bluuebunny/crossref_metadata_2025 huggingface dataset:
O5-S2.05 Role of regional reference laboratories for sexually transmitted infections in improvement of second generation HIV surveillance experience from the Central America Region
Authors: Ye T , Steele L , Juarez S I , Chen C Y , Ballard R C
Published: July 2011

Background

WHO/UNAIDS recommends National HIV/AIDS and Sexually Transmitted Infection STI) Control Programs to implement integrated HIV, STI and behavioural surveillance to assess the disease burden, and to monitor the temporal trends of HIV/STI prevalence and high-risk sexual behaviours. Despite this recommendation, there is limited STI prevalence data available in many resource poor countries owing to lack of STI laboratory capacity to detect multiple STIs. The CDC STD lab explored the feasibility of a decentralised laboratory strengthening approach by applying more advanced molecular STI diagnostic methods to support the second generation surveillance (SGS) activities in the Central American Region during 2007–2011.

Methods

CDC STD lab developed a real-time multiplex PCR (MPCR) to detectNeisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis,andMycoplasma genitalium. In collaboration with regional partners, CDC identified and transferred the diagnostic technology to a regional STI reference laboratory in 2008. The regional reference laboratory provides MPCR testing on specimens collected for surveillance purpose. This standardised SGS study design was implemented at regular intervals in multiple countries in the region to estimate the disease burden and to monitor temporal STI trends.

Results

During 2007–2010, four national integrated sexual behavioural and biomarker surveys were implemented using CDC's affiliated regional STI reference center. The quality STI prevalence data was made available to the national HIV/STI programs in Honduras, El Salvador, Nicaragua and Colombia. Similar CDC supported surveillance studies are in-preparation in Guatemala, Belize, Panama, Honduras (second round) and the Dominican Republic.

Conclusions

Based on the experience from the Central American Region, it is feasible to implement integrated HIV, STI and behavioural surveillance surveys using robust molecular techniques in resource poor settings. In collaboration with regional partners, CDC's approach to STI laboratory capacity strengthening through establishing a regional reference laboratory should be expanded to other regions.
O5-S3.01 Use and effectiveness of expedited partner therapy in an inner-city STD clinic
Authors: Mickiewicz T , Al-Tayyib A , Mettenbrink C , Rietmeijer C
Published: July 2011

Background

In November 2006, the Denver Metro Health (STD) Clinic (DMHC) began offering Expedited Partner Therapy EPT) to heterosexual patients infected with Chlamydia trachomatis (Ct) orNeisseria gonorrhoeae(GC). Among those who accept EPT, the patient delivers treatment to his or her partner(s), removing the need for a clinic visit. We investigate demographic differences among patients who accepted EPT and examine re-infection rates among those who return to the clinic.

Methods

Data were extracted from the electronic medical record (EMR) for 2644 eligible patients offered EPT between November 2006 and October 2010. Acceptance rates are compared across demographics and infection status. Rates of re-infection are examined among the 339 patients who returned for re-testing within 21 to 90 days of treatment. Dual infections are excluded.

Results

Overall, 763 (28.3%) eligible patients accepted EPT. Women were more likely than men to accept EPT (35.9% vs 23.8%, p<0.01). Patients younger than 40 accepted EPT at a higher rate than those 40 or older (29.6% vs 20.0%, p<0.01). African Americans were least likely to accept EPT (23.0%), whereas approximately 30% of Hispanics and Whites accepted and those reporting multiple races accepted at the highest rate (43.6%) (p<0.01). Ct infected patients were significantly more likely to accept EPT than those infected with GC (32.7% vs 24.6%, p<0.01). Within 21 to 90 days of treatment initiation, 339 patients returned for re-testing (221 for Ct and 118 for GC). Overall, re-infection rates differed significantly by EPT acceptance at the initial visit with 11.1% re-testing positive among those who accepted EPT compared to 20.4% among those who refused (p=0.04) (Abstract O5-S3.01 table 1). When stratified by type of infection, the differences were no longer significant but the direction of the relationship remained. Among those originally Ct-infected, 9.1% of those who accepted EPT re-tested positive vs 15.3% among those who refused (p=0.19). Among those originally GC-infected, 16.1% of EPT acceptors re-tested positive compared to 28.7% of those who refused (p=0.17).

Abstract O5-S3.01 Table 1

Use and effectiveness of expedited partner therapy in an inner-city STD clinic Mickiewicz T, Al-Tayyib AA, Mettenbrink C, Rietmeijer CA

Re-infection rates among those returning to clinic for re-testingCtGCCt or GC*Accepted EPT7/77 (9.1%)5/31 (16.1%)12/108 (11.1%)Refused EPT22/144 (15.3%)25/87 (28.7%)47/231 (20.4%)*

p<0.05.

Conclusions

In a busy inner-city STD clinic, EPT is more likely to be accepted by women, those who are younger and those infected with Ct. Re-infection rates among patients returning to the clinic suggest that EPT reduces the risk of re-infection, with the greatest benefit among those originally infected with GC.
O5-S3.02 Implementation of an Expedited Partner Therapy (EPT) Program in an inner-city STD clinic
Authors: Mickiewicz T , Al-Tayyib A , Mettenbrink C , Rietmeijer C
Published: July 2011

Background

Expedited partner therapy (EPT) is the practice of treating sex partners of persons with sexually transmitted diseases (STD) without an intervening medical evaluation. In 2006, the CDC issued guidelines for providing EPT to heterosexual patients diagnosed with gonorrhoea/chlamydial infection, allowing them to deliver treatment to their partner(s). In November 2006, the Denver Metro Health (STD) Clinic (DMHC) began offering EPT. We describe EPT implementation challenges and process improvements.

