Diverging Neisseria gonorrhoeae Morbidity in Non-Hispanic Black and White Females: Application of Group-Based Trajectory Modeling to Trends in County-Level Morbidity 2003-2018.

National trends in gonorrhea rates may obscure informative local variations in morbidity. We used group-based trajectory models to identify groups of counties with similar gonorrhea rate trajectories among non-Hispanic White (NHW) and non-Hispanic Black (NHB) females using county-level data on gonorrhea cases in US females from 2003 to 2018. We assessed models with 1-15 groups and selected final models based on fit statistics and identification of divergent trajectory groups with distinct intercepts and/or slopes. We mapped counties by assigned trajectory group and examined the association of county characteristics with group membership. We identified 7 distinct gonorrhea trajectory groups for NHW females and 9 distinct trajectory groups for NHB females. All identified groups for NHW female morbidity experienced increasing gonorrhea rates with a limited range (11.6-183.3/100,000 NHW females in 2018); trajectories of NHB female morbidity varied widely in rates (146.6-966.0/1000 NHB females in 2018) and included 3 groups of counties that experienced a net decline in gonorrhea rates. Counties with higher NHW female morbidity had lower adult sex ratios, lower health insurance coverage, and lower marital rates among NHW adults. Counties with higher NHB female morbidity were more urban, experienced higher rates of poverty, and had lower rates of marriage among NHB adults. Morbidity patterns did not always follow geographic proximity, which could be explained by variation in social determinants of health. Our results demonstrated a highly heterogenous gonorrhea epidemic among NHW and NHB US females, which should prompt further analysis into the differential drivers of gonorrhea morbidity.

Trends and Characteristics of Sexually Transmitted Infections During Pregnancy: United States, 2016-2018.

Objectives-This report presents data on recent trends for three sexually transmitted infections (STIs)-chlamydia, gonorrhea, and syphilis-reported among women giving birth in the United States from 2016 through 2018, and rates by selected characteristics for 2018. Methods-Data are from birth certificates and are based on 100% of births registered in the United States for 2016, 2017, and 2018. Birth certificate data on infections during pregnancy are recommended to be collected from the mother's medical records (1). Mothers are to be reported as having an infection if there is a confirmed diagnosis or documented treatment for the infection in their medical record (2). Results-Among women giving birth in 2018, the overall rates of chlamydia, gonorrhea, and syphilis were 1,843.9, 310.2, and 116.7 per 100,000 births, respectively. The rates for these STIs increased 2% (chlamydia), 16% (gonorrhea), and 34% (syphilis) from 2016 through 2018. In 2018, rates of chlamydia and gonorrhea decreased with advancing maternal age, whereas those for syphilis decreased with maternal age through 30-34 years and then increased for women aged 35 and over. In 2018, rates of all three STIs were highest for non-Hispanic black women, women who smoked during pregnancy, women who received late or no prenatal care, and women for whom Medicaid was the principal source of payment for the delivery. Among women aged 25 and over, rates of each of the STIs decreased with increasing maternal education.

Diagnosis and Treatment of Sexually Transmitted Infections: A Review.

