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

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

Using the exploration, preparation, implementation, sustainment (EPIS) framework to assess the cooperative re-engagement controlled trial (CoRECT).

Background: "Data to Care" (D2C) is a strategy which relies on a combination of public health surveillance data supplemented by clinic data to support continuity of HIV care. The Cooperative Re-Engagement Controlled Trial (CoRECT) was a CDC-sponsored randomized controlled trial of a D2C model, which provided an opportunity to examine the process of implementing an intervention for people with HIV (PWH) who are out-of-care across three public health department jurisdictions. Using the EPIS (Exploration, Preparation, Implementation, Sustainment) framework, we aimed to retrospectively describe the implementation process for each site to provide insights and guidance to inform future D2C activities implemented by public health agencies and their clinical and community partners. Methods: After completion of CoRECT, the three (Connecticut, Massachusetts, Philadelphia) trial sites reviewed study protocols and held iterative discussions to describe and compare their processes regarding case identification, interactions with partnering clinics and patients, and sustainability. The EPIS framework provided a structure for comparing key organizational and operational practices and was applied to the entire implementation process. Results: The trial sites varied in their implementation processes and the specific elements of the intervention. Factors including prior D2C experience, data management and analytic infrastructure, staff capacity, and relationships with clinic partners informed intervention development and implementation. Additionally, this review identified key lessons learned including to: (1) explore new supplemental sources for public health surveillance data; (2) work with stakeholders representing core functions/components in the early stages of the intervention design process; (3) build flexibility into all components of the follow-up activities; and (4) integrate data sharing, project management, and follow-up activities within existing DPH organizational structure. Conclusion: The CoRECT study provides a general blueprint and lessons learned for implementing a D2C intervention for re-engagement in HIV care. Interventions should be tailored to local operational and structural factors, and responsive to evolving clinical and public health practices.

Impact of an Electronic Medical Record Best Practice Alert on Expedited Partner Therapy for Chlamydia Infection and Reinfection.

BACKGROUND: Atrius Health implemented a best practice alert (BPA) to encourage clinicians to provide expedited partner therapy (EPT) in October 2014. We assessed (1) the impact of the BPA on EPT provision and chlamydial reinfection and (2) the impact of EPT on testing for chlamydia reinfection and reinfection rates. METHODS: We included patients ≥15 years with ≥1 positive chlamydia test between January 2013 and March 2019. Tests-of-reinfection were defined as chlamydia tests 28-120 days after initial infection, and corresponding positive results were considered evidence of reinfection. We used interrupted time series analyses to identify changes in (1) frequency of EPT, (2) tests-of-reinfection, and (3) reinfections after the BPA was released. Log-binomial regression models, with generalized estimating equation methods, assessed associations between (1) EPT and tests-of-reinfection and (2) EPT and reinfection. RESULTS: Among 7267 chlamydia infections, EPT was given to 1475 (20%) patients. Expedited partner therapy frequency increased from 15% to 22% of infections between January 2013 and September 2014 (ß = 0.003, P = .03). After the BPA was released, EPT frequency declined to 19% of infections by March 2019 (ß = -0.004, P = .008). On average, 35% of chlamydia infections received a test-of-reinfection and 7% were reinfected; there were no significant changes in these percentages after BPA implementation. Patients given EPT were more likely to receive tests-of-reinfection (prevalence ratio [PR] 1.09; 95% confidence interval [CI], 1.01-1.16) but without change in reinfections (PR 0.88; 95% CI, 0.66-1.17). CONCLUSIONS: Best practice alerts in electronic medical record systems may not be effective at increasing EPT prescribing and decreasing chlamydial reinfection. However, patients given EPT were more likely to receive a test of chlamydia reinfection.

Chlamydia Treatment Practices and Time to Treatment in Massachusetts: Directly Observed Therapy Versus Pharmacy Prescriptions.

BACKGROUND: Directly observed therapy (DOT) is recommended for the treatment of chlamydia, however pharmacy prescriptions are frequently used. Adherence to DOT and the association between treatment method and time to treatment is unknown. METHODS: We conducted a retrospective review of a randomized 2% of laboratory-confirmed chlamydia infections reported to the Massachusetts Department of Public Health from January 1, 2019 to May 31, 2019. Clinicians and pharmacies were contacted to ascertain treatment methods and timing. We assessed frequency of DOT and pharmacy prescriptions in the treatment of chlamydia infection in Massachusetts. We used log rank test to compare time to treatment initiation for patients receiving DOT versus pharmacy prescriptions. Data were stratified according to whether treatment was empiric or laboratory-driven. KEY RESULTS: We ascertained full outcomes for 199 patients. Eighty patients received DOT and 119 patients received pharmacy prescriptions. DOT was more common among those receiving empiric treatment and pharmacy prescriptions were more common among those receiving laboratory-driven treatment. The median time to treatment was 1.5 days for patients treated with DOT and 3 days for those treated with pharmacy prescriptions. For both groups, the median time to treatment for empiric therapy was 0 days and for laboratory-driven therapy was 4 days. The differences in time to treatment were not statistically significant. CONCLUSIONS: Pharmacy prescriptions are frequently used for the treatment of chlamydia in Massachusetts. We did not observe a significant difference in the time to treatment between DOT and pharmacy prescriptions.

