Background Patients in sexually transmitted disease (STD) clinic waiting rooms represent a potential audience for delivering health messages via video-based interventions. A controlled trial at 3 sites found that patients exposed to one intervention, Safe in the City, had a significantly lower incidence of STDs compared with patients in the control condition. An evaluation of the intervention's cost could help determine whether such interventions are programmatically viable.Materials and Methods The cost of producing the Safe in the City intervention was estimated using study records, including logs, calendars, and contract invoices. Production costs were divided by the 1650 digital video kits initially fabricated to get an estimated cost per digital video. Clinic costs for showing the video in waiting rooms included staff time costs for equipment operation and hardware depreciation and were estimated for the 21-month study observation period retrospectively.Results The intervention cost an estimated $416,966 to develop, equaling $253 per digital video disk produced. Per-site costs to show the video intervention were estimated to be $2699 during the randomized trial.Conclusions The cost of producing and implementing Safe in the City intervention suggests that similar interventions could potentially be produced and made available to end users at a price that would both cover production costs and be low enough that the end users could afford them.

Observational studies have found mixed results on the impact of jail-based chlamydia screen-and-treat programs on community prevalence. In the absence of controlled trials or prospectively designed studies, dynamic mathematical models that incorporate movements in and out of jail and sexual contacts (including disease transmission) can provide useful information. We explored the impact of jail-based chlamydia screening on a hypothetical community's prevalence with a deterministic compartmental model focusing on heterosexual transmission. Parameter values were obtained from the published literature. Two analyses were conducted. One used national values (large community); the other used values reported among African Americans--the population with the highest incarceration rates and chlamydia burden (small community). A comprehensive sensitivity analysis was carried out. For the large-community analysis, chlamydia prevalence decreased by 13% (from 2.3% to 2.0%), and based on the ranges of parameter values (including screening coverage of 10%-100% and a postscreening treatment rate of 50%-100%) used in the sensitivity analysis, this decrease ranged from 0.1% to 58%. For the small-community analysis, chlamydia prevalence decreased by 54% (from 4.6% to 2.1%). Jail-based chlamydia screen-and-treat programs have the potential to reduce chlamydia prevalence in communities with high incarceration rates. However, the magnitude of this potential decrease is subject to considerable uncertainty.

BACKGROUND:Millions of cases of sexually transmitted infections (STIs) occur in the United States each year, resulting in substantial medical costs to the nation. Previous estimates of the total direct cost of STIs are quite dated. We present updated direct medical cost estimates of STIs in the United States.METHODS:We assembled recent (i.e., 2002-2011) cost estimates to determine the lifetime cost per case of 8 major STIs (chlamydia, gonorrhea, hepatitis B virus, human immunodeficiency virus (HIV), human papillomavirus, genital herpes simplex virus type 2, trichomoniasis and syphilis). The total direct cost for each STI was computed as the product of the number of new or newly diagnosed cases in 2008 and the estimated discounted lifetime cost per case. All costs were adjusted to 2010 US dollars.RESULTS:Results indicated that the total lifetime direct medical cost of the 19.7 million cases of STIs that occurred among persons of all ages in 2008 in the United States was $15.6 (range, $11.0-$20.6) billion. Total costs were as follows: chlamydia ($516.7 [$258.3-$775.0] million), gonorrhea ($162.1 [$81.1-$243.2] million), hepatitis B virus ($50.7 [$41.3-$55.6] million), HIV ($12.6 [$9.5-$15.7] billion), human papillomavirus ($1.7 [$0.8-$2.9] billion), herpes simplex virus type 2 ($540.7 [$270.3-$811.0] million), syphilis ($39.3 [$19.6-$58.9] million), and trichomoniasis ($24.0 [$12.0-$36.0] million). Costs associated with HIV infection accounted for more than 81% of the total cost. Among the nonviral STIs, chlamydia was the most costly infection.CONCLUSIONS:Sexually transmitted infections continue to impose a substantial cost burden on the payers of medical care in the United States. The burden of STIs would be even greater in the absence of STI prevention and control efforts.

