Background: Two risk-reduction counseling sessions can prevent sexually transmitted diseases (STDs); however, return rates for test results are low.Study: A randomized, controlled trial compared rapid HIV testing and counseling in 1 visit with standard HIV testing and counseling in 2 visits. Main outcomes were STDs (gonorrhea, chlamydia, trichomoniasis, syphilis, HIV) within 12 months. Participants were 15- to 39-year-old STD clinic patients in Denver, Long Beach, and Newark. STD screening and questionnaires were administered every 3 months.Results: Counseling was completed by 1632 of 1648 (99.0%) of the rapid-test group and 1144 of 1649 (69.4%) of the standard-test group. By 12 months, STD was acquired by 19.1% of the rapid group and 17.1% of the standard group (relative risk [RR], 1.11; confidence interval [CI], 0.96-1.29). STD incidence was higher in the rapid-test group than in the standard-test group among men (RR, 1.34; CI, 1.06-1.70), men who had sex with men (RR, 1.86; 95% CI, 0.92-3.76), and persons with no STDs at enrollment (RR, 1.21; 95% CI, 0.99-1.48). Behavior was similar in both groups.Conclusions: Counseling with either test had similar effects on STD incidence. For some persons, counseling with standard testing may be more effective than counseling with rapid testing.

From the Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia Correspondence: John M. Douglas, Jr, MD, Division of STD Prevention, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30333. E-mail: [email protected]. Received for publication May 31, 2005, and accepted July 19, 2005.

Peterman, Thomas A. MD, MSc; Heffelfinger, James D. MD, MPH; Swint, Emmett B. MS; Groseclose, Samuel L. DVM, MPH Author Information

BACKGROUND:The objective of this study was to identify the socioeconomic and health characteristics of communities with the largest proportional increases in incidence rates of acquired immunodeficiency syndrome (AIDS).METHODS:Reported AIDS cases (1981-1990 and 1995-1999) were used for a comparison between 20 US counties with the largest proportional increases in incidence rates of AIDS and 20 US counties with the smallest increases. Data were obtained from Community Health Status Indicators Reports of the Health Resources and Services Administration (HRSA) and from the US Census Bureau.RESULTS:Counties with the largest increases in the incidence of AIDS had lower levels of income, education, and literacy; higher incidence rates of syphilis, age-adjusted mortality (all causes), and infant mortality; more low-birth-weight infants; and higher levels on all 9 specific mortality measures in the HRSA reports.CONCLUSIONS:The incidence of AIDS increased the most in areas where many other health problems occurred. Research is needed to identify and address the root causes of ill health.

Background: Many women with positive screening tests for chlamydia or gonorrhea are not promptly treated and are at risk for complications and further disease transmission. Improved methods for notifying infected patients might increase timely treatment in this population.Goal: Describe notification procedures at STD clinics in Washington, DC; Los Angeles; and San Diego and compare timeliness of treatment during 2000 to 2002.Study: Interviews were conducted to determine methods for notifying infected patients. Data were abstracted from 327 medical records of women with chlamydia or gonorrhea who had not been treated presumptively. The interval between specimen collection and treatment ("time to treatment") was calculated.Results: Each clinic had different procedures for notifying untreated infected women. Among those treated, the median time to treatment was 18 days in Washington, DC, and 8 days in Los Angeles. In San Diego, the median time to treatment was initially 14 days, which improved to 7 days after patient-notification procedures were changed.Conclusion: Simple changes in patient notification procedures can decrease time to treatment at STD clinics. STD programs should evaluate time to treatment and institute methods for efficient patient follow-up.

