Geomapping of chlamydia and gonorrhoea in Birmingham

Individual- and Community-Level Factors in the STD Status of Justice-Involved Youth: Multi-Group, Exploratory Two-Level Analysis

Justice-involved youth display higher prevalence rates of sexually transmitted diseases (STDs), in comparison with youth in the general population, highlighting a critical public health concern. Individual factors are important predictors of STDs, but only provide a partial understanding of this public health issue. Communities experiencing higher levels of disorder and lower levels of cohesion tend to have fewer institutional resources available, which may impact sexual risk behavior and STDs. However, few studies have examined the association between community characteristics and STD prevalence among adolescents. The current study examined community-level (n = 106) characteristics and individual-level attributes in explaining STDs among justice-involved youth (n = 1233: n = 515 female; n = 718 male). At the individual level, results showed older males and those with more drug-related problems were more likely to be STD positive, while females with more sexual partners and those with less drug-related problems were more likely to be STD positive. At the community level, females residing in areas with fewer educated residents were more likely to be STD positive. These gender differences were significant, suggesting a gendered perspective is important for understanding STD infection. The justice system represents a critical opportunity in the treatment and prevention of STDs for youth.

Love moderates the relationship between partner type and condom use among women engaging in transactional vaginal sex

Background Relationship characteristics and day-to-day variation in affective state have been associated with HIV risk behaviour. However, no research has assessed the impact of these factors on event-level condom use among women engaging in transactional sex.

METHODS

Twenty-six women engaging in transactional sex were enrolled in a prospective study of their sexual health. They completed diaries about multi-level predictors of condom use during vaginal sex twice, daily.

RESULTS

Over 4 weeks, 18 participants reported 87 paid/traded vaginal intercourse events. Of these, 51.7% were condom protected. The majority of paid/traded events (81.5%) occurred with a non-romantic partner. After controlling for partner type, feeling in love on a given day was associated with higher odds of condom use during paid/traded sexual events, while having sex on the weekend and at night were associated with lower odds of condom use (all P≤0.05). There was a significant interaction between being in love and using condoms during transactional sex (P<0.01). In paid/traded sexual events with romantic partners, the frequency of condom use was 71.4% (5/7) when women did not report love and 40% (4/10) when love was reported. In sexual events with non-romantic partners, the frequency of condom use was 43.8% (14/32) when women did not report love and 59.5% (22/37) when love was reported.

CONCLUSIONS

Women were less likely to report protected sex with romantic partners and more likely to report protected sex with non-romantic partners when they are in love. Interventions focusing on the link between day-to-day variation in affective state on condom use may help women with risk management across partner types.

Ethnicity and sexual risk in heterosexual people attending sexual health clinics in England: a cross-sectional, self-administered questionnaire study

Objectives

In the UK, people of black ethnicity experience a disproportionate burden of HIV and STI. We aimed to assess the association of ethnicity with sexual behaviour and sexual health among women and heterosexual men attending genitourinary medicine (GUM) clinics in England.

Methods

The Attitudes to and Understanding of Risk of Acquisition of HIV is a cross-sectional, self-administered questionnaire study of HIV negative people recruited from 20 GUM clinics in England, 2013–2014. Modified Poisson regression with robust SEs was used to calculate adjusted prevalence ratios (aPR) for the association between ethnicity and various sexual risk behaviours, adjusted for age, study region, education and relationship status.

Results

Questionnaires were completed by 1146 individuals, 676 women and 470 heterosexual men. Ethnicity was recorded for 1131 (98.8%) participants: 550 (48.6%) black/mixed African, 168 (14.9%) black/mixed Caribbean, 308 (27.2%) white ethnic groups, 105 (9.3%) other ethnicity. Compared with women from white ethnic groups, black/mixed African women were less likely to report condomless sex with a non-regular partner (aPR (95% CI) 0.67 (0.51 to 0.88)), black/mixed African and black/mixed Caribbean women were less likely to report two or more new partners (0.42 (0.32 to 0.55) and 0.44 (0.29 to 0.65), respectively), and black/mixed Caribbean women were more likely to report an STI diagnosis (1.56 (1.00 to 2.42)). Compared with men from white ethnic groups, black/mixed Caribbean men were more likely to report an STI diagnosis (1.91 (1.20 to 3.04)), but did not report risk behaviours more frequently. Men and women of black/mixed Caribbean ethnicity remained more likely to report STI history after adjustment for sexual risk behaviours.

Discussion

Risk behaviours were reported less frequently by women of black ethnicity; however, history of STI was more prevalent among black/mixed Caribbean women. In black/mixed Caribbean men, higher STI history was not explained by ethnic variation in reported risk behaviours. The association between STI and black/mixed Caribbean ethnicity remained after adjustment for risk behaviours.

Reducing Missed Opportunities: Pairing Sexually Transmitted Infection Screening With Syringe Exchange Services

About 17.5% of sexually active injection drug users recruited from a syringe exchange in Camden, NJ (n = 120) screened positive for chlamydia/gonorrhea. Among these cases, 40% were detected via extragenital screening. This pilot demonstrates that colocating sexually transmitted infection control with syringe exchange leads to sexually transmitted infection case finding.

Strategies and methodological basics for prevention of sexually transmitted infections in the high-risk subpopulations

A review article presents theoretical basics of the development of innovative STI prevention programs for high-risk groups Urgent need for integrated multidisciplinary preventive strategies aimed at correcting risky behaviors and adapted for the particular vulnerable populations is justified.

Care Seeking Behaviour and Barriers to Accessing Services for Sexual Health Problems among Women in Rural Areas of Tamilnadu State in India

Background. Sexually transmitted infections (STIs) may be either asymptomatic or symptomatic. Regardless of the presence or absence of symptoms all STIs can lead to major complications if left untreated. Objective. To assess the care seeking behaviour and barriers to accessing services for sexual health problems among young married women in rural areas of Thiruvarur district of Tamil Nadu state in India. Methods. A community based cross-sectional study was conducted in 28 villages selected using multistage sampling technique for selecting 605 women in the age group of 15–24 years during July 2010–April 2011. Results. The prevalence rate of reproductive tract infections (RTIs) and STIs was observed to be 14.5% and 8.8%, respectively, among the study population. Itching/irritation over vulva, thick white discharge, discharge with unpleasant odor, and frequent and uncomfortable urination were most commonly experienced symptoms of sexual health problems. Around three-fourth of the women received treatment for sexual health problems. Perception of symptoms as normal, feeling shy, lack of female health workers, distance to health facility, and lack of availability of treatment were identified as major barriers for not seeking treatment for RTIs/STIs. Conclusion. Family tradition and poor socioeconomic conditions of the family appear to be the main reasons for not utilizing the health facility for sexual health problems. Integrated approach is strongly suggested for creating awareness to control the spread of sexual health problems among young people.

