Predictors of PrEP Retention and Attrition in an Urban Publicly Funded Safety-net Specialty Clinic.

Pre-exposure prophylaxis (PrEP) is an effective tool for human immunodeficiency virus (HIV) prevention. The purpose of this study is to identify correlates of PrEP retention using patient data from an urban, publicly funded safety-net clinic in Washington, DC. Cox proportional hazards regression, logistical regression, and survival curves were used to assess the association of age, gender, race/ethnicity, insurance, number of partners, and sexually transmitted infection (STI) diagnosis at PrEP initiation with time on PrEP. From August 2016-December 2020, 1,126 people were prescribed PrEP - patients were mostly Black (44.8%) or Latinx (30.4%) and identified as cisgender men (84.6%). Half had no insurance (49.1%), with the remaining patients reporting private (28.9%) or public (21.5%) insurance. Age at PrEP prescription ranged from 15 to 66 with 80% being 20 to 39 years. For the 87.7% (n = 987) of patients who discontinued PrEP, mean PrEP time was 158 days and median was 28 days. The highest rates of discontinuation were observed within the first month with 44.3% discontinuing by day 30, 52.3% by 3 months, and 73.2% by 1 year. Cisgender women, transgender persons, and those younger than 30 years were more likely to discontinue PrEP. Latinx and patients with less than 3 male partners in the last 90 days were less likely to discontinue PrEP. We demonstrated a high level of PrEP uptake among populations disproportionally affected by HIV. Future analyses are needed to examine ways of reducing barriers to PrEP initiation and improving PrEP adherence.

Refining Timely Diagnosis of Early Syphilis by Using Treponema pallidum PCR or IgM Immunoblotting Next to Conventional Serology for Syphilis.

Treponema pallidum subsp. pallidum is a fastidious spirochete and the etiologic agent of syphilis, a sexually transmitted infection (STI). Syphilis diagnoses and disease staging are based on clinical findings and serologic testing. Moreover, according to most international guidelines, PCR analysis of swab samples from genital ulcers is included in the screening algorithm where possible. It has been suggested that PCR might be omitted from the screening algorithm due to low added value. As an alternative to PCR, IgM serology might be used. In this study, we wanted to establish the added value of PCR and IgM serology for diagnosing primary syphilis. Added value was defined as finding more cases of syphilis, preventing overtreatment, or limiting the extent of partner notification to more recent partners. We found that both PCR and IgM immunoblotting could aid the timely diagnosis of early syphilis in ~24% to 27% of patients. PCR has the greatest sensitivity and can be applied to cases with an ulcer with suspected reinfection or primary infection. In the absence of lesions, the IgM immunoblot could be used. However, the IgM immunoblot has better performance in cases with suspected primary infection than in reinfections. The target population, testing algorithm, time pressures, and costs should determine whether either test provides sufficient value to be implemented in clinical practice.

Testing for sexually transmitted infection: who and where? A data linkage study using population and provider data in the Rotterdam area, the Netherlands.

BACKGROUND: In the Netherlands, insight into sexually transmitted infection (STI) testing and characteristics of those tested by general practitioners (GPs) and sexual health centres (SHC) is limited. This is partly due to lacking registration of socio-demographics at GPs. We aimed to fill this gap by linking different registers. METHODS: Individual STI testing data of GPs and SHC were linked to population register data (aged ≥15 years, Rotterdam area, 2015-2019). We reported population-specific STI positivity, proportion STI tested, and GP-SHC testing rate comparison using negative binomial generalised additive models. Factors associated with STI testing were determined by the provider using logistic regression analyses with generalised estimating equations. RESULTS: The proportion of STI tested was 2.8% for all residents and up to 9.8% for younger and defined migrant groups. STI positivity differed greatly by subgroup and provider (3.0-35.3%). Overall, GPs performed 3 times more STI tests than the SHC. The smallest difference in GP-SHC testing rate was for 20-24-year-olds (SHC key group). Younger age, non-western migratory background, lower household income, living more urbanised, and closer to a testing site were associated with STI testing by either GP or SHC. GPs and SHC partly test different groups: GPs test women and lower-educated more often, the SHC men and middle/higher educated. CONCLUSIONS: This study highlights GPs' important role in STI testing. The GPs' role in the prevention, diagnosis, and treatment of STIs needs continued support and strengthening. Inter-professional exchange and collaboration between GP and SHC is warranted to reach vulnerable groups.

