Social and behavioural research prospects for sexually transmissible infection prevention in the era of advances in biomedical approaches.

In the past two decades, major advances in biomedical intervention approaches to prevent HIV and many sexually transmissible infections (STIs) have shown great promise. However, challenges to prevention remain in the area of achieving population-level impact for biomedical prevention approaches. In this paper we address what social and behavioural research approaches can contribute beyond well-known behaviour change and counselling interventions. We organise work into five areas. Adherence and disinhibition research is primarily into individual-level constructs pertaining to maximising intervention effectiveness. Coverage research represents a population-level construct germane to maximising efficient prioritisation for prevention. Research covering social determinants, a second population-level construct, contributes to both prioritisation and effectiveness. Finally, disparities and social inequities need to be incorporated into prevention, given the pervasive and persistent disparities found in rates of HIV and STIs and in their antecedents.

Geographic correlates of primary and secondary syphilis among men who have sex with men in the United States.

PURPOSE: Primary and secondary (P&S) syphilis in men who have sex with men (MSM) has been increasing; however, there is a lack of research on geographic factors associated with MSM P&S syphilis. METHODS: We used multiple data sources to examine associations between social and environmental factors and MSM P&S syphilis rates at the state- and county-level in 2014 and 2015, separately. General linear models were used for state-level analyses, and hurdle models were used for county-level models. Bivariate analyses (P < .25) were used to select variables for adjusted models. RESULTS: In 2014 and 2015 state models, a higher percentage of impoverished persons (2014 ß = 1.24, 95% confidence interval, 0.28-2.20; 2015 ß = 1.19; 95% confidence interval, 0.42-1.97) was significantly associated with higher MSM P&S syphilis rates. In the 2015 county model, policies related to sexual orientation (marriage, housing, hate crimes) were significant correlates of MSM P&S syphilis rates (P < .05). CONCLUSIONS: Our state-level findings that poverty is associated with MSM P&S syphilis are consistent with research at the individual level across different subpopulations and various sexually transmitted diseases. Our findings also suggest that more research is needed to further evaluate potential associations between policies and sexually transmitted diseases. Geographic-level interventions to address these determinants may help curtail the rising syphilis rates and their sequelae in MSM.

The Impact of Budget Cuts on Sexually Transmitted Disease Programmatic Activities in State and Local Health Departments With Staffing Reductions in Fiscal Year 2012.

Staffing reductions in state and local health departments in fiscal year 2012 were concentrated in disease investigation specialists and clinicians (local) and disease investigation specialists and administrative staff (state). Local health departments with budget cuts were significantly more likely to report reduced partner services if they had staffing reductions.

Assessing Sexually Transmitted Disease Partner Services in State and Local Health Departments.

State and local health department sexually transmitted disease (STD) programs provide several partner services to reduce disease transmission. Budget cuts and temporary staff reassignments for public health emergencies may affect the provision of partner services. Determining the impact of staffing reductions on STD rates and public health response should be further assessed.

US Public Sexually Transmitted Disease Clinical Services in an Era of Declining Public Health Funding: 2013-14.

BACKGROUND: We examined the infrastructure for US public sexually transmitted disease (STD) clinical services. METHODS: In 2013 to 2014, we surveyed 331 of 1225 local health departments (LHDs) who either reported providing STD testing/treatment in the 2010 National Profile of Local Health Departments survey or were the 50 local areas with the highest STD cases or rates. The sample was stratified by jurisdiction population size. We examined the primary referral clinics for STDs, the services offered and the impact of budget cuts (limited to government funding only). Data were analyzed using SAS, and analyses were weighted for nonresponse. RESULTS: Twenty-two percent of LHDs cited a specialty STD clinic as their primary referral for STD services; this increased to 53.5% of LHDs when combination STD-family planning clinics were included. The majority of LHDs (62.8%) referred to clinics providing same-day services. Sexually transmitted disease clinics more frequently offered extragenital testing for chlamydia and/or gonorrhea (74.7%) and gonorrhea culture (68.5%) than other clinics (52.9%, 46.2%, respectively; P < 0.05). The majority of LHDs (61.5%) reported recent budget cuts. Of those with decreased budgets, the most common impacts were fewer clinic hours (42.8%; 95% confidence interval [CI], 24.4-61.2), reduced routine screening (40.2%; 95% CI, 21.7-58.8) and reductions in partner services (42.1%; 95% CI, 23.6-60.7). One quarter of those with reduced STD budgets increased fees or copays for clients. CONCLUSIONS: Findings demonstrate gaps and reductions in US public STD services including clinical services that play an important role in reducing disease transmission. Furthermore, STD clinics tended to offer more specialized STD services than other public clinics.