Using the theory of planned behaviour and self-identity to explain chlamydia testing intentions in young people living in deprived areas

OBJECTIVES

The study sought to (1) explain intentions to get tested for chlamydia regularly in a group of young people living in deprived areas using the theory of planned behaviour (TPB); and (2) test whether self-identity explained additional variance in testing intentions.

DESIGN

A cross-sectional design was used for this study.

METHODS

Participants (N = 278, 53% male; M = 17.05 years) living in deprived areas of a UK city were recruited from a vocational education setting. Participants completed a self-administered questionnaire, including measures of attitude, injunctive subjective norm, descriptive norm, perceived behavioural control, self-identity, intention and past behaviour in relation to getting tested for chlamydia regularly.

RESULTS

The TPB explained 43% of the variance in chlamydia testing intentions with all variables emerging as significant predictors. However, self-identity explained additional variance in intentions (ΔR(2)  = .22) and emerged as the strongest predictor, even when controlling for past behaviour.

CONCLUSIONS

The study identified the key determinants of intention to get tested for chlamydia regularly in a sample of young people living in areas of increased deprivation: a hard-to-reach, high-risk population. The findings indicate the key variables to target in interventions to promote motivation to get tested for chlamydia regularly in equivalent samples, amongst which self-identity is critical.

STATEMENT OF CONTRIBUTION

What is already known on this subject? Young people living in deprived areas have been identified as an at-risk group for chlamydia. Qualitative research has identified several themes in relation to factors affecting the uptake of chlamydia testing, which fit well with the constructs of the Theory of Planned Behaviour (TPB). Identity concerns have also been identified as playing an important part in young people's chlamydia testing decisions. What does this study add? TPB explained 43% of the variance in chlamydia testing intentions and all variables were significant predictors. Self-identity explained additional 22% of the variance in intentions and emerged as the strongest predictor. Indicates key variables to target in interventions to promote regular chlamydia testing in deprived young people.

Does core area theory apply to sexually transmitted diseases in rural environments?

BACKGROUND

Our objective was to determine the extent to which geographical core areas for gonorrhea and syphilis are located in rural areas as compared with urban areas.

METHODS

Incident gonorrhea (January 1, 2005-December 31, 2010) and syphilis (January 1, 1999-December 31, 2010) rates were estimated and mapped by census tract and quarter. Rurality was measured using percent rural and rural-urban commuting area (rural, small town, micropolitan, or urban). SaTScan was used to identify spatiotemporal clusters of significantly elevated rates of infection. Clusters lasting 5 years or longer were considered core areas; clusters of shorter duration were considered outbreaks. Clusters were overlaid on maps of rurality and qualitatively assessed for correlation.

RESULTS

Twenty gonorrhea core areas were identified: 65% were in urban centers, 25% were in micropolitan areas, and the remaining 10% were geographically large capturing combinations of urban, micropolitan, small town, and rural environments. Ten syphilis core areas were identified with 80% in urban centers and 20% capturing 2 or more rural-urban commuting areas. All 10 (100%) of the syphilis core areas overlapped with gonorrhea core areas.

CONCLUSIONS

Gonorrhea and syphilis rates were high for rural parts of North Carolina; however, no core areas were identified exclusively for small towns or rural areas. The main pathway of rural sexually transmitted disease (STI) transmission may be through the interconnectedness of urban, micropolitan, small town, and rural areas. Directly addressing STIs in urban and micropolitan communities may also indirectly help address STI rates in rural and small town communities.

Comparability of results from pair and classical model formulations for different sexually transmitted infections

The "classical model" for sexually transmitted infections treats partnerships as instantaneous events summarized by partner change rates, while individual-based and pair models explicitly account for time within partnerships and gaps between partnerships. We compared predictions from the classical and pair models over a range of partnership and gap combinations. While the former predicted similar or marginally higher prevalence at the shortest partnership lengths, the latter predicted self-sustaining transmission for gonorrhoea (GC) and Chlamydia (CT) over much broader partnership and gap combinations. Predictions on the critical level of condom use (C(c)) required to prevent transmission also differed substantially when using the same parameters. When calibrated to give the same disease prevalence as the pair model by adjusting the infectious duration for GC and CT, and by adjusting transmission probabilities for HIV, the classical model then predicted much higher C(c) values for GC and CT, while C(c) predictions for HIV were fairly close. In conclusion, the two approaches give different predictions over potentially important combinations of partnership and gap lengths. Assuming that it is more correct to explicitly model partnerships and gaps, then pair or individual-based models may be needed for GC and CT since model calibration does not resolve the differences.

The importance of distinguishing between black Caribbeans and Africans in understanding sexual risk and care-seeking behaviours for sexually transmitted infections: evidence from a large survey of people attending genitourinary medicine clinics in England

BACKGROUND

In the UK, black Caribbean and African populations experience disproportionately high rates of sexually transmitted infections (STIs) and HIV. Often studies do not differentiate between these populations notwithstanding differences in STI epidemiology and sociodemographics.

METHODS

Patterns of care-seeking behaviour for STIs were explored separately for black Caribbean (n = 345), black African (n = 193) and white people through a cross-sectional survey of 2824 people attending five genitourinary medicine (GUM) clinics in England.

RESULTS

Black Caribbean men were least likely to use, or try to use, their general practice surgery prior to GUM clinic attendance (16.6%). Symptomatic black Caribbean and African men were least likely to delay seeking care (30.8 and 26.3%, respectively). Symptomatic black Caribbean men faced the least provider delay in accessing care (27.3%). Black Caribbean men and women were most likely, and black African men and women least likely, to be diagnosed with an STI (49.7 and 32.0% versus 26.8 and 16.3%, respectively). Among symptomatic women, black Caribbeans and, among symptomatic men, black Africans were most likely to report abstaining from sex (46.3 and 73.1%, respectively).

