Factors Associated With Delays in Presentation and Treatment of Gonorrhea, Massachusetts 2015-2019.

BACKGROUND: Rates of gonorrhea are increasing across the United States. Understanding and addressing contributing factors associated with longer time to diagnosis and treatment may shorten the duration of infectiousness, which in turn may limit transmission. METHODS: We used Massachusetts data from the US Centers for Disease Control and Prevention Sexually Transmitted Disease Surveillance Network collected between July 2015 and September 2019, along with routinely reported surveillance data, to assess time from gonorrhea symptom onset to presentation to care, and time from presentation to care to receipt of treatment. Factors associated with longer time to presentation (TTP) and time to treatment (TTT) were assessed using Cox proportional hazard models with a constant time variable. RESULTS: Among symptomatic patients (n = 672), 31% did not receive medical care within 7 days of symptom onset. Longer TTP was associated with younger age, female gender, reporting cost as a barrier to care, and provider report of proctitis. Among patients with symptoms and/or known contact to gonorrhea (n = 827), 42% did not receive presumptive treatment. Longer TTT was associated with female gender, non-Hispanic other race/ethnicity, and clinics with less gonorrhea treatment experience. Among asymptomatic patients without known exposure to STI (n = 235), 26% did not receive treatment within 7 days. Longer TTT was associated with sexually transmitted disease clinic/family planning/reproductive health clinics and a test turnaround time of ≥3 days. CONCLUSIONS: Delays in presentation to care and receipt of treatment for gonorrhea are common. Factors associated with longer TTP and TTT highlight multiple opportunities for reducing the infectious period of patients with gonorrhea.

Gaps in HIV Preexposure Prophylaxis Continuum of Care Following State Partner Services for Massachusetts Primary and Secondary Syphilis Cases, 2017 to 2018.

BACKGROUND: Human immunodeficiency virus (HIV) preexposure prophylaxis (PrEP) reduces HIV acquisition. We used a PrEP continuum of care to measure impact of field epidemiologist-facilitated referrals for PrEP-naive infectious syphilis cases across multiple clinical and pharmacy sites of care. METHODS: Retrospective analysis of 2017 to 2018 primary and secondary syphilis cases, medical charts, and pharmacy data to identify PrEP education, referral offer, referral acceptance, first visit, prescription pickup (PrEP initiation) and 2 to 3 months (PrEP persistence). The HIV seroconversion was determined using database match at syphilis diagnosis date and at 12 months. χ 2 or Fisher's exact tests were used to compare demographic characteristics associated with steps with lower progression rates. RESULTS: Of 1077 syphilis cases, partner services engaged 662 of 787 (84%) HIV-negative cases; 490 were PrEP-naive, 266 received education, 166 were offered referral, 67 accepted referral, 30 attended an initial appointment, and 22 were prescribed PrEP. Of 16 with pharmacy data, 14 obtained medication, and 8 persisted on PrEP at 2 to 3 months. Continuum progression was lowest from (1) PrEP-naïve to receiving PrEP education, (2) offered referral to referral acceptance, and (3) referral acceptance to initial PrEP appointment. Men with male partners were more likely to receive PrEP education or accept a referral. Higher social vulnerability was associated with increased PrEP referral acceptance. CONCLUSIONS: Few individuals accepted PrEP referrals and persisted on PrEP. Field and clinic data capture were inconsistent, possibly underestimating referral volume and impact of field engagement. Efforts aimed at increasing referral acceptance and clinic attendance may improve PrEP uptake especially among women and heterosexual men with syphilis.

Can Machine Learning Help Identify Patients at Risk for Recurrent Sexually Transmitted Infections?