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

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

Extragenital Gonorrhea and Chlamydia Positivity and the Potential for Missed Extragenital Gonorrhea With Concurrent Urethral Chlamydia Among Men Who Have Sex With Men Attending Sexually Transmitted Disease Clinics-Sexually Transmitted Disease Surveillance Network, 2015-2019.

BACKGROUND: Extragenital gonorrhea (GC) and chlamydia (CT) are usually asymptomatic and only detected through screening. Ceftriaxone plus azithromycin is the recommended GC treatment; monotherapy (azithromycin or doxycycline) is recommended for CT. In urethral CT-positive/urethral GC-negative persons who are not screened extragenitally, CT monotherapy can lead to GC undertreatment and may foster the development of gonococcal antimicrobial resistance. We assessed urethral and extragenital GC and CT positivity among men who have sex with men (MSM) attending sexually transmitted disease clinics. METHODS: We included visit data for MSM tested for GC and CT at 30 sexually transmitted disease clinics in 10 jurisdictions during January 1, 2015, and June 30, 2019. Using an inverse-variance random effects model to account for heterogeneity between jurisdictions, we calculated weighted test visit positivity estimates and 95% confidence intervals (CI) for GC and CT at urethral and extragenital sites, and extragenital GC among urethral CT-positive/GC-negative test visits. RESULTS: Of 139,718 GC and CT test visits, we calculated overall positivity (GC, 16.7% [95% CI, 14.4-19.1]; CT, 13.3% [95% CI, 12.7-13.9]); urethral positivity (GC, 7.5% [95% CI, 5.7-9.3]; CT, 5.2% [95% CI, 4.6-5.8]); rectal positivity (GC, 11.8% [95% CI, 10.4-13.2]; CT, 12.6% [95% CI, 11.8-13.4]); and pharyngeal positivity (GC, 9.1% [95% CI, 7.9-10.3]; CT, 1.8% [95% CI, 1.6-2.0]). Of 4566 urethral CT-positive/GC-negative test visits with extragenital testing, extragenital GC positivity was 12.5% (95% CI, 10.9-14.1). CONCLUSIONS: Extragenital GC and CT were common among MSM. Without extragenital screening of MSM with urethral CT, extragenital GC would have been undetected and undertreated in approximately 13% of these men. Undertreatment could potentially select for antimicrobial resistance. These findings underscore the importance of extragenital screening in MSM.

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

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

The Use of Theory-Based Formative Research to Design Suicide Prevention Messaging for U.S. Veterans in Midlife.

BACKGROUND: Communication campaigns offer a viable mechanism to promote suicide prevention and reinforce mental health for U.S. veterans in midlife, a group with a high suicide burden. However, little empirical investigation of this type of messaging has been conducted, with formative campaign research conspicuously missing from the limited literature. AIMS: Using the theory of planned behavior as a guide, formative research was conducted to inform the design of suicide prevention messaging by (a) describing and measuring several theoretical constructs among our audience and (b) modeling associations between constructs and intentions to seek help for suicidal behaviors and mental health more broadly. METHODS: Telephone-based cross-sectional surveys were collected between 2014 and 2016 from a nationally representative sample of veterans with analyses restricted to those aged between 44 and 65 years ( n = 809). Multiple logistic regression was used to identify significant factors associated with intentions to seek help for either suicidal behaviors or mental health. RESULTS: Perceived behavioral control was one of the largest predictors of intentions to seek help for both suicidal behaviors and mental health concerns. Descriptive norms were also significantly associated with suicide-related intentions. Data further suggest several types of attitudes (i.e., discordant beliefs, stereotypes) to consider when designing messages for this group. DISCUSSION: This study represents one of the first efforts to document and describe theoretical constructs and their influence on intentions among veterans in midlife to contribute to the development of evidence-based messaging for veterans informed by a conceptual framework. CONCLUSION: Findings have important implications as the use of communication strategies for suicide prevention grows increasingly popular.

Does Nonmetropolitan Residence Impact Timely Chlamydia Treatment in Massachusetts?

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

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

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

Promoting Help Seeking to Veterans.