Health Care Communication Laws in the United States, 2013: Implications for Access to Sensitive Services for Insured Dependents.

Young adults may not seek sensitive health services when confidentiality cannot be ensured. To better understand the policy environment for insured dependent confidentiality, we systematically assessed legal requirements for health insurance plan communications using WestlawNext to create a jurisdiction-level data set of health insurance plan communication regulations as of March 2013. Two jurisdictions require plan communications be sent to a policyholder, 22 require plan communications to be sent to an insured, and 36 give insurers discretion to send plan communications to the policyholder or insured. Six jurisdictions prohibit disclosure, and 3 allow a patient to request nondisclosure of certain patient information. Our findings suggest that in many states, health insurers are given considerable discretion in determining to whom plan communications containing sensitive health information are sent. Future research could use this framework to analyze the association between state laws concerning insured dependent confidentiality and public health outcomes and related sensitive services.

Willingness to Use Health Insurance at a Sexually Transmitted Disease Clinic: A Survey of Patients at 21 US Clinics.

OBJECTIVES: To survey patients of publicly funded sexually transmitted disease (STD) clinics across the United States about their willingness to use health insurance for their visit. METHODS: In 2013, we identified STD clinics in 21 US metropolitan statistical areas with the highest rates of chlamydia, gonorrhea, and syphilis according to Centers for Disease Control and Prevention surveillance reports. Patients attending the identified STD clinics completed a total of 4364 surveys (response rate = 86.6%). RESULTS: Nearly half of the insured patients were willing to use their health insurance. Patients covered by government insurance were more likely to be willing to use their health insurance compared with those covered by private insurance (odds ratio [OR] = 3.60; 95% confidence interval [CI] = 2.79, 4.65), and patients covered by their parents' insurance were less likely to be willing to use their insurance compared with those covered by private insurance (OR = 0.72; 95% CI = 0.52, 1.00). Reasons for unwillingness to use insurance were privacy and out-of-pocket cost. CONCLUSIONS: Before full implementation of the Affordable Care Act, privacy and cost were barriers to using health insurance for STD services. PUBLIC HEALTH IMPLICATIONS: Barriers to using health insurance for STD services could be reduced through addressing issues of stigma associated with STD care and considering alternative payment sources for STD services.

Sexually Transmitted Infection Testing Among Adolescents and Young Adults in the United States.

PURPOSE: Persons aged 15-25 years have high sexually transmitted infection (STI) rates and suboptimal screening. There has been limited research analyzing barriers to STI testing at a national level. We examined STI testing among 15-25 year olds and reasons for not testing. METHODS: We used data from a national survey of youth. Bivariate and multivariable analyses examined differences in testing behaviors by demographics, separately by sex. Among sexually experienced respondents who reported never being tested, health system-related reasons for not testing were examined in bivariate and multivariable analyses. RESULTS: Females (16.6%) were more likely to have ever been tested compared with males (6.1%, p < .01) in the last 12 months. Among sexually experienced respondents who were never tested, 41.8% did not seek testing because they felt they were not at risk for STIs. Males (60.1%) had significantly higher reports of foregoing testing for confidentiality reasons compared with females (39.9%, p < .01). Non-Hispanic whites (44.9%) the highest reports of this compared with other ethnic/racial groups (p < .01). CONCLUSIONS: This national-level study found that most of the 15-25 year olds never received an STI test. In addition, confidentiality concerns may deter youth from seeking STI testing. Appropriate strategies to minimize these concerns may be useful. Potential strategies to ameliorate these issues may include engaging clinicians who frequently serve adolescents and young adults to address confidentiality issues with youth patients.

The HoMBReS and HoMBReS Por un Cambio Interventions to Reduce HIV Disparities Among Immigrant Hispanic/Latino Men.