Importance: Approximately 1 in 5 adults in the US had a sexually transmitted infection (STI) in 2018. This review provides an update on the epidemiology, diagnosis, and treatment of gonorrhea, chlamydia, syphilis, Mycoplasma genitalium, trichomoniasis, and genital herpes. Observations: From 2015 to 2019, the rates of gonorrhea, chlamydia, and syphilis increased in the US; from 1999 to 2016, while the rates of herpes simplex virus type 1 (HSV-1) and HSV-2 declined. Populations with higher rates of STIs include people younger than 25 years, sexual and gender minorities such as men and transgender women who have sex with men, and racial and ethnic minorities such as Black and Latinx people. Approximately 70% of infections with HSV and trichomoniasis and 53% to 100% of extragenital gonorrhea and chlamydia infections are asymptomatic or associated with few symptoms. STIs are associated with HIV acquisition and transmission and are the leading cause of tubal factor infertility in women. Nucleic acid amplification tests have high sensitivities (86.1%-100%) and specificities (97.1%-100%) for the diagnosis of gonorrhea, chlamydia, M genitalium, trichomoniasis, and symptomatic HSV-1 and HSV-2. Serology remains the recommended method to diagnose syphilis, typically using sequential testing to detect treponemal and nontreponemal (antiphospholipid) antibodies. Ceftriaxone, doxycycline, penicillin, moxifloxacin, and the nitroimidazoles, such as metronidazole, are effective treatments for gonorrhea, chlamydia, syphilis, M genitalium, and trichomoniasis, respectively, but antimicrobial resistance limits oral treatment options for gonorrhea and M genitalium. No cure is available for genital herpes. Effective STI prevention interventions include screening, contact tracing of sexual partners, and promoting effective barrier contraception. Conclusions and Relevance: Approximately 1 in 5 adults in the US had an STI in 2018. Rates of gonorrhea, chlamydia, and syphilis in the US have increased, while rates of HSV-1 and HSV-2 have declined. Ceftriaxone, doxycycline, penicillin, moxifloxacin, and the nitroimidazoles are effective treatments for gonorrhea, chlamydia, syphilis, Mycoplasma genitalium, and trichomoniasis, respectively, but antimicrobial resistance limits oral therapies for gonorrhea and Mycoplasma genitalium, and no cure is available for genital herpes.

Ethnically diverse urban transmission networks of Neisseria gonorrhoeae without evidence of HIV serosorting.

OBJECTIVE: We aimed to characterise gonorrhoea transmission patterns in a diverse urban population by linking genomic, epidemiological and antimicrobial susceptibility data. METHODS: Neisseria gonorrhoeae isolates from patients attending sexual health clinics at Barts Health NHS Trust, London, UK, during an 11-month period underwent whole-genome sequencing and antimicrobial susceptibility testing. We combined laboratory and patient data to investigate the transmission network structure. RESULTS: One hundred and fifty-eight isolates from 158 patients were available with associated descriptive data. One hundred and twenty-nine (82%) patients identified as male and 25 (16%) as female; four (3%) records lacked gender information. Self-described ethnicities were: 51 (32%) English/Welsh/Scottish; 33 (21%) white, other; 23 (15%) black British/black African/black, other; 12 (8%) Caribbean; 9 (6%) South Asian; 6 (4%) mixed ethnicity; and 10 (6%) other; data were missing for 14 (9%). Self-reported sexual orientations were 82 (52%) men who have sex with men (MSM); 49 (31%) heterosexual; 2 (1%) bisexual; data were missing for 25 individuals. Twenty-two (14%) patients were HIV positive. Whole-genome sequence data were generated for 151 isolates, which linked 75 (50%) patients to at least one other case. Using sequencing data, we found no evidence of transmission networks related to specific ethnic groups (p=0.64) or of HIV serosorting (p=0.35). Of 82 MSM/bisexual patients with sequencing data, 45 (55%) belonged to clusters of ≥2 cases, compared with 16/44 (36%) heterosexuals with sequencing data (p=0.06). CONCLUSION: We demonstrate links between 50% of patients in transmission networks using a relatively small sample in a large cosmopolitan city. We found no evidence of HIV serosorting. Our results do not support assortative selectivity as an explanation for differences in gonorrhoea incidence between ethnic groups.

Two Distinct Gonorrhea Trends and Risk Factors Among Women in Australia.

BACKGROUND: In recent years, gonorrhea notifications have increased in women in Australia and other countries. We measured trends over time and risk factors among Australian Aboriginal and Torres Strait Islander ("Aboriginal") and non-Aboriginal women. METHODS: We conducted a cross-sectional analysis of data from 41 sexual health clinics. Gonorrhea positivity at each patient's first visit (first-test positivity) during the period 2009 to 2016 was calculated. Univariate and multivariate analyses assessed risk factors for first-test positivity in Aboriginal and non-Aboriginal women. RESULTS: Gonorrhea positivity decreased among Aboriginal women (7.1% in 2009 to 5.2% in 2016, P < 0.001) and increased among non-Aboriginal women (0.6%-2.9%, P < 0.001). Among Aboriginal women, first-test positivity was independently associated with living in a regional or remote area (adjusted odds ratio [aOR], 4.29; 95% confidence interval [CI], 2.52-7.31; P < 0.01) and chlamydia infection (aOR, 4.20; 95% CI,3.22-5.47; P < 0.01). Among non-Aboriginal women, first-test positivity was independently associated with greater socioeconomic disadvantage (second quartile: aOR, 1.68 [95% CI, 1.31-2.16; P < 0.01]; third quartile: aOR, 1.54 [95% CI, 1.25-1.89; P < 0.01]) compared with least disadvantaged quartile: recent sex work (aOR, 1.69; 95% CI, 1.37-2.08; P < 0.01), recent injecting drug use (aOR, 1.85; 95% CI, 1.34-2.57; P < 0.01), and chlamydia infection (aOR, 2.35; 95% CI, 1.90-2.91; P < 0.01). For non-Aboriginal women, being aged 16 to 19 years (aOR, 0.62; 95% CI, 0.49-0.80; P < 0.01) compared with those ≥30 years was a protective factor. CONCLUSIONS: These findings highlight 2 different epidemics and risk factors for Aboriginal and non-Aboriginal women, which can inform appropriate health promotion and clinical strategies.

