Factors associated with unsuccessful follow-up in patients undertreated for gonorrhea and chlamydia infections

INTRODUCTION

Neisseria gonorrhea (GC) and Chlamydia trachomatis (CT) are two commonly encountered sexually transmitted infections in the Emergency Department (ED).

METHODS

The study was a single-center, retrospective cohort of patients screened for GC/CT infections at an urban, academic medical center ED. Participants were identified through electronic medical record reports. Patients were excluded if they absconded, were discharged against medical advice, or had a chief complaint of sexual assault. Patients were classified as having tested positive or negative for GC/CT and further classified as having received adequate treatment, overtreatment, or undertreatment. The undertreatment group was further assessed for successful versus unsuccessful follow-up. The primary aim was to determine factors associated with unsuccessful follow-up in patients undertreated. Secondary aims included rate of overtreatment, rate of undertreatment, and method of contact in patients with successful follow-up.

RESULTS

A total of 10,452 patients were included. Of the 456 undertreated patients, follow-up was successful in 425 (93.2%) patients and unsuccessful in 31 (6.8%) patients. No history of STIs was associated with a higher rate of unsuccessful follow-up in patients undertreated for GC/CT infections (52.9% versus 74.2%, difference = -21.3%, 95% CI -37.4%, -5.1%). Rate of overtreatment was 19.1%, and rate of undertreatment was 46.5%. Phone contact was the most frequent method of successful contact, which occurred in 98.6% of patients.

CONCLUSIONS

GC/CT infections continue to be overtreated in the ED. Based on this study, no history of prior sexually transmitted infections was associated with unsuccessful follow-up in patients undertreated for GC/CT infections after discharge from the ED.

Health-related quality of life and psychosocial impacts of a diagnosis of non-specific genital infection in symptomatic heterosexual men attending UK sexual health clinics: a feasibility study

INTRODUCTION

Non-specific genital infection (NSGI; non-Chlamydia trachomatis, non-Neisseria gonorrhoeae-associated urethritis) is a common diagnosis in symptomatic heterosexual men attending UK sexual health clinics (SHCs). but little is known about the psychosocial impact of this diagnosis.

METHODS

We conducted an observational study among symptomatic heterosexual men attending SHCs to evaluate the psychosocial impact of an NSGI diagnosis compared with a diagnosis of Chlamydia trachomatis (CT), Neisseria gonorrhoeae or no abnormalities detected focusing on the feasibility of our study methodology. Participants completed a computer-assisted self-interviewing (CASI) including two validated measures of psychosocial impact: the EQ-5D-5L health-related quality of life and Rosenberg Self-Esteem Scale, before diagnostic testing and 2 weeks after receiving test results (follow-up 1 (FU-1)) and a qualitative interview. We compared scores between diagnostic groups using paired t-tests, qualitative data were analysed thematically and feasibility was assessed by process analysis.

RESULTS

60 men completed the baseline CASI (75% response rate). 46 (76.6%) were eligible for follow-up; 11/46 (23.9%) completed the follow-up CASI, and 3/11 (27.3%) completed the qualitative interview. 81.7% of all participants left CASI feedback at baseline: 73.5% reported the questionnaire as 'fine' or 'very good'. Qualitative interview participants reported the study was acceptable. Compared with baseline, among patients completing FU-1, only patients with a diagnosis of NSGI (p<0.05) or CT (p<0.05) showed increased EQ-5D-5L Index, whereas patients with a diagnosis of NSGI (p=0.05) showed decreased mean Rosenberg Self-Esteem Scale score.

CONCLUSIONS

Although most participants indicated study acceptability at baseline, and we employed measures to increase retention (CASI questionnaires, reminder messages and a focus on men's health), we experienced high loss to follow-up. We found that heterosexual men attending SHCs with symptoms of urethritis experience both positive and negative psychosocial impacts following their clinic attendance, which warrants further investigation.

Willingness to change behaviours to reduce the risk of pharyngeal gonorrhoea transmission and acquisition in men who have sex with men: a cross-sectional survey

OBJECTIVES

The aim of this study was to examine the willingness of men who have sex with men (MSM) to change their behaviours to potentially reduce the risk of pharyngeal gonorrhoea transmission and acquisition.

METHODS

A cross-sectional questionnaire-based study was conducted among MSM attending the Melbourne Sexual Health Centre, Australia, between March and September 2015. Participants were asked how likely they would change their behaviours to reduce the risk of pharyngeal gonorrhoea. Six different potential preventive interventions were asked: (1) stop tongue kissing; (2) stop having receptive oral sex; (3) stop performing rimming; (4) stop using saliva as a lubricant during anal sex; (5) use of condoms during oral sex; and (6) use of alcohol-containing mouthwash daily.

RESULTS

Of the 926 MSM who completed the questionnaire, 65.4% (95% CI 62.3% to 68.5%) expressed they were likely to use mouthwash daily to reduce the risk of pharyngeal gonorrhoea, 63.0% (95% CI 59.8% to 66.1%) would stop using saliva as a lubricant, and 49.5% (95% CI 46.2% to 52.7%) would stop rimming. In contrast, 77.6% (95% CI 74.8% to 80.3%) of MSM expressed they were unlikely to stop tongue kissing. MSM who were younger and had less male partners expressed they were unlikely to use mouthwash daily as an intervention to reduce risk of pharyngeal gonorrhoea acquisition.

CONCLUSIONS

The practices MSM are willing to change to reduce the risk of pharyngeal gonorrhoea transmission and acquisition vary greatly; however, the majority of men are likely to use mouthwash daily to reduce the risk of pharyngeal gonorrhoea.

