Admissions to jails and prisons in the United States number 10 million yearly; persons entering locked correctional facilities have high prevalence of sexually transmitted infections (STIs). These individuals come disproportionately from communities of color, with lower access to care and prevention, compared with the United States as a whole. Following PRISMA guidelines, the authors present results of a systematic review of literature published since 2012 on STIs in US jails, prisons, Immigration and Customs Enforcement detention centers, and juvenile facilities. This updates an earlier review of STIs in short-term facilities. This current review contributed to new recommendations in the Centers for Disease Control and Prevention 2021 treatment guidelines for STIs, advising screening for Trichomonas in women entering correctional facilities. The current review also synthesizes recommendations on screening: in particular, opt-out testing is superior to opt-in protocols. Carceral interventions—managing diagnosed cases and preventing new infections from occurring (eg, by initiating human immunodeficiency virus preexposure prophylaxis before release)—can counteract structural racism in healthcare.

Objectives California is experiencing a syphilis and congenital syphilis epidemic, and many persons diagnosed with syphilis report a history of recent incarceration or sexual contact with a person who has recently been incarcerated. Fresno County's local health department and jail collaborated to implement a routine syphilis screening policy for male adults aged 18-30 and female adults aged 18-35 booked into the facility. We evaluated syphilis screening, case finding, and treatment rates after implementation of the new policy. Methods We linked jail census and laboratory data to syphilis surveillance data to assess screening coverage, positivity, and treatment rates for age-eligible persons who were booked into Fresno County Jail from April 1, 2016, through December 31, 2017. Results Of 24 045 age-eligible persons who were booked into the jail during the study period, 5897 (24.5%) were female and 18 148 (75.5%) were male. Of 7144 (29.7%) persons who were screened for syphilis, 611 (8.6%) had a reactive rapid plasma reagin blood test result (16.4% [253 of 1546] of female adults; 6.4% [358 of 5598] of male adults) and 238 (3.3%) were newly diagnosed with syphilis, as confirmed by matching to the surveillance system (6.9% [106 of 1546] of female adults; 2.4% [132 of 5598] of male adults). Of persons identified with syphilis, 51.7% (n = 123 of 238) received adequate recommended treatment (59.4% [63 of 106] of female adults; 45.5% [60 of 132] of male adults). Conclusions The age-based syphilis screening policy adopted in this jail yielded high positivity, including newly identified syphilis infections among female adults of childbearing age. The targeted screening policy was formalized in the county-negotiated contract with the jail's private correctional health care company in 2018-a strategy that can be replicated.

Objectives California is experiencing a syphilis and congenital syphilis epidemic, and many persons diagnosed with syphilis report a history of recent incarceration or sexual contact with a person who has recently been incarcerated. Fresno County’s local health department and jail collaborated to implement a routine syphilis screening policy for male adults aged 18-30 and female adults aged 18-35 booked into the facility. We evaluated syphilis screening, case finding, and treatment rates after implementation of the new policy. Methods We linked jail census and laboratory data to syphilis surveillance data to assess screening coverage, positivity, and treatment rates for age-eligible persons who were booked into Fresno County Jail from April 1, 2016, through December 31, 2017. Results Of 24 045 age-eligible persons who were booked into the jail during the study period, 5897 (24.5%) were female and 18 148 (75.5%) were male. Of 7144 (29.7%) persons who were screened for syphilis, 611 (8.6%) had a reactive rapid plasma reagin blood test result (16.4% [253 of 1546] of female adults; 6.4% [358 of 5598] of male adults) and 238 (3.3%) were newly diagnosed with syphilis, as confirmed by matching to the surveillance system (6.9% [106 of 1546] of female adults; 2.4% [132 of 5598] of male adults). Of persons identified with syphilis, 51.7% (n = 123 of 238) received adequate recommended treatment (59.4% [63 of 106] of female adults; 45.5% [60 of 132] of male adults). Conclusions The age-based syphilis screening policy adopted in this jail yielded high positivity, including newly identified syphilis infections among female adults of childbearing age. The targeted screening policy was formalized in the county-negotiated contract with the jail’s private correctional health care company in 2018—a strategy that can be replicated.

