Successful Provision of Long-Acting Reversible Contraception in a Sexual Health Clinic

BACKGROUND

Women who attend sexual health clinics are at high risk for sexually transmitted infections and unintended pregnancy. Long-acting reversible contraceptives (LARC) are very effective contraceptive methods, but the provision of LARC in such clinics is not well described in the literature.

METHODS

We conducted a retrospective chart review of women who presented to Denver Sexual Health Clinic for any reason and received family planning services between April 1, 2016, and October 31, 2018. We assessed demographic and clinical factors associated with contraceptive method received and conducted a subanalysis of those with intrauterine device (IUD) insertions on the same-day versus delayed insertion. Among those who received an IUD, we assessed rates of pelvic inflammatory disease (PID) 30 days after insertion.

RESULTS

Of the 5064 women who received family planning services in our clinic, 1167 (23%) were using a LARC method at the time of their visit. Of the 3897 who were not using a LARC, fewer women, 12.6%, chose LARC (IUD and progestin implant), compared with 33.3% who chose new short-acting reversible contraceptives. Further analysis of the 270 IUD initiators revealed 202 (74.8%) received the IUD on the same day, whereas 68 (25.2%) had delayed IUD insertion. There were 9 incident cases of gonorrhea or chlamydia in those who received same-day IUD and 1 incident case among those who had delayed IUD insertion. There were no cases of PID at 30 days after insertion in either group.

CONCLUSIONS

Study findings support IUD provision in a sexual health clinic on the day of initial visit without increased risk of PID.

Adolescent Female Perspectives in an Urban Safety Net: Developing an Intervention Focusing on Sexual Health and Text-Messaging

Our goal was to develop a patient-centered text-message intervention for adolescent females in an urban safety-net health system. We conducted interviews with adolescent females to explore sexual health knowledge and inform the development of a text-messaging intervention. Focused group discussions (FGDs) verified or challenged interview themes and elicited preferences for intervention design. Forty-two females participated, including 15 interviewees and 27 FGD participants. Over half (67%) were Hispanic/Latina, 19% Black, 10% White and 5% Asian. The average age was 16 (±1.5) and 55% reported ever having sex. Participants felt susceptible to and were more concerned with preventing unintended pregnancies than sexually transmitted infections, and described more barriers to condom use than other contraceptive methods. Their input informed the development of a text-messaging intervention, which is described. This study supports the acceptability of a patient-centered texting intervention for promoting and normalizing healthy sexual behaviors among adolescent females in an urban safety-net setting.

Estimating costs of hospitalizations associated with opioid use disorder or opioid misuse at a large, urban safety-net hospital-Denver, Colorado, 2017

INTRODUCTION

The national and state economic burden of the opioid crisis is substantial. This study estimated the number of hospitalizations associated with opioid use disorder (OUD) or opioid misuse (OM) and the cost of those hospitalizations at Denver Health (DH) Medical Center, a large, urban safety-net hospital.

METHODS

For 2017, direct inpatient medical costs for hospitalizations associated with OUD or OM at DH Medical Center were estimated and categorized by group and insurance type. Data were from the DH electronic health records database that included charge data. Hospitalizations associated with OUD or OM were identified using diagnostic codes and an expanded set of inclusion criteria including diagnostic codes, opioid withdrawal assessments, opioid-related admission notes, and medication prescriptions to treat OUD. Costs were estimated using cost-to-charge ratios specific to DH.

RESULTS

During 2017, 220 hospitalizations, $9,834,979 in total charges, $3,690,724 in estimated total costs, and $2,115,990 in total reimbursements were identified using diagnostic codes. Using the most expansive set of inclusion criteria, 739 hospitalizations, $35,033,157 in total charges, $13,346,099 in estimated total costs, and $7,020,877 in total reimbursements were identified. Of the 739 hospitalizations, Medicaid covered 546 hospitalizations (74 %), the largest proportion of total reimbursement (65 %), with estimated total costs of $10,135,048 (77 %).

CONCLUSIONS

Our study identified considerable costs for hospitalizations associated with OUD or OM for DH. Estimating costs for hospitalizations associated with OUD or OM through use of expanded inclusion methodology can guide future program planning to allocate resources efficiently for hospitals such as DH Medical Center.

Acceptability and Efficacy of a Sexual Health Texting Intervention Designed to Support Adolescent Females

OBJECTIVE

To evaluate the feasibility, acceptability, and initial efficacy of a pilot texting intervention ("t4she") in primary care designed to increase sexual health knowledge and promote dual protection strategies to reduce unintended pregnancies and sexually transmitted infections among adolescent females.

METHODS

Participants were recruited from 2 federally qualified health centers. Eligibility included: being 13 to 18 years of age; assigned female at birth; English-speaking; not currently pregnant and/or intending to become pregnant; and having texting capabilities. A randomized controlled trial assessed between-group differences at 3 and 6 months on knowledge, Health Belief Model constructs, and sexual behaviors. Input on intervention acceptability was obtained at 3 months.

RESULTS

Among 244 participants enrolled and randomized, the average age was 16 (±1.6), 80% were Hispanic/Latina, 53% had ever had vaginal sex, and 50% had used prescription birth control with 24% currently using a long-acting reversible method. Among those sexually active, 29% reported consistent condom use and 24% reported engaging in dual protection behaviors at last sex. Among participants with all follow-up data (N = 136), intervention participants had significant increases in sexual health knowledge and reported more prescription birth control use at follow-up than control participants. No significant outcome differences were found for condom use or dual protection behaviors. Intervention participants reported receiving messages, being introduced to new information, and reading and sharing the messages.

CONCLUSIONS

The pilot t4she sexual health intervention significantly improved knowledge and use of short-acting prescription birth control among young females in primary care and was acceptable by youth and feasible to implement.

The Detection of Opioid Misuse and Heroin Use From Paramedic Response Documentation: Machine Learning for Improved Surveillance

Background

Timely, precise, and localized surveillance of nonfatal events is needed to improve response and prevention of opioid-related problems in an evolving opioid crisis in the United States. Records of naloxone administration found in prehospital emergency medical services (EMS) data have helped estimate opioid overdose incidence, including nonhospital, field-treated cases. However, as naloxone is often used by EMS personnel in unconsciousness of unknown cause, attributing naloxone administration to opioid misuse and heroin use (OM) may misclassify events. Better methods are needed to identify OM.

Objective

This study aimed to develop and test a natural language processing method that would improve identification of potential OM from paramedic documentation.

Methods

First, we searched Denver Health paramedic trip reports from August 2017 to April 2018 for keywords naloxone, heroin, and both combined, and we reviewed narratives of identified reports to determine whether they constituted true cases of OM. Then, we used this human classification as reference standard and trained 4 machine learning models (random forest, k-nearest neighbors, support vector machines, and L1-regularized logistic regression). We selected the algorithm that produced the highest area under the receiver operating curve (AUC) for model assessment. Finally, we compared positive predictive value (PPV) of the highest performing machine learning algorithm with PPV of searches of keywords naloxone, heroin, and combination of both in the binary classification of OM in unseen September 2018 data.