Objectives The objective of this study was to determine the optimal time interval for a repeated Chlamydia trachomatis (chlamydia) test.Methods The authors used claims data for US women aged 15-25 years who were enrolled in commercial health insurance plans in the MarketScan database between 2002 and 2006. The authors determined the numbers of initial positive and negative tests that were followed by a repeated test and the positivity of repeated tests. The authors used a dynamic transmission pair model that reflects the partnership formation and separation processes in 15-25 year olds to determine the time course of repeated infections in women under different levels of notifying the current partner. The authors then explored the additional impact of repeated testing uptake on reducing chlamydia prevalence.Results 40% (4949/12 413) of positive tests were followed by a repeated test compared with 22% (89 119/402 659) of negative tests at any time. Positivity of repeated tests followed by an initial positive test was high: 15% (736) after a positive test versus 3% (2886) after a negative test. The transmission model showed a peak in repeated infections between 2 and 5 months after treatment. For a chlamydia testing uptake of 10% per year, the additional impact of repeated testing on reducing chlamydia population prevalence was modest.Conclusions The mathematical model predictions support the recommended interval for repeat chlamydia testing. This study provides information that can be used to design randomised controlled trials to determine more effective interventions to prevent chlamydial reinfection.

Objectives. We examined the association between racial disparity in income and reported race-specific county-level bacterial sexually transmitted infections (STIs) in the United States focusing on disparities between Blacks and Whites.Methods. Data are from the US 2000 decennial census. We defined 2 race-income county groups (high and low race-income disparity) on the basis of the difference between Black and White median household incomes. We used 2 approaches to examine disparities in STI rates across the groups. In the first approach, we computed and compared race-specific STI rates for the groups. In the second approach, we used spatial regression analyses to control for potential confounders.Results. Consistent with the STI literature, chlamydia, gonorrhea, and syphilis rates for Blacks were substantially higher than were those for Whites. We also found that racial disparities in income were associated with racial disparities in chlamydia and gonorrhea rates and, to a lesser degree, syphilis rates.Conclusions. Racial disparities in household income may be a more important determinant of racial disparities in reported STI morbidity than are absolute levels of household income.

To assess chlamydia testing in women in community health centers, we analyzed data from national surveys of ambulatory health care. Women with chlamydial symptoms were tested at 16% of visits, and 65% of symptomatic women were tested if another reproductive health care service (pelvic examination, Papanicolaou test, or urinalysis) was performed. Community health centers serve populations with high sexually transmitted disease rates and fill gaps in the provision of sexual and reproductive health care services as health departments face budget cuts that threaten support of sexually transmitted disease clinics.

Background: Annual chlamydia screening for sexually active women aged <= 25 years is recommended, and chlamydia testing rates have continuously increased. However, several studies have shown that many providers screen all women of reproductive age in public settings.Purpose: To examine chlamydia testing patterns in private settings for women and young women aged 15-44 years (hereafter referred to as women).Methods: A large commercial claims database was used to estimate the chlamydia testing rate for women aged 15-44 years who had reproductive health services in 2008. Such services and tests were identified using diagnostic and procedural codes in 2008.Results: Of 3.2 million women aged 15-44 years who had reproductive health services in 2008, 19.2% had at least a claim for a sexually transmitted disease (STD), 29.3% for pregnancy, and 81.2% for a gynecologic exam. Of those 3.2 million, 22.3% had chlamydia testing: 34.2% aged 15-25 years vs 18.3% aged 26-44 years. Of the 0.7 million who were tested, 65% were aged 26-44 years, and the reason for the healthcare visit in which their first chlamydia test was performed was an STD for 22.7% and pregnancy for 33.5%.Conclusions: In this population of insured women, young women are undertested and older women are overtested for chlamydia. Efforts to improve screening practices should be evaluated. (Am J Prev Med 2012;42(4):337-341) Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine

Using the 2006-2008 National Survey of Family Growth, we estimated a 37.9% annual chlamydia testing rate for sexually active US women aged 15 to 25 years, defined as having ≥ 1 sex partner in the past year. Our results highlight the need for increased testing among sexually active young women.

Background: HIV-infected men who have sex with men (MSM) are at increased risk of viral hepatitis because of similar behavioral risk factors for acquisition of these infections. Our objective was to estimate adherence to HIV management guidelines that recommend screening HIV-infected persons for hepatitis A, B, and C infection, and vaccinating for hepatitis A and B if susceptible.Methods: We evaluated hepatitis prevention services received by a random sample of HIV-infected MSM in 8 HIV clinics in 6 US cities. We abstracted medical records of all visits made by the patients to the clinic during the period from 2004 to 2007, to estimate hepatitis screening and vaccination rates overall and by clinic site.Results: Medical records of 1329 patients who had 14,831 visits from 2004 to 2006 were abstracted. Screening rates for hepatitis A, B, and C were 47%, 52%, and 54%, respectively. Among patients who were screened and found to be susceptible, 29% were vaccinated for hepatitis A and 25% for hepatitis B. The percentage of patients screened and vaccinated varied significantly by clinic.Conclusions: Awareness of hepatitis susceptibility and hepatitis coinfection status in HIV-infected patients is essential for optimal clinical management. Despite recommendations for hepatitis screening and vaccination of HIV-infected MSM, rates were suboptimal at all clinic sites. These low rates highlight the importance of routine review of adherence to recommended clinical services. Such reviews can prompt the development and implementation of simple and sustainable interventions to improve the quality of care.