PARTNER NOTIFICATION OUTCOMES AMONG MALE GONORRHEA PATIENTS AT BANGRAK HOSPITAL, BANGKOK, THAILAND

Partner notification (PN) is an important strategy to control sexually transmitted infections. The objective of this study was to assess the outcomes of PN in order to improve control of sexually transmitted infections. We retrospectively reviewed heterosexual male gonorrhea cases who presented for treatment to Bangrak Hospital during 2008 to determine the percent PN, the percent of successful partner management (SPM) and the factors associated with both. We used univariate and multivariate analyses to determine significant associations between characteristics of index cases and PN outcomes. We reviewed the medical records of 418 index cases. The median age of the subjects reviewed was 30 years old (range: 14-63). Six hundred ninety-two partners were identified. Of those, 367 partners (53.0%) were notified by 311 index cases; 95 partners (25.9% of the notifications) of the 89 index cases presented for treatment. The medical records of 92 partners were available to review: 61 (66%) had gonorrhea, chlamydia, or genital herpes infections. The median period from being notified to seeking care was 2.5 days (range: 0-92); 80% sought care within 9 days of notification. Spouses and girlfriends were the major partners being notified and had greater SPM. On multivariate analysis, a greater notification rate was found among index cases who were government workers or had a steady relationship. A higher SPM rate was associated with index cases who were aged ≥25 years, married or had a steady relationship. The PN rate among the studied index cases was inadequate. Further studies are needed to develop successful methods to improve PN rates and SPM rates in order to improve sexually transmitted infection control in the study population.

Pharyngeal Gonorrhoea: The Willingness of Australian Men Who Have Sex with Men to Change Current Sexual Practices to Reduce Their Risk of Transmission-A Qualitative Study

Background

The pharynx is a common site of gonorrhoea among men who have sex with men (MSM) and may serve as a reservoir for infection, with saliva implicated in transmission possibly through oral sex, kissing, and rimming. Reducing sexual activities involving saliva may reduce pharyngeal gonorrhoea. This study aimed to explore MSM’s views and knowledge of pharyngeal gonorrhoea and their willingness to change saliva transmitting sexual practices. MSM were also asked their views on using alcohol-containing mouthwash to potentially reduce transmission.

Methods

Using a qualitative descriptive approach, 30 MSM who were part of a larger study (GONE) conducted at the Melbourne Sexual Health Centre agreed to take part in semi-structured interviews between 14^th May and 8^th September 2015. The 10 interviews conducted face to face and 20 by telephone, lasted between 20–45 minutes. Data were analysed using qualitative content analysis.

Results

Most men considered pharyngeal gonorrhoea to be a non-serious sexually transmitted infection and attributed transmission primarily to oral sex. Almost all men reported they would not stop kissing, oral sex, or consider using condoms for oral sex to reduce their risk of pharyngeal gonorrhoea. Kissing and oral sex were commonly practised and considered enjoyable low risk sexual activities. Men were more likely to consider stopping sexual activities they did not enjoy or practice often, in particular insertive rimming. If proven effective, the majority of men reported they would use alcohol-containing mouthwash to reduce or prevent their risk of pharyngeal gonorrhoea.

Conclusion

Findings from this study suggest MSM are unlikely to stop saliva transmitting sexual practices they enjoy and consider low risk. Men would, however, consider using alcohol-containing mouthwash if found to be effective, highlighting the importance of exploring innovative strategies to reduce pharyngeal gonorrhoea.

Sexual Behavior and Network Characteristics and Their Association with Bacterial Sexually Transmitted Infections among Black Men Who Have Sex with Men in the United States

Background

Black men who have sex with men (MSM) have a high prevalence of bacterial sexually transmitted infections (STIs), and individual risk behavior does not fully explain the higher prevalence when compared with other MSM. Using the social-ecological framework, we evaluated individual, social and sexual network, and structural factors and their association with prevalent STIs among Black MSM.

Methods

The HIV Prevention Trials Network 061 was a multi-site cohort study designed to determine the feasibility and acceptability of a multi-component intervention for Black MSM in six US cities. Baseline assessments included demographics, risk behavior, and social and sexual network questions collected information about the size, nature and connectedness of their sexual network. Logistic regression was used to estimate the odds of having any prevalent sexually transmitted infection (gonorrhea, chlamydia, or syphilis).

Results

A total of 1,553 Black MSM were enrolled in this study. In multivariate analysis, older age (aOR = 0.57; 95% CI 0.49–0.66, p<0.001) was associated with a lower odds of having a prevalent STI. Compared with reporting one male sexual partner, having 2–3 partners (aOR = 1.74; 95% CI 1.08–2.81, p<0.024) or more than 4 partners (aOR = 2.29; 95% CI 1.43–3.66, p<0.001) was associated with prevalent STIs. Having both Black and non-Black sexual partners (aOR = 0.67; 95% CI 0.45–0.99, p = 0.042) was the only sexual network factor associated with prevalent STIs.

Conclusions

Age and the number and racial composition of sexual partners were associated with prevalent STIs among Black MSM, while other sexual network factors were not. Further studies are needed to evaluate the effects of the individual, network, and structural factors on prevalent STIs among Black MSM to inform combination interventions to reduce STIs among these men.

Childhood lead exposure and sexually transmitted infections: New evidence

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Use of Expedited Partner Therapy for Sexually Transmitted Diseases in College and University Health Centers in the United States, 2011-2012

We examined expedited partner therapy for chlamydia and gonorrhea in college and university health centers by institutional and policy characteristics. Expedited partner therapy awareness and use was low (44.1% used), did not differ by institutional characteristics, and differed by policy environment. Our findings suggest missed opportunities for sexually transmitted disease prevention in college and university health centers.