Results

In total, 54,359 trip reports were filed from August 2017 to April 2018. Approximately 1.09% (594/54,359) indicated naloxone administration. Among trip reports with reviewer agreement regarding OM in the narrative, 57.6% (292/516) were considered to include information revealing OM. Approximately 1.63% (884/54,359) of all trip reports mentioned heroin in the narrative. Among trip reports with reviewer agreement, 95.5% (784/821) were considered to include information revealing OM. Combined results accounted for 2.39% (1298/54,359) of trip reports. Among trip reports with reviewer agreement, 77.79% (907/1166) were considered to include information consistent with OM. The reference standard used to train and test machine learning models included details of 1166 trip reports. L1-regularized logistic regression was the highest performing algorithm (AUC=0.94; 95% CI 0.91-0.97) in identifying OM. Tested on 5983 unseen reports from September 2018, the keyword naloxone inaccurately identified and underestimated probable OM trip report cases (63 cases; PPV=0.68). The keyword heroin yielded more cases with improved performance (129 cases; PPV=0.99). Combined keyword and L1-regularized logistic regression classifier further improved performance (146 cases; PPV=0.99).

Conclusions

A machine learning application enhanced the effectiveness of finding OM among documented paramedic field responses. This approach to refining OM surveillance may lead to improved first-responder and public health responses toward prevention of overdoses and other opioid-related problems in US communities.

Monitoring opioid addiction and treatment: Do you know if your population is engaged?

BACKGROUND

Assessment of people affected by opioid-related problems and those receiving care is challenging due to lack of common definitions and scattered information. We sought to fill this gap by demonstrating a method to describe a continuum of opioid addiction care in a large, public safety-net institution.

METHODS

Using 2017 clinical and administrative data from Denver Health (DH), we created operational definitions for opioid use disorder (OUD), opioid misuse (OM), and opioid poisoning (OP). Six stages along a continuum of patient engagement in opioid addiction care were developed, and operational definitions assigned patients to stages for a specific time point of analysis. National data was used to estimate the Denver population affected by OUD, OM and OP.

RESULTS

In 2017, an estimated 6688 people aged ≥12 years were affected by OUD, OM, or OP in Denver; 48.4% (3238/6688) were medically diagnosed in DH. Of those, 32.5% (1051/3238) were in the medication assisted treatment stage, and, of those, 59.8% (629/1051) in the adhered to treatment stage. Among that latter group, 78.4% (493/629) adhered at least 90 days and 52.3% (329/629) for more than one year. Among patients who received medication assisted treatment, less than one third (31.3%, 329/1051) were adherent for more than one year.

CONCLUSIONS

A health-system level view of the continuum of opioid addiction care identified improvement opportunities to better monitor accuracy of diagnosis, treatment capacity, and effectiveness of patient engagement. Applied longitudinally at local, state and national levels, the model could better synergize responses to the opioid crisis.

Text Messaging, Teen Outreach Program, and Sexual Health Behavior: A Cluster Randomized Trial

OBJECTIVES

To consider whether Youth All Engaged! (a text message intervention) intensified the effects of the adolescent pregnancy prevention Teen Outreach Program (control) for youths.

METHODS

In this trial performed in Denver, Colorado, from 2011 to 2014, we randomized 8 Boys & Girls Clubs each of 4 years into 32 clubs per year combinations to ensure each club would serve as a treatment site for 2 years and a control site for 2 years. Control intervention consisted of the Teen Outreach Program only. We enrolled 852 youths (aged 14-18 years), and 632 were retained at follow-up, with analytic samples ranging from 50 to 624 across outcomes. We examined program costs, and whether the intervention increased condom and contraceptive use, access to care, and pregnancy prevention.

RESULTS

Control program costs were $1184 per participant, and intervention costs were an additional $126 per participant (+10.6%). There were no statistically significant differences in primary outcomes for the full sample. Hispanic participants in the intervention condition had fewer pregnancies at follow-up (1.79%) than did those in the control group (6.72%; P = .02).

CONCLUSIONS

Youth All Engaged is feasible, low cost, and could have potential benefits for Hispanic youths.

Promoting “Dual Protection” From Pregnancy and Sexually Transmitted Disease: A Social Ecological Approach

High rates of unintended pregnancy and sexually transmitted disease in women challenge health promotion to identify improvements in “dual protection” interventions. Findings from an exploratory qualitative study using a social ecological model identify causal, contextual, and intervening factors that influence dual protection. The study examined 48 U.S. women completing a sexually transmitted disease clinic process and focused on women at high risk of unwanted pregnancy and sexually transmitted disease. We frame findings from these interviews using social ecology to illustrate the levels where intervention to promote the concept of dual protection and associated behaviors might occur. Presenting findings within this framework offer an understanding of complex factors that influence dual protection and also present an opportunity to consider strategies for promoting dual protection that include interventions at the structural/environmental level, the social/interpersonal level, and the individual level.

Factors associated with neurocognitive test performance at baseline: a substudy of the INSIGHT Strategic Timing of AntiRetroviral Treatment (START) trial

OBJECTIVES

We describe neuropsychological test performance (NP) in antiretroviral treatment (ART)-naïve HIV-positive individuals with CD4 cell counts above 500 cells/μL.

METHODS

In a neurology substudy of the International Network for Strategic Initiatives in Global HIV Trials (INSIGHT) Strategic Timing of AntiRetroviral Treatment (START) study, eight neurocognitive tests were administered. The primary measure of NP was the quantitative NP z-score (QNPZ-8), the average of the z-scores for the eight tests. Associations of baseline factors with QNPZ-8 scores were assessed by multiple regression. Mild neurocognitive impairment (NCI) was defined as z-scores < -1 in at least two of six cognitive domains.

RESULTS

A total of 608 participants had a median age of 34 years; 11% were women and 15% were black; the median time since HIV diagnosis was 0.9 years; the median CD4 cell count was 633 cells/μL; 19.9% had mild NCI. Better NP was independently associated with younger age, being white, higher body mass index (0.10 per 10 kg/m(2) higher), and higher haematocrit percentage (0.19 per 10% higher). Worse NP was associated with longer time since HIV diagnosis (-0.17 per 10 years), diabetes (-0.29) and higher Framingham risk score (-0.15 per 10 points higher). QNPZ-8 scores differed significantly between geographical locations, with the lowest scores in Brazil and Argentina/Chile.

CONCLUSIONS

This is the largest study of NP in ART-naïve HIV-positive adults with CD4 counts > 500 cells/μL. Demographic factors and diabetes were most strongly associated with NP. Unmeasured educational/sociocultural factors may explain geographical differences. Poorer NP was independently associated with longer time since HIV diagnosis, suggesting that untreated HIV infection might deleteriously affect NP, but the effect was small.

Implementing a School-Located Vaccination Program in Denver Public Schools

BACKGROUND

School-located vaccination (SLV) offers an opportunity to deliver vaccines to students, particularly those without a primary care provider.

METHODS

This SLV program offered 2 clinics at each of 20 elementary schools (influenza vaccine) and 3 clinics at each of 7 middle/preschool-eighth-grade schools (adolescent platform plus catch-up vaccines) during the 2009-2010 and 2010-2011 school years. Established programmatic processes for immunization delivery in an outreach setting were used. Billing and vaccine inventory management processes were developed. Vaccines from the federal Vaccines for Children program were used for eligible students. Third-party payers were billed for insured students; parents were not billed for services.

RESULTS

The proportion of enrolled students who received at least 1 dose of vaccine increased from year 1 to year 2 (elementary: 28% to 31%; middle: 12% to 19%). Issues identified and addressed included program planning with partners, development and implementation of billing processes, development of a solution to adhere to the Family Educational Rights and Privacy Act requirements, development and utilization of an easy-to-comprehend consent form, and implementation of standard work procedures.

