Assessment of the Chad guinea worm surveillance information system: A pivotal foundation for eradication

Background

In the absence of a vaccine or pharmacological treatment, prevention and control of Guinea worm disease is dependent on timely identification and containment of cases to interrupt transmission. The Chad Guinea Worm Eradication Program (CGWEP) surveillance system detects and monitors Guinea worm disease in both humans and animals. Although Guinea worm cases in humans has declined, the discovery of canine infections in dogs in Chad has posed a significant challenge to eradication efforts. A foundational information system that supports the surveillance activities with modern data management practices is needed to support continued program efficacy.

Methods

We sought to assess the current CGWEP surveillance and information system to identify gaps and redundancies and propose system improvements. We reviewed documentation, consulted with subject matter experts and stakeholders, inventoried datasets to map data elements and information flow, and mapped data management processes. We used the Information Value Cycle (IVC) and Data-Information System-Context (DISC) frameworks to help understand the information generated and identify gaps.

Results

Findings from this study identified areas for improvement, including the need for consolidation of forms that capture the same demographic variables, which could be accomplished with an electronic data capture system. Further, the mental models (conceptual frameworks) IVC and DISC highlighted the need for more detailed, standardized workflows specifically related to information management.

Conclusions

Based on these findings, we proposed a four-phased roadmap for centralizing data systems and transitioning to an electronic data capture system. These included: development of a data governance plan, transition to electronic data entry and centralized data storage, transition to a relational database, and cloud-based integration. The method and outcome of this assessment could be used by other neglected tropical disease programs looking to transition to modern electronic data capture systems.

Guinea worm disease has no pharmacological treatment or vaccines, and therefore existing prevention and control strategies (e.g., case containment, health education, chemical treatment of water bodies) are critically dependent on timely, accurate, and actionable data. We conducted informant interviews, used conceptual frameworks, and mapped data flow to evaluate the Chad Guinea Worm Eradication Program’s current information system. We identified areas for improvement including the need to consolidate variables across data collection forms and the need to develop streamlined workflows. We proposed a four-phased roadmap for transitioning to an electronic data capture system and centralizing data storage. Our approach and proposed roadmap could be adopted by other neglected tropical disease control programs looking to modernize data collection and storage procedures.

Syphilis management in pregnancy: a review of guideline recommendations from countries around the world

Guidelines can help healthcare practitioners manage syphilis in pregnancy and prevent perinatal death or disability. We conducted systematic reviews to locate guidance documents describing management of syphilis in pregnancy, 2003–2017. We compared country and regional guidelines with current World Health Organization (WHO) guidelines. We found 64 guidelines with recommendations on management of syphilis in pregnancy representing 128 of the 195 WHO member countries, including the two WHO guidelines published in 2016 and 2017. Of the 62 guidelines, 16 were for countries in Africa, 21 for the Americas, two for Eastern Mediterranean, six for Europe and 17 for Asia or the Pacific. Fifty-seven (92%) guidelines recommended universal syphilis screening in pregnancy, of which 46 (81%) recommended testing at the first antenatal care visit. Also, 46 (81%) recommended repeat testing including 21 guidelines recommended this during the third pregnancy trimester and/or at delivery. Fifty-nine (95%) guidelines recommended benzathine penicillin G (BPG) as the first-line therapy for syphilis in pregnancy, consistent with WHO guidelines. Alternative regimens to BPG were listed in 42 (68%) guidelines, primarily from Africa and Asia; only 20 specified that non-penicillin regimens are not proven-effective in treating the fetus. We identified guidance recommending use of injectable penicillin in exposed infants for 112 countries. Most guidelines recommended universal syphilis testing for pregnant women, repeat testing for high-risk women and treatment of infected women with BPG; but several did not. Updating guidance on syphilis testing and treatment in pregnancy to reflect global norms could prevent congenital syphilis and save newborn lives.

Malaria and Parasitic Neglected Tropical Diseases: Potential Syndemics with COVID-19?

The COVID-19 pandemic, caused by SARS-CoV-2, have surpassed 5 million cases globally. Current models suggest that low- and middle-income countries (LMICs) will have a similar incidence but substantially lower mortality rate than high-income countries. However, malaria and neglected tropical diseases (NTDs) are prevalent in LMICs, and coinfections are likely. Both malaria and parasitic NTDs can alter immunologic responses to other infectious agents. Malaria can induce a cytokine storm and pro-coagulant state similar to that seen in severe COVID-19. Consequently, coinfections with malaria parasites and SARS-CoV-2 could result in substantially worse outcomes than mono-infections with either pathogen, and could shift the age pattern of severe COVID-19 to younger age-groups. Enhancing surveillance platforms could provide signals that indicate whether malaria, NTDs, and COVID-19 are syndemics (synergistic epidemics). Based on the prevalence of malaria and NTDs in specific localities, efforts to characterize COVID-19 in LMICs could be expanded by adding testing for malaria and NTDs. Such additional testing would allow the determination of the rates of coinfection and comparison of severity of outcomes by infection status, greatly improving the understanding of the epidemiology of COVID-19 in LMICs and potentially helping to mitigate its impact.

Evaluating coverage of maternal syphilis screening and treatment within antenatal care to guide service improvements for prevention of congenital syphilis in Countdown 2030 Countries

Background

Countdown to 2030 (CD2030) tracks progress in the 81 countries that account for more than 90% of under-five child deaths and 95% of maternal deaths in the world. In 2017, CD2030 identified syphilis screening and treatment during antenatal care (ANC) as priority indicators for monitoring.

Methods

Country-reported data in the UNAIDS Global AIDS Monitoring System (GAM) system were used to evaluate four key syphilis indicators from CD2030 countries: (1) maternal syphilis screening and (2) treatment coverage during ANC, (3) syphilis seroprevalence among ANC attendees, and (4) national congenital syphilis (CS) case rates. A cascade analysis for CD2030 countries with coverage data for the number of women attending at least 4 antenatal care visits (ANC4), syphilis testing, seroprevalence and treatment was performed to estimate the number of CS cases that were attributable to missed opportunities for syphilis screening and treatment during antenatal care.

Results

Of 81 countries, 52 (64%) reported one or more values for CS indicators into the GAM system during 2016-2017; only 53 (65%) had maternal syphilis testing coverage, 41 (51%) had screening positivity, and 40 (49%) had treatment coverage. CS case rates were reported by 13 (16%) countries. During 2016-2017, four countries reported syphilis screening and treatment coverage of ≥95% consistent with World Health Organization (WHO) targets. Sufficient data were available for 40 (49%) of countries to construct a cascade for data years 2016 and 2017. Syphilis screening and treatment service gaps within ANC4 resulted in an estimated total of 103 648 adverse birth outcomes with 41 858 of these occurring as stillbirths among women attending ANC4 (n = 31 914 408). Women not in ANC4 (n = 25 619 784) contributed an additional 67 348 estimated adverse birth outcomes with 27 198 of these occurring as stillbirths for a total of 69 056 preventable stillbirths attributable to syphilis in these 40 countries.

Conclusion

These data and findings can serve as an initial baseline evaluation of antenatal syphilis surveillance and service coverage and can be used to guide improvement of delivery and monitoring of syphilis screening and treatment in ANC for these priority countries.

An Evaluation of Infertility Among Women in the Republic of Palau, 2016

Fertility challenges are a personal and important part of a woman's reproductive health and are associated with health and lifestyle factors. Limited data exist on infertility among women in Palau. We describe the lifetime prevalence of self-reported infertility in a nationally representative sample of women in Palau and investigate the association between tobacco and/or betel nut use and infertility. During May-December 2016, a population-based survey of noncommunicable diseases was conducted in Palau using a geographically stratified random sample of households (N=2409). Men and women ≥18 years of age were chosen randomly from each selected household. The prevalence of a self-reported lifetime episode of infertility (having tried unsuccessfully to become pregnant for ≥12 months) was evaluated among 874 women aged ≥18 years by key health and lifestyle factors. Prevalence ratios (PR) and 95% confidence intervals (CI) were calculated. Of 315 women who ever tried to become pregnant, 39.7% (95% CI: 34.2%, 45.3%) reported a lifetime episode of infertility. Prevalence was higher in women of Palauan vs other ethnicity (PR=1.6, 95% CI: 1.1, 2.3), those who self-reported poor/not good vs. excellent/ very good health status (PR=2.1, 95% CI: 1.4, 3.3), and those with a body mass index (BMI) ≥30 vs <30 (PR=1.7, 95% CI: 1.3, 2.2). Adjusted models showed that tobacco and/or betel nut users were almost twice as likely to report infertility versus non-users (PR=1.8, 95% CI: 1.3, 2.5). More research is needed to understand the infertility experiences of women in Palau and to promote lifestyle factors contributing to optimal reproductive health.

