Knowledge, Attitudes, and Practices Related to Ebola Virus Disease at the End of a National Epidemic - Guinea, August 2015.

Health communication and social mobilization efforts to improve the public's knowledge, attitudes, and practices (KAP) regarding Ebola virus disease (Ebola) were important in controlling the 2014-2016 Ebola epidemic in Guinea (1), which resulted in 3,814 reported Ebola cases and 2,544 deaths.* Most Ebola cases in Guinea resulted from the washing and touching of persons and corpses infected with Ebola without adequate infection control precautions at home, at funerals, and in health facilities (2,3). As the 18-month epidemic waned in August 2015, Ebola KAP were assessed in a survey among residents of Guinea recruited through multistage cluster sampling procedures in the nation's eight administrative regions (Boké, Conakry, Faranah, Kankan, Kindia, Labé, Mamou, and Nzérékoré). Nearly all participants (92%) were aware of Ebola prevention measures, but 27% believed that Ebola could be transmitted by ambient air, and 49% believed they could protect themselves from Ebola by avoiding mosquito bites. Of the participants, 95% reported taking actions to avoid getting Ebola, especially more frequent handwashing (93%). Nearly all participants (91%) indicated they would send relatives with suspected Ebola to Ebola treatment centers, and 89% said they would engage special Ebola burial teams to remove corpses with suspected Ebola from homes. Of the participants, 66% said they would prefer to observe an Ebola-affected corpse from a safe distance at burials rather than practice traditional funeral rites involving corpse contact. The findings were used to guide the ongoing epidemic response and recovery efforts, including health communication, social mobilization, and planning, to prevent and respond to future outbreaks or sporadic cases of Ebola.

Delivery of HIV Antiretroviral Therapy Adherence Support Services by HIV Care Providers in the United States, 2013 to 2014.

BACKGROUND: Little is known about clinicians' adoption of recommendations of the International Association of Providers of AIDS Care and others for supporting adherence to antiretroviral therapy (ART). METHODS: We surveyed a probability sample of US HIV care providers to estimate the percentage offering 3 ART adherence support services to most or all patients and assessed the characteristics of providers offering all 3 services (comprehensive support) to most or all patients. RESULTS: Almost all providers (95.5%) discussed ART adherence at every visit, 60.1% offered advice about tools to increase adherence, 53.5% referred nonadherent patients for supportive services, and 42.8% provided comprehensive support. Nurse practitioners were more likely to offer comprehensive support as were providers who practiced at Ryan White HIV/AIDS Program-funded facilities, provided primary care, or started caring for HIV-infected patients within 10 years. CONCLUSION: Less than half of HIV care providers offered comprehensive ART adherence support. Certain subgroups may benefit from interventions to increase delivery of adherence support.

Recommendations for HIV Screening of Gay, Bisexual, and Other Men Who Have Sex with Men - United States, 2017.

CDC's 2006 recommendations for human immunodeficiency virus (HIV) testing state that all persons aged 13-64 years should be screened for HIV at least once, and that persons at higher risk for HIV infection, including sexually active gay, bisexual, and other men who have sex with men (MSM), should be rescreened at least annually (1). Authors of reports published since 2006, including CDC (2), suggested that MSM, a group that is at highest risk for HIV infection, might benefit from being screened more frequently than once each year. In 2013, the U.S. Preventive Services Task Force (USPSTF) found insufficient evidence to specify an HIV rescreening interval but recommended annual screening for MSM as a reasonable approach (3). However, some HIV providers have begun to offer more frequent screening, such as once every 3 or 6 months, to some MSM. A CDC work group conducted a systematic literature review and held four expert consultations to review programmatic experience to determine whether there was sufficient evidence to change the 2006 CDC recommendation (i.e., at least annual HIV screening of MSM in clinical settings). The CDC work group concluded that the evidence remains insufficient to recommend screening more frequently than at least once each year. CDC continues to recommend that clinicians screen asymptomatic sexually active MSM at least annually. Each clinician can consider the benefits of offering more frequent screening (e.g., once every 3 or 6 months) to individual MSM at increased risk for acquiring HIV infection, weighing their patients' individual risk factors, local HIV epidemiology, and local testing policies.

Attitudes about vaccines to prevent Ebola virus disease in Guinea at the end of a large Ebola epidemic: Results of a national household survey.