CONCLUSIONS

This SLV program offered an alternative approach for providing vaccinations to students outside of the primary care setting. To be successful, ongoing partnerships are needed.

Methods to assess youth engagement in a text messaging supplement to an effective teen pregnancy program

Youth are prolific users of cell phone minutes and text messaging. Numerous programs using short message service text messaging (SMS) have been employed to help improve health behaviors and health outcomes. However, we lack information on whether and what type of interaction or engagement with SMS program content is required to realize any benefit. We explored youth engagement with an automated SMS program designed to supplement a 25-session youth development program with demonstrated efficacy for reductions in teen pregnancy. Using two years of program data, we report on youth participation in design of message content and response frequency to messages among youth enrolled in the intervention arm of a randomized controlled trial (RCT) as one indicator of engagement. There were 221 youth between the ages of 14-18 enrolled over two years in the intervention arm of the RCT. Just over half (51%) were female; 56% were Hispanic; and 27% African American. Youth were sent 40,006 messages of which 16,501 were considered bi-directional where youth were asked to text a response. Four-fifths (82%) responded at least once to a text. We found variations in response frequency by gender, age, and ethnicity. The most popular types of messages youth responded to include questions and quizzes. The first two months of the program in each year had the highest response frequency. An important next step is to assess whether higher response to SMS results in greater efficacy. This future work can facilitate greater attention to message design and content to ensure messages are engaging for the intended audience.

Effects of HIV Infection on Body Composition Changes Among Men of Different Racial/Ethnic Origins

PURPOSE

To compare racial/ethnic differences and effects of HIV on body composition among antiretroviral (ART)-naïve HIV seropositive (HIV+) men to a representative sample of HIV seronegative (HIV-) men. We hypothesized that the effect of HIV infection will be uniform across all racial/ethnic groups.

METHOD

A cross-sectional analysis was performed comparing HIV- (NHANES 1999-2002) and ART-naïve HIV+ men (CPCRA 061). Regional subcutaneous fat area was estimated by skinfold caliper. Total body fat (TBF), fat-free mass (FFM), and body fat index (BFI) were derived by Durnin-Womersley formula (TBF-DW, FFM-DW, BFI [TBF-DW/height(2)]). Bioelectric impedance analyses (BIA) was used to assess TBF-BIA, FFM-BIA, and body cell mass (BCM). Multivariate regression modeling adjusted for age, smoking, and hepatitis C for each measurement was performed.

RESULTS

HIV+ men (n = 321) were older and more likely to be smokers than HIV- men (n = 1,996). The HIV- men were heavier in weight (+17.8 kg, p < .001) and had higher BMI (+4.3 kg/m(2), p < .001), BCM (+2.4 kg, p = .02), FFM (+5.9 kg, p < .001), TBF-DW (+5.95 kg, p < .001), BFI (+1.6 kg/m(2), p < .001), and regional fat mass than the HIV+ men. In the multivariate model, there were significant percentage differences between HIV- and HIV+ African American men for all body composition measurements (weight +15.3%; BMI +14.5%; BCM +5.2%; TBF-DW +15%; BFI 13.9%; FFM-DW 7.9%) and all circumference and skinfold measurements; all ps < .05. For Caucasian men, the following differences were significant between HIV- and HIV+: weight +14.4%; BMI +14.0%; BCM +6.0%; TBF-DW +17.7%; BFI 17.1%; FFM-DW 8.7%; and all circumference and skinfold measurements. Similarly, among Latino men the following differences were significant: weight +10.1%; BMI +12.3%; FFM-DW +7.7%; and arm, waist, and thigh circumferences and mid-arm skinfold fat area. The interaction terms for race/ethnicity were not significant across the three racial groups for weight, BMI, BCM, TBF-BIA, and BFI.

CONCLUSION

Compared to HIV uninfected men, among HIV-infected ART-naïve men there was a significant effect of HIV infection itself on body composition among all racial/ethnic groups.

School-located influenza vaccination with third-party billing: outcomes, cost, and reimbursement

OBJECTIVE

To assess rates of immunization; costs of conducting clinics; and reimbursements for a school-located influenza vaccination (SLIV) program that billed third-party payers.

METHODS

SLIV clinics were conducted in 19 elementary schools in the Denver Public School district (September 2010 to February 2011). School personnel obtained parental consent, and a community vaccinator conducted clinics and performed billing. Vaccines For Children vaccine was available for eligible students. Parents were not billed for any fees. Data were collected regarding implementation costs and vaccine cost was calculated using published private sector prices. Reimbursement amounts were compared to costs.

RESULTS

Overall, 30% of students (2784 of 9295) received ≥1 influenza vaccine; 39% (1079 of 2784) needed 2 doses and 80% received both. Excluding vaccine costs, implementation costs were $24.69 per vaccination. The percentage of vaccine costs reimbursed was 62% overall (82% from State Child Health Insurance Program (SCHIP), 50% from private insurance). The percentage of implementation costs reimbursed was 19% overall (23% from private, 27% from Medicaid, 29% from SCHIP and 0% among uninsured). Overall, 25% of total costs (implementation plus vaccine) were reimbursed.

CONCLUSIONS

A SLIV program resulted in vaccination of nearly one third of elementary students. Reimbursement rates were limited by 1) school restrictions on charging parents fees, 2) low payments for vaccine administration from public payers and 3) high rates of denials from private insurers. Some of these problems might be reduced by provisions in the Affordable Care Act.

School-located influenza vaccination with third-party billing: what do parents think?

OBJECTIVE

School-located influenza vaccination (SLIV) may be instrumental in achieving high vaccination rates among children. Sustainability of SLIV programs may require third-party billing. This study assessed, among parents of elementary school students, the attitudes about SLIV and billing at school, as well as factors associated with being supportive of SLIV.

METHODS

We conducted a survey (April 2010 to June 2010) of parents of 1000 randomly selected primarily low-income children at 20 elementary schools at which SLIV with billing had occurred.

RESULTS

Response rate was 70% (n = 699). Eighty-one percent agreed (61% strongly) they "would be okay" with SLIV for their child. Many agreed it was better to get vaccinated at their child's doctor's office because they could take care of other health issues (72%) and the doctor knows the child's medical history (65%). However, an equal percentage (47%) thought the best place for influenza vaccination was the child's doctor's office and the child's school. Twenty-five percent did not want to give health insurance information necessary for billing at school. Factors independently associated with strongly supporting SLIV included parental education of high school or less (relative risk 1.30; 95% confidence interval 1.09-1.58), Hispanic ethnicity (1.25; 1.08-1.45); believing the vaccine is efficacious (1.49; 1.23-1.84); and finding school delivery more convenient (2.37; 1.82-3.45). Having concerns about the safety of influenza vaccine (0.80; 0.72-0.88) and not wanting their child to be vaccinated without a parent (0.74; 0.64-0.83) were negatively associated.

CONCLUSIONS

The majority of parents were supportive of SLIV, although parental concerns about not being present for vaccination and about the safety and efficacy of the vaccine will need to be addressed.