Undergraduate Students' Knowledge and Practice of Gonorrhea and other Sexually Transmitted Infections

BACKGROUND

Sexually transmitted infections (STIs) are a major public health issue. Adolescents and youth (15-24 years) are the age groups at the greater risk for acquiring them. Also a large percentage of new STIs occur in this age group with 7000 young people worldwide acquiring the infection every day. Sexually transmitted infections (STIs) are poorly recognized and inadequately treated in Nigeria despite the fact that they constitute a major risk factor for sexual transmission of HIV infection. The shortage of trained human resources is among the most important obstacles to strengthening health systems in low-income countries.

OBJECTIVE

This study is to document the knowledge and practice of undergraduate students about gonorrhoea and other STIs as a baseline survey for future intervention work.

METHODS

It was a questionnaire-based, cross sectional descriptive study of the knowledge and practice of STIs among students in the seven public tertiary academic institutions in Lagos State using list obtained from the Lagos State Ministry of Education. Thirty (30) students who agreed to be surveyed were conveniently selected from each school. Pre-tested, semi-structured, validated questionnaires were administered and collected back. Data was entered into Microsoft Excel and analysed using EPI Info, SPSS version 15 and Microsoft Excel. Results were considered to be statistically significant if p < 0.05.

RESULTS

Majority of the respondents were of the 21 - 25 year age range (48%) and were mainly single (95%), Christian (61%) and Yoruba (81%). About 51% of the respondents had at least good knowledge of gonorrhoea and other STIs. Knowledge about symptoms and transmission was higher than knowledge of prevention, consequences and drugs. Among those that are sexually active 24% do not use condom while 10% reuse condom. Use of both modern and traditional medical practitioners (TMP) was documented among the students.

CONCLUSIONS

Awareness programs with key messages about gonorrhoea and other STIs should be developed and circulated widely in tertiary institutions in the state to improve students' practice. Also strategies to embrace TMP for STI management should be evolved.

Human immunodeficiency virus and chlamydia/gonorrhea testing among heterosexual college students: who is getting tested and why do some not?

OBJECTIVE

This study explored college students' reported history of human immunodeficiency virus (HIV) and chlamydia/gonorrhea and characteristics of students reporting testing. Additionally, it assessed their motivation regarding future testing and reasons for lack of motivation.

PARTICIPANTS

The sample consisted of 292 sexually experienced college students self-identifying as heterosexual at a midwestern university.

METHODS

Participants completed a 26-item survey during the 2010-2011 academic year.

RESULTS

Demographics (sex, age, race/ethnicity), behaviors (higher numbers of sex partners, currently not using condoms), and motivation for future testing distinguished those who had been tested ever and those who had not. Half of participants were not motivated to seek testing in the next 3 months; the most common reason for no motivation being perceived lack of risk.

CONCLUSIONS

Interventions promoting testing can use these findings to target those likely to never have been tested. These results also highlight the need to find ways to motivate students to get tested.

African-American female adolescents who engage in oral, vaginal and anal sex: "doing it all" as a significant marker for risk of sexually transmitted infection

African-American female adolescents who engaged in vaginal sex only (N = 272) were compared to adolescents who engaged in two types (vaginal plus oral or anal; N = 295) and three types (vaginal, oral and anal; N = 144) on a constellation of other sexual risk behaviors (SRBs) and on sexually transmitted infections (STIs). Adjusted contrasts among groups revealed that adolescents who engaged in two and in three types of sex as compared to those who engaged in vaginal sex only were more likely to engage in six of the seven SRBs, but were just as likely to have a STI. One SRB, having >/= 4 lifetime sex partners, was in turn associated with STI. Two-way interactions indicated that having a casual sex partner and having multiple sex partners in the last 60 days increased the likelihood of STI, but only for adolescents who engaged in all three types.

Prevalence of Chlamydia trachomatis/Neisseria gonorrhoeae and human papilloma virus among women-at risk in the Aegian region of Turkey, and their knowledge about HIV/AIDS

BACKGROUND

The aim of this study was to determine the prevalence of selected sexually transmitted diseases (STDs) and the level of knowledge and attitudes regarding HIV/AIDS among Turkish brothel based sex-workers (SWs).

SUBJECTS AND METHODS

A pre-designed questionnaire was administered to 199 SWs to obtain their sexual behaviours and their level of knowledge of HIV/AIDS. The specimens collected for C trachomatis/N gonorrhoeae and human papillomavirus (HPV) were tested using Gen-Probe PACE 2 and HPV-screening assays, respectively.

RESULT

Aproximately sixty-seven per cent of the SWs knew that condoms afforded protection against HIV/AIDS and 62% reported continued use of condoms. Although most of the SWs had heard about HIV/AIDS, thorough knowledge of transmission and prevention was lacking. The overall estimated rates for C trachomatis/N gonorrhoeae and HPV were 18.6% and 9.7%, respectively.

CONCLUSION

There is a need for further studies to generate more data on the prevalence of STDs and the knowledge of STDs in this population.

Chlamydia trachomatis and Neisseria gonorrhoeae infection and the sexual behaviour of men who have sex with men

BACKGROUND

Rates of bacterial sexually transmitted infections (STIs) continue to rise among men who have sex with men (MSM) in the UK.

OBJECTIVE

To evaluate factors associated with Chlamydia trachomatis and Neisseria gonorrhoeae among MSM attending a genitourinary medicine clinic in inner London.

STUDY DESIGN

599 MSM undergoing testing for STIs were recruited. Specimens for ligase chain reaction (LCR), strand displacement amplification (SDA) assay and culture were collected from the pharynx, urethra and rectum for the detection of C trachomatis and N gonorrhoeae. Details regarding demographics, symptoms, signs and sexual behaviour were recorded. Associations of these factors with each infection were tested, adjusting for other risk factors.