CONCLUSIONS

Our analyses highlight the importance of distinguishing between black ethnic groups and the need for future studies to ensure sufficiently large samples to permit such analyses.

Using health information technology to engage communities in health, education, and research

The August 2011 Clinical and Translational Science Awards conference "Using IT to Improve Community Health: How Health Care Reform Supports Innovation" convened four "Think Tank" sessions. Thirty individuals, representing various perspectives on community engagement, attended the "Health information technology (HIT) as a resource to improve community health and education" session, which focused on using HIT to improve patient health, education, and research involvement. Participants discussed a range of topics using a semistructured format. This article describes themes and lessons that emerged from that session, with a particular focus on using HIT to engage communities to improve health and reduce health disparities in populations.

Sexually transmitted disease core theory: roles of person, place, and time

The authors' purpose was to expand sexually transmitted disease core theory by examining the roles of person, place, and time in differentiating geographic core areas from outbreak areas. The authors mapped yearly census-tract-level syphilis rates for San Francisco, California, based on new primary and secondary syphilis cases reported to the San Francisco City sexually transmitted disease surveillance program between January 1, 1985, and December 31, 2007. SaTScan software (Information Management Services, Inc., Silver Spring, Maryland) was used to identify geographic clusters of significantly elevated syphilis rates over space and time. The authors graphed epidemic curves for 1) core areas, 2) outbreak areas, 3) neither core nor outbreak areas, and 4) noncore areas, where noncore areas included outbreaks, and stratified these curves according to demographic characteristics. Five clusters of significantly elevated primary and secondary syphilis rates were identified. A 5-year threshold was useful for differentiating core clusters from outbreak clusters. Epidemic curves for core areas, outbreak areas, neither core nor outbreak areas, and noncore areas were perfectly synchronized in phase trends and wavelength over time, even when broken down by demographic characteristics. Between epidemics, the occurrence of syphilis affected all demographic groups equally. During an epidemic, a temporary disparity in syphilis occurrence arose and a homogeneous core group of cases could be defined.

Are neighborhood sociocultural factors influencing the spatial pattern of gonorrhea in North Carolina?

PURPOSE

To determine if the spatial pattern of gonorrhea observed for North Carolina was influenced by neighborhood-level sociocultural determinants of health, including race/ethnicity.

METHODS

A generalized linear mixed model with spatially correlated random effects was fit to measure the influence of socio-cultural factors on the spatial pattern of gonorrhea reported to the North Carolina State Health Department (January 1, 2005 to March 31, 2008).

RESULTS

Neighborhood gonorrhea rates increased as the percent single mothers increased (25th to 75th neighborhood percentile Relative Rate 1.18, 95% CI 1.12, 1.25), and decreased as socioeconomic status increased (Relative Rate 0.89, 95% CI 0.84, 0.95). Increasing numbers of men in neighborhoods with more women than men did not change the gonorrhea rate, but was associated with decreased rates in neighborhoods with more men than women. Living in the mountains was protective for all race/ethnicities. Rurality was associated with decreased rates for Blacks and increased rates for Native Americans outside the mountains.

PURPOSE

Neighborhood-level sociocultural factors, primarily those indicative of neighborhood deprivation, explained a significant proportion of the spatial pattern of gonorrhea in both urban and rural communities. Race/ethnicity was an important proxy for social and cultural factors not captured by measures of socioeconomic status.

A spatial analysis of county-level variation in syphilis and gonorrhea in Guangdong Province, China

Background

Sexually transmitted infections (STI) have made a resurgence in many rapidly developing regions of southern China, but there is little understanding of the social changes that contribute to this spatial distribution of STI. This study examines county-level socio-demographic characteristics associated with syphilis and gonorrhea in Guangdong Province.

Methods/Principal Findings

This study uses linear regression and spatial lag regression to determine county-level (n = 97) socio-demographic characteristics associated with a greater burden of syphilis, gonorrhea, and a combined syphilis/gonorrhea index. Data were obtained from the 2005 China Population Census and published public health data. A range of socio-demographic variables including gross domestic product, the Gender Empowerment Measure, standard of living, education level, migrant population and employment are examined. Reported syphilis and gonorrhea cases are disproportionately clustered in the Pearl River Delta, the central region of Guangdong Province. A higher fraction of employed men among the adult population, higher fraction of divorced men among the adult population, and higher standard of living (based on water availability and people per room) are significantly associated with higher STI cases across all three models. Gross domestic product and gender inequality measures are not significant predictors of reported STI in these models.

Conclusions/Significance

Although many ecological studies of STIs have found poverty to be associated with higher reported STI, this analysis found a greater number of reported syphilis cases in counties with a higher standard of living. Spatially targeted syphilis screening measures in regions with a higher standard of living may facilitate successful control efforts. This analysis also reinforces the importance of changing male sexual behaviors as part of a comprehensive response to syphilis control in China.

The seroprevalence of human papillomavirus by immune status and by ethnicity in London

Background

The natural history of cutaneous HPV is unclear and in particular, seroprevalence among individuals with different levels of immune function and ethnicity is unknown. As part of a study of cutaneous squamous cell carcinoma (SCC) and HPV among organ transplant recipients (OTR) from London, we investigated the seroprevalence and risk factors for 34 HPV types (detected using Luminex technology) among 409 OTR patients without skin cancer (243 Caucasians and 166 non-Caucasians), 367 individuals with end stage renal failure on dialysis (222 Caucasians and 145 non-Caucasians) and 152 immunocompetent (IC) individuals without skin cancer (102 Caucasians and 50 non-Caucasians) to compare the HPV seroprevalence in patients with differing immune status and ethnicity. In total, seroprevalence data from 928 individuals, all from London, was available.

Results

Overall, no difference between HPV seroprevalence by immune status was observed (P = 0.3) among Caucasian or among non-Caucasian individuals, with seroprevalence varying from 87% to 94% across different immune status and ethnic groups. Those individuals seropositive to multiple types of one genus were more likely to be seroreactive to multiple types of another genus, independent of immune status or ethnicity. Lower seroprevalence for gammaHPV 4, and to a lesser extent gammaHPV 48, were observed among OTR compared to IC and dialysis patients. Higher seroprevalence against antibodies to betaHPV 93 were detected more frequently in non-Caucasians than Caucasians whereas muHPV 1 and, to a lesser extent, gammaHPV 4 were found more frequently among Caucasians - these findings were independent of immune status. Within non-Caucasian subgroups, the seroprevalence of 8 HPV (alpha-mucosal HPV16 and 13, alpha-cutaneous HPV7 and 2, betaHPV8, 17, 23 and 38) was significantly (P < 0.02) higher in Black compared to Asian patients. HPV16 being sexually transmitted, this might suggest a potential sexual route of transmission for some beta HPV types.