Background: The purpose of this study was to examine rates of 3 bacterial sexually transmitted diseases (STDs; syphilis, gonorrhea, and chlamydia) in 8 subpopulations (known as the “eight Americas”) defined by race and a small number of county-level sociodemographic and geographical characteristics. The eight Americas are (1) Asians and Pacific Islanders in specific counties; (2) Northland low-income rural white; (3) Middle America; (4) Low-income whites in Appalachia and Mississippi Valley; (5) Western Native American; (6) Black middle America; (7) Southern low-income rural black; and (8) High-risk urban black. Methods: A list of the counties comprising each of the eight Americas was obtained from the corresponding author of the original eight Americas project, which examined disparities in mortality rates across the eight Americas. Using county-level STD surveillance data, we calculated syphilis, gonorrhea, and chlamydia rates (new cases per 100,000) for each of the eight Americas. Results: Reported STD rates varied substantially across the eight Americas. STD rates were generally lowest in Americas 1 and 2 and highest in Americas 6, 7, and 8. Conclusions: Although disparities in STDs across the eight Americas are generally similar to the well-established disparities in STDs across race/ethnicity, the grouping of counties into the eight Americas does offer additional insight into disparities in STDs in the United States. The high STD rates we found for black Middle America are consistent with the assertion that sexual networks and social factors are important drivers of racial disparities in STDs.

Background The purpose of this study was to examine rates of three STDs (primary and secondary syphilis, gonorrhoea, and chlamydia) in eight subpopulations (known as the eight Americas) defined by a small number of sociodemographic and geographical characteristics. Methods A list of the race-county combinations comprising each of the eight Americas was obtained from the corresponding author of the original eight Americas project, which examined disparities in mortality rates across the eight Americas. Using county-level STD surveillance data, we calculated syphilis, gonorrhoea, and chlamydia rates (new cases per 100 000) for each of the eight Americas. Results STD rates varied substantially across the eight Americas. STD rates were generally lowest in America 1 (Asian and Pacific Islanders in selected counties) and America 2 (Northland low-income rural white) and highest in America 6 (Black Middle America), America 7 (Southern low-income rural black), and America 8 (High-risk urban black) see Abstract P1-S5.44 Table 1. Abstract P1-S5.44 Table 1 STD rates (new cases per 100 000) in the Eight Americas, 2008 America Primary and secondary syphilis Gonorrhoea Chlamydia 1. Asian 1.4 14.5 100.6 2. Northland low-income rural white 0.3 9.2 125.5 3. Middle America 2.7 30.0 172.4 4. Low-income whites in Appalachia and the Mississippi Valley 1.1 23.8 139.4 5. Western Native American 2.9 80.9 820.7 6. Black Middle America 14.5 475.3 1,063.6 7. Southern low-income rural black 15.3 482.2 1,109.4 8. High-risk urban black 25.3 507.2 1,155.9 Conclusions The disparities in STD rates we observed across the eight Americas were akin to the disparities in mortality rates and life expectancy reported by the authors of the original eight Americas study. Although disparities in STDs across the eight Americas are generally similar to the well-established disparities in STDs across race/ethnicity, the grouping of US race-counties into the eight Americas does offer additional insight into disparities in STDs in the USA. The high STD rates we found for Black Middle America relative to Middle America are consistent with the assertion that sexual networks and social factors are more important drivers of racial disparities in STDs than differences in sexual behaviours.

We conducted a literature review of studies of the economic burden of sexually transmitted diseases in the United States. The annual direct medical cost of sexually transmitted diseases (including human immunodeficiency virus) has been estimated to be $16.9 billion (range: $13.9-$23.0 billion) in 2010 US dollars.