RESULTS

The prevalence of C trachomatis and N gonorrhoeae was 11.0% and 16.0%, respectively. LCR and SDA performed well for the detection of C trachomatis and N gonorrhoeae from urethra and rectum. Using either method, compared with our current testing policy, over 18% of those with C trachomatis and N gonorrhoeae would not have had their infection diagnosed or treated. Age, sexual behaviour, urethral and rectal symptoms and signs were strongly associated with both infections. A total of 33.7% of men reported at least one episode of unprotected anal intercourse in the previous month. Men reporting multiple episodes were markedly more likely to be HIV positive.

CONCLUSION

The prevalence of infection, rates of partner acquisition and unprotected anal intercourse reported among these MSM are alarming. Improved detection of C trachomatis and N gonorrhoeae using nucleic acid amplification tests has major public health implications for STI and possibly HIV transmission in this population.

Predictors of partner notification for C. trachomatis and N. gonorrhoeae: an examination of social cognitive and psychological factors

Efforts to control chlamydial and gonococcal infections include notifying eligible sexual partners of possible infection, primarily by asking the diagnosed patient to notify their partners. This approach, known as patient referral, is widely used but poorly understood. The current study examined psychosocial and cognitive factors associated with patient referral among an urban, minority sample of 168 participants recently diagnosed with Chlamydia trachomatis or Neisseria gonorrhoeae. At a follow-up interview 1-month from diagnosis, participants were more likely to have notified all eligible partners if they had greater intention to notify at baseline (OR = 3.72; 95% CI = 1.34, 10.30) and if they had only one partner at baseline (OR = 4.08; 95% CI = 1.61, 10.31). There were also gender differences as well as differences based on type of partner (i.e., regular, casual, one-time). The implications of these findings for the design of programs to promote patient referral for sexually transmitted infections are discussed.

Family influences and biologically confirmed sexually transmitted infections among detained adolescents

Data from a convenience sample of 476 detained adolescents were used to examine the relationship between family influences and biologically confirmed sexually transmitted diseases (STDs). Results indicated that frequent parental monitoring was negatively associated with STD infection and that this relationship was modified by age, gender, and race. Findings suggest that STD prevention efforts for detained adolescents (particularly high-risk minority females older than age 16) might focus on increasing monitoring by a parent or parental figure.

New sexual partners and readiness to seek screening for chlamydia and gonorrhoea: predictors among minority young women

OBJECTIVES

To determine (1) level of readiness and (2) demographic and behavioural predictors of readiness to seek chlamydia (CT) and gonorrhoea (NGC) screening in the absence of symptoms after sex with a "new" partner.

METHODS

Baseline data, obtained as part of a larger randomised controlled clinical trial in young women, were analysed. Readiness to seek screening for CT and NGC after sex with a "new" partner was assessed using the stages of change framework from the transtheoretical model of change-precontemplation, contemplation, preparation, and action. Ordinal logistic regression, using the proportional odds model, was used to determine predictors of being in action for or having already been screened for CT and NGC after sex with a "new" partner.

RESULTS

The sample consisted of 376 predominantly African American (67%) young women (mean age 18.5 (SD 1.4) years). The distribution of readiness to seek CT and NGC screening was 4% precontemplation, 11% contemplation, 28% preparation, and 57% action. The best fitting logistic model that predicted being in action for seeking screening after sex with a "new" partner included high perceived seriousness of acquiring a sexually transmitted infection (OR = 2.02, 95% CI 1.05 to 3.89), and having "other" (not steady) partners in the last 6 months (OR = 0.50, 95% C.I. 0.32 to 0.78)

CONCLUSIONS

Many young women report that they were not getting screened for CT and NGC after sex with a "new" partner and therefore may be at increased risk of an untreated STI. Enhancing level of perceived seriousness of acquiring an STI from a "new" partner may increase a young woman's readiness to seek screening after initiating a new sexual relationship.

Knowledge of sex partner treatment for past bacterial STI and risk of current STI

OBJECTIVES

Effective partner management is critical in reducing the spread of bacterial sexually transmitted infections (STIs). The purpose of this study was to determine the relation between knowledge of partner treatment for a past STI and current infection in the index patient.

METHODS

In a cross sectional analysis, 97 adolescent females sampled from community based health clinics reported that they had a past diagnosis of chlamydia or gonorrhoea in structured, face to face interviews. At the time of the interview, adolescents were also tested for chlamydia and gonorrhoea using urine based ligase chain reaction testing.

RESULTS

66% of the adolescents reported knowing that their partner was treated for the past infection. Those who knew their partner was treated were less likely to have a current infection, compared to those who did not know (11% v 30%, adjusted odds ratio and 95% confidence interval 4.46 (1.41 to 14.29), p<0.05). Correlates of not knowing the sex partner was treated included younger age and being in new sex partnership.

CONCLUSIONS

Efforts to encourage young women to follow up directly with their partners regarding treatment may help to reduce repeat infections and further spread. Furthermore, alternative strategies such as patient delivered therapy may help with partner treatment in this vulnerable population.

Perceived risk of chlamydial and gonococcal infection among sexually experienced young adults in the United States

CONTEXT

Understanding young adults' perceived risk of chlamydial and gonococcal infection can inform interventions to reduce the prevalence of these sexually transmitted diseases.

METHODS

Bivariate and multivariate analyses, using data from Wave 3 of the National Longitudinal Study of Adolescent Health (2001-2002), were conducted to examine relationships between perceived risk and selected characteristics in two groups: a nationally representative sample of sexually experienced 18-26-year-olds and a subsample of those who tested positive for chlamydia or gonorrhea. The relationship between current infection and perceived risk was also evaluated.