Conclusion

We did not observe major disturbance in antibody response between immunocompetent, dialysis and OTR individuals, but significant differences in HPV seroprevalence were identified according to ethnicity. Further research is needed to clarify the natural history of cutaneous HPV, particularly given the growing research interest in its possible role in the pathogenesis of cutaneous SCC.

Individual and community risk factors and sexually transmitted diseases among arrested youths: a two level analysis

High rates of infection for chlamydia and gonorrhea have been noted among youths involved in the juvenile justice system. Although both individual and community-level factors have been found to be associated with sexually transmitted disease (STD) risk, their relative importance has not been tested in this population. A two-level logistic regression analysis was completed to assess the influence of individual-level and community-level predictors on STD test results among arrested youths processed at a centralized intake facility. Results from weighted two level logistic regression analyses (n = 1,368) indicated individual-level factors of gender (being female), age, race (being African American), and criminal history predicted the youths' positive STD status. For the community-level predictors, concentrated disadvantage significantly and positively predicted the youths' STD status. Implications of these findings for future research and public health policy are discussed.

Monitoring inequalities in the National Chlamydia Screening Programme in England: added value of ACORN, a commercial geodemographic classification tool

Background: Monitoring socioeconomic inequalities in sexual health service use is needed to ensure equitable service provision. There are limitations to current methods, particularly when applied to young people. The present study examined the validity and added value of combining ACORN, a commercial tool, with an established deprivation index to improve monitoring of inequalities in the National Chlamydia Screening Programme (NCSP) in England. Methods: ACORN categories and the Index of Multiple Deprivation 2004 (IMD 2004) quintiles were linked to England population estimates and 145 975 records from the NCSP. Results: ACORN’s validity was demonstrated by moderate agreement between IMD 2004 and ACORN in segmenting the population and consistent gradients in the relative risk of chlamydia positivity between the most and least deprived areas assessed by IMD 2004 (relative risk (RR) 1.32; 95% confidence interval (CI) 1.23, 1.40) and ACORN (RR 1.32; 95% CI 1.25, 1.40). ACORN’s fine level of geographic resolution demonstrated that the NCSP was reaching the most deprived neighbourhoods within larger areas classified overall as deprived by IMD 2004. Within the most deprived IMD 2004 quintile, areas classified as most deprived by ACORN had higher chlamydia screening coverage (3.15%; 95% CI 3.11, 3.19%) than the least deprived (1.81%; 95% CI 1.56, 2.08%). Furthermore, ACORN identified highest screening coverage (9.2%) in areas classified as ‘communal housing.’ Conclusions: These findings illustrate that a commercial geodemographic tool in combination with an established deprivation index may overcome limitations in monitoring inequalities in sexual health service use. ACORN had value as a supplementary deprivation marker for monitoring inequalities in chlamydia screening in England.

A metapopulation modelling framework for gonorrhoea and other sexually transmitted infections in heterosexual populations

Gonorrhoea continues to be a public health problem in the UK, and is the second most common bacterial sexually transmitted infection (STI) after chlamydia. In the UK, gonorrhoea is disproportionately concentrated in epidemiologically distinct subpopulations, with much higher incidence rates in young people, some ethnic minorities and inner city subpopulations. The original model of STI transmission proposed by Hethcote and Yorke explained some of these features through the concept of the 'core group'. Since then, several authors have modified the original model approach to include multiple sexual activity classes, but found this modelling approach to be inadequate when applied to low-prevalence settings such as the UK. We present a metapopulation framework for modelling gonorrhoea and other STIs. The model proposes that the epidemiology of gonorrhoea is largely driven by subpopulations with higher than average concentrations of individuals with high sexual risk activity. We show how this conceptualization of gonococcal epidemiology overcomes key limitations associated with some of the prior efforts to model gonorrhoea. We also use the model to explain several epidemiological features of gonorrhoea, such as its asymmetric distribution across subpopulations, and the contextual risk experienced by members of at-risk subpopulations. Finally, we extend the model to explain the distribution of other STIs, using chlamydia as an example of a more ubiquitous bacterial STI.

The case for social marketing in gonorrhoea prevention: insights from sexual lifestyles in Glasgow genitourinary medicine clinic attendees

We conducted a matched case-control study to investigate social factors associated with gonorrhoea acquisition among genitourinary (GU) medicine clinic attendees, designed to inform appropriate prevention strategies. Detailed social and behavioural data were elicited using a self-completed questionnaire. The effect sizes of these characteristics were quantified using univariate and multivariable conditional logistic regression in 53 cases and 106 matched controls. Homo-bisexual orientation was the strongest independent predictor of gonorrhoea acquisition (Adjusted odds ratio 31.1 (95% confidence intervals, 3.09-312.92). Other independent predictors were not currently being in a relationship and concordant residential characteristics. Three principal implications for sexual health policy were identified; social marketing approaches to gonorrhoea prevention should focus on gay men and individuals not in established relationships; gonorrhoea prevention should be more closely integrated with wider social inclusion policies; finally, more proactive, systematic and theory-based approaches should capitalize on opportunities for sexual health promotion in GU medicine clinic settings.

Sexual health knowledge, attitudes and behaviours: variations among a religiously diverse sample of young people in London, UK

OBJECTIVE

To report young people's variations in sexual health knowledge, attitudes and behaviours by religious affiliation.

DESIGN

A cross-sectional, questionnaire-based survey administered in 16 Secondary/High schools in London, UK. The sample consisted of 3007 students in school Years 11-13 (aged 15-18), present in school on the day of questionnaire administration. Excluding those who described themselves as 'Other religious', 15.9% (n=418) described themselves as having no religious affiliation, 36.3% (n=957) were Christian, 25.8% (n=679) were Muslim and 22.1% were Hindu (n=582). The religious affiliation varied within and across different ethnic groups.