INTRODUCTION: In 2014-2016, an Ebola epidemic devastated Guinea; more than 3800 cases and 2500 deaths were reported to the World Health Organization. In August 2015, as the epidemic waned and clinical trials of an experimental, Ebola vaccine continued in Guinea and neighboring Sierra Leone, we conducted a national household survey about Ebola-related knowledge, attitudes, and practices (KAP) and opinions about "hypothetical" Ebola vaccines. METHODS: Using cluster-randomized sampling, we selected participants aged 15+ years old in Guinea's 8 administrative regions, which had varied cumulative case counts. The questionnaire assessed socio-demographic characteristics, experiences during the epidemic, Ebola-related KAP, and Ebola vaccine attitudes. To assess the potential for Ebola vaccine introduction in Guinea, we examined the association between vaccine attitudes and participants' characteristics using categorical and multivariable analyses. RESULTS: Of 6699 persons invited to participate, 94% responded to at least 1 Ebola vaccine question. Most agreed that vaccines were needed to fight the epidemic (85.8%) and that their family would accept safe, effective Ebola vaccines if they became available in Guinea (84.2%). These measures of interest and acceptability were significantly more common among participants who were male, wealthier, more educated, and lived with young children who had received routine vaccines. Interest and acceptability were also significantly higher among participants who understood Ebola transmission modes, had witnessed Ebola response teams, knew Ebola-affected persons, believed Ebola was not always fatal, and would access Ebola treatment centers. In multivariable analyses of the majority of participants living with young children, interest and acceptability were significantly higher among those living with vaccinated children than among those living with unvaccinated children. DISCUSSION: The high acceptability of hypothetical vaccines indicates strong potential for introducing Ebola vaccines across Guinea. Strategies to build public confidence in use of Ebola vaccines should highlight any similarities with safe, effective vaccines routinely used in Guinea.

Eurogin 2010 roadmap on cervical cancer prevention.

The EUROGIN 2010 roadmap represents a continuing effort to provide and interpret updated information on cervical cancer screening and vaccination against the cause of the disease, high-risk human papillomavirus (HPV). Contrary to the two previous reports in 2008 and 2009, the present roadmap gives equal room to HPV-based screening and HPV vaccination, as a result of the recent strengthening of the evidence on the efficacy and feasibility of both approaches. The superiority of HPV testing in primary screening compared to cytology (in more developed countries) and to cytology or visual inspection methods (in less developed countries) has been demonstrated in several randomised trials. High vaccine efficacy has been confirmed up to 7 years after vaccination; school-based programmes in some countries have been able to reach over 70% coverage among adolescent girls. Demonstration projects have indicated that the delivery of HPV vaccines in less developed countries is feasible and favourably received by populations where cervical cancer is very common. HPV-based screening can diminish cervical cancer incidence more quickly than HPV vaccination, but vaccination can eventually facilitate screening efforts, especially if new vaccines against a greater number of HPV types are introduced. The availability of two highly complementary prevention tools such as HPV testing and HPV vaccination makes it possible to conceive integrated strategies for the elimination of cervical cancer that have no precedent in the cancer field. HPV tests and HPV vaccines remain, however, too expensive, and large-scale financing of screening and vaccination in less developed countries is sorely lacking.

STD screening of HIV-infected MSM in HIV clinics.

BACKGROUND: National guidelines for the care of human immunodeficiency virus (HIV)-infected persons recommend asymptomatic routine screening for sexually transmitted diseases (STDs). Our objective was to determine whether providers who care for HIV-infected men who have sex with men (MSM) followed these guidelines. METHODS: We abstracted medical records to evaluate STD screening at 8 large HIV clinics in 6 US cities. We estimated the number of men who had at least one test for syphilis, chlamydia (urethral and/or rectal), or gonorrhea (urethral, rectal, and/or pharyngeal) in 2004, 2005, and 2006. Urethral testing included nucleic acid amplification tests of both urethral swabs and urine. We also calculated the positivity of syphilis, chlamydia, and gonorrhea among screened men. RESULTS: Medical records were abstracted for 1334 HIV-infected MSM who made 14,659 visits from 2004-2006. The annual screening rate for syphilis ranged from 66.0% to 75.8% during 2004-2006. Rectal chlamydia and rectal and pharyngeal gonorrhea annual screening rates ranged from 2.3% to 8.5% despite moderate to high positivity among specimens from asymptomatic patients (3.0%-9.8%) during this period. Annual urethral chlamydia and gonorrhea screening rates were higher than rates for nonurethral sites, but were suboptimal, and ranged from 13.8% to 18.3%. CONCLUSIONS: Most asymptomatic HIV-infected MSM were screened for syphilis, indicating good provider adherence to this screening guideline. Low screening rates for gonorrhea and chlamydia, especially at rectal and pharyngeal sites, suggest that substantial barriers exist for complying with these guidelines. The moderate to high prevalence of asymptomatic chlamydial and gonococcal infections underscores the importance of screening. A range of clinical quality improvement interventions are needed to increase screening, including increasing the awareness of nucleic acid amplification tests for nonurethral screening.