Improved neurocognitive test performance in both arms of the SMART study: impact of practice effect

We evaluated factors associated with improvement in neurocognitive performance in 258 HIV-infected adults with baseline CD4 lymphocyte counts above 350 cells/mm³ randomized to intermittent, CD4-guided antiretroviral therapy (ART) (128 participants) versus continuous therapy (130) in the Neurology substudy of the Strategies for Management of Antiretroviral Therapy trial. Participants were enrolled in Australia, North America, Brazil, and Thailand, and neurocognitive performance was assessed by a five-test battery at baseline and month 6. The primary outcome was change in the quantitative neurocognitive performance z score (QNPZ-5), the average of the z scores of the five tests. Associations of the 6-month change in test scores with ART use, CD4 cell counts, HIV RNA levels, and other factors were determined using multiple regression models. At baseline, median age was 40 years, median CD4 cell count was 513 cells/mm³, 88 % had plasma HIV RNA ≤ 400 copies/mL, and mean QNPZ-5 was -0.68. Neurocognitive performance improved in both treatment groups by 6 months; QNPZ-5 scores increased by 0.20 and 0.13 in the intermittent and continuous ART groups, respectively (both P < 0.001 for increase and P = 0.26 for difference). ART was used on average for 3.6 and 5.9 out of the 6 months in the intermittent and continuous ART groups, respectively, but the increase in neurocognitive test scores could not be explained by ART use, changes in CD4, or plasma HIV RNA, which suggests a practice effect. The impact of a practice effect after 6 months emphasizes the need for a control group in HIV studies that measure intervention effects using neurocognitive tests similar to ours.

Modeling the impact of quadrivalent HPV vaccination on the incidence of Pap test abnormalities in the United States

BACKGROUND

We present data on Pap test results and HPV prevalence from the HPV Sentinel Surveillance project, a multiyear surveillance project enrolling women from a diverse set of 26 clinics throughout the US from 2003 to 2005. We use mathematical modeling to illustrate the potential timing and magnitude of decreases in Pap test abnormalities in sexually transmitted disease (STD), family planning, and primary care clinics in the US as a result of HPV vaccination.

METHODS

The probability of an abnormal Pap result was based on three factors: (1) infection with HPV 16/18, or both; (2) infection with high-risk HPV types other than HPV 16/18; and (3) infection with HPV 6/11, or both. We estimated the relative reduction in the probability of an abnormal Pap result over the first 25 years of a female-only, quadrivalent HPV vaccination program, compared to a scenario of no HPV vaccination in which the probability of abnormal Pap results was assumed constant.

RESULTS

The probability of an abnormal Pap result ranged from 7.0% for the lowest risk group (those without any high-risk HPV types and without HPV 6/11) to 45.2% for the highest risk group (those with HPV 16/18 and at least one other high-risk HPV type). Estimated reductions in abnormal Pap results among women in the 21- to 29-year age group were 0.8%, 10.2%, and 11.3% in years 5, 15, and 25 of the vaccine program respectively, in the lower vaccine coverage scenario, and 7.4%, 21.4%, and 22.2%, respectively, in the higher coverage scenario.

CONCLUSIONS

Our results suggest that HPV vaccination will have a discernable impact on the probability of Pap abnormalities, but the timing and magnitude of the reduction will depend substantially on vaccine coverage and the degree of cross-protection against high risk HPV types other than HPV 16/18.

Early lessons learned from extramural school programs that offer HPV vaccine

BACKGROUND

There has been little evaluation of school-located vaccination programs that offer human papillomavirus (HPV) vaccine in US schools without health centers (ie, extramural programs). This article summarizes lessons learned from such programs.

METHODS

In July to August 2010, 5 programs were identified. Semistructured, in-depth telephone interviews were conducted with program representatives about practical aspects of planning and implementation, including configuration and effectiveness.

RESULTS

Most programs offered HPV vaccine as part of a broader effort to increase uptake of adolescent vaccines. Respondents stressed the importance of building partnerships with local school systems throughout all aspects of the planning and implementation phases. All programs offered HPV vaccine at no cost to students. Most did not have a mechanism to bill private insurance, and some found Medicaid reimbursements to be a challenge. Programs achieved modest rates of initiation of the 3-dose HPV vaccine series (median 10%); however, among those who initiated the series, completion rates were high (median 78%). HPV vaccine uptake was lowest for a program that offered only HPV vaccine.

CONCLUSIONS

Extramural programs may increase uptake of vaccines and decrease absenteeism due to noncompliance with vaccine requirements for school entry. Until extramural programs in the US receive better access to billing private insurers and Medicaid, sustainability of these programs relies on grant funding. Better integration of extramural school-located vaccine programs with existing local healthcare and other programs at schools is an area for growth.

Monitoring HPV type-specific prevalence over time through clinic-based surveillance: a perspective on vaccine effectiveness

We investigated the feasibility of monitoring trends in prevalence of vaccine-preventable human papillomavirus (HPV) types in different clinic populations. We collected cervical specimens from women presenting to family planning, primary care, and sexually transmitted disease (STD) clinics for routine pap smears in five US cities during 2003-2005. We performed HPV genotyping and calculated annual type-specific prevalences; pre-vaccine era prevalence was highest for HPV 16 (6.0; 95% confidence interval [CI] 5.5-6.6%) and annual prevalences for vaccine-preventable types were stable, with few exceptions, after controlling for clinic type, age group, and city. With sufficient sample size and stable population characteristics, clinic-based surveillance systems can contribute to monitoring HPV vaccine impact in the cervical screening population.

Reducing cardiovascular disease risk using patient navigators, Denver, Colorado, 2007-2009

INTRODUCTION

Early identification of cardiovascular disease (CVD) risk is important to reach people in need of treatment. At-risk patients benefit from behavioral counseling in addition to medical therapy. The objective of this study was to determine whether enhanced counseling, using patient navigators trained to counsel patients on CVD risk-reduction strategies and facilitate patient access to community-based lifestyle-change services, reduced CVD risk among at-risk patients in a low-income population.

METHODS

We compared clinical characteristics at baseline and 12-month follow-up among 340 intervention and 340 comparison patients from community health centers in Denver, Colorado, between March 2007 and June 2009; all patients had a Framingham risk score (FRS) greater or equal to 10% at baseline. The intervention consisted of patient-centered counseling by bilingual patient navigators. At baseline and at 6-month and 12-month follow-up, we assessed health behaviors of intervention participants. We used an intent-to-treat approach for all analyses and measured significant differences by χ(2) and t tests.

RESULTS

We found significant differences in several clinical outcomes. At follow-up, the mean FRS was lower for the intervention group (mean FRS, 15%) than for the comparison group (mean FRS, 16%); total cholesterol was lower for the intervention group (mean total cholesterol, 183 mg/dL) than for the comparison group (mean total cholesterol, 197 mg/dL). Intervention participants reported significant improvements in some health behaviors at 12-month follow-up, especially nutrition-related behaviors. Behaviors related to tobacco use and cessation attempts did not improve.

CONCLUSION

Patient navigators may provide some benefit in reducing risk of CVD in a similar population.

The association of current hormonal contraceptive use with type-specific HPV detection

BACKGROUND

Increased duration of hormonal contraceptive (HC) use may be positively associated with the risk of invasive cervical cancer.

METHODS

This is a secondary analysis from the HPV Sentinel Surveillance Study. The authors examined the association between type-specific human papillomavirus (HPV) detection and current HC use among 7718 women attending 26 sexually transmitted disease, family planning and primary care clinics in the USA.