Methods

Three phases of implementation are described: 1) the pilot phase, 2) implementation of a quality assurance protocol and 3) initiation of a prompt in the electronic medical record (EMR). Data were extracted from the EMR to calculate acceptance rates of EPT among the 2056 eligible patients over this time period. Rates were examined by month and for each phase.

Results

Before initiation of the pilot phase, a protocol to dispense EPT was developed and staff trained. During the pilot phase (September 2007–April 2008), patient acceptance rates averaged 17% (range: 8%–22%). As rates were not improving, EMR data were examined to determine potential areas for intervention. At DHMC, clinical services are provided by health care partners (HCP) and licensed nurse practitioners (LNP). Analyses revealed significant differences in patient acceptance of EPT by provider type: HCP providers were less likely to have patients accept EPT than LNP providers (prevalence ratio=1.7, 95% CI: 1.5% to 1.9%), likely due to the nature of the visit and the volume of patients seen by HCP providers. Targeted re-training was initiated and quality assurance reports were generated monthly. Although the acceptance rate increased significantly to 22% (p=0.04), there was no indication that rates were increasing with time. In January 2009, the EMR was amended, requiring all providers to document EPT referral, acceptance or refusal (and reason for refusal), before closing the patient EMR. Rates improved significantly to an overall rate of 49% (p<0.01) through October 2010 (Abstract O5-S3.02 figure 1). Reasons for refusal among those who did not accept EPT included that partner would be notified (42.5%), partner was being treated (30.1%) or the patient was not able to contact the partner (21.9%).

Abstract O5-S3.02 Figure 1

Acceptance rates of EPT Denver Metro Health (STD) clinic.

Conclusions

In a busy inner-city STD clinic, an automated EMR prompt that forces documentation of EPT provided the greatest success. An EPT acceptance rate of 50% may be the optimum rate in a real-world setting.
O5-S3.03 Incremental cost-effectiveness of introducing partner notification with selective screening for STD control in Louisiana
Authors: Rahman M , Khan M , Longfellow L
Published: July 2011

Background

Selective screening and partner notification are the two strategies used by the STD control programs in USA to reduce and or eliminate syphilis. So far no study has assessed the cost and effectiveness of either approach at the state level. The objective of this study is to assess the incremental cost effectiveness (ICE) of adding partner notification with selective screening (SS) in detecting early syphilis and to measure ICE of intensity of partner notification in Louisiana.

Method

The cost effectiveness analysis (CEA) was done from the point of view of health care delivery. Micro costing approach was used in cost analysis and the CEA was performed by using the recurrent direct costs associated with detecting syphilis by SS and by SS with partner notification see Abstract O5-S3.03 figure 1. For ICE of intensity of partner notification, cost was calculated for every attempt made to contact a partner and effectiveness was calculated by the number of partners identified as well as the number of cases identified through partner notification.

Abstract O5-S3.03 Figure 1

Steps involved in syphilis case detection by partner notification and selective screening and cost associated in each method. Partner notification: A- cost for phlebotomy B- cost of tests C- cost for surveillance D- cost for case management including travel. Selective screening: 1- cost for phlebotomy, 2- cost of tests, 3- cost to contact infected patients including phone call and letter or field visit related supplies and travel.

Results

The estimates of direct costs associated with SS was $6.4 million for 1005 early syphilis cases detected and $6.7 million for SS with partner notification. Partner notification detected additional 279 early syphilis cases with an additional cost of $314 498. Incremental cost of adding partner notification with SS was $2808 per primary and secondary syphilis case, $1883 per early latent syphilis case, and $1127 per early syphilis case identified. ICE of identifying partner showed a decline with the increase in number of attempts but the ICE values of case detection through partner notification did not show any systematic pattern.

Conclusion

This study demonstrates that adding partner notification with SS is more CE in syphilis detection in Louisiana compared to case detection by SS alone. In terms of intensity of partner notification, it was found that increasing the number of attempts to contact the partners remained cost effective but due to variability in the number of attempts to contact cases, it was not possible to determine the optimal number of attempts.
O5-S3.04 Individual and population level effects of partner notification forChlamydia trachomatis
Authors: Althaus C L , Heijne J C M , Herzog S A , Roellin A , Low N ,   Partner Notification Modelling Project Group
Published: July 2011

Background

Partner notification (PN) is an essential part of the case management of sexually transmitted infections STI), including Chlamydia trachomatis. Failure to notify current partners might cause re-infection of the index case, whilst failure to notify previous partners could result in ongoing transmission in the population. The impact of PN at both the individual and population level is, however, unclear.