BACKGROUND: Few studies have considered different messaging strategies that may augment campaign efficacy to generate help-seeking behaviors among populations at increased risk for suicide, mainly US military veterans. AIMS: Findings are presented from the pilot evaluation of the It's Your Call campaign implemented by the Department of Veterans Affairs (VA). Three messaging strategies (with varying intensity and mix of messages) were compared to explore which best promote use of the Veterans Crisis Line (VCL) among veteran populations. METHOD: Daily VCL call data were obtained for 10 US cities during 2011-2012 where the campaign was active, and modeled using Poisson regression to identify changes in utilization patterns associated with the implementation of different messaging strategies. RESULTS: Significant increases in call rates were only evident during the campaign in communities where mixed messages were disseminated. Further, use of mixed messages yielded greater increases in call rates when compared with the other tested strategies. This was an observational study where identification of causal relationships between variables was limited. CONCLUSION: Findings are encouraging as messaging was associated with help seeking, and they provide insights into strategies that may rapidly promote crisis line use. Results also underscore the need for further research on suicide prevention campaigns and dissemination practices.

Promoting Help Seeking Among Veteran Households: Associations Between Exposure to Multiple Types of Health Messages and Intentions to Utilize Related Public Health Hotlines.

This study presents preliminary evidence that exposure to different health campaigns enhance intentions to seek help from telephone hotlines among Veteran households. Data were collected from telephone surveys (N = 8,756) conducted with both Veteran (n = 3,904), and for comparison, non-Veteran households (n = 4,852). Cox proportional hazard models were used to identify associations between message exposure variables ("type" or "number") with a high intent to use different hotlines (e.g., suicide prevention, domestic violence). As the number of types of messages an individual was exposed to increased, reported high intent for hotline use also increased. This remained significant across hotline type and for both Veteran and non-Veterans households. Results underscore the need for further research on dissemination strategies of public messaging and their impact on health behavior among Veteran populations.

Investigating the debate of home birth safety: A critical review of cohort studies focusing on selected infant outcomes.

AIM: There is a debate within the medical community regarding the safety of planned home births. The presumption of increased risk of maternal and infant morbidity and mortality at home due to limited access to life-saving interventions is not clearly supported by research. The aim of the present study was to assess strengths and limitations of the methodological approaches of cohort studies that compare home births with hospital births by focusing on selected infant outcomes. METHODS: Studies were identified that assess the risk for at least one of three infant outcomes (mortality, Apgar score, and admission to the neonatal intensive care unit [NICU]) of home births compared with hospital births. RESULTS: Fifteen cohort studies were included. Two studies of low-risk births and two including higher risk births found home births to be at an increased risk of neonatal mortality. However, mortality is rare in developed nations and may not be the best measure of safety. When studies focused on low-risk pregnancies, planned birth location, and well-trained birth attendants, there was no difference in neonatal morbidity (Apgar score and NICU admission). CONCLUSION: Many methodological challenges were identified among these studies. This review contributes to the home birth published work by identifying key strengths and limitations that need to be accounted for in the interpretation of study findings and the development of future studies. Based on this review, the key variables that would strengthen future studies are birth attendant identification, documented planned birth location, and specification of the birth risk level. Uniformity of data collection and minimizing missing data are also critical.

Relationship Factors and Condom Use Among Women with a History of Intimate Partner Violence.

Women who experience intimate partner violence (IPV) are at increased risk for HIV infection. To further the understanding of the dyadic factors that impact condom use among women, we investigated the impact of three relationship factors (i.e., power, fear, and dependence) on the association between HIV-related information, motivation, and behavioral skills [constructs from the information-motivation-behavioral skills (IMB) model] and condom use among abused women. Data from 133 urban, low-income women recruited from several community-based agencies (e.g., domestic violence agencies, women's health organizations, hospitals, Department of Health and Human Services, and Family Court) showed that these women experienced high levels of IPV and that relationship power, fear of abuse, and partner dependence were all associated with condom use. Multivariable models revealed that fear of abuse and partner dependence moderated the association between IMB constructs and condom use but relationship power did not. Results highlight the critical need to incorporate strategies to address relationship factors in HIV prevention programs with abused women.

Project VOGUE: A partnership for increasing HIV knowledge and HIV vaccine trial awareness among House Ball leaders in Western New York.

Men who sleep with men (MSM) and transgender individuals of color, the largest demographic in the House Ball community (HBC) are amongst the group at highest risk for HIV infection in the United States. The HBC have limited access to culturally appropriate HIV education. This study aimed to develop a partnership with HBC leaders to uncover strategies for increasing HIV prevention knowledge, including participation in HIV vaccine trials. To this end a research institution-community-HBC partnership was established. In-depth qualitative and quantitative data were collected from the 14 HBC leaders in western New York, revealing that knowledge of HIV and related vaccine trials was limited. Barriers to increasing HIV knowledge included fear of peer judgment, having inaccurate information about HIV, and lack of education. Among the HBC, community partnerships will further aid in the development of future HIV prevention programs and increase individuals' willingness to participate in future HIV vaccine trials.