State Policies Relevant to Disease Intervention Specialists in the United States.

BACKGROUND: The functions of disease intervention specialists (DIS) represent core infectious disease control practices and have legal foundations in the United States. Although important for state and local health departments to understand this authority, these policies have not been systematically collected and analyzed. We analyzed the authority for investigation of sexually transmitted infections (STIs) across all 50 US states and the District of Columbia. METHODS: In January 2022, we collected state policies addressing the investigation of STIs using a legal research database. We coded these policies into a database on variables of interest: (1) whether the policy authorized/required investigation, (2) what type of infection triggers an investigation, (3) and the entity who is authorized/required to perform the investigation. RESULTS: All 50 US states and District of Columbia explicitly authorize/require investigation of cases of STI. Of these jurisdictions, 62.7% require investigations, 41% authorize investigations, and 3.9% both authorize and require investigations. Sixty-seven percent authorize/require investigations for cases of communicable disease (inclusive of an STI), 45.1% authorize/require investigations for cases of STIs generally, and 3.9% authorize/require investigations for cases of a specific STI. Eighty-two percent of jurisdictions authorize/require the state to investigate, 62.7% authorize/require local governments to investigate, and 39.2% authorize/require investigations by both state and local governments. CONCLUSIONS: State laws that establish authority or duties regarding the investigation of STIs differ across states. It may be useful for state and local health departments to examine these policies relative to the morbidity of their jurisdiction and their STI prevention priorities.

Characterizing Financial Sustainability of Sexually Transmitted Disease Clinics Through Insurance Billing Practices.

CONTEXT: Sexually transmitted infections (STIs) continue to increase in the United States. Publicly funded sexually transmitted disease (STD) clinics provide important safety net services for communities at greater risk for STIs. However, creating financially sustainable models of STI care remains a challenge. OBJECTIVE: Characterization of clinic insurance billing practices and patient willingness to use insurance. DESIGN: Cross-sectional survey assessment of clinic administrators and patients. SETTING: Twenty-six STD clinics and 4138 patients attending these clinics in high STD morbidity metropolitan statistical areas in the United States. PARTICIPANTS: Clinic administrators and patients of these clinics. INTERVENTION: Survey assessment. MAIN OUTCOME MEASURE: Insurance billing practices of STD clinics and patient insurance status and willingness to use their insurance. RESULTS: Fifteen percent of clinics (4/26) indicated that they billed only Medicaid, 58% (15/26) billed both Medicaid and private insurance, 27% (7/26) did not bill for any health insurance, and none (0%) billed only private health insurance companies. Of 4138 patients surveyed, just more than one-half of patients (52.6%) were covered by some form of health insurance. More than one-half (57.2%) of all patients covered by health insurance indicated that they would be willing to use their health insurance for that visit. After adjusting for patient demographics and clinic characteristics, the patients covered by government insurance were 3 times as likely (odds ratio: 3.16; 95% confidence interval, 2.44-4.10) than patients covered by private insurance to be willing to use their insurance for their visit. CONCLUSION: Opportunities exist for sustainable STI services through the enhancement of billing practices in STD clinics. The STD clinics provide care to large numbers of individuals who are both insured and who are willing to use their insurance for their care. As Medicaid expansion continues across the country, efforts focused on improving reimbursement rates for Medicaid may improve financial sustainability of STD clinics.

State Laws Related to Billing Third Parties for Health Care Services at Public Sexually Transmitted Disease Clinics in the United States.

BACKGROUND: Health departments (HDs) cite state laws as barriers to billing third parties for sexually transmitted disease (STD) services, but the association between legal/policy barriers and third-party HD billing has not been examined. This study investigates the relationship between laws that may limit HDs' ability to bill, clinic perceptions of billing barriers, and billing practices. METHODS: Two surveys, (1) clinic managers (n = 246), (2) STD program managers (n = 63), conducted via a multiregional needs assessment of federally funded HD clinics' capacity to bill for STD services, billing/reimbursement practices, and perceived barriers were combined with an analysis of state laws regarding third-party billing for STD services. Statistical analyses examined relationships between laws that may limit HDs' ability to bill, clinic perceptions, and billing practices. RESULTS: Clinic managers reported clinics were less likely to bill Medicaid and other third parties in jurisdictions with a state law limiting their ability to bill compared with respondents who billed neither or 1 payer (odds ratio [OR], 0.31; 95% confidence interval [CI], 0.10-0.97) and cited practical concerns as a primary barrier to billing (OR, 2.83; 95% CI, 1.50-5.37). The STD program managers report that the staff believed that STD services should be free (OR, 0.34; 95% CI, 0.13-0.90) was associated with not billing (not sure versus no resistance to billing); confidentiality concerns was not a reported barrier to billing among either sample. CONCLUSIONS: Practical concerns and clinic staff beliefs that STD services should be free emerged as possible barriers to billing, as were laws to a lesser extent. Attempts to initiate HD billing for STD services may benefit from staff education as well as addressing perceived legal barriers and staff concerns.