RESULTS

Only 14% of all respondents and 33% of infected participants reported some perceived risk of chlamydial or gonococcal infection. In the overall sample, the odds of perceiving risk were significantly elevated among blacks, Hispanics, unmarried respondents, inconsistent condom users and nonusers, respondents who reported multiple partners in the past year, those who had received a diagnosis of chlamydia or gonorrhea in the past year, and those reporting current symptoms (odds ratios, 1.5-3.3). Currently infected participants were significantly more likely than those who were not infected to perceive some risk of infection (2.4). Among infected respondents, the factors positively associated with perceived risk were being black or Hispanic, using condoms inconsistently or not using them, having exchanged money for sex, having been tested in the past year but with no diagnosis, having received a diagnosis, and reporting current symptoms (2.5-5.2).

CONCLUSIONS

Interventions to increase the accuracy of young adults' risk perceptions may influence sexual and health care-seeking behaviors in a way that will reduce rates of chlamydia and gonorrhea.

Perceived Social Cohesion and Prevalence of Sexually Transmitted Diseases

BACKGROUND

Although physical attributes have been shown to be associated with sexually transmitted disease (SD) rates, there is little information about the association between social attributes and STD rates.

GOAL

The objective of this study was to determine the association between gonorrhea prevalence and perceptions of social cohesion in impoverished, urban neighborhoods.

STUDY DESIGN

We conducted a street-based survey of 18- to 24-year-olds residing in selected census block groups in Baltimore City, Maryland. Census block groups eligible for selection were defined as impoverished (greater than 20% in poverty) and unstable (lowest 25th percentile for stability). From the eligible census block groups, 5 from high gonorrhea rate (greater than the 75th percentile) census block groups and 5 from the lower gonorrhea rate (lowest 25th percentile to equal or greater than the 75th percentile) census block groups were randomly selected. Participants within the 10 selected census block groups were recruited using a street-intercept method. Participants were asked about perceived social cohesion and control.

RESULTS

Results showed that for young adults 18 to 24 years of age residing in high gonorrhea census block groups, the mean social cohesion index scores were 1.7 points lower than mean social cohesion index scores of the participants residing in the low gonorrhea census block groups (P <0.01).

CONCLUSION

Future research needs to be conducted to determine the temporal association between gonorrhea prevalence and local social cohesion dynamics.

High-risk behaviors among men who have sex with men in 6 US cities: baseline data from the EXPLORE Study

OBJECTIVES

We describe the prevalence of risk behaviors at baseline among men who have sex with men (MSM) who were enrolled in a randomized behavioral intervention trial conducted in 6 US cities.

METHODS

Data analyses involved MSM who were negative for HIV antibodies and who reported having engaged in anal sex with 1 or more partners in the previous year.

RESULTS

Among 4295 men, 48.0% and 54.9%, respectively, reported unprotected receptive and insertive anal sex in the previous 6 months. Unprotected sex was significantly more likely with 1 primary partner or multiple partners than with 1 nonprimary partner. Drug and alcohol use were significantly associated with unprotected anal sex.

CONCLUSIONS

Our findings support the continued need for effective intervention strategies for MSM that address relationship status, serostatus of partners, and drug and alcohol use.

Avoiding risky sex partners: perception of partners' risks v partners' self reported risks

BACKGROUND

Key strategies advocated for lowering personal risk of sexual exposure to STD/HIV include having fewer partners and avoiding risky partners. However, few studies have systematically examined how well people can actually discern their sex partners' risk behaviours.

METHODS

We conducted face to face interviews with 151 heterosexual patients with gonorrhoea or chlamydial infection and 189 of their sex partners. Interviews examined the patients' perceptions of their sex partners' sociodemographic characteristics and risk behaviours. Patients' perceptions of partners were then sociometrically compared for agreement with partner self reports, using the kappa statistic for discrete variables and concordance correlation for continuous variables.

RESULTS

Agreement was highest for perceived partner age, race/ethnicity, and duration of sexual partnership; and lowest for knowledge of partner's work in commercial sex, number of other sex partners, and for perceived quality of communication within the partnership. Index patients commonly underestimated or overestimated partners' risk characteristics. Reported condom use was infrequent and inconsistent within partnerships.

CONCLUSION

Among people with gonorrhoea or chlamydial infection, patients' perceptions of partners' risk behaviours often disagreed with the partners' self reports. Formative research should guide development and evaluation of interventions to enhance sexual health communication within partnerships and within social networks, as a potential harm reduction strategy to foster healthier partnerships.

Relationships of stigma and shame to gonorrhea and HIV screening

OBJECTIVES

The purpose of this study was to assess the relationships between stigma and shame associated with seeking treatment for sexually transmitted diseases (STDs) and undergoing testing for gonorrhea and HIV.

METHODS

Participants were 847 males and 1126 females (mean age: 24.9 years) in 7 cities. Two scales assessed STD-related stigma and STD-related shame.

RESULTS

Rates of stigma and shame were higher among participants without a gonorrhea test in the past year and among those without an HIV test. Sex, age, health service use, previous suspicion of gonorrhea, and low levels of stigma were independently associated with gonorrhea testing. Age, enrollment site, use of health services, gonorrhea testing, and low levels of stigma were independently associated with HIV testing.

CONCLUSIONS

Shame is part of the experience of seeking STD-related care, but stigma may be a more powerful barrier to obtaining such care.

[Substantial increase in gonorrhea and syphilis among clients of Amsterdam Sexually Transmitted Diseases Clinic]

In the Sexually Transmitted Diseases (STD) clinic of the Amsterdam Municipal Health Service standardized data are collected about all visitors, which makes it possible to gain insight into the STD trends. In 1999, 706 new cases of gonorrhoea and 76 new cases of infectious syphilis were diagnosed, increases of 46% and 111% respectively compared with 1998. The largest increase was seen among men who had sex with men. In this group the number of diagnosed cases of anorectal gonorrhoea in 1999 was twice as high as in 1998 (186 versus 94) and the number of infectious syphilis cases four times as high (40 versus 9). These data indicate an increase in unsafe sexual behaviour, possibly because of a change in attitudes about AIDS, now that effective antiretroviral treatment is available.