Methods

We developed an individual-based modelling framework called Rstisim, which can simulate transmission of any STI through a dynamic sexual network and track the history of an individual's partnerships. The effect of different PN strategies forC trachomatiswas investigated in three models with increasing levels of complexity of the sexual partnership dynamics: a) an instantaneous contact model which is based on the widely used assumption that sexual contacts happen instantaneously; b) a pair model where sexual partnerships last for a certain period; c) a triple model in which individuals can have up to two concurrent partnerships. We used data from the National Survey of Sexual Attitudes and Lifestyles (Natsal) 2000 for 16–25-year-old women and men to parameterise the sexual behaviour of young adults.

Results

The models all have a baseline chlamydia prevalence of 3%. In the triple model, chains of contacts can be seen at cross-section, whereas there are, by definition, no ongoing partnerships in the instantaneous contact model. In all three models, we find that a substantial proportion of partners (>10%) from partnerships that ended as far back as 18 months is infected withC trachomatis. We then investigated the population level effect of PN (with 50% success) as a complementary strategy to screening (at a rate of 0.1 per year). Increasing both the number of notified partners and the PN period results in lower levels ofC trachomatis. Under the most realistic assumptions of the sexual partnership dynamic, most of the effect of PN results from notifying the current partner.

Conclusions

We found that extended PN periods can efficiently identify new chlamydia-infected cases. At low screening levels, the additional benefit of PN in decreasing chlamydia prevalence is minor and primarily derives from notifying the current partners in order to prevent re-infection. This study exemplifies the differences between individual and population level outcomes of PN as an intervention for the management ofC trachomatisinfections.
O5-S3.05 Partner notification for STI And HIV: patients' views and experiences of notifying partners
Authors: Wayal S , Cassell J , Scambler G , Hart G , Low N
Published: July 2011

Background

Partner notification (PN) involves contacting the sexual and needle-sharing partners of patients diagnosed with STI/HIV. Effective PN can prevent onward STI/HIV transmission. However, little is known about the socio-cultural factors affecting PN. We synthesised qualitative literature on views and experiences of PN among people recently diagnosed with STI/HIV and their contacts.

Methods

We conducted a systematic search of 4 electronic databases for PN literature from 1990 to August 2009. Meta-ethnography was used to synthesise data from the 16 studies that met our inclusion criteria. We identified key metaphors and themes from individual studies and compared them and their explanations with other studies to enable further interpretations. We then examined the emerging concepts that have implications for STI/HIV PN policy and programs.

Results

Our synthesis revealed that PN is influenced not only by type of partnership or infection but also by the socio-cultural, religious, and legal framework governing sex and sexuality. Paradoxically while PN is perceived as altruistic, and as a moral responsibility towards partners, it is also feared as 'social suicide'. 'Breaking the bad news' is perceived as a difficult and potentially troublesome task; however, patient referral is preferred to provider referral. STI/HIV diagnosis invokes 'embodied shame' which can result in non-disclosure, or selective disclosure, or confronting and blaming the partner, especially a main current partner. While the experience of notifying partners is typically not as bad as expected, it occasionally results in violence against women. Injecting drug users felt less able to notify drug-using partners due to legal implications. Provider-led notification is considered protective against fear of violence and social stigma.

Conclusions

Meta-ethnography enabled the synthesis of qualitative literature to derive new interpretations and comparative explanations from these data. Our synthesis reveals that PN should be voluntary and confidential and a choice of patient and provider referral methods should be offered. PN programmes should support patients in coping with feelings of shame and guilt to assist notification and facilitate timely testing and treatment of sexual partners. Further research on the sexual health outcomes of PN, its effect on partnerships and how best to reduce the fear of stigma and discrimination associated with STI and PN is needed.
O5-S3.06 Testing for STIs in population-based sexual health surveys without returning results: development of an ethical and pragmatic approach
Authors: Field N , Tanton C , Mercer C , Nicholson S , Sjordin S , Soldan K , Beddows S , Ison C , Johnson A , Sonnenberg P
Published: July 2011

Background

Sexual health surveys are enhanced by biological measures, such as non-invasive testing for STIs. The Third British National Survey of Sexual Attitudes and Lifestyles (Natsal 3) will estimate the population prevalence of five STIs (C trachomatis,N gonorrhoeae, type-specific Human Papilloma Virus, HIV andM genitalium) in a probability sample aged 16–44 y. This raises complex ethical issues, including return of results, testing in under-18s, appropriate consent and confidentiality. We describe the development of an ethically sound and acceptable approach to urine testing for STIs, without returning results, in Natsal 3.

Methods

The Natsal team considered the following: (1) more appropriate settings to obtain free STI testing and advice are now widely available, (2) survey conditions and sample type limit accuracy and timeliness, (3) for some STIs, the clinical and public health implications are unknown, (4) a uniform approach is easier to explain and be understood, (5) non-return of results is more cost efficient, enabling wider STI testing, (6) practical difficulties in returning results, (7) non-clinical interviewers. This rationale was subjected to peer-review as part of the funding process, stakeholders were engaged, and it was then submitted to a research ethics committee (REC). Piloting was performed in the general population to test acceptability and feasibility. Findings The agreed approach involved written consent for voluntary anonymised testing with the knowledge that results are not returned and the option of sample storage for future research. Confidentiality was assured by keeping STI data and personal identifiers at separate institutions, and a detailed protocol was designed to ensure that STI data were irreversibly unlinked after 3 months. In piloting, 61% (68/111) of participants agreed to provide a sample and 93% (63/68) agreed to sample storage for future research. All participants were given information about accessing clinical tests and STI advice.