RESULTS

There was an association between HC use and HPV-16 detection (adjusted prevalence rate ratio 1.34 (95% CI 1.05 to 1.71) for oral contraceptive users and 1.41 (1.01 to 2.04) for depot-medroxyprogesterone acetate users); there was no association between HC use and detection of other HPV types or any HPV overall.

CONCLUSIONS

Longitudinal studies are needed to better define this type-specific association and its clinical significance.

Prevalence of high-risk HPV types and abnormal cervical cytology in American Indian/Alaska Native women, 2003-2005

OBJECTIVES; We described prevalence estimates of high-risk human papillomavirus (HR-HPV), HPV types 16 and 18, and abnormal Papanicolaou (Pap) smear tests among American Indian/Alaska Native (AI/AN) women compared with women of other races/ethnicities.

METHODS

A total of 9,706 women presenting for cervical screening in a sentinel network of 26 clinics (sexually transmitted disease, family planning, and primary care) received Pap smears and HR-HPV type-specific testing. We compared characteristics of 291 women self-identified as AI/AN with other racial/ethnic minority groups.

RESULTS

In our population, AI/AN and non-Hispanic white (NHW) women had similar age- and clinic-adjusted prevalences of HR-HPV (29.1%, 95% confidence interval [CI] 23.9, 34.3 for AI/AN women vs. 25.8%, 95% CI 24.4, 27.2 for NHW women), HPV 16 and 18 (6.7%, 95% CI 3.9, 9.6 for AI/AN women vs. 8.8%, 95% CI 7.9, 9.7 for NHW women), and abnormal Pap smear test results (16%, 95% CI 11.7, 20.3 for AI/AN women vs. 14.9%, 95% CI 13.7, 16.0 for NHW women). AI/AN women had a higher prevalence of HR-HPV than Hispanic women, and a similar prevalence of HPV 16 and 18 as compared with Hispanic and African American women.

CONCLUSIONS

We could not demonstrate differences in the prevalence of HR-HPV, HPV 16 and 18, or abnormal Pap smear test results between AI/AN and NHW women. This finding should improve confidence in the benefit of HPV vaccine and Pap smear screening in the AI/AN population as an effective strategy to reduce rates of cervical cancer.

Boosted protease inhibitors and the electrocardiographic measures of QT and PR durations

BACKGROUND

There are contradictory reports regarding the effects of protease inhibitors on the ECG measures of QT and PR interval durations. The effect of interrupting use of protease inhibitors on QT and PR progression is also unknown.

METHODS

This analysis included 3719 participants from the Strategies for Management of Antiretroviral Therapy (SMART) study, of whom 1879 were randomized to receive intermittent antiretroviral therapy (ART) (drug conservation group), whereas the rest received these drugs continuously (viral suppression group). Linear regression analysis was used to compare four ritonavir-boosted protease inhibitor (protease inhibitor/r) regimens [saquinavir (SQV/r), lopinavir (LPV/r), atazanavir (ATV/r), and other protease inhibitor/r], and nonboosted protease inhibitor regimens with nonnucleoside reverse transcriptase inhibitor (NNRTI) regimens for Bazett's (QTcB) and Fredericia's (QTcF) heart rate corrected QT and PR. Changes in QTcB, QTcF, and PR after 12 and 24 months of randomization were compared in the drug conservation group and viral suppression group.

RESULTS

Average levels of QTcB, QTcF, and PR duration at entry were 415, 406, and 158 ms. At study entry, 49% of participants were taking an NNRTI (no protease inhibitor)-based regimen and 31% were prescribed a boosted protease inhibitor, the most common being LPV/r. After adjustment for baseline factors, QTcB and QTcF levels did not vary by boosted protease inhibitor group (P = 0.26 and P = 0.34, respectively). For those given any of the boosted protease inhibitors, QTcB was 1.5 ms lower than the NNRTI group (P = 0.04). Both boosted and nonboosted protease inhibitor-containing regimens were significantly associated (P < 0.01 for each) with longer PR intervals compared to the NNRTI group. After adjustment, the difference between boosted protease inhibitors and the NNRTI group was 5.11 ms (P < 0.01); for nonboosted protease inhibitors, this difference was 3.00 ms (P < 0.01). Following ART interruption, PR duration declined for both the boosted and nonboosted protease inhibitor groups and compared to the viral suppression group, significant changes in PR interval were observed 24 months after ART interruption of boosted protease inhibitors (P < 0.01).

CONCLUSION

Different protease inhibitor-based regimens have a similar, minimal effect on QT compared to NNRTI-based regimens. All protease inhibitor-based regimens (boosted and nonboosted) were associated with prolongation of PR, and interruption of protease inhibitor regimens reduced the prolonged PR duration. Further research is needed to confirm the findings of this study and assess the clinical relevance of the differences.

Cardiovascular risk factors associated with lower baseline cognitive performance in HIV-positive persons

OBJECTIVE

To determine factors associated with baseline neurocognitive performance in HIV-infected participants enrolled in the Strategies for Management of Antiretroviral Therapy (SMART) neurology substudy.

METHODS

Participants from Australia, North America, Brazil, and Thailand were administered a 5-test neurocognitive battery. Z scores and the neurocognitive performance outcome measure, the quantitative neurocognitive performance z score (QNPZ-5), were calculated using US norms. Neurocognitive impairment was defined as z scores <-2 in two or more cognitive domains. Associations of test scores, the QNPZ-5, and impairment with baseline factors including demographics and risk factors for HIV-associated dementia (HAD) and cardiovascular disease (CVD) were determined in multiple regression.

RESULTS

The 292 participants had a median CD4 cell count of 536 cells/mm(3), 88% had an HIV viral load < or =400 copies/mL, and 92% were taking antiretrovirals. Demographics, HIV, and clinical factors differed between locations. The mean QNPZ-5 score was -0.72; 14% of participants had neurocognitive impairment. For most tests, scores and z scores differed significantly between locations, with and without adjustment for age, sex, education, and race. Prior CVD was associated with neurocognitive impairment. Prior CVD, hypercholesterolemia, and hypertension were associated with poorer neurocognitive performance but conventional HAD risk factors and the CNS penetration effectiveness rank of antiretroviral regimens were not.

CONCLUSIONS

In this HIV-positive population with high CD4 cell counts, neurocognitive impairment was associated with prior CVD. Lower neurocognitive performance was associated with prior CVD, hypertension, and hypercholesterolemia, but not conventional HAD risk factors. The contribution of CVD and cardiovascular risk factors to the neurocognition of HIV-positive populations warrants further investigation.

Association between provision of initial family planning services and unintended pregnancy among women attending an STD clinic

BACKGROUND

Most sexually transmitted disease (STD) clinics focus solely on STD treatment and prevention. However, women seeking care are also at high risk for unintended pregnancy. We sought to examine the relationship between baseline demographic and clinical characteristics and incident pregnancy among women provided initial contraceptive services in an STD clinic.

METHODS

Computerized record review of women attending an STD clinic who initiated contraception, were seen at least twice within a 4-year period (repeat attendees), and indicated no intention of pregnancy were included in these analyses. Associations between baseline demographic, behavioral, and clinical characteristics and incident pregnancy were assessed using multivariate logistic regression.

