Shigellosis Cases With Bacterial Sexually Transmitted Infections: Population-Based Data From 6 US Jurisdictions, 2007 to 2016.

BACKGROUND: Shigella species, which cause acute diarrheal disease, are transmitted via fecal-oral and sexual contact. To better understand the overlapping populations affected by Shigella infections and sexually transmitted infections (STIs) in the United States, we examined the occurrence of reported STIs within 24 months among shigellosis case-patients. METHODS: Culture-confirmed Shigella cases diagnosed from 2007 to 2016 among residents of 6 US jurisdictions were matched to reports of STIs (chlamydia, gonorrhea, and all stages of syphilis) diagnosed 12 months before or after the shigellosis case. We examined epidemiologic characteristics and reported temporal trends of Shigella cases by sex and species. RESULTS: From 2007 to 2016, 10,430 shigellosis cases were reported. The annual number of reported shigellosis cases across jurisdictions increased 70%, from 821 cases in 2007 to 1398 cases in 2016; males saw a larger increase compared with females. Twenty percent of male shigellosis case-patients had an STI reported in the reference period versus 4% of female case-patients. The percentage of male shigellosis case-patients with an STI increased from 11% (2007) to 28% (2016); the overall percentage among females remained low. CONCLUSIONS: We highlight the substantial proportion of males with shigellosis who were diagnosed with STIs within 24 months and the benefit of matching data across programs. Sexually transmitted infection screening may be warranted for male shigellosis case-patients.

Effectiveness of a serogroup B outer membrane vesicle meningococcal vaccine against gonorrhoea: a retrospective observational study.

BACKGROUND: Declining antimicrobial susceptibility to current gonorrhoea antibiotic treatment and inadequate treatment options have raised the possibility of untreatable gonorrhoea. New prevention approaches, such as vaccination, are needed. Outer membrane vesicle meningococcal serogroup B vaccines might be protective against gonorrhoea. We evaluated the effectiveness of a serogroup B meningococcal outer membrane vesicle vaccine (MenB-4C) against gonorrhoea in individuals aged 16-23 years in two US cities. METHODS: We identified laboratory-confirmed gonorrhoea and chlamydia infections among individuals aged 16-23 years from sexually transmitted infection surveillance records in New York City and Philadelphia from 2016 to 2018. We linked gonorrhoea and chlamydia case records to immunisation registry records to determine MenB-4C vaccination status at infection, defined as complete vaccination (two MenB-4C doses administered 30-180 days apart), partial vaccination (single MenB-4C vaccine dose), or no vaccination (serogroup B meningococcal vaccine naive). Using log-binomial regression with generalised estimating equations to account for correlations between multiple infections per patient, we calculated adjusted prevalence ratios (APR) and 95% CIs to determine if vaccination was protective against gonorrhoea. We used individual-level data for descriptive analyses and infection-level data for regression analyses. FINDINGS: Between Jan 1, 2016, and Dec 31, 2018, we identified 167 706 infections (18 099 gonococcal infections, 124 876 chlamydial infections, and 24 731 gonococcal and chlamydial co-infections) among 109 737 individuals linked to the immunisation registries. 7692 individuals were vaccinated, of whom 4032 (52·4%) had received one dose, 3596 (46·7%) two doses, and 64 (<1·0%) at least three doses. Compared with no vaccination, complete vaccination series (APR 0·60, 95% CI 0·47-0·77; p<0·0001) and partial vaccination series (0·74, 0·63-0·88; p=0·0012) were protective against gonorrhoea. Complete MenB-4C vaccination series was 40% (95% CI 23-53) effective against gonorrhoea and partial MenB-4C vaccination series was 26% (12-37) effective. INTERPRETATION: MenB-4C vaccination was associated with a reduced gonorrhoea prevalence. MenB-4C could offer cross-protection against Neisseria gonorrhoeae. Development of an effective gonococcal vaccine might be feasible with implications for gonorrhoea prevention and control. FUNDING: None.

Brief Report: Use of Remnant Specimens to Assess Use of HIV PrEP Among Populations With Risk of HIV Infection: A Novel Approach.

