Diagnosis of Neisseria gonorrhoeae infections in women by using the ligase chain reaction on patient-obtained vaginal swabs

Evaluation of the performance of nucleic acid amplification tests (NAATs) in detection of chlamydia and gonorrhoea infection in vaginal specimens relative to patient infection status: a systematic review

OBJECTIVE

We evaluated the performance of nucleic acid amplification tests (NAATs) using vaginal specimens in comparison to specimens from the cervix or urine in their ability to detect chlamydia and gonorrhoea infection in women based on patient infection status (PIS).

DESIGN

Systematic review.

DATA SOURCES

EMBASE and Ovid MEDLINE databases were searched through 3 October 2017.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included studies that tested samples from the vagina and ≥1 other site (cervix and/or urine) with ≥2 NAATs for chlamydia and ≥2 NAATs or 1 NAAT and culture for gonorrhoea for each site.

DATA EXTRACTION AND SYNTHESIS

Performance is defined as the sensitivity of a NAAT using a specimen site and PIS of the patient. We assessed risk of bias using modified QUADAS-2.

RESULTS

Nine publications met the inclusion criteria (eight for chlamydia; six for gonorrhoea) and were narratively reviewed. Pooled summary estimates were not calculated due to the variable methodology and PIS definitions. Tests performed on vaginal specimens accomplished similar performance to cervical and urine specimens for chlamydia (range of performance estimates: vaginal 65%-100%, cervical 59%-97%, urine 57%-100%) and gonorrhoea (vaginal 64%-100%, cervical 85%-100%, urine 67%-94%). Vaginal specimens were estimated to have a performance >80% for chlamydia and gonorrhoea infections in all but one study.

CONCLUSIONS

Performance of the NAATs for chlamydia and gonorrhoea detection using vaginal specimens was similar to that of cervical and urine specimens relative to PIS. As vaginal samples have a higher acceptability and lower cost, the study can support clinical testing guidelines by providing evidence that vaginal samples are a suitable alternative to traditionally used specimens.

Vaginal swabs are the optimal specimen for detection of genital Chlamydia trachomatis or Neisseria gonorrhoeae using the Cobas 4800 CT/NG test

Performance characteristics of the Cobas 4800 CT/NG assay were estimated for vaginal swab samples from more than 4000 women. Vaginal samples identified 92.9% and 98.5% of Chlamydia and Gonorrhea infections, respectively, which was more than any other single specimen type (endocervical swabs or urine) regardless of collection method (clinician collected or self-obtained).

European guideline for the organization of a consultation for sexually transmitted infections, 2012

This guideline is intended to serve as a framework for those working in any location where sexually transmitted infections (STIs) are managed. It offers recommendations which will need to be adapted depending on local facilities and policies, and is not intended to be all encompassing. This guideline should be read in conjunction with other European guidelines on the management of specific infections (see http://www.iusti.org/ ).

Performance of the Abbott RealTime CT/NG for detection of Chlamydia trachomatis and Neisseria gonorrhoeae

A multicenter clinical study was conducted to evaluate the performance characteristics of the Abbott RealTime CT/NG assay, a multiplex real-time PCR assay, for simultaneous detection of Chlamydia trachomatis and Neisseria gonorrhoeae. The specimens were collected from a total of 3,832 male and female subjects at 16 geographically diverse sites. Specimens included male and female urine samples, male urethral swabs, female endocervical swabs, and self-collected and clinician-collected vaginal swabs. Specimens were tested with the automated Abbott RealTime CT/NG assay, Aptima Combo 2 assay (Gen-Probe), ProbeTec ET CT/GC assay (Becton Dickinson), and culture for N. gonorrhoeae. The Aptima Combo 2 assay, the ProbeTec assay, and the N. gonorrhoeae culture were used as the reference assays. For each subject, a patient infected status (PIS) was determined based on the combined results from the reference assays. The overall prevalence in female subjects was 8.9% for C. trachomatis and 3.8% for N. gonorrhoeae. The overall male prevalence was 18.2% for C. trachomatis and 16.7% for N. gonorrhoeae. The overall sensitivity and specificity of the Abbott RealTime CT/NG assay were 92.4% and 99.2% for C. trachomatis and 96.9% and 99.7% for N. gonorrhoeae, respectively. In comparison, the sensitivity and specificity, respectively, for the Aptima Combo 2 assay were 94.5% and 99.0% for C. trachomatis and 96.1% and 99.5% for N. gonorrhoeae, and those for the ProbeTec ET assay were 90.3% and 99.5% for C. trachomatis and 92.0% and 97.3% for N. gonorrhoeae in this study. The Abbott RealTime CT/NG assay offers C. trachomatis and N. gonorrhoeae dual detection with high sensitivity and specificity. The automated assay provides a useful alternative nucleic acid amplification assay for clinical laboratories and clinicians.

From the NIH: proceedings of a workshop on the importance of self-obtained vaginal specimens for detection of sexually transmitted infections

On June 27, 2006, the NIH conducted a workshop to review published data and current field practices supporting the use of self-obtained vaginal swabs (SOVs) as specimens for diagnosis of sexually transmitted infections (STIs). The workshop also explored the design of studies that could support FDA clearance of SOVs for STI testing, particularly for specimens collected in nonclinical settings including patients' homes. This report summarizes the workshop findings and recommendations. Participants concluded that self-obtained vaginal swabs are well accepted by women of all ages and that SOVs perform as well as or better than other specimen types for Chlamydia trachomatis and Neisseria gonorrhoeae detection using transcription-mediated amplification. In addition, workshop participants recommended the validation of SOV testing by public health practitioners and manufacturers of STI diagnostic tests to expedite incorporation of SOVs as a diagnostic option in clinical and nonclinical settings for Chlamydia trachomatis and Neisseria gonorrhoeae testing. Similarly, SOVs should be explored for use in the diagnosis of other sexually transmitted pathogens.

Associations Between Recent Gender-Based Violence and Pregnancy, Sexually Transmitted Infections, Condom Use Practices, and Negotiation of Sexual Practices Among HIV-Positive Women

BACKGROUND

This study sought to document the prevalence of recent gender-based violence (rGBV) among seropositive women and to determine the association between rGBV and pregnancy, sexually transmitted infections (STIs), condom use, and negotiation of sexual practices.

METHODS

A total of 304 seropositive women recruited from HIV clinics in the southeastern United States who reported being sexually active in the previous 6 months with 1 partner were included in analyses. Gender-based violence during the previous 3 months, condom use, and negotiation of sexual practices were assessed. Biologic samples for pregnancy and STI testing were collected.

RESULTS

A total of 10.2% of women reported a history of rGBV. rGBV was related to inconsistent condom use practices, pregnancy, and abuse stemming from requests for condom use. No associations were found between rGBV and negotiation of sexual practices and STIs.

CONCLUSIONS

The prevalence of rGBV among HIV-positive women emphasizes the need for screening of abuse and highlights the need for the design and implementation of integrated intervention approaches necessary in addressing the needs of this population.

Diagnosis of gonococcal infection in high risk women using a rapid test

OBJECTIVE

To assess the performance and acceptability for patients and health care workers of the NGThermo Biostar (GC OIA) to diagnose gonococcal infection compared with culture using modified Thayer Martin medium.

METHODS

This study involved 326 high-risk women presenting with vaginal discharge or referral by sexual partner with urethral discharge at a sexually transmitted infections (STI) clinic in Manaus, Brazil. Endocervical swabs collected from the women were tested with both the NG Biostar and modified Thayer Martin culture as the reference standard test. Clinic staff were trained to perform the NG Biostar on site and the culture was performed in the laboratory of the clinic.