Preventing coronavirus disease 2019 (COVID-19) in correctional and detention facilities* can be challenging because of population-dense housing, varied access to hygiene facilities and supplies, and limited space for isolation and quarantine (1). Incarcerated and detained populations have a high prevalence of chronic diseases, increasing their risk for severe COVID-19-associated illness and making early detection critical (2,3). Correctional and detention facilities are not closed systems; SARS-CoV-2, the virus that causes COVID-19, can be transmitted to and from the surrounding community through staff member and visitor movements as well as entry, transfer, and release of incarcerated and detained persons (1). To better understand SARS-CoV-2 prevalence in these settings, CDC requested data from 15 jurisdictions describing results of mass testing events among incarcerated and detained persons and cases identified through earlier symptom-based testing. Six jurisdictions reported SARS-CoV-2 prevalence of 0%-86.8% (median = 29.3%) from mass testing events in 16 adult facilities. Before mass testing, 15 of the 16 facilities had identified at least one COVID-19 case among incarcerated or detained persons using symptom-based testing, and mass testing increased the total number of known cases from 642 to 8,239. Case surveillance from symptom-based testing has likely underestimated SARS-CoV-2 prevalence in correctional and detention facilities. Broad-based testing can provide a more accurate assessment of prevalence and generate data to help control transmission (4).

Background Compared with receiving medication dispensed in a health center, patients receiving prescriptions must take additional steps for treatment. Few clinics have protocols for ensuring prescriptions are filled. This study evaluated prescription fill rates for chlamydia treatment based on claims data in California Title X clinics and examined fill rates by patient demographics and clinic type. Methods We collected treatment information during Title X site audits for a convenience sample of patients with a positive chlamydia test between January 2008 and March 2013. We categorized patients as receiving treatment on-site versus via prescription and matched prescriptions to pharmacy billing claims within 90 days of test date. We examined treatment rates by patient age, gender, and race/ethnicity, and by clinic type, and assessed the median time to treatment. Results Among 790 patients diagnosed with chlamydia across 79 clinics, 65% (n = 513) were treated on-site and 33% (n = 260) via prescription; 17 (2%) did not have treatment information. Sixty-seven percent of prescriptions had confirmed receipt of treatment. Prescription fill rates were lower for patients age 18 years and younger (47% vs. 71%, P < 0.01) and for patients attending federally qualified health centers compared with stand-alone family planning clinics (63% vs. 88%, P < 0.01). Median time to treatment was similar for patients treated on-site (5 days) or via prescription (4 days). Conclusions Delays in chlamydia treatment increase risk of complications and ongoing transmission. Providing medications on-site can improve treatment rates, especially among younger patients. These insights can inform clinic treatment protocols and efforts to improve quality of chlamydia care.

Background In California, congenital syphilis (CS) increased for the fifth consecutive year in 2017, and contributed one third of CS cases in the United States. In response, state and local STD programs implemented CS prevention strategies. A CS Prevention Cascade monitors impact, assesses prenatal care (PNC) gaps, and estimates CS cases averted. Methods This analysis used 2017 California Project Area surveillance data for women diagnosed with syphilis during pregnancy or at delivery. Cases were assessed for the following, each met≥30 days prior to delivery: documented PNC, syphilis screening, treatment initiation, and treatment adequacy by stage. Data for each cascade bar included women counted in the preceding bar(s). The final bar represented the CS Prevention Ratio (CSPR) – the proportion of pregnant syphilis cases who did not deliver a CS infant. This cascade was then stratified by MU, defined as having either self-reported use upon interview or positive urine toxicology in pregnancy or at delivery. Three groups were identified: Non-MU (NMU); Positive-MU (PMU); Not interviewed (NI). A post-hoc stratified cascade included only pregnant syphilis cases with documented PNC, to explore how MU might impact CS case aversion once PNC is initiated. Results 616 women were included; 239/118/259 were NMU/PMU/NI respectively. Within these groups 95%/86%/71% met PNC criteria, 89%/81%/66% received syphilis screening, 84%/75%/63% initiated treatment, 82%/73%/61% met treatment adequacy, and CSPR were 79%/69%/59% (p<0.001). However, when considering only those with documented PNC(n=226/101/183): 94%/95%/94% received syphilis screening, 88%/88%/89% initiated treatment, 87%/85%/87% met treatment adequacy, and CSPR were 84%/81%/84% (p=0.84). Conclusion Compared to NMU, PMU and NI were associated with a decreased CSPR. When considering only those with documented PNC, significant differences between groups were not observed, suggesting PNC entry may be a key intervention for CS prevention. Disclosure No significant relationships.