Assessing stakeholder perceptions of the acceptability and feasibility of national scale-up for a dual HIV/syphilis rapid diagnostic test in Malawi

OBJECTIVES

The WHO recommends pregnant women receive both HIV and syphilis testing at their first antenatal care visit, as untreated maternal infections can lead to severe, adverse pregnancy outcomes. One strategy for increasing testing for both HIV and syphilis is the use of point-of-care (rapid) diagnostic tests that are simple, proven effective and inexpensive. In Malawi, pregnant women routinely receive HIV testing, but only 10% are tested for syphilis at their first antenatal care visit. This evaluation explores stakeholder perceptions of a novel, dual HIV/syphilis rapid diagnostic test and potential barriers to national scale-up of the dual test in Malawi.

METHODS

During June and July 2015, we conducted 15 semistructured interviews with 25 healthcare workers, laboratorians, Ministry of Health leaders and partner agency representatives working in prevention of mother-to-child transmission in Malawi. We asked stakeholders about the importance of a dual rapid diagnostic test, concerns using and procuring the dual test and recommendations for national expansion.

RESULTS

Stakeholders viewed the test favourably, citing the importance of a dual rapid test in preventing missed opportunities for syphilis diagnosis and treatment, improving infant outcomes and increasing syphilis testing coverage. Primary technical concerns were about the additional procedural steps needed to perform the test, the possibility that testers may not adhere to required waiting times before interpreting results and difficulty reading and interpreting test results. Stakeholders thought national scale-up would require demonstration of cost-savings, uniform coordination, revisions to testing guidelines and algorithms, training of testers and a reliable supply chain.

CONCLUSIONS

Stakeholders largely support implementation of a dual HIV/syphilis rapid diagnostic test as a feasible alternative to current antenatal testing. Scale-up will require addressing perceived barriers; negotiating changes to existing algorithms and guidelines; and Ministry of Health approval and funding to support training of staff and procurement of supplies.

Global burden of maternal and congenital syphilis in 2008 and 2012: a health systems modelling study

Summary

Background

In 2007, WHO launched a global initiative for the elimination of mother-to-child transmission of syphilis (congenital syphilis). An important aspect of the initiative is strengthening surveillance to monitor progress towards elimination. In 2008, using a health systems model with country data inputs, WHO estimated that 1 4 million maternal syphilis infections caused 520 000 adverse pregnancy outcomes. To assess progress, we updated the 2008 estimates and estimated the 2012 global prevalence and cases of maternal and congenital syphilis.

Methods

We used a health systems model approved by the Child Health Epidemiology Reference Group. WHO and UN databases provided inputs on livebirths, antenatal care coverage, and syphilis testing, seropositivity, and treatment in antenatal care. For 2012 estimates, we used data collected between 2009 and 2012. We updated the 2008 estimates using data collected between 2000 and 2008, compared these with 2012 estimates using data collected between 2009 and 2012, and performed subanalyses to validate results.

Findings

In 2012, an estimated 930 000 maternal syphilis infections caused 350 000 adverse pregnancy outcomes including 143 000 early fetal deaths and stillbirths, 62 000 neonatal deaths, 44 000 preterm or low weight births, and 102 000 infected infants worldwide. Nearly 80% of adverse outcomes (274 000) occurred in women who received antenatal care at least once. Comparing the updated 2008 estimates with the 2012 estimates, maternal syphilis decreased by 38% (from 1 488 394 cases in 2008 to 927 936 cases in 2012) and congenital syphilis decreased by 39% (from 576 784 to 350 915). India represented 65% of the decrease. Analysis excluding India still showed an 18% decrease in maternal and congenital cases of syphilis worldwide.

Interpretation

Maternal and congenital syphilis decreased worldwide from 2008 to 2012, which suggests progress towards the elimination of mother-to-child transmission of syphilis. Nonetheless, maternal syphilis caused substantial adverse pregnancy outcomes, even in women receiving antenatal care. Improved access to quality antenatal care, including syphilis testing and treatment, and robust data are all important for achieving the elimination of mother-to-child transmission of syphilis.

Funding

The UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction in WHO, and the US Centers for Disease Control and Prevention.

Syphilis

Treponema pallidum subspecies pallidum (T. pallidum) causes syphilis via sexual exposure or via vertical transmission during pregnancy. T. pallidum is renowned for its invasiveness and immune-evasiveness; its clinical manifestations result from local inflammatory responses to replicating spirochaetes and often imitate those of other diseases. The spirochaete has a long latent period during which individuals have no signs or symptoms but can remain infectious. Despite the availability of simple diagnostic tests and the effectiveness of treatment with a single dose of long-acting penicillin, syphilis is re-emerging as a global public health problem, particularly among men who have sex with men (MSM) in high-income and middle-income countries. Syphilis also causes several hundred thousand stillbirths and neonatal deaths every year in developing nations. Although several low-income countries have achieved WHO targets for the elimination of congenital syphilis, an alarming increase in the prevalence of syphilis in HIV-infected MSM serves as a strong reminder of the tenacity of T. pallidum as a pathogen. Strong advocacy and community involvement are needed to ensure that syphilis is given a high priority on the global health agenda. More investment is needed in research on the interaction between HIV and syphilis in MSM as well as into improved diagnostics, a better test of cure, intensified public health measures and, ultimately, a vaccine.

A systematic review and meta-analysis of studies evaluating the performance and operational characteristics of dual point-of-care tests for HIV and syphilis

Background

Mother-to-child transmission (MTCT) of syphilis and HIV continue to be important yet preventable causes of perinatal and infant morbidity and mortality.

Objectives

To systematically review, critically appraise and perform a meta-analysis to evaluate the operational characteristics of dual rapid diagnostic tests (RDTs) for HIV/syphilis and evaluate whether they are cost effective, acceptable and easy to use.

Design

Systematic review and meta-analysis.

Data sources

We searched seven electronic bibliographic databases from 2012 to December 2016 with no language restrictions. Search keywords included HIV, syphilis and diagnosis.

Review methods

We included studies that evaluated the operational characteristics of dual HIV/syphilis RDTs. Outcomes included diagnostic test accuracy, cost effectiveness, ease of use and interpretation and acceptability. All studies were assessed against quality criteria and assessed for risk of bias.

Results

Of 1914 identified papers, 18 were included for the meta-analysis of diagnostic accuracy for HIV and syphilis. All diagnostic accuracy evaluation studies showed a very high sensitivity and specificity for HIV and a lower, yet adequate, sensitivity and specificity for syphilis, with some variation among types of test. Dual screening for HIV and syphilis was more cost effective than single rapid tests for HIV and syphilis and prevented more adverse pregnancy outcomes. Qualitative data suggested dual RDTs were highly acceptable to clients, who cited time to result, cost and the requirement of a single finger prick as important characteristics of dual RDTs.

Conclusion

The results of this systematic review and meta-analysis can be used by policy-makers and national programme managers who are considering implementing dual RDTs for HIV and syphilis.

Syphilis testing practices in the Americas

OBJECTIVE

To present the findings of the Pan American Health Organization's 2014 survey on syphilis testing policies and practices in the Americas.

METHODS

Representatives of national/regional reference and large, lower-level laboratories from 35 member states were invited to participate. A semi-structured, electronically administered questionnaire collected data on syphilis tests, algorithms, equipment/commodities, challenges faced and basic quality assurance (QA) strategies employed (i.e. daily controls, standard operating procedures, technician training, participating in external QA programmes, on-site evaluations).

