Recent directions in clinical-epidemiologic research on STIs include (1) population-level estimates of STI prevalence (e.g., WHO’s 2011 publication of global estimates), and formal population-level surveys of STI prevalence and risk determinants; (2) analysis of global mortality and disability attributable to major diseases, including STIs (the Global Burden of Disease Study, published in the December 2012 triple issue of The Lancet); (3) conceptualization and implications of the “Treatment and Care Cascade” and the “Prevention Cascade” currently focused on HIV infection; and (4) emerging interest in Program Science, linking programme implementers and scientists in needs assessments, conceptualization, design, advocacy for funding, implementation, evaluation, cost-effectiveness, and continuous strengthening of STI/HIV programmes. The global emergence and rapid spread of anti-microbial resistant pathogens, suggests the clinical mantra of “first do no harm” to the individual patient must be mirrored in a similar public health mantra - “first do no harm” to the population. This means selective use and more systematic evaluation of the impact of antimicrobial use on human and animal pathogens and microbiomes. The reemergence of syphilis and persistence of other STIs in vulnerable populations, and the limited implementation of cost-effective interventions for STI control reflects global neglect of STI programmes, and perhaps increasing failure to effectively integrate STI, HIV/AIDS, and reproductive health programmes globally (for example, the very limited integration of HIV PMTCT with elimination of congenital syphilis programmes). Nonetheless, progress in sexual health promotion and STI control can be made possible with cost-effective use by clinicians and public health leaders of effective, available tools, such as scale up of HPV and HBV vaccines, and linked delivery of other sociobehavioral and biomedical STI interventions in vulnerable populations. Rigorous evaluation of the impact of such programmes, with assessment of what is not working as well as what is working, is essential.

Background Congenital syphilis and syphilis in pregnancy in Peru persist as important public health issues, and improvement of screening/treatment for pregnant women remains challenging. Rapid syphilis testing (RST) allows simple and immediate diagnosis and treatment at a single clinic visit and could increase screening and treatment coverage reducing the incidence of stillbirth and congenital syphilis and generate in the long term a sustainable cost effective intervention. Methods We tested the feasibility, performance, impact and cost-effectiveness of implementing RST in an underserved urban area at a biggest maternity hospital in Peru and a network of 16 peripheral health centres offering prenatal care in a periurban poor area in Callao-Ventanilla, Peru. RST (integrated with HIV rapid test: the “two for one”) were offered at the first prenatal visit (ANC), at delivery and within miscarriage/abortion services. Results Data from the baseline pre-implementation evaluation revealed limited coverage of screening and treatment services for maternal syphilis and a complex and inefficient system for ANC. RST was started in January 2010. Overall success of implementation was measured by rates of maternal syphilis screening and treatment coverage, partner treatment, and acceptability of RST among providers and patients. We also performed a cost-effectiveness analysis of RST against the Rapid Plasma Reagin (RPR). Attention was paid to the process of dissemination and transfer activities to the Ministry of Health of Peru, through the involvement of both the National Program of STIs and HIV and the Reproductive Health Program. National guidelines have been modified, and recommend the use of both tests, RST and rapid HIV testing in the screening of pregnant women. Conclusions RST implementation was feasible, successful, acceptable and cost effective. Its introduction catalysed improvements in the quality of care, and by the end of the project it has been introduced in the country as a National policy.