Syphilis cases were reviewed to see if reported stages met the Centers for Disease Control and Prevention case definition. Classification was excellent for primary and secondary and good for late latent, but half of early latent and unknown duration were misclassified. New surveillance definitions are suggested, comments requested.Background: Uncertainty when staging latent syphilis should lead clinicians to call it late latent (requires more treatment) and disease investigators to call it early latent (priority for partner investigation). Accurate surveillance requires consistent case definitions. Objective: Assess validity of reported syphilis stages. Methods: Record reviews in 6 jurisdictions to determine if reported cases met the Centers for Disease Control and Prevention case definitions.Results: Nine hundred seventy-three records from 6 jurisdictions in 2002 showed excellent agreement for reported primary (94.0%) and secondary (95.4%), good agreement for late latent (80.2%), and poor agreement for early latent (48.4%) and unknown duration (49.7%). Unknown duration (age less than or equal to35 and nontreponemal test titer greater than or equal to32) was often misinterpreted to mean "not known." Early latent (within the past year, documented: seroconversion, fourfold titer increase, symptoms, or contact with an independently documented early syphilis case) was often misinterpreted to include patients with risky behavior, young age, or high nontreponemal test titers.Conclusions: The unknown duration stage should be dropped. Surveillance of latent syphilis would be more consistent if cases were reported as having high or low titers on nontreponemal test. Alternative approaches are solicited from readers.

BACKGROUND:The study sought to characterize the seroprevalence, seropersistence, and seroincidence of human papillomavirus (HPV)-16 antibody, as well as the behavioral risk factors for HPV-16 seropositivity.METHODS:Serologic data at baseline and at 6- and 12-month follow-up visits were used to examine the seroprevalence, seropersistence, and seroincidence of HPV-16 antibody in 1595 patients attending United States clinics treating sexually transmitted disease. Testing for antibody to HPV-16 was performed by capture enzyme-linked immunosorbent assay (ELISA) using viruslike particles.RESULTS:The seroprevalence of HPV-16 antibody was 24.5% overall and was higher in women than in men (30.2% vs. 18.7%, respectively). In those who were HPV-16 seropositive at baseline, antibody response persisted to 12 months in 72.5% of women and in 45.6% of men. The seroincidence of HPV-16 antibody was 20.2/100 person-years (py) overall, 25.4/100 py in women, and 15.7/100 py in men. In multivariate analysis, the seroprevalence of HPV-16 antibody was significantly associated with female sex, age >20 years, and the number of episodes of sex with occasional partners during the preceding 3 months, whereas the seroincidence of HPV-16 antibody was significantly associated with female sex, age >20 years, baseline negative ELISA result greater than the median value, and the number of episodes of unprotected sex with occasional partners during the preceding 3 months.CONCLUSION:Sex- and age-related differences in both the seropositivity and seroincidence of HPV-16 antibody persisted after adjustment for behavioral and sociodemographic risk factors, and behavioral risk factors during the preceding 3 months were stronger predictors of the seroprevalence and seroincidence of HPV-16 antibody than was lifetime sexual behavior.

This analysis examined the importance of differential exposure to infected partners in epidemiologic studies of latex condom effectiveness for prevention of sexually transmitted infections. Cross-sectional, enrollment visit data were analyzed from Project RESPECT, a trial of counseling interventions conducted at five publicly funded US sexually transmitted disease clinics between 1993 and 1997. The association between consistent condom use in the previous 3 months and prevalent gonorrhea and chlamydia (Gc/Ct) was compared between participants known to have infected partners and participants whose partner infection status was unknown. Among 429 participants with known Gc/Ct exposure, consistent condom use was associated with a significant reduction in prevalent gonorrhea and chlamydia (30% vs. 43%; adjusted prevalence odds ratio = 0.42, 95% confidence interval: 0.18, 0.99). Among 4,314 participants with unknown Gc/Ct exposure, consistent condom use was associated with a lower reduction in prevalent gonorrhea and chlamydia (24% vs. 25%; adjusted prevalence odds ratio = 0.82, 95% confidence interval: 0.66, 1.01). The number of unprotected sex acts was significantly associated with infection when exposure was known (p for trend < 0.01) but not when exposure was unknown (p for trend = 0.73). Restricting analyses to participants with known exposure to infected partners provides a feasible and efficient mechanism for reducing confounding from differential exposure to infected partners in condom effectiveness studies.