RESULTS

The 69 participating laboratories from 30 (86%) member states included 41 (59%) national/regional reference and 28 (41%) lower-level laboratories. Common syphilis tests conducted were the rapid plasma reagin (RPR) (62% of surveyed laboratories), venereal disease research laboratory (VDRL) (54%), fluorescent treponemal antibody absorption (FTA-ABS) (41%) and Treponema pallidum haemagglutination assay (TPHA) (32%). Only three facilities reported using direct detection methods, and 28 (41% overall, 32% of lower-level facilities) used rapid tests. Most laboratories (62%) used only traditional testing algorithms (non-treponemal screening and treponemal confirmatory testing); however, 12% used only a reverse sequence algorithm (treponemal test first), and 14% employed both algorithms. Another nine (12%) laboratories conducted only one type of serologic test. Although most reference (97%) and lower-level (89%) laboratories used at least one QA strategy, only 16% reported using all five basic strategies. Commonly reported challenges were stock-outs of essential reagents or commodities (46%), limited staff training (73%) and insufficient equipment (39%).

CONCLUSIONS

Many reference and clinical laboratories in the Americas face challenges in conducting appropriate syphilis testing and in ensuring quality of testing.

Can incentives reduce the barriers to use of antenatal care and delivery services in Kenya?: Results of a qualitative inquiry

A qualitative inquiry was used to assess if incentives consisting of a hygiene kit, protein-fortified flour, and delivery kit reduced barriers to antenatal care and delivery services in Nyanza Province, Kenya. We conducted 40 interviews (baseline: five nurses, six mothers, one focus group of five mothers; follow-up: nine nurses, 19 mothers) to assess perceptions of these services. Mothers and nurses identified poor quality of care, fear of HIV diagnosis and stigma, inadequate transport, and cost of care as barriers. Nurses believed incentives encouraged women to use services; mothers described wanting good birth outcomes as their motivation. While barriers to care did not change during the study, incentives may have increased service use. These findings suggest that structural improvements-upgraded infrastructure, adequate staffing, improved treatment of women by nurses, low or no-cost services, and provision of transport-could increase satisfaction with and use of services, improving maternal and infant health.

Estimating Benzathine Penicillin Need for the Treatment of Pregnant Women Diagnosed with Syphilis during Antenatal Care in High-Morbidity Countries

BACKGROUND

Congenital syphilis continues to be a preventable cause of global stillbirth and neonatal morbidity and mortality. Shortages of injectable penicillin, the only recommended treatment for pregnant women and infants with syphilis, have been reported by high-morbidity countries. We sought to estimate current and projected annual needs for benzathine penicillin in antenatal care settings for 30 high morbidity countries that account for approximately 33% of the global burden of congenital syphilis.

METHODS

Proportions of antenatal care attendance, syphilis screening coverage in pregnancy, syphilis prevalence among pregnant women, and adverse pregnancy outcomes due to untreated maternal syphilis reported to WHO were applied to 2012 birth estimates for 30 high syphilis burden countries to estimate current and projected benzathine penicillin need for prevention of congenital syphilis.

RESULTS

Using current antenatal care syphilis screening coverage and seroprevalence, we estimated the total number of women requiring treatment with at least one injection of 2.4 MU of benzathine penicillin in these 30 countries to be 351,016. Syphilis screening coverage at or above 95% for all 30 countries would increase the number of women requiring treatment with benzathine penicillin to 712,030. Based on WHO management guidelines, 351,016 doses of weight-based benzathine penicillin would also be needed for the live-born infants of mothers who test positive and are treated for syphilis in pregnancy. Assuming availability of penicillin and provision of treatment for all mothers diagnosed with syphilis, an estimated 95,938 adverse birth outcomes overall would be prevented including 37,822 stillbirths, 15,814 neonatal deaths, and 34,088 other congenital syphilis cases.

CONCLUSION

Penicillin need for maternal and infant syphilis treatment is high among this group of syphilis burdened countries. Initiatives to ensure a stable and adequate supply of benzathine penicillin for treatment of maternal syphilis are important for congenital syphilis prevention, and will be increasingly critical in the future as more countries move toward elimination targets.

Introduction of rapid syphilis testing in antenatal care: A systematic review of the impact on HIV and syphilis testing uptake and coverage

BACKGROUND

Global guidelines recommend universal syphilis and HIV screening for pregnant women. Rapid syphilis testing (RST) may contribute toward achievement of universal screening.

OBJECTIVES

To examine the impact of RST on syphilis and HIV screening among pregnant women.

SEARCH STRATEGY

We searched MEDLINE for English- and non-English language articles published through November, 2014.

SELECTION CRITERIA

We included studies that used a comparative design and reported on syphilis and HIV test uptake among pregnant women in low- and middle-income countries (LMICs) following introduction of RST.

DATA COLLECTION AND ANALYSIS

Data were extracted from six eligible articles presenting findings from Asia, Africa, and Latin America.

MAIN RESULTS

All studies reported substantial increases in antenatal syphilis testing following introduction of RST; the latter did not appear to adversely impact antenatal HIV screening levels at sites already offering rapid HIV testing and may increase HIV screening among pregnant women in some settings. Qualitative data revealed that women were highly satisfied with RST. Nevertheless, ensuring adequate training for healthcare workers and supplies of commodities were cited as key implementation barriers.

CONCLUSIONS

RST may increase antenatal syphilis and HIV screening and contribute to the improvement of antenatal care in LMICs.

Syphilis testing in antenatal care: Policies and practices among laboratories in the Americas

Objective:

To asses laboratory syphilis testing policies and practices among laboratories in the Americas.

Methods:

Laboratory directors or designees from PAHO member countries were invited to participate in a structured, electronically-delivered survey between March and August, 2014. Data on syphilis tests, algorithms, and quality control (QC) practices were analyzed, focusing on laboratories receiving specimens from antenatal clinics (ANCs).

Results:

Surveys were completed by 69 laboratories representing 30 (86%) countries. Participating laboratories included 36 (52%) national or regional reference labs and 33 (48%) lower-level laboratories. Most (94%) were public sector facilities and 71% reported existence of a national algorithm for syphilis testing in pregnancy, usually involving both treponemal and non-treponemal testing (72%). Less than half (41%) used rapid syphilis tests (RSTs); and only seven laboratories representing five countries reported RSTs were included in the national algorithm for pregnant women. Most (83%) laboratories serving ANCs reported using some type of QC system; 68% of laboratories reported participation in external QC. Only 36% of laboratories reported data to national/local surveillance. Half of all laboratories serving ANC settings reported a stockout of one or more essential supplies during the previous year (median duration, 30 days).

Conclusion:

Updating laboratory algorithms, improving testing standards, integrating data into existing surveillance, and improved procurement and distribution of commodities may be needed to ensure elimination of MTCT of syphilis in the Americas.

Can the Perinatal Information System in Peru be used to measure the proportion of adverse birth outcomes attributable to maternal syphilis infection?

OBJECTIVE

To describe the capacity of Peru's Perinatal Information System (Sistema Informático Perinatal, SIP) to provide estimates for monitoring the proportion of stillbirths and other adverse birth outcomes attributable to maternal syphilis.

METHODS

A descriptive study was conducted to assess the quality and completeness of SIP data from six Peruvian public hospitals that used the SIP continuously from 2000 - 2010 and had maternal syphilis prevalence of at least 0.5% during that period. In-depth interviews were conducted with Peruvian stakeholders about their experiences using the SIP.

RESULTS

Information was found on 123 575 births from 2000 - 2010 and syphilis test results were available for 99 840 births. Among those 99 840 births, there were 1 075 maternal syphilis infections (1.1%) and 619 stillbirths (0.62%). Among women with syphilis infection in pregnancy, 1.7% had a stillbirth, compared to 0.6% of women without syphilis infection. Much of the information needed to estimate the proportion of stillbirths attributable to maternal syphilis was available in the SIP, with the exception of syphilis treatment information, which was not collected. However, SIP data collection is complex and time-consuming for clinicians. Data were unlinked across hospitals and not routinely used or quality-checked. Despite these limitations, the SIP data examined were complete and valid; in 98% of records, information on whether or not the infant was stillborn was the same in both the SIP and clinical charts. Nearly 89% of women had the same syphilis test result in clinical charts and the SIP.