Hispanics/Latinos in the United States are affected disproportionately by human immunodeficiency virus (HIV) infection, acquired immunodeficiency syndrome (AIDS), and other sexually transmitted diseases (STDs); however, few effective evidence-based prevention interventions for this population exist. This report describes the Hombres Manteniendo Bienestar y Relaciones Saludables (Men Maintaining Wellbeing and Healthy Relationships) (HoMBReS) intervention, which was developed by a community-based, participatory research partnership in North Carolina and initially implemented during 2005-2009. HoMBReS is an example of an effective intervention that uses lay health advisors (known as Navegantes [navigators]) in the context of existing social networks (i.e., recreational soccer teams) to promote consistent condom use and HIV and STD testing among Hispanic/Latino men. In 2012, HoMBReS was classified as a best-evidence community-level HIV prevention intervention (CDC. Compendium of evidence-based behavioral interventions and best practices for HIV prevention. Atlanta, GA: US Department of Health and Human Services, CDC; 2015). The intervention has been implemented elsewhere, enhanced, and further evaluated in longitudinal intervention and implementation studies. HoMBReS has been adapted for other populations, including men who have sex with men and transgender persons. Additional evaluation has found that Navegantes continue in their roles as health advisors, opinion leaders, and community advocates after study support ends. Hispanic/Latino men's social networks can be leveraged to promote sexual health within the community by decreasing HIV risk behaviors among Hispanics/Latinos in the United States.

Estimating the Size and Cost of the STD Prevention Services Safety Net.

The Patient Protection and Affordable Care Act is expected to reduce the number of uninsured people in the United States during the next eight years, but more than 10% are expected to remain uninsured. Uninsured people are one of the main populations using publicly funded safety net sexually transmitted disease (STD) prevention services. Estimating the proportion of the uninsured population expected to need STD services could help identify the potential demand for safety net STD services and improve program planning. In 2013, an estimated 8.27 million people met the criteria for being in need of STD services. In 2023, 4.70 million uninsured people are expected to meet the criteria for being in need of STD services. As an example, the cost in 2014 U.S. dollars of providing chlamydia screening to these people was an estimated $271.1 million in 2013 and is estimated to be $153.8 million in 2023. A substantial need will continue to exist for safety net STD prevention services in coming years.

Continuing Need for Sexually Transmitted Disease Clinics After the Affordable Care Act.

OBJECTIVES: We assessed the characteristics of sexually transmitted disease (STD) clinic patients, their reasons for seeking health services in STD clinics, and their access to health care in other venues. METHODS: In 2013, we surveyed persons who used publicly funded STD clinics in 21 US cities with the highest STD morbidity. RESULTS: Of the 4364 STD clinic patients we surveyed, 58.5% were younger than 30 years, 72.5% were non-White, and 49.9% were uninsured. They visited the clinic for STD symptoms (18.9%), STD screening (33.8%), and HIV testing (13.6%). Patients chose STD clinics because of walk-in, same-day appointments (49.5%), low cost (23.9%), and expert care (8.3%). Among STD clinic patients, 60.4% had access to another type of venue for sick care, and 58.5% had access to another type of venue for preventive care. Most insured patients (51.6%) were willing to use insurance to pay for care at the STD clinic. CONCLUSIONS: Despite access to other health care settings, patients chose STD clinics for sexual health care because of convenient, low-cost, and expert care. Policy Implication. STD clinics play an important role in STD prevention by offering walk-in care to uninsured patients.

Acculturation, sexual behaviors, and health care access among Hispanic and non-Hispanic white adolescents and young adults in the United States, 2006-2010.