RESULTS

The prevalence of gonococcal infection as measured by the reference standard was 15% (50/326) overall. Among asymptomatic participants, the prevalence of infection was 17.7% (25/141) and among symptomatic women it was 13.5% (25/185) (p = 0.3). Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for the NG Biostar test, with 95% confidence intervals (CI), were 60% (46.4% to 73.6%), 89.9% (86.2% to 93.6%), 55.6% (42.4% to 68.8%), and 92.6% (89.5% to 95.7%), respectively; 98.8% of study participants were willing to wait approximately 1 hour in the clinic for test results.

CONCLUSION

Syndromic management protocols for treatment of STI in developing countries require refinement because, as currently described, they lead to over-treatment of cervical infection. A rapid test done during patients' initial presentation and leading to immediate treatment if positive would help improve the accuracy of diagnosis and could also be used to screen asymptomatic women. Even though the NG Biostar had a low sensitivity and PPV, which is less than ideal, it could still improve the rates of treatment over the gold standard test that requires return visits for patients to receive results and to benefit from treatment. Cost-effectiveness studies using rapid point-of-care tests for Neisseria gonorrhoeae infection compared to the syndromic approach should be carried out to assess their value in STI diagnosis and treatment in developing nations.

Efficacy of an HIV prevention program among female adolescents experiencing gender-based violence

OBJECTIVES

We examined the efficacy of an HIV prevention intervention among African American female adolescents reporting a history of gender-based violence.

METHODS

In this analysis of a subgroup of participants involved in a randomized controlled trial, consistent condom use, psychosocial mediators associated with HIV-preventive behaviors, and presence of sexually transmitted diseases were assessed at 6- and 12-month follow-ups. The intervention emphasized ethnic and gender pride, HIV knowledge, condom attitudes, healthy relationships, communication, and condom use skills.

RESULTS

Relative to the comparison condition, participants randomized to the intervention reported using condoms more consistently, had fewer episodes of unprotected vaginal sex, engaged in a greater proportion of protected intercourse acts, were more likely to have used a condom during their most recent intercourse, were less likely to have a new sexual partner, were less likely to have a sexually transmitted disease, and demonstrated more proficient condom skills.

CONCLUSIONS

Given the substantial prevalence of gender-based violence among female adolescents and the associations observed between gender-based violence, HIV risk, and HIV infection, it is essential that HIV interventions involving young women address partner violence.

Patterns of sexually transmitted infections in adolescents and youth in Dar es Salaam, Tanzania

BACKGROUND

Syndromic management of STIs has been advocated as simplified and cheap approach. Youth have been reported to be at increased risk of acquiring STIs which can facilitate HIV transmission. We have investigated the relationship between the syndromic management and specific aetiology diagnosis and its relationship with HIV infection and health seeking behaviour among youth attending a reproductive health clinic in Dar es Salaam, Tanzania.

METHODS

Between September 1998 and February 1999 among 1895 adolescents and youth below 25 years seen in the clinic 199 (10.5%) were randomly selected and consented to participate in the study. A standard questionnaire was administered. Blood and vaginal or urethral specimens were taken and investigated for STI causative agents.

RESULTS

Among a total of 199 studied adolescents and youth 22.6 % were teenagers, with fewer females 17.8% than males; 27.5% (p < 0.018). 20.8% of the females compared to 11.5% in males were HIV infected. Genital discharge was the most common complaint which was reported in 54.1% of male and 63.4 % of female patients. All males with gonorrhoea and four out of five with Chlamydia were given appropriate treatment with syndromic management, while 28% women with gonorrhoea or Chlamydia received appropriate treatment by syndromic management. All patients found with active syphilis by serology had not complained of genital ulcers and would not have been assigned to syndromic treatment for syphilis at the initial visit.

CONCLUSION

The burden of STIs in this youth population is large indicating that youth are at increased risk of STIs and will certainly require youth friendly clinics. There is a need to refine the current syndromic management guidelines.

Women find it easy and prefer to collect their own vaginal swabs to diagnose Chlamydia trachomatis or Neisseria gonorrhoeae infections

BACKGROUND

Self-collected specimens can be used to screen asymptomatic women for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC). We surveyed women's opinions on ease and preferences as to sampling after collecting their own vaginal swab and urine and a physician collection of vaginal swab and cervical swab.

METHODS

In 7 North American cities, a questionnaire was used for women after they participated in a clinical trial of nucleic acid amplification testing of various specimens. A total of 1,090 women consenting to gynecologic sampling for CT and GC (82% of those sampled) volunteered to complete the survey. We analyzed the data for ease of self-collection and preferences for a vaginal swab, urine, or cervical swab.

RESULTS

The average age was 26.6 years; 59.6% were black, 25.5% white, 11% Hispanic, 1.9% Asian, and 2% unknown. Thirty-five percent had more than one sex partner in the past 6 months, 84.9% had been previously tested for a sexually transmitted infection (STI), and 49.2% had experienced an STI. A total of 90.4% found it very easy to self-collect a vaginal swab. This was not influenced by age, education, or study site. Seventy-six percent preferred a vaginal swab over a pelvic examination, 60% over a urine collection, and 94% indicated that they would be tested more often if a vaginal swab was available.

CONCLUSION

Self-collected vaginal swabs were easy to collect and patients preferred them over urine and cervical swabs.

Diagnosis of sexually transmitted infections (STI) using self-collected non-invasive specimens

Paramount in control of transmission of sexually transmitted infections (STIs) is their prompt recognition and appropriate treatment. In countries where definitive diagnoses are difficult, a 'syndromic approach' to management of STIs is recommended and practiced, yet many STIs have common symptoms or are asymptomatic and therefore go undetected and untreated. This is of particular concern with the recognition that HIV transmission is increased with co-existent STIs: the attributable risk for each STI varying with the prevalence within a particular population. Hence, HIV public health prevention approaches must include STI preventative strategies to be effective. Even then, microbiological screening is incorporated into STI control strategies; lack of access to appropriate services (especially in rural and remote areas), reluctance of at-risk populations to attend for treatment, fear of invasive genital examinations, and lower sensitivities of conventional diagnostic assays reduces the effectiveness of such programmes. Therefore, accurate, cost-effective, reliable diagnostic assays (preferably those which can be used in the field) are needed to impact on the incidence of the various STIs, as well as HIV. With the advent of molecular technologies, including target and signal amplification methods, diagnoses of STIs have been revolutionised and allow the use of non or minimally invasive sampling techniques, some of which are self-collected by the patient, e.g. first-void urine, cervico-vaginal lavage, low vaginal swabs, and tampons. Most studies evaluating such self-sampling with molecular diagnostic techniques have demonstrated an equivalent or superior detection of STIs as compared to conventional sampling and detection methods. These sampling methods can also be used to determine prevalence of STIs in various populations, but particularly those with difficult access to medical care. In this article, the utility of self-sampling collection devices for detection of various STIs, particularly in women, is reviewed as one step towards formulating appropriate strategies in control of STIs, and which are especially suited for remote areas.

Vaginal swabs are the specimens of choice when screening for Chlamydia trachomatis and Neisseria gonorrhoeae: results from a multicenter evaluation of the APTIMA assays for both infections

BACKGROUND

Vaginal swabs were recently U.S. Food and Drug Administration-cleared for detecting Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) using Gen-Probe Incorporated's APTIMA COMBO2 Assay (AC2). We assessed the APTIMA CT Assay (ACT) for CT, APTIMA GC Assay (AGC) for GC, and AC2 for both organisms using patient- and clinician-collected vaginal swabs.