Background Congenital syphilis (CS), the transmission of Treponema pallidum from mother to fetus during pregnancy, can cause adverse birth outcomes. In 2012 to 2014, the CS rate in California increased more than 200% from 6.6 to 20.3 cases per 100,000 live births. Our objectives were to identify characteristics associated with delivering an infant with CS and missed opportunities for prevention among syphilis-infected pregnant women in California. Methods We linked California Department of Public Health syphilis surveillance records from women aged 15 to 45 years—diagnosed from March 13, 2012, to December 31, 2014—to birth records. We compared characteristics among mothers who delivered an infant with CS (CS mothers) with mothers who delivered an infant without CS (non-CS mothers) by using χ2 or Fisher exact tests. To visualize gaps in prevention among syphilis-infected pregnant women, we constructed a CS prevention cascade, a figure that shows steps to prevent CS. Results During the selected period, 2498 women were diagnosed as having syphilis, and 427 (17%) linked to birth records; 164 (38%) were defined as CS mothers and 263 (62%) as non-CS mothers. Mothers with CS were more likely than non-CS mothers to have their first prenatal care visit in the third trimester. High proportions of mothers in both groups reported high-risk sexual behaviors, methamphetamine use, or incarceration (13%–29%). The CS prevention cascade showed decrements of 5% to 11% in prenatal care receipt, testing, and treatment steps; only 62% of potential CS births were prevented. Conclusions Multifaceted efforts are needed to address gaps in the CS prevention cascade and reduce CS cases in California.

Purpose: Primary care (PC) historically reports low chlamydia screening rates, however engaging PC practices in QI has been challenging. Traditional QI methods require 6–12 months to test new protocols, a demanding commitment for busy practices. “Lean” rapid-QI methods applied during brief onsite events may be effective for engaging PC to partner on public health QI priorities. Our objective was to assess the impact of lean rapid-QI methods on engaging PC in QI and improving adolescent sexual health clinical care outcomes, including chlamydia screening rates.

Background: Adolescent girls and young women experience high rates of sexually transmitted infection (STI) with currently available contraceptive methods, yet few studies examine the burden of chlamydial infection by contraceptive method used. Materials and Methods: In this cross-sectional analysis, we linked July 2012-June 2013 claims from a publicly-funded family planning program in California to chlamydia laboratory test results. Female clients were classified by the most effective contraceptive method reported by providers during the year: tier 1 (high-efficacy permanent or long-acting reversible methods), tier 2 (shorter-acting hormonal methods), or tier 3 (barrier methods, emergency contraception, or natural family planning). In addition, we identified clients who received condoms from providers. We used log-binomial models to estimate adjusted prevalence ratios comparing chlamydia positivity by contraceptive method(s). Results: Of 74,636 female clients of ages 15-29 years with chlamydia test results, 5.1% had at least one positive test during the year. Chlamydia positivity was highest among tier 2 users (5.3%) compared with 4.5% and 4.9% among tiers 1 and 3 users, respectively (p<0.001). Positivity was higher among clients who received condoms from providers than those who did not (6.3% vs. 4.3%, p<0.001). In adjusted analyses, there were no significant differences in positivity by contraceptive tier. However, clients who received condoms had 1.32 (95% confidence interval: 1.24-1.40) times the positivity of those who did not.female family planning clients regardless of contraceptive method. The development and provision of additional Conclusions: We found high chlamydia positivity among young Multipurpose Prevention Technologies that confer protection against both pregnancy and STIs may help to address unmet need for STI prevention.