Transactional Sex and Incident Chlamydia and Gonorrhea Among Black Men Who Have Sex With Men in Atlanta, Georgia.

BACKGROUND: Black men who have sex with men (BMSM) are disproportionately affected by sexually transmitted infections (STI), including chlamydia and gonorrhea. Transactional sex is an hypothesized risk factor for STI acquisition in BMSM. METHODS: We estimated the association of transactional sex with incident chlamydia/gonococcal infection among BMSM using longitudinal data from a randomized trial in Atlanta (2012-2015). BMSM were eligible for inclusion if they tested human immunodeficiency virus (HIV)-antibody-negative and reported both ≥2 male sex partners and any condomless anal sex in the last year. We defined chlamydia/gonorrhea incidence as the first occurrence of either rectal or urogenital chlamydia or gonococcal infections after a negative result at enrollment. We used Poisson regression to estimate the incidence rate (IR) for chlamydia/gonorrhea over 12 months. Incidence rate ratios (IRR) compared estimates by reported experience of transactional sex. Subgroup analyses assessed potential heterogeneity by age and sexual identity. RESULTS: This analysis included 416 BMSM, of whom 191 (46%) were gay-identified, 146 (42%) reported a history of transactional sex, and 57 (14%) had prevalent chlamydia/gonococcal infection at baseline. Over a median of 1 year of follow-up, an additional 55 men tested laboratory-positive for chlamydia/gonorrhea (IR, 17.3 per 100 person-years). Transactional sex was not associated with chlamydia/gonorrhea incidence overall. However, among gay-identified BMSM, transactional sex was associated with incident chlamydia/gonorrhea (IRR, 2.9; 95% confidence interval, 1.2-6.8). CONCLUSIONS: Economic and social vulnerabilities may motivate engagement in high-risk sexual behaviors through commodified sex, potentially increasing the burden of STIs among BMSM. In this investigation, the relationship between transactional sex and chlamydia/gonorrhea was not homogenous across BMSM with diverse sexual identities in Atlanta, suggesting that within select sexual networks, transactional sex may drive STI risks. Delivering accessible and targeted STI screening for marginalized BMSM should be prioritized for STI and HIV prevention.

Gonorrhea Prevalence Among Young Women and Men Entering the National Job Training Program, 2000-2017.

Objectives. To examine long-term gonorrhea prevalence trends from a sentinel surveillance population of young people at elevated risk for gonorrhea.Methods. We analyzed annual cross-sectional urogenital gonorrhea screening data from 191 991 women (2000-2017) and 224 348 men (2003-2017) 16 to 24 years of age entering the National Job Training Program, a US vocational training program. We estimated prevalence among women using an expectation-maximization algorithm incorporated into a logistic regression to account for increases in screening test sensitivity; log-binomial regression was used to estimate prevalence among men.Results. The adjusted gonorrhea prevalence among women followed a U-shaped curve, falling from 2.9% to 1.6% from 2000 through 2011 before rising to 2.7% in 2017. The prevalence among men declined from 1.4% to 0.8% from 2003 through 2017. In the case of both women and men, the prevalence was highest across all study years among those who were Black or American Indian/Alaska Native and those who resided in the South or Midwest.Conclusions. Trends among National Job Training Program enrollees suggest that gonorrhea prevalence is rising among young women while remaining low and steady among young men.