Immunizing school-age children and adolescents: experience from low- and middle-income countries.

OBJECTIVE: Given the increased attention on the need for booster immunizations of older children and adolescents, as well as new primary vaccine series that specifically target school-age children and adolescents, we reviewed the current state of vaccine delivery to school-age children and adolescents in low- and middle-income countries. METHODS: We searched the published literature and unpublished sources for articles, meeting presentations, technical reports and program documents related to immunization policies and programs for school-age children and/or adolescents between 6 and 19 years of age in low- and middle-income countries. FINDINGS: We found several examples of ongoing school-age children and adolescent immunization in low- and middle-income countries. Reasons to vaccinate this age group include vaccines specifically targeted for this age group, waning immunity from prior vaccination, "catch-up" vaccination, acceleration of disease control or elimination efforts, and age distribution shift in the incidence of vaccine-preventable diseases. Multiple delivery strategies are currently in use: routine immunization, supplementary immunization activities, and Child Health Days and similar activities. Vaccines can be delivered in fixed sites, or through outreach. Most immunization programs that target adolescents and school-aged children are providing boosters of infant vaccines at school entry age, with scant experience in delivery of primary vaccination series in adolescents. Few of these programs have been formally evaluated and dissemination of lessons learned is limited. CONCLUSIONS: This baseline description may facilitate immunization program planning in countries considering vaccinating this age group. Additionally, this summary may inform plans for operational research and program evaluation designed to expand vaccine delivery to school-age children and adolescents in low- and middle-income countries.

Access of Black, Hispanic, and nonprivately insured women to liquid-based cytology, human papillomavirus DNA testing, and on-site colposcopy in the United States.

OBJECTIVE: To determine whether patient race, ethnicity, or insurance status was associated with access to cervical cancer screening with liquid-based cytology (LBC) and with human papillomavirus (HPV) DNA testing and with access to on-site colposcopy at the provider's principal practice site. MATERIALS AND METHODS: We conducted a nationally representative survey of clinicians in specialties that provide cervical cancer screening. Adjusted odds ratios (OR) were estimated for the associations between race, ethnicity, and insurance status of patients and provider use of LBC, HPV DNA testing, and on-site colposcopy. RESULTS: Providers who cared for >or=20% Hispanic patients were less likely to use LBC (OR 0.60, 95% CI=0.42-0.84). Providers who cared for >or=25% black women (OR 0.71, 95% CI=0.51-0.98) and providers who cared for <75% privately insured patients (OR 0.66, 95% CI=0.46-0.95) were less likely to use HPV DNA testing. Providers who cared for <75% privately insured patients were less likely to have on-site colposcopy (OR 0.57, 95% CI=0.37-0.89), but those who cared for >or=20% Medicaid patients were more likely to have on-site colposcopy (OR 1.86, 95% CI=1.26-2.73). CONCLUSIONS: Given the high rates of cervical cancer in minority women, access to cervical cancer screening and diagnostic follow-up must be ensured. It may also be beneficial to ensure affordable access to technologies such HPV DNA testing that increases the sensitivity of disease detection and to on-site colposcopy that facilitates follow-up of abnormal cytology.

Early experience with human papillomavirus vaccine introduction in the United States, Canada and Australia.

Successful incorporation of a new vaccine into a nation's vaccination program requires addressing a number of issues, including: 1) establishing national recommendations; 2) assuring education of and acceptance by the public and medical community; 3) establishing and maintaining an appropriate infrastructure for vaccine delivery; 4) financing the vaccine and the program, in addition to political will. This article reviews the early experience with implementation of human papillomavirus (HPV) vaccination programs. It focuses on the United States of America and Canada and provides a brief report on Australia, where introduction is underway.