Abstract Background Resistant Neisseria gonorrheae (NG) is a growing concern in California, nationally, and globally. Since 1987, California has participated in the Gonococcal Isolate Surveillance Project (GISP), a Centers for Disease Control and Prevention-funded project to monitor trends in antimicrobial susceptibility in sentinel STD clinic sites throughout the United States. We sought to describe trends in California NG susceptibility to ceftriaxone (CRO) and azithromycin (AZI), recommended therapy for NG, for 2005–2016. Methods Per GISP protocol, cultures are collected from the first 25 men presenting with NG urethritis each month at GISP clinic sites in California, and antimicrobial susceptibility testing (AST) is performed via agar dilution at GISP regional laboratories. Reduced susceptibility (RS) to CRO was defined as minimum inhibitory concentration (MIC) ≥0.125 µg/ml and AZI MIC ≥2 µg/ml. Demographics and MIC trends over time were examined. Results Between 2005 and 2016, there were 9,692 NG isolates submitted in California GISP clinics. There were 24 (0.25%) isolates with RS to CRO and 92 (0.96%) isolates with RS to AZI. There was a higher proportion of isolates from men who have sex with men with RS to AZI (but not CRO) compared with men who have sex with women (chi-squared P-values: AZI = 0.0015; CRO = 0.70). In 2016, the percent of isolates demonstrating RS to AZI increased to 3.69% (n = 32), compared with 0.69% of isolates with RS to AZI in 2005–2015 (chi-squared P-value < .0001); there was no significant difference in the percent of isolates with RS to CRO in 2016 compared with prior years (Figure 1). Figures 2 and 3 demonstrate the distribution of AZI MICs and CRO MICs, respectively, from 2005–2016. There have been no isolates to date in California GISP with RS to both ceftriaxone and azithromycin. Conclusion Gonococcal surveillance data demonstrate an increase in the proportion of isolates with decreased susceptibility to azithromycin in 2016 in California compared with prior years. Although there has never been a documented treatment failure to the recommended therapy of CRO and AZI in California, clinicians should remain vigilant for treatment failures given these concerning increases. Disclosures All authors: No reported disclosures.

Background Inequalities in Neisseria gonorrhoeae (gonorrhea) burden by sexual minority status in the United States are difficult to quantify. Sex of sex partner is not routinely collected for reported cases. Population estimates of men who have sex with men (MSM) necessary to calculate case rates have not been available until recently. For these reasons, trends in reported gonorrhea rates among MSM have not been described across multiple jurisdictions. Methods We estimated of the number of MSM cases reported in 6 jurisdictions continuously participating in the STD Surveillance Network 2010–2015 based on interviews with a random sample of cases. Data were obtained for Baltimore, Philadelphia, New York City, San Francisco, California (excluding San Francisco), and Washington State. Estimates of the MSM, heterosexual male (MSW) and female populations were obtained from recently published estimates and census data. Case rates and rate-ratios were calculated comparing trends in reported cases among MSM, heterosexual males and women. Results The proportion of male gonorrhea cases among MSM varied by jurisdiction (range: 20% to 98%). Estimated MSM rate increased from 1369 cases per 100,000 in 2010 to 3435 cases per 100,000 in 2015. Between 2010 and 2015, the MSM-to-Women gonorrhea rate ratio increased from 13:1 to 24:1, and the MSM-to-MSW gonorrhea rate ratio increased from 16:1 to 31:1. Conclusions Estimated gonorrhea rate among MSM increased in a network of 6 geographically diverse US jurisdictions. Estimating the size of this population, determining MSM among reported cases and estimating rates are essential first steps for better understanding the changing epidemiology of gonorrhea.

BACKGROUND:Lacking information on men who have sex with men (MSM) for most reported cases, sexually transmitted disease (STD) programs in the United States have used crude measures such as male-to-female case ratios (MFCR) as a rule of thumb to gauge MSM involvement at the local level, primarily with respect to syphilis cases in the past. Suitability of this measure for gonorrhea incidence has not previously been investigated.METHODS:A random sample of gonorrhea cases reported from January 2010 through June 2013 were interviewed in selected counties participating in the STD Surveillance Network to obtain gender of sex partners and history of transactional sex. Weighted estimates of proportion of cases among MSM and proportion reporting transactional sex were developed; correlation between MFCR and proportion MSM was assessed.RESULTS:Male-to-female case ratio ranged from 0.66 to 8.7, and the proportion of cases occurring among MSM varied from 2.5% to 62.3%. The MFCR was strongly correlated with proportion of cases among MSM after controlling for transactional sex (Pearson partial r = 0.754, P < 0.0001).CONCLUSIONS:Male-to-female case ratio for gonorrhea at the county level is a reliable proxy measure indicating MSM involvement in gonorrhea case incidence and should be used by STD programs to tailor their programmatic mix to include MSM-specific interventions.