The seroincidence of herpes simplex virus type 2 (HSV-2) infection was determined among 1766 patients attending sexually transmitted disease (STD) clinics and enrolled in a randomized, controlled trial of human immunodeficiency virus (HIV)/STD risk-reduction counseling (RRC). Arm 1 received enhanced RRC (4 sessions); arm 2, brief RRC (2 sessions); and arm 3, the control arm, brief informational messages. The overall incidence rate was 11.7 cases/100 person-years (py). Independent predictors of incidence of HSV-2 infection included female sex; black race; residence in Newark, New Jersey; <50% condom use with an occasional partner; and, in females, incident trichomoniasis and bacterial vaginosis. Only 10.8% of new HSV-2 infections were diagnosed clinically. Incidence rates were 12.9 cases/100 py in the control arm, 11.8 cases/100 py in arm 2, and 10.3 cases/100 py in arm 1 (hazard ratio, 0.8 [95% confidence interval, 0.6-1.1], vs. controls). The possible benefit of RRC in preventing acquisition of HSV-2 infection offers encouragement that interventions more specifically tailored to genital herpes may be useful and should be an important focus of future studies.

BACKGROUND:Partner notification (PN), originally designed for syphilis control, has been used to control the spread of HIV since 1985. Because HIV infection is noncurable, the benefit of contact tracing and treatment demonstrated for the control of syphilis may not apply to HIV. For HIV, PN must facilitate behavior change that will reduce the spread of the infection. One concern is that HIV PN can promote the breakup of old partnerships and increase the acquisition of new partners, thereby spreading HIV infections.GOAL:The purpose of this study was to determine the effect of partner notification (PN) on sexual behavior and relationship stability among HIV partnerships, with use of syphilis partnerships for comparison.STUDY DESIGN:Partnerships were eligible if the index case was interviewed by a disease intervention specialist (DIS) for PN and named at least one sex partner. Partnership information was reported by index cases interviewed at baseline and 3 and 6 months post-PN. Trends in partnership dissolution and acquisition, sexual abstinence, condom use, emotional abuse, and physical violence reported by HIV infection and syphilis index cases were compared.RESULTS:A total of 157 index cases (76 HIV infection and 81 syphilis) reported 220 partnerships (94 HIV and 126 syphilis). The PN process was completed for 32.7% of partnerships and it was completed more often for partnerships that were classified as main and cohabiting. After PN, 46.8% of partnerships dissolved, 15.9% of cases acquired a new partner, and emotional abuse and physical violence decreased significantly. HIV index cases were somewhat more likely to report using condoms at last sex act and less likely to acquire a new sex partner after PN compared to syphilis index cases. There was no difference post-PN between HIV infection and syphilis partnerships for partnership dissolution, physical violence, emotional abuse and abstention from sex.CONCLUSION:HIV PN did not appear to cause greater partnership dissolution, new partner acquisition, or violence compared with syphilis PN.

BACKGROUND AND OBJECTIVE:Few studies have examined the effect of partner notification (PN) on behavior change and partnerships. This study investigated both.GOAL:The goal was to examine the effect of PN on sexual behaviors and partnership dissolution and formation. STUDY DESIGN Subjects included HIV-positive persons interviewed to identify partners for notification, partners notified of exposure, and HIV-negative persons receiving HIV counseling and testing (controls). Subjects were interviewed about behaviors and relationships at baseline and at 3- and 6-month visits. Partnerships in which both subject and partner received PN were compared to partnerships in which only the subject received PN and to control partnerships.RESULTS:Partnerships where both persons received PN were less likely to break up or acquire new partners and more likely to use condoms at follow-up.CONCLUSION:PN did not increase partnership dissolution or formation and was associated with higher condom use, suggesting the value of PN in HIV prevention.

Background: The study objectives were to determine whether a community-based organization's intensive counseling intervention would reduce sexually transmitted disease (STD) acquisition among high-risk STD clinic patients and to determine whether a low-cost trial could be conducted in a community-based setting with passive follow-up.Methods: Participants were randomly assigned to routine counseling or intensive counseling consisting of three I-hour sessions. We reviewed clinic records to determine I-year cumulative incidence of STD.Results: From September 1994 through December 1995, we enrolled 581 high-risk black men. Among the intervention group, 38% did not attend any intervention session; 38% attended all three. The 1-year cumulative incidence of STD did not differ significantly between the intervention (16%) and control groups (12%) (P = 0.20).Conclusion: Our results suggest that the intensive counseling did not reduce STD acquisition. We encountered problems in conducting this low-cost trial, making results difficult to interpret. Future trials should schedule follow-up STD assessments and will likely need more staff.