The influence of race and sex on gonorrhea and chlamydia treatment in the emergency department.

BACKGROUND: Emergency Departments (EDs) are a care source for patients with sexually transmitted diseases (STDs). St. Louis, MO reports among the highest rates of gonorrhea and chlamydia infection. We examined STD treatment in a high-volume urban ED, in St. Louis MO, to identify factors that may influence treatment. METHODS: A retrospective chart review and analysis was conducted on visits to a high volume, academic ED in St. Louis, MO where patients received a gonorrhea/chlamydia nucleic acid amplification test (NAAT) with a valid matching test result over two years. Using multiple logistic regression, we examined available predictors for under and overtreatment. RESULTS: NAATs were performed on 3.3% of all ED patients during the study period. Overall prevalence was 6.9% for gonorrhea (95% CI: 6.2, 7.7) and 11.6% for chlamydia (95% CI: 10.6, 12.5). Race was not a statistically significant predictor for undertreatment but Black patients were significantly more likely to be overtreated compared to White patients. (OR 1.83, 95% CI: 1.5, 2.2). Females were more likely to be undertreated when positive for infection compared to males (OR 7.34, 95% CI: 4.8, 11.2) and less likely to be overtreated when negative for infection (OR 0.27, 95% CI: 0.2, 0.3). CONCLUSION: The burden of STDs in a high-volume academic ED was significant and treatment varied across groups. Attention should be paid to particular groups, specifically women and patients reporting Black as their race, to ensure appropriate treatment is administered. Patients would benefit from targeted STD management protocols and training in the ED.

The epidemiology of HIV and other sexually transmitted infections in African, Caribbean and Black men in Toronto, Canada.

BACKGROUND: African, Caribbean, and Black (Black) men account for 16.5% of new HIV diagnoses among men in Ontario. There is substantial evidence that sexually transmitted infections (STIs) are associated with increased likelihood of HIV infection; however, little is known regarding the prevalence of HIV/STI co-infections among Black men in Toronto. Progress has been made in understanding factors contributing to racial/ethnic disparities in HIV between among men who have sex with men (MSM). In this study, we investigate within-racial group patterns of HIV/STI infection between Black MSM and Black men who only have sex with women (MSW). METHODS: A cross-sectional descriptive epidemiological study was conducted with a non-probability sample of Black men recruited from Toronto, Ontario. Audio Computer Assisted Self-Interviews (ACASI) surveys were used to collect demographic and behavioral data. Biological specimens were collected to screen for HIV and other STIs. Chi-Square tests were used to compare the prevalence of (1) HIV and current STIs between MSM and MSW and (2) current STIs between people living with HIV and people not living with HIV. Logistic regression models were constructed to assess whether or not history of STIs were associated with current HIV infection. RESULTS: The prevalence of HIV (9.2%), syphilis (7.2%), hepatitis B (2.7%), and high-risk anal HPV (8.4%) and penile HPV (21.3%) infections were high in Black men (N = 487) and were significantly increased in Black MSM compared with MSW; the prevalence of syphilis and high-risk HPV were also increased in men living with HIV. Men with a history of syphilis (OR = 6.48, 95% CI: 2.68,15.71), genital warts (OR = 4.32, 95% CI: 1.79,10.43) or genital ulcers (OR = 21.3, 95% CI: 1.89,239.51) had an increased odds of HIV infection. CONCLUSIONS: The HIV/STI prevalence was high among this sample of Black men, although the study design may have led to oversampling of men living with HIV. The associations between STIs and current HIV infection highlight the need for integrated of HIV/STI screening and treatment programs for Black men. Public health strategies are also needed to reduce disproportionate HIV/STI burden among Black MSM-including improving HPV vaccine coverage.

Extragenital Chlamydia and Gonorrhea in Young Black Men Who Have Sex With Men: Missed Treatment Opportunities for Human Immunodeficiency Virus-Infected Men Who Have Sex With Men?