BackgroundSeveral recent articles compared the cost and cost-effectiveness syphilis testing strategies to avert congenital syphilis in settings with high syphilis prevalence. Current study contributes analysis in low-prevalence setting. Methods. Rapid syphilis testing (RST) was implemented at two different settings, both with syphilis prevalences of around 1%: (a) The Ventanilla-Network of outpatient clinics and a small hospital at a peripheral district in Peru, where the rapid syphilis test was implemented together with the rapid HIV testing (One finger stick, two tests"); (b) The National Maternal and Perinatal Institute (INMP) a tertiary hospital with a high number of patients, and Initially in both settings the only test available was RPR with low coverage. For the costing of RPR we included supplies, capital costs, human resources and costs associated to treatment. For the costing of RST, we included also start up costs (advocacy meetings with authorities, training, supervision, monitoring) and the cost of implementing a quality assurance system. Cost-effectiveness analyses compared the cost of screening and treatment for the joint program to the disability adjusted life-years saved when congenital syphilis was averted.ResultsFor the Ventanilla-Network the total cost was $5.98 for RST and $5.22 for RPR per woman screened and $580.83 and $1845.55 respectively per woman treated. In contrast, the total cost was $2.53 for rapid syphilis test and $3.15 for RPR per woman screened (the lower costs probably associated to the economy of scale, due to the large number of women seen at the INMP) and $336.80 and $1051.59 at INMP. At Ventanilla-Network, the cost per DALY saved from averting cases of congenital syphilis was $35.23 for rapid syphilis test and $111.95 for RPR. In incremental analysis, the rapid test was cost-saving. At INMP, the cost per DALY saved was $20.43 for rapid syphilis test and $63.79. For the Ventanilla-Network and the INMP the RST was cost-effective by the WHO standard of $64/DALY.ConclusionSyphilis screening is cost-effective even in a low-prevalence setting. To the extent that HIV rapid tests are funded by PMTCT programs, the cost of scaling up rapid syphilis tests would be lower than these estimates, because the joint cost of blood sample collection would be borne by the PMTCT program.

Background This study aims to evaluate health-seeking and HIV/STD preventive behaviours among FSW in mid-sized cities in Peru associated with a community randomised trial intervention and with venue of sex work. Methods Through the Peru PREVEN multi-component intervention, mobile team outreach to FSW was conducted in an effort to lower STD rates and increase condom use as well as care-seeking from local Ministry of Health clinics for screening and evaluation of STDs. Relative risks for behavioural outcomes were calculated using multivariate Poisson regression models with robust standard errors and accounting for clustering by city. Analyses were adjusted for city-specific baseline outcomes and by brothel venue, as there were a higher proportion of brothels in intervention cities. A sub-analysis of outcomes associated with brothel venue did not control for baseline but did adjust for age, marital/cohabitation status, alcohol use, geographical region, education and randomisation arm. Results 4156 FSW were enrolled in 20 cities; 2063 from control and 2093 from intervention cities. The median age at first paid sex was 21 years and the median duration of sex work was 20 months. Sex work was relatively frequent, with a median of 6 days worked in the last week, 4 weeks in the last month and 8 months in the last year. Frequency of sex work increased with age (p<0.001). Twenty-one per cent of FSW were brothel based, 23% street based and 56% were bar or nightclub based. Although proportions of care-seeking behaviours were higher in intervention cities, differences were not statistically significant. In evaluating relationships of venue and health-seeking behaviours, brothel-based FSW reported significantly lower rates of non-condom use with clients (RR=0.18; 95% CI 0.07% to 0.44%), and higher rates of recent health screening exams (RR=1.97; 95%CI 1.58% to 2.45%) and of HIV testing in the last year (RR=1.74; 95% CI 1.45% to 2.09%), compared with FSW who were street or bar-based. Brothel-based FSW also more frequently reported knowledge of STDs (RR=1.07; 95% CI 1.04% to 1.09%) and recognition of STD symptoms in women (RR=1.39; 95%CI 1.22% to 1.59%) and in men (RR=1.32; 95% CI 1.12% to 1.57%). Conclusions Sex work venue is significantly associated with the health care-seeking and STD preventive behaviours of sex workers. Interventions to promote STD detection and prevention among FSW should consider structural or regulatory factors related to sex work venue.