BACKGROUND: A substantial fraction of sexually transmitted infections (STIs) occur in patients who have previously been treated for an STI. We assessed whether routine electronic health record (EHR) data can predict which patients presenting with an incident STI are at greatest risk for additional STIs in the next 1 to 2 years. METHODS: We used structured EHR data on patients 15 years or older who acquired an incident STI diagnosis in 2008 to 2015 in eastern Massachusetts. We applied machine learning algorithms to model risk of acquiring ≥1 or ≥2 additional STIs diagnoses within 365 or 730 days after the initial diagnosis using more than 180 different EHR variables. We performed sensitivity analysis incorporating state health department surveillance data to assess whether improving the accuracy of identifying STI cases improved algorithm performance. RESULTS: We identified 8723 incident episodes of laboratory-confirmed gonorrhea, chlamydia, or syphilis. Bayesian Additive Regression Trees, the best-performing algorithm of any single method, had a cross-validated area under the receiver operating curve of 0.75. Receiver operating curves for this algorithm showed a poor balance between sensitivity and positive predictive value (PPV). A predictive probability threshold with a sensitivity of 91.5% had a corresponding PPV of 3.9%. A higher threshold with a PPV of 29.5% had a sensitivity of 11.7%. Attempting to improve the classification of patients with and without repeat STIs diagnoses by incorporating health department surveillance data had minimal impact on cross-validated area under the receiver operating curve. CONCLUSIONS: Machine algorithms using structured EHR data did not differentiate well between patients with and without repeat STIs diagnosis. Alternative strategies, able to account for sociobehavioral characteristics, could be explored.

Modeling the Cost-Effectiveness of Express Multisite Gonorrhea Screening Among Men Who Have Sex With Men in the United States.

BACKGROUND: Men who have sex with men (MSM) experience high rates of gonococcal infection at extragenital (rectal and pharyngeal) anatomic sites, which often are missed without asymptomatic screening and may be important for onward transmission. Implementing an express pathway for asymptomatic MSM seeking routine screening at their clinic may be a cost-effective way to improve extragenital screening by allowing patients to be screened at more anatomic sites through a streamlined, less costly process. METHODS: We modified an agent-based model of anatomic site-specific gonococcal infection in US MSM to assess the cost-effectiveness of an express screening pathway in which all asymptomatic MSM presenting at their clinic were screened at the urogenital, rectal, and pharyngeal sites but forewent a provider consultation and physical examination and self-collected their own samples. We calculated the cumulative health effects expressed as gonococcal infections and cases averted over 5 years, labor and material costs, and incremental cost-effectiveness ratios for express versus traditional scenarios. RESULTS: The express scenario averted more infections and cases in each intervention year. The increased diagnostic costs of triple-site screening were largely offset by the lowered visit costs of the express pathway and, from the end of year 3 onward, this pathway generated small cost savings. However, in a sensitivity analysis of assumed overhead costs, cost savings under the express scenario disappeared in the majority of simulations once overhead costs exceeded 7% of total annual costs. CONCLUSIONS: Express screening may be a cost-effective option for improving multisite anatomic screening among US MSM.

Potential for Point-of-Care Tests to Reduce Chlamydia-associated Burden in the United States: A Mathematical Modeling Analysis.

BACKGROUND: Point-of-care testing (POCT) assays for chlamydia are being developed. Their potential impact on the burden of chlamydial infection in the United States, in light of suboptimal screening coverage, remains unclear. METHODS: Using a transmission model calibrated to data in the United States, we estimated the impact of POCT on chlamydia prevalence, incidence, and chlamydia-attributable pelvic inflammatory disease (PID) incidence, assuming status quo (Analysis 1) and improved (Analysis 2) screening frequencies. We tested the robustness of results to changes in POCT sensitivity, the proportion of patients getting treated immediately, the baseline proportion lost to follow-up (LTFU), and the average treatment delay. RESULTS: In Analysis 1, high POCT sensitivity was needed to reduce the chlamydia-associated burden. With a POCT sensitivity of 90%, reductions from the baseline burden only occurred in scenarios in which over 60% of the screened individuals would get immediate treatment and the baseline LTFU proportion was 20%. With a POCT sensitivity of 99% (baseline LTFU 10%, 2-week treatment delay), if everyone were treated immediately, the prevalence reduction was estimated at 5.7% (95% credible interval [CrI] 3.9-8.2%). If only 30% of tested persons would wait for results, the prevalence reduction was only 1.6% (95% CrI 1.1-2.3). POCT with 99% sensitivity could avert up to 12 700 (95% CrI 5000-22 200) PID cases per year, if 100% were treated immediately (baseline LTFU 20% and 3-week treatment delay). In Analysis 2, when POCT was coupled with increasing screening coverage, reductions in the chlamydia burden could be realized with a POCT sensitivity of 90%. CONCLUSIONS: POCT could improve chlamydia prevention efforts if test performance characteristics are significantly improved over currently available options.

More Screening or More Disease? Gonorrhea Testing and Positivity Patterns Among Men in 3 Large Clinical Practices in Massachusetts, 2010-2017.

BACKGROUND: Gonorrhea diagnosis rates in the United States increased by 75% during 2009-2017, predominantly in men. It is unclear whether the increase among men is being driven by more screening, an increase in the prevalence of disease, or both. We sought to evaluate changes in gonorrhea testing patterns and positivity among men in Massachusetts. METHODS: The analysis included men (aged ≥15 years) who received care during 2010-2017 in 3 clinical practice groups. We calculated annual percentages of men with ≥1 gonorrhea test and men with ≥1 positive result, among men tested. Log-binomial regression models were used to examine trends in these outcomes. We adjusted for clinical and demographic characteristics that may influence the predilection to test and probability of gonorrhea disease. RESULTS: On average, 306 348 men had clinical encounters each year. There was a significant increase in men with ≥1 gonorrhea test from 2010 (3.1%) to 2017 (6.4%; adjusted annual risk ratio, 1.12; 95% confidence interval, 1.12-1.13). There was a significant, albeit lesser, increase in the percentage of tested men with ≥1 positive result (1.0% in 2010 to 1.5% in 2017; adjusted annual risk ratio, 1.07; 95% confidence interval, 1.04-1.09). CONCLUSIONS: We estimated significant increases in the annual percentages of men with ≥1 gonorrhea test and men with ≥1 positive gonorrhea test result between 2010 and 2017. These results suggest that observed increases in gonorrhea rates could be explained by both increases in screening and the prevalence of gonorrhea.

Population-level Benefits of Extragenital Gonorrhea Screening Among Men Who Have Sex With Men: An Exploratory Modeling Analysis.

BACKGROUND: Men who have sex with men (MSM) are disproportionately burdened by gonorrhea and face high rates of extragenital (rectal and pharyngeal) infection, which is mostly asymptomatic and often missed by urogenital-only screening. Extragenital screening likely remains below Centers for Disease Control and Prevention-recommended levels. Because increasing screening coverage is often resource-intensive, we assessed whether improved extragenital screening among men already presenting at clinics could lead to substantial reductions in prevalence and incidence. METHODS: We calibrated an agent-based model of site- and race-specific gonorrhea infection in MSM to explicitly model multisite infection within an individual and transmission via anal, orogenital, and ororectal sex. Compared with current screening levels, we assessed the impact of increasing screening at (1) both extragenital sites, (2) only the rectal site, and (3) only the pharyngeal site among men already being urogenitally screened. RESULTS: All scenarios reduced prevalence and incidence, with improved screening at both extragenital sites having the largest effect across outcomes. Extragenitally screening 100% of men being urogenitally screened reduced site-specific prevalence by an average of 42% (black MSM) and 50% (white MSM), with these values dropping by approximately 10% and 20% for each race group when targeting only the rectum and only the pharynx, respectively. However, increasing only rectal screening was more efficient in terms of the number of screens needed to avert an infection as this avoided duplicative screens due to rectum/pharynx multisite infection. CONCLUSIONS: Improved extragenital screening substantially reduced site-specific gonorrhea prevalence and incidence, with strategies aimed at increasing rectal screening proving the most efficient.

The Potential Population-Level Impact of Different Gonorrhea Screening Strategies in Baltimore and San Francisco: An Exploratory Mathematical Modeling Analysis.

BACKGROUND: Baltimore and San Francisco represent high burden areas for gonorrhea in the United States. We explored different gonorrhea screening strategies and their comparative impact in the 2 cities. METHODS: We used a compartmental transmission model of gonorrhea stratified by sex, sexual orientation, age, and race/ethnicity, calibrated to city-level surveillance data for 2010 to 2017. We analyzed the benefits of 5-year interventions which improved retention in care cascade or increased screening from current levels. We also examined a 1-year outreach screening intervention of high-activity populations. RESULTS: In Baltimore, annual screening of population aged 15 to 24 years was the most efficient of the 5-year interventions with 17.9 additional screening tests (95% credible interval [CrI], 11.8-31.4) needed per infection averted while twice annual screening of the same population averted the most infections (5.4%; 95% CrI, 3.1-8.2%) overall with 25.3 (95% CrI, 19.4-33.4) tests per infection averted. In San Francisco, quarter-annual screening of all men who have sex with men was the most efficient with 16.2 additional (95% CrI, 12.5-44.5) tests needed per infection averted, and it also averted the most infections (10.8%; 95% CrI, 1.2-17.8%). Interventions that reduce loss to follow-up after diagnosis improved outcomes. Depending on the ability of a short-term outreach screening to screen populations at higher acquisition risk, such interventions can offer efficient ways to expand screening coverage. CONCLUSIONS: Data on gonorrhea prevalence distribution and time trends locally would improve the analyses. More focused intervention strategies could increase the impact and efficiency of screening interventions.

Opioid Use Fueling HIV Transmission in an Urban Setting: An Outbreak of HIV Infection Among People Who Inject Drugs-Massachusetts, 2015-2018.

Objectives. To describe and control an outbreak of HIV infection among people who inject drugs (PWID).Methods. The investigation included people diagnosed with HIV infection during 2015 to 2018 linked to 2 cities in northeastern Massachusetts epidemiologically or through molecular analysis. Field activities included qualitative interviews regarding service availability and HIV risk behaviors.Results. We identified 129 people meeting the case definition; 116 (90%) reported injection drug use. Molecular surveillance added 36 cases to the outbreak not otherwise linked. The 2 largest molecular groups contained 56 and 23 cases. Most interviewed PWID were homeless. Control measures, including enhanced field epidemiology, syringe services programming, and community outreach, resulted in a significant decline in new HIV diagnoses.Conclusions. We illustrate difficulties with identification and characterization of an outbreak of HIV infection among a population of PWID and the value of an intensive response.Public Health Implications. Responding to and preventing outbreaks requires ongoing surveillance, with timely detection of increases in HIV diagnoses, community partnerships, and coordinated services, all critical to achieving the goal of the national Ending the HIV Epidemic initiative.

COVID-19-Associated Multisystem Inflammatory Syndrome in Children - United States, March-July 2020.

In April 2020, during the peak of the coronavirus disease 2019 (COVID-19) pandemic in Europe, a cluster of children with hyperinflammatory shock with features similar to Kawasaki disease and toxic shock syndrome was reported in England* (1). The patients' signs and symptoms were temporally associated with COVID-19 but presumed to have developed 2-4 weeks after acute COVID-19; all children had serologic evidence of infection with SARS-CoV-2, the virus that causes COVID-19 (1). The clinical signs and symptoms present in this first cluster included fever, rash, conjunctivitis, peripheral edema, gastrointestinal symptoms, shock, and elevated markers of inflammation and cardiac damage (1). On May 14, 2020, CDC published an online Health Advisory that summarized the manifestations of reported multisystem inflammatory syndrome in children (MIS-C), outlined a case definition,† and asked clinicians to report suspected U.S. cases to local and state health departments. As of July 29, a total of 570 U.S. MIS-C patients who met the case definition had been reported to CDC. A total of 203 (35.6%) of the patients had a clinical course consistent with previously published MIS-C reports, characterized predominantly by shock, cardiac dysfunction, abdominal pain, and markedly elevated inflammatory markers, and almost all had positive SARS-CoV-2 test results. The remaining 367 (64.4%) of MIS-C patients had manifestations that appeared to overlap with acute COVID-19 (2-4), had a less severe clinical course, or had features of Kawasaki disease.§ Median duration of hospitalization was 6 days; 364 patients (63.9%) required care in an intensive care unit (ICU), and 10 patients (1.8%) died. As the COVID-19 pandemic continues to expand in many jurisdictions, clinicians should be aware of the signs and symptoms of MIS-C and report suspected cases to their state or local health departments; analysis of reported cases can enhance understanding of MIS-C and improve characterization of the illness for early detection and treatment.

Provision of STD Services in Community Settings After the Loss and Return of State Funding to Support Service Provision: Observations From Select Providers in Massachusetts, 2010 and 2013.

CONTEXT: In 2008, the $1.2 M sexually transmitted disease (STD) services line item supporting STD clinical services by the Massachusetts Department of Public Health was eliminated, forcing the cessation of all state-supported STD service delivery. OBJECTIVE: To determine the impact on community provision of STD services after the elimination of state funds supporting STD service provision. DESIGN AND SETTING: Rapid ethnographic assessments were conducted in May 2010 and September 2013 to better understand the impact of budget cuts on STD services in Massachusetts. The rapid ethnographic assessment teams identified key informants through Massachusetts's STD and human immunodeficiency virus programs. PARTICIPANTS: Fifty providers/clinic administrators in 19 sites (15 unique) participated in a semistructured interview (community health centers [n = 10; 53%], hospitals [n = 4; 21%], and other clinical settings [n = 5; 26%]). RESULTS: Results clustered under 3 themes: financial stability of agencies/clinics, the role insurance played in the provision of STD care, and perceived clinic capacity to offer appropriate STD services. Clinics faced hard choices about whether to provide care to patients or refer elsewhere patients who were unable or unwilling to use insurance. Clinics that decided to see patients regardless of ability to pay often found themselves absorbing costs that were then passed along to their parent agency; the difficulty and financial strain incurred by a clinic's parent agency by providing STD services without support by state grant dollars emerged as a primary concern. Meeting patient demand with staff with appropriate training and expertise remained a concern. CONCLUSIONS: Provision of public health by private health care providers may increase concern among some community provision sites about the sustainability of service provision absent external funds, either from the state or from the third-party billing. Resource constraints may be felt across clinic operations. Provision of public health in the for-profit health system involves close consideration of resources, including those: leveraged, used to provide uncompensated care, or available for collection through third-party billing.

Characteristics of Cases With Repeated Sexually Transmitted Infections, Massachusetts, 2014-2016.

Background: Persons with prior sexually transmitted infections (STIs) are at high risk for reinfection. No recent studies have examined frequency with which persons are diagnosed and reported with multiple bacterial STIs over time. Methods: We conducted a retrospective, of confirmed syphilis, gonorrhea, and chlamydial infections reported to Massachusetts state surveillance system within a 2-year period, 28 July 2014-27 July 2016. Results: Among Massachusetts population aged 13-65 years (4847510), 49142 (1.0%) were reported with ≥1 STIs; 6999 (14.2% of those with ≥1 STI) had ≥2 STIs, accounting for 27.7% of STIs. Of cases with ≥5 or more STIs (high-volume repeaters), 118 (74%) were men and 42 (26%) were women. Men spanned the age spectrum and were predominantly non-Hispanic white; 87% reported same-sex contacts. Women were younger, predominantly nonwhite, and without known same-sex contacts. Women were reinfected with gonorrhea and chlamydia or chlamydia alone; none had syphilis or human immunodeficiency virus (HIV) infection. All men with syphilis also had gonorrhea and/or chlamydia; 35% were diagnosed with HIV before, during, or within 10 months after study period. The majority (56%) of high-volume repeaters were seen at more than 1 care site/system. Conclusions: In Massachusetts, a large proportion of bacterial STIs are reported from a small subpopulation, many of whom have repeated infections and are likely to have higher impact on STI and HIV rates. Public health can play a crucial role in reaching high-volume repeaters whose STI histories may be hidden from clinicians due to fragmented care.

Does Nonmetropolitan Residence Impact Timely Chlamydia Treatment in Massachusetts?

A mean of 4.5 days until treatment was documented in a subset of reported laboratory-confirmed Massachusetts chlamydia cases selected for active case report form completion. Treatment delay was associated with longer test result turnaround time, and absence of symptoms or contact to sexually transmitted disease. Nonmetropolitan versus metropolitan residence did not appear to impact treatment time.

Getting What You Pay For: The Economics of Quality Care for Sexually Transmitted Infections.

BACKGROUND: Understanding the relationship between charges, reimbursement, and quality for sexually transmitted infection (STI) care is necessary to evaluate consequences of shifting patients from STI specialty to nonspecialty settings and to inform quality improvement efforts in this area. METHODS: Chart reviews were used to evaluate quality of documented STI care among 450 patients across 5 different clinical settings within a large safety net hospital in Massachusetts for patients presenting with penile discharge/dysuria or vaginal discharge. Charges billed and recouped by the hospital for each visit were extracted from billing records. Univariate methods examined unadjusted differences between quality and other patient and practice characteristics, and charges billed and recouped, whereas a multivariable model predicted the effect of quality on charges and reimbursements after adjusting for potential confounders. RESULTS: Higher documented quality of care was associated with higher charges, with each additional quality point predicting a 9% increase in visit charges. However, these charges were not recouped by the institution, as quality was not associated with higher levels of hospital reimbursement. Among sites of care, the STI clinic had the highest average quality score, as well as the lowest average amount billed and recouped. CONCLUSIONS: The relationship we find between documented quality and charges billed may reflect resource use for patient visits. The hospital, however, did not recoup any more on average from higher-quality visits, thus posing an incentive problem for the institution. Our findings suggest that loss of government funds for STI clinics may not be replaced by hospital billing and may lead to lower quality of care.

