Diverging trends in US male-female condom use by STI risk factors: a nationally representative study.

OBJECTIVE: Condom use behaviours are proximal to recent STI increases in the USA, yet it remains unclear whether the use of condoms has changed over time among unmarried, non-cohabiting young men who have sex with women (MSW) and how this variability is influenced by STI risk factors. METHODS: To examine condom use over time among MSW aged 15-29, we used three cross-sectional surveys from the 2002, 2006-2010 and 2011-2017 National Survey of Family Growth. We estimated weighted percentages, adjusted prevalence ratios (APRs) and 95% confidence intervals (CI) to assess changes in condom use, stratified by whether MSW reported any STI risk factors in the past 12 months (ie, perceived partner non-monogamy, male-to-male sex, sex in exchange for money or drugs, sex partner who injects illicit drugs, or an HIV-positive sex partner). RESULTS: We observed a divergence in trends in condom use at last sex between men aged 15 -29 with STI risk factors in the past 12 months and those without such history. We saw significant declines in condom use from 2002 to 2011-2017 among men with STI risk factors (APR=0.80, 95% CI 0.68 to 0.95), specifically among those aged 15-19 (APR=0.73, 95% CI 0.57 to 0.94) or non-Hispanic white (APR=0.71, 95% CI 0.54 to 0.93). In contrast, trends in condom use among men with no STI factors remained stable or increased. Across all time periods, the most prevalent STI risk factor reported was perception of a non-monogamous female partner (23.0%-26.9%). Post-hoc analyses examined whether condom use trends changed once this variable was removed from analyses, but no different patterns were observed. CONCLUSIONS: While STIs have been increasing, men aged 15-29 with STI risk factors reported a decline in condom use. Rising STI rates may be sensitive to behavioural shifts in condom use among young MSW with STI risk factors.

Availability of Sexually Transmitted Disease and HIV Clinical Services: Ending the HIV Epidemic Versus Non-Ending the HIV Epidemic Jurisdictions, 2018.

ABSTRACT: We assessed sexually transmitted disease/human immunodeficiency virus (HIV) service availability at the primary sexually transmitted disease safety net clinic by phase I Ending the HIV Epidemic jurisdiction status. HIV testing was >90%. In Ending the HIV Epidemic jurisdictions, 22% of primary safety net clinics initiated and/or provided preexposure prophylaxis (PrEP), 46.6% provided PrEP education or referral only, and 29.9% did not provide any PrEP services.

Identification of United States Counties at Elevated Risk for Congenital Syphilis Using Predictive Modeling and a Risk Scoring System, 2018.

BACKGROUND: The persistence of congenital syphilis (CS) remains an important concern in the United States. We use the 2018 data to refine a previous predictive model that identifies US counties at elevated risk for CS in 2018. METHODS: Using county-level socioeconomic and health-related data from various sources, we developed a logistic regression predictive model to identify county-level factors associated with a county having had 1 or more CS case reported to the National Notifiable Diseases Surveillance System in 2018. We developed a risk scoring algorithm, identified the optimal risk score cutpoint to identify counties at elevated risk, and calculated the live birth to CS case ratio for counties by predicted risk level to compare counties at elevated risk with counties not at elevated risk. RESULTS: We identified several county-level factors associated with a county having 1 or more CS case in 2018 (area under the curve, 88.6%; Bayesian information criterion, 1551.1). Using a risk score cutoff of 8 or higher (sensitivity, 83.2%; specificity, 79.4%), this model captured 94.7% (n = 1,253) of CS cases born in 2018 and identified 850 (27%) counties as being at elevated risk for CS. The live birth to CS case ratio was lower in counties identified as at elevated risk (2,482) compared with counties categorized as not at elevated risk (10,621). CONCLUSIONS: Identifying which counties are at highest risk for CS can help target prevention efforts and interventions. The relatively low live birth to CS case ratio in elevated risk counties suggests that implementing routine 28-week screening among pregnant women in these counties may be an efficient way to target CS prevention efforts.

Successful Provision of Long-Acting Reversible Contraception in a Sexual Health Clinic.