METHOD

Women attending family planning, obstetrics and gynecology, or sexually transmitted disease (STD) clinics had first-catch urines (FCUs), patient-collected vaginal swabs, clinician-collected vaginal swabs, and endocervical swabs tested by ACT, AGC, and AC2. A second endocervical swab and FCU were tested using BD ProbeTec (Becton Dickinson) for CT and GC. We calculated sensitivity and specificity using vaginal swabs to detect CT and GC.

RESULTS

Of 1,464 subjects enrolled, 180 had CT and 78 GC. ACT sensitivities and specificities for patient-collected vaginal swabs were 98.3% and 96.5%, respectively; for clinician-collected vaginal swabs, 97.2% and 95.2%, respectively. AGC sensitivities and specificities for patient-collected vaginal swabs were 96.1% and 99.3%, respectively; for clinician-collected vaginal swabs, 96.2% and 99.3%, respectively. AC2 results were similar. If an FCU tested positive for CT or GC, >94% of matching vaginal swabs were positive. Positive endocervical swabs showed slightly less concordance (>90% and >88%, respectively). More infected patients were identified using vaginal swabs than FCUs. With AC2, 171 CT-infected patients were identified using FCUs and 196 using patient-collected vaginal swabs. This difference was more pronounced for CT than for GC.

CONCLUSIONS

Vaginal swab specimens allowed sensitive and specific detection of CT and GC in the APTIMA assays. Vaginal swabs identified as many infected patients as endocervical swabs and more than FCUs, and may well be the specimen of choice for screening.

A randomized controlled trial to reduce HIV transmission risk behaviors and sexually transmitted diseases among women living with HIV: The WiLLOW Program

OBJECTIVE

To evaluate the efficacy of an intervention to reduce HIV transmission risk behaviors and sexually transmitted diseases (STDs) and enhance HIV-preventive psychosocial and structural factors among women living with HIV.

DESIGN

A randomized controlled trial of 366 women living with HIV in Alabama and Georgia.

INTERVENTION

The intervention emphasized gender pride, maintaining current and identifying new network members, HIV transmission knowledge, communication and condom use skills, and healthy relationships.

PRIMARY OUTCOME

Unprotected vaginal intercourse. OTHER OUTCOMES: Proportion never used condoms, incident STDs, psychosocial factors, and number of supportive network members.

RESULTS

Over the 12-month follow-up, women in the WiLLOW intervention, relative to the comparison, reported fewer episodes of unprotected vaginal intercourse (1.8 vs. 2.5; P = 0.022); were less likely to report never using condoms (odds ratio [OR] = 0.27; P = 0.008); had a lower incidence of bacterial infections (Chlamydia and gonorrhea) (OR = 0.19; P = 0.006); reported greater HIV knowledge and condom use self-efficacy, more network members, fewer beliefs that condoms interfere with sex, and fewer partner-related barriers to condom use; and demonstrated greater skill in using condoms.

CONCLUSION

This is the first trial to demonstrate reductions in risky sexual behavior and incident bacterial STDs and to enhance HIV-preventive psychosocial and structural factors among women living with HIV.

Nucleic acid amplification tests for gonorrhea and chlamydia: practice and applications

Nucleic acid amplification tests (NAATs), which are highly sensitive and specific, have provided the ability to use alternative sam-ple types for the diagnosis of sexually transmitted infections (STIs). Self-collected genital specimens, such as urine or even vaginal swabs, can now be accurately used to diagnose gonorrhea or chlamydia infections. In many cases, use of these sample types can decrease the necessity for a clinician to perform a pelvic examination on women or to collect a urethral swab from men, thus extending the diagnostic capability for detecting these infections to nonclinic screening venues. As most chlamydia infections and many gonorrhea infections are asymptomatic, the use of NAATs for self-collected samples greatly increases the types and numbers of patients that can be screened outside of clinic settings. Self-sampling also allows clinicians to easily screen patients in the clinic for STIs who are not presenting for pelvic or urogenital examinations. The application of NAATs to self-collected specimens has the potential to augment public health programs designed to control the epidemic of STIs in the community.

The Cost Effectiveness of Gonorrhea Screening in Urban Emergency Departments

BACKGROUND

The prevalence of gonorrhea (GC) among adolescent and young women attending some urban emergency departments (EDs) ranges from 1% to 7%, but historically screening has not been logistically practical.

GOAL

The primary goal of the study was to assess the cost effectiveness of GC screening in women ages 15 to 29, seeking care in urban EDs, using noninvasive or rapid point-of-care tests.

STUDY

We developed a state-transition Markov model to compare the net lifetime health consequences, costs, and cost effectiveness of routine ED care (no screening for women without genitourinary symptoms) to GC screening using 1 of 5 detection methods: Gram-stained smears of endocervical swab specimens, urine-based nucleic acid amplification tests (NAATs), NAATs performed on endocervical swabs, rapid immunochromotographic strip test (RIS) performed on clinician-collected vaginal swabs, and RIS on patient-collected vaginal swabs.

RESULTS

Screening women between 15 and 29 years of age using urine-based NAATs prevented 1247 cases of pelvic inflammatory disease (PID) and saved 177 US dollars per patient compared with no screening. Compared with urine-based NAAT, screening with RIS using clinician-obtained vaginal swabs prevented an additional 220 cases of PID and had an incremental cost effectiveness ratio of 6490 US dollars per quality-adjusted life year (QALY). Results were sensitive to assumptions about loss to follow-up, gonorrhea prevalence, and test costs.

CONCLUSION

Screening females aged 15 to 29 for gonorrhea in some urban EDs will prevent substantial reproductive morbidity. Screening with rapid, point-of-care tests is cost effective compared with other well-accepted preventive interventions.

Urine nucleic acid amplification tests for the diagnosis of sexually transmitted infections in clinical practice

PURPOSE OF REVIEW

With the advent of highly sensitive and specific nucleic acid amplification assays, this report will demonstrate that self-collected genital specimens, such as urine or even vaginal swabs can be accurately used to diagnose sexually transmitted infections.

RECENT FINDINGS

Use of self collected samples can eliminate the necessity of a clinician to perform a pelvic examination for women or collect a urethral swab for men, thus extending the diagnostic capability for sexually transmitted infections to non-clinic screening venues. As many sexually transmitted infections are asymptomatic, this ability to use self-sampling greatly increases the numbers of patients that can be screened, and has the potential to augment public health programs designed to control the epidemic of sexually transmitted infections in the community. Patient collected samples are highly acceptable, highly accurate, and are becoming widely used. Self-sampling also allows clinicians to easily screen patients in the clinic, who are not presenting for pelvic or urogenital examinations, for sexually transmitted infections.

SUMMARY

Highly accurate molecular tests and easily obtained self-collected urogenital samples represent the ideal combination for obtaining the public health goal of decreasing the sexually transmitted infection epidemic among sexually active persons in the United States today.

Associations between sexually transmitted disease diagnosis and subsequent sexual risk and sexually transmitted disease incidence among adolescents

BACKGROUND

Empiric evidence is lacking in regard to the subsequent sexually transmitted disease (STD)-associated risk behaviors of adolescents diagnosed and treated for an STD.

GOAL

The goal of this study was to prospectively identify associations between STD diagnosis and subsequent sexual risk and STD incidence among a sample of U.S. adolescents.

STUDY DESIGN

A cohort of 455 adolescents (age 15-21 years) was followed for 3 months. Adolescents were recruited from primary care clinics and through outreach activities.