The Value of Experiential Sexually Transmitted Disease Clinical Training in the Digital Age.

BACKGROUND: The translation of evidence-based guidelines for sexually transmitted disease (STD) care into clinical practice is crucial for the prevention and control of STDs. METHODS: Participants in a hands-on, multifaceted, small-group STD Clinical Intensive Course from 2006 to 2013 were asked to complete a survey regarding course content and value compared with other continuing education courses. Survey respondents with demographic and professional information were compared with all other course participants. χ Statistics were used to test for differences in proportions; the Cochran-Armitage trend test was used to evaluate for trends in response rate by year of training. RESULTS: Of 113 respondents (35.9% response rate), 92.9% felt that clinical knowledge stayed longer, 84.1% changed clinical practice more, and 90.3% recommended the course more, compared with other continuing education programs in which they had participated previously. Respondents' average suggested registration fee should the course no longer be free was $188.90. Physician assistants and advanced practice nurses were overrepresented among respondents (69.4% vs. 58.1%, P = 0.04); more recent course participants were more likely to respond (P < 0.01). CONCLUSIONS: These findings suggest that this STD experiential clinical training program is still relevant to participants in the digital age and is valued more highly than other continuing education experiences. A significant disconnect was identified between what participants are willing/able to pay versus actual course costs, indicating that cost is likely to become a barrier to participation should the course no longer be free.

Sexually Transmitted Disease Program Evolution in Response to Changes in the Public Health Environment: A Massachusetts Example.

BACKGROUND: In 2008, the line item supporting sexually transmitted disease (STD) services in the Massachusetts state budget was cut as a result of budget shortfalls. Shortly thereafter, direct provision of STD clinical services supported by the Massachusetts Department of Public Health (MDPH) was suspended. Massachusetts Department of Public Health requested an initial assessment of its internal response and impact in 2010. A follow-up assessment occurred in September 2013. METHODS: In 2010 and 2013, 39 and 46 staff, respectively, from MDPH and from clinical partner agencies, were interviewed about changes in the role of the MDPH, partnerships, STD services, challenges, and recommendations. Interview notes were summarized, analyzed, and synthesized by coauthors using qualitative analysis techniques and NVivo software. RESULTS: The withdrawal of state funding for STD services, and the subsequent reduction in clinical service hours, erected numerous barriers for Disease Intervention Specialists (DIS) seeking to ensure timely STD treatment for index cases and their partners. After initial instability, MDPH operations stabilized due partly to strong management, new staff, and intensified integration with human immunodeficiency virus services. Existing contracts with human immunodeficiency virus providers were leveraged to support alternative STD testing and care sites. Massachusetts Department of Public Health strengthened its clinical and epidemiologic expertise. The DIS expanded their scope of work and were outposted to select new sites. Challenges remained, however, such as a shortage of DIS staff to meet the needs. CONCLUSIONS: Although unique in many ways, MA offers experiences and lessons for how a state STD program can adapt to a changing public health context.

Sexual Assault and Sexually Transmitted Infections in Adults, Adolescents, and Children.

Survivors of sexual assault are at risk for acquiring sexually transmitted infections (STIs). We conducted literature reviews and invited experts to assist in updating the sexual assault section for the 2015 Centers for Disease Control and Prevention sexually transmitted diseases (STD) treatment guidelines. New recommendations for STI management among adult and adolescent sexual assault survivors include use of nucleic acid amplification tests (NAATs) for detection of Trichomonas vaginalis by vaginal swabs; NAATs for detection of Neisseria gonorrhoeae and Chlamydia trachomatis from pharyngeal and rectal specimens among patients with a history of exposure or suspected extragenital contact after sexual assault; empiric therapy for gonorrhea, chlamydia, and trichomoniasis based on updated treatment regimens; vaccinations for human papillomavirus (HPV) among previously unvaccinated patients aged 9-26 years; and consideration for human immunodeficiency virus (HIV) nonoccupational postexposure prophylaxis using an algorithm to assess the timing and characteristics of the exposure. For child sexual assault (CSA) survivors, recommendations include targeted diagnostic testing with increased use of NAATs when appropriate; routine follow-up visits within 6 months after the last known sexual abuse; and use of HPV vaccination in accordance with national immunization guidelines as a preventive measure in the post-sexual assault care setting. For CSA patients, NAATs are considered to be acceptable for identification of gonococcal and chlamydial infections from urine samples, but are not recommended for extragenital testing due to the potential detection of nongonococcal Neisseria species. Several research questions were identified regarding the prevalence, detection, and management of STI/HIV infections among adult, adolescent, and pediatric sexual assault survivors.