Conclusions

The testing of STIs and the decision not to return results was accepted by a REC, in the context of a stakeholder consensus, and was acceptable to participants in developmental pilot work. Our experiences, both in developing the approach, and in the mechanisms to achieve this, may inform the ethical considerations of researchers, RECs and funders in study design and ethical approaches to population-based biological sampling.
O5-S4.03 HIV testing among patients infected withNeisseria gonorrhoeae-STD surveillance network, USA, 2009–2010
Authors: Bradley H , Asbel L , Bernstein K , Mattson M , Pathela P , Pino R , Samuel M , Schwebke J , Stenger M , Tabidze I , Zenilman J , Dowell D , Weinstock H
Published: July 2011

Background

An estimated 21% of 1.1 million HIV-infected US residents do not know they are infected and may unknowingly transmit HIV. Because people with sexually transmitted diseases (STDs) are at increased risk of HIV, CDC recommends HIV screening for patients seeking STD treatment. We investigated whether patients given a diagnosis ofNeisseria gonorrhoeaeduring January 2009-June 2010 were concurrently tested for HIV.

Methods

We used data from interviews with randomly selected gonorrhoea-infected patients in the 12 state and local health jurisdictions constituting the STD Surveillance Network. We compared the prevalence of HIV testing concurrent with gonorrhoea testing or treatment among patients seeking care in STD clinics and patients in other practice settings (emergency rooms, public and private outpatient facilities, hospitals, and family planning clinics).

Results

Of 6658 eligible patients, 3462 (52%) were successfully interviewed. Complete data were available for 1845/3462 (53%). Of these, 51% were tested for HIV when they were tested or treated for gonorrhoea. The proportion of gonorrhoea patients tested for HIV ranged from 22% to 74% by jurisdiction. STD clinic patients were more likely to be tested for HIV than those in other practice settings (61% vs 46%, p <0.01), see Abstract O5-S4.03 figure 1 and women were more likely than men to be tested for HIV in STD clinics (71% vs 58%, p=0.01). HIV testing was more common among black (53%) and Hispanic women (54%) compared with white women (36%, p=0.01). Men who have sex with men (MSM) were generally more likely to be tested for HIV compared with other men (56% vs 48%, p=0.02), though 58% of both MSM and MSW were tested for HIV in STD clinics. We found no association between HIV testing and race (among men), age, or having multiple sex partners.

Abstract O5-S4.03 Figure 1

Percentage of patients tested for HIV concurrently with gonorrhea testing or treatment by facility type and jurisdiction.

Conclusions

HIV testing among gonorrhoea-infected patients is sub-optimal. While patients are more likely to be HIV-tested in STD clinics than in other practice settings, even STD clinics miss many opportunities to test high risk groups such as MSM, who are less likely than women to be HIV tested in this setting. Interventions are urgently needed to increase HIV testing among STD patients.
O5-S4.04 Targeted STD screening among high-risk men who have sex with men
Authors: Perkins R , Furness B , Hager M , McLaughlin R , Goforth J , Davies M
Published: July 2011

Background

Subgroups of men who have sex with men (MSM) are at high risk for HIV infection and other viral and bacterial STDs. Since the mid-1990s, increased rates of early syphilis, gonorrhoea, and chlamydial infection and higher rates of unsafe sexual behaviours have been documented among MSM in the USA and virtually all industrialised countries.

Methods

The Gay Men's Health & Wellness (GMH&W) Clinic is a Tuesday and Thursday evening STD clinic for men at Whitman-Walker Clinic (WWC), a Washington, DC community health center specialising in HIV/AIDS care and lesbian, gay, bisexual, and transgender care. As an outreach of this bi-weekly clinic, WWC, Gilead Foundation, and the local HIV/AIDS, Hepatitis, STD, and TB Administration collaborated to provide STD screening in the Crew Club, the District's only bathhouse serving MSM, for ∼4 h each Tuesday night beginning July 2010. All participating men were offered HIV screening, syphilis screening, and nucleic acid amplification testing NAAT) for gonorrhoea and chlamydia of urine, pharyngeal, and rectal specimens.

Results

During the first 6 months of testing at the Crew Club, 173 unique clients were screened. Of those, five new HIV and 18 new syphilis cases were identified (Abstract O5-S4.04 table 1). In addition, two urethral, six pharyngeal, and two rectal gonorrhoeal infections were identified and five urethral, two pharyngeal, and 14 rectal chlamydial infections were identified. In comparison, during 2010, 2487 unique clients were tested at the GMH&W Clinic. Of those, 37 HIV and 189 syphilis cases were identified. In addition, 115 urethral and 89 rectal gonorrhoeal infections were identified and 139 urethral and 124 rectal chlamydial infections were identified. Pharyngeal results from the GMH&W Clinic were not yet available.

