while accounting for confounders (condom and alcohol availability, crime, and an index of concentrated disadvantage).

RESULTS

Incident GC rates were found to cluster across census tracts (Moran's I=0.13, p=0.006). After accounting for confounders and their spatial dependence, a linear relationship existed between lead exposure and GC incidence across census tracts, with higher GC rates occurring in the northern part of St. Louis City

CONCLUSIONS

At the census-tract level, higher lead exposure is associated with higher STI rates. Visualizing these patterns through maps may help deliver targeted interventions to reduce geographic disparities in GC rates.

Impact of public housing relocations: are changes in neighborhood conditions related to STIs among relocaters?

BACKGROUND

Cross-sectional and ecologic studies suggest that place characteristics influence sexual behaviors and sexually transmitted infections (STIs). Using data from a predominately substance-misusing cohort of African American adults relocating from US public housing complexes, this multilevel longitudinal study tested the hypothesis that participants who experienced greater postrelocation improvements in neighborhood conditions (i.e., socioeconomic disadvantage, social disorder, STI prevalence, and male/female sex ratios) would have reduced the odds of testing positive for an STI over time.

METHODS

Baseline data were collected in 2009 from 172 public housing residents before relocations occurred; 3 waves of postrelocation data were collected every 9 months thereafter. Polymerase chain reaction methods were used to test participants' urine for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis. Individual-level characteristics were assessed via survey. Administrative data described the census tracts where participants lived at each wave (e.g., sex ratios, violent crime rates, and poverty rates). Hypotheses were tested using multilevel models.

RESULTS

Participants experienced improvements in all tract-level conditions studied and reductions in STIs over time (baseline: 29% tested STI positive; wave 4: 16% tested positive). Analyses identified a borderline statistically significant relationship between moving to tracts with more equitable sex ratios and reduced odds of testing positive for an STI (odds ratio, 0.16; 95% confidence interval, 0.02-1.01). Changes in other neighborhood conditions were not associated with this outcome.

DISCUSSION

Consonant with past research, our findings suggest that moving to areas with more equitable sex ratios reduces the risk of STI infection. Future research should study the extent to which this relationship is mediated by changes in sexual network dynamics.

Public housing relocations in Atlanta, Georgia, and declines in spatial access to safety net primary care

This analysis investigates changes in spatial access to safety-net primary care in a sample of US public housing residents relocating via the HOPE VI initiative from public housing complexes to voucher-subsidized rental units; substance misusers were oversampled. We used gravity-based models to measure spatial access to care, and used mixed models to assess pre-/post-relocation changes in access. Half the sample experienced declines in spatial access of ≥ 79.83%; declines did not vary by substance misuse status. Results suggest that future public housing relocation initiatives should partner with relocaters, particularly those in poor health, to help them find housing near safety-net clinics.