RESULTS

A total of 10.8% were initially diagnosed with at least one STD. After adjusting for observed covariates, these adolescents (compared with those testing negative) were 2.8 times (P = 0.0001) more likely to be abstinent from sex and 2.2 times more likely to report always using condoms (P = 0.04). However, during the ensuing 3 months, they were approximately 2.4 times more likely to report having sex with multiple partners (P = 0.01), 8.9 times more likely to test positive for trichomonas (P = 0.009), and 3.0 times more likely to test positive for chlamydia (P = 0.04).

CONCLUSIONS

Compared with those testing negative, adolescents diagnosed with an STD may subsequently adopt safer sex behaviors, including abstinence. However, perhaps in part as a result of having sex with multiple partners, they might fail to practice safer sex behaviors stringently enough to avoid subsequent STD acquisition.

High prevalence of sexually transmitted diseases in young women seeking HIV testing in Rio de Janeiro, Brazil

BACKGROUND AND OBJECTIVES

Few data are available on the prevalence of and risk factors for sexually transmitted diseases (STDs) other than HIV in Brazil.

GOAL

The goal of this study was to determine the prevalence of HIV infection and other STDs in Brazilian women who seek HIV testing, investigate risk factors for these infections, and assess feasibility of screening in HIV test clinic settings.

STUDY DESIGN

We conducted a cross-sectional study of 200 women, aged 14 to 29 years, who attended an HIV testing site in central Rio de Janeiro. Participants completed a questionnaire and received testing for HIV, syphilis, chlamydia, and gonorrhea.

RESULTS

HIV and other STDs were common (HIV 8%, syphilis 6.5%, chlamydial infection 8%, and gonorrhea 9.5%). HIV was significantly associated with lower education and with having an HIV-infected partner. Other STDs were significantly associated with younger age at first intercourse, heavy alcohol consumption, and marijuana use.

CONCLUSION

STDs appear to be substantial health problems among young Brazilian women seeking HIV testing. HIV testing sites in Brazil should consider offering screening and treatment for STDs and substance abuse as part of their HIV prevention services.

Detection of Chlamydia trachomatis and Neisseria gonorrhoeae by strand displacement amplification and relevance of the amplification control for use with vaginal swab specimens

Vaginal swab specimens may be preferable to cervical swab or urine specimens for the detection of Chlamydia trachomatis and Neisseria gonorrhoeae because of the ease of specimen collection and transport. The purpose of this study was to evaluate whether vaginal swab specimens are equivalent to cervical swab specimens for the detection of N. gonorrhoeae and C. trachomatis by the Becton Dickinson strand displacement amplification assay (SDA) with the BDProbeTec ET instrument and then to evaluate the use of the amplification control in a clinical research setting. In the first phase, vaginal and cervical swab specimens were obtained from 455 symptomatic women aged 18 to 40 attending primary health care and sexually transmitted disease clinics. Thirty-nine specimens (8.6%) had true-positive results for N. gonorrhoeae and 37 specimens (8.1%) had true-positive results for C. trachomatis. The sensitivity of SDA was superior to that of culture for the detection of N. gonorrhoeae with vaginal swab specimens and equivalent to that of the Roche PCR for the detection of C. trachomatis with cervical swab specimens. In the second phase of the study, 1,411 consecutively collected vaginal swab specimens were evaluated, with 357 (25.3%) specimens giving indeterminate readings on the basis of the result for the amplification control. The prevalences of sexually transmitted pathogens in vaginal swab specimens with and without use of the amplification control were 6.0 and 5.8%, respectively, for C. trachomatis and 3.1 and 3.0%, respectively, for N. gonorrhoeae. Although, vaginal swab specimens were equivalent to cervical swab specimens for the detection of N. gonorrhoeae and C. trachomatis by SDA with respect to sensitivity, one in four vaginal swab specimens yielded an indeterminate result when the amplification control was used. The amplification control has limited value for use with vaginal swab specimens.

Vaginal swabs are appropriate specimens for diagnosis of genital tract infection with Chlamydia trachomatis

Because self-collected vaginal swabs (VS) are potentially very useful for screening asymptomatic women for Chlamydia trachomatis infection, a multicenter study evaluated that specimen with nucleic acid amplification tests (NAATs). The objective was to determine whether VS are equal to Food and Drug Administration (FDA)-cleared specimens (cervical swabs and first-catch urines [FCU]) for diagnosing genital chlamydial infection. All NAATs then commercially available (October 1996 to October 1999) were used (ligase chain reaction [LCx Probe System; Abbott Laboratories, Abbott Park, Ill.]; PCR [Amplicor; Roche Molecular Systems, Branchburg, N.J.]; and transcription-mediated amplification, [Amplified CT Assay; Gen-Probe Inc., San Diego, Calif.]). NAATs were performed on FCU, urethral, cervical, self- and clinician-collected VS. Sensitivity was compared to isolation using cervical and urethral swabs. Agreement of NAAT results between VS and cervical swabs or FCU was calculated. Specimens from 2,517 15- to 25-year-old asymptomatic women attending clinics at nine different centers were evaluated. Results with self- and clinician-collected VS were equivalent and were at least as good as results with FCU and cervical swabs. Across all sites, summary specificities for all specimens were >99%. Among culture-positive women, NAAT sensitivity with VS (93%) was as high as or higher than NAAT sensitivity with cervical swabs (91%) or FCU (80.6%) or culture of cervical swabs (83.5%). VS are appropriate specimens for diagnosing chlamydial genital tract infection by NAATs. That patients can efficiently collect them offers important benefits for screening programs. It would be beneficial for public health programs if the NAAT manufacturers sought FDA clearance for this specimen.

Female prisoners' preferences of collection methods for testing for Chlamydia trachomatis and Neisseria gonorrhoeae infection

BACKGROUND

There is an increasing reliance on noninvasive techniques to collect specimens for the detection of sexually transmitted infections. The acceptability of these methods among the general population has been explored, but little is known about their acceptability among women confined in prison.

GOAL

The goal was to compare female prisoners' preferences for collection of specimens (self-collected vaginal swab specimens, urine collection, or pelvic examination) for detection of Chlamydia trachomatis and Neisseria gonorrhoeae.

STUDY DESIGN

A cross-section of inmates in a large federal prison provided urine samples and self-collected vaginal swab specimens. Women then completed a questionnaire regarding the ease of each method and their preferences for future specimen collection.

RESULTS

A total of 535 women between the ages of 18 and 52 years (median = 33) participated in the study. More than half of the participants (57%) reported no difference between urine and swab in terms of ease of collection. Approximately 30% of participants said they would prefer to give a swab specimen in the future rather than collect urine (21%), but nearly half of the women expressed no preference for one method over the other. Most participants (60%) expressed a preference for providing a self-collected swab specimen rather than having a pelvic examination (23%), but nearly 17% expressed a preference for one over the other.

CONCLUSION

The study population of female federal prisoners expressed no aversion to the self-collection of either vaginal swab or urine specimens for STD testing. A majority of participants expressed a preference for noninvasive techniques rather than a pelvic examination.

Older partners and STD prevalence among pregnant African American teens

BACKGROUND

Several recent studies have addressed the question of whether adolescent females who have sex with older partners have a greater risk of sexually transmitted disease (STD) acquisition.

GOAL

The goal was to identify differences in STD prevalence and selected measures of behavioral risk between unmarried pregnant African American adolescent females reporting sex with older partners and those reporting sex with similar-age partners.

STUDY DESIGN

Adolescents (n = 169) were recruited during their first prenatal visit. Adolescents completed a self-administered survey and a face-to-face interview and provided urine specimens for nucleic acid amplification assays.