BACKGROUND:For two decades, treatment guidelines for sexually transmitted diseases (STDs) have recommended empirical co-treatment for chlamydia when patients are treated for gonorrhea. Because the epidemiology of and diagnostic testing for STDs have changed over time, co-treatment may no longer be needed as a clinical or public health strategy.OBJECTIVE:To assess the prevalence of chlamydia among patients at STD clinics who are infected with and treated for Neisseria gonorrhoeae and to determine whether co-treatment recommendations are still justified.DESIGN:Cross-sectional analysis of data from a multisite study.SETTING:Five public STD clinics (Baltimore, Maryland; Denver, Colorado; Long Beach, California; Newark, New Jersey; and San Francisco, California), July 1993 through October 1995.PATIENTS:3885 heterosexual patients (2184 men and 1701 women) who agreed to participate in a trial of counseling interventions and had conclusive results from diagnostic tests for gonorrhea and chlamydia performed routinely as part of the trial.MEASUREMENTS:Infection with Chlamydia trachomatis as determined by polymerase chain reaction.RESULTS:Chlamydia trachomatis was detected in 20% (95% CI, 16% to 24%) of 411 men and 42% (CI, 35% to 50%) of 151 women with laboratory-confirmed N. gonorrhoeae. Chlamydia trachomatis was detected in 19% (CI, 15% to 22%) of 410 men and 35% (CI, 28% to 43%) of 154 women with treatment indications for gonorrhea who would not otherwise have been treated for chlamydia: chlamydia prevalence among these patients was significantly higher than among patients without treatment indications for either gonorrhea or chlamydia: 7% in men and 9% in women (relative risk, 2.58 [CI, 1.92 to 3.47] and 4.12 [CI, 3.05 to 5.57], respectively).CONCLUSION:The frequent presence of chlamydia among patients at STD clinics who received treatment for gonorrhea, including sex partners of gonorrhea-infected patients, supports continuing current recommendations for co-treatment.

Background Sexual acquisition of HIV is influenced by choice of partner, sex act, and condom use. However, current risk-reduction strategies focus mainly on condom use. Goal To estimate the contribution of choice of partner, sex act, and condom use on the per-act relative and absolute risks for HIV infection. Study Design Per-act relative risk for HIV infection was calculated with use of estimates of HIV prevalence, risk of condom failure, HIV test accuracy, and per-act risk of HIV transmission for different sex acts. Absolute risks were calculated on the basis of these relative risk estimates. Results Choosing a partner who tested negative instead of an untested partner reduced the relative risk of HIV infection 47-fold; using condoms, 20-fold; and choosing insertive fellatio rather than insertive anal sex, 13-fold. Choosing one risk-reduction behavior substantially reduces absolute risk of HIV infection for heterosexuals but not for men who have sex with men. Conclusion Clarifying the magnitude of risk associated with different choices may help people make effective and sustainable changes in behavior.

The seroprevalence of herpes simplex virus type 2 (HSV-2) infection was studied among 4128 patients from sexually transmitted disease (STD) clinics who were enrolled in a randomized controlled trial of human immunodeficiency virus and STD counseling efficacy. HSV-2 seroprevalence was 40.8% and was higher in women than in men (52.0% vs. 32.4%; P<.0001) and higher in blacks than in nonblacks (48.1% vs. 29.6%; P<.0001). Among 14-19-year-old patients, 36.8% of black women and 25.8% of nonblack women were infected with HSV-2. Independent predictors of HSV-2 seropositivity included female sex, black race, older age, less education, more lifetime sex partners, prior diagnosis of syphilis or gonorrhea, and lack of HSV-1 antibody. The majority of HSV-2-seropositive persons (84.7%) had never received a diagnosis of genital herpes. HSV-2 infection is common in STD clinic attendees in the United States, even among young age groups, especially among women. Efforts to prevent genital herpes should begin at an early age. The high rate of undiagnosed HSV-2 infection likely contributes to ongoing transmission.