Background Partner notification and treatment has the potential to be one of the most important strategies in the control of STIs. However, studies indicate that this approach is not often used. Additionally, there is not much information about STIs among sexual partnerships. Objectives To determine the prevalence of several STIs in sexual partnerships and to estimate the potential utility of partner treatment. Methods We enrolled males and females 18–29 years of age from a random household sample in 24 cities in Peru and enrolled same-residence sex partners of the participants. Participants and partners responded to demographic and sexual behaviour questionnaires and provided biological samples tested for Neisseria gonorrhoeae , Chlamydia trachomatis , and Trichomonas vaginalis , syphilis, HSV-2 and HIV. Results Of 2302 couples enrolled, 2163 couples had laboratory results available for either CT or TV and 1696 couples for either HIV, HSV-2 or early syphilis. CT, TV, early syphilis, HSV-2, and HIV were found in 7.1%, 4.4%, 1.2%, 24.8%, and 0.2% of couples, respectively. Among couples in which at least one subject was affected by a specific STIs, both partners had CT in 53 (39.3%) couples, TV in 22 (25.0%) couples, early syphilis in 3 (14.3%) couples, HSV-2 in 215 (51.1%) couples, and HIV in 2 (66.7%). Of couples affected by CT, 18/131(13.7%) had TV; 1/109 (1.3%) had early syphilis; 41/109 (41.6%) had HSV-2; and no one had HIV. Among females affected only by CT, 52.3% of partners had CT and 2.6% had TV; and among those only affected by TV, 13.7% of partners had CT and 26.2% had TV. Among males affected only by CT, 68.8% of partners had CT and 14.3% had TV; and among those affected only by TV, 11.5% of partners had CT and 84.6% had TV. Conclusions A relatively high proportion of males and females affected by an STI had the same infection than their partners and not an infrequent number had different infections. Strategies to increase utilisation of partner notification and treatment may help STI control. Further review of partner treatment guidelines needs to be performed.

The aim of this study was to assess prevalence and risk factors for sexually transmitted infections (STIs) among fishermen along Lake Victoria, Kenya. This cross-sectional study surveyed 250 fishermen from beaches in Kisumu District using proportional-to-size sampling based on the number of registered boats per beach. Participants provided demographic and sexual behaviour information, blood for HIV-1 herpes simplex virus type 2 (HSV-2) and syphilis serological tests urine for transcription-mediated amplification assays for Neisseria gonorrhoeae and Chlamydia trachomatis and penile and scrotal swabs for human papillomavirus (HPV) DNA assay. Consistent condom use with the three most recent sexual partners was reported by 30%; 38% reported concurrent sexual partnerships and 65% reported ever having transactional sex. HIV seroprevalence was 26%, HSV-2 seroprevalence by Western blot assay was 58% and 9.5% were rapid plasma reagin and Treponema pallidum particle agglutination assay positive. Genital HPV DNA of any type was detected in 57.2% with 74% of these having two or more HPV types. C. trachomatis and N. gonorrhoeae were detected in 3.2% and 1.2% respectively. Risk factors for syphilis seropositivity included working on multiple beaches during the past year (adjusted odds ratio [AOR] 3.81; 95% confidence interval [CI] 1.29-11.28). HPV infection was associated with owning a radio which is a marker for higher socioeconomic status (AOR 6.33; 95% CI 2.94-7.14) and reporting transactional sex with the most recent sexual partner (AOR 3.03; 95% CI 1.23-7.69). In conclusion, 90% of fishermen had evidence of one or more STIs. This exceptionally high-risk occupational group represents a high priority for preventive interventions.

Over the past several years, some policy makers have emphasized abstinence only education for youth, have questioned the effectiveness of condoms in preventing STD, and have suggested that promotion of early condom use may increase subsequent sexual risk behaviors. This prospective observational study compares sexual behavior outcomes of adolescents who did and did not report using a condom at sexual debut.

Purpose: Sexually active adolescents remain at high risk for sexually transmitted infections (STI’s). Regular condom use provides protection against STI’s, but determinants of adolescent condom use are only partially understood. While acknowledging the influence of demographic, individual, behavioral and partnership characteristics on condom use in adolescents, we draw from evidence in behavioral science suggesting regular patterns of behavior are often established by early experiences. We propose an imprinting hypothesis, which predicts using a condom during sexual debut will increase the likelihood of subsequent condom use, independent of other relevant associations.