RESULTS

Among 4617 women seen from 2003 to 2006, 710 (15%) were repeat attendees and 3907 (85%) were single attendees (seen only during a single year). Among the repeat attendees, 642 (90%) indicated no interest in pregnancy, of whom 124 (19%) had a subsequent pregnancy. Using multivariate analysis and controlling for age and race/ethnicity, incident pregnancy was associated with previous pregnancy (OR 2.57, 95% CI 1.63-4.04), <or=150% federal poverty level (OR 2.22, 95% CI 1.05-4.71), and no contraceptive use at last sex (OR 1.67, 95% CI: 1.11-2.52). Incident pregnancy was not associated with educational level, sexual frequency, age of first pregnancy, number of partners, prior therapeutic abortion, or provision of effective contraception at the initial STD clinic visit.

CONCLUSIONS

Certain baseline characteristics identified a subset of women seen in an STD clinic that were associated with future unintended pregnancy. Targeted interventions addressing these factors are needed.

Long-Term Body Composition and Metabolic Changes in Antiretroviral Naive Persons Randomized to Protease Inhibitor-, Nonnucleoside Reverse Transcriptase Inhibitor-, or Protease Inhibitor Plus Nonnucleoside Reverse Transcriptase Inhibitor-Based Strategy

OBJECTIVE

To assess changes in metabolic parameters and body composition among 422 antiretroviral-naive patients randomized to 3 antiretroviral therapy (ART) strategies: protease inhibitor (PI; n = 141)-, nonnucleoside reverse transcriptase inhibitor (NNRTI; n = 141)-, or PI + NNRTI (n = 140)-based strategies with a median follow-up of 5 years.

METHODS

At baseline and 1-month (metabolic parameters only) and 4-month follow-up intervals, fat-free mass (FFM) and total body fat were calculated, anthropometric measurements were performed, and fasting metabolic parameters were obtained. Rates of change and mean change were compared.

RESULTS

The PI + NNRTI strategy resulted in greater increases in triglycerides and low-density lipoprotein cholesterol compared with the PI and the NNRTI strategies (P < 0.005), with no differences between the PI and NNRTI strategies. High-density lipoprotein cholesterol increased significantly more in the NNRTI strategy than in the PI strategy (P < 0.005). Insulin and insulin resistance increased similarly with all 3 strategies. Changes in total and regional body composition (loss of subcutaneous tissue area and gains in FFM, nonsubcutaneous tissue area, and visceral tissue area) were observed but did not differ by strategy.

CONCLUSIONS

Long-term follow-up of participants initiating 3 ART strategies demonstrated similar changes in total and regional fat, with no differences by ART strategy. The differential effects on lipid metabolism by strategy and the overall increases in insulin and insulin resistance with all 3 strategies necessitate close monitoring of patients on ART.

Body Composition and Metabolic Changes in Antiretroviral-Naive Patients Randomized to Didanosine and Stavudine vs. Abacavir and Lamivudine

Comparisons of body composition and metabolic changes among antiretroviral-naive patients randomly assigned to didanosine and stavudine- (ddI+d4T) vs. abacavir and lamivudine- (ABC+3TC) containing regimens were assessed in a nested substudy of an ongoing multicenter randomized trial. At baseline and every 4 months, body cell mass and total body fat were calculated, anthropometric measurements were performed, and fasting metabolic parameters were obtained. The rates of change (unit/mo) estimated using the slopes of regression lines and overall mean changes from baseline were compared by study assignment. Among 96 patients enrolled, 46 received ddI+d4T- and 50 received ABC+3TC-containing regimens with a median follow-up of 32.4 months. For both study arms, an overall increase in the rates of change was seen for body cell mass. For ddI+d4T, after an initial increase, the rates of change declined for regional fat and total body fat compared with an increase for ABC+3TC, with the 2 arms being significantly different (P<0.05). For high-density lipoprotein cholesterol rates of change, ddI+d4T decreased, while ABC+3TC increased. For both arms, low-density lipoprotein cholesterol decreased, while triglycerides increased. Early and sustained increases in insulin and insulin resistance were seen only for ddI+d4T. In this prospective study, metabolic and body composition changes varied according to whether subjects received ddI+d4T or ABC+3TC.

A cost-effectiveness analysis of four management strategies in the determination and follow-up of atypical squamous cells of undetermined significance

Atypical squamous cells of undetermined significance (ASC-US) are the most common abnormal cytological result on Papanicolaou (Pap) smear. We analyzed four management strategies in a hypothetical cohort of women divided by age group: (1) immediate colposcopy, (2) repeat cytology after an ASC-US Pap smear result, (3) conventional Pap with reflex human papillomavirus (HPV) testing, and (4) liquid-based cytology with reflex HPV testing. Parameter variables were collected from previously published data. Strategies that included reflex HPV testing had the lowest overall costs for all age groups combined. Repeat Pap smears had the highest number of true positive results throughout all stages but also had the uppermost number of missed cancers and highest costs. Immediate colposcopy had the second highest overall costs and detected fewer true positive results than liquid-based cytology. Younger women (aged 18-24 yr) consistently had higher total costs for all strategies investigated. Using the incremental cost-effectiveness (CE) ratio, the immediate colposcopy strategy was more costly and less effective than liquid-based cytology and, therefore, was dominated. The incremental CE ratio was lowest for liquid-based cytology compared with conventional cytology and liquid-based cytology with reflex HPV testing was the most cost-effective strategy.

Comparison of sexually transmitted disease prevalence by reported condom use: errors among consistent condom users seen at an urban sexually transmitted disease clinic

BACKGROUND

The protective effect of condom use is controversial as a result of limited data.

GOAL

The goal of this study was to assess the association between condom use errors in consistent condom users and the prevalence of various sexually transmitted diseases (STDs).

STUDY

We conducted a cross-sectional study of visits to an urban STD clinic between January 2001 and January 2003, by women, men who have sex with women (MSW), and men who have sex with men (MSM) by consistent condom users with or without a condom use error.

METHODS

Prevalence rates were calculated for gonorrhea, chlamydia, trichomonas, nongonococcal urethritis (NGU), and pelvic inflammatory disease. Rates were stratified by reported errors in condom use over the past 4 months for consistent users with adjusted odds ratios calculated by logistic regression.

RESULTS

Among 1973 consistent condom users with error information available, any condom use error was reported more commonly among women (57%) than MSW (48%), or MSM (P <0.001 for each comparison), with breakage being the most frequently reported error. Among MSW, having a condom use error was associated with gonorrhea (adjusted odds ratio [AOR], 5.53; 95% confidence interval [CI], 2.48-12.35), chlamydia (AOR, 3.19; 95% CI, 1.80-5.65), and NGU (AOR, 2.09; 95% CI, 1.45-3.01), whereas, for women and MSM, no associations were seen for any STD.

CONCLUSIONS

Condom use errors were common among subjects reporting consistent condom use and for MSW, condom error was associated with a significant increased risk of STD. These data support the premise that correctness of condom use is an important methodologic issue in studies assessing condom effectiveness.

Comparison of Sexually Transmitted Disease Prevalence by Reported Level of Condom Use Among Patients Attending an Urban Sexually Transmitted Disease Clinic

BACKGROUND

There is controversy as to the protective effect of condoms in preventing various sexually transmitted diseases (STDs).

GOAL

The goal of this study was to assess the association of various levels of condom use with a variety of STD.

STUDY DESIGN

We conducted a cross-sectional study of female and heterosexual male visits to an urban STD clinic between 1990 and 2001.