OBJECTIVES: This study of young black men who have sex with men (YBMSM) assessed the prevalence of extragenital chlamydia and gonorrhea among those testing negative for urethral infections, and compared prevalence of both by human immunodeficiency virus (HIV) status. METHODS: A convenience sample of 609 YBMSM was recruited for a cross-sectional study from 2 sexual health clinics located in Jackson, MS. To detect Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG), nucleic acid amplification testing was performed on urine, rectal swabs, and oral swabs. OraSure was used to detect HIV. RESULTS: Seventy-three percent of all chlamydia infections and 77% of gonorrhea infections were found from anal and oral swabs in the absence of urethral positivity. Compared with HIV-uninfected men, HIV-infected men were significantly more likely to have pharyngeal chlamydia (P = 0.03), multiple CT infections (P = 0.02), rectal NG (P < 0.001), multiple NG infections (P = 0.04), both CT/NG rectal infections (P = 0.001). CONCLUSIONS: As much as three quarters of all chlamydia and gonorrhea infections may be missed when only urine-based nucleic acid amplification testing is used to screen YBMSM for bacterial sexually transmitted infections. These missed opportunities for diagnosis may be particularly likely among HIV-infected YBMSM.

Using Reported Rates of Sexually Transmitted Diseases to Illustrate Potential Methodological Issues in the Measurement of Racial and Ethnic Disparities.

BACKGROUND: Racial disparities in the burden of sexually transmitted diseases (STDs) have been documented and described for decades. Similarly, methodological issues and limitations in the use of disparity measures to quantify disparities in health have also been well documented. The purpose of this study was to use historic STD surveillance data to illustrate four of the most well-known methodological issues associated with the use of disparity measures. METHODS: We manually searched STD surveillance reports to find examples of racial/ethnic distributions of reported STDs that illustrate key methodological issues in the use of disparity measures. The disparity measures we calculated included the black-white rate ratio, the Index of Disparity (weighted and unweighted by subgroup population), and the Gini coefficient. RESULTS: The 4 examples we developed included illustrations of potential differences in relative and absolute disparity measures, potential differences in weighted and nonweighted disparity measures, the importance of the reference point when calculating disparities, and differences in disparity measures in the assessment of trends in disparities over time. For example, the gonorrhea rate increased for all minority groups (relative to whites) from 1992 to 1993, yet the Index of Disparity suggested that racial/ethnic disparities had decreased. CONCLUSIONS: Although imperfect, disparity measures can be useful to quantify racial/ethnic disparities in STDs, to assess trends in these disparities, and to inform interventions to reduce these disparities. Our study uses reported STD rates to illustrate potential methodological issues with these disparity measures and highlights key considerations when selecting disparity measures for quantifying disparities in STDs.

Assessing Spatial Relationships between Race, Inequality, Crime, and Gonorrhea and Chlamydia in the United States.

Incidence rates of chlamydia and gonorrhea reached unprecedented levels in 2015 and are concentrated in southern counties of the USA. Using incidence data from the Center for Disease Control, Moran's I analyses assessed the data for statistically significant clusters of chlamydia and gonorrhea at the county level in 46 states of the USA. Lagrange multiplier diagnostics justified selection of the spatial Durbin regression model for chlamydia and the spatial error model for gonorrhea. Rates of chlamydia (Moran's I = .37, p < .001) and gonorrhea (Moran's I = .38, p < .001) were highly clustered particularly in the southern region of the USA. Logged percent in poverty (B = .49, p < .001 and B = .48, p < .001) and racial composition of African-Americans (B = .16, p < .001 and B = .40, p < .001); Native Americans (B = .12, p < .001 and B = .20, p < .001); and Asians (B = .14, p < .001 and B = .09, p < .001) were significantly associated with greater rates of chlamydia and gonorrhea, respectively, after accounting for spatial dependence in the data. Logged rates of rates violent crimes were associated with chlamydia (B = .053, p < .001) and gonorrhea (B = .10, p < .001). Logged rates of drug crimes (.052, p < .001) were only associated with chlamydia. Metropolitan census designation was associated with logged rates of chlamydia (B = .12, p < .001) and gonorrhea (B = .24, p < .001). Spatial heterogeneity in the distribution of rates of chlamydia and gonorrhea provide important insights for strategic public health interventions in the USA and inform the allocation of limited resources for the prevention of chlamydia and gonorrhea.

Trends in Selected Measures of Racial and Ethnic Disparities in Gonorrhea and Syphilis in the United States, 1981-2013.