CONCLUSIONS

The large number of syphilis infections reported in Peru's SIP and the ability to link maternal characteristics to newborn outcomes make the system potentially useful for monitoring the proportion of stillbirths attributable to congenital syphilis in Peru. To ensure good data quality and sustainability of Peru's SIP, data collection should be simplified and information should be continually quality-checked and used for the benefit of participating facilities.

The cost and cost-effectiveness of scaling up screening and treatment of syphilis in pregnancy: a model

BACKGROUND

Syphilis in pregnancy imposes a significant global health and economic burden. More than half of cases result in serious adverse events, including infant mortality and infection. The annual global burden from mother-to-child transmission (MTCT) of syphilis is estimated at 3.6 million disability-adjusted life years (DALYs) and $309 million in medical costs. Syphilis screening and treatment is simple, effective, and affordable, yet, worldwide, most pregnant women do not receive these services. We assessed cost-effectiveness of scaling-up syphilis screening and treatment in existing antenatal care (ANC) programs in various programmatic, epidemiologic, and economic contexts.

METHODS AND FINDINGS

We modeled the cost, health impact, and cost-effectiveness of expanded syphilis screening and treatment in ANC, compared to current services, for 1,000,000 pregnancies per year over four years. We defined eight generic country scenarios by systematically varying three factors: current maternal syphilis testing and treatment coverage, syphilis prevalence in pregnant women, and the cost of healthcare. We calculated program and net costs, DALYs averted, and net costs per DALY averted over four years in each scenario. Program costs are estimated at $4,142,287 - $8,235,796 per million pregnant women (2010 USD). Net costs, adjusted for averted medical care and current services, range from net savings of $12,261,250 to net costs of $1,736,807. The program averts an estimated 5,754 - 93,484 DALYs, yielding net savings in four scenarios, and a cost per DALY averted of $24 - $111 in the four scenarios with net costs. Results were robust in sensitivity analyses.

CONCLUSIONS

Eliminating MTCT of syphilis through expanded screening and treatment in ANC is likely to be highly cost-effective by WHO-defined thresholds in a wide range of settings. Countries with high prevalence, low current service coverage, and high healthcare cost would benefit most. Future analyses can be tailored to countries using local epidemiologic and programmatic data.

Correlates of syphilis seropositivity and risk for syphilis-associated adverse pregnancy outcomes among women attending antenatal care clinics in the Democratic Republic of Congo

Screening and treatment for syphilis among pregnant women is the primary means of prevention of congenital syphilis. Sentinel surveillance for syphilis can inform these prevention efforts. We reviewed antenatal syphilis screening results to assess trends and to identify correlates of seropositivity among women attending antenatal care clinics in the Democratic Republic of Congo during 2011. Syphilis seropositivity among the 17,669 women attending the antenatal care clinics during 2011 was 4.2% (range 0.4%-16.9%). Syphilis seropositivity was significantly higher among women attending rural clinics (5.0%) as compared to urban clinics (3.0%) and those tested in antenatal care clinics in the provinces of Equateur (7.6%) and Orientale (7.7%) as compared to other provinces (p < 0.001). Based on the antenatal care syphilis seroprevalence and national pregnancy estimates, we estimate that approximately 128,591 pregnant women countrywide would have tested seropositive for syphilis during 2011. Over 85,000 adverse pregnancy outcomes would have resulted from these maternal infections, assuming prenatal syphilis diagnosis and treatment were not available. The prevalence of syphilis was highest in rural areas, but exceeded 1% in every area, indicating a need to assure screening and treatment throughout Democratic Republic of Congo. These sentinel surveillance estimates can be used to guide national congenital syphilis prevention efforts.

Untreated maternal syphilis and adverse outcomes of pregnancy: a systematic review and meta-analysis

OBJECTIVE

To perform a systematic review and meta-analysis of reported estimates of adverse pregnancy outcomes among untreated women with syphilis and women without syphilis.

METHODS

PubMed, EMBASE and Cochrane Libraries were searched for literature assessing adverse pregnancy outcomes among untreated women with seroreactivity for Treponema pallidum infection and non-seroreactive women. Adverse pregnancy outcomes were fetal loss or stillbirth, neonatal death, prematurity or low birth weight, clinical evidence of syphilis and infant death. Random-effects meta-analyses were used to calculate pooled estimates of adverse pregnancy outcomes and, where appropriate, heterogeneity was explored in group-specific analyses.

FINDINGS

Of the 3258 citations identified, only six, all case-control studies, were included in the analysis. Pooled estimates showed that among untreated pregnant women with syphilis, fetal loss and stillbirth were 21% more frequent, neonatal deaths were 9.3% more frequent and prematurity or low birth weight were 5.8% more frequent than among women without syphilis. Of the infants of mothers with untreated syphilis, 15% had clinical evidence of congenital syphilis. The single study that estimated infant death showed a 10% higher frequency among infants of mothers with syphilis. Substantial heterogeneity was found across studies in the estimates of all adverse outcomes for both women with syphilis (66.5% [95% confidence interval, CI: 58.0-74.1]; I(2) = 91.8%; P < 0.001) and women without syphilis (14.3% [95% CI: 11.8-17.2]; I(2) = 95.9%; P < 0.001).

CONCLUSION

Untreated maternal syphilis is associated with adverse pregnancy outcomes. These findings can inform policy decisions on resource allocation for the detection of syphilis and its timely treatment in pregnant women.

Utilization of HIV voluntary counseling and testing in Vietnam: an evaluation of 5 years of routine program data for national response

This study evaluated the utilization of HIV voluntary counseling-and-testing (VCT) services targeting high-risk populations in Vietnam in order to inform decisions on program improvement and expansion. A total of 158,888 records collected from 55 VCT sites supported by the U.S. Centers for Disease Control and Prevention's Global AIDS Program in the period of 2002 to 2007 were used to analyze sociodemographic characteristics, risk exposures, seropositivity, test refusal, and failure to return for test results among VCT clients. High-risk exposures, such as injection drug use, commercial sex work, homosexual contacts or heterosexual contacts with high-risk sex partners, were reported in 126,815 (81%) records. Among high-risk clients, any condom use in the past month ranged from 34% to 71%. During the study period, 19% of the VCT encounters resulted in a positive HIV test; of those persons tested, 23% of men and 13% of women were HIV-positive. High HIV positivity rates were associated with injection drug use, being ill/recommended by health care provider, and having an HIV-infected sex partner. Of all records, 6.1% documented refusal of HIV testing. Failure to return for results was reported in 3.5% of records for clients who were tested. Previously testing positive was the strongest predictor of test refusal, and being referred by peer educators was associated with failure to return for results. The VCT program in Vietnam successfully targeted high-risk populations, and clients had high return rates using a standard testing strategy. Interventions to increase consistent condom use and promote access to prevention services among sex partners of high-risk individuals should be implemented and evaluated.

A road map for the global elimination of congenital syphilis

Congenital syphilis is the oldest recognized congenital infection, and continues to account for extensive global perinatal morbidity and mortality today. Serious adverse pregnancy outcomes caused by maternal syphilis infection are prevented with screening early in pregnancy and prompt treatment of women testing positive. Intramuscular penicillin, an inexpensive antibiotic on the essential medicine list of nations all over the world, effectively cures infection and prevents congenital syphilis. In fact, at a cost of $11-15 per disability adjusted life year (DALY) averted, maternal syphilis screening and treatment is among the most cost-effective public health interventions in existence. Yet implementation of this basic public health intervention is sporadic in countries with highest congenital syphilis burden. We discuss the global burden of this devastating disease, current progress and ongoing challenges for its elimination in countries with highest prevalence, and next steps in ensuring a world free of preventable perinatal deaths caused by syphilis.

Brief counseling for reducing sexual risk and bacterial STIs among drug users--results from project RESPECT

OBJECTIVE

Project RESPECT's brief risk reduction counseling (BRRC) reduced sexual risk and bacterial STIs among at-risk heterosexuals and has been packaged for use with this population. We assessed BRRC's efficacy with RESPECT participants who used drugs and examined BRRC's applicability to present-day users of heroin, cocaine, speedball, or crack.

METHODS

We compared baseline demographic and economic variables, risk behaviors, and prevalence and correlates of bacterial STIs for ever-injectors ([EIs], N=335) and never-injectors ([NIs], N=3963). We assessed changes in risk behaviors and bacterial STIs for EIs and NIs at 12 months. We compared prevalence of HSV-2, hepatitis B core antigen virus (HBV), hepatitis C virus (HCV), and trichomonas among EIs with recently reported rates among drug users.