RESULTS

Approximately 65% of adolescents reported that their male sex partners were >/=2 years older, while 35% reported having similar-age male sex partners. In age-adjusted analyses, adolescents with older partners were four times more likely to test positive for chlamydia (P < 0.04) and were more than twice as likely to report that their partner was also having sex with other women (P < 0.04). With use of a 30-day recall period, the mean number of unprotected vaginal sexual encounters among adolescents with older partners was 4.1, as compared to a mean of 6.9 among those reporting similar-age partners; this difference approached significance (P = 0.051). Prevalence of trichomoniasis as well as scale measures of adolescents' self-efficacy for condom negotiation and frequency of sexual communication with partners did not differ between those adolescents with older or similar-age male sex partners.

CONCLUSION

In resource-constrained clinical settings, one implication of these findings is that pregnant adolescents reporting older partners may be a priority for targeted delivery of partner services. More frequent screening for chlamydia may also be cost-effective for pregnant adolescents with older partners.

Performance of the APTIMA Combo 2 assay for detection of Chlamydia trachomatis and Neisseria gonorrhoeae in female urine and endocervical swab specimens

The greater sensitivity of nucleic acid amplification tests (NAATs) for Chlamydia trachomatis and Neisseria gonorrhoeae permits the use of urine and other noninvasive specimens, which can increase the reach and decrease the costs of public health screening programs aimed at controlling these infections. This study evaluated the performance of the APTIMA Combo 2 assay, a multiplex assay based on the transcription-mediated amplification reaction, for the simultaneous detection of both pathogens in endocervical swab and urine specimens from females. Combo 2 assay results were compared with patient infected status, which were available by using other commercial NAATs. Sensitivity and specificity for C. trachomatis were 94.2 and 97.6%, respectively, in swabs and 94.7 and 98.9%, respectively, in first-catch urine (FCU). Sensitivity and specificity for N. gonorrhoeae were 99.2 and 98.7%, respectively, in swabs and 91.3 and 99.3%, respectively, in FCU. The assay reliably detected both infections in coinfected patients. The Combo 2 assay can be recommended for use with endocervical swab and urine specimens from females, especially for screening tests for asymptomatic women in sexually transmitted disease surveillance programs. This Food and Drug Administration-cleared assay can be a useful tool in efforts to reduce the prevalence and incidence of C. trachomatis and N. gonorrhoeae infections in sexually active women and to prevent their costly and serious sequelae.

Self-collected vaginal swabs for the detection of multiple sexually transmitted infections in adolescent girls

OBJECTIVE

To evaluate the use of self-collected vaginal swabs to test for Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis, and to describe the acceptability of this technique to adolescents.

DESIGN

Comparison of a new protocol for sexually transmitted infection (STI) testing with the current standard of care, using the same subjects. Survey of attitudes regarding the self-collection technique.

SETTING

A juvenile correctional facility in western Pennsylvania.

PARTICIPANTS

Convenience sample of 133 detainees, 12-17 years of age.

INTERVENTION

Girls were invited to undergo STI screening using a self-collected vaginal swab. Polymerase chain reaction was used to test this specimen for each of the above three infections. Pelvic exams and endocervical testing were performed at the discretion of the physician performing the intake physical, independent of the study.

MAIN OUTCOME MEASURES

The number of infections diagnosed using the self-testing protocol, compared to the number diagnosed using standard practices; acceptability of the self-collection technique.

RESULTS

Twenty-four percent of sexually active subjects had one or more infections diagnosed by self-testing: 11.3% had C. trachomatis, 8.5% had N. gonorrhoeae, and 11.7% had T. vaginalis. Only 30% of subjects with infections had pelvic exams while detained; therefore 70% of girls with infections would have been missed in the absence of the self-testing option. The self-collection technique was acceptable to 95% of subjects.

CONCLUSIONS

STI testing using self-collected vaginal specimens is highly acceptable to adolescent girls, and can dramatically increase the detection rate for these three treatable infections when pelvic exams are not performed.

Gang involvement and the health of African American female adolescents

OBJECTIVE

To examine the association between gang involvement and female adolescents' health.

METHODS

African American adolescent females (N = 522) completed a survey that assessed their history of gang involvement and health behaviors and provided specimens that were analyzed for marijuana use and sexually transmitted diseases.

RESULTS

In logistic regression analyses, adolescents with a history of gang involvement were more likely to have been expelled from school (odds ratio [OR]: 3.6), be a binge drinker (OR: 3.3), have a positive toxicologic test for marijuana (OR: 2.6), have been in 3 or more fights in the past 6 months (OR: 3.8), have a nonmonogamous partner (OR: 2.4), and test positive for Trichomonas vaginalis (OR: 2.2) and Neisseria gonorrhoeae (OR: 3.6).

CONCLUSION

This study extends the current research on risk behaviors associated with gang involvement to include biological markers for substance use and sexual health outcomes, namely, marijuana use and sexually transmitted diseases.

Duration of persistence of gonococcal DNA detected by ligase chain reaction in men and women following recommended therapy for uncomplicated gonorrhea

Neisseria gonorrhoeae infection remains relatively common in the United States, representing a public health challenge. Ligase chain reaction (LCR) is both highly sensitive and specific for the detection of N. gonorrhoeae in urine and patient-obtained vaginal swab specimens. Because of the LCR test's exquisite sensitivity, it may potentially detect DNA from nonviable organisms following effective therapy, leading to false-positive test results and unnecessary additional treatment. The purpose of the present study was to determine the duration that gonococcal DNA is detectable by LCR following therapy for uncomplicated gonococcal infection. One hundred thirty men and women between the ages of 16 and 50 years presenting to a sexually transmitted disease clinic with urogenital gonorrhea were enrolled. After the standard history was taken and a genital examination was done, the patients were asked to submit either a urine specimen (men) or a urine specimen plus a self-obtained vaginal swab specimen (women) for N. gonorrhoeae testing by LCR at the initial visit and each day during the study period. At enrollment, patients were treated with single doses of ofloxacin, cefixime, or ceftriaxone. The median time to a negative urine LCR test result was 1 day for the men (mean, 1.6 +/- 0.14 days) and 2 days for the women (mean, 1.7 +/- 0.19 days). Among the women the clearance time was significantly longer for vaginal specimens (mean, 2.8 +/- 0.30 days) than for urine specimens (mean, 1.7 +/- 0.11 days). Irrespective of patient gender and specimen type, gonococcal DNA can be expected to be absent from urogenital specimens within 2 weeks following successful therapy.

Association of adolescents' history of sexually transmitted disease (STD) and their current high-risk behavior and STD status: a case for intensifying clinic-based prevention efforts

BACKGROUND

Adolescents are at high risk of sexually transmitted disease (STD)/HIV infection, and one vulnerable subgroup is African American females. The association between adolescents' previous experience of STD and recent sexual risk behaviors has been ill-defined.

GOAL

The goal was to examine the associations between adolescents' self-reported history of STD diagnosis and current sexual risk behaviors, prevention knowledge and attitudes, and STD infection status.

STUDY DESIGN

This was a cross-sectional survey. Recruitment sites were in low-income neighborhoods of Birmingham, Alabama, characterized by high rates of unemployment, substance abuse, violence, and STDs. Participants were sexually active adolescent females (N = 522) 14 to 18 years of age. Information on STD history and current sexual behaviors (within the 30 days before assessment) was collected in face-to-face interviews. Less sensitive topics, such as STD prevention knowledge, attitudes about condom use, and perceived barriers to condom use, were addressed via self-administered survey. DNA amplification of vaginal swab specimens provided by the adolescents was performed to determine current STD status. Outcomes associated with past STD diagnosis were determined by means of logistic regression to calculate adjusted odds ratios (AORs) in the presence of observed covariates.