METHOD

Self-administered questionnaire completed under 'exam' conditions, either in tutor groups or a school hall. The 30-minute questionnaires were distributed and collected by a team of ethnically and religiously diverse fieldworkers.

RESULTS

Religious students, as opposed to those reporting no religious affiliation, generally reported poorer sexual health knowledge, and were more conservative in their attitudes to sex. Among males and females, those with no religious affiliation and Christian students reported the highest prevalence of sexual intercourse by some margin (around 20 percentage points) over the Hindus and Muslims. Christian males most frequently reported sexual intercourse at 49.7%, and Muslim females the least at 9.0%. Among those reporting sexual intercourse, risk behaviours among all religious and non-religious students were evident. Over one-third of Muslim females who had sexual intercourse did not use contraception on their first occasion compared to 10% of those with no religious affiliation, 12% of Christians and 20% of Hindus. Christian and Muslim females reported the highest prevalence of ever not using contraception at 55%, and non-use of contraception with two or more sexual intercourse partners at 14%.

CONCLUSION

The findings demonstrate diverse sexual health knowledge, sexual attitudes and sexual behaviours among young people with different religious affiliations. These variations demonstrate the importance of tailoring health education and promotion interventions to meet the specific needs of young people from a variety of different religions. The challenge ahead is to find ways to work with these young people to broach such sensitive issues.

'People make assumptions about our communities': sexual health amongst teenagers from black and minority ethnic backgrounds in East london

OBJECTIVES

(1) To explore sexual behaviour and relationships amongst Black and minority ethnic (BME) teenagers in East London. (2) To examine how these relationships are shaped by culture, gender, peer norms and religion. (3) To describe the implications for sexual health policy and practice in urban, multicultural areas.

DESIGN

This report draws primarily on the qualitative arm of a mixed methods study which collected data from 126 young people, aged 15-18, largely through focus groups in the London boroughs of Hackney, Newham and Tower Hamlets.

RESULTS

Previous research has reported culture influencing the patterning of risk/protection amongst BME groups. Our data suggest that this is mediated by gender, religion and youth. Religion reportedly influenced young women's sexual behaviour in multiple ways. Young people described gendered norms in meeting and flirting with partners, and the role of mobile phones and peer pressure.

CONCLUSION

Our paper suggests culture, gender, religion and youth influence BME teenagers in aspects of sexual relationships, and that these social markers may have different contextual meanings for individuals. The multiplicity of factors affecting attitudes/behaviour requires a range of contraceptive, counselling, screening and sex education services available for all teenagers, although delivery patterns may differ in response to differing needs.

Use of geographic information systems for planning HIV prevention interventions for high-risk youths

Geographic information system (GIS) analysis is an emerging tool for public health intervention planning. Connect to Protect, a researcher-community collaboration working in 15 cities to reduce HIV infection among youths, developed GIS databases of local health, crime, and demographic data to evaluate the geographic epidemiology of sexually transmitted infections and HIV risk among adolescents. We describe the process and problems of data acquisition, analysis, and mapping in the development of structural interventions, demonstrating how program planners can use this technology to inform and improve planning decisions. The Connect to Protect project's experience suggests strategies for incorporating public data and GIS technology into the next generation of public health interventions.

Geographical and demographic clustering of gonorrhoea in London

BACKGROUND

Gonorrhoea is an important cause of sexual ill health and is concentrated in geographical areas and demographic groups. This study explores the distribution of gonorrhoea across London.

METHODS

Epidemiological data on all gonorrhoea cases were collected from 13 major genitourinary clinics in London between 1 June and 30 November 2004. Samples were stored centrally and typed using NG-MAST. The postcode of each case's main residence was used to calculate incidence of gonorrhoea by borough using data from the UK 2001 census and a population survey on residence of men who have sex with men (MSM).

RESULTS

2,891 cases were confirmed, 1,822 of which had postcode data, resided in London, and had their strain successfully typed. There was a very high incidence of gonorrhoea in MSM (1,834 per 100,000 population) and heterosexuals of black ethnicity (392 per 100,000). The incidence among heterosexuals was highest in City of London (390 per 100,000, 95% CI 213 to 566), Southwark (308 per 100,000, 95% CI 280 to 336), Hackney (284 per 100,000, 95% CI 254 to 313), and Lambeth (216 per 100,000, 95% CI 194 to 239) and was not associated with measures of social deprivation (correlation coefficient = 0.0008, p = 0.97) but was strongly associated with black ethnicity (correlation coefficient = 0.48, p = 0.01). 45% of cases had one of the 21 major strains; eight of these strains were significantly clustered geographically and persisted for a shorter duration than those that were not clustered. Patients travelled a mean of 7.7 km from their home to the clinic.

CONCLUSIONS

High gonorrhoea incidence in London is observed in MSM and heterosexuals of black ethnicity. Endemic strains in both MSM and heterosexuals are diagnosed at multiple clinics. Interventions, including partner notification, must therefore operate between clinics.

Direct and indirect associations of neighborhood disorder with drug use and high-risk sexual partners

BACKGROUND

On a macrosocial level, neighborhood characteristics have been found to be associated with the prevalence of HIV and other bloodborne and sexually transmitted infections. The current study used structural equation modeling to examine the relationship between neighborhood social and physical disorder and high-risk sexual partners.

METHODS

A cohort (N=838) recruited for an HIV prevention study of drug users (2002-2004) in Baltimore, Maryland, was interviewed about their neighborhood characteristics, drug use, depressive symptoms (using the Centers for Epidemiological Studies Depression Scale), and HIV/sexually transmitted infection risk behaviors of exchanging sex for money or drugs, having multiple sexual partners, and having partners who injected drugs or smoked crack cocaine. Data were analyzed in February 2005.

RESULTS

Model fit statistics from Mplus (Muthen & Muthen, Los Angeles CA, 2004) indicated statistically significant direct associations between neighborhood disorder and psychologic distress, neighborhood disorder and sexual risk behaviors, and neighborhood disorder and drug use. There were also significant indirect associations of neighborhood disorder on sexual risk behaviors.

CONCLUSIONS

These results highlight the importance of viewing drug use, chronic stress, depression and hopelessness, and infectious diseases such as HIV and hepatitis C as interlinked epidemics that are fostered by neighborhood social and physical disorder. Neighborhood, network, and community level interventions are needed to address these intertwined public health issues.