BACKGROUND: The purpose of this study was to examine selected measures of racial and ethnic disparities in the reported incidence of syphilis and gonorrhea from 1981 to 2013 in the United States. METHODS: For each year, from 1981 to 2013, we calculated values for 5 disparity measures (Gini coefficient, 2 versions of the index of disparity, population attributable proportion, and the black-to-white rate ratio) for 5 racial/ethnic categories (non-Hispanic white, non-Hispanic black, Hispanic, American Indian/Alaska Native, and Asian/Pacific Islander). We also examined annual and 5-year changes to see if the disparity measures agreed on the direction of change in disparity. RESULTS: With a few exceptions, the disparity measures increased from 1981 to 1993 and decreased from 1993 to 2013, whereas syphilis and gonorrhea rates decreased for most groups from 1981 to 1993 and increased from 1993 to 2013. Overall, the disparity measures we examined were highly correlated with one another, particularly when examining 5-year changes rather than annual changes in disparity. For example, all 5 measures agreed on the direction of change in the disparity of syphilis in 56% of the annual comparisons and in 82% of the 5-year comparisons. CONCLUSIONS: Although the disparity measures we examined were generally consistent with one another, these measures can sometimes yield divergent assessments of whether racial/ethnic disparities are increasing or decreasing for a given sexually transmitted disease from one point in time to another, as well as divergent assessments of the relative magnitude of the change.

Increased Gonorrhea Cases - Utah, 2009-2014.

Gonorrhea (caused by infection with Neisseria gonorrhoeae) is the second most commonly reported notifiable disease in the United States (1). Left untreated, gonorrhea is associated with serious long-term adverse health effects, including pelvic inflammatory disease, ectopic pregnancy, and infertility. Infection also facilitates transmission of human immunodeficiency virus (2,3). Effective gonorrhea control relies upon early detection and effective antimicrobial treatment. To assess gonorrhea rate trends in Utah, the Utah Department of Health (UDOH) analyzed Utah National Electronic Disease Surveillance System (UT-NEDSS) data for the state during 2009-2014. After declining during 2009-2011, the statewide gonorrhea rate increased fivefold to 49 cases per 100,000 population in 2014. During 2009-2014, the proportion of cases among women increased from 21% to 39% (decreasing among males from 79% to 61%). Among male patients, the proportion who identified as men who have sex with men (MSM) decreased from 67% to 42%. These demographic changes suggest that increased heterosexual transmission of gonorrhea in Utah might be occurring. Health departments need to work with providers to ensure populations at high risk are being screened and properly treated for gonorrhea. Clinicians need to be aware of increases in the risk for infection among women and non-MSM males when making screening and testing decisions and educate their patients regarding gonorrhea transmission and prevention practices.

Testing the efficacy of a brief sexual risk reduction intervention among high-risk American Indian adults: study protocol for a randomized controlled trial.

BACKGROUND: American Indian adults are more likely to experience co-occurring mental health and substance use disorders than adults of other racial/ethnic groups and are disproportionately burdened by the most common sexually transmitted infections, namely chlamydia and gonorrhea. Several behavioral interventions are proven efficacious in lowering risk for sexually transmitted infection in various populations and, if adapted to address barriers experienced by American Indian adults who suffer from mental health and substance use problems, may be useful for dissemination in American Indian communities. The proposed study aims to examine the efficacy of an adapted evidence-based intervention to increase condom use and decrease sexual risk-taking and substance use among American Indian adults living in a reservation-based community in the Southwestern United States. METHODS/DESIGN: The proposed study is a randomized controlled trial to test the efficacy of an adapted evidence-based intervention compared to a control condition. Participants will be American Indian adults ages 18-49 years old who had a recent episode of binge substance use and/or suicide ideation. Participants will be randomized to the intervention, a two-session risk-reduction counseling intervention or the control condition, optimized standard care. All participants will be offered a self-administered sexually transmitted infection test. Participants will complete assessments at baseline, 3 and 6 months follow-up. The primary outcome measure is condom use at last sex. DISCUSSION: This is one of the first randomized controlled trials to assess the efficacy of an adapted evidence-based intervention for reducing sexual risk behaviors among AI adults with substance use and mental health problems. If proven successful, there will be an efficacious program for reducing risk behaviors among high-risk adults that can be disseminated in American Indian communities as well as other rural and under-resourced health systems. TRIAL REGISTRATION: Clinical Trials NCT02513225.