Country recommendations on the inclusion of HPV vaccines in national immunization programmes among high-income countries, June 2006-January 2008.

We analysed country recommendations and funding plans finalized through January 2008 for the inclusion of quadrivalent and bivalent human papillomavirus (HPV) vaccines in national immunization programmes. Fifteen industrialized countries have recommended HPV vaccine use based on careful review of scientific evidence and cost-effectiveness. There was a strong consensus among the guidelines regarding assessment of vaccine safety and efficacy, selection of primary target populations for vaccination, vaccine delivery strategies, and the need for vaccinated females to seek cervical cancer screening. The analysis informs ongoing discussions in several countries considering HPV vaccines for national immunization programmes and discussions at the World Health Organization about global recommendations for HPV vaccine use for national immunization programmes.

Receipt of HIV and STD testing services during routine general medical or gynecological examinations: variations by patient sexual risk behaviors.

OBJECTIVE: Clinical practice guidelines in the United States recommend screening patients who report high-risk sexual behaviors (HRSB) for human immunodeficiency virus (HIV) and selected sexually transmitted diseases (STDs). The objective of this study was to estimate HIV and STD diagnostic and testing practices during routine general medical examinations (RGME) or gynecological examinations (GYNE) of patients by their reported HRSB status. METHODS: We analyzed medical claims data from commercially-insured patients in the United States who sought care during 2000-2003. International Classification of Disease-9 (ICD-9) diagnostic and Current Procedural Terminology procedural codes were used to identify claims for HRSB, RGME or GYNE, HIV and STD diagnoses, and HIV and STD tests. RESULTS: Of 4296 patients aged 15 to 54 years during RGME or GYNE, almost none had ICD-9 codes for HIV, syphilis, Chlamydia trachomatis (CT) or Neisseria gonorrhoeae (NG) infection. Patients with claims for HRSB were significantly more likely than patients without a claim for HRSB to be tested for HIV, syphilis, CT, and NG. Among patients with HRSB-RGME, men were significantly more likely to be tested for HIV (79.3% vs. 38.8%) and syphilis (39.1% vs. 27.6%) and less likely to be tested for CT (20.7% vs. 56.9%) and NG (20.7% vs. 50.9%) than were women. CONCLUSIONS: A large proportion of patients with HRSB at RGME or GYNE did not receive HIV and STD tests. Interventions to increase HIV and STD testing of patients at visits with claims for HRSB are needed to enhance guideline adherence.

Providers' perceived barriers to sexually transmitted disease care in 2 large health maintenance organizations.

GOAL: To identify providers' perceived barriers to sexually transmitted disease (STD) care in 2 health plans and plan-, clinician-, and patient-level factors that were associated with these barriers in order to inform quality improvement interventions. STUDY DESIGN: Surveys were mailed to a stratified sample of 1000 physicians, physician assistants, and nurse practitioners at 2 large health plans in 1999-2000. Of the 743 (82%) providers who received questionnaires and responded, data were analyzed from 699 with complete specialty information. RESULTS: Ninety-five percent of providers identified at least 1 barrier to STD care. The most commonly cited barriers in both plans related to insufficient time and staff to address STDs, to counsel patients or manage sex partners, to keep current with managing high-risk patients, and to monitor patient adherence to recommendations to abstain from sex or use condoms during treatment. Nurse practitioners and specialists in obstetrics and gynecology were more likely to cite these barriers. Providers in staff models were more likely to cite the most common patient-level barriers. Few cited barriers related to diagnostic and treatment services. CONCLUSIONS: Interventions in health plans are necessary to address constraints related to time and staff performing STD related care, keeping current with managing high-risk patients, and supporting patient adherence to provider recommendations.

Cervical cancer screening and management practices among providers in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP).