BACKGROUND: Women who attend sexual health clinics are at high risk for sexually transmitted infections and unintended pregnancy. Long-acting reversible contraceptives (LARC) are very effective contraceptive methods, but the provision of LARC in such clinics is not well described in the literature. METHODS: We conducted a retrospective chart review of women who presented to Denver Sexual Health Clinic for any reason and received family planning services between April 1, 2016, and October 31, 2018. We assessed demographic and clinical factors associated with contraceptive method received and conducted a subanalysis of those with intrauterine device (IUD) insertions on the same-day versus delayed insertion. Among those who received an IUD, we assessed rates of pelvic inflammatory disease (PID) 30 days after insertion. RESULTS: Of the 5064 women who received family planning services in our clinic, 1167 (23%) were using a LARC method at the time of their visit. Of the 3897 who were not using a LARC, fewer women, 12.6%, chose LARC (IUD and progestin implant), compared with 33.3% who chose new short-acting reversible contraceptives. Further analysis of the 270 IUD initiators revealed 202 (74.8%) received the IUD on the same day, whereas 68 (25.2%) had delayed IUD insertion. There were 9 incident cases of gonorrhea or chlamydia in those who received same-day IUD and 1 incident case among those who had delayed IUD insertion. There were no cases of PID at 30 days after insertion in either group. CONCLUSIONS: Study findings support IUD provision in a sexual health clinic on the day of initial visit without increased risk of PID.

Assessing Partner Services Provided by State and Local Health Departments, 2018.

BACKGROUND: Surveillance reports have shown that reported sexually transmitted diseases (STDs) are increasing. The provision of partner services is an effective tool for preventing and reducing the spread of STDs. We examined partner services provided by health departments and assessed for associations with jurisdiction size, STD morbidity, and region. METHODS: We used stratified random sampling to select 668 local health departments (LHDs) and selected all (n = 50) state health departments (SHDs). Rao-Scott χ2 analyses were performed to examine partner services by health department type (SHD vs. LHD), region, jurisdiction size (LHD only), and STD morbidity (LHD only). RESULTS: Approximately 49.0% of LHDs and 88.0% of SHDs responded to the survey. Most LHDs (81.6%) and SHDs (79.5%) provided partner services for some STDs (P = 0.63). Compared with SHDs, a higher proportion of LHDs provided expedited partner therapy for chlamydia (66.8% vs. 34.2%, P < 0.01) and gonorrhea (39.3% vs. 22.9%, P = 0.09). Partner service staff performed other activities such as conducting enhanced surveillance activities (23.0% of LHDs, 34.3% of SHDs; P = 0.20) and participating in outbreak response and emergency preparedness (84.8% of LHDs, 80.0% of SHDs; P = 0.51). Associations were found when partner services were stratified by health department type, jurisdiction size, STD morbidity, and region. All LHDs in high-morbidity areas provided partner services and 45.4% performed serologic testing of syphilis contacts in the field. CONCLUSIONS: A majority of STD programs in LHDs and SHDs provide a variety of partner services and partner service-related activities. It is imperative to continue monitoring the provision of partner services to understand how critical public health needs are being met.

Extent and sufficiency of STD/HIV disease intervention specialists in the United States of America, 2016.

Disease intervention specialists (DIS) conduct partner notification for STD and HIV to interrupt the transmission of STD/HIV. In 2016, we collected information from health departments in the United States of America to determine the number of DIS and whether this number was sufficient for STD/HIV prevention. We identified 1610 STD/HIV DIS positions in the USA and 379 DIS supervisory positions. Of DIS positions, 85% were filled indicating potential issues with turnover. Using nationally reportable data from 2016, we found that states with more primary and secondary syphilis cases had more DIS. DIS participated in public health emergencies in 57% of states. Most USA states indicated that the DIS workforce was not sufficient for STD/HIV prevention. Knowledge of information about DIS workload (e.g. number of STD/HIV cases assigned per DIS) would be helpful.

Trends in factors indicating increased risk for STI among key subpopulations in the United States, 2002-2015.