Knowledge of Chlamydia trachomatis genital infection and its consequences in people attending a genitourinary medicine clinic

OBJECTIVES

To assess knowledge of Chlamydia trachomatis infections, with a comparison of knowledge of Neisseria gonorrhoeae infections.

METHODS

A cross sectional survey, by self completed questionnaire, of 200 subjects attending a genitourinary outpatient clinic.

RESULTS

The response rate was 82% (90 male and 73 female). 51% of men (60% of females) had heard of chlamydia. 65 (82%) were unaware of the potential consequences of infection. 66% were unaware that the disease could be asymptomatic. Significantly more men (77%) than women (60%) had heard of gonorrhoea. Most participants (68%-82%) knew little of the possible consequences of this infection, and only 26% were aware that it could be asymptomatic. Knowledge was higher regarding fertility topics. There was no correlation between knowledge and either age or socioeconomic status. However, greater knowledge was displayed by those who read health information leaflets always or often. For both men and women, the preferred source of health information was the doctor. Other popular sources were health information leaflets, women's magazines, and television.

CONCLUSIONS

Barely half the participants had heard of chlamydia and gonorrhoea. Further knowledge of either infection was very poor. There are serious implications for public health. The reasons for this are unclear and require exploration before targeted health promotion. Doctors and the popular media are acceptable, and potentially effective, sources of information. Acquisition of knowledge is important, both to reduce sexual risk taking behaviour and its consequences, and to allow for informed consent for chlamydia screening programmes.

The transmission dynamics of gonorrhoea: modelling the reported behaviour of infected patients from Newark, New Jersey

A survey of the sexual behaviour of gonorrhoea patients in Newark was undertaken to evaluate parameters within a model of gonorrhoea transmission. Modelling work aimed to explain observed epidemiological patterns and to explore the potential impact of interventions. Reported behaviours, along with values derived from the literature, were used within a standard deterministic model of gonorrhoea transmission, where the population was stratified according to sex and rates of sex-partner change. The behaviours reported, particularly among women, are insufficient by themselves to explain the continued existence of gonorrhoea within the population. The majority of symptomatic patients seek treatment within a few days, and report that they do not have unprotected sex while symptomatic. The proportion of patients with low numbers of sex partners suggests that sexual mixing between people categorized according to sexual behaviour is near random. To explain the persistence of gonorrhoea, there must be some patients who, when infected, do not seek care in public clinics. In addition, gonorrhoea incidence in the model is sensitive to change, such that very small reductions in risk behaviour could lead to its elimination. This does not accord with the observed failure of many interventions to eliminate infection, suggesting that the modelled infection is too sensitive to change. The model, which has been influential in gonorrhoea epidemiology, is not consistent with the observed epidemiology of gonorrhoea in populations. Alternative models need to explore the observed stability of gonorrhoea before robust modelling conclusions can be drawn on how best to control infection. However, the current results do highlight the potential importance of asymptomatic infections and infections in those who are diseased and do not attend public health services. Screening and contact-tracing to identify asymptomatic infections in both men and women will be more effective in reaching those who maintain the infection within the community rather than simply treating symptomatic cases.

The role of sexual partnership networks in the epidemiology of gonorrhea

BACKGROUND

Empirical studies have the potential to collect data on patterns of sexual mixing and network structures.

GOAL

To explore the contribution of different network measures in sexually transmitted disease epidemiology.

STUDY DESIGN

Individual-based stochastic simulations of a network of sexual partnerships and sexually transmitted disease transmission are analyzed using logistic regression.

RESULTS AND CONCLUSIONS

Measures accumulated over times similar to the duration of infection are more informative than are static cross sections. The patterns of sexual mixing and network structure influence patterns of infection. In particular, the establishment of infection is most sensitive to the proportion of nonmonogamous pairs, the component distribution and cohesion among those with high activity. The subsequent prevalence is most sensitive to the assortativeness of mixing in the high-activity class and a measure of cohesion, both of which reflect the decrease in prevalence brought about by less widespread connections. A person's risk for infection is determined by local rather than global network structures.

Knowledge of gonorrhea in adolescent females with a history of STD

The purpose of this study is to examine how a previous infection with gonorrhea or another sexually transmitted disease (STD) will impact on patients' knowledge of gonorrhea. Adolescent girls were recruited from a primary-care adolescent clinic. Those with a history of an STD were overrecruited. Participants were given a standardized questionnaire regarding several symptoms and sequelae of STD. The results of this study revealed that girls (N = 248, mean age = 16.9 years) with a personal history of gonorrhea had more correct responses than those with no history of an STD, but they were not statistically different from those with a nongonococcal STD. No group had a mean correct score greater than 6.66 out of 13. Nearly two out of three participants reported that an individual had to always have one of four symptoms (discharge, pain on urination, rash, or sores) when there is a gonococcal infection. Overall, adolescents have an inaccurate foundation of knowledge regarding symptoms and sequelae of gonorrhea. Although those with a previous history of gonorrhea had higher mean scores than those with no history of an STD, they still identified the correct responses only half the time. Additionally, adolescents with a history of gonorrhea or another STD were no more likely to have identified the possibility of asymptomatic infection, despite several having only a history of asymptomatic infection.