RESULTS

Twenty-six percent of adolescents reported ever having an STD diagnosed. Although past STD diagnosis was associated with increased STD prevention knowledge, it was not associated with increased motivation to use condoms. Compared with adolescents who had never had an STD, adolescents with a history of diagnosed STD were more likely to report not using a condom at most recent intercourse (AOR = 2.54; 95% CI = 1.64-3.93; = 0.0001), recent unprotected vaginal intercourse (AOR = 1.79; 95% CI = 1.15-2.79; = 0.010), inconsistent condom use (AOR = 2.27; 95% CI = 1.46-3.51; < .0001), sexual intercourse while drinking alcohol (AOR = 2.09; 95% CI = 1.33-3.28; = 0.001), and unprotected intercourse with multiple partners (AOR = 3.29; 95% CI = 1.09-9.89; = 0.034). Past STD diagnosis was associated with increased risk for current biologically confirmed gonorrhea and trichomoniasis (AOR = 2.48; 95% CI = 1.09-5.23; = 0.030; and AOR = 2.05; 95% CI = 1.18-3.59; = 0.011, respectively). Past STD diagnosis was not significantly associated with increased risk of current biologically confirmed chlamydia (AOR = 0.78; 95% CI = 0.45-1.37; = 0.38).

CONCLUSION

Among this sample of female adolescents, past STD diagnosis was an indicator of current high-risk sexual activity and increased risk for two common STDs: gonorrhea and trichomoniasis. Although adolescents may gain factual knowledge from the experience of having an STD diagnosed, they are not applying that knowledge to their current sexual behaviors. Thus, these adolescents remain at risk for subsequent STD infection. Therefore, the findings suggest that there is a need to intensify clinic-based prevention efforts directed toward adolescents with a history of STDs, as a strategy for reducing STD-associated risk behaviors and, consequently, the likelihood of new STD infections.

The diagnosis of chlamydia, gonorrhoea, and trichomonas infections by self obtained low vaginal swabs, in remote northern Australian clinical practice

OBJECTIVE

To examine the diagnostic performance of self obtained low vaginal swabs (SOLVS) and polymerase chain reaction (PCR) techniques in the diagnosis of Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), and Trichomonas vaginalis (TV) infection in a variety of clinical practice settings in remote north western Australia.

DESIGN

A cross sectional field study of microbiological collection techniques in women undergoing gynaecological investigation in remote settings performed by a variety of practitioner types over 10 months.

PARTICIPANTS AND SETTING

349 women from remote towns and communities in the Kimberley region of north west Western Australia having gynaecological examinations for clinical reasons, well women screening, antenatal screening, and sexual health examinations.

RESULTS

The overall prevalence of infection in the study population based on any positive conventional sample was 9.2%, 7.6%, and 16.1% for CT, NG, and TV respectively. The detection rates for CT and NG by SOLVS were 89% and 96% respectively, compared with 79% and 91% for endocervical swabs and 79% and 83% for first void urine. SOLVS had a sensitivity of 93% for TV detection, equal to that of clinician obtained low vaginal swabs. None of these differences reached statistical significance. A combination of SOLVS and first void urine detected 96% of the CT cases, 100% of the NG cases, and 96% of TV cases.

CONCLUSIONS

Self obtained low vaginal swabs are an acceptable, simple and sensitive diagnostic sample for the detection of CT, NG, and TV, and have particular applications in remote clinical practice and as a screening technique.

Associations between biologically confirmed marijuana use and laboratory-confirmed sexually transmitted diseases among African American adolescent females

BACKGROUND

Numerous studies have examined the association between adolescents' marijuana use and their high-risk sexual behaviors and sexually transmitted diseases (STDs). However, the validity of the findings is questionable because most of the studies relied on self-reporting for measurement of marijuana use and key outcome (i.e., STDs).

GOAL

The goal was to investigate associations between biologically confirmed marijuana use and laboratory-confirmed STDs and condom use.

STUDY DESIGN

African American females adolescents (n = 522) completed a self-administered survey and face-to-face interview. The adolescents provided urine and vaginal swab specimens that were analyzed for marijuana metabolites and STDs, respectively.

RESULTS

Among the study subjects, 5.4% tested positive for marijuana. These adolescents were more likely to test positive for Neisseria gonorrhoeae (adjusted odds ratio [AOR] = 3.4) and Chlamydia trachomatis (AOR = 3.9). They were more likely to have never used condoms in the previous 30 days (AOR = 2.9) and to have not used condoms consistently in the previous 6 months (AOR = 3.6).

CONCLUSION

The findings represent unique biologic evidence that STDs and sexual risk behavior may co-occur with marijuana use. Interventions designed to reduce adolescents' risk of STDs and HIV infection should address marijuana use.

Pregnant African-American teens are less likely than their nonpregnant peers to use condoms

OBJECTIVE

The aim of this study was to prospectively compare pregnant and nonpregnant adolescents' recent condom use and sexually transmitted disease (STD) acquisition.

METHODS

Sexually active African-American females (N = 522), ages 14-18, were recruited from clinics and schools. Adolescents completed baseline interviews and provided vaginal swabs for STD testing, and urine for pregnancy testing. Assessments were repeated 6 and 12 months post baseline assessment. Analyses compared adolescents who became pregnant between baseline and the 6-month assessment with their peers who had negative pregnancy tests. Condom use between the 6- and 12-month assessments and incidence of STDs at the 12-month assessment served as outcomes. Adolescents who did not report sexual activity between the 6- and 12-month assessments were excluded.

RESULTS

Ten percent of the adolescents became pregnant and continued sexual activity. Pregnant adolescents reported less overall condom use (P < 0.0001), more infrequent condom use (adjusted odds ratio [AOR] = 4.5, P < 0.001), and more unprotected vaginal sex (AOR = 4.7, P < 0.003). Pregnant adolescents were equally likely to test positive for STDs (31% vs 26%) and to self-report having STDs at the 12-month follow-up period (30% vs 23%).

CONCLUSIONS

Findings suggest that pregnant adolescents may be less likely to use condoms than their nonpregnant peers and that STD incidence among pregnant adolescents may be high. Condom use promotion may be important during adolescents' prenatal care.

The Use of Urine and Self-obtained Vaginal Swabs for the Diagnosis of Sexually Transmitted Diseases

Studies have reported that self-collected specimens, such as urine or vaginal swabs, can be successfully used to diagnose sexually transmitted infections when they are used with nucleic acid amplification assays. This eliminates the necessity for a clinician-performed pelvic examination for women, or a urethral swab for men, for sample collection. These nucleic acid amplification assays used with self-collected specimens are highly sensitive and specific, and their use may be extended to broad nonclinic screening venues, where their use can augment public health programs designed to control the epidemic of sexually transmitted diseases.

Evaluation of dry and wet transported intravaginal swabs in detection of Chlamydia trachomatis and Neisseria gonorrhoeae infections in female soldiers by PCR

Screening women for sexually transmitted diseases (STD) in nonclinic settings is highly desirable because many infections are asymptomatic. This is especially true for military women, for whom logistical, social, and other job-related obstacles present barriers to accessing medical care. We assessed the accuracy of intravaginal swabs transported by mail in a wet versus a dry state for PCR (Amplicor CT/NG test) detection of chlamydia and gonorrhea infections in a cross-sectional study of 793 active-duty military women attending an STD clinic. PCR tests of vaginal swabs (wet and dry) were compared to local clinical methods used on cervical swabs. Standard wet vaginal swab PCR testing detected more chlamydia (11.6%) than cervical enzyme immunoassay (9.3%). For detection of chlamydia using wet swabs, the sensitivity and specificity compared with adjudicated true positives were 94.6% (87 of 92) and 99.3% (696 of 701), respectively. Comparing dry swabs to true-positives for chlamydia, the sensitivity was 91.3% (84 of 92) and the specificity was 99.3% (696 of 701). Standard wet vaginal swab PCR detected more gonorrhea (3.3%) than routine cervical culture (2.1%). The sensitivity and specificity of PCR testing of wet swabs compared to true-positives (infected patients) were 96.3% (26 of 27) and 98.2% (752 of 766) for gonorrhea, respectively. For gonorrhea, the sensitivity and specificity of dry swabs compared to true-positives (infected patients) were 88.9% (24 of 27) and 98.3% (753 of 766), respectively. PCR testing of wet and dry transported intravaginal swabs to detect chlamydia and gonorrhea infections was an accurate diagnostic method for military women.