OBJECTIVES: Within the context of rising rates of reportable STIs in the USA, we used national survey data to examine temporal trends in high-risk factors that indicate need for STI/HIV preventive services among key subpopulations with disproportionate STI rates. METHODS: We used data from the 2002 (n=12 571), 2006-2010 (n=22 682) and 2011-2015 (n=20 621) National Survey of Family Growth (NSFG). NSFG is a national probability survey of 15-44 year olds living in US households. We examined STI risk factors among sexually active men who have sex with men (MSM) and Hispanic, non-Hispanic black, 15-19 year old, 20-24 year old, and 25-29 year old women who have sex with men (WSM) and men who have sex with women (MSW). Risk behaviours included: received money or drugs for sex, gave money or drugs for sex, partner who injected drugs, partner who has HIV, non-monogamous partner (WSM, MSW only) and male partner who had sex with other men (WSM only). Endorsement of any of these behaviours was recoded into a composite variable focusing on factors indicating increased STI risk (yes/no). We used chi-squares and logistic regression (calculating predicted marginals to estimate adjusted prevalence ratios (aPRs)) to examine STI risk factors over time among the key subpopulations. RESULTS: From 2002 to 2011-2015, reported STI risk factors did not change or declined over time among key subpopulations in the USA. In adjusted analyses comparing 2002 to 2011-2015, we identified significant declines among WSM: Hispanics (aPR=0.84 (0.68-1.04), non-Hispanic blacks (aPR=0.69 (0.58-0.82), adolescents (aPR=0.71 (0.55-0.91) and 25-29 year olds (aPR=0.76 (0.58-0.98); among MSW: Hispanics (aPR=0.53 (0.40-0.70), non-Hispanic blacks (aPR=0.74 (0.59-0.94) and adolescents (aPR=0.63 (0.49-0.82); and among MSM (aPR=0.53 (0.34-0.84). CONCLUSIONS: While reported STIs have increased, STI risk factors among key subpopulations were stable or declined. Condom use related to these risk factors, sexual mixing patterns and STI testing should be examined.

Self-Reported Sexually Transmitted Disease-Related Health Services Among Men Who Have Sex With Men in the United States, 2011 to 2017.

From a nationally representative survey, 2011 to 2017, we found that 80.7% of sexually active men who have sex with men were insured and 82.0% had a usual place for care, but only 39.8% received sexual risk assessment and 45.8% received sexually transmitted disease screening, of whom 58.0% received extragenital sexually transmitted disease screening.

Identification of US Counties at Elevated Risk for Congenital Syphilis Using Predictive Modeling and a Risk Scoring System.

BACKGROUND: Although preventable through timely screening and treatment, congenital syphilis (CS) rates are increasing in the United States, occurring in 5% of counties in 2015. Although individual-level factors are important predictors of CS, given the geographic focus of CS, it is also imperative to understand what county-level factors are associated with CS. METHODS: This is a secondary analysis of reported county CS cases to the National Notifiable Diseases Surveillance System during the periods 2014-2015 and 2016-2017. We developed a predictive model to identify county-level factors associated with CS and use these to predict counties at elevated risk for future CS. RESULTS: Our final model identified 973 (31.0% of all US counties) counties at elevated risk for CS (sensitivity, 88.1%; specificity, 74.0%). County factors that were predictive of CS included metropolitan area, income inequality, primary and secondary syphilis rates among women and men who have sex with men, and population proportions of those who are non-Hispanic black, Hispanic, living in urban areas, and uninsured. The predictive model using 2014-2015 CS outcome data was predictive of 2016-2017 CS cases (area under the curve value, 89.2%) CONCLUSIONS: Given the dire consequences of CS, increasing prevention efforts remains important. The ability to predict counties at most elevated risk for CS based on county factors may help target CS resources where they are needed most.

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.

Sexually transmissible infection testing among pregnant women in the US, 2011-15.