RESULTS

At baseline, 19% of EIs and 29% of NIs had bacterial STIs. Both groups had similar baseline STI correlates. At 12 months, 4% of EIs and 7% of NIs had bacterial STIs. Twelve-month cumulative incidence of bacterial STIs in BRRC was 21% lower among EIs and 18% lower among NIs compared to the informational condition. At 12 months, EIs reported fewer sexual risk behaviors than at baseline. Baseline positivity rates of trichomoniasis in EIs (female: 15%) and in male and female EIs of HSV-2 (39%, 68%), HBV (41%, 37%), and HCV (60%, 58%) were similar to rates in present-day drug users.

CONCLUSION

Efficacy of BRRC in reducing sexual risk and bacterial STIs in EIs, and similar profiles for EIs and present-day drug users suggest evaluating BRRC with present-day drug users.

Immunogenetic risk and protective factors for the development of L-tryptophan-associated eosinophilia-myalgia syndrome and associated symptoms

OBJECTIVE

To assess L-tryptophan (LT) dose, age, sex, and immunogenetic markers as possible risk or protective factors for the development of LT-associated eosinophilia-myalgia syndrome (EMS) and related clinical findings.

METHODS

HLA-DRB1 and DQA1 allele typing and Gm/Km phenotyping were performed on a cohort of 94 white subjects with documented LT ingestion and standardized evaluations. Multivariate analyses compared LT dose, age, sex, and alleles among groups of subjects who ingested LT and subsequently developed surveillance criteria for EMS, developed EMS or characteristic features of EMS (EMS spectrum disorder), or developed no features of EMS (unaffected).

RESULTS

Considering all sources of LT, higher LT dose (odds ratio [OR] 1.4, 95% confidence interval [95% CI] 1.1-1.8), age >45 years (OR 3.0, 95% CI 1.0-8.8), and HLA-DRB1*03 (OR 3.9, 95% CI 1.2-15.2), DRB1*04 (OR 3.9, 95% CI 1.1-16.4), and DQA1*0601 (OR 13.7, 95% CI 1.3-1.8) were risk factors for the development of EMS, whereas DRB1*07 (OR 0.12, 95% CI 0.02-0.48) and DQA1*0501 (OR 0.23, 95% CI 0.05-0.85) were protective. Similar risk and protective factors were seen for developing EMS following ingestion of implicated LT, except that DRB1*03 was not a risk factor and DQA1*0201 was an additional protective factor. EMS spectrum disorder also showed similar findings, but with DRB1*04 being a risk factor and DRB1*07 and DQA1*0201 being protective. There were no differences in sex distribution, Gm/Km allotypes, or Gm/Km phenotypes among any groups.

CONCLUSION

In addition to the xenobiotic dose and subject age, polymorphisms in immune response genes may underlie the development of certain xenobiotic-induced immune-mediated disorders, and these findings may have implications for future related epidemics.

Mitigating risky sexual behaviors among Russian narcology hospital patients: the PREVENT (Partnership to Reduce the Epidemic Via Engagement in Narcology Treatment) randomized controlled trial

AIM

To assess the effectiveness of a sexual risk reduction intervention in the Russian narcology hospital setting.

DESIGN, SETTING AND PARTICIPANTS

This was a randomized controlled trial from October 2004 to December 2005 among patients with alcohol and/or heroin dependence from two narcology hospitals in St Petersburg, Russia.

INTERVENTION

Intervention subjects received two personalized sexual behavior counseling sessions plus three telephone booster sessions. Control subjects received usual addiction treatment, which did not include sexual behavior counseling. All received a research assessment and condoms at baseline.

MEASUREMENTS

Primary outcomes were percentage of safe sex episodes (number of times condoms were used / by number of sexual episodes) and no unprotected sex (100% condom use or abstinence) during the previous 3 months, assessed at 6 months.

FINDINGS

Intervention subjects reported higher median percentage of safe sex episodes (unadjusted median difference 12.7%; P = 0.01; adjusted median difference 23%, P = 0.07); a significant difference was not detected for the outcome no unprotected sex in the past 3 months [unadjusted odds ratio (OR) 1.6, 95% confidence interval (CI) 0.8-3.1; adjusted OR 1.5, 95% CI 0.7-3.3].

CONCLUSIONS

Among Russian substance-dependent individuals, sexual behavior counseling during addiction treatment should be considered as one potential component of efforts to decrease risky sexual behaviors in this HIV at-risk population.

Preventing mother-to-child transmission of HIV in Vietnam: an assessment of progress and future directions

Preliminary to the development a new program supporting perinatal HIV prevention, this assessment was conducted to evaluate Vietnam's national prevention of mother-to-child HIV transmission (PMTCT) program by estimating HIV prevalence among prenatal women and analyzing the healthcare system capacity to deliver services. In 2002-03, a technical team reviewed existing national and local surveillance and program data and conducted on-site interviews and observations at maternal-child health (MCH) programs in the seven provinces with highest HIV rates. The team found that despite high (85%) prenatal service utilization and widespread availability of HIV testing and dissemination of prevention protocols, few HIV-infected mothers were identified in time to allow effective perinatal HIV prevention. Program deficits clustered around the general areas of provider misunderstanding of occupational HIV risk and MTCT, impractical PMTCT policies, and practices hampering effective use of prevention and treatment protocols. Existing problems were significant but modifiable, and will require implementation of practical and appropriate guidelines, enhanced clinical and laboratory capacity, and continued program management and monitoring.

Problems with condom use among patients attending sexually transmitted disease clinics: prevalence, predictors, and relation to incident gonorrhea and chlamydia

Condom use remains important for sexually transmitted disease (STD) prevention. This analysis examined the prevalence of problems with condoms among 1,152 participants who completed a supplemental questionnaire as part of Project RESPECT, a counseling intervention trial conducted at five publicly funded STD clinics between 1993 and 1997. Altogether, 336 participants (41%, 95% confidence interval: 38, 45) reporting condom use indicated that condoms broke, slipped off, leaked, or were not used throughout intercourse in the previous 3 months. Correspondingly, 8.9% (95% confidence interval: 7.0, 9.5) of uses resulted in STD exposure if partners were infected because of delayed application of condoms (4.3% of uses), breakage (2.0%), early removal (1.4%), slippage (1.3%), or leakage (0.4%). Use problems were significantly associated with reporting inconsistent condom use, multiple partners, and other condom problems. One-hundred thirty participants completing the questionnaire were tested for gonorrhea and chlamydia at this time and also 3 months earlier. Twenty-one (16.2%) were infected with incident gonorrhea and chlamydia, with no infections among consistent users reporting no use problems. Exact logistic regression revealed a significant dose-response relation between increased protection from condom use and reduced gonorrhea and chlamydia risk (p(trend) = 0.032). Both consistency of use and use problems must be considered in studies of highly infectious STD to avoid underestimating condom effectiveness.

Changes in sexual behavior and STD prevalence among heterosexual STD clinic attendees: 1993-1995 versus 1999-2000

OBJECTIVE

To examine trends in sex behaviors and STD prevalence over time among heterosexual STD clinic populations from 3 urban STD clinics in the United States.

STUDY DESIGN

Cross-sectional analysis comparing baseline data on risk (self-reported) and STDs (laboratory defined) from 2 randomized controlled trials evaluating counseling efficacy conducted about 5 years apart, Project RESPECT (1993-1995) and RESPECT-2 (1999-2000).

RESULTS

The participants from RESPECT (n = 2457) and RESPECT-2 (n = 3080) were demographically similar. However, the proportion of participants reporting any unprotected anal sex was much higher in RESPECT-2 (women: 7% vs. 18%; men: 7% vs. 17%). Also, substantially more participants reported a new sex partner in RESPECT-2 (women: 43% vs. 61%; men: 54% vs. 72%). In addition, more women reported 2 or more partners (37% vs. 48%) and a partner with another concurrent sex partner (19% vs. 32%). Slightly more women and men in RESPECT-2 reported 2 protective behaviors, having an HIV test and any condom use; however, consistent condom use did not differ. Conversely, the proportion of participants with bacterial STDs (chlamydia, gonorrhea, or syphilis) was much lower in RESPECT-2 (women: 24% vs. 18%; men: 38% vs. 24%).