METHODS

Prevalence rates were calculated for gonorrhea, chlamydia, trichomonas, recent-onset genital warts, first-episode herpes, and molluscum contagiosum by reported level of condom use over the past 4 months, with adjusted odds ratios (AOR) calculated by logistic regression.

RESULTS

Among 126,220 patient visits (39% women and 61% men), condom use over the past 4 months was reported by 54%, with 38% reporting inconsistent use and 16% consistent use. Condom users reported greater sexual risk in the past 4 months than nonusers (ie, new sex partners: 63% vs. 41%, P <0.001; multiple sex partners: 60% vs. 36%, P <0.001). When all condom users were compared with nonusers, there was limited evidence of protection against specific STD. However, when the analysis was restricted to condom users, infection rates were significantly lower in consistent than inconsistent users for both men and women for gonorrhea (AOR, 0.87 and 0.71, respectfully) and chlamydia (AOR, 0.66 and 0.74, respectfully), for trichomonas in women (AOR, 0.87), and for genital herpes in men (AOR, 0.73).

CONCLUSIONS

Comparisons of STD between condom users and nonusers are confounded by greater sexual risk in users. Comparing consistent with inconsistent users reduces this confounding, revealing protection for both men and women for nonviral STD and for genital herpes for men.

Initiating contraception in sexually transmitted disease clinic setting: a randomized trial

OBJECTIVE

Our purpose was to determine the effectiveness of sexually transmitted disease (STD) clinic-initiated contraceptive care.

STUDY DESIGN

Nonpregnant women (n=877) attending an urban STD clinic using either no contraception or only condoms were randomly assigned to either an intervention (n=437) or control group (n=440). Both groups received condoms with spermicide and a referral list of primary care providers (PCP) for ongoing reproductive health care, and the intervention group also received enhanced contraceptive counseling, initial provision of contraception, and facilitated referral to a PCP. Outcomes measured at 4-, 8-, and 12-month follow-up were transition to a PCP, effective contraceptive use (ECU), interval pregnancy, and STD.

RESULTS

The median time to PCP transition was 79 days for the intervention group versus 115 days for the control group (P=.007). Rates of ECU were higher for the intervention group than for control group at the 4-month visit (50% vs 22%, P<.0001) as well as the 8-month visit, although in the intervention group ECU diminished over the course of the study. During follow-up, pregnancy outcomes were documented for 229 women (26.1%), for an overall pregnancy rate of 38.2 per 100 person-years of follow-up. Of the 159 pregnancies defined by patient self-report, 153 (96.2%) were described as unintended and 32 (20%) resulted in a therapeutic abortion. The pregnancy rate was 15% lower in the intervention (105/437, 24.0%) than the control group (124/440, 28.2%) (P=.16), but this difference was not statistically significant.

CONCLUSION

The intervention helped women transition to a PCP and initiate ECU but did not significantly reduce the pregnancy rate. More intensive interventions are needed to prevent unintended pregnancy in this high-risk population.

Predicting pregnancy risk in women attending an STD clinic

BACKGROUND

Although sexually transmitted disease (STD) clinics focus mainly on STD treatment and prevention, women attending these clinics are also at high risk for pregnancy.

GOAL

To evaluate the relationship between certain demographic and behavioral characteristics and the probability of pregnancy in women attending an urban STD clinic.

STUDY DESIGN

Non-contraceptive-using women in an STD clinic-initiated randomized controlled contraception study (n = 877) were interviewed at baseline, and incident pregnancies within 1 year of enrollment were measured. Association between baseline demographic and behavioral characteristics with incident pregnancy was assessed by chi-square analysis, and logistic regression was used to assess factors associated with an incident pregnancy.

RESULTS

Among the 673 women (76.7%) for whom follow-up pregnancy information was available, 220 (32.7%) incident pregnancies occurred within 1 year. By logistic regression controlling for study assignment, incident pregnancy was associated with age < or =19 years (odds ratio [OR], 2.8; 95% CI: 1.5-5.2), previous abortion (OR, 3.1; 95% CI: 1.7-5.4), frequency of sexual encounters of at least once a week (OR, 1.8; 95% CI: 1.2-2.6), and having a chlamydial infection at the time of enrollment (OR, 1.8; 95% CI: 1.0-3.2). With a combination of demographic and behavioral characteristics correlated by univariate analysis with incident pregnancy (i.e., age < or =19 years, nonwhite race, high school/general equivalency diploma or less education, previous pregnancy, no use of birth control with last intercourse, sex at least once a week, previous abortion, > or =3 partners within the past month, and <17 years of age at first pregnancy), the cumulative risk of pregnancy with 6 or more of the 9 characteristics was 51%, compared with 25.6% for women with < or =5 characteristics.

CONCLUSION

For this STD clinic population, a combination of demographic and behavioral characteristics was useful when combined for identifying a subgroup of women at higher risk for subsequent pregnancy. Targeted intervention by STD care providers should include the provision for both pregnancy and STD prevention counseling.

Predictors of contraceptive discontinuation in a sexually transmitted disease clinic population

CONTEXT

Women who attend sexually transmitted disease (STD) clinics are at high risk for unintended pregnancy. Little information is available, however, on the rates of discontinuation of effective contraceptive method use among this population.

METHODS

As part of a study on contraceptive services offered by an STD clinic in Denver, 406 clients who accepted these services in 1996-1999 were interviewed about their contraceptive practice, experience of side effects and method-use problems at baseline and at four, eight and 12 months of follow-up. Multivariate survival analysis was used to assess predictors of discontinuation of effective contraceptive use.

RESULTS

Twenty-nine percent of women discontinued use by the end of one year. Coxproportional hazards models show that compared with women who reported no method-use problems, those who experienced one problem were three times as likely (hazard ratio, 3.0) to discontinue effective use, and women who had at least two problems were five times as likely (5.0) to discontinue use. The experience of side effects with either a past or a current method, however, was not associated with the risk of discontinuation. Furthermore, women who reported risky sexual behavior in the year before enrollment were significantly less likely to discontinue effective method use (hazard ratio, 0.4), as were women who were covered by medical insurance or who gained such coverage during a follow-up interval (hazard ratio, 0.5 for each).

CONCLUSIONS

In this study population of STD clinic users, method-use problems appear to be a more fundamental issue for contraceptive compliance than the pastor current experience of side effects. The unexpected association between method-use problems and the risk of discontinuation needs to be further delineated so that effective interventions addressing these problems can be developed and implemented.

Prediction of cervical intraepithelial neoplasia grade 2-3 using risk assessment and human papillomavirus testing in women with atypia on papanicolaou smears

OBJECTIVE

To determine whether human papillomavirus (HPV) DNA testing and risk assessment can predict cervical intraepithelial neoplasia (CIN) 2-3 on biopsies in women with atypia on Papanicolaou smears.

METHODS

One hundred ninety-five consenting women were referred for colposcopy because of atypia on Papanicolaou smears between September 1997 and April 1999. Before colposcopy, women completed risk assessments and had cervical swabs collected for HPV testing using the Hybrid Capture-II assay (Digene Corporation, Silver Spring, MD). Associations of demographic and clinical variables were assessed by chi(2) analysis, and logistic regression was used to assess factors associated with CIN 2-3. The cost-effectiveness of routine colposcopy versus reflex HPV testing by either conventional or liquid-based Papanicolaou smear media was compared.