IN STUDIES OF SEXUALLY TRANSMITTED DISEASE (STD) and HIV epidemiology and prevention, it is tempting to focus on the measurement of risk behaviors rather than on the measurement of STDs and HIV themselves. Particularly in intervention studies, measuring biomedical outcomes can be complicated and costly. An intervention study where the goal is to have 80% likelihood of finding a difference between intervention and control groups at P < 0.05, requires 313 persons per arm if the outcome of interest is an increase in condom use from 20% to 30%. On the other hand, if the outcome of interest is a decrease from 10% to 8% in the gonorrhea reinfection rate in an STD clinic population, 3,312 persons would be required per arm. A decrease in HIV incidence from 0.5% to 0.4% would require 72,307 persons per arm. Measuring risk behaviors in lieu of STDs and HIV, however, is problematic. A number of observational studies that explored the relationship between behavioral and biomedical outcomes failed to show a strong relationship between behaviors and acquisition of sexually transmitted infection. 1–9 Moreover, some behavioral intervention studies also failed to show a strong relationship between behaviors and STD acquisition. 10–12 The debate surrounding the issue of discordance between behavioral and biomedical outcome measures has focused on the imperfections in behavioral outcome measurement. 1–6,13 In this issue of Sexually Transmitted Diseases, Shain and colleagues 14 present results of additional analyses of data from project SAFE. 15 They put forth the compelling argument that incorporating context into the conceptualization of behavioral measurements and considering several behaviors simultaneously may resolve the inconsistencies between behavioral and biomedical outcomes. Current approaches to STD epidemiology recognize at least three distinct components of STD transmission dynamics: transmissibility of infection upon exposure between an infected and an uninfected person, likelihood of sexual exposure between infected and uninfected individuals, and duration of infection among infected persons. 16 Consistent with this recognition, behavioral interventions aimed at reducing STD transmission focus on: (1) behaviors related to transmission of infection between infected and uninfected partners, including condom use (or unsafe sex), sexual practices such as anal sex or dry sex, douching practices and abstaining from sex until the completion of therapy; (2) behaviors related to sexual exposure between infected and uninfected persons, including sex with infected or untreated partners, lack of mutual monogamy, rapid partner turnover, number of partners, number of new partners, and choice of partners; and (3) duration of infection or infectiousness, such as the timely seeking of healthcare and treating of partners. Despite clear recognition of the three distinct components of STD transmission dynamics, in general, neither observational nor intervention studies of the relationship between behavioral and biomedical outcomes of STD transmission adequately differentiate among these three components. Such studies often rely on the measurement of relevant behaviors and statistical analyses as they attempt to relate behaviors to the overall outcome—acquisition of a sexually transmitted infection. While some intervention studies have incorporated aspects of the three components into the intervention 15,17 and measurement of behavior, too often these issues are not taken into consideration in study design. Specification of the behaviors, the outcomes, and the sexually transmitted infection in question may have important implications for study design, study populations, and follow-up periods. Transmission Probability and Behaviors Behaviors related to transmissibility can be evaluated effectively only in discordant partners. 18–20 In project SAFE the strongest association between behavioral and biomedical outcomes (new infection) was found for persons who had sex with an untreated partner. 14 In the 1980s a number of partner studies examined the probability of heterosexual transmission of HIV. 21 Transmission probabilities of other sexually transmitted infections generally have not been examined through discordant partner studies. One behavior that is closely related to transmission probability is condom use. Many studies of the association between use of condoms and acquisition of sexually transmitted infections have yielded paradoxical results. People who use condoms are found to be at least as likely to acquire infections as people who do not use condoms. People tend to use condoms with partners who they think are risky but not with partners who they consider to be safe. Consequently, increased condom use may be a marker either of decreased STD transmission risk or of increased likelihood of STD exposure. Outside the context of discordant partner studies, it may be almost impossible to tease out the effects of interaction between behaviors and risk, and to study the relationship between behaviors and transmissibility effectively. Specification of the sexually transmitted infection under consideration may have implications for the required period of observation and sexual activity level of the study population. Infections caused by highly infectious pathogens such as gonorrhea may be studied in moderately sexually active discordant couples over relatively short observation periods. Infections caused by pathogens of low infectivity such as herpes may necessitate the enrollment of highly sexually