BACKGROUND: HIV-uninfected persons being evaluated for sexually transmitted infections (STIs) may be good HIV pre-exposure prophylaxis (PrEP) candidates. We measured PrEP use in a sentinel STI patient population. DESIGN: Cross-sectional study, New York City Sexual Health Clinics (January 2019-June 2019). METHODS: Remnant serum samples from 644 HIV-uninfected men who have sex with men (MSM) and 97 women diagnosed with chlamydia, gonorrhea, and/or early syphilis were assayed for tenofovir and emtricitabine levels using a validated liquid chromatography-mass spectrometry assay. Using paired test results and medical records, we assessed (1) prevalence and (2) correlates of PrEP use on the day of STI diagnosis (adjusted prevalence ratios [aPRs]). RESULTS: PrEP use among 741 patients was 32.7% [95% confidence interval (CI): 29.3 to 36.0]; 37.3% for MSM and 2.1% for women. PrEP use was high among White MSM (46.8%) and lowest among women. Among MSM with rectal chlamydia/gonorrhea or early syphilis, PrEP use was associated with age [aPR = 1.7 (95% CI: 1.2 to 2.4) for ages 25-34 years and aPR = 2.0 (1.4 to 2.9) for ages 35-44 years, vs. 15 to 24 years]; number of recent sex partners [aPR = 1.4 (1.0 to 2.0) for 3-5 partners, aPR = 2.1 (1.5 to 3.0) for 6-10 partners, aPR = 2.2 (1.6 to 3.1) for >10 partners, vs. ≤2 partners]; having sex/needle-sharing partners with HIV [aPR = 1.4 (1.1-1.7)]; and inconsistent condom use [aPR = 3.3 (1.8-6.1)]. Race/ethnicity, past-year STI diagnosis, and postexposure prophylaxis use were not associated. CONCLUSIONS: One in 3 people with newly diagnosed STIs had detectable serum PrEP, and PrEP use was exceedingly rare among women. Routinely collected remnant samples can be used to measure PrEP use in populations at high risk of HIV acquisition.

Effectiveness of Syphilis Partner Notification After Adjusting for Treatment Dates, 7 Jurisdictions.

BACKGROUND: Disease intervention specialists (DIS) prevent syphilis by ensuring treatment for patients' sex partners through partner notification (PN). Different interpretations of how to measure partners treated due to DIS efforts complicates PN evaluation. We measured PN impact by counting partners treated for syphilis after DIS interviewed the patient. METHODS: We reviewed data from early syphilis cases reported during the 2015-2017 period in 7 jurisdictions. We compared infected partners brought to treatment using the following: (1) DIS-assigned disposition codes or (2) all infected partners treated 0 to 90 days after the patient's interview (adjusted treatment estimate). Stratified analyses assessed patient characteristics associated with the adjusted treatment estimate. RESULTS: Disease intervention specialists interviewed 23,613 patients who reported 20,890 partners with locating information. Many of the 3569 (17.1%) partners classified by DIS as brought to treatment were treated before the patient was interviewed. There were 2359 (11.3%) partners treated 0 to 90 days after the patient's interview. Treatment estimates were more consistent between programs when measured using our adjusted estimates (range, 6.1%-14.8% per patient interviewed) compared with DIS-assigned disposition (range, 6.1%-28.3%). Treatment for ≥1 partner occurred after 9.0% of interviews and was more likely if the patient was a woman (17.9%), younger than 25 years (12.6%), interviewed ≤7 days from diagnosis (13.9%), HIV negative (12.6%), or had no reported history of syphilis (9.8%). CONCLUSIONS: Counting infected partners treated 0 to 90 days after interview reduced variability in reporting and facilitates quality assurance. Identifying programs and DIS who are particularly good at finding and treating partners could improve program impact.

Test of Cure Return Rate and Test Positivity, Strengthening the US Response to Resistant Gonorrhea, United States, 2018-2019.