Comparison of Digene hybrid capture 2 and conventional culture for detection of Chlamydia trachomatis and Neisseria gonorrhoeae in cervical specimens

Digene's Hybrid Capture 2 (HC2) CT/GC, CT-ID, and GC-ID DNA tests were evaluated by comparison to traditional culture methods for detecting Chlamydia trachomatis and Neisseria gonorrhoeae infections in 669 cervical specimens from high-risk female populations attending two sexually transmitted disease clinics. For detection of either or both infections, the HC2 CT/GC test algorithm had 93.8% sensitivity and 95.9% specificity compared to those of culture. After resolution of discrepant results by direct fluorescent-antibody (DFA) staining or PCR assay, the relative sensitivity and specificity of the HC2 CT/GC test algorithm increased to 94.8 and 99.8%, while the values for culture were 83.6% (McNemar's P value, 0.0062) and 100%, respectively. For detection of the individual pathogens, the relative sensitivities for the HC2 CT-ID and GC-ID tests were 97.2 and 92.2% and the specificities were greater than 99% compared to culture adjucated by DFA staining and PCR. Test performance varied at the two clinics: the HC2 CT/GC algorithm, CT-ID, and GC-ID tests had significantly higher sensitivities (McNemar's P value, <0.05) than that of culture for the population at one clinic as well as for the combined populations. At the other clinic, the HC2 tests performed as well as culture.

Comparison of Digene hybrid capture 2 and conventional culture for detection of Chlamydia trachomatis and Neisseria gonorrhoeae in cervical specimens

Digene's Hybrid Capture 2 (HC2) CT/GC, CT-ID, and GC-ID DNA tests were evaluated by comparison to traditional culture methods for detecting Chlamydia trachomatis and Neisseria gonorrhoeae infections in 669 cervical specimens from high-risk female populations attending two sexually transmitted disease clinics. For detection of either or both infections, the HC2 CT/GC test algorithm had 93.8% sensitivity and 95.9% specificity compared to those of culture. After resolution of discrepant results by direct fluorescent-antibody (DFA) staining or PCR assay, the relative sensitivity and specificity of the HC2 CT/GC test algorithm increased to 94.8 and 99.8%, while the values for culture were 83.6% (McNemar's P value, 0.0062) and 100%, respectively. For detection of the individual pathogens, the relative sensitivities for the HC2 CT-ID and GC-ID tests were 97.2 and 92.2% and the specificities were greater than 99% compared to culture adjucated by DFA staining and PCR. Test performance varied at the two clinics: the HC2 CT/GC algorithm, CT-ID, and GC-ID tests had significantly higher sensitivities (McNemar's P value, <0.05) than that of culture for the population at one clinic as well as for the combined populations. At the other clinic, the HC2 tests performed as well as culture.

Neisseria gonorrhoeae and Chlamydia trachomatis infections in patients attending STD and family planning clinics in Bissau, Guinea-Bissau

Accurate clinical and laboratory data about sexually transmitted diseases (STD) prevalence in Guinea-Bissau are not available. These data are important, since HIV2 is prevalent in this country, rates of HIV1 are increasing and STDs facilitate HIV transmission. Since DNA amplification methods have demonstrated to accurately diagnose chlamydial infections and gonorrhoea, the Amplicor CT/NG PCR Assay with Internal Control of Amplification (Roche Diagnostic System, Branchburg, NJ, USA) was used to estimate the prevalence of Neisseria gonorrhoeae and Chlamydia trachomatis genital infections in STDs and Family Planning Clinic attenders in Bissau, from March to July 1997. Two hundred and two cervical swabs and 31 urethral swabs were examined. Two women were excluded from this study because their cervical swabs contained inhibitory substances. N. gonorrhoeae was identified in 34/200 (17%) women and in 12/31 (38.7%) men. C. trachomatis was detected in 8/200 (4%) women there were no positive C. trachomatis results among the 31 men with urethritis. One woman presented a mixed infection with both organisms. The prevalence difference between men and women was not statistically significant (P=0.6) for C. trachomatis infection, but it was significant for N. gonorrhoeae infection (P=0.01). The prevalence rates of these infections found in this study, support the need for an urgent strategy to control STD in the region.

Evaluation of use of a single intravaginal swab to detect multiple sexually transmitted infections in active-duty military women

The accuracy and suitability of use of a single intravaginal swab (SIS) for polymerase chain reaction detection of Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, and human papillomavirus infection was assessed in a cross-sectional study of 841 active-duty military women. The SIS, compared with standard diagnostic tests, allowed detection of more gonorrhea, more chlamydial infection, and more trichomoniasis. Sensitivity and specificity of SIS detection compared with adjudicated true-positive diagnoses were 95.8% and 97.8%, respectively, for gonorrhea, 94.6% and 99.3% for chlamydial infection, and 92.2% and 98.2% for trichomonal infection. Results with SISs were comparable to those with cervical swabs tested for human papillomavirus. Assay of clinician-collected and self-collected SISs yielded prevalences similar to those of standard diagnostic tests for all sexually transmitted infections. Therefore, the use of SISs is acceptable for the simultaneous diagnosis of multiple sexually transmitted infections and has potential for use as a self-administered diagnostic tool with widespread applicability among women.

Validity of self-reported sexually transmitted diseases among African American female adolescents participating in an HIV/STD prevention intervention trial

BACKGROUND

Studies assessing the validity attributed to self-reported measures of sexually transmitted diseases (STDs) clearly are needed, particularly those used for high-risk populations such as female adolescents, in whom STD prevention is a priority.

GOAL

To determine the accuracy of self-reported STD test results in female adolescents over a relatively brief period ( approximately 28 days).

STUDY DESIGN

A prospective, randomized, controlled clinical trial of STD/HIV prevention for African American females, ages 14 to 18, was conducted. Study participants were recruited from medical clinics and school health classes in low-income neighborhoods of Birmingham, Alabama, that had high rates of unemployment, substance abuse, violence, STDs, and teenage pregnancy.

RESULTS

Of the 522 adolescents enrolled in the trial, 92% (n = 479) completed baseline STD testing and follow-up surveys. At baseline, 28% had positive test results for at least one disease: 4.8% for Neisseria gonorrhoeae, 17.1% for Chlamydia trachomatis, and 12.3% for Trichomonas vaginalis. Of the adolescents with negative STD test results, 98.8% were accurate in their self-report of STD status, as compared with 68.7% of the adolescents with positive results. Underreporting varied by type of STD. Adolescents who accurately reported their positive STD status were significantly more likely to report their receipt of treatment accurately (P < 0.001).

CONCLUSIONS

The substantial underreporting of STD incidence in this study suggests that reliance on self-reports of STD history may introduce misclassification bias, potentially leading to false conclusions regarding the efficacy of prevention interventions. This observation highlights the importance of using biologic indicators as outcome measures.