CONCLUSIONS

Despite substantial promotion of safer sex behaviors over the past decade, many risk behaviors were stable over time, and some behaviors, such as unprotected anal sex, appeared substantially higher. Even in the absence of widespread behavior change, the prevalence of common bacterial STDs appeared to have decreased appreciably.

Male circumcision for prevention of HIV transmission: what the new data mean for HIV prevention in the United States

Recent clinical trials in Africa found that male circumcision reduces the risk of acquiring HIV from heterosexual sex--what are the implications of these studies for the United States?

Seroepidemiology of infection with human papillomavirus 16, in men and women attending sexually transmitted disease clinics in the United States

BACKGROUND

The study sought to characterize the seroprevalence, seropersistence, and seroincidence of human papillomavirus (HPV)-16 antibody, as well as the behavioral risk factors for HPV-16 seropositivity.

METHODS

Serologic data at baseline and at 6- and 12-month follow-up visits were used to examine the seroprevalence, seropersistence, and seroincidence of HPV-16 antibody in 1595 patients attending United States clinics treating sexually transmitted disease. Testing for antibody to HPV-16 was performed by capture enzyme-linked immunosorbent assay (ELISA) using viruslike particles.

RESULTS

The seroprevalence of HPV-16 antibody was 24.5% overall and was higher in women than in men (30.2% vs. 18.7%, respectively). In those who were HPV-16 seropositive at baseline, antibody response persisted to 12 months in 72.5% of women and in 45.6% of men. The seroincidence of HPV-16 antibody was 20.2/100 person-years (py) overall, 25.4/100 py in women, and 15.7/100 py in men. In multivariate analysis, the seroprevalence of HPV-16 antibody was significantly associated with female sex, age >20 years, and the number of episodes of sex with occasional partners during the preceding 3 months, whereas the seroincidence of HPV-16 antibody was significantly associated with female sex, age >20 years, baseline negative ELISA result greater than the median value, and the number of episodes of unprotected sex with occasional partners during the preceding 3 months.

CONCLUSION

Sex- and age-related differences in both the seropositivity and seroincidence of HPV-16 antibody persisted after adjustment for behavioral and sociodemographic risk factors, and behavioral risk factors during the preceding 3 months were stronger predictors of the seroprevalence and seroincidence of HPV-16 antibody than was lifetime sexual behavior.

Is HIV/sexually transmitted disease prevention counseling effective among vulnerable populations?: a subset analysis of data collected for a randomized, controlled trial evaluating counseling efficacy (Project RESPECT)

OBJECTIVE

The objective of this study was to evaluate counseling efficacy among high-risk groups.

STUDY

We conducted a subset analysis of data collected from July 1993 through September 1996 during a randomized, controlled trial (Project RESPECT). Participants (n = 4328) from 5 public U.S. sexually transmitted disease (STD) clinics were assigned to enhanced counseling, brief counseling, or educational messages. For 9 subgroups (sex, age, city, education, prior HIV test, STD at enrollment, race/ethnicity, injection drug use, exchanging sex for money/drugs), we compared STD outcomes for those assigned either type of counseling with STD outcomes for those assigned educational messages.

RESULTS

After 12 months, all subgroups assigned counseling (brief or enhanced) had fewer STDs than those assigned educational messages. STD incidence was similar for most subgroups assigned enhanced or brief counseling. All subgroups had an appreciable number of STDs prevented per 100 persons counseled, especially adolescents (9.4 per 100) and persons with STD at enrollment (8.4 per 100).

CONCLUSIONS

HIV/STD prevention counseling (brief or enhanced counseling) resulted in fewer STDs than educational messages for all subgroups of STD clinic clients, including high-risk groups such as adolescents and persons with STDs at enrollment.

Incidence of herpes simplex virus type 2 infection in 5 sexually transmitted disease (STD) clinics and the effect of HIV/STD risk-reduction counseling

The seroincidence of herpes simplex virus type 2 (HSV-2) infection was determined among 1766 patients attending sexually transmitted disease (STD) clinics and enrolled in a randomized, controlled trial of human immunodeficiency virus (HIV)/STD risk-reduction counseling (RRC). Arm 1 received enhanced RRC (4 sessions); arm 2, brief RRC (2 sessions); and arm 3, the control arm, brief informational messages. The overall incidence rate was 11.7 cases/100 person-years (py). Independent predictors of incidence of HSV-2 infection included female sex; black race; residence in Newark, New Jersey; <50% condom use with an occasional partner; and, in females, incident trichomoniasis and bacterial vaginosis. Only 10.8% of new HSV-2 infections were diagnosed clinically. Incidence rates were 12.9 cases/100 py in the control arm, 11.8 cases/100 py in arm 2, and 10.3 cases/100 py in arm 1 (hazard ratio, 0.8 [95% confidence interval, 0.6-1.1], vs. controls). The possible benefit of RRC in preventing acquisition of HSV-2 infection offers encouragement that interventions more specifically tailored to genital herpes may be useful and should be an important focus of future studies.

Are counselor demographics associated with successful human immunodeficiency virus/sexually transmitted disease prevention counseling?

BACKGROUND AND OBJECTIVE

HIV prevention counseling has changed behavior and reduced incident sexually transmitted diseases (STDs) in research participants.

GOAL

This article assesses whether counselor demographics or counselor-client dyad characteristics influenced prevention counseling in Project RESPECT as measured by intervention completion and incident STD after counseling.

STUDY DESIGN

We analyzed data from Project RESPECT, a randomized, controlled trial of HIV counseling interventions in STD clinics.

RESULTS

There was no significant association between client failure to complete the intervention and demographic characteristics of the 32 counselors or dyad characteristics. Clients who did not complete the intervention were significantly more likely to acquire a new STD infection by the 12-month visit than those who completed the intervention (adjusted odds ratio, 1.7; confidence interval, 1.2-2.4). There was no significant association between new STDs and counselor characteristics or dyad characteristics.

CONCLUSIONS

Counselor or counselor-client dyad characteristics evaluated in this study were not associated with intervention completion or the prevention of new STDs.

Condom effectiveness for reducing transmission of gonorrhea and chlamydia: the importance of assessing partner infection status

This analysis examined the importance of differential exposure to infected partners in epidemiologic studies of latex condom effectiveness for prevention of sexually transmitted infections. Cross-sectional, enrollment visit data were analyzed from Project RESPECT, a trial of counseling interventions conducted at five publicly funded US sexually transmitted disease clinics between 1993 and 1997. The association between consistent condom use in the previous 3 months and prevalent gonorrhea and chlamydia (Gc/Ct) was compared between participants known to have infected partners and participants whose partner infection status was unknown. Among 429 participants with known Gc/Ct exposure, consistent condom use was associated with a significant reduction in prevalent gonorrhea and chlamydia (30% vs. 43%; adjusted prevalence odds ratio = 0.42, 95% confidence interval: 0.18, 0.99). Among 4,314 participants with unknown Gc/Ct exposure, consistent condom use was associated with a lower reduction in prevalent gonorrhea and chlamydia (24% vs. 25%; adjusted prevalence odds ratio = 0.82, 95% confidence interval: 0.66, 1.01). The number of unprotected sex acts was significantly associated with infection when exposure was known (p for trend < 0.01) but not when exposure was unknown (p for trend = 0.73). Restricting analyses to participants with known exposure to infected partners provides a feasible and efficient mechanism for reducing confounding from differential exposure to infected partners in condom effectiveness studies.

Chlamydia trachomatis among patients infected with and treated for Neisseria gonorrhoeae in sexually transmitted disease clinics in the United States

BACKGROUND

For two decades, treatment guidelines for sexually transmitted diseases (STDs) have recommended empirical co-treatment for chlamydia when patients are treated for gonorrhea. Because the epidemiology of and diagnostic testing for STDs have changed over time, co-treatment may no longer be needed as a clinical or public health strategy.

OBJECTIVE

To assess the prevalence of chlamydia among patients at STD clinics who are infected with and treated for Neisseria gonorrhoeae and to determine whether co-treatment recommendations are still justified.