A sexual health quality improvement program (SHIMMER) triples chlamydia and gonorrhoea testing rates among young people attending Aboriginal primary health care services in Australia.

BACKGROUND: In Australia, chlamydia is the most commonly notifiable infection and over the past ten years chlamydia and gonorrhoea notification rates have increased. Aboriginal compared with non-Aboriginal Australians have the highest notifications rates of chlamydia and gonorrhoea. Regular testing of young people for chlamydia and gonorrhoea is a key prevention strategy to identify asymptomatic infections early, provide treatment and safe sex education. This study evaluated if a sexual health quality improvement program (QIP) known as SHIMMER could increase chlamydia and gonorrhoea testing among young people attending four Aboriginal primary health care services in regional areas of New South Wales, Australia. METHODS: We calculated the proportion of 15-29 year olds tested and tested positivity for chlamydia and gonorrhoea in a 12-month before period (March 2010-February 2011) compared with a 12-month QIP period (March 2012-February 2013). Logistic regression was used to assess the difference in the proportion tested for chlamydia and gonorrhoea between study periods by gender, age group, Aboriginal status and Aboriginal primary health service. Odds ratios (OR) and their 95 % confidence intervals (CIs) were calculated with significance at p < 0.05. RESULTS: In the before period, 9 % of the 1881 individuals were tested for chlamydia, compared to 22 % of the 2259 individuals in the QIP period (OR): 1.43, 95 % CI: 1.22-1.67). From the before period to the QIP period, increases were observed in females (13 % to 25 %, OR: 1.32, 95 % CI: 1.10-1.59) and males (3 % to 17 %, OR: 1.85, 95 % CI: 1.36-2.52). The highest testing rate in the QIP period was in 15-19 year old females (16 % to 29 %, OR: 1.02, 95 % CI: 0.75-1.37), yet the greatest increase was in 20-24 year olds males (3 % to 19 %, OR: 1.65, 95 % CI: 1.01-2.69). Similar increases were seen in gonorrhoea testing. Overall, there were 70 (11 %) chlamydia diagnoses, increasing from 24 in the before to 46 in the QIP period. Overall, 4 (0.7 %) gonorrhoea tests were positive. CONCLUSIONS: The QIP used in SHIMMER almost tripled chlamydia and gonorrhoea testing in young people and found more than twice as many chlamydia infections. The QIP could be used by other primary health care centres to increase testing among young people.

HIV, Chlamydia, Gonorrhea, and Primary and Secondary Syphilis among American Indians and Alaska Natives Within Indian Health Service Areas in the United States, 2007-2010.

National rates from human immunodeficiency virus (HIV) and sexually transmitted disease (STD) surveillance may not effectively convey the impact of HIV and STDs on American Indian/Alaska Native (AI/AN) communities. Instead, we compared average annual diagnosis rates per 100,000 population of HIV, chlamydia (CT), gonorrhea (GC), and primary and secondary (P&S) syphilis, from 2007 to 2010, among AI/AN aged ≥ 13 years residing in 625 counties in the 12 Indian Health Service Areas, all AI/AN, and all races/ethnicities to address this gap. AI/AN comprised persons reported as AI/AN only, with or without Hispanic ethnicity. Out of 12 IHS Areas, 10 had higher case rates for CT, 3 for GC, and 4 for P&S syphilis compared to rates for all races/ethnicities. Eight Areas had higher HIV diagnosis rates than for all AI/AN, but HIV rates for all IHS Areas were lower than national rates for all races/ethnicities. Two IHS Areas ranking highest in rates of CT and GC and four Areas with highest P&S syphilis also had high HIV rates. STD and HIV rates among AI/AN were greater in certain IHS Areas than expected from observing national rates for AI/AN. Integrated surveillance of overlapping trends in STDs and HIV may be useful in guiding prevention efforts for AI/AN populations.

Notes from the field: increase in gonorrhea cases in counties associated with American Indian Reservations -- Montana, January 2012-August 2014.