Introduction Sexually transmissible infections (STIs) are increasing in the US. Pregnant women and infants are susceptible to serious STI-related sequelae; however, some STIs can be cured during pregnancy with appropriate, timely screening. METHODS: We used data from the 2011-15 National Survey of Family Growth to examine STI testing (in the past 12 months) among women who were pregnant in the past 12 months (n = 1155). In bivariate and multivariable analyses, we examined associations between demographics, health care access and two outcome variables, namely receipt of a chlamydia test and receipt of other STI tests. RESULTS: Among women who were pregnant in the past 12 months, 48% reported receiving a chlamydia test and 54% reported that they received an STI test other than chlamydia in the past 12 months. In adjusted analyses, non-Hispanic Black women were more likely to receive a chlamydia test (adjusted odds ratio (aOR) 2.82; 95% confidence interval (CI) 1.86-4.26) and other STI tests (aOR 2.43; 95% CI 1.58-3.74) than non-Hispanic White women. Women living in a metropolitan statistical area but not the principal city were less likely to report chlamydia (aOR 0.62; 95% CI 0.44-0.86) and other STI (aOR 0.57; 95% CI 0.40-0.81) testing than women living in a principal city. Women born outside the US were significantly less likely to have received a chlamydia test (aOR 0.35; 95% CI 0.19-0.64) or other STI test (aOR 0.34; 95% CI 0.20-0.58), whereas those who had received prenatal care were more likely to receive a chlamydia test (aOR 2.10; 95% CI 1.35-3.28) or another STI test (aOR 2.32; 95% CI 1.54-3.49). CONCLUSIONS: The findings suggest that interventions are needed to increase adherence to recommended STI screenings during pregnancy.

Availability of Injectable Antimicrobial Drugs for Gonorrhea and Syphilis, United States, 2016.

We estimated the availability of the injectable antimicrobial drugs recommended for point-of-care treatment of gonorrhea and syphilis among US physicians who evaluated patients with sexually transmitted infections in 2016. Most physicians did not have these drugs available on-site. Further research is needed to determine the reasons for the unavailability of these drugs.

Pregnancy, Penile-anal Sex, and Other Sexual Behaviors in the United States, 2011-2015.

We used the US national survey data to examine sexual behavior by pregnancy status and found that, overall, pregnant women did not differ from nonpregnant women in penile-anal sex and associated condom use. Compared with nonpregnant women, pregnant women had lower or similar reports of other sexual behaviors.

Sexually Transmitted Infection Risk Reduction Strategies Among US Adolescents and Adults With Multiple Opposite-Sex Sex Partners or Perceived Partner Nonmonogamy, 2011-2017.

BACKGROUND: This study examined condom use and sexually transmitted infection (STI) testing among unmarried, non-cohabiting women and men who had multiple past-year partnerships or perceived their partner's involvement in another sexual relationship. METHODS: We identified 5868 and 5330 unmarried, non-cohabiting sexually active women and men aged 15 to 44 years using National Survey of Family Growth data for 2011 to 2017. To measure multiple partnerships, we created 4 dichotomous variables that included both past-year number of opposite-sex sex partners (1, 2 or more) and perceived partner nonmonogamy (PPNM) (yes, no). Results were stratified by relationship type at last sex ("steady" vs "casual"). RESULTS: Overall, 39.4% of women and 48.3% of men reported multiple partnerships and 23.4% and 24.0% reported PPNM. Lower condom use was seen for women and men who had 2 or more partners in the past year and PPNM than those with only 1 partner and no PPNM (women, 28.5%; 95% confidence interval [CI], 24.1-32.9 vs 39.3%; 95% CI, 36.6-41.9) (men, 37.7%; 33.5-41.8 vs 54.9%; 51.9-57.9). STI testing was higher for groups with PPNM. Men with a steady sex partner had higher prevalence of past-year STI testing if they reported PPNM than not (adjusted prevalence ratio, 2.00; 95% CI, 1.63-2.45). CONCLUSIONS: Screening practices that include a standardized sexual risk assessment could identify those with multiple sex partners or PPNM and improve linkage to STI services. Availability of point-of-care tests and expedited partner therapy could provide targeted strategies that prioritize rapid diagnosis and effective partner treatment which may prevent further STI spread.

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.

Heterosexual Anal and Oral Sex in Adolescents and Adults in the United States, 2011-2015.