Evaluating Quality of Care for Sexually Transmitted Infections in Different Clinical Settings.

BACKGROUND: We examined quality of care across different clinical settings within a large safety-net hospital in Massachusetts for patients presenting with penile discharge/dysuria or vaginal discharge. METHODS: Using a modified Delphi approach, a list of sex-specific sexually transmitted infection (STI) quality measures, covering 7 domains of clinical care (history, examination, laboratory testing, assessment, treatment, additional screening, counseling), was selected as standard of care by a panel of 5 STI experts representing emergency department (ED), obstetrics/gynecology (Ob/Gyn), family medicine (FM), primary care (PC), and infectious disease. Final measures were piloted with 50 charts per sex from the STI Clinic and age, sex, and visit date-matched charts from PC, FM, ED, and Ob/Gyn. Performance was scored as compliance among individual measures within 7 domains, standardized to add up to one to adjust for variable number of measures per domain, with an overall score of 7 indicating complete adherence to standards. RESULTS: Expert review process took 2 weeks and resulted in 24 and 34 final measures for male and female patients, respectively. Performance on 7 clinical domains ranged from 3.16 to 4.36 for male patients and 3.17 to 4.33 for female patients. Sexually transmitted infection clinic seemed to score higher on laboratory testing, additional screening, and counseling, but lower on examination and assessment, and ED seemed to score higher on examination and treatment, PC and FM on laboratory testing for male patients and on examination and treatment for female patients, and Ob/Gyn on treatment. CONCLUSIONS: An instrument to discern standard of care and identify strengths and weaknesses in specific domains of clinical documentation for patients presenting with STI complaints can be developed and implemented for quality evaluation across care settings. Further research is needed on whether these findings can be integrated into site-specific quality improvement processes and linked to cost analyses.

Lifetime quality-adjusted life years lost due to genital herpes acquired in the United States in 2018: a mathematical modeling study.

Background: Genital herpes (GH), caused by herpes simplex virus type 1 and type 2 (HSV-1, HSV-2), is a common sexually transmitted disease associated with adverse health outcomes. Symptoms associated with GH outbreaks can be reduced by antiviral medications, but the infection is incurable and lifelong. In this study, we estimate the long-term health impacts of GH in the United States using quality-adjusted life years (QALYs) lost. Methods: We used probability trees to model the natural history of GH secondary to infection with HSV-1 and HSV-2 among people aged 18-49 years. We modelled the following outcomes to quantify the major causes of health losses following infection: symptomatic herpes outbreaks, psychosocial impacts associated with diagnosis and recurrences, urinary retention caused by sacral radiculitis, aseptic meningitis, Mollaret's meningitis, and neonatal herpes. The model was parameterized based on published literature on the natural history of GH. We summarized losses of health by computing the lifetime number of QALYs lost per genital HSV-1 and HSV-2 infection, and we combined this information with incidence estimates to compute the total lifetime number of QALYs lost due to infections acquired in 2018 in the United States. Findings: We estimated 0.05 (95% uncertainty interval (UI) 0.02-0.08) lifetime QALYs lost per incident GH infection acquired in 2018, equivalent to losing 0.05 years or about 18 days of life for one person with perfect health. The average number of QALYs lost per GH infection due to genital HSV-1 and HSV-2 was 0.01 (95% UI 0.01-0.02) and 0.05 (95% UI 0.02-0.09), respectively. The burden of genital HSV-1 is higher among women, while the burden of HSV-2 is higher among men. QALYs lost per neonatal herpes infection was estimated to be 7.93 (95% UI 6.63-9.19). At the population level, the total estimated lifetime QALYs lost as a result of GH infections acquired in 2018 was 33,100 (95% UI 12,600-67,900) due to GH in adults and 3,140 (95% UI 2,260-4,140) due to neonatal herpes. Results were most sensitive to assumptions on the magnitude of the disutility associated with post-diagnosis psychosocial distress and symptomatic recurrences. Interpretation: GH is associated with substantial health losses in the United States. Results from this study can be used to compare the burden of GH to other diseases, and it provides inputs that may be used in studies on the health impact and cost-effectiveness of interventions that aim to reduce the burden of GH. Funding: The Center for Disease Control and Prevention.