In May 2012, the Montana Department of Public Health and Human Services noted that 23 cases of gonorrhea were reported in Roosevelt County during October 2011-March 2012, compared with only three cases during January-September 2011. An analysis of surveillance data for Roosevelt County and the six other Montana counties most closely associated with American Indian (AI) reservations showed that, during 2000-2011, the annual incidence rates in the seven counties ranged from 9-43 cases per 100,000, compared with 4-19 cases per 100,000 for all the remaining 49 Montana counties, and 98-129 cases per 100,000 for the United States. Since May 2012, the rates have continued to increase in the seven counties. The 2012 and 2013 incidence rates in counties associated with AI reservations were 74 and 131 cases per 100,000, respectively, compared with four and 10 cases per 100,000 in the remaining counties, and 108 cases per 100,000 in the United States during 2012. This increase in gonorrhea incidence in counties associated with AI reservations began in 2012. During January 2012-August 2014, of the 553 gonorrhea cases reported in Montana, 315 (57%) had a race classification of AI/Alaska Native (AN). In comparison, 6.5% of Montana's population is classified as AI/AN. Cases were concentrated in few of Montana's 56 counties; 327 (59%) occurred among residents of seven counties associated with AI reservations that are the home of just 9.8% of Montana's population. Among all reported Montana cases, the median patient age was 24 years (range = 12-70 years), and 258 (47%) occurred among males. Gonorrhea incidence in Montana counties associated with AI reservations is now comparable to U.S. incidence rates.

Efficacy of an HIV/STI sexual risk-reduction intervention for African American adolescent girls in juvenile detention centers: a randomized controlled trial.

Few HIV/STI interventions exist for African American adolescent girls in juvenile detention. The objective was to evaluate the efficacy of an intervention to reduce incident STIs, improve HIV-preventive behaviors, and enhance psychosocial outcomes. We conducted a randomized controlled trial among African American adolescent girls (13-17 years, N = 188) in juvenile detention from March 2011 to May 2012. Assessments occurred at baseline and 3- and 6-months post-randomization and included: audio computer-assisted self-interview, condom skills assessment, and self-collected vaginal swab to detect Chlamydia and gonorrhea. The Imara intervention included three individual-level sessions and four phone sessions; expedited partner therapy was offered to STI-positive adolescents. The comparison group received the usual care provided by the detention center: STI testing, treatment, and counseling. At the 6-month assessment (3-months post-intervention), Imara participants reported higher condom use self-efficacy (p < 0.001), HIV/STI knowledge (p < 0.001), and condom use skills (p < 0.001) compared to control participants. No significant differences were observed between trial conditions in incident Chlamydia or gonorrhea infections, condom use, or number of vaginal sex partners. Imara for detained African American adolescent girls can improve condom use skills and psychosocial outcomes; however, a critical need for interventions to reduce sexual risk remains.

Racial variation in toll-like receptor variants among women with pelvic inflammatory disease.

BACKGROUND: Racial disparities exist in gynecological diseases. Variations in Toll-like receptor (TLR) genes may alter signaling following microbial recognition. METHODS: We explored genotypic differences in 6 functional variants in 4 TLR genes (TLR1, TLR2, TLR4, TLR6) and the adaptor molecule TIRAP between 205 African American women and 51 white women with clinically suspected pelvic inflammatory disease (PID). A permutated P < .007 was used to assess significance. Associations between race and endometritis and/or upper genital tract infection (UGTI) were explored. Logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: The TT genotype for TLR1 rs5743618, the GG genotype for TLR1 rs4833095, the CC genotype for TLR2 rs3804099, the TLR6 rs5743810 T allele, and the CC genotype for TIRAP rs8177374 significantly differed between races (P < .007). African American race was associated with endometritis and/or UGTI (OR, 4.2 [95% CI, 2.0-8.7]; P = .01). Among African Americans, the TLR6 rs5743810 T allele significantly decreased endometritis and/or UGTI (OR, 0.4 [95% CI, .2-.9]; P = .04). Additionally, rs5743618, rs4833095, and rs8177374 increased endometritis and/or UGTI, albeit not significantly. CONCLUSIONS: Among women with PID, TLR variants that increase inflammation are associated with African American race and may mediate the relationship between race and endometritis and/or UGTI.