PURPOSE: To examine national estimates of sexual behaviors and health care access by acculturation among adolescents. METHODS: Using the 2006-2010 National Survey of Family Growth, four acculturation groups of Hispanic and non-Hispanic whites aged 15-24 years were analyzed by sexual behaviors and health care access. RESULTS: In analyses adjusted for demographics, English-speaking immigrants, Hispanic natives, and non-Hispanic white youth were less likely to have a partner age difference of ≥6 years (adjusted odds ratio [AOR], .28; 95% confidence interval [CI], .13-.60; AOR, .13; 95% CI, .07-.26; AOR, .16; 95% CI, .08-.32, respectively) and more likely to use a condom at the first vaginal sex (AOR, 1.99; 95% CI, 1.10-3.61; AOR, 2.10; 95% CI, 1.33-3.31; AOR, 2.39; 95% CI, 1.53-3.74, respectively) than Spanish-speaking immigrants. Non-Hispanic white youth and Hispanic natives were more likely to have a regular place for medical care (AOR, 2.07; 95% CI, 1.36-3.16; AOR, 3.66; 95% CI, 2.36-5.68, respectively) and a chlamydia test in the past 12 months (AOR, 3.62; 95% CI, 1.52-8.60; AOR, 2.94; 95% CI, 1.32-6.54) than Spanish-speaking immigrants. CONCLUSIONS: Interventions to reduce risk and increase health care access are needed for immigrant Hispanic youth, particularly Spanish-speaking immigrants.

Trends in receipt of sexually transmitted disease services among women 15 to 44 years old in the United States, 2002 to 2006-2010.

BACKGROUND: To describe recent trends in the receipt of sexually transmitted disease (STD) services among women (age, 15-44 years) from 2002 to 2006-2010 using the National Survey of Family Growth. METHODS: We analyzed trends in demographics, health insurance, and visit-related variables of women reporting receipt of STD services (counseling, testing, or treatment) in the past 12 months. We also analyzed trends in the source of STD services and the payment method used. RESULTS: Receipt of STD services reported by women in the past 12 months increased from 2002 (12.6%) to 2006-2010 (16.0%; P < 0.001). Receipt of services did not increase among adolescents (P = 0.592). Among women receiving STD services from a private doctor/HMO, the percentage with private insurance decreased over time (74.6%-66.8%), whereas the percentage with Medicaid increased (12.8%-19.7%; P = 0.020). For women receiving STD services at a public clinic or nonprimary care facility, there were no statistically significant differences by demographics, except that fewer adolescents but more young adults reported using a public clinic over time (P = 0.038). Among women who reported using Medicaid as payment, receipt of STD services at a public clinic significantly decreased (36.8%-25.4%; P = 0.019). For women who paid for STD services with private insurance, the only significant difference was an increase in having a copay over time (61.3%-70.1%; P = 0.012). CONCLUSIONS: Despite a significant increase in receipt of STD services over time, many women at risk for STDs did not receive services including adolescents. In addition, we identified important shifts in payment methods during this time frame.

Correlates of self-reported pelvic inflammatory disease treatment in sexually experienced reproductive-aged women in the United States, 1995 and 2006-2010.

BACKGROUND: Few studies have examined recent temporal trends in self-reported receipt of pelvic inflammatory disease (PID) treatment. We assessed trends in receipt of PID treatment and associated correlates using national survey data. METHODS: We used data from the National Survey of Family Growth, a multistage national probability survey of 15- to 44-year-old women. We examined trends in self-reported receipt of PID treatment from 1995, 2002, to 2006-2010. In addition, we examined correlates of PID treatment in 1995 and 2006-2010 in bivariate and adjusted analyses. RESULTS: From 1995 to 2002, receipt of PID treatment significantly declined from 8.6% to 5.7% (P < 0.0001); however, there was no difference from 2002 to 2006-2010 (5.0%, P = 0.16). In bivariate analyses, racial differences in PID treatment declined across time; in 2006-2010, there was no significant difference between racial/ethnic groups (P = 0.22). Also in bivariate analyses, similar to 1995, in 2006 to 2010, some of the highest reports of receipt of PID treatment were women who were 35 to 44 years old (5.6%), had an income less than 150% of poverty level (7.5%), had less than high school education (6.7%), douched (7.7%), had intercourse before age 15 years (10.3%), and had 10 or more lifetime partners (8.0%). In adjusted analyses, differing from 1995, women at less than 150% of the poverty level were more likely (adjusted odds ratio [AOR], 2.60; 95% confidence interval [CI], 1.79-3.76) than women at 300% or more of the poverty level to have received PID treatment in 2006-2010. CONCLUSIONS: Receipt of PID treatment declined from 1995 to 2006-2010, with the burden affecting women of lower socioeconomic status.

The association between racial disparity in income and reported sexually transmitted infections.