What can be gained from comprehensive disaggregate surveillance? The Avon Surveillance System for Sexually Transmitted Infections

OBJECTIVE

To describe a new disaggregate surveillance system covering key diagnosed sexually transmitted infections in a UK locality.

METHODS

The Avon System for Surveillance of Sexually Transmitted Infections (ASSIST) collects computerised person- and episode-based information about laboratory-diagnosed sexually transmitted infections from genitourinary medicine (GUM) clinics, the Avon Brook Clinic, and the Health Protection Agency and trust laboratories in primary care trusts in Avon. The features of the system are illustrated here, by describing chlamydia-testing patterns according to the source of test, age and sex, and by mapping the distribution of chlamydia across Bristol, UK.

RESULTS

Between 2000 and 2004, there were 821,685 records of tests for sexually transmitted infections, with 23,542 positive results. The proportion of tests and positive results for chlamydia and gonorrhoea sent from general practice increased over time. Most chlamydia tests in both GUM and non-specialist settings were performed on women aged >25 years, but positivity rates were highest in women aged <25 years. The positivity rate remained stable between 2000 and 2004. Including data from all diagnostic settings, chlamydia rates were about twice as high as those estimated only from genitourinary clinic cases.

CONCLUSIONS

The ASSIST model could be a promising new tool for planning and measuring sexual health services in England if it can become sustainable and provide more timely data using fewer resources. Collecting denominator data and including infections diagnosed in primary care are essential for meaningful surveillance.

Spatial bridges and the spread of Chlamydia: the case of a county in Sweden

OBJECTIVES

The so-called small-world effect can have a great impact on efforts to control the incidence and prevalence of sexually transmitted infections. This is because a small number of so-called spatial bridgers (individuals who, through sexual contacts, interconnect geographically distant areas) can drastically lower the average path length in the sexual network and, as a result, make locally based intervention programs much less effective. The objectives of this study were to analyze the sociodemographic characteristics of these bridgers and to compare the result with the remaining study population. The purpose was to determine whether it is possible to identify them for targeted intervention programs.

STUDY DESIGN

During 2001, contact tracing was performed in approximately 98% of all cases with positive test results in Värmland County. The sexual networks obtained constituted a study population of 851 individuals. Statistical analysis was used to characterize individuals engaged in spatial bridging behavior.

RESULTS

Approximately 8% of the study population was characterized as spatial bridgers. Using multivariate analysis, we found almost no significant differences between these individuals and the rest of the study population when it came to sociodemographic variables, including education, economy, and ethnicity.

CONCLUSION

The number of spatial bridgers is high enough to create a small-world network with links that can fuel the endemic chlamydia in Värmland County. Sociodemographic information could not be used to characterize spatial bridgers. In interventions against chlamydia, spatial bridgers shall be considered as potentially important for sustaining the disease.

Experience of sexual intercourse and reported risk behaviour among an ethnically diverse sample of young people

BACKGROUND

Certain Black and Minority Ethnic (BME) groups have been identified as bearing a disproportionate burden of sexual ill health in the UK. There still exists a significant gap in the evidence-base concerning the sexual behaviours of BME youth.

METHODS

We conducted a cross-sectional survey of 16 secondary schools in London, where the proportion of BME students exceeded two-thirds of the intake. The aim was to identify the factors associated with sexual intercourse and sexual risk behaviours.

RESULTS

2801 students aged 15 to 18 completed questionnaires. Compared with White British males, Black males were significantly more likely to report sexual intercourse (OR 3.04, 95% CI 1.92-4.81). Compared with White British females, Asian females were significantly less likely to report sexual intercourse (OR 0.43, 95% CI 0.27-0.69). Both sexes reporting school as their main source of information, as opposed to their family, had a lower likelihood of intercourse (males OR 0.33, 95% CI 0.21-0.53, females OR 0.39, 95% CI 0.25-0.62). Compared with White British males, contraceptive use at first ever intercourse was significantly less likely among Black males (OR 0.35, 95% CI 0.16-0.98) and males of Mixed ethnicity (OR 0.24, 95% CI 0.06-0.92). Among females, higher sexual health knowledge was associated with contraceptive use (OR 4.69, 95% CI 1.76-12.49). Males reporting higher sexual health knowledge were more likely to be 'sexually competent' at first ever intercourse (OR 2.28, 95% CI 1.10-4.69).

CONCLUSIONS

Given the importance of sexual health knowledge, ensuring this is improved among all ethnic groups, especially the Black and Mixed male groups, is a key message to arise from this study. Delivering this information in a 'culturally competent' manner is an important goal.

Modeling a syphilis outbreak through space and time using the Bayesian maximum entropy approach

PURPOSE

The aim of the study is to describe changes in the spatial distribution of syphilis before, during, and after an outbreak in Baltimore, MD, by using Bayesian maximum entropy (BME), a modern geostatistical technique for space-time analysis and mapping.

METHODS

BME was used to conduct simple and composite space-time analyses of the density of syphilis infection based on primary, secondary and early latent syphilis cases reported to the Baltimore City Health Department between January 1, 1994, and December 31, 2002.

RESULTS

Spatiotemporal covariance plots indicated that the distribution of the density of syphilis cases showed both spatial and temporal dependence. Temporally dependent disease maps suggested that syphilis increased within two geographic core areas of infection and spread outward. A new core area of infection was established to the northwest. As the outbreak waned, density diminished and receded in all core areas. Morbidity remained elevated in the two original central and new northwestern core areas after the outbreak.

CONCLUSIONS

Density of syphilis infection was a simple informative measure easily compared across years. The BME approach was useful for quantitatively and qualitatively describing the spatial development and spread of syphilis. Our results are specific to Baltimore; however, the BME approach is generalizable to other settings and diseases.

The interrelation of demographic and geospatial risk factors between four common sexually transmitted diseases

OBJECTIVES

To examine the interrelation between demographic and geospatial risk factors for gonorrhoea, chlamydia, genital warts, and genital herpes.

DESIGN

We analysed age, sex, ethnicity, socioeconomic status, and area of residence for Leeds residents aged 15-54 with Neisseria gonorrhoeae, genital Chlamydia trachomatis, first episode genital herpes, and first episode genital warts during 1994-5. The 1991 UK census provided denominator population information.