BACKGROUND: Reduced antibiotic susceptibility (RS) in Neisseria gonorrhoeae (GC) may increase treatment failure. Conducting tests of cure (TOC) for patients with RS-GC may facilitate identification of treatment failures. METHODS: We examined 2018 to 2019 data from 8 jurisdictions participating in the US Centers for Disease Control and Prevention's Strengthening US Response to Resistant Gonorrhea project. Jurisdictions collected GC isolates and epidemiological data from patients and performed antimicrobial susceptibility testing. Minimum inhibitory concentrations of ceftriaxone, 0.125 µg/mL or greater; cefixime, 0.250 µg/mL or greater; or azithromycin, 2.0 µg/mL or greater were defined as RS. Patients with RS infections were asked to return for a TOC 8 to 10 days posttreatment. We calculated a weighted TOC return rate and described time to TOC and suspected reasons for any positive TOC results. RESULTS: Overall, 1165 patients were diagnosed with RS infections. Over half returned for TOC (weighted TOC, 61%; 95% confidence interval, 50.1%-72.6%; range by jurisdiction, 32%-80%). Test of cure rates were higher among asymptomatic (68%) than symptomatic patients (53%, P = 0.001), and men who have sex with men (62%) compared with men who have sex with women (50%; P < 0.001). Median time between treatment and TOC was 12 days (interquartile range, 9-16). Of the 31 (4.5%) TOC patients with positive results, 13 (42%) were suspected because of reinfection and 11 (36%) because of false-positive results. There were no treatment failures suspected to be due to RS-GC. CONCLUSIONS: Most patients with a RS infection returned for a TOC, though return rates varied by jurisdiction and patient characteristics. Test of cure can identify and facilitate treatment of reinfections, but false-positive TOC results may complicate interpretation and clinical management.

Epidemiology of Reported HIV and Other Sexually Transmitted Infections During the COVID-19 Pandemic, New York City.

Early in the coronavirus disease 2019 (COVID-19) crisis, a statewide executive order (PAUSE) severely restricted the movement of New Yorkers from 23 March to 7 June 2020. We used New York City surveillance data for human immunodeficiency virus (HIV), chlamydia, gonorrhea, and syphilis to describe trends in diagnosis and reporting surrounding PAUSE. During PAUSE, the volume of positive HIV/sexually transmitted infection tests, and diagnoses of HIV, chlamydia, gonorrhea, and syphilis declined substantially, reaching a nadir in April before rebounding. Some shifts in characteristics of reported cases were identified.

Assessing the Burden of Infant Deaths Due to Herpes Simplex Virus, Human Immunodeficiency Virus, and Congenital Syphilis: United States, 1995 to 2017.

BACKGROUND: Despite advances in diagnosis and treatment, neonatal infection with herpes simplex virus (HSV) has a high case fatality rate. The national burden of neonatal HSV and associated deaths is unknown because this condition is not nationally notifiable. We investigated trends in HSV-related infant deaths compared with infant deaths from congenital syphilis (CS) and human immunodeficiency virus (HIV). METHODS: Linked birth-death files for infant deaths from 1995 to 2017 were obtained from the National Center for Health Statistics. These files include infants who were born alive and died in the first 365 days of life and exclude stillbirths. We searched death certificates for disease codes indicating HSV, CS, or HIV, and calculated the frequency and rate of deaths for each infection, overall, by infant sex, and birthing parent age and race/ethnicity. RESULTS: Nationally, 1591 deaths related to the infections of interest were identified: 1271 related to HSV (79.9%), 234 to HIV (14.7%), and 86 to CS (5.4%). Herpes simplex virus-related deaths increased significantly from 0.83/100,000 live births (95% confidence interval [CI], 0.57-1.17) in 1995 to 1.77 (95% CI, 1.37-2.24) in 2017. In contrast, HIV-related deaths declined: 1.64/100,000 (95% CI, 1.27-2.10) in 1995 to 0.00 in 2017. There was a median of 3 CS-related deaths/year, with elevated frequencies in 1995 to 1996 and 2017 (n = 8). Herpes simplex virus-related death rates were elevated among infants born to birthing parents younger than 20 years (4.17/100,000; 95% CI, 3.75-4.59) and to Black parents (2.86/100,000; 95% CI, 2.58-3.15). CONCLUSIONS: Nationally, HSV-related infant deaths exceeded those caused by HIV and CS and seem to be increasing. Our findings underscore the need for an effective HSV vaccine, test technologies enabling rapid identification of infants exposed to HSV at delivery, and a focus on equity in prevention efforts.

Estimating Neonatal Herpes Simplex Virus Incidence and Mortality Using Capture-recapture, Florida.