Chlamydia became a nationally notifiable disease in 1995, and shortly thereafter, the Centers for Disease Control and Prevention released national chlamydia screening recommendations and other control strategies related to treatment and partner management.1 In 2014, an all-time high of more than 1.4 million chlamydia cases were reported, far exceeding any other reportable communicable disease.2 The strategy for chlamydia control has focused on implementing widespread screening of sexually active young women to detect asymptomatic infections and prevent adverse reproductive outcomes such as pelvic inflammatory disease (PID), ectopic pregnancy, and tubal factor infertility. Federal support for chlamydia screening began in 1988 as a demonstration project in US Public Health Service Region X. In 1993, congressional legislation authorized an expansion known as the Infertility Prevention Program (IPP), a collaboration between the Centers for Disease Control and Prevention and the Office of Population Affairs.3 By the mid-1990s, sexually transmitted disease (STD) programs across the nation were collaborating with Title X-funded family planning agencies to implement widespread screening of young women. It was not until 1996 that the first randomized trial demonstrating the benefit of chlamydia screening was published,4 which prompted national recommendations from the US Preventive Services Task Force,5 and inclusion of chlamydia screening as a national healthcare performance measure.6 To match the scale of numbers of young women at risk and the associated undetected chlamydia burden projected from the original prevalence studies, significant annual investment was placed in IPP to enable screening of young women seeking care in family planning, STD clinics, and correctional settings. IPP funding ended December 2013 as chlamydia screening became standard of care for young women and alternative sources of funding were identified. For population-level observational studies, it is not unreasonable to expect that screening and treatment of a common communicable disease would lead to reduced burden of infection in the population–decreased prevalence and incidence. Although reductions in positivity among screened populations were observed in the early years of IPP, there has been little evidence for sustained reduction in chlamydia burden.7 Several parallel sentinel (e.g., IPP and National Job Training Program8) and population-level (e.g., National Health and Nutrition Examination Survey9) surveillance systems were enlisted to monitor trends in chlamydia positivity. All have demonstrated declines in conjunction with chlamydia screening, but declines have not been sustained. Meanwhile, annual chlamydia incidence, as measured by government public health surveillance systems in the United States, steadily increased from the late 90s until very recently when rates began to plateau at their highest level.2 These increases are at least partially explained by increased detection and reporting of infection, including improvements in the sensitivity of diagnostic tests. Interpreting incidence as a measure of transmission is especially challenging because chlamydia infection in women is largely asymptomatic. Why does chlamydia prevalence seem to be stable while incidence seems to be rising? There are a number of scenarios to consider from biological, behavioral, and clinical practice perspectives. Were there changes in pathogenicity or transmissibility of the circulating strains? What if the optimal screening interval to identify asymptomatic infection should actually be shorter than current annual screening to reduce the time for complications to develop? What is the true benefit of screening in the detection of long-standing prevalent infection that causes low-grade inflammation that leads to scarring and long-term complications? What is the role of trends in risk behaviors (condom use, multiple and concurrent partner) in response to cultural shifts? Perhaps the earlier declines in chlamydia positivity resulted from fear of HIV, with a concomitant increase in protective behaviors and decrease in STDs overall. Does timely treatment reduce the immunological response and increase the size of the susceptible population? Are recent declines in incidence among adolescent females a reflection of reduced infection or reduced screening, or both? To what extent do increases in access and use of male urine-based tests contribute to decreased transmission? Interpreting trends in PID as the outcome of interest for chlamydia prevention has been subject to similar dilemmas. In the United States and western Europe, trends in both hospital discharges and outpatient diagnoses show consistent marked declines in parallel with expansion of chlamydia screening rates.2,10 However, these population-level associations are fundamentally ecological such that reductions in PID could be explained by concurrent changes in management standards favoring outpatient treatment. Furthermore, the accuracy and validity of studies using administrative or billing data are limited by variations in coding practices and case capture techniques. Quantifying the true benefits of chlamydia screening remains elusive with available data. In a recent analysis, Moore et al.11 try in earnest to address this critical question by triangulating multiple diverse data sources to creatively examine chlamydia and gonorrhea infections and related diagnoses that function as outcomes of screening as well as predictors of PID outcomes. The authors evaluated trends over a 23-year period (1988–2010) in 4 outcomes: PID, ectopic pregnancy, gonorrhea incidence, and chlamydia positivity in family planning settings. Although concurrent declines were observed in all 4 outcomes, the overall picture remained mixed in that the steepest declines occurred within the first 6 years of the observation period. Stronger associations were observed between infection outcomes and inpatient PID and ectopic pregnancy, which may indicate that improved detection and treatment yielded the greatest benefit in reducing the most severe complications. Limitations of using these 4 outcomes were apparent. Both reported case rates and positivity could have been used because all of the reasons cited for rejecting case rates–changes in populations being screened and number and type of tests performed–pertain to positivity, even with somewhat stable clinics contributing to data. Furthermore, these confounding factors also affected measurements and interpretation of gonorrhea incidence, particular among women, half of whom have no symptoms and thus depend on screening to identify their infections. The authors' conclusions rested upon a complex array of assumptions and estimations which were needed to overcome limits in their population surveillance, sentinel surveillance, and administrative data sources. For instance, IPP positivity data were applied to the statewide female population. Similarly, the application of national outpatient PID/ectopic pregnancy rates to Washington and the triangulation of data from one health plan to further adjust ectopic pregnancy rates had unclear validity. These limitations are a reminder of ongoing challenges to measuring meaningful outcomes of chlamydia screening. Relying on existing case-based surveillance and sentinel prevalence monitoring for the evaluation of chlamydia screening requires accounting for the myriad provider and laboratory factors which affect trends in those measures. Case-based surveillance data are influenced by changes in reporting mandates, adherence to, and mechanisms for reporting, such as electronic laboratory reporting; screening practices, test volume, and changes in populations tested; on-site testing and presumptive treatment; changes in test technology that alter sensitivity or specificity, and availability and use of rectal and throat specimens; and rates of partner testing in the context of increasing expedited partner treatment. Moore and colleagues' analytical approach of triangulating multiple data sources on chlamydia infections and adverse outcomes is the latest in efforts to demonstrate the impact of chlamydia screening on a population basis. But given the different populations that these observational data sources represent, whether examined here in the United States or in Europe, it remains difficult to satisfy the basic tenets of causality. Low has argued that 2 other approaches are more compelling: (1) randomized controlled trials of chlamydia screening on a population level and (2) modeling the impact of chlamydia control programs in a population by including multiple parameters such as screening coverage, partner management, and screening for repeat infection to assess the potential reduction in PID risk.12 Are these alternative approaches informative for implementing population-level chlamydia screening? Beyond the Scholes trial that demonstrated a 60% reduction in risk of PID, subsequent trials have been less compelling. The Prevention of Pelvic Infection trial in the UK was unable to demonstrate a significant decreased PID incidence among participants due to lower-than-anticipated PID incidence and consequent lack of statistical power to detect an effect.13 Conducting modeling to address the limitations and feasibility issues associated with randomized trial approaches has been an attractive alternative to evaluating the benefits of chlamydia screening for PID prevention.14 Unfortunately, public health programs are hard pressed to demonstrate return on investment in expanded chlamydia screening programs and must rely on observational data collected from surveillance and health program data, which reflect the gap between idealized scenarios and real-world challenges in screening uptake, inadequate partner treatment, and low rates of repeat screening.15,16 Advances in health information technology offer promising opportunities to reconsider the utility of observational data for evaluating the benefit of chlamydia screening.17 The transition to capturing medical information in electronic health records that integrate clinical, laboratory, and pharmacy data enables the creation of registries and cohorts of patients who are eligible for and receive sexual health care. By leveraging Meaningful Use requirements for providers who transition to electronic health records,18,19 the potential for having systematic capture of chlamydia testing, treatment, partner management, and repeat infection as well as PID outcomes becomes more apparent. Indeed, such systems facilitate clinical decision support tools such as automated reminders to both providers and patients for improving adherence to chlamydia screening, treatment and retesting recommendations, further ensuring improved uptake of these prevention strategies. The development of health information exchanges further synergizes the ability of diverse providers across a community to take advantage of these tools and increases the access to sexual health services as well as other population databases, including birth records and hospital and emergency room discharge data.20 But from a program perspective, there are population-level data with higher consistency and validity in measuring who receives what services and experiences what relevant outcomes, all of which contribute to more robust evaluation of these services. We must also acknowledge, though, that to achieve such population health data integration and to maximize the benefits of evaluation also requires additional expertise in informatics and adept data mining. Given the high volume of morbidity and many unanswered questions regarding public health interventions, major investments are needed to support informatics capacity building, training, and infrastructure in the STD field. In conjunction with advances in information technology and analytic capacities, it is important to consider the role of data policy issues. Ensuring data security and confidentiality are paramount. Striking a balance between preventing breaches of confidentiality and ensuring access to data for public health data analyses is critical. Unnecessary restrictions that limit access and use of data risk delays in understanding key population health threats and benefits of public health and clinical interventions. With greater legal protections against discrimination and loss of health care coverage due to preexisting conditions, current data security policies may need to be reexamined. Public health programs have the health information technology tools to build surveillance systems that can demonstrate a return on investment in population-based chlamydia control efforts. These efforts must involve integrating health data from all health providers, across settings, and populations served to minimize the pitfalls of fragmented services and isolated data systems. By fostering collaborations between STD and family planning agencies to implement and evaluate chlamydia screening programs on a regional level, IPP was a step in this direction.21 The program data systems supporting IPP have been the basis for continuous quality improvement related to screening, treatment, and partner management, and are a model for how further integration and capture of reproductive outcomes may be accomplished with the move to electronic health records. Title X and family planning partners continue to be key players in providing STD clinical services to at-risk populations. Since the 1990s, many of these clinics began providing care for gay, bisexual and other men who have sex with men, and transgender patients. With the closures of many publicly-funded categorical STD clinics, these community partners have become a core component of STD control in the United States. Under the Affordable Care Act, this model of best practices in chlamydia prevention strategies can further extend to other public sector programs providing primary care and be a resource to private sector managed care providers. Using the integrated data from all of these programs to demonstrate return on investment can provide the evidence needed to support chlamydia screening programs in the future.