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.

Use of Patient-Delivered Partner Therapy in US College Settings: Associations With Legality, Perceived Legality and Other Sexual and Reproductive Health Services.

BACKGROUND: Young adults, including college students, have higher rates of chlamydia than the general population. Patient-delivered partner therapy (PDPT) is a partner treatment option for sex partners of individuals diagnosed with chlamydia or gonorrhea. We examined college health center use of PDPT in a national sample of colleges. METHODS: During 2014 to 2015, we collected data from 482 colleges and universities (55% of 885 surveyed), weighting responses by institutional characteristics abstracted from a national database (eg, 2-year vs 4-year status). We asked whether the school had a student health center and which sexual and reproductive health (SRH) services were offered. We also assessed the legal and perceived legal status of PDPT in states where schools were located. We then estimated PDPT availability at student health centers and measured associations with legal status and SRH services. RESULTS: Most colleges (n = 367) reported having a student health center; PDPT was available at 36.6% of health centers and associated with perceived legality of PDPT in the state in which the college was located (odds ratio [OR], 4.63; 95% confidence interval [CI], 1.17-18.28). Patient-delivered partner therapy was significantly associated with availability of SRH services, including sexually transmitted disease diagnosis and treatment of STI (56.2% vs 1.1%), gynecological services (60.3% vs 12.2%), and contraceptive services (57.8% vs 7.7%) (all P < .001). Compared with schools taking no action, PDPT was more likely to be available at schools that notified partners directly (OR, 8.29; 95% CI, 1.28-53.85), but not schools that asked patients to notify partners (OR, 3.47; 95% CI, 0.97-12.43). CONCLUSIONS: PDPT was more likely to be available in colleges that offered SRH services and where staff believed PDPT was legal. Further research could explore more precise conditions under which PDPT is used.

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.

Use of Expedited Partner Therapy for Sexually Transmitted Diseases in College and University Health Centers in the United States, 2011-2012.

We examined expedited partner therapy for chlamydia and gonorrhea in college and university health centers by institutional and policy characteristics. Expedited partner therapy awareness and use was low (44.1% used), did not differ by institutional characteristics, and differed by policy environment. Our findings suggest missed opportunities for sexually transmitted disease prevention in college and university health centers.

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.

Chlamydia screening for sexually active young women under the Affordable Care Act: new opportunities and lingering barriers.

The Affordable Care Act of 2010 (ACA) contains a provision requiring private insurers issuing or renewing plans on or after September 23, 2010, to provide, without cost sharing, preventive services recommended by US Preventive Services Task Force (grades A and B), among other recommending bodies. As a grade A recommendation, chlamydia screening for sexually active young women 24 years and younger and older women at risk for chlamydia falls under this requirement. This article examines the potential effect on chlamydia screening among this population across private and public health plans and identifies lingering barriers not addressed by this legislation. Examination of the impact on women with private insurance touches upon the distinction between coverage under grandfathered plans, where the requirement does not apply, and nongrandfathered plans, where the requirement does apply. Acquisition of private health insurance through health insurance Marketplaces is also discussed. For public health plans, coverage of preventive services without cost sharing differs for individuals enrolled in standard Medicaid, covered under the Medicaid expansion included in the ACA, or those enrolled under the Children's Health Insurance Program or who fall under Early, Periodic, Screening, Diagnosis and Treatment criteria. The discussion of lingering barriers not addressed by the ACA includes the uninsured, physician reimbursement, cost sharing, confidentiality, low rates of appropriate sexual history taking by providers, and disclosures of sensitive information. In addition, the role of safety net programs that provide health care to individuals regardless of ability to pay is examined in light of the expectation that they also remain a payer of last resort.

A historical note on the association between the legal status of expedited partner therapy and physician practice.