Background Perinatal transmission of sexually transmitted infections is a preventable source of morbidity. In the USA, the incidence of congenital syphilis has increased by 23% since 2005 and, in 2008, 141 infants were infected with HIV, despite the fact that the CDC recommends routine prenatal syphilis and HIV screening. To encourage compliance with guidelines, many payers rely on claims data to track utilisation. In this study, the percentage of women screened for syphilis or HIV during their pregnancy was estimated using MarketScan claims data, as a measure of compliance and of the feasibility of using these data for assessment of prenatal screening. Methods We analysed data from the MarketScan database, that allows linkage of de-identified patient and utilisation data from varying sites of care. The analysis was restricted to women who delivered a live birth in 2008, and who were continuously enrolled in one health plan for at least 293 days prior to delivery. The eligible population was identified using the coding algorithm for a live birth defined by HEDIS. Results Among the 220 571 women with a live birth in 2008, 87.0% received a syphilis test during their pregnancy, 74.1% received an HIV test and 73.3% received both. The test rate for syphilis was highest for those 31–35 yrs (88.2%) and lowest for those 15–20 yrs (78.3%). The test rate for HIV was highest among those 21–25 yrs (75.2%) and lowest among those 15–20 yrs (70%). Both prenatal syphilis and HIV test rates were highest among those insured by a preferred provider plan. Regionally, testing rates were highest in the South (89.8% for syphilis and 82.1% for HIV) and lowest in the Northeast for syphilis (82.8%) and in the West for HIV (62.9%). Conclusions The results suggest fairly good compliance with guidelines for prenatal HIV and syphilis screening, although utilisation still varies by age, insurance type and geographic region. The MarketScan database represents individuals covered by employment-based health plans, which is how most Americans are insured. These data provide a unique opportunity to assess utilisation among the insured, at a time when the USA is poised to move a larger proportion of the population into this group. Tracking of year-to-year changes could help public health and healthcare organizations partner to improve care and target interventions to ensure equal access to these critical services.

We conducted a literature review of studies of the economic burden of sexually transmitted diseases in the United States. The annual direct medical cost of sexually transmitted diseases (including human immunodeficiency virus) has been estimated to be $16.9 billion (range: $13.9-$23.0 billion) in 2010 US dollars.

BACKGROUND:Routine chlamydia screening is a recommended preventive intervention for sexually active women aged </=25 years in the U.S. but rates of regular uptake are not known. PURPOSE:This study aimed to examine rates of annual chlamydia testing and factors associated with repeat testing in a population of U.S. women. METHODS:Women aged 15-25 years at any time from January 1, 2002, to December 31, 2006 who were enrolled in 130 commercial health plans were included. Data relating to chlamydia tests were analyzed in 2009. Chlamydia testing rates (per 100 woman-years) by age and rates of repeated annual testing were estimated. Poisson regression was used to examine the effects of age and previous testing on further chlamydia testing within the observation period. RESULTS:In total, 2,632,365 women were included. The chlamydia testing rate over the whole study period was 13.6 per 100 woman years after adjusting for age-specific sexual activity; 8.5 (95% CI=6.0, 12.3) per 100 woman-years in those aged 15 years; and 17.7 (95% CI=17.1, 18.9) in those aged 25 years. Among women enrolled for the entire 5-year study period, 25.9% had at least one test but only 0.1% had a chlamydia test every year. Women tested more than once and older women were more likely to be tested again in the observation period. CONCLUSIONS:The low rates of regular annual chlamydia testing do not comply with national recommendations and would not be expected to have a major impact on the control of chlamydia infection at the population level.

OBJECTIVE: To estimate trends in the rates of diagnosis and treatment of ectopic pregnancy in the United States.METHODS: We analyzed data from a large administrative claims database of more than 200 U. S. commercial health plans, and estimated time trends in the rate and incidence of ectopic pregnancy among girls and women aged 15-44 years by 5-year age groups and by region from 2002 to 2007. We also estimated time trends in the proportion of cases that were treated surgically, either by laparoscopy or laparotomy, or medically with methotrexate.RESULTS: We identified 11,989 ectopic pregnancies during the period from 2002 to 2007. The overall rate of ectopic pregnancy among pregnant girls and women aged 15-44 years during the 6-year study period was 0.64%. We did not observe a trend in the rate of ectopic pregnancy by 5-year age group or by geographic region. The ectopic pregnancy rate increased with age; it was 0.3% among girls and women aged 15-19 years and 1.0% among women aged 35-44 years. Methotrexate treatment increased from 11.1% in 2002 to 35.1% in 2007 (P<.001); the methotrexate failure rate was 14.7% over the 6-year study period. Surgical management with laparotomy decreased over the study period from 40.0% to 33.1% (P<.001).CONCLUSION: We did not find an increasing or decreasing trend in the rate of ectopic pregnancy among U. S. commercially insured women from 2002 to 2007. The use of administrative claims data are likely the most feasible method for estimating the rate and monitoring trends of ectopic pregnancy in the United States. (Obstet Gynecol 2010;115:495-502)