Abstract O5-S4.04 Table 1

Testing results, gay men's health & wellness clinic (2010) vs STD Screening at the Crew Club (July–December 2010)

TestGMH&W clinicCrew clubTestsPositives% PositiveTestsPositives% PositiveHIV2747371.35%18973.70%Syphilis29691896.37%191189.42%Urethral GC17531156.56%18421.09%Pharyngeal GC2017N/A–18963.17%Rectal GC1138897.82%18321.09%Urethral CT17531397.93%18452.72%Pharyngeal CT2017N/A–18921.06%Rectal CT113812410.90%183147.65%

Conclusions

A higher percentage of presumably asymptomatic clients tested positive for HIV and syphilis infections during STD screening in this non-traditional venue than during the diagnosis and routine screening that occurred at the clinic. Conversely, a higher percentage of clients, many of whom were symptomatic, tested positive for gonorrhoea and chlamydia during the GMH&W Clinic than during the Tuesday night outreach. This effort allows us to engage hard-to-reach men who may be among the core transmitters driving the HIV and syphilis epidemics in the DC area. Costs per HIV and syphilis cases detected need to be calculated /estimated for this fruitful outreach endeavour.
O5-S4.05 Introduction of a sexual health practice nurse increases STI testing among MSM in general practice
Authors: Chen M Y , Snow A F , Cummings R , Owen L , El-Hyak C , Hellard M E , Vodstrcil L , Fairley C K , Chen M Y
Published: July 2011

Introduction

Increased screening among MSM could improve STI control in this population; however published data on interventions that improve screening rates is limited. The aim of this study was to determine if introducing a sexual health practice nurse (SHPN) into a general practice clinic could increase HIV and STI testing among MSM who attend.

Methods

In October 2008, Melbourne Sexual Health Centre introduced a SHPN into a Melbourne general practice with a high caseload of MSM. We undertook an observational study comparing the proportion and STI tests undertaken in the 9 months before (Period 1), and after the SHPN was introduced (Period 2). Consistent with Australian national STI testing guidelines for MSM, complete testing was defined as HIV and syphilis serology, urine test and anal swab for chlamydia, pharyngeal and rectal swabs for gonorrhoea, from the same man on the same date. MSM were stratified and analysed according to HIV status. The Qui-Square Test for Independence was used to compare the difference in proportions of tests. In the case of syphilis tests among HIV positive MSM the median number of tests was compared using the Mann–Whittney U Test.

Results

Among HIV negative MSM, the propotion of MSM tested, increased from Period 1 to Period 2 as follows; HIV from 57.8% to 66.2%; syphilis from 59.9% to 76.6%; urethral chlamydia from 67.7% to 75.8%; pharyngeal gonorrhoea 62.5% to 69.9%; and rectal gonorrhoea/chlamydia from 58.5% to 69.5% (all p<0.001). The proportion of episodes of complete tesing, also increased from 41.1% to 51.9% (p<0.001). Among HIV positive MSM, the proportion of MSM tested, increased from Period 1 to Period 2 as follows; urethral chlamydia from 66.5% to 80.2%, pharyngeal gonorrhoea 58.7% to 77.2% and rectal gonorrhoea/chlamydia from 55.3% to 75.3%, (all p<0.001). Prior to Period 1, the clinic had a policy of testing HIV positive MSM for syphilis with each three monthly routine HIV monitoring blood tests. Therefore, the median number of syphilis tests was the same in both study periods (median 2, range 0 to 6, p=0.817). The proportion of episodes of complete tesing, also increased from 32.3% to 56.2% (p<0.001).

Conclusion

The introduction of a SHPN into general practice significantly increased HIV and STI testing among MSM. The magnitude of the effect of this intervention may be greater in MSM high case load general practices where the culture of STI testing is less well established.
O5-S4.06 Improving HIV screening at an urban STD clinic
Authors: Furness B W , Coursey J , Flemming T , Hess P , Sankar S , Elias N Kamanu
Published: July 2011

Background

At the end of 2006 (the most recent year that data are available), an estimated 1 106 400 persons in the USA were living with HIV infection, with 21% undiagnosed. In September 2006, the Centers for Disease Control & Prevention (CDC) released new guidelines recommending routine HIV screening of adults, adolescents, and pregnant women in health care settings and reducing barriers to HIV testing. According to the 2009 city report, 3% of Washington, D.C., residents were infected with HIV or AIDS - a figure that ranked as the highest in the nation and far exceeded the 1% benchmark at which a disease becomes a “generalised and severe” epidemic.

Methods

In July 2009, the SE STD Clinic, the only publicly funded STD clinic in Washington, DC, began providing opt-out HIV testing. All clients who were not previously known to be HIV infected and had not been tested in the previous 30 days were screened using the OraQuick ADVANCE Rapid HIV-1/2 Antibody Test. Disease Intervention Specialists (DIS) ceased pre-test counselling and written consent for HIV testing was incorporated into the general consent form.

Results

From July 2008 through June 2009, 9537 unique clients visited the SE STD Clinic, of which 5972 (62.6%) were screened for HIV, 2558 (26.8%) were deemed ineligible, and 1007 (10.6%) refused. Of those tested, 48 (0.8%) were positive—35 (72.9%) were new infections, 11 (22.9%) were previous positives, and 2 (4.2%) were false positives. From July 2009 through June 2010, 12 154 unique clients visited the SE STD Clinic, of which 9702 (79.8%) were screened for HIV, 2039 (16.8%) were deemed ineligible, and 413 (3.4%) refused. Of those ineligible, 1832 (89.8%) had been tested in the previous 30 days, 197 (9.7%) were previous positives, and 10 (0.5%) were listed as Other.” Of those tested, 89 (0.9%) were positive—59 (66.3%) were new infections, 25 (28.1%) were previous positives, 2 (2.2%) were false positives, and 3 (3.4%) were “Out of Jurisdiction.”