Potential legal liability for practicing expedited partner therapy is a common concern among providers, although it has been uncertain how these concerns translate into clinical practice. This study suggests that providers are more likely to practice expedited partner therapy in more favorable legal environments.

The legal aspects of expedited partner therapy practice: do state laws and policies really matter?

BACKGROUND: Expedited partner therapy (EPT) is a potential partner treatment strategy. Significant efforts have been devoted to policies intended to facilitate its practice. However, few studies have attempted to evaluate these policies. METHODS: We used data on interviewed gonorrhea cases from 12 sites in the STD Surveillance Network in 2010 (n = 3404). Patients reported whether they had received EPT. We coded state laws relevant to EPT for gonorrhea using Westlaw legal research database and the general legal status of EPT in STD Surveillance Network sites from Centers for Disease Control and Prevention's Web site in 2010. We also coded policy statements by medical and other boards. We used χ tests to compare receipt of EPT by legal/policy variables, patient characteristics, and provider type. Variables significant at P < 0.10 in bivariate analyses were included in a logistic regression model. RESULTS: Overall, 9.5% of 2564 interviewed patients with gonorrhea reported receiving EPT for their partners. Receipt of EPT was significantly higher where laws and policies authorizing EPT existed. Where EPT laws for gonorrhea existed and EPT was permissible, 13.3% of patients reported receiving EPT as compared with 5.4% where there were no EPT laws and EPT was permissible, and 1.0% where there were no EPT laws and EPT was potentially allowable (P < 0.01). Expedited partner therapy was higher where professional boards had policy statements supporting EPT (P < 0.01). Receipt of EPT did not differ by most patient characteristics or provider type. Policy-related findings were similar in adjusted analyses. CONCLUSIONS: Expedited partner therapy laws and policies were associated with higher reports of receipt of EPT among interviewed gonorrhea cases.

Trans-radial embolization of epistaxis in patients with end-stage liver disease.

INTRODUCTION: Endovascular treatment of epistaxis in patients with bleeding disorders is challenging due to the intrinsic risk of hemorrhagic complication related to the arterial access. We describe the use of trans-radial approach for the endovascular embolization of epistaxis due to end-stage liver disease and resultant severe coagulopathy. METHODS: Two patients waiting for liver transplant continued to have epistaxis despite the aggressive correction of the coagulopathy and nose packing. After performing the Allen's test, trans-radial embolization of the epistaxis was performed in both patients. RESULTS: The complete cessation of epistaxis was achieved after the trans-radial embolization of bilateral maxillary arteries with particles. The radial access sites were manually compressed for 1 h, followed by a compression dressing for 12 h. The cessation of the epistaxis helped the subsequent treatment of correcting the coagulopathy. There was no complication related to the arterial puncture. CONCLUSION: Trans-radial embolization for epistaxis was a safe and effective method for the patient with end-stage liver disease and resultant severe coagulopathy.

A New Call to Action to Combat an Old Nemesis: Addressing Rising Congenital Syphilis Rates in the United States.

Congenital syphilis (CS) is on the rise in the United States and is a growing public health concern. CS is an infection with Treponema pallidum in an infant or fetus, acquired via transplacental transmission when a pregnant woman has untreated or inadequately treated syphilis. Pregnant women with untreated syphilis are more likely to experience pregnancies complicated by stillbirth, prematurity, low birth weight, and early infant death, while their children can develop clinical manifestations of CS such as hepatosplenomegaly, bone abnormalities, developmental delays, and hearing loss. One of the ways CS can be prevented is by identifying and treating infected women during pregnancy with a benzathine penicillin G regimen that is both appropriate for the maternal stage of syphilis and initiated at least 30 days prior to delivery. In this article we discuss many of the challenges faced by both public health and healthcare systems with regards to this preventable infection, summarize missed opportunities for CS prevention, and provide practical solutions for future CS prevention strategies.

Differences in rapid increases in county-level COVID-19 incidence by implementation of statewide closures and mask mandates - United States, June 1-September 30, 2020.