BACKGROUND: Neonatal herpes simplex virus infection (nHSV) leads to severe morbidity and mortality, but national incidence is uncertain. Florida regulations require that healthcare providers report cases, and clinical laboratories report test results when herpes simplex virus (HSV) is detected. We estimated nHSV incidence using laboratory-confirmed provider-reported cases and electronic laboratory reports (ELR) stored separately from provider-reported cases. Mortality was estimated using provider-reported cases, ELR, and vital statistics death records. METHODS: For 2011-2017, we reviewed: provider-reported cases (infants ≤ 60 days of age with HSV infection confirmed by culture or polymerase chain reaction [PCR]), ELR of HSV-positive culture or PCR results in the same age group, and death certificates containing International Classification of Disease, Tenth Revision, codes for herpes infection: P35.2, B00.0-B00.9, and A60.0-A60.9. Provider-reported cases were matched against ELR reports. Death certificates were matched with provider and ELR reports. Chapman's capture-recapture method was used to estimate nHSV incidence and mortality. Mortality from all 3 sources was estimated using log-linear modeling. RESULTS: Providers reported 114 nHSV cases, and ELR identified 197 nHSV cases. Forty-six cases were common to both datasets, leaving 265 unique nHSV reports. Chapman's estimate suggests 483 (95% confidence interval [CI], 383-634) nHSV cases occurred (31.5 infections per 100 000 live births). The nHSV deaths were reported by providers (n = 9), ELR (n = 18), and vital statistics (n = 31), totaling 34 unique reports. Log-linear modeling estimates 35.8 fatal cases occurred (95% CI, 34-40). CONCLUSIONS: Chapman's estimates using data collected over 7 years in Florida conclude nHSV infections occurred at a rate of 1 per 3000 live births.

The Distribution and Spread of Susceptible and Resistant Neisseria gonorrhoeae Across Demographic Groups in a Major Metropolitan Center.

BACKGROUND: Genomic epidemiology studies of gonorrhea in the United States have primarily focused on national surveillance for antibiotic resistance, and patterns of local transmission between demographic groups of resistant and susceptible strains are unknown. METHODS: We analyzed a convenience sample of genome sequences, antibiotic susceptibility, and patient data from 897 gonococcal isolates cultured at the New York City (NYC) Public Health Laboratory from NYC Department of Health and Mental Hygiene (DOHMH) Sexual Health Clinic (SHC) patients, primarily in 2012-2013. We reconstructed the gonococcal phylogeny, defined transmission clusters using a 10 nonrecombinant single nucleotide polymorphism threshold, tested for clustering of demographic groups, and placed NYC isolates in a global phylogenetic context. RESULTS: The NYC gonococcal phylogeny reflected global diversity with isolates from 22/23 of the prevalent global lineages (96%). Isolates clustered on the phylogeny by patient sexual behavior (P < .001) and race/ethnicity (P < .001). Minimum inhibitory concentrations were higher across antibiotics in isolates from men who have sex with men compared to heterosexuals (P < .001) and white heterosexuals compared to black heterosexuals (P < .01). In our dataset, all large transmission clusters (≥10 samples) of N. gonorrhoeae were susceptible to ciprofloxacin, ceftriaxone, and azithromycin, and comprised isolates from patients across demographic groups. CONCLUSIONS: All large transmission clusters were susceptible to gonorrhea therapies, suggesting that resistance to empiric therapy was not a main driver of spread, even as risk for resistance varied across demographic groups. Further study of local transmission networks is needed to identify drivers of transmission.

Unnamed Partners From Syphilis Partner Services Interviews, 7 Jurisdictions.

BACKGROUND: Reducing transmission depends on the percentage of infected partners treated; if many are missed, impact on transmission will be low. Traditional partner services metrics evaluate the number of partners found and treated. We estimated the proportion of partners of syphilis patients not locatable for intervention. METHODS: We reviewed records of early syphilis cases (primary, secondary, early latent) reported in 2015 to 2017 in 7 jurisdictions (Florida, Louisiana, Michigan, North Carolina, Virginia, New York City, and San Francisco). Among interviewed syphilis patients, we determined the proportion who reported named partners (with locating information), reported unnamed partners (no locating information), and did not report partners. For patients with no reported partners, we estimated their range of unreported partners to be between one and the average number of partners for patients who reported partners. RESULTS: Among 29,719 syphilis patients, 23,613 (80%) were interviewed and 18,581 (63%) reported 84,224 sex partners (average, 4.5; 20,853 [25%] named and 63,371 [75%] unnamed). An estimated 11,138 to 54,521 partners were unreported. Thus, 74,509 to 117,892 (of 95,362-138,745) partners were not reached by partner services (78%-85%). Among interviewed patients, 71% reported ≥1 unnamed partner or reported no partners; this proportion was higher for men who reported sex with men (75%) compared with men who reported sex with women only (65%) and women (44%). CONCLUSIONS: Approximately 80% of sex partners were either unnamed or unreported. Partner services may be less successful at interrupting transmission in networks for men who reported sex with men where a higher proportion of partners are unnamed or unreported.

Do Prescriptions for Expedited Partner Therapy for Chlamydia Get Filled? Findings From a Multi-Jurisdictional Evaluation, United States, 2017-2019.

BACKGROUND: Expedited partner therapy (EPT) is commonly provided by prescription; however, the efficacy of this modality is unknown. We examined whether EPT prescriptions are filled when the cost barrier is removed. METHODS: To track EPT prescription fill rates, we used single-use pharmacy vouchers that covered the cost of azithromycin, 1 g (chlamydia treatment). We recruited clinical sites to distribute vouchers to patients with chlamydia who would receive an EPT prescription under clinic policies. When distributing vouchers, sites recorded and retained: voucher unique identifier, sex and age of index patient, distribution date, and whether partner name was written on the EPT prescription. Pharmacists receiving vouchers entered the identifier, sex and age of presenting person, and redemption date into a standard pharmacy claim transmission system. Data for redeemed vouchers were retrieved from an industry portal and linked with data retained at clinical sites. RESULTS: Thirty-two clinical sites distributed 931 vouchers during September 2017 to January 2019; 382 (41%) were redeemed. Vouchers distributed to patients 18 years or younger (49 [30%] of 163) were less likely to be redeemed compared with those distributed to patients older than 18 years (322 [44%] of 736; P = 0.001). Just over half of vouchers were redeemed the same day (196 [56%] of 352) and 1 mile or less from the clinical site (188 [54%] of 349). After excluding an outlier site, vouchers accompanied by EPT prescriptions including a partner name (15 [56%] of 27) were more likely to be redeemed than those lacking a name (83 [34%] of 244; P = 0.03). CONCLUSIONS: Less than half of EPT prescriptions were filled, even when medication was free. Whenever possible, EPT should be provided as drug-in-hand.

Frequency and Characteristics of Biological False-Positive Test Results for Syphilis Reported in Florida and New York City, USA, 2013 to 2017.

Discordant syphilis test results, with a reactive nontreponemal test and nonreactive treponemal test are usually considered biological false-positive test results (BFPs), which can be attributed to other conditions. Syphilis surveillance laws mandate laboratory reporting of reactive syphilis tests, which include many BFPs. We describe the frequency of BFPs, titer distributions, and titer increases from reported test results in Florida and New York City (NYC). Reactive nontreponemal tests for individuals with at least one nonreactive treponemal test and no reactive treponemal test were extracted from sexually transmitted disease (STD) surveillance systems in Florida and NYC from 2013 to 2017. Characteristics of individuals with BFPs were analyzed after selecting the observation with the highest titer from each individual. We next considered all results from individuals to characterize persons who had a 4-fold titer increase between successive nontreponemal tests. Among 526,540 reactive nontreponemal tests, there were 57,580 BFPs (11%) from 39,920 individuals. Over 90% (n = 52,330) of BFPs were low titer (≤1:4), but 654 (1%) were high-titer BFPs (≥1:32). Very high-titer (≥1:128) BFPs were more common among individuals over 60 years of age (odds ratio [OR], 2.68; 95% confidence interval [CI], 1.22 to 5.91). A 4-fold increase in titer was observed among 1,863 (14%) individuals with more than one reported BFP. Most BFPs detected by surveillance were low titer, but some were high titer and some had a 4-fold increase in titer. Review of patient histories might identify underlying conditions contributing to these high and rising titers.

Incidence and Characteristics of Neonatal Herpes: Comparison of Two Population-Based Data Sources, New York City, 2006-2015.

BACKGROUND: Neonatal herpes (nHSV) is a potentially fatal disease caused by herpes simplex virus (HSV) infection during the neonatal period. Neonatal herpes simplex virus infections are not nationally notifiable, and varying incidence rates have been reported. Beginning in 2006, New York City (NYC) required reporting of nHSV infections and conducted case investigations. We compared the use of administrative hospital data with active surveillance to monitor trends in nHSV infection. METHODS: We compared the incidence and characteristics of nHSV cases as measured using population-based surveillance and administrative hospital discharge data collected between 2006 and 2015. Surveillance cases were defined as laboratory-confirmed HSV infections in NYC-resident infants aged 60 days or younger at diagnosis. Administrative cases were defined as NYC-resident infants aged 60 days or younger at hospital admission whose records included an HSV diagnosis. Neonatal herpes cases after ritual Jewish circumcision with direct orogenital suction were excluded. RESULTS: There were 107 surveillance cases (9.9 per 100,000 live births) and 131 administrative cases (12.1 per 100,000 live births). Incidence was highest in infants born to non-Hispanic black mothers aged 20 years or younger (surveillance, 57.2 per 100,000 live births; administrative data, 31.2 per 100,000 live births). The distribution of cases by year did not significantly differ across data sources. Surveillance cases had a higher case-fatality rate (18.7%) compared with administrative cases (8.4%; P = 0.019). CONCLUSIONS: Administrative hospital data can be used to measure the incidence of nHSV infection and describe disease burden across population subgroups in jurisdictions where nHSV reporting is not required. However, administrative data may underascertain nHSV case fatality.

Lymphogranuloma Venereum: An Increasingly Common Anorectal Infection Among Men Who Have Sex With Men Attending New York City Sexual Health Clinics.

Using Chlamydia trachomatis anorectal specimens routinely tested for lymphogranuloma venereum (LGV) (2008-2011) and samples of archived specimens tested for LGV (2012-2015), we observed increased LGV positivity among men who have sex with men attending NYC Sexual Health Clinics. Using clinical data, we determined predictors of anorectal LGV that may guide clinical management.

Factors Contributing to Congenital Syphilis Cases - New York City, 2010-2016.

Congenital syphilis occurs when syphilis is transmitted from a pregnant woman to her fetus; congenital syphilis can be prevented through screening and treatment during pregnancy. Transmission to the fetus can occur at any stage of maternal infection, but is more likely during primary and secondary syphilis, with rates of transmission up to 100% at these stages (1). Untreated syphilis during pregnancy can cause spontaneous abortion, stillbirth, and early infant death. During 2013-2017, national rates of congenital syphilis increased from 9.2 to 23.3 cases per 100,000 live births (2), coinciding with increasing rates of primary and secondary syphilis among women of reproductive age (3). In New York City (NYC), cases of primary and secondary syphilis among women aged 15-44 years increased 147% during 2015-2016. To evaluate measures to prevent congenital syphilis, the NYC Department of Health and Mental Hygiene (DOHMH) reviewed data for congenital syphilis cases reported during 2010-2016 and identified patient-, provider-, and systems-level factors that contributed to these cases. During this period, 578 syphilis cases among pregnant women aged 15-44 years were reported to DOHMH; a congenital syphilis case was averted or otherwise failed to occur in 510 (88.2%) of these pregnancies, and in 68, a case of congenital syphilis occurred (eight cases per 100,000 live births).* Among the 68 pregnant women associated with these congenital syphilis cases, 21 (30.9%) did not receive timely (≥45 days before delivery) prenatal care. Among the 47 pregnant women who did access timely prenatal care, four (8.5%) did not receive an initial syphilis test until <45 days before delivery, and 22 (46.8%) acquired syphilis after an initial nonreactive syphilis test. These findings support recommendations that health care providers screen all pregnant women for syphilis at the first prenatal care visit and then rescreen women at risk in the early third trimester.

HIV Care and Viral Load Suppression After Sexual Health Clinic Visits by Out-of-Care HIV-Positive Persons.

Outcomes among people living with HIV (PLWH) in New York City (NYC) remain suboptimal. To assess the potential role of the city's sexual health clinics (SHCs) in improving HIV outcomes and reducing HIV transmission, we examined HIV care status and its correlates among HIV-positive SHC patients in NYC. Clinic electronic medical records were merged with longitudinal NYC HIV surveillance data to identify HIV-positive patients and derive their retrospective and prospective HIV care status. Evidence of HIV care and viral load suppression (VLS) after clinic visit were considered outcomes. Logistic regression models were used to assess their correlates. A third of the 1045 PLWH who visited NYC SHCs in 2012 were out of HIV care (OOC) in the 12 months preceding the clinic visit, and were less likely than those previously in HIV care (IC) to have subsequent evidence of HIV care (42% vs. 72%) or VLS in the 12 months after the visit (39% vs. 76%). VLS was particularly low among patients diagnosed with ≥2 sexually transmitted infections (46%). The odds of VLS were lowest among those OOC before the clinic visit [versus those IC, adjusted odds ratio (aOR): 0.21, 95% confidence interval (CI): 0.16-0.29], non-Hispanic blacks (versus non-Hispanic whites, aOR: 0.58, 95% CI: 0.37-0.90), and residents of high-poverty neighborhoods (>30% vs. <10%, aOR: 0.51, 95% CI: 0.29-0.89). Our findings suggest that SHCs could serve as an intervention point to (re-)link PLWH to HIV care. Real-time provider alerts about patients' OOC status could help achieve that goal.

Reactor Grids for Prioritizing Syphilis Investigations: Are Primary Syphilis Cases Being Missed?

BACKGROUND: Health departments prioritize investigations of reported reactive serologic tests based on age, gender, and titer using reactor grids. We wondered how reactor grids are used in different programs, and if administratively closing investigations of low-titer tests could lead to missed primary syphilis cases. METHODS: We obtained a convenience sample of reactor grids from 13 health departments. Interviews with staff from several jurisdictions described the role of grids in surveillance and intervention. From 5 jurisdictions, trends in reactive nontreponemal tests and syphilis cases over time (2006-2015) were assessed by gender, age, and titer. In addition, nationally-reported primary syphilis cases (2013-2015) were analyzed to determine what proportion had low titers (≤1:4) that might be administratively closed by grids without further investigation. RESULTS: Grids and follow-up approaches varied widely. Health departments in the study received a total of 48,573 to 496,503 reactive serologies over a 10-year period (3044-57,242 per year). In 2006 to 2015, the number of reactive serologies increased 37% to 169%. Increases were largely driven by tests for men although the ratios of tests per reported case remained stable over time. Almost one quarter of reported primary syphilis had low titers that would be excluded by most grids. The number of potentially missed primary syphilis cases varied by gender and age with 41- to 54-year-old men accounting for most. CONCLUSIONS: Reactor grids that close tests with low titers or from older individuals may miss some primary syphilis cases. Automatic, computerized record searches of all reactive serologic tests could help improve prioritization.

Gaps Along the HIV Care Continuum: Findings Among a Population Seeking Sexual Health Care Services in New York City.

BACKGROUND: Linkage/relinkage to HIV care for virally unsuppressed people with new sexually transmitted infections is critical for ending the HIV epidemic. We quantified HIV care continuum gaps and viral suppression among HIV-positive patients attending New York City (NYC) sexual health clinics (SHCs). METHODS: One thousand six hundred forty-nine HIV-positive patients and a 10% sample of 11,954 patients with unknown HIV status on clinic visit date (DOV) were matched against the NYC HIV registry. Using registry diagnosis dates, we categorized matched HIV-positive patients as "new-positives" (newly diagnosed on DOV), "recent-positives (diagnosed ≤90 days before DOV), "prevalent-positives" (diagnosed >90 days before DOV), and "unknown-positives" (previously diagnosed but status unknown to clinic on DOV). We assessed HIV care continuum outcomes before and after DOV for new-positives, prevalent-positives, and unknown-positives using registry laboratory data. RESULTS: In addition to 1626 known HIV-positive patients, 5% of the unknown sample (63/1196) matched to the registry, signifying that approximately 630 additional HIV-positive patients attended SHCs. Of new-positives, 65% were linked to care after DOV. Of prevalent-positives, 66% were in care on DOV; 43% of the out-of-care patients were relinked after DOV. Of unknown-positives, 40% were in care on DOV; 21% of the out-of-care patients relinked after DOV. Viral suppression was achieved by 88% of in-care unknown-positives, 76% in-care prevalent-positives, 50% new-positives, 42% out-of-care prevalent-positives, and 16% out-of-care unknown-positives. CONCLUSIONS: Many HIV-positive people, including those with uncontrolled HIV infection, attend SHCs and potentially contribute to HIV spread. However, HIV status often is not known to staff, resulting in missed linkage/relinkage to care opportunities. Better outcomes could be facilitated by real-time ascertainment of HIV status and HIV care status.