active couples over longer observation periods. Risk of STD Exposure and Behaviors The association between behavior and exposure to infected sex partners may be effectively studied among partnered and nonpartnered persons. Behaviors of both the respondent and his/her partners are critical determinants of exposure risk. A large number of behavioral and epidemiologic indicators are used in attempts to assess partners’ infection status. Parameters including number of sex partners, number of new partners, presence of concurrent partnerships, the gap between sex partners, partners’ number of partners, and risk status of partners’ partners have all been used to assess sex partners’ infection status. The particular sexually transmitted infection under consideration may have important implications for the study of the association between risk of STD exposure and related behaviors. The association may be easier to study when the sexually transmitted infection under consideration is moderately prevalent in a population. For sexually transmitted infections of very low prevalence, e.g., chancroid in the United States, even very large numbers of new partners or high levels of concurrency may not be associated with risk of STD exposure. Conversely, for sexually transmitted infections of very high prevalence, e.g., human papillomavirus, even very small numbers of sex partners or low levels of other risk-taking activities may be associated with risk of STD exposure. Thus, in choosing the study population it is important to consider the specific STD being studied; both the distributions of relevant behaviors and the distribution of infection are important in this context. Measurement Error and the Relationship Between Behaviors and Biomedical Outcomes Measurement of sexual behaviors almost by definition depends on self-reports of respondents. Consequently, sampling procedures, representativeness of the sample of respondents, response or participation rates, item specific response rates, bias in reporting and recall may all contribute to errors in measurement. 18 Systematic measurement errors in study design and analysis may have an important impact on inferences of association. The role of differential misclassification or systematic measurement error is widely recognized and, in most studies, care is taken to minimize this type of bias. 18 The effects of random measurement error, or nondifferential misclassification, on epidemiologic inference often receive less attention. 22 Nondifferential misclassification of exposures and outcomes will lead to an attenuation of the resulting measure of association. Sexual behavior measurement involves the measurement of and cross-adjustment for several sexual behaviors that are often related to each other. Random measurement error in potential confounding variables may influence the inferences made from study results. 22 Nondifferential misclassification of a dichotomous confounding variable may lead to residual confounding and the false appearance of statistical interaction. 23 Random measurement error in confounders that are continuous variables may bias the adjusted measure of association unpredictably. 24,25 Such misclassification is of greatest concern when the exposure-disease association is relatively weak compared to the exposure-confounder and outcome-confounder relation. 26 Small random errors may have major effects on adjusted measures of association, and multivariate analyses may compound the unpredictability of the effects of misclassification. 27 Random measurement error may play an important role in studies that attempt to adjust for sexual behaviors such as numbers and types of sex partners, condom use practices, or number of sex acts. All STD studies that focus on sexual behavior have to adjust for some sexual behaviors as they attempt to measure the effects of others. The relationship between behavior and biomedical parameters in the epidemiology of sexually transmitted infections is complex. The aggregated approach, which tends to combine behaviors related to transmission and behaviors related to exposure as “sexual risk behavior,” and all sexually transmitted infections as “biomedical outcome,” leads to the persistence of the behavioral/biomedical outcome conundrum. Perhaps the time has come for a more analytical, stratified approach.

BACKGROUND:Errors in the classification of male circumcision status could bias studies linking infection to lack of circumcision.GOAL:To determine the frequency and factors associated with the reproducibility of reporting circumcision status.STUDY DESIGN:Secondary analysis of data using logistic regression modeling from a multicenter randomized controlled trial was performed.RESULTS:At follow-up assessment, 15.6% of clinician reports on circumcision status disagreed with baseline reports. Disagreement was more common if both clinicians were women than if both were men (odds ratio [OR], 2.8; 95% CI, 1.9-4.1). As compared with whites reported as circumcised (4%, 19/532 visits), the highest disagreement involved uncircumcised Hispanic (OR, 3.3; 95% CI, 1.7-6.3), white (OR, 12.2; 95% CI, 5.8-25.6), or black (OR, 17.1; 95% CI, 10.4-27.9) men.CONCLUSIONS:This is one study among a small number of studies examining the reproducibility of clinician-reported circumcision status by comparing multiple clinical examinations of the same patient. The magnitude of the misclassification discovered could bias results and indicates the need for greater accuracy in reporting circumcision status in future studies.