Caring for the sexually assaulted child: Follow-up matters.

181 Clinical Knowledge of Human Immunodeficiency Virus Among Emergency Providers at Two Level 1 Trauma Centers in Cleveland, Ohio

There is limited evidence from randomised controlled trials for STI control as an effective HIV prevention strategy. Improved STI treatment services have been shown to reduce HIV incidence in an environment characterised by an emerging HIV epidemic (low and slowly rising prevalence), where STI treatment services are poor and where STIs are highly prevalent. There is no evidence for substantial benefit from treatment of all community members. The addition of the Kamali trial to the existing evidence supports the data from the Rakai trial of no effect. There are, however, other compelling reasons why STI treatment services should be strengthened, and the available evidence suggests that when an intervention is accepted it can substantially improve quality of services provided. The Kamali trial shows an increase in the use of condoms, a marker for improved risk behaviors. Further community-based randomised controlled trials that test a range of alternative STI control strategies are needed in a variety of different settings. Such trials should aim to measure a range of factors that include health seeking behaviour and quality of treatment, as well as HIV, STI and other biological endpoints.

The objective of this study was to evaluate human immunodeficiency virus (HIV) counseling, testing, and referral practices of emergency department health care professionals (i.e., medical doctors [MD], physician assistants [PA], nurse practitioners [NP], and registered nurses [RN]) for patients presenting with other sexually transmitted diseases (STD). All health care professionals from 10 emergency departments in a northeastern county were asked to complete an anonymous survey. The surveys were returned by 154 (41%) health care professionals (RN = 99, NP = 5, PA = 7, MD = 39, other = 4). The average years in practice were 11. Only 7% of respondents were certified to provide state mandated HIV pretest counseling (certification not required for MD). Respondents reported caring for an average of 13 patients per week with suspