Sexually transmitted infection clinics as safety net providers: exploring the role of categorical sexually transmitted infection clinics in an era of health care reform.

BACKGROUND: For many individuals, the implementation of the US Affordable Care Act will involve a transition from public to private health care venues for sexually transmitted infection (STI) care and prevention. To anticipate challenges primary care providers may face and to inform the future role of publicly funded STI clinics, it is useful to consider their current functions. METHODS: Data collected by 40 STI clinics that are a part of the Sexually Transmitted Disease Surveillance Network were used to describe patient demographic and behavioral characteristics, STI diagnoses, and laboratory testing data in 2010 and 2011. RESULTS: A total of 608,536 clinic visits were made by 363,607 unique patients. Most patients (61.9%) were male; 21.9% of men reported sex with men (MSM). Roughly half of patients were 20 to 29 years old (47.1%) and non-Hispanic black (56.2%). There were 212,765 STI diagnoses (mostly nonreportable) that required clinical examinations. A high volume of chlamydia, gonorrhea, and HIV testing was performed (>350,000 tests); the prevalence was 11.5% for chlamydia, 5.8% for gonorrhea, 0.9% for HIV, and varied greatly by sex and MSM status. Among MSM with chlamydia or gonorrhea, 40.1% (1811/4448) of chlamydial and 46.2% (3370/7300) of gonococcal infections were detected at extragenital sites. CONCLUSIONS: Sexually Transmitted Disease Surveillance Network clinics served populations with high STI rates. Given experience with diagnoses of both nonreportable and reportable STIs and extragenital chlamydia and gonorrhea testing, STI clinics comprise a critical specialty network in STI diagnosis, treatment, and prevention.

Evaluation of gonorrhea test of cure at 1 week in a Los Angeles community-based clinic serving men who have sex with men.

BACKGROUND: Because of the decreasing susceptibility of Neisseria gonorrhoeae to cephalosporin therapy, the Centers for Disease Control and Prevention recommends test of cure (TOC) 1 week after gonorrhea (GC) treatment if therapies other than ceftriaxone are used. In addition, the Centers for Disease Control and Prevention asks clinicians, particularly those caring for men who have sex with men (MSM) on the west coast, to consider retesting all MSM at 1 week. However, it is unclear if this is acceptable to providers and patients or if nucleic acid amplification tests (NAATs) are useful for TOC at 7 days. METHODS: Between January and July 2012, MSM with GC were advised to return 1 week after treatment for TOC using NAAT. A multivariate logistic regression model was used to determine demographic and behavioral differences between MSM who returned for follow-up and MSM who did not. RESULTS: Of 737 men with GC, 194 (26.3%) returned between 3 and 21 days of treatment. Individuals who returned were more likely to have no GC history (P = 0.0001) and to report no initial symptoms (P = 0.02) when compared with individuals who did not return for TOC. Of those who returned, 0% of urethral samples, 7.4% of rectal samples, and 5.3% of pharyngeal samples were NAAT positive at TOC. CONCLUSIONS: Although TOC may be an important strategy in reducing complications and the spread of GC, low return rates may make implementation challenging. If implemented, extra efforts should be considered to enhance return rates among individuals with a history of GC. If TOCs are recommended at 1 week and NAATs are used, the interpretation of positive results, particularly those from extragenital sites, may be difficult.

Opportunities for chlamydia control in the era of healthcare reform: lessons from two decades of innovative family planning care.

In the USA, family planning clinics are primary providers of reproductive healthcare to young women and their male partners and have long provided quality sexually transmitted infection (STI) care and prevention. Chlamydia, an easily treatable STI that can lead to serious adverse outcomes if untreated, is the most common bacterial STI in the USA, and annual chlamydia screening is recommended for sexually active women aged ≤25 years. As early adopters of routine screening, family planning clinics screen >50% of all care-seeking eligible women for chlamydia, performing better than private sector healthcare plans. To achieve high levels of quality care, family planning clinics have been leaders in implementing evidence-based care delivery and developing prevention innovations. As national healthcare reform is implemented in the USA and categorical STI clinics close, public-sector demand on family planning clinics will increase.

Parent attitudes about school requirements for human papillomavirus vaccine in high-risk communities of Los Angeles, California.

BACKGROUND: Human papillomavirus (HPV) immunization requirements for school entry could increase HPV vaccine uptake but are controversial. This study assessed parents' attitudes about HPV immunization requirements. METHODS: During October 2007 to June 2008, we conducted telephone surveys with 484 parents of girls attending middle/high schools serving communities in Los Angeles County with elevated cervical cancer rates. RESULTS: Parents were mostly Hispanic (81%) or African American (15%); 71% responded in Spanish. Many parents did not know if HPV vaccine works well (42%) or is unsafe (41%). Overall, 59% of parents agreed that laws requiring HPV vaccination for school attendance "are a good idea." In multivariable analysis, African Americans and Hispanics responding in English were less likely than Hispanics responding in Spanish to agree (aOR 0.1, 95% CI: 0.1-0.3; aOR 0.4, 95% CI: 0.2-0.8, respectively). Parents were less likely to agree with these laws if they did not believe the vaccine works well (aOR 0.2, 95% CI: 0.1-0.5) but more likely to agree if they believed the vaccine is not "too new for laws like these" (aOR 4.5, 95% CI: 2.6-8.0). Agreement with laws increased to 92% when including agreement that "these laws are okay only if parents can opt out." CONCLUSIONS: In this at-risk community, more than half of the parents agreed with HPV immunization requirements generally, and the vast majority agreed when including opt-out provisions. IMPACT: Support for HPV vaccine requirements may depend on race/ethnicity and inclusion of opt-out provisions. Information about vaccine efficacy and safety may increase support and reduce uncertainty about HPV vaccine in high-risk populations.

Human papillomavirus vaccine initiation among adolescent girls in high-risk communities.

BACKGROUND: We assessed human papillomavirus (HPV) vaccine uptake among adolescent girls, parents' intentions to vaccinate daughters, and barriers and facilitators of vaccination in a population at elevated risk for cervical cancer. METHODS: Between October 2007 and June 2008, telephone surveys were conducted with randomly selected parents/guardians of 11-18 year old girls attending public middle and high schools serving economically disadvantaged populations in Los Angeles County. RESULTS: We surveyed 509 predominantly Hispanic (81%) and African American (16%) parents; 71% responded in Spanish. Overall, 23% reported their daughter had received ≥ 1 dose of HPV vaccine. Although 93% of daughters had seen a doctor in the past year, only 30% reported that a provider recommended HPV vaccine. Characteristics positively associated with odds of having initiated HPV vaccine were having heard of the vaccine (adjusted odds ratio [aOR] 2.6), belief in vaccine effectiveness (aOR 2.9), and doctor recommendation (aOR 48.5). Negative attitudes toward HPV vaccine (aOR 0.2) and needing more information about it (aOR 0.1) were negatively associated with vaccine initiation. Of those with unvaccinated daughters (n=387), 62% said they "probably/definitely will" vaccinate within the next year and 21% were undecided or didn't know; only 11% said they definitely won't. CONCLUSIONS: About one-quarter of adolescent girls in this at-risk community had initiated HPV vaccine by mid-2008. Provider recommendation was the single most important factor associated with vaccination. Because a substantial proportion of parents remain undecided about HPV vaccine, health care providers can play a key role by providing needed information and offering HPV vaccine to all eligible adolescents.

Chlamydia screening and management practices of primary care physicians and nurse practitioners in California.

BACKGROUND: Because sexually transmitted chlamydial infections are common among young women, it is critical that providers screen and manage these infections appropriately. OBJECTIVE: To assess the Chlamydia care practices of California primary care physicians and nurse practitioners. DESIGN: Cross-sectional, self-report mail survey. PARTICIPANTS: A stratified random sample of primary care physicians and a convenience sample of primary care nurse practitioners in California. MEASUREMENTS AND MAIN RESULTS: Survey content included 5 topic areas: sexual history taking, management of cervicitis, management of a nonpregnant Chlamydia-infected patient, availability of onsite STD services, and Chlamydia screening practices and attitudes. Main outcome measure was the reported frequency of Chlamydia screening of sexually active women age 25 and younger. Respondents included 708 physicians (49% response rate) and 895 nurse practitioners (63% response rate). Nearly half of physicians (47%, 95% confidence interval [CI], 42% to 51%) and a majority of nurse practitioners (79%, 95% CI, 77% to 82%) reported routine Chlamydia screening of women under age 20; similar proportions reported routinely screening women aged 20 to 25 years. Independent predictors of screening among physicians were adolescent medicine specialty, female gender, practicing in a nonprivate setting, and having a higher volume of female patients. Additional findings included the overscreening of women over age 25 by nurse practitioners and the shared concern among providers that Chlamydia screening may not be reimbursed. CONCLUSIONS: The Chlamydia care practices of many California primary care providers are inconsistent with current guidelines. Targeted provider education and improved reimbursements are potential strategies for improvement.

Recommendations for the selective use of herpes simplex virus type 2 serological tests.

BACKGROUND: Herpes simplex virus (HSV) type-specific serological tests are now widely available, but indications for their use have not been well defined. The California Sexually Transmitted Diseases (STD) Controllers Association convened a committee of clinicians and researchers to make recommendations for the use of type-specific HSV type 2 (HSV-2) serological tests. METHODS: By means of a systematic review of the literature, evidence to support screening in selected high-risk groups was compiled. Screening recommendations were developed by applying standard screening criteria to each specific population. RESULTS: The committee concluded that, in addition to serological testing for the diagnostic evaluation of patients with symptoms, screening of asymptomatic patients is likely to be beneficial among the following groups: those at high risk for STDs and human immunodeficiency virus (HIV) infection who are motivated to reduce their sexual risk behavior, HIV-infected patients, and patients with sex partners with genital herpes. In contrast, universal screening for HSV-2 infection in pregnant women is unlikely to be beneficial. CONCLUSIONS: The targeted use of HSV-2 serological tests for specific diagnostic situations and selected populations should benefit patients, providers, and the community. Until more data become available, these recommendations provide justification for selective diagnostic and screening uses of HSV-2 serological tests.