Ocular syphilis, a manifestation of Treponema pallidum infection, can cause a variety of ocular signs and symptoms, including eye redness, blurry vision, and vision loss. Although syphilis is nationally notifiable, ocular manifestations are not reportable to CDC. Syphilis rates have increased in the United States since 2000. After ocular syphilis clusters were reported in early 2015, CDC issued a clinical advisory (1) in April 2015 and published a description of the cases in October 2015 (2). Because of concerns about an increase in ocular syphilis, eight jurisdictions (California, excluding Los Angeles and San Francisco, Florida, Indiana, Maryland, New York City, North Carolina, Texas, and Washington) reviewed syphilis surveillance and case investigation data from 2014, 2015, or both to ascertain syphilis cases with ocular manifestations. A total of 388 suspected ocular syphilis cases were identified, 157 in 2014 and 231 in 2015. Overall, among total syphilis surveillance cases in the jurisdictions evaluated, 0.53% in 2014 and 0.65% in 2015 indicated ocular symptoms. Five jurisdictions described an increase in suspected ocular syphilis cases in 2014 and 2015. The predominance of cases in men (93%), proportion of those who are men who have sex with men (MSM), and percentage who are HIV-positive (51%) are consistent with the epidemiology of syphilis in the United States. It is important for clinicians to be aware of potential visual complications related to syphilis infections. Prompt identification of potential ocular syphilis, ophthalmologic evaluation, and appropriate treatment are critical to prevent or manage visual symptoms and sequelae of ocular syphilis.

