Trends in Neisseria gonorrhoeae Incidence Among HIV-Negative and HIV-Positive Men in Washington State, 1996-2007.

Considerable evidence suggests that co-infection with human immunodeficiency virus (HIV) and bacterial sexually transmitted diseases (STDs) can act synergistically to facilitate HIV transmission.1 Clinical studies have demonstrated that infection with Neisseria gonorrhoeae (N. gonorrhoeae) can significantly amplify the concentration of HIV in seminal fluid2 and can promote HIV replication in human dendritic cells.3 Dendritic cells are likewise known to serve as a reservoir for delivery of virus to activated CD4+ T lymphocytes.4 These observations suggest that N. gonorrhoeae may play an epidemiologically meaningful role in HIV transmission at the population level. Moreover, incident N. gonorrhoeae co-infection in an individual with HIV disease provides an unambiguous biological marker for recent sexual risk behavior, which is of interest to HIV prevention efforts at both the individual and aggregate levels. The Centers for Disease Control and Prevention (CDC) identifies prevention for HIV-positive individuals as a key strategy for preventing new domestic HIV infections.5 Both HIV and gonorrhea are nationally notifiable diseases, and routine, nonidentified public health surveillance data are readily available. These data are used to describe overall trends in HIV infection and gonorrhea incidence. However, case report data are not integrated by individual patient in national registries, severely limiting the utility of these public health surveillance data for assessing trends in co-infection. Systemic, technological, and programmatic barriers exist to integrating case surveillance data at the state level, many of which have historical antecedents. These barriers constrain the integration of surveillance data in many jurisdictions. Additionally, structural differences in surveillance systems and coding schema present a challenge to integrating records at the patient level. Many health departments use a CDC-developed database called STD*MIS to manage STD surveillance information.6 HIV/acquired immunodeficiency virus (AIDS) surveillance data are managed using the CDC-mandated HIV/AIDS Reporting System (eHARS).7 Differences in file structures between these two systems necessitate external processing to match and merge records. Differences in how patient information is collected and coded also present challenges. For example, until relatively recently, the schema for coding race and ethnicity data differed significantly between STD and HIV surveillance systems, making these data difficult to use as criteria in matching records. Differences, both real and perceived, in data security and confidentiality standards between HIV and STD programs at the state level also present a barrier to assessing the extent of comorbidity based on merged surveillance records. This is the situation in Washington State as elsewhere in the U.S., where provisions in state administrative codes strictly govern the uses of HIV surveillance data while similar provisions do not exist for STD-related data. This article describes methods used in Washington State to integrate HIV/STD registries in light of these concerns and describes findings from our analysis of HIV/gonorrhea co-infection.