BACKGROUND: This study was conducted to describe clinicians serving women in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) with regard to demographic and practice characteristics and their usual practices in cervical cancer screening and abnormal cytology management, as well as human papillomavirus (HPV) test use. METHODS: The authors analyzed data from a nationally representative survey conducted in 2004 of providers practicing 7 specialties that commonly offer cervical cancer screening. The program providers were compared with nonprogram providers. RESULTS: Program providers were found to be significantly more likely than nonprogram providers to be midlevel providers and to serve low-income, racial/ethnic minorities who are insured by Medicaid. In addition, they had significantly more patients with abnormal Papanicolaou tests and were more likely to offer onsite colposcopy (57% vs 40%). Program providers were less likely to use liquid-based cytology (LBC) as their sole method for cytology. Approximately 20% of program and nonprogram providers used HPV DNA testing as an adjunct to screening cytology and two-thirds used HPV tests to manage patients with abnormal cytology results. However, many also used HPV testing for reasons not approved by the U.S. Food and Drug Administration (FDA), such as for screening women age <30 years. CONCLUSIONS: As of mid-2004, program providers served racially and ethnically diverse, low-income patients who are at high risk for cervical cancer compared with nonprogram providers, as intended by this program. Because many providers offered on-site colposcopy, used LBC, and used HPV tests for patients with abnormal cytology results, they are well equipped to reduce the risk of cervical cancer. Many program providers used the HPV test for reasons that were not approved of by the FDA or reimbursed by the NBCCEDP. The results of this survey have informed training materials for program providers, reimbursement policies for LBC and HPV tests, and interventions to discourage inappropriate HPV testing.

Use of DNA tests for human Papillomavirus infection by US clinicians, 2004.

Since 1999, human papillomavirus (HPV) DNA tests have been approved only for abnormal cervical cytology management and as an adjunct to cervical cytology screening. To assess HPV DNA testing practices, we mailed surveys to 6906 randomly selected clinicians in mid-2004. Awareness (87%) and ever use (67%) of HPV DNA tests was high. Test users were more likely than nonusers to be obstetricians/gynecologists or midwives, to be female, and to serve mainly privately insured patients. Respondents reported ever using HPV DNA tests for both approved and nonapproved indications, which included testing for HPV infection in women with anogenital warts or other sexually transmitted diseases, in their sex partners, and in men. Interventions are needed to discourage HPV DNA test use for nonapproved indications.

Anogenital warts knowledge and counseling practices of US clinicians: results from a national survey.

OBJECTIVES: To examine messages US clinicians use when counseling patients diagnosed with anogenital warts. STUDY DESIGN: In mid-2004, we conducted a confidential mail survey of nationally representative samples of physicians practicing internal and adolescent medicine, family/general practice, obstetrics/gynecology, urology, or dermatology; nurse midwives; physician assistants; and nurse practitioners. The survey assessed knowledge and counseling practices of clinicians who had diagnosed anogenital warts. RESULTS: After adjusting for survey eligibility, 81% responded. Most (89%) were aware that human papillomavirus (HPV) causes anogenital warts, but only 48% were aware that oncogenic and wart-related HPV genotypes usually differ. Most (>95%) clinicians reported telling patients with warts that warts are an STD, are caused by a virus, or that their sex partners may have or may acquire warts. Many clinicians (>/=85%) also reported discussing STD prevention or assessing STD risk with such patients. Most reported addressing ways to prevent HPV (89%), including using condoms; limiting sex partners or practicing monogamy; or abstinence. Many also reported recommending prompt (82%) or more frequent (52%) Pap testing to female patients with anogenital warts. Potential barriers to counseling included providing definitive answers on how HPV infection was acquired, dealing with patients' psychosocial issues, and inadequate reimbursement. CONCLUSIONS: Most surveyed clinicians appropriately counseled patients about the cause and prevention of anogenital warts. However, many clinicians were unaware that oncogenic and wart-related HPV types usually differ, and this may explain why many reported recommending more aggressive cervical cancer screening for female patients with warts.

A cost-effectiveness evaluation of a jail-based chlamydia screening program for men and its impact on their partners in the community.

BACKGROUND: Few cost-effectiveness evaluations of screening men in jails for chlamydia have been published, and none have evaluated the cost-effectiveness of providing partner notification services to the partners of chlamydia-infected inmates. GOAL: The goal of this study was to evaluate the cost-effectiveness of the chlamydia screening and partner notification programs for men conducted by a Massachusetts jail compared with 3 hypothetical alternatives. STUDY DESIGN: Using jail cost and testing data, we used decision analyses to compare the cost and effectiveness of universal screening, age-based screening with 2 age cutoffs, and testing of symptomatic inmates at intake using treated cases of chlamydia and gonorrhea as the primary outcome. We also evaluated the cost-effectiveness of adding partner notification to these alternatives. RESULTS: Universal screening was the most effective and expensive alternative. Age-based screening would have identified slightly fewer cases at half the cost of universal screening. The net cost of partner notification was low. Assuming high sequelae costs in female partners made partner notification a cost-saving intervention. CONCLUSIONS: Age-based screening could lower costs without substantially sacrificing effectiveness. Notifying partners of infected inmates was a cost-effective adjunct to screening inmates.