In 2014, the California Department of Public Health was notified by a local health department of a diagnosis of acute human immunodeficiency virus (HIV) infection* and rectal gonorrhea in a male adult film industry performer, aged 25 years (patient A). Patient A had a 6-day history of rash, fever, and sore throat suggestive of acute retroviral syndrome at the time of examination. He was informed of his positive HIV and gonorrhea test results 6 days after his examination. Patient A had a negative HIV-1 RNA qualitative nucleic acid amplification test (NAAT)(†) 10 days before symptom onset. This investigation found that during the 22 days between the negative NAAT and being informed of his positive HIV test results, two different production companies directed patient A to have condomless sex with a total of 12 male performers. Patient A also provided contact information for five male non-work-related sexual partners during the month before and after his symptom onset. Patient A had additional partners during this time period for which no locating information was provided. Neither patient A nor any of his interviewed sexual partners reported taking HIV preexposure prophylaxis (PrEP). Contact tracing and phylogenetic analysis of HIV sequences amplified from pretreatment plasma revealed that a non-work-related partner likely infected patient A, and that patient A likely subsequently infected both a coworker during the second film production and a non-work-related partner during the interval between his negative test and receipt of his positive HIV results. Adult film performers and production companies, medical providers, and all persons at risk for HIV should be aware that testing alone is not sufficient to prevent HIV transmission. Condom use provides additional protection from HIV and sexually transmitted infections (STIs). Performers and all persons at risk for HIV infection in their professional and personal lives should discuss the use of PrEP with their medical providers.