BACKGROUND: Heterosexual anal and oral sex are related to the acquisition and transmission of sexually transmitted diseases (STDs). As common reportable STDs (chlamydia, gonorrhea, and syphilis) in the United States are increasing, it is important to understand recent oral and anal sexual behaviors. METHODS: We examined the prevalence and correlates of heterosexual anal and oral sex, associated condom use, and having multiple partners among men and women aged 15 to 44 years. RESULTS: Approximately one third of women and men had ever engaged in anal sex, including 11% of adolescents (15-19 years). Most women and men had ever received or given oral sex (at >75%). Six percent and 7% of women and men, respectively, used a condom at last oral sex compared with 20% and 30% who used a condom at last anal sex. Having multiple sex partners in the past year was most common among adolescents, never or formerly married persons, and those who had a nonmonogamous partner. Less than 10% reported multiple anal sex partners in the past year. A substantial minority had multiple oral or anal sex partners; black women and men had the highest reports of oral sex partners by race/ethnicity. CONCLUSIONS: Anal and oral sex are common sexual practices. Given the low rates of condom use during these behaviors, it is important that recommendations for sexual risk assessments are followed. Tailored messaging regarding risk for STD and human immunodeficiency virus acquisition during oral and anal sex may benefit adolescents, singles, and divorced individuals. Future discussions regarding the benefits of extragenital STD testing for heterosexuals may be useful.

The Spatial Association Between Federally Qualified Health Centers and County-Level Reported Sexually Transmitted Infections: A Spatial Regression Approach.

BACKGROUND: The number of categorical sexually transmitted disease (STD) clinics is declining in the United States. Federally qualified health centers (FQHCs) have the potential to supplement the needed sexually transmitted infection (STI) services. In this study, we describe the spatial distribution of FQHC sites and determine if reported county-level nonviral STI morbidity were associated with having FQHC(s) using spatial regression techniques. METHODS: We extracted map data from the Health Resources and Services Administration data warehouse on FQHCs (ie, geocoded health care service delivery [HCSD] sites) and extracted county-level data on the reported rates of chlamydia, gonorrhea and, primary and secondary (P&S) syphilis (2008-2012) from surveillance data. A 3-equation seemingly unrelated regression estimation procedure (with a spatial regression specification that controlled for county-level multiyear (2008-2012) demographic and socioeconomic factors) was used to determine the association between reported county-level STI morbidity and HCSD sites. RESULTS: Counties with HCSD sites had higher STI, poverty, unemployment, and violent crime rates than counties with no HCSD sites (P < 0.05). The number of HCSD sites was associated (P < 0.01) with increases in the temporally smoothed rates of chlamydia, gonorrhea, and P&S syphilis, but there was no significant association between the number of HCSD per 100,000 population and reported STI rates. CONCLUSIONS: There is a positive association between STI morbidity and the number of HCSD sites; however, this association does not exist when adjusting by population size. Further work may determine the extent to which HCSD sites can meet unmet needs for safety net STI services.

State Requirements for Prenatal Syphilis Screening in the United States, 2016.

Objectives This study assesses U.S. state laws related to prenatal syphilis screening, including whether these laws align with CDC screening recommendations and include legal penalties for failing to screen. Methods Statutes and regulations regarding syphilis screening during pregnancy and at delivery effective in 2016 were examined for all 50 U.S. states and the District of Columbia (DC). Targeted search terms were used to identify laws in legal research databases. The timing of the screening mandates for each state law was coded for: (1) first visit, (2) third trimester, and (3) delivery. Descriptive statistics were calculated to examine the number of states with each type of requirement and whether requirements adhered to the CDC STD treatment guidelines. Results Only six states (11.8%) do not require prenatal syphilis screening. Of states with screening requirements (n = 45), the majority (84.3%) require testing at first prenatal visit or soon after. 17 states (33.3%) require screening during the third trimester with five requiring screening only if the patient is considered at high risk. 8 (15.7%) states require screening at delivery with five requiring testing only if the woman is at high risk. 14 (27.5%) states include punishments for failing to screen (civil penalties, criminal penalties and license revocation). Conclusions for Practice Most states had prenatal syphilis screening requirements; a minority corresponded to or extended CDC recommendations. States vary in when they require testing, who must be tested, and whether a failure to screen could result in a punishment for the provider.