Risks associated with dermal exposure to contaminated soil are not well-characterized, but nevertheless must be estimated to define endpoints for remedial strategies. Among the parameters contributing to the uncertainty of these estimates is soil adherence to skin. Pre- and postactivity soil loadings have been obtained from hands, forearms, lower legs, faces, and/or feet of volunteers engaged in various occupational and recreational activities. These data are distinguished from other sources of estimates of soil adherence by the manner of their collection. Soil loads were obtained directly from multiple body parts before and after uncontrived exposure scenarios. Data presented for the first time here supplement prior results and roughly double the available data base. This expanded data base provides a useful perspective on types of behavior likely to lead to soil contact falling within general classes of activity (e.g., background, low, moderate, or high contact). Prior conclusions supported by the additional data include the following: (1) post-activity loadings are typically higher than preactivity levels, demonstrating that exposure is episodic; (2) hand loadings are dependent upon class of activity; (3) hand loadings generally provide conservative estimates of loadings on nonhand body parts within activity classes; and (4) hand loadings do not provide conservative estimates of nonhand loadings across activity classes. Finally quantitative estimates of relative loads on unclothed nonhand body parts are presented.

In Brief Objective To correlate symptoms, signs, and risk factors with positive wet mounts or cultures for Candida albicans and to develop an algorithm to diagnose vulvovaginal candidiasis. Methods This cross-sectional study of 774 randomly selected women from an urban sexually transmitted disease (STD) clinic evaluated symptoms, signs, and risk factors associated with C albicans, detected by wet mount and culture, and constructed an algorithm. Results C albicans, recovered from 186 (24%) of the 774 women, was associated with chief complaints of vulvar pruritus or burning. Elicited symptoms were vulvar pruritus, pain or burning, and external dysuria; signs were vulvar erythema, edema, fissures, vaginal erythema, and thick, curdy vaginal discharge. Among 545 women with symptoms of either increased vaginal discharge or vulvar pruritus or burning, only 155 (28%) had positive C albicans cultures, whereas bacterial vaginosis or other sexually transmitted infections were found in 288 (53%). In multivariate analysis, risk factors for positive C albicans culture included condom use, presentation after the 14th menstrual cycle day, sexual intercourse more than four times per month, recent antibiotic use, young age, past gonococcal infection, and absence of current gonorrhea or bacterial vaginosis. A clinical algorithm based on symptoms, signs, and selective use of wet mounts and cultures would have provided prompt treatment to 150 of 167 (90%) women with vulvovaginal candidiasis while minimizing the number of cultures performed. Conclusion A simple algorithm using symptoms, signs, wet mounts, and selective cultures can identify 90% of women with vulvovaginal candidiasis. In this STD clinic, vulvovaginal symptoms also require assessment for bacterial vaginosis, trichomoniasis, and cervical infection. An algorithm to diagnose vulvovaginal candidiasis uses symptoms, signs, wet mount, and culture for women with signs or multiple symptoms.

Dermal contact with contaminated soils may be a significant route of human exposure to toxic substances under some circumstances. Soil adherence to skin is an important determinant of such exposures, but factors influencing soil adherence are generally not well characterized. Petroleum hydrocarbons are often found in contaminated soils at relatively high concentrations. Results of an investigation of the influence of motor oil on soil adherence to skin are reported here. Studies were conducted at three oil concentrations (0, 1, and 10% by weight) under wet and dry conditions in three different soil types. Only two of six soil/moisture combinations showed consistently increasing adherence with increasing oil content. Overall, an increase was found in wet, but not dry soils. The results indicate that high concentrations of petroleum contaminants can increase the dermal adherence of soil, but that the magnitude of the effect is likely to be modest.