Cervical cancer screening, abnormal cytology management, and counseling practices in the United States.

OBJECTIVE: We assessed clinician knowledge and practices since the marketing of tests for sexually transmitted human papillomavirus (HPV) and the release of HPV testing guidelines for two indications: 1) as an adjunct to cytologic screening and 2) to guide colposcopic triage of patients with atypical squamous cells of undetermined significance (ASC-US) cytology results. METHODS: In mid-2004, we surveyed nationally representative, random samples of clinicians practicing specialties that provide cytologic screening. Mail surveys addressed HPV-related knowledge, screening, abnormal cytology management, HPV testing, and counseling practices. RESULTS: The overall adjusted response rate was 82%. Of the 2,980 (89%) clinicians providing cytologic screening, 99% knew that HPV infection increases cervical cancer risk, and 91% were aware of HPV tests. Of the 21% who reported ever using HPV tests as an adjunct to cytology, more reported usually testing patients aged less than 30 years (which guidelines do not recommend) than older patients (which guidelines do recommend). Of the 63% of clinicians who ever ordered HPV tests for abnormal cytology results, 84% usually ordered tests for ASC-US results and preferentially advised colposcopy if HPV tests were positive, as guidelines recommend. However, more than 60% usually ordered HPV tests for higher-grade abnormalities, which is not recommended for colposcopy triage. Although few sought HPV test consent, most discussed sexually transmitted HPV with patients with abnormal cytology or positive HPV tests despite potentially negative psychosocial consequences. CONCLUSION: New HPV tests and testing guidelines have transformed screening, abnormal cytology management, and counseling practices. Although many U.S. clinicians reported using HPV tests according to guidelines, many also reported inappropriate use.

Family physicians' knowledge of genital human papillomavirus (HPV) infection and HPV-related conditions, United States, 2004.

BACKGROUND AND OBJECTIVES: Information about human papillomavirus (HPV) has evolved rapidly and HPV DNA tests are now available. Little is known about family physicians' knowledge about HPV and how it relates to HPV test use and counseling practices. METHODS: In mid-2004, confidential surveys were mailed to a nationally representative sample of 760 family physicians. We assessed and analyzed relationships between knowledge about HPV, HPV test use, and counseling messages provided when collecting cervical cytology and managing anogenital warts. RESULTS: The adjusted response rate was 68% (n=368). Ninety-one percent provided cervical cancer screening, and 90% had managed genital warts. Responses indicated that more than 90% had up-to-date knowledge about several issues: HPV infection is common, persistent infection increases risk of cervical neoplasia, and treatment does not eliminate the causative infection. However, fewer than 50% were aware that HPV infections may clear spontaneously and that the HPV types associated with warts and cervical neoplasia differ. Only 57% had ever used HPV tests. Some HPV knowledge varied by clinician characteristics, and knowledge was associated with HPV test use but not counseling messages. CONCLUSIONS: Most physicians were aware of new information about HPV infection, but some were unaware of important information relevant for patient counseling. These topics have been highlighted in new clinical training and patient education materials.

Gonorrhea prevention and clinical care in the private sector: lessons learned and priorities for quality improvement.

We reviewed literature on gonorrhea prevention and clinical care in the private sector, the setting where most gonorrhea cases in the United States are now diagnosed. Although most private-sector health settings had a low prevalence of gonorrhea (0.1-2.5%), some private emergency departments and specialty clinics that serve a large number of high-risk or infected patients had prevalences ranged from 1.7% to 11.0%. Studies of diverse settings and populations suggest that, in general, diagnostic testing of symptomatic patients (69-83%), appropriate treatment (61-100%), and case reporting (64-94%) are delivered more commonly than risk assessment for asymptomatic patients (15-28%), routine screening of pregnant women (31-77%), risk-reduction counseling (35-78%), and sex partner management (0-82%). To sustain the recent declines in gonorrhea incidence in the United States, private-sector providers and health systems must continue to offer gonorrhea prevention and clinical services and consider implementing interventions to improve delivery of risk assessment, risk-reduction counseling, and partner management services.