Conclusion

“Routinisation” of HIV screening among this high-risk population increased the percentage of clients tested, decreased the percentage of clients that were ineligible or refused screening and increased the number of new infections identified (0.37% vs 0.49%, respectively). From July 2009 through June 2010, 3730 more HIV tests were conducted (compared to July 2008 through June 2009) identifying 14 additional new HIV infections.”
O1-S03.06 Evidence of circulating macrolide resistance inMycoplasma genitaliuminfections and development of a rapid assay to detect resistance
Authors: Twin J , Bradshaw C , Garland S , Fairley C , Jensen J , Tabrizi S
Published: July 2011

Background

Mycoplasma genitalium(Mg) is a sexually transmitted bacterium causing urethritis, cervicitis and longer term sequelae such as pelvic inflammatory disease. At Melbourne Sexual Health Centre (MSHC), Australia, from December 2007 to December 2009, 111M genitaliuminfected patients (86 males/25 females) were treated with 1 g azithromycin with a cure rate of 69% (95% CI 60% to 77%). Resistance to macrolide antibiotics such as azithromycin occurs via mutations of the Mg 23S rRNA gene in response to exposure of sub-therapeutic doses of the drug. It is our hypothesis that the unacceptably high rate of treatment failures seen at this clinic is due to macrolide resistant Mg strains circulating in the community. To test this theory, we determined whether resistance was present in initial consult samples collected at MSHC, and we developed a rapid assay able to detect resistance during routine diagnostics.

Methods

A subset of 83 Mg positive samples from patients taken prior to azithromycin was analysed in this study (62 males/20 females); 56 of these patients were subsequently cured by azithromycin and 27 cases failed azithromycin. DNA sequencing was then carried out to determine each respective 23S rRNA sequence type. A real-time PCR assay coupled with high resolution melt analysis was developed to detect the mutational changes in the Mg 23S rRNA gene, dubbed MARS (Macrolide Antibiotic Resistance Screen), and was tested against a panel of known macrolide resistant Mg isolates and the subset of samples from MSHC.

Results

In total, 16/83 (19%) of the pre-treatment samples tested possessed 23S rRNA mutations conveying macrolide resistance; significantly more patients who failed 1 g azithromycin had pre-existing macrolide mutations (12/27; 44%) compared to those who were cured by 1 g azithromycin (4/56; 7%); p<0.0001 (Abstract O1-S03.06 table 1). The MARS assay that was developed was able to identify when a 23S rRNA mutation was present in 100% of these samples.

Abstract O1-S03.06 Table 1

23S rRNA gene mutations present in a subset of 2007–2009 Mg positive samples from initial consult from MSHC

Sequence typePatients failing azithromycin, n=26 (%)Patients cured by azithromycin, n=56 (%)p ValueDetection with MARSDetection of any 23S rRNA gene mutation12 (44)4 (7)<0.0001100%A2059G730.01A2058G410.04A2059C1––Wild type1452<0.0001100%

Conclusions

This data shows compelling evidence that macrolide resistance is circulating in certain populations and is attributing to a significant level of treatment failures seen in an Australian sexual health clinic. The development of a rapid molecular assay to detect resistance provides the means for clinicians to choose a more appropriate second line treatment option such as moxifloxacin, and thereby reduce transmission of resistant strains and avoiding sequelae associated with persistent infection.
O1-S04.01 Increasing adolescent HIV prevalence in Northeastern Zimbabwe: evidence of long-term survivors of mother to child transmission
Authors: Eaton J , Takavarasha F , Gregson S , Hallett T , Mason P , Robertson L , Schumacher C , Nyamukapa C , Garnett G
Published: July 2011

Background

Longitudinal data from eastern Zimbabwe suggested an increase in HIV prevalence among 15 to 17 year olds between 2005 and 2008. Prevalence increased from 1.2% to 2.6% among adolescent males and from 2.2% to 2.8% in females (see Abstract O1-S04.01 figure 1). This is surprising given a general trend of decreasing HIV prevalence in the past decade associated with a reduction in sexual risk behaviour. It is unknown whether the increase is the result of resurgence in risky sexual behaviour, or long-term survival of infants infected perinatally during the early 1990s when prevalence was increasing exponentially among pregnant women in Zimbabwe

Abstract O1-S04.01 Figure 1

Methods

We use data from the Manicaland HIV/STD Prevention Project collected between 2006 and 2008 to test hypotheses indicating whether adolescent HIV infections are likely sexually acquired or perinatally acquired. We use Fisher's exact test and relative risk regression to examine the association between adolescent HIV infection and (i) maternal mortality, (ii) adolescent sexual behaviour, and (iii) chronic illness.

Results

There were 990 males and 972 females aged 15 to 17 years included in the cohort. Mothers of HIV positive adolescent males were more likely to be deceased than those of HIV negative males (RR 2.72, p <0.001). Mothers of HIV positive females were not more likely to be deceased, but were more likely to be HIV positive if still alive (RR 3.68, p <0.001). Among males there was no association between having had sex and HIV status. Sexually active females were more likely to be HIV positive (RR 2.44, p =0.042). During the period that adolescent prevalence increased, the proportion of adolescent males who reported having had sex reduced from 14% to 8% (p <0.001), and did not change in females. HIV positive adolescents were more likely to report recurring sickness or chronic illness, indicative of late-stage HIV infection.