BACKGROUND AND OBJECTIVE: Community mitigation strategies could help reduce COVID-19 incidence, but there are few studies that explore associations nationally and by urbanicity. In a national county-level analysis, we examined the probability of being identified as a county with rapidly increasing COVID-19 incidence (rapid riser identification) during the summer of 2020 by implementation of mitigation policies prior to the summer, overall and by urbanicity. METHODS: We analyzed county-level data on rapid riser identification during June 1-September 30, 2020 and statewide closures and statewide mask mandates starting March 19 (obtained from state government websites). Poisson regression models with robust standard error estimation were used to examine differences in the probability of rapid riser identification by implementation of mitigation policies (P-value< .05); associations were adjusted for county population size. RESULTS: Counties in states that closed for 0-59 days were more likely to become a rapid riser county than those that closed for >59 days, particularly in nonmetropolitan areas. The probability of becoming a rapid riser county was 43% lower among counties that had statewide mask mandates at reopening (adjusted prevalence ratio = 0.57; 95% confidence intervals = 0.51-0.63); when stratified by urbanicity, associations were more pronounced in nonmetropolitan areas. CONCLUSIONS: These results underscore the potential value of community mitigation strategies in limiting the COVID-19 spread, especially in nonmetropolitan areas.

Examining the Diagnostic Validity of Autism Measures Among Adults in an Outpatient Clinic Sample.

Background: Previous research has questioned the validity of diagnostic measures for autism spectrum disorder (ASD) among adults. This study examined the correspondence between several measures and clinician diagnosis. Methods: We conducted a retrospective chart review for 93 adults (18-61 years; 72% male) who received an ASD evaluation at a specialty outpatient clinic. Thirty-one individuals (33%) in the sample were diagnosed with ASD. We compared participant scores on the Autism Spectrum Quotient (AQ), the Ritvo Autism Asperger's Diagnostic Scale-Revised (RAADS-R), and the Autism Diagnostic Observation Schedule (ADOS) to clinician diagnosis of ASD. We calculated sensitivity, specificity, and area under the curve (AUC) for each measure. Results: Participants diagnosed with ASD scored significantly higher, on average, on the ADOS than those who were not diagnosed with ASD, but not on the RAADS-R or AQ. The AUC was relatively low for each measure: ADOS = 0.69 (95% confidence interval [CI] 0.58-0.81), RAADS-R = 0.58 (95% CI 0.46-0.72), and AQ = 0.40 (95% CI 0.28-0.52). Sensitivity and specificity of all three measures were in the poor to fair range. When dichotomized at the optimal cutoffs for this sample, the ADOS had a sensitivity of 0.65 and a specificity of 0.76; the RAADS-R had a sensitivity of 0.52 and a specificity of 0.73; and the AQ had a sensitivity of 0.45 and a specificity of 0.52. Conclusions: Results of the study suggest that clinicians should not rely solely on self-report measures or the ADOS when diagnosing adults on the spectrum. Further development of measures is needed, including self-report measures with higher diagnostic validity, that are sensitive across age, gender, and cognitive functioning, and that differentiate autism from psychiatric diagnoses. Lay Summary: Why was this study done?: Diagnosing adults with autism spectrum disorder (ASD) is difficult. Other research has suggested that the few measures that exist for autistic adults may not be very effective for accurate diagnoses. We wanted to see how closely the results of commonly used ASD assessment tools compared with clinical diagnoses in a real-life outpatient setting.What did the researchers do?: This study looked at adults who went to an adult ASD outpatient clinic for an initial ASD diagnosis over 3 years. Of these 93 adults, one-third were diagnosed as autistic. As part of the evaluation, all participants completed two commonly used autism screening surveys-the Autism Spectrum Quotient (AQ) and the Ritvo Autism Asperger's Diagnostic Scale-Revised (RAADS-R)-and took part in a semistructured diagnostic interview called the Autism Diagnostic Observation Schedule (ADOS). The clinicians also collected additional information and, when possible, spoke to family members before jointly making a diagnosis. The researchers compared how those diagnosed with ASD and those who were not diagnosed with ASD scored on the AQ, the RAADS-R, and the ADOS.What were the results of this study?: Although adults on the spectrum scored higher on average on the ADOS clinical interview than those who did not receive an autism diagnosis, they did not score higher on the AQ and RAADS-R self-report measures. All three of the measures were only moderately effective at showing who would be diagnosed with ASD and who was not.What do these findings add to what was already known?: These results confirm and expand on findings from other prior studies. The findings suggest that ASD diagnostic measures should not be used alone or considered the only source of information when making an initial autism diagnosis in adulthood.What are potential weaknesses in the study?: When studying the accuracy of diagnostic tests, it is best to compare the results of the tests being studied with an "independent gold standard," that is, a test that we know is very good and that is totally separate from the tests being studied. In this case, there is no clear "gold standard," so we had to compare the tests with the next best thing-the clinicians' final decision about whether or not a client has a diagnosis of ASD. It is possible that the clinicians did not make the right diagnosis. Also, the diagnosis was not "independent" of the tests being studied, since the clinicians used the results of the tests to help make the diagnosis. Clinicians only diagnosed about one-third of adults in this study with ASD, whereas previous studies in community clinics have had a higher percentage of adults diagnosed; this factor may have influenced the measures' accuracy. Lastly, clinicians in this study did not assess clients for any other mental health conditions, which may have provided more information about the clients who were not diagnosed with ASD.How will these findings help autistic adults now or in the future?: The findings from this study suggest that none of these measures are very accurate on their own. Thus, we recommend multiple measures (interviews and questionnaires) should be used together when clinicians diagnose ASD in adulthood. Results of this study also suggest that measures for adults with ASD should be tested in real-world community clinics, so that clinicians and researchers see how the measures perform when used for initial diagnosis in adulthood.