RESULTS

Regression analysis showed that young age (15-24 years), ethnicity (with a gradient of risk black >white >Asian), and residence in inner city areas of deprivation were independent risk factors for all STDs. There were highly significant correlations in the geospatial distribution of incidence rates between the four infections. However, there was variation in the degree of central urban clustering, with gonorrhoea having the most restricted, and genital warts and chlamydia the widest distribution. 31% of all disease occurred in the four inner city census wards, representing 15% of the population.

CONCLUSION

These results are in keeping with core group theory applying in a unified manner to the four most common UK sexually transmitted diseases in this urban area. Population based studies are needed to clarify whether ethnicity is associated with differing sexual behavioural or mixing patterns. Our data suggest that chlamydia screening in women <25 years of age could detect 70% of cases in the community, that such programmes should give particular emphasis to implementation in core group areas, and that they could function as unifying strategies for the control of most common STDs within urban areas.

Incidence of sexually transmitted diseases in Hokkaido, Japan, 1998 to 2001

The objective of this study was to provide precise data on the incidence of sexually transmitted diseases (STDs) in Hokkaido. The goal of this prospective surveillance, study was to clarify the STD incidence between 1998 and 2001 in Hokkaido, Japan. The incidence of gonococcal infection in men was found to be 127-199 per 100 000 people per year, which was three or four times higher than that for women. Female genital chlamydial infection had an incidence of 300-400 with a female to male ratio of two or three to one. Younger adults had higher incidences of gonococcal and chlamydial infections than older people. In conclusion, the current study of STDs revealed high incidences of gonococcal and chlamydial infections in the Hokkaido area, and there was no decreasing trend in STD incidence during these 4 years.

Spatial analysis and mapping of sexually transmitted diseases to optimise intervention and prevention strategies

OBJECTIVE

We analysed and mapped the distribution of four reportable sexually transmitted diseases, chlamydial infection/non-gonococcal urethritis (chlamydial infection), gonorrhoea, primary and secondary syphilis (syphilis), and HIV infection, for Wake County, North Carolina, to optimise an intervention.

METHODS

We used STD surveillance data reported to Wake County, for the year 2000 to analyse and map STD rates. STD rates were mathematically represented as a spatial random field. We analysed spatial variability by calculating and modelling covariance functions of random field theory. Covariances are useful in assessing spatial patterns of disease locally and at a distance. We combined observed STD rates and appropriate covariance models using a geostatistical method called kriging, to predict STD rates and associated prediction errors for a grid covering Wake County. Final disease estimates were interpolated using a spline with tension and mapped to generate a continuous surface of infection.

RESULTS

Lower incidence STDs exhibited larger spatial variability and smaller neighbourhoods of influence than higher incidence STDs. Each reported STD had a clustered spatial distribution with one primary core area of infection. Core areas overlapped for all four STDs.

CONCLUSIONS

Spatial heterogeneity within STD suggests that STD specific prevention strategies should not be targeted uniformly across Wake County, but rather to core areas. Overlap of core areas among STDs suggests that intervention and prevention strategies can be combined to target multiple STDs effectively. Geostatistical techniques are objective, population level approaches to spatial analysis and mapping that can be used to visualise disease patterns and identify emerging outbreaks.

Investigating ethnic differences in sexual health: focus groups with young people

OBJECTIVES

To compare normative beliefs about sexual health in young men and women from black Caribbean, black African, and white ethnic groups in order to better understand ethnic inequalities in sexual health.

METHODS

Focus group discussions with young people living in an area with known high prevalence of gonorrhoea and chlamydia. Groups were stratified by sex and self defined ethnicity.

RESULTS

22 male and 20 female 16-25 year olds of black Caribbean, black African, and white ethnicity took part in eight discussions. Participants from black ethnic groups were more aware of gonorrhoea than white participants but all ethnic groups regarded these as being less important than unplanned pregnancy or HIV/AIDS. Most participants believed that they would have obvious symptoms if they had a sexually transmitted infection and could determine the cleanliness of sexual partners by visual or behavioural cues. Black Caribbean women were alone in acknowledging the likelihood of their partners having concurrent sexual relationships. Some black Caribbean women described negative attitudes of staff in genitourinary medicine clinics who were from the same ethnic background.

CONCLUSION

In this focus group study we identified ethnic differences in terminology, awareness of sexually transmitted infections, non-exclusive sexual relationships, and experience of sexual health services but gender had a greater influence on normative beliefs. The similarities in norms for all ethnic groups might reflect common social and cultural exposures. The low priority given to sexually transmitted infections by young people from all ethnic groups needs to be addressed if they are to be tackled successfully.

Geographic correlation between deprivation and risk of meningococcal disease: an ecological study

Background

Meningitis caused by Neisseria meningitidis is a serious infection which is most common in young children and adolescents. This study investigated the relationships between the incidence and age distribution of meningococcal disease, and socioeconomic environment.

Methods

An ecological design was used, including mapping using a Geographical Information System (GIS) at census ward level.

Results

Incidence of meningococcal disease was highest in the most deprived wards, with a relative risk of 1.97 (1.55 – 2.51). Mapping revealed geographical coincidence of deprivation and meningococcal disease, particularly in urban areas. Two-thirds of the increased incidence was due to cases in the under fives.

Conclusions

The results suggest that area deprivation is a risk factor for meningococcal disease, and that its effects are seen most in young children.

Recent trends in HIV and other STIs in the United Kingdom: data to the end of 2002

Sexual health in the United Kingdom has deteriorated in recent years with further increases in HIV and other sexually transmitted infections (STIs) reported in 2002. This paper describes results from the available surveillance data in the United Kingdom from the Health Protection Agency and its national collaborators. The data sources range from voluntary reports of HIV/AIDS from clinicians, CD4 cell count monitoring, a national census of individuals living with HIV, and the Unlinked Anonymous Programme, to statutory reports of STIs from genitourinary medicine (GUM) clinics and enhanced STI surveillance systems. In 2002, an estimated 49500 adults aged over 15 years were living with HIV in the United Kingdom, of whom 31% were unaware of their infection. Diagnoses of new HIV infections have doubled from 1997 to 2002, mainly driven by heterosexuals who acquired their infection abroad. HIV transmission also continues within the United Kingdom, particularly among homo/bisexual men who, in 2002, accounted for 80% of all newly diagnosed HIV infections acquired in the United Kingdom. New diagnoses of syphilis have increased eightfold, and diagnoses of chlamydia and gonorrhoea have doubled from 1997 to 2002 overall; STI rates disproportionately affect homo/bisexual men and young people. Effective surveillance is essential in the provision of timely information on the changing epidemiology of HIV and other STIs; this information is necessary for the targeting of prevention efforts and through providing baseline information against which progress towards targets can be monitored.