Conclusions

Increasing HIV prevalence in adolescent males cannot be explained by a rebound in sexual risk behaviour and is likely attributable to long-term survivors of perinatal HIV transmission. Among females, both perinatal and sexual transmission account for adolescent HIV infections. These findings question the interpretation of HIV prevalence in young people as an indicator of recent trends in HIV incidence. They suggest an urgent need to prevent onward HIV transmissions by perinatally infected adolescents and the expansion of HIV testing and treatment to include young people.
O1-S01.02 The incidence of genitalChlamydia trachomatisin a cohort of young Australian women
Authors: Walker J , Fairley C , Bradshaw C , Tabrizi S , Chen M , Twin J , Taylor N , Donovan B , Kaldor J , Hocking J
Published: July 2011

Background

Chlamydia is a sexually transmitted infection that can cause serious upper genital tract infections, however, in Australia there are limited population data for chlamydia. Understanding the incidence of chlamydia will be important in the design of a chlamydia screening program in Australia.

Method

Women aged 16–25 years were recruited from sexual health clinics (SHC) and general practice clinics (GP) in South-Eastern Australia and consented to participate in longitudinal study over a 12-month period. Participants were requested to send back questionnaires and self-collected vaginal swabs through the post which were tested for chlamydia.

Results

Overall, 1116 women were recruited from 29 clinics; with a 79% retention rate.C trachomatisprevalence at baseline was 4.9% (95% CI: 2.9% to 7.0%) and incidence rate for the 12-month study period was 4.4 per 100 women-years (95% CI: 3.3% to 5.9%). PrevalentC trachomatiswas associated with having hadC trachomatispreviously [AOR: 2.0 (95% CI: 1.1% to 3.9%)], increased numbers of sexual partners [AOR: 6.4 (95% CI: 3.6% to 11.3%)] and unprotected sex [AOR: 3.1 (95% CI: 1.0% to 9.5%)]. Antibiotic use and older age were protective against having a prevalent infection ([AOR: 0.4 (95% CI: 0.2% to 1.0%)] and [AOR: 0.9 (95% CI: 0.8% to 1.0%)] respectively) and an incident infection ([AHR: 0.1 (95% CI: 0.0% to 0.6%)] and [AHR: 0.4 (95% CI: 0.2% to 0.8%)] respectively). IncidentC trachomatiswas also associated with more partners [AHR: 4.0 (95% CI: 1.9% to 8.6%)]. More than 20% of women withC trachomatishad a re-infection during the study [20.3% (95% CI: 11.6% to 31.7%)] with an infection rate of 20.0 (95% CI: 11.9% to 33.8%) per 100 women years. The median chlamydia organism load was 1.4×105/5цl and the most common serovar identified was serovar E (51.9%).

Conclusion

Chlamydia is a common STI in young Australian women, and an incidence of 4.9 per 100 women years for chlamydia suggests annual testing is appropriate for a chlamydia screening program. The high re-infection rate indicates the importance of partner notification and re-testing 3 months after treatment.
O1-S04.04 Predictors of repeatChlamydia trachomatisand/orNeisseria gonorrhoeaeinfections among African-American adolescent females
Authors: Swartzendruber A , DiClemente R , Sales J , Brown J L , Rose E
Published: July 2011

Background

Young African-American females have the highest rates of Chlamydia (CT) and gonorrhoea (GC) in the US. Few studies have explored predictors of repeat STDs among this population. The objective was to identify predictors of repeat CT and/or GC infections among African-American adolescent females positive for at least one of these STDs at baseline.

Methods

Sociodemographic, psychosocial and sexual behaviour data were collected via ACASI at baseline and every 6 months for 2 years from 701 African-American females (15–19 years) enrolled in an HIV prevention trial. Vaginal swabs were self-collected at each visit and assayed for CT and GC using DNA amplification. Participants with a positive test result received directly observable single-dose antimicrobial treatment and risk-reduction counselling. Repeat infection was defined as a positive test result following a negative result or documented treatment. Among those who tested positive for CT and/or GC at baseline, bivariate and multivariable analyses compared study variables for those who did vs did not have a repeat infection during the 2-year follow-up.

Results

Of 615 (88%) participants with ≥1 follow-up test result, 122 (20%) had a positive CT and/or GC test result at baseline; 49 (40% of baseline positives and 8% of total) had a repeat infection during the study period. Of those with a repeat infection, 30 (61%) were positive at only one follow-up visit, 18 (37%) at two and 1 (2%) at three follow-up visits. In bivariate analyses, relative to those positive at baseline only, participants with repeat infection were less likely to have a boyfriend (71 vs 83%, p=0.043) and see themselves marrying their current boyfriend (57.1 vs 76.2%, p=0.05) and more likely to have had sex with a man who had sex with other men (8.2 vs 0%, p=0.013). Participants with repeat infection had higher mean impulsivity scores (p=0.027). Controlling for age and treatment assignment, greater impulsivity (AOR: 1.1, p=0.018) was associated with increased likelihood of a repeat infection and having a boyfriend (AOR: 0.21, p=0.006) with decreased likelihood of a repeat infection.