OBJECTIVES: We examined the association between racial disparity in income and reported race-specific county-level bacterial sexually transmitted infections (STIs) in the United States focusing on disparities between Blacks and Whites. METHODS: Data are from the US 2000 decennial census. We defined 2 race-income county groups (high and low race-income disparity) on the basis of the difference between Black and White median household incomes. We used 2 approaches to examine disparities in STI rates across the groups. In the first approach, we computed and compared race-specific STI rates for the groups. In the second approach, we used spatial regression analyses to control for potential confounders. RESULTS: Consistent with the STI literature, chlamydia, gonorrhea, and syphilis rates for Blacks were substantially higher than were those for Whites. We also found that racial disparities in income were associated with racial disparities in chlamydia and gonorrhea rates and, to a lesser degree, syphilis rates. CONCLUSIONS: Racial disparities in household income may be a more important determinant of racial disparities in reported STI morbidity than are absolute levels of household income.

The use of prescription medications obtained from non-medical sources among immigrant Latinos in the rural southeastern U.S.

We explored the relationships between behavioral, socio-cultural, and psychological characteristics and the use of prescription medications obtained from non-medical sources among predominantly Spanish-speaking Latinos in the rural southeastern U.S. Respondent-driven sampling (RDS) was used to identify, recruit, and enroll immigrant Latinos to participate in an interviewer-administered assessment. A total of 164 respondents were interviewed in 2009. Average age was 34 years old, 64% of respondents were female, and nearly 85% reported being from Mexico. Unweighted and RDS-weighted prevalence estimates of any non-medical source of prescription medications were 22.6% and 15.1%, respectively. In multivariable modeling, respondents who perceived their documentation status as a barrier to health care and those with higher educational attainment were significantly more likely to report use of non-medical sources. Interventions are needed to increase knowledge of eligibility to sources of medical care and treatment and ensure culturally congruent services for immigrant communities in the U.S.

Intent to receive HPV vaccine and reasons for not vaccinating among unvaccinated adolescent and young women: findings from the 2006-2008 National Survey of Family Growth.

BACKGROUND AND PURPOSE: HPV vaccine coverage for females has increased in the U.S., although challenges to achieving high coverage remain. HPV vaccine coverage continues to lag behind that of other routinely recommended adolescent vaccines and these gaps in coverage are widening. To inform strategies to improve uptake, we explore correlates of vaccine intention and describe reasons for refusing HPV vaccination among unvaccinated females in a nationally representative sample of adolescents and young adults during early stages of HPV vaccine availability. METHODS: In 2007-2008, 1243 females aged 15-24 years were asked about HPV vaccination in the National Survey of Family Growth (NSFG). For unvaccinated women (n=955), we evaluated demographic and sexual behavior correlates of likelihood to receive the vaccine in the next 12 months in bivariate and multivariable analyses by age. Correlates to the main reasons for foregoing vaccination are described. RESULTS: A minority (42.5%) of unvaccinated respondents said they intended to receive HPV vaccine in the next 12 months: 37.6% of adolescents (15-19 years) and 42.0% of young adults (20-24 years). Sexually experienced women were more than twice as likely as non-sexually experienced women to intend to receive HPV vaccine (15-19 years: aOR=2.39, 95% CI=1.15, 4.94; 20-24 years: aOR=2.17, 95% CI=1.08, 4.33). Having health insurance was associated with being likely to receive HPV vaccine among adolescents. Hispanic young adults were more likely than non-Hispanic Whites to be likely to receive HPV vaccine. The belief of not being at risk for HPV and institutional barriers were the two most commonly cited reasons for foregoing vaccination.Among unvaccinated women who did not intend to get vaccinated, respondents who never had sex were more likely to report not being at risk as the main reason for not needing the vaccine compared to women with sexual experience (44.5 vs. 24.4%) but this finding was only marginally significant in our limited sample. CONCLUSION: In the first years immediately post-licensure of an HPV vaccine, the majority of unvaccinated women indicated that they were unlikely to seek vaccination. Intent to receive the HPV vaccine is tied to sexual experience and most women who do not intend to get vaccinated and have never had sex believe they are not at risk of HPV or do not need an HPV vaccine. These findings highlight the need to better communicate information regarding lifetime risk for HPV and the importance of receiving HPV vaccine prior to sexual initiation. These findings should inform strategies to increase vaccine uptake.