DESIGN

Cross-sectional analysis of data from a multisite study.

SETTING

Five public STD clinics (Baltimore, Maryland; Denver, Colorado; Long Beach, California; Newark, New Jersey; and San Francisco, California), July 1993 through October 1995.

PATIENTS

3885 heterosexual patients (2184 men and 1701 women) who agreed to participate in a trial of counseling interventions and had conclusive results from diagnostic tests for gonorrhea and chlamydia performed routinely as part of the trial.

MEASUREMENTS

Infection with Chlamydia trachomatis as determined by polymerase chain reaction.

RESULTS

Chlamydia trachomatis was detected in 20% (95% CI, 16% to 24%) of 411 men and 42% (CI, 35% to 50%) of 151 women with laboratory-confirmed N. gonorrhoeae. Chlamydia trachomatis was detected in 19% (CI, 15% to 22%) of 410 men and 35% (CI, 28% to 43%) of 154 women with treatment indications for gonorrhea who would not otherwise have been treated for chlamydia: chlamydia prevalence among these patients was significantly higher than among patients without treatment indications for either gonorrhea or chlamydia: 7% in men and 9% in women (relative risk, 2.58 [CI, 1.92 to 3.47] and 4.12 [CI, 3.05 to 5.57], respectively).

CONCLUSION

The frequent presence of chlamydia among patients at STD clinics who received treatment for gonorrhea, including sex partners of gonorrhea-infected patients, supports continuing current recommendations for co-treatment.

New sexually transmitted diseases in HIV-infected patients: markers for ongoing HIV transmission behavior

OBJECTIVE

The objective of this study was to describe the rate of new sexually transmitted diseases (STDs) among HIV-infected patients and to define the behavioral and clinical characteristics of HIV-infected patients who return with a new STD in follow-up.

DESIGN

The study design was a record-based clinical cohort study focusing on patients testing HIV-seropositive in the STD clinics of Baltimore, Maryland from 1993 to 1998.

METHODS

The authors identified those HIV-infected patients later diagnosed with an STD in follow-up and compared their demographic, behavioral, and clinical characteristics with those who were not diagnosed with an STD in follow-up.

RESULTS

Of 796 men and 354 women with HIV infection, 13.9% of men and 11.9% of women were diagnosed with an STD after their initial HIV diagnosis. HIV-infected men returned with a new STD at a rate of 7 cases per 100 person-years; HIV-infected women returned at a rate of 5.6 cases per 100 person-years. In men, multiple sex partners and sex worker contact were associated with a subsequent STD diagnosis (OR = 1.67, p =.037; OR = 1.82, p =.015, respectively). In women, age younger than 30 years was associated with the diagnosis of an STD after the diagnosis of HIV infection (OR = 2.94, p =.0009).

CONCLUSIONS

Patients diagnosed with HIV in an STD clinic setting commonly return with new STDs in follow-up, suggesting continued exposure of HIV to others. More intensive screening and counseling interventions focused on STD prevention in those with HIV infection is a necessary HIV prevention strategy.

Seroprevalence and correlates of herpes simplex virus type 2 infection in five sexually transmitted-disease clinics

The seroprevalence of herpes simplex virus type 2 (HSV-2) infection was studied among 4128 patients from sexually transmitted disease (STD) clinics who were enrolled in a randomized controlled trial of human immunodeficiency virus and STD counseling efficacy. HSV-2 seroprevalence was 40.8% and was higher in women than in men (52.0% vs. 32.4%; P<.0001) and higher in blacks than in nonblacks (48.1% vs. 29.6%; P<.0001). Among 14-19-year-old patients, 36.8% of black women and 25.8% of nonblack women were infected with HSV-2. Independent predictors of HSV-2 seropositivity included female sex, black race, older age, less education, more lifetime sex partners, prior diagnosis of syphilis or gonorrhea, and lack of HSV-1 antibody. The majority of HSV-2-seropositive persons (84.7%) had never received a diagnosis of genital herpes. HSV-2 infection is common in STD clinic attendees in the United States, even among young age groups, especially among women. Efforts to prevent genital herpes should begin at an early age. The high rate of undiagnosed HSV-2 infection likely contributes to ongoing transmission.

Assessing the Center for Disease Control and Prevention's 1994 HIV counseling, testing, and referral: standards and guidelines: how closely does practice conform to existing recommendations?

BACKGROUND

Growing support for the focus of the 1994 HIV Counseling, Testing, and Referral Guidelines on early recognition of HIV infection and the findings of a multicenter, randomized controlled trial establishing the efficacy of the client-centered model of the Centers for Disease Control and Prevention have placed a new focus on the need for the effective delivery of HIV prevention counseling.

GOAL

The goal of this study was to compare published national guidelines on HIV counseling, testing, and referral with actual practice.

STUDY DESIGN

The study employed a cross-sectional design and involved 51 interviews.

RESULTS

Sixty-one percent of sites routinely completed personalized risk-reduction plans. Thirty-one percent of respondents indicated that HIV-positive clients spoke more than the counselor during posttest counseling, and 23% said the same for HIV-negative clients. Sixty-eight percent of respondents indicated that individual risks were discussed in the typical counseling session, whereas 30% reported discussing a combination of general information and individual risks. Most sites met referral standards (86%), found and notified HIV-positive clients who did not return for their test results (85%), and had at least one counselor observation per year (79%).

CONCLUSIONS

Several measures indicated areas in which practice did not conform to guidelines, which may compromise the potential benefits of the HIV counseling, testing, and referral services.

Fleeting foreskins: the misclassification of male circumcision status

BACKGROUND

Errors in the classification of male circumcision status could bias studies linking infection to lack of circumcision.

GOAL

To determine the frequency and factors associated with the reproducibility of reporting circumcision status.

STUDY DESIGN

Secondary analysis of data using logistic regression modeling from a multicenter randomized controlled trial was performed.

RESULTS

At follow-up assessment, 15.6% of clinician reports on circumcision status disagreed with baseline reports. Disagreement was more common if both clinicians were women than if both were men (odds ratio [OR], 2.8; 95% CI, 1.9-4.1). As compared with whites reported as circumcised (4%, 19/532 visits), the highest disagreement involved uncircumcised Hispanic (OR, 3.3; 95% CI, 1.7-6.3), white (OR, 12.2; 95% CI, 5.8-25.6), or black (OR, 17.1; 95% CI, 10.4-27.9) men.

CONCLUSIONS

This is one study among a small number of studies examining the reproducibility of clinician-reported circumcision status by comparing multiple clinical examinations of the same patient. The magnitude of the misclassification discovered could bias results and indicates the need for greater accuracy in reporting circumcision status in future studies.

Circumcision and STD in the United States: cross sectional and cohort analyses

BACKGROUND

Male circumcision status has been shown to be associated with sexually transmitted disease (STD) acquisition in some, but not all, studies. Most studies have been cross sectional.

OBJECTIVES

We examined the association between circumcision status and the prevalence and incidence of gonorrhoea, chlamydia, and syphilis.

METHODS

We analysed cross sectional and cohort study data from a multicentre controlled trial in the United States. Between July 1993 and September 1996, 2021 men visiting public inner city STD clinics in the United States were examined by a clinician at enrolment and 1456 were examined at follow up visits 6 and 12 months later. At each visit, men had laboratory tests for gonorrhoea, chlamydia, and syphilis and were examined for circumcision status. We used multiple logistic regression to compare STD risk among circumcised and uncircumcised men adjusted for potentially confounding factors.

RESULTS

Uncircumcised men were significantly more likely than circumcised men to have gonorrhoea in the multivariate analyses, adjusted for age, race, and site, in both the cross sectional (odds ratio (OR), 1.3; 95% confidence interval (CI), 0.9 to 1.7) and in the cohort analysis (OR, 1.6; 95% CI, 1.0 to 2.6). There was no association between lack of circumcision and chlamydia in either the cross sectional (OR, 1.0; 95% CI 0.7-1.4) or the cohort analysis (OR, 0.9; 95% CI 0.5-1.5). The magnitude of association between lack of circumcision and syphilis was similar in the cross sectional (OR, 1.4; 95% CI 0.6 to 3.3) and cohort analysis (OR, 1.5; 95% CI 0.4 to 6.1).