Determinants of penicillinase producing Neisseria gonorrhoeae infections in heterosexuals in Amsterdam

BACKGROUND AND OBJECTIVES

At the STD clinic of the Municipal Health Service in Amsterdam, the annual number of infections with penicillinase-producing Neisseria gonorrhoeae (PPNG) strains remained relatively stable from 1983 until 1990, while the number of non-PPNG infections declined dramatically. To investigate the PPNG and non-PPNG epidemic, a cross sectional study was conducted in 1989 and 1990. The purpose of this study was to assess determinants of PPNG infections among heterosexuals diagnosed with gonorrhoeae.

METHODS

In addition to routinely collected data in new consultations for STDs, information on alcohol use, drug use and sexual behaviour was obtained from patients diagnosed with gonorrhoea. The diagnosis of gonorrhoea was based on a positive culture and isolates were screened for PPNG. Logistic regression analysis was used to assess independent predictors of PPNG infection.

RESULTS

Additional information was available of 328 women and 995 heterosexual men diagnosed with gonorrhoea. PPNG was diagnosed in 86/328 (26%) women and in 329/995 (33%) men. Logistic regression analysis identified a Central/South American nationality (odds ratio(OR) = 2.46) and older age (OR = 1.04 per year) as positively associated with PPNG infection in female patients. An inverse relation was found with use of hard drugs (OR = 0.29). Among men diagnosed with gonorrhoea, sexual contacts with window prostitutes (mainly women from Central/South America) (OR = 1.98) and a foreign nationality (OR = 1.78) were positively associated with PPNG infection, and sexual contact with drug using prostitutes (OR = 0.47) inversely.

CONCLUSIONS

PPNG infections were especially common among Central and South American window prostitutes and their clients, but not among hard-drug addicted prostitutes and their clients. Since window prostitutes originating from Central and South American countries are transient in Amsterdam, prevention activities targeted at these prostitutes and their clients should be continued to limit the spread of PPNG and other STDs within these groups.

Psychological consequences of genital herpes, an exploratory study with a gonorrhea control-group

Measurements of some psychosocial variables were obtained from 27 patients with a genital herpes infection and compared with those from 12 patients with a gonorrhea infection. The measurements referred to the period before and during the infection. Evidence was found that during the infection patients were more anxious, more sexually inhibited, more bitter towards their partners, and had more psychological complaints than before the infection. Generally there was no difference between the two groups of patients, with one exception: patients with genital herpes judged themselves as having fewer psychological complaints prior to the disease than did patients with gonorrhea.

Assessment of sexual mixing patterns

The manner in which people with varying partner change rates choose their partners may have important implications for the future of the AIDS epidemic. A relatively rapid but small epidemic can be expected if sexual mixing patterns are highly assortative so that those with high partner change rates nearly always choose partners with similar rates. Direct estimation of sexual mixing is exceedingly difficult. On the other hand, information on the way people mix is implicitly contained in the epidemiology of other sexually transmitted diseases (STDs). If mixing is highly assortative, one might expect gonorrhea to be largely confined to a small subsection of the population who would frequently contract the disease repeatedly. In this paper a model of gonorrhea transmission in which partner change rates and preference are dealt with as continuous variables is used to extract information on mixing from data on an Australian heterosexual population. It was found that in this population mixing is not far from random with respect to partner change rates.

Knowledge of AIDS and other sexually transmitted diseases among women attending a family planning clinic in Nairobi, Kenya

We interviewed 1,716 women attending a family planning clinic in Nairobi between January 1990 and May 1991 about their knowledge of the acquired immunodeficiency syndrome (AIDS) and other sexually transmitted diseases (STDs). When participants in the study were asked to name spontaneously the STDs they knew, more than 90% of the women named gonorrhea and AIDS, and 75.0% named syphilis; 65.4% could name two or more signs of AIDS; and 96.9%, 66.5%, and 58.3% mentioned sexual transmission, transmission via blood transfusion, and perinatal transmission, respectively, as routes of transmission of AIDS. Knowledge of most symptoms and routes of transmission of AIDS, as well as knowledge of gonorrhea and syphilis, was significantly positively associated with level of education. Unmarried women were significantly less likely to know symptoms and routes of transmission of AIDS than were married women. Level of knowledge of gonorrhea and syphilis was significantly positively associated with number of lifetime sexual partners. Although awareness of AIDS was very high, detailed knowledge of signs of AIDS and routes of transmission was deficient, particularly among less educated women. This positive association of detailed AIDS knowledge with level of education suggests a need to design AIDS prevention activities that are more accessible to, and better understood by, women who have little education.

Venereal diseases and aggression management among Native Americans

An analysis of secondary data yielded no significant ecological correlations for venereal disease rates and aggression management indices based on suicide and homicide rates for the 11 US Indian Health Services areas. This outcome does not cross-culturally replicate research on Field's aggression management hypothesis.

Consumption by semen loss in India and elsewhere

Using ethnographical data from a rural site of Oriya culture, the purpose of this article is to show that the Indian obsession regarding the harmful consequences of semen loss does not constitute a specific Indian culture-bound preoccupation, but represents a survival example of a much widespread system of beliefs that can be traced for instance in Western culture to the Hippocratic notion of "back consumption" and the classical concept of gonorrhoea. At the core of this system of beliefs are found ancient conceptions of the nature and functions of semen in human life. These conceptions and their cultural influences incidentally inform us about one of the origins of the reprobation of onanism, as well as one possible way, among many others, for traditional thinking to explain the clinical enigma of depressive syndrome.