Conclusions

Repeat CT and/or GC infections are common among African-American adolescent females. Among young African-American females who test positive for CT and/or GC, tailored interventions for more impulsive adolescents and those without a boyfriend may help prevent repeat infections.
O1-S05.03 Behavioural factors associated withBacterial vaginosis(BV) in women who have sex with women (WSW): the Women On Women's (WOW) Health Study
Authors: Bradshaw C , Bilardi J , Walker S , Vodstrcil L , Garland S , Hocking J , Chen M , Peterson S , Fehler G , Fairley C
Published: July 2011

Background

We are conducting a national 2 year cohort study in 400 Australian WSW to determine the behavioural and microbiological factors associated with prevalent and incident BV in women and their sexual partners. Data from the cross-sectional study will be presented.

Methods

WSW were recruited using internet, festival and media-based promotion and were ineligible if they are postmenopausal, pregnant or had not had a female sex partner (FSP) in the last 18 months. Study-kits containing consent forms, questionnaires, swabs and slides were sent to participants and returned by post. At baseline, women self-collected three consecutive vaginal swabs and slides at weekly intervals and completed detailed demographic behavioural data via an online or paper-based questionnaire. Gram-stained self-collected vaginal smears (SCVS) were scored by the Nugent method. Women were classified as having prevalent BV if ≥1 slides had a Nugent score (NS) of 7–10, intermediate flora if ≥1 slides had a NS=4–6 and normal flora if all three slides had a NS=0–3. Univariate and multivariate analyses were performed using SPSS to examine the association between BV and behavioural practices.

Results

In February 2011, 342 (86%) women had been recruited and 314 (92%) women had completed all cross-sectional requirements. Median age was 31 years (range 19–49), 309 (98%) reported a FSP in the last year, 253 (81%) had a current sexual partner (95% female) and 246 (78%) reported vaginal sex with a male in the past. The prevalence of BV was 29% (95% CI 20% to 38%) in women providing ≥1 SCVS. Two hundred and seventy-five (88%) women provided all three SCVS of which 178 (65%) had stable normal flora on all slides, 56 (20%) stable BV and 41 (15%) had unstable flora transitioning between ≥1 Nugent categories over the three slides. Multivariate analysis found that being a current smoker of cigarettes or marijuana (Adjusted OR AOR =2.2; 95% CI: 1.3% to 3.8%) and having >5 lifetime FSPs (AOR =1.8; 1.0 to 3.01) was significantly associated with prevalent BV. A borderline association with FSP receptive oral sex (AOR=3.2; 0.9 to 11.0) was evident. BV was not associated with increased age or numbers of male partners.

Conclusion

Prevalent BV is common (30%) in WSW and is strongly associated with smoking and increasing numbers of FSPs but not male partners. A high proportion of WSW had stable vaginal flora (85%) over a 3 week period. This study aims to advance our understanding of epidemiology of BV in WSW.
O1-S06.02 Impact of pill sharing on drug-resistance and population-level effectiveness of a wide-scale oral PrEP intervention in resource-constrained settings
Authors: Dimitrov D , Boily M C , Mâsse B
Published: July 2011

Background

In 2010 two randomised trials suggested that pre-exposure prophylaxis (PrEP) products based on tenofovir, an antiretroviral drug either administered daily orally (oral PrEP) or applied topically (vaginal microbicides), significantly reduced HIV acquisition among adherent users. Behavioural studies also suggest that some PrEP users are compelled to share product with sex partners, family, or friends. Pill sharing (PS) decreases the adherence levels of the intended PrEP users and creates an uncontrolled environment for the development of drug-resistance. However PS effects on the expected population-level impact of PrEP interventions have never been assessed. Thus, we aim to evaluate the potential impact of PS on the PrEP effectiveness to prevent HIV transmission and the spread of drug-resistance in heterosexual populations in resource-constrained settings.

Methods

A transmission dynamic model was used to assess the population-level impact of oral PrEP in a variety of intervention scenarios and high HIV prevalence settings. The cumulative fractions of new HIV infections prevented (CPF) and transmitted drug-resistance (TDR) are evaluated over fixed time periods under various epidemiological conditions. The influence of different factors (eg, acquisition rate, PrEP coverage, rates of resistance development) on CPF and TDR is studied through simulations, using parameter sets sampled from ranges representative of countries in Sub-Saharan Africa.

Results

Without PS, a 70% effective oral PrEP intervention used by 60% of the population prevents about 52% (95% CI 49.6% to 53.8%) of all new HIV infections over 10 years (10 years CPF) if adherence is 100%. CPF increases by 7% in populations with 10% PS, assuming no efficacy reduction for those who share PrEP and reduces by 2% if the efficacy reduction for sharers (prescribers or untracked users) is 50%. However, the fraction of transmitted drug-resistance (TDR) increases 2- to 6-fold in all scenarios investigated. It depends on the success in preventing PrEP usage by HIV infected individuals.

Conclusions

PS may increase the PrEP coverage level achieved in the population but it also affects the PrEP efficacy for the users who do not follow the prescribed dosing. It creates a pool of untracked users who do not receive counselling, remain hidden and unreached by the effort to avoid the PrEP usage by HIV infected individuals. This increases substantially the potential risk of drug-resistance development.