Black Caribbean adults with HIV in England, Wales, and Northern Ireland: an emerging epidemic?

BACKGROUND

HIV is now well established in the Caribbean, with prevalence in several countries being surpassed only by those of sub-Saharan Africa. Continuing inward migration from the Caribbean and a high incidence of some bacterial STIs among Britain's black Caribbean communities, suggests a considerable potential for HIV spread.

METHODS

Data from three national HIV/AIDS surveillance systems were reviewed, providing information on new HIV diagnoses, numbers accessing treatment and care services, and HIV prevalence.

RESULTS

Between 1997 and 2001, 528 black Caribbean adults were newly diagnosed with HIV; 62 new diagnoses in 1997, rising to 176 in 2001. Probable heterosexual acquisition accounted for 335 (63%) infections (161 (48%) males, 174 females), and sex between men 171 (32%). Infection was acquired both in the Caribbean and in the United Kingdom. Numbers of black Caribbeans accessing treatment and care services more than doubled between 1997 (294) and 2001 (691). In 2001, 528 (76%) black Caribbeans accessing services were London residents. Among the Caribbean born previously undiagnosed heterosexuals, HIV prevalence was 0.7%; among men who have sex with men (MSM) it was 10.4%. Of those born in the Caribbean, 73% of male heterosexuals, 50% of female heterosexuals, and 65% of MSM who were previously undiagnosed left the clinic unaware of their HIV infection.

CONCLUSIONS

Numbers of black Caribbean adults newly diagnosed and accessing treatment and care services in England, Wales, and Northern Ireland increased between 1997 and 2001. Despite a high prevalence of diagnosed bacterial STIs, prevalence among Caribbean born heterosexuals remains low, but it is high among MSM. Surveillance data highlight the need for targeted HIV prevention among black Caribbeans.

Reducing the risk of gonorrhoea in black Caribbean men: can we identify risk factors?

OBJECTIVES

Grouping patients by self assigned ethnicity may hide intraethnic differences in disease associations and sexual behaviour patterns. The aim of the study was to detect associations between gonorrhoea with differences in ancestry, degree of acculturation, and religious belief in young black Caribbean men, which could subsequently be used to target health promotion interventions.

METHODS

A questionnaire based case-control study of black Caribbean men with gonorrhoea and a community control group without gonorrhoea.

RESULTS

A lesser degree of acculturation, attending a single sex school, increasing numbers of partners, lack of condom use, not being married, and a belief that sex before marriage was not wrong were associated with an increased risk of gonorrhoea. Country of birth and religious belief were not associated with gonorrhoea.

CONCLUSIONS

A number of factors were identified which may be useful in designing healthcare interventions in young black Caribbean men and these differed little from those in other ethnic groups. The healthcare intervention should include advice on reducing the number of partners and increasing the use of condoms.

Geographic epidemiology of gonorrhoea and chlamydia on a large military installation: application of a GIS system

OBJECTIVES

The geographic epidemiology of infectious diseases can help in identifying point source outbreaks, elucidating dispersion patterns, and giving direction to control strategies. We sought to establish a geographic information system (GIS) infectious disease surveillance system at a large US military post (Fort Bragg, North Carolina) using STDs as the initial outcome for the model.

METHODS

Addresses of incident cases were plotted onto digitised base maps of Fort Bragg (for on-post addresses) and surrounding Cumberland County, NC (for off-post addresses) using MAPINFO Version 5. We defined 26 geographic sectors on the installation. Active duty soldiers attending the post preventive medicine clinic were enrolled between July 1998 and June 1999.

RESULTS

Gonorrhoea (GC) was diagnosed in 210/2854 (7.4%) and chlamydia (CT) in 445/2860 (15.6%). African-American male soldiers were at higher risk for GC (OR = 4.6 (95% CL 3.0 to 7.2)) and chlamydia (OR = 2.0 (1.4 to 2.7)). For women, there were no ethnic differences in gonorrhoea prevalence, but chlamydia was higher in African-Americans (OR = 2.0 (1.4-2.7)). Rank and housing type were associated with gonorrhoea and chlamydia in men, but were not significant factors in women. For gonorrhoea, two geographic sectors had prevalences between 14.0%-16.5%, three between 10.3%-13.9%, three between 7.1%-10.2%, and five between 3.0%-7.1%. The geographic distribution demonstrated a core-like pattern where the highest sectors were contiguous and were sectors containing barracks housing lower enlisted grade personnel. In contrast, chlamydia prevalence was narrowly distributed.

CONCLUSION

GIS based disease surveillance was easily and rapidly implemented in this setting and should be useful in developing preventive interventions.

Sexual networks and sexually transmitted infections: a tale of two cities

Research on risk behaviors for sexually transmitted infections (STIs) has revealed that they seldom correspond with actual risk of infection. Core groups of people with high-risk behavior who form networks of people linked by sexual contact are essential for STI transmission, but have been overlooked in epidemiological studies. Social network analysis, a subdiscipline of sociology, provides both the methods and analytical techniques to describe and illustrate the effects of sexual networks on STI transmission. Sexual networks of people from Colorado Springs, Colorado, and from Winnipeg, Manitoba, Canada, infected with chlamydia during a 6-month period were compared. In Winnipeg, 442 networks were identified, comprising 571 cases and 663 contacts, ranging in size from 2 to 20 individuals; Colorado Springs data yielded 401 networks, comprising 468 cases and 700 contacts, ranging in size from 2 to 12 individuals. Taking differing partner notification methods and the slightly smaller population size in Colorado Springs into account, the networks from both places were similar in both size and structure. These smaller, sparsely linked networks, peripheral to the core, may form the mechanism by which chlamydia can remain endemic, in contrast with larger, more densely connected networks, closer to the core, which are associated with steep rises in incidence.