Gonorrhea care in a clinic for low-income patients

There are few studies from family practice offices summarizing experience with culture-proven gonorrhea. Seventy-nine such cases were identified over a six-year period in a family practice model office in Gainesville, Florida, a rate of 5.8 cases per 10,000 patient visits. Ninety-six percent of the patients in the study had limited financial resources by insurance classification. The most commonly recognized presentations in men were complaints of discharge or dysuria or both. Nine (15%) of the women gave a history of contact with a person said to have a sexually transmitted disease, but none of the men did. Of the 62 women, gonorrhea was found on routine cervical culture in only two (3%), 38 (61%) had pelvic pain, and 40 (65%) had discharge as an initial complaint. Fifty-one of the patients (88%) reported symptomatic improvement with treatment, and seven (12%) reported no improvement by the treatment. Post-treatment gonorrhea cultures were positive in two (3%), negative in thirty-three (42%), not done in seventeen (22%), and twenty-seven of the patients (34%) did not return for scheduled follow-up. Difficulties in treating patients with gonorrhea in this population appeared to be largely related to problems with patient follow-up.

The patient with gonococcal infection

Despite the availability of effective antimicrobial therapy since the middle of the twentieth century, gonococcal disease remains a common and expensive public health problem. The patient who presents to the primary care office with gonococcal disease, or one who is found to be infected after screening, still faces significant emotional and economic barriers to effective treatment and control of the spread of the disease. Along with the emergence of resistant strains and the previously existing problems of asymptomatic carriers and reluctance to seek treatment, physicians are charged with the problems of identifying patients at risk for the disease, providing effective treatment for those infected, and preventing further spread of infection. Simple, effective, and inexpensive therapies that also treat the frequently present coinfections with other sexually transmitted diseases are not yet available. Antibiotic therapy must still be chosen with regard to the patient's history and circumstances. The approach to counseling the patient about avoidance of complications, prevention of reinfection, and prevention of transmission of infection must be mastered by the primary care physician if progress is to be made toward the eradication of gonococcal disease.

The impact of a clinic-based educational videotape on knowledge and treatment behavior of men with gonorrhea

The impact of a ten-minute, soap opera-style videotape on knowledge and treatment behavior of black men with gonorrhea was tested in randomized clinical trials. The videotape, shown to individual patients after diagnosis, produced a sizeable increase in the percentage of patients who returned for their test-of-cure examination: while only 43.3% of control group patients returned, 53.5% of those in the videotape group did so; chi 2(1) = 9.0; P less than 0.003. In a follow-up study, similar results were found: videotape group (59.0%), control group (39.1%); chi 2(1) = 6.2; P less than 0.015. The videotape also produced large, significant increases in patient knowledge, as measured by a test administered during patients' clinic visit (P less than 0.0001). No measureable effect of the videotape was detected on patients' willingness to refer sexual contacts for treatment. The findings suggest that clinic-based educational materials, particularly soap opera-style videotapes that engender audience identification, create emotional significance for the viewer, and model requisite communication skills, may have a significant role to play in control of sexually transmitted diseases.

Failure of a lottery incentive to increase compliance with return visit for test-of-cure culture for Neisseria gonorrhoeae

The impact of the financial incentive of playing a lottery on the rate of return for test-of-cure cultures was evaluated at a clinic for sexually transmitted diseases. All teenagers and young adults treated for gonorrhea (or as contacts of patients with gonorrhea) who were given a test-of-cure appointment were eligible to participate; in order to win, they had to keep the appointment. The return rate was documented during a baseline and a lottery phase for 519 patients. Females were significantly more likely to keep the appointment (47%) than males (27%), regardless of intervention, but there was no improvement in the return appointment rates with the lottery (baseline, 31% vs. lottery, 33%). Although teenaged males were more likely to participate in the lottery than young adult males and all females, only young adult females who participated were significantly more likely to return (68%). Reasons for failure of the lottery are discussed. Thus, despite the successful use of a lottery in previous studies, it is not always helpful in improving compliant behavior in certain populations.

Gonococcal strains from homosexual men have outer membranes with reduced permeability to hydrophobic molecules

Loci designated penA, penB, and mtr contribute additively to penicillin G resistance in Neisseria gonorrhoeae; the mtr locus also confers resistance to hydrophobic dyes, detergents, and antibiotics, env mutations suppress the phenotypic expression of mtr and penB and are responsible for increased sensitivity to various hydrophobic molecules. We postulated that the host environment is important in the selection of gonococcal strains with these particular outer membrane phenotypes. Thus, mtr strains should predominate in environments that are high in hydrophobic molecules. To test this hypothesis we determined the outer membrane phenotype of 152 strains of N. gonorrhoeae. Rectal and urethral isolates from 58 homosexual men, urethral isolates from 55 heterosexual men, and cervical and rectal isolates from 39 heterosexual women were used in this study. Strains from 43 of the homosexual men were matched with those from heterosexual men with respect to auxotype and year and season of isolation. Cell envelope phenotype was determined for each strain on the basis of its resistance to various hydrophobic compounds. The identity of mtr strains was confirmed by genetic transformation. Among the matched pairs, mtr strains were significantly more prevalent among isolates from homosexual men than among those from heterosexual men (P = 0.03). Serogrouping by coagglutination demonstrated that 17 of 19 mtr strains versus 76 of 131 non-mtr strains belonged to coagglutination group WII (P = 0.01). Coagglutination group WII strains were also associated with homosexuality (P = 0.02). Gonococci were also tested for resistance to fecal lipids, mtr strains were more resistant to growth inhibition by fecal lipids than were non-mtr strains.

Self-reported behavior patterns of patients attending a sexually transmitted disease clinic

Records of the sexually transmitted disease (STD) clinic visits of 12,728 patients in Columbus, Ohio were analyzed to better understand the behavior patterns of these patients. Among heterosexual men, a greater proportion of Blacks than Whites reported a previous history of urethritis. After controlling for previous STD among heterosexual men with discharge or dysuria, we found that Black men sought treatment sooner and were more likely to curtail sexual activity than White men after becoming symptomatic with gonorrhea or nongonococcal urethritis.