RESULTS

Cervical intraepithelial neoplasia was diagnosed in 70 of 195 women (35.9%), 55 (28.2%) with CIN 1 and 15 (7.7%) with CIN 2-3. High-risk HPV types were detected in 31.3% of all subjects, 36.4% of those with CIN 1, and 93.3% of those with CIN 2-3. By logistic regression, CIN 2-3 was associated only with detection of high-risk HPV (odds ratio 110.08, 95% confidence interval 8.35, 999. 00). The sensitivity of high-risk HPV for detecting CIN 2-3 was 93. 3%, specificity 73.9%, positive predictive value 23.0%, and negative predictive value 99.3%. The cost of reflex HPV testing using conventional smear or liquid-based media was less than routine colposcopy ($4809 and $4308, respectively, versus $4875 per case detected).

CONCLUSIONS

Triage based on HPV testing would result in referral of approximately 31% of patients to colposcopy and appears to be a sensitive and cost-effective alternative to colposcopy.

Acupuncture and amitriptyline for pain due to HIV-related peripheral neuropathy: a randomized controlled trial. Terry Beirn Community Programs for Clinical Research on AIDS

CONTEXT

Peripheral neuropathy is common in persons infected with the human immunodeficiency virus (HIV) but few data on symptomatic treatment are available.

OBJECTIVE

To evaluate the efficacy of a standardized acupuncture regimen (SAR) and amitriptyline hydrochloride for the relief of pain due to HIV-related peripheral neuropathy in HIV-infected patients.

DESIGN

Randomized, placebo-controlled, multicenter clinical trial. Each site enrolled patients into 1 of the following 3 options: (1) a modified double-blind 2 x 2 factorial design of SAR, amitriptyline, or the combination compared with placebo, (2) a modified double-blind design of an SAR vs control points, or (3) a double-blind design of amitriptyline vs placebo.

SETTING

Terry Beirn Community Programs for Clinical Research on AIDS (HIV primary care providers) in 10 US cities.

PATIENTS

Patients with HIV-associated, symptomatic, lower-extremity peripheral neuropathy. Of 250 patients enrolled, 239 were in the acupuncture comparison (125 in the factorial option and 114 in the SAR option vs control points option), and 136 patients were in the amitriptyline comparison (125 in the factorial option and 11 in amitriptyline option vs placebo option).

INTERVENTIONS

Standardized acupuncture regimen vs control points, amitriptyline (75 mg/d) vs placebo, or both for 14 weeks.

MAIN OUTCOME MEASURE

Changes in mean pain scores at 6 and 14 weeks, using a pain scale ranging from 0.0 (no pain) to 1.75 (extremely intense), recorded daily.

RESULTS

Patients in all 4 groups showed reduction in mean pain scores at 6 and 14 weeks compared with baseline values. For both the acupuncture and amitriptyline comparisons, changes in pain score were not significantly different between the 2 groups. At 6 weeks, the estimated difference in pain reduction for patients in the SAR group compared with those in the control points group (a negative value indicates a greater reduction for the "active" treatment) was 0.01 (95% confidence interval [CI], -0.11 to 0.12; P=.88) and for patients in the amitriptyline group vs those in the placebo group was -0.07 (95% CI, -0.22 to 0.08; P=.38). At 14 weeks, the difference for those in the SAR group compared with those in the control points group was -0.08 (95% CI, -0.21 to 0.06; P=.26) and for amitriptyline compared with placebo was 0.00 (95% CI, -0.18 to 0.19; P=.99).

CONCLUSIONS

In this study, neither acupuncture nor amitriptyline was more effective than placebo in relieving pain caused by HIV-related peripheral neuropathy.

Pap smear screening in an urban STD clinic. Yield of screening and predictors of abnormalities

BACKGROUND

Pap smear screening studies in STD clinics have reported high rates of squamous intraepithelial lesions (SIL); however, there are limited data on levels of unsatisfactory smears of characteristics associated with cytologic abnormalities.

GOAL

To assess the yield to Pap smear screening in an STD clinic and to evaluate the rates of and risk factors for atypia, low-grade SIL (LSIL), and high-grade SIL (HSIL).

STUDY DESIGN

A chart review of the clinic records of women undergoing Pap smear screening between 1991 and 1994 was conducted. Results were assessed from two different screening protocols, the first using a Dacron swab to obtain the endocervical sample and the second using a cytobrush.

RESULTS

Of 2034 Pap smears, 1313 (64.6%) were negative, 202 (9.9%) were unsatisfactory, 257 (12.6%) were atypical, 211 (10.4%) had LSIL, and 51 (2.5%) had HSIL. With the change to the cytobrush protocol, the rate of unsatisfactory smears decreased from 14.4% to 3% (p < 0.001), atypia increased from 10% to 16.7% (p < 0.001), and HSIL rose from 1.7% to 3.7% (p < 0.001). By multivariate analysis, atypia was associated with genital warts (odds ratio (OR) 1.53, 95% confidence interval (CI): 1.16-2.02); LSIL with younger age (p < 0.001, for trend), black race (OR 1.51, 95% CI: 1.08-2.10), genital warts (OR 1.81, 95% CI: 1.33-2.47), and an abnormal appearance of the cervix on examination (OR 2.49, 95% CI: 1.85-3.35); and HSIL with a previous abnormal Pap smear (OR 2.48, 95% CI: 1.08-2.10). Overall, abnormality rates were significantly higher in adolescents (35.5%) than older women (21.7%) (p < 0.01).

CONCLUSIONS

Obtaining satisfactory Pap smears among women undergoing screening in an STD clinic is feasible and cytologic abnormalities are common. These results continue to support the need for Pap smear screening in STD clinics, but the high rates in adolescents, a group in whom the natural history of cytologic abnormalities has not been well-defined, raise questions about the need to develop age-appropriate screening and management strategies.

Human immunodeficiency virus seroprevalence and risk assessment of a homeless population in Denver

OBJECTIVE

TO determine the prevalence of human immunodeficiency virus (HIV) infection among the homeless of Denver and to describe behaviors in the homeless that may be associated with HIV infection.

DESIGN

A cross-sectional cohort study.

METHODS

From July 1990 through June 1994, the authors conducted an unlinked survey collecting demographic and risk exposure data, and from August 1990 through June 1992, a more detailed risk behavior survey was completed on persons who attended the largest homeless clinic in Denver.

RESULTS

For the combined survey years, the overall seroprevalence rate in the unlinked survey was 0.9%. Men were more likely to be seropositive than women (1.3% versus 0.1%) (P < 0.001). Black and Hispanic men had higher seroprevalence rates than white men (3.1% and 2.2% versus 0.5%) (P < 0.001). Gay and bisexual men, men who were injection drug users, and men with partners at risk had a nearly fivefold higher seroprevalence rate compared to other risk groups (3.1% versus 0.7%, P < 0.001). During the 4 study years, 14% of homeless persons tested positive for tuberculosis. In the risk behavior survey, 41% of the clients reported previous injection drug use (since 1978), and 22% reported recent use (past 12 months); of this 22%, 16% reported sharing their works (needles and paraphernalia). Seventy percent of the study participants stated that they changed their sexual behavior, and 39% reported using condoms in the past 12 months.

CONCLUSIONS

In this homeless Denver population, there is a low seroprevalence of HIV but a high rate of HIV risk behavior. Certain groups of homeless persons are at high risk for HIV infection, and targeted interventions are necessary.