Medicaid Coverage of Sexually Transmitted Disease Service Visits.

INTRODUCTION: Chlamydia and gonorrhea are the most commonly reported notifiable infections in the U.S., with direct medical costs for the treatment of these infections exceeding $700 million annually. Medicaid currently covers approximately 80 million low-income Americans, including a high percentage of racial and ethnic minorities. Studies have shown that racial and ethnic minority populations, particularly those with low SES, are at an increased risk of acquiring a sexually transmitted disease. Therefore, as Medicaid expands, there will likely be a greater demand for sexually transmitted disease services in community-based physician offices. To determine demand for these services among Medicaid enrollees, this study examined how often Medicaid was used to pay for sexually transmitted disease services received in this setting. METHODS: This study combined 2014 and 2015 data from the National Ambulatory Medical Care Survey and tested for differences in the proportion of visits with an expected payment source of Medicaid when sexually transmitted disease services were and were not provided. All analyses were conducted in October 2018. RESULTS: During 2014-2015, an estimated 25 million visits received a sexually transmitted disease service. Medicaid paid for a greater percentage of sexually transmitted disease visits (35.5%, 95% CI=22.5%, 51.1%) compared with non-sexually transmitted disease visits (12.1%, 95% CI=10.8%, 13.6%). Logistic regression modeling, controlling for age, sex, and race of the patient, showed that visits covered by Medicaid had increased odds of paying for a sexually transmitted disease service visit (OR=1.97, 95% CI=1.12, 3.46), compared with other expected payment sources. CONCLUSIONS: Focusing sexually transmitted disease prevention in Medicaid populations could reduce sexually transmitted disease incidence and resulting morbidity and costs.

State policies in the United States impacting drug-related convictions and their consequences in 2015.

BACKGROUND: Criminal justice system involvement has been associated with health issues, including sexually transmitted disease. Both incarceration and sexually transmitted disease share associations with various social conditions, including poverty, stigma, and drug use. METHODS: United States state laws (including Washington, D.C.) regarding drug possession and consequences of drug-related criminal convictions were collected and coded. Drug possession policies focused on mandatory sentences for possession of marijuana, crack cocaine and methamphetamines. Consequences of drug-related convictions included ineligibility for public programmes, ineligibility for occupational licences and whether employers may ask prospective employees about criminal history. We analysed correlations between state sexually transmitted disease rates and percentage of a state's population convicted of a felony. RESULTS: First-time possession of marijuana results in mandatory incarceration in one state; first-time possession of crack cocaine or methamphetamines results in mandatory incarceration in 12 (23.5%) states. Many states provide enhanced punishment upon a third possession conviction. A felony drug conviction results in mandatory ineligibility for the Supplemental Nutrition Assistance Program and/or Temporary Assistance for Needy Families in 17 (33.3%) states. Nine (17.6%) states prohibit criminal history questions on job applications. Criminal convictions limit eligibility for various professional licences in all states. State chlamydia, gonorrhoea and syphilis rates were positively associated with the percentage of the state population convicted of a felony (p < 0.05). CONCLUSION: While associations between crime, poverty, stigma and health have been investigated, our findings could be used to investigate the relationship between the likelihood of criminal justice system interactions, their consequences and public health outcomes including sexually transmitted disease risk.

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.