CONCLUSION

Uncircumcised men in the United States may be at increased risk for gonorrhoea and syphilis, but chlamydia risk appears similar in circumcised and uncircumcised men. Our results suggest that risk estimates from cross sectional studies would be similar to cohort findings.

Partner violence, partner notification, and women's decisions to have an HIV test

OBJECTIVES

Reports of partner violence against HIV-positive women after they have disclosed their serostatus have led some to reassess partner notification strategies and to speculate that fear of partner violence following partner notification may influence women's HIV testing decisions. We studied whether associations exist between women's declining to have an HIV test and history of partner violence, fear of partner violence, previous experience with partner notification, or beliefs about partner notification.

METHODS

In this cross-sectional study, we interviewed women seen at Newark and Miami sexually transmitted disease clinics. The women were at least 18 years old, not known to be HIV positive, not tested for HIV in the previous 3 months, and offered HIV testing during the clinic visit. Women who declined testing were compared with women who accepted.

RESULTS

Of 490 participants (89% of eligible women), 16% reported partner violence in the past year, and 28% declined HIV testing. Declining the test was not significantly (p >.05) associated with history or fear of partner violence, previous experience with partner notification, or beliefs about partner notification. When specifically asked, only 2 women responded that their declining the test was related to fear that their partner or partners might harm them if the women tested positive.

CONCLUSIONS

Among women seen at these clinics, we did not find evidence that declining the HIV test was strongly influenced by partner violence, previous experience with partner notification, or beliefs about partner notification. However, many women reported partner violence. Therefore, providers should assess the potential for partner violence and be prepared to make appropriate referrals.

Misconceptions about STD-protective behavior. Project RESPECT Study Group

CONTEXT

Misconceptions about STD-protective behaviors have not been studied before and after STD counseling. Further, to the best of our knowledge, the relationship of these misconceptions to condom use and STD incidence has not previously been described in published reports.

OBJECTIVES

The main purpose of the study was to determine the prevalence of misconceptions about STD prevention among STD clinic attendees (N=3498) in five large cities, as well as whether misconceptions decreased after STD diagnosis, STD counseling, or both. The study also identified predictors of persistent misconceptions and determined the relationship of STD incidence and unprotected sex to persistent misconceptions.

METHODS

Data from a randomized controlled trial evaluating HIV/STD counseling interventions (Project RESPECT) were used for the present analyses. Participants completed an interview upon study enrollment and every 3 months following enrollment for a 1-year period. A portion of the interview assessed participants' misconceptions about STD-protective behaviors.

RESULTS

At baseline, 16.3% believed that washing the genitals after sex protected from STDs. Likewise, urinating after sex (38.7%), douching (45.7%), and use of oral contraceptives (19. 9%) were believed to prevent STDs. Prevalence of misconceptions was significantly diminished at a 3-month follow-up (p<.001). Those continuing to have misconceptions were more likely to be aged > or = 24 and African American. Those continuing to have these misconceptions did not have higher STD incidence.

CONCLUSIONS

Misconceptions about STD-protective behaviors are common, and the event of an STD or STD counseling or both generally reduces these misconceptions. Although these misconceptions may not directly translate into risky behavior, they may preclude movement toward safer sex.

Does measured behavior reflect STD risk? An analysis of data from a randomized controlled behavioral intervention study. Project RESPECT Study Group

BACKGROUND

Many studies measure sex behavior to determine the efficacy of sexually transmitted disease (STD)/HIV prevention interventions.

GOAL

To determine how well measured behavior reflects STD incidence.

STUDY DESIGN

Data from a trial (Project RESPECT) were analyzed to compare behavior and incidence of STD (gonorrhea, chlamydia, syphilis, HIV) during two 6-month intervals.

RESULTS

A total of 2879 persons had 5062 six-monthly STD exams and interviews; 8.9% had a new STD in 6 months. Incidence was associated with demographic factors but only slightly associated with number of partners and number of unprotected sex acts with occasional partners. Many behaviors had paradoxical associations with STD incidence. After combining behavior variables to compare persons with highest and lowest risk behaviors, the STD incidence ratio was only 1.7.

CONCLUSION

Behavioral interventions have prevented STD. We found people tend to have safe sex with risky partners and risky sex with safe partners. Therefore, it is difficult to extrapolate the disease prevention efficacy of an intervention from a measured effect on behavior alone.

Efficacy of risk-reduction counseling to prevent human immunodeficiency virus and sexually transmitted diseases: a randomized controlled trial. Project RESPECT Study Group

CONTEXT

The efficacy of counseling to prevent infection with the human immunodeficiency virus (HIV) and other sexually transmitted diseases (STDs) has not been definitively shown.

OBJECTIVE

To compare the effects of 2 interactive HIV/STD counseling interventions with didactic prevention messages typical of current practice.

DESIGN

Multicenter randomized controlled trial (Project RESPECT), with participants assigned to 1 of 3 individual face-to-face interventions.

SETTING

Five public STD clinics (Baltimore, Md; Denver, Colo; Long Beach, Calif; Newark, NJ; and San Francisco, Calif) between July 1993 and September 1996.

PARTICIPANTS

A total of 5758 heterosexual, HIV-negative patients aged 14 years or older who came for STD examinations.

INTERVENTIONS

Arm 1 received enhanced counseling, 4 interactive theory-based sessions. Arm 2 received brief counseling, 2 interactive risk-reduction sessions. Arms 3 and 4 each received 2 brief didactic messages typical of current care. Arms 1, 2, and 3 were actively followed up after enrollment with questionnaires at 3, 6, 9, and 12 months and STD tests at 6 and 12 months. An intent-to-treat analysis was used to compare interventions.

MAIN OUTCOME MEASURES

Self-reported condom use and new diagnoses of STDs (gonorrhea, chlamydia, syphilis, HIV) defined by laboratory tests.

RESULTS

At the 3- and 6-month follow-up visits, self-reported 100% condom use was higher (P<.05) in both the enhanced counseling and brief counseling arms compared with participants in the didactic messages arm. Through the 6-month interval, 30% fewer participants had new STDs in both the enhanced counseling (7.2%; P= .002) and brief counseling (7.3%; P= .005) arms compared with those in the didactic messages arm (10.4%). Through the 12-month study, 20% fewer participants in each counseling intervention had new STDs compared with those in the didactic messages arm (P = .008). Consistently at each of the 5 study sites, STD incidence was lower in the counseling intervention arms than in the didactic messages intervention arm. Reduction of STD was similar for men and women and greater for adolescents and persons with an STD diagnosed at enrollment.

CONCLUSIONS

Short counseling interventions using personalized risk reduction plans can increase condom use and prevent new STDs. Effective counseling can be conducted even in busy public clinics.

What about money? Effect of small monetary incentives on enrollment, retention, and motivation to change behaviour in an HIV/STD prevention counselling intervention. The Project RESPECT Study Group

OBJECTIVES

We studied the effect of small monetary incentives and non-monetary incentives of similar value on enrollment and participation in clinic based HIV/STD prevention counselling. We examined incident STDs to try to assess whether participants offered money may be less motivated to change risky behaviours than those offered other incentives.

METHODS

Patients from five US STD clinics were invited to enroll in a multisession risk reduction counselling intervention and, based on their enrollment date, were offered either $15 for each additional session or non-monetary incentives worth $15. The two incentive groups were compared on participants' enrollment, completion of intervention sessions, and new STDs over the 24 months after enrollment.

RESULTS

Of 648 patients offered money, 198 (31%) enrolled compared with 160 (23%) of 696 patients offered other incentives (p = 0.002). Enrollees in the two incentive groups had similar baseline characteristics, including condom use. Of the 198 participants offered money, 109 (55%) completed all sessions compared with 59 (37%) of the participants offered other incentives (p < 0.0001). Comparing those offered money with those offered other incentives STD rates were similar after 6, 12, and 24 months.

CONCLUSIONS

Small monetary incentives enhanced enrollment and participation compared with other incentives of similar value. Regardless of incentive offered, participants had similar post-enrollment STD rates, suggesting that the type of incentive does not adversely affect motivation to change behaviour. Money may be useful in encouraging high risk individuals to participate in and complete counselling or other public health interventions.