Background: National guidelines for the care of human immunodeficiency virus (HIV)-infected persons recommend asymptomatic routine screening for sexually transmitted diseases (STDs). Our objective was to determine whether providers who care for HIV-infected men who have sex with men (MSM) followed these guidelines.Methods: We abstracted medical records to evaluate STD screening at 8 large HIV clinics in 6 US cities. We estimated the number of men who had at least one test for syphilis, chlamydia (urethral and/or rectal), or gonorrhea (urethral, rectal, and/or pharyngeal) in 2004, 2005, and 2006. Urethral testing included nucleic acid amplification tests of both urethral swabs and urine. We also calculated the positivity of syphilis, chlamydia, and gonorrhea among screened men.Results: Medical records were abstracted for 1334 HIV-infected MSM who made 14,659 visits from 2004-2006. The annual screening rate for syphilis ranged from 66.0% to 75.8% during 2004-2006. Rectal chlamydia and rectal and pharyngeal gonorrhea annual screening rates ranged from 2.3% to 8.5% despite moderate to high positivity among specimens from asymptomatic patients (3.0%-9.8%) during this period. Annual urethral chlamydia and gonorrhea screening rates were higher than rates for nonurethral sites, but were suboptimal, and ranged from 13.8% to 18.3%.Conclusions: Most asymptomatic HIV-infected MSM were screened for syphilis, indicating good provider adherence to this screening guideline. Low screening rates for gonorrhea and chlamydia, especially at rectal and pharyngeal sites, suggest that substantial barriers exist for complying with these guidelines. The moderate to high prevalence of asymptomatic chlamydial and gonococcal infections underscores the importance of screening. A range of clinical quality improvement interventions are needed to increase screening, including increasing the awareness of nucleic acid amplification tests for nonurethral screening.

Los Angeles County has experienced a rapid increase in early syphilis among men who have sex with men (MSM) in recent years, with the number of cases rising from 126 in 2000 to 809 in 2005. As part of the public health response to this outbreak, a sustained social marketing campaign was launched in 2002, with the objectives of increasing syphilis testing, knowledge, and awareness among MSM in Los Angeles. This campaign, as implemented, exemplified key principles of social marketing, including market research, audience segmentation, and branding. A cross-sectional study conducted in 2004 to evaluate the campaign found that those MSM who were aware of the campaign were nearly twice as likely to have tested for syphilis in the past 6 months as those MSM who were not aware of the campaign. Those MSM who were aware of the campaign also had more syphilis awareness and knowledge in key areas.

To determine the effects of school closure, we surveyed 214 households after a 1-week elementary school closure because of pandemic (H1N1) 2009. Students spent 77% of the closure days at home, 69% of students visited at least 1 other location, and 79% of households reported that adults missed no days of work to watch children.

OBJECTIVE: To analyze whether rectal testing among women increased chlamydia and gonorrhea case-finding and whether reported receptive anal intercourse was a risk factor for rectal infection.METHODS: From March 2007 to August 2008, women receiving pelvic examinations at the San Francisco sexually transmitted disease clinic were tested for rectal gonorrhea and chlamydia by using a transcription-mediated amplification assay. Results of testing and clinical and demographic data were analyzed using a cross-sectional study design.RESULTS: Of 1,308 women with both rectal and vaginal tests, test results were positive for 79 patients (6.0%) for rectal chlamydia or gonorrhea and 88 patients (6.7%) for genital chlamydia or gonorrhea. Test results were positive for 13 patients (1.0%) at the rectum only, increasing detection from 88 to 101 patients (14.8%; 95% confidence interval 8.1-23.9). No correlation existed between reported anal sex and rectal chlamydia (P=.74); however, 50% of women with rectal gonorrhea reported anal sex compared with 21% of women without rectal gonorrhea (P=.002).CONCLUSION: Sexually transmitted disease clinics might improve chlamydia and gonorrhea case-finding through rectal testing of women, but more study is needed to determine the effects of finding and treating such infections. Reporting anal intercourse did not predict rectal chlamydial infection among women tested at both the rectum and the vagina. (Obstet Gynecol 2010;115:753-9)