Condom carrying is not associated with condom use and lower prevalence of sexually transmitted diseases among minority adolescent females

BACKGROUND

Most of the studies associated with condom carrying and use have been conducted with adults. Because minority teenage females are particularly at risk for STD/HIV infection, further investigations specifically focusing on this population are warranted.

GOAL

To determine whether observed condom carrying among adolescent females was associated with multiple measures of self-reported condom use, self-reported history of sexually transmitted diseases, and prevalence of biologically confirmed sexually transmitted diseases.

METHODS

For this study, 522 sexually active African American adolescent females were recruited from low-income neighborhoods in Birmingham, Alabama. Measures of self-reported condom use, STD history, and condom carrying were collected. Adolescents were also tested for three prevalent sexually transmitted diseases.

RESULTS

At the time of the assessment, 8% of the adolescents were observed to have a condom with them. Condom carrying was not found to be significantly associated with condom use and prevalence of sexually transmitted diseases.

CONCLUSION

Condom carrying may not be an important outcome of sexually transmitted disease/HIV prevention programs designed to reduce HIV/sexually transmitted disease risk among adolescent females.

Parental monitoring: association with adolescents' risk behaviors

CONTEXT

Contemporary threats to adolescents' health are primarily the consequence of risk behaviors and their related adverse outcomes. Identifying factors associated with adolescents' risk behaviors is critical for developing effective prevention strategies. A number of risk factors have been identified, including familial environment; however, few studies have examined the impact of parental monitoring.

OBJECTIVE

To examine the influence of less perceived parental monitoring on a spectrum of adolescent health-compromising behaviors and outcomes. Design. Survey.

SETTING

A family medicine clinic. Participants. To assess eligibility, recruiters screened a sample of 1130 teens residing in low-income neighborhoods. Adolescents were eligible if they were black females, between the ages of 14 and 18 years, sexually active in the previous 6 months, and provided written informed consent. Most teens (n = 609) were eligible, with 522 (85.7%) agreeing to participate.

MAIN OUTCOME MEASURES

Variables in 6 domains were assessed, including: sexually transmitted diseases, sexual behaviors, marijuana use, alcohol use, antisocial behavior, and violence.

RESULTS

In logistic regression analyses, controlling for observed covariates, adolescents perceiving less parental monitoring were more likely to test positive for a sexually transmitted disease (odds ratio [OR]: 1.7), report not using a condom at last sexual intercourse (OR: 1.7), have multiple sexual partners in the past 6 months (OR: 2.0), have risky sex partners (OR: 1.5), have a new sex partner in the past 30 days (OR: 3.0), and not use any contraception during the last sexual intercourse episode (OR: 1.9). Furthermore, adolescents perceiving less parental monitoring were more likely to have a history of marijuana use and use marijuana more often in the past 30 days (OR: 2.3 and OR: 2.5, respectively); a history of alcohol use and greater alcohol consumption in the past 30 days (OR: 1.4 and OR: 1.9, respectively); have a history of arrest (OR: 2.1); and there was a trend toward having engaged in fights in the past 6 months (OR: 1.4).

CONCLUSIONS

The findings demonstrate a consistent pattern of health risk behaviors and adverse biological outcomes associated with less perceived parental monitoring. Additional research needs to focus on developing theoretical models that help explain the influence of familial environment on adolescent health and develop and evaluate interventions to promote the health of adolescents.

Detection of Chlamydia trachomatis and Neisseria gonorrhoeae by enzyme immunoassay, culture, and three nucleic acid amplification tests

The purpose of this study was to evaluate and compare three commercially available nucleic acid amplification tests (NAATs) for the detection of Neisseria gonorrhoeae and Chlamydia trachomatis. Roche PCR and Becton Dickinson strand displacement amplification (SDA) were performed on 733 endocervical swab specimens from commercial sex workers. Abbott ligase chain reaction (LCR) was performed on a subset of 396 samples. Endocervical specimens from all women were also tested by culture for N. gonorrhoeae and by Syva MicroTrak enzyme immunoassay (EIA) for C. trachomatis. A positive N. gonorrhoeae result was defined as a positive result by culture or by two NAATs, and a positive C. trachomatis result was defined as a positive result by two tests. According to these definitions, the sensitivities and specificities for the subsample of 396 specimens of N. gonorrhoeae culture, PCR, SDA, and LCR were 69.8, 95.2, 88.9, and 88.9% and 100, 99.4, 100, and 99.1%, respectively; the sensitivities and specificities of C. trachomatis EIA, PCR, SDA, and LCR were 42.0, 98.0, 94.0, and 90.0% and 100, 98.0, 100, and 98.6%, respectively. The performance characteristics of N. gonorrhoeae culture, PCR, and SDA and C. trachomatis EIA, PCR, and SDA for all 733 specimens were defined without inclusion of LCR results and by discrepant analysis after resolution of discordant N. gonorrhoeae PCR results and of discordant C. trachomatis EIA and PCR results by LCR testing. The sensitivities of N. gonorrhoeae culture, PCR, and SDA before and after LCR resolution were 67.8, 95.7, and 93.9% and 65, 95.8, and 90.0%, respectively. The sensitivities of C. trachomatis EIA, PCR, and SDA decreased from 39.4, 100, and 100% to 38.7, 98.7, and 94.7%, respectively. All three NAATs proved to be superior to N. gonorrhoeae culture and to C. trachomatis EIA. The accuracies of the different NAATs were quite similar. SDA was the only amplification assay with 100% specificity for detection of both N. gonorrhoeae and C. trachomatis in endocervical specimens.

Exposure to X-rated movies and adolescents' sexual and contraceptive-related attitudes and behaviors

OBJECTIVES

To examine the association between exposure to X-rated movies and teens' contraceptive attitudes and behaviors.

METHODS

Black females, 14 to 18 years old (n = 522) were recruited from adolescent medicine clinics, health departments, and school health clinics.

RESULTS

Exposure to X-rated movies was reported by 29.7% of adolescents. Exposure to X-rated movies was associated with being more likely to have negative attitudes toward using condoms (odds ratio [OR]: 1.4), to have multiple sex partners (OR: 2.0), to have sex more frequently (OR: 1.8), to not have not used contraception during the last intercourse (OR: 1.5), to have not used contraception in the past 6 months (OR: 2.2), to have a strong desire to conceive (OR: 2.3), and to test positive for chlamydia (OR: 1.7).

CONCLUSIONS

Additional research is needed to understand the impact of X-rated movies on adolescents' sexual and contraceptive health.

Impact of New Sexually Transmitted Disease Diagnostics on Clinical Practice and Public Health Policy

Nucleic acid amplification tests (NAAT) offer enhanced sensitivity and excellent specificity for many sexually transmitted diseases. For some pathogens for which a practical diagnostic test does not exist, such as human papillomavirus (HPV), NAAT are also useful. Further, most NAAT can be applied to less "invasive" patient specimens, including urine and vaginal fluid. This dramatically increases opportunities to test persons outside of traditional clinic settings. Use of NAAT has resulted in revisions of the proportion of sexually transmitted diseases (STDs) that are asymptomatic, and has increased measured prevalence of some STDs, notably Chlamydia trachomatis. NAAT have helped to clarify the eitiologies of genital ulcer disease and urethritis, and have provided a more complete picture of the natural history of genital herpes and HPV. The ability of polymerase chain reaction to detect HPV may change the management of patients who have abnormal Pap smears. Efforts to bear the relatively high cost of NAAT, such as pooling urine, are under study. NAAT for bacterial STD should be in populations at high risk for asymptomatic STD, especially those who might not access routine STD screening at traditional settings. Working through the cost to health care systems, including the public health arena, and implementation at the laboratory level are challenges to overcome before NAAT become the standard of care in most settings.