The characteristics of patients frequently tested and repeatedly infected with Chlamydia trachomatis in Southwest Limburg, the Netherlands.

BACKGROUND: Repeat Chlamydia trachomatis (CT) infections are common. To better understand the characteristics of patients frequently infected with CT at our sexually transmitted infection (STI) care services, we assessed the differences between patients repeatedly infected with CT and those who repeatedly tested negative. METHODS: In this cross-sectional analysis of cohort data, we assessed individuals tested for CT at different STI care providers between 2011 and mid-2018 in Southwest Limburg, the Netherlands (n = 17,616). Patients with ≥2 repeat CT infections in the study period were categorized as "patients with repeat CT infections." Multivariable logistic regression analyses were performed for the binary outcome measure: patients with repeat CT infections versus patients who repeatedly tested negative (reference group). Additional analyses were performed for only the STI clinic population. RESULTS: Patients aged < 25 years (OR: 1.83; 95%CI:1.38-2.43), co-infected with HIV (OR: 2.07; 95%CI: 1.02-4.22) or co-infected with Neisseria gonorrhoeae (NG) (OR: 5.04; 95%CI: 3.33-7.63) had more repeat CT infections. In additional analyses among exclusively STI clinic visitors, patients with urogenital symptoms (OR: 2.17; 95%CI: 1.41-3.35), and patients notified for STIs (OR: 4.55; 95%CI: 3.17-6.54) had more frequent repeat CT infections. CONCLUSIONS: Patients aged < 25 years and patients coinfected with HIV or NG had more frequent repeat CT infections, accounting for ~ 20% of the diagnosed CT infections. These patients are likely at the highest risk for transmitting and acquiring CT. Therefore, testing and retesting this group remains important to enhance CT control.

Study protocol of the iMPaCT project: a longitudinal cohort study assessing psychological determinants, sexual behaviour and chlamydia (re)infections in heterosexual STI clinic visitors.

BACKGROUND: Chlamydia trachomatis (chlamydia), the most commonly reported sexually transmitted infection (STI) in the Netherlands, can lead to severe reproductive complications. Reasons for the sustained chlamydia prevalence in young individuals, even in countries with chlamydia screening programs, might be the asymptomatic nature of chlamydia infections, and high reinfection rates after treatment. When individuals are unaware of their infection, preventive behaviour or health-care seeking behaviour mostly depends on psychological determinants, such as risk perception. Furthermore, behaviour change after a diagnosis might be vital to reduce reinfection rates. This makes the incorporation of psychological determinants and behaviour change in mathematical models estimating the impact of interventions on chlamydia transmission especially important. Therefore, quantitative real-life data to inform these models is needed. METHODS: A longitudinal cohort study will be conducted to explore the link between psychological and behavioural determinants and chlamydia (re)infection among heterosexual STI clinic visitors aged 18-24 years. Participants will be recruited at the STI clinics of the public health services of Amsterdam, Hollands Noorden, Kennemerland, and Twente. Participants are enrolled for a year, and questionnaires are administrated at four time points: baseline (before an STI consultation), three-week, six-month and at one-year follow-up. To be able to link psychological and behavioural determinants to (re)infections, participants will be tested for chlamydia at enrolment and at six-month follow-up. Data from the longitudinal cohort study will be used to develop mathematical models for curable STI incorporating these determinants to be able to better estimate the impact of interventions. DISCUSSION: This study will provide insights into the link between psychological and behavioural determinants, including short-term and long-term changes after diagnosis, and chlamydia (re)infections. Our mathematical model, informed by data from the longitudinal cohort study, will be able to estimate the impact of interventions on chlamydia prevalence, and identify and prioritise successful interventions for the future. These interventions could be implemented at STI clinics tailored to psychological and behavioural characteristics of individuals. TRIAL REGISTRATION: Dutch Trial Register NTR-6307 . Retrospectively registered 11-nov-2016.

Repeat Chlamydia trachomatis testing among heterosexual STI outpatient clinic visitors in the Netherlands: a longitudinal study.

BACKGROUND: Chlamydia infections are common in both men and women, are often asymptomatic and can cause serious complications. Repeat testing in high-risk groups is therefore indicated. In the Netherlands, guidelines on repeat chlamydia testing differ between testing facilities, and knowledge on repeat testing behaviour is limited. Here, we analyse the current repeat testing behaviour of heterosexual STI clinic visitors, and aim to identify groups for which repeat testing advice could be advantageous. METHODS: Longitudinal surveillance data from all Dutch STI outpatient clinics were used, which included all STI clinic consultations carried out among heterosexual men and women between June 2014 and December 2015. Repeat testing was defined as returning to the same STI clinic between 35 days and 12 months after initial consultation. We calculated chlamydia positivity at repeat test stratified by initial test result and time between consultations. Logistic regression analyses were used to identify predictors of repeat testing, and predictors of having a chlamydia positive repeat test. RESULTS: In total, 140,486 consultations in 75,487 women and 46,286 men were available for analyses. Overall, 15.4% of women and 11.1% of men returned to the STI clinic within the study period. Highest chlamydia positivity at repeat test was seen 3-5 months after initial positive test. Among both women and men, repeat testing was associated with non-Western ethnicity, having had more than two sex partners in the past 6 months, reporting STI symptoms, having a history of STI, and having a chlamydia positive initial test. Among repeat testers, chlamydia positive repeat test was most strongly associated with younger age, followed by a chlamydia positive initial test. CONCLUSIONS: Repeat testing most often resulted in a positive test result among young heterosexuals (<25) and heterosexuals of any age with a chlamydia infection at the initial consultation. Further efforts are needed to determine optimal repeat testing strategies.

Chlamydia trachomatis re-infection in Spain: A STI clinic-based cohort study.

BACKGROUND: Chlamydia trachomatis (C. trachomatis) is the most frequently reported sexually transmitted infection (STI) in developed countries, but there is a lack data on its incidence and population dynamics in Spain. The objectives of this study were to estimate the incidence of C. trachomatis in patients seeking medical attention in an STI clinic with a defined population catchment area, to identify factors associated with this infection, and to explore differences between factors associated with new infections and re-infections. METHODS: A retrospective study was conducted on a cohort of patients from a STI clinic who underwent chlamydia testing at least twice between 2007 and 2015. RESULTS: Of the 2633 patients who met study selection criteria, 795 (30.2%) tested positive for C. trachomatis at baseline (baseline Chlamydia). The overall incidence was 7.97/100 person-years (95% CI: 7.2-8.8): 5.9/100 person-years (95% CI: 5.2-6.7) among patients testing negative for C. trachomatis at baseline, and 18.3 person-years (95% CI: 15.6-21.5) among those testing positive at baseline. In multivariate analysis, the factors independently associated with overall incidence were a history of infection with C. trachomatis in the previous 6 months (hazard ratio=3.6; 95% CI: 2.3-5.4), younger age (HR <20 vs ≥35 years=5.5; 95% CI: 3.2-9.5), male sex, 2 or more sexual partners in the previous month and year, and inconsistent condom use. CONCLUSIONS: Guidelines should be established for C. trachomatis in Spain, including recommendations on the need for follow-up and re-testing, independently of age. Though data concerning the optimal timing of re-testing are inconclusive, our findings support the establishment of a 3-6 month interval.

Evidence for increased Chlamydia case finding after the introduction of rectal screening among women attending 2 Canadian sexually transmitted infection clinics.

BACKGROUND: Chlamydia trachomatis is the most common notifiable disease in Canada, and extragenital sites are believed to serve as hidden reservoirs for ongoing transmission of infection. There are no specific Canadian screening guidelines for asymptomatic individuals from extragenital sites. We sought to determine the prevalence and factors associated with rectal C. trachomatis among female sexually transmitted infection (STI) clinic attendees in Alberta, Canada. METHODS: Between 20 July and 31 December 2012, all female attendees at 2 Provincial STI clinics receiving a pelvic examination, regardless of a history of anal intercourse, were screened for rectal C. trachomatis using the Gen-Probe Aptima COMBO 2 Assay. Demographic and behavior variables were compared between rectal-only chlamydia cases and genitourinary cases using χ(2) or Fisher exact test, Mann-Whitney test, and logistic regression. RESULTS: A total of 3055 women were screened for rectal chlamydia. The prevalence of rectal chlamydia ranged from 11.7% to 13.5%. There were 133 rectal-only cases, increasing case detection by 44.3% from 300 genitourinary cases to 433 total cases, ranging from 21.7% to 88.2% by clinic. Women who were a contact to an STI were less likely to have rectal-only chlamydia for both clinics (P ≤ .001). CONCLUSIONS: Our findings add to the growing body of evidence supporting universal rectal screening in high-risk women such as those undergoing pelvic exams at STI clinics.

Pattern and clinico-epidemiological profile of female patients of RTI/STIs attending an STI clinic in Uttarakhand, India.

Context: Reproductive tract infections/sexual tract infections (RTI/STIs) have a huge economic impact in terms of costs of healthcare, loss of productivity and the long-term sequelae. Aims: This study was aimed at documenting the pattern of RTI/STIs and clinico-epidemiological profiles of patients attending an STI clinic. Settings and Design: Seventy-six female patients attending the STI clinic at the Department of Obstetrics and Gynaecology, AIIMS Rishikesh between November 2017 and March 2018 were recruited after taking informed verbal consent in this cross-sectional study. Methods and Materials: All patients were evaluated and managed according to the syndromic approach (NACO). Patients were interviewed and data were entered into a semi-structured questionnaire. Statistical Analysis Used: The data were analysed using Microsoft Excel 2016 (Microsoft Corporation, released September 22, 2015). Results: The average age of the patients was 34.46 ± 8.77 years, with a maximum of patients (41%) in the age group 25-35 years. The majority of patients were from an urban background (62%), Hindu (91%), married (95%) and housewives (74%). Most had some level of formal education (97%) and belonged to the lower middle class (43%). The most common diagnosis was lower abdominal pain (LAP) (68%) followed by vaginal/cervical discharge (VD/CD) (30%). Only one patient out of 76 had genital ulcer disease - herpetic (GUD-H). Conclusions: There is a need for focussed community-based interventions targeting the young, urban, lower-middle-class population to reduce the burden of STIs, particularly LAP.

A study on satisfaction level among patients attending sexually transmitted infections clinic.

INTRODUCTION: Patient satisfaction has become a favourite debate for enhancing quality of OPD services, however it still needs a lot of improvement for the better delivery of health care services. AIM: The aim was to study the satisfaction level among STI (Sexually transmitted infection) patients regarding quality of care and services provided in STI clinic. MATERIALS AND METHODS: The present study was a cross sectional study conducted on 88 patients with ages ranging from 16-65 years attending STI clinic at the department of Dermatology, Venereology and Leprology of a tertiary care hospital in Gujarat, India from December 2016 to april 2017. An effort was made to bring into focus significant areas to target for improvement. Satisfaction was assessed using 13 questions modified from patient satisfaction questionnaire by Wirral Community NHS Trust.Patients were asked to give rating to these questions. Likert's 5 point rating scale was used. RESULTS: It was noticed that total satisfaction in present study was 82.9%. Most of the questions of patient satisfaction were statistically highly significant (p <0.0001). CONCLUSION: Overall patient satisfaction with services provided at our STI Clinic was high (93.2%) except length of waiting time (<30 minutes), waiting area & other amenities of the hospital.

An Abstinence and Safer Sex Intervention for Adolescents Attending the Public Sexually Transmitted Infection Clinic in Singapore.

PURPOSE: The objective of this study was to evaluate the efficacy of a behavioral intervention in increasing secondary abstinence and safer sex among heterosexually active adolescents aged 16-19 years. METHODS: This was a randomized controlled trial conducted at the only national sexually transmitted infection clinic in Singapore. The intervention focused on information giving, motivation, and skills building to abstain or practice safer sex. The outcome measures were self-reported secondary abstinence, consistent condom use, and keeping to one partner in the past 6 months over a 12-month period. We recruited 688 adolescents, with 337 participants receiving intervention and 351 receiving standard care (control). RESULTS: At the 12-month follow-up, 187 (56%) intervention participants and 189 (54%) control participants were retained. Over the 12-month period, the intervention had a significant effect on secondary abstinence in adolescent boys (42% vs. 27%, adjusted risk ratio [aRR] 1.80, 95% confidence interval [CI] 1.29-2.34) but not in adolescent girls (21% vs. 24%, aRR 1.10, 95% CI .68-1.66). Consistent condom use was higher among intervention adolescent girls than control adolescent girls (40% vs. 20%, aRR 2.01, 95% CI 1.32-2.82), but this effect was not evident in adolescent boys (51% vs. 43%, aRR 1.27, 95% CI .78-1.88). Intervention effect on keeping to one partner was evident in both adolescent boys (76% vs. 45%, aRR 1.35, 95% CI 1.06-1.50) and adolescent girls (79% vs. 65%, aRR 1.20, 95% CI 1.02-1.23). CONCLUSIONS: An intervention targeting adolescents in a clinical care setting did achieve an increase in secondary abstinence in adolescent boys, consistent condom use in adolescent girls, and keeping to one partner in both genders at 1-year assessment.

Hepatitis B virus infection among sexually active individuals in Nigeria: a cross-sectional study.

INTRODUCTION: Hepatitis B virus (HBV) infection is a major health challenge in sub-Saharan African countries. Chronic HBV infection is a risk factor for severe disease progression. Perinatal and sexual transmissions of Hepatitis B virus are the main routes of infection in HBV endemic countries like Nigeria. However, there is paucity of data as regards the major contributory route of transmission to chronic HBV infection in this region. Also, in Nigeria, not everyone at high risk of the infection has been identified. Therefore our study investigated the prevalence of HBV infection among sexually active individuals in Nigeria. METHODS: Blood samples collected from 463 participants (360 sexually active individuals and 103 teenagers) recruited from health institutions across the country were tested for the presence of HBsAg, and HBV nucleic acid related antigen (HBVNRAg) by ELISA. Positive samples were further tested for the presence of HBeAg and antiHBe by ELISA. Data were analyzed using Chi-square and binary logistic regression at p = 0.05. RESULTS: HBsAg and HBVNRAg were detected in 10.4% and 7.6% of the participants respectively. STI clinic attendees had the highest prevalence for HBsAg (17%; p = 0.002). Teenagers had the lowest HBsAg (1.9; p = 0.002) and HBVNRAg (2.9%; p = 0.0001) prevalence rates. Male gender (p = 0.01) and reproductive age group (p=0.009) were the major predictors of chronic HBV infection. CONCLUSION: Sexual transmission was identified as the major contributor to chronic HBV infection. Sexually active individuals especially those with STIs are high risk groups for chronic HBV infection. Interventions targeted at this group is therefore recommended.

With whom did you have sex? Evaluation of a partner notification training for STI professionals using motivational interviewing.

OBJECTIVE: To enhance partner notification (PN) practices in Dutch STI clinics, a PN training using motivational interviewing as core strategy was offered to STI professionals and evaluated. METHODS: The effectiveness of PN training on professionals' attitude, self-efficacy, skills and behavior toward PN, was examined using within-subject and between-subject comparison. Before the training and at three months follow-up, a questionnaire was completed by the intervention group (n=54) and a non-random control group (n=37). RESULTS: In the within-subject comparison, positive changes were observed in self-efficacy, skills, and PN behaviors (all p<.05), but not in attitudes toward PN. When we examined differences in change-scores between the intervention and control group, self-efficacy was no longer significant. CONCLUSION: The PN training significantly improved PN skills and -behavior, but had no effect on professionals' attitudes or self-efficacy toward PN. The selection of a convenience control sample seems to offer a more rigorous test of hypotheses than pre-post evaluation only. PRACTICE IMPLICATIONS: The beneficial effect of PN training of STI professionals seems to support a wider roll-out of the training to all STI clinics in the Netherlands, although effects on the number of partners notified and transmissions prevented need to be examined in future research.

Prevalence and risk factors for chronic hepatitis B in HIV patients attended at a sexually-transmitted disease clinic in Vitoria, Brazil

This study assessed the prevalence of and correlated factors for chronic hepatitis B infection (HBV) among HIV patients attending the Reference Center for Sexually Transmitted Infections (STI) and AIDS in Vitória, ES, Brazil. HIV patients were studied from 1993 to 2004, using information recorded in a database of the STI Clinic. Demographic data, clinical characteristics, patterns of risk behavior and test results (ELISA-HIV, IFA-HIV, HBsAg, viral load and CD4 counts) were analyzed. We analyzed 851 HIV patients. Median age was 35.0 (interquartile range 30; 42) years and median years of education was 8.0 (IQR 5; 11). The prevalence of chronic HBV was 3.8 percent (95 percent CI 2.5-5.1). Illicit drug use was reported in 185 (21.7 percent) cases, alcohol abuse in 80 (9.4 percent) cases, men who have sex with men in 116 (13.6 percent) cases, and past STI in 320 (37.6 percent) cases. Chronic HBV was associated with intravenous drug use, male gender, STI associated with HIV diagnosis, and death. There is a need for prevention and assistance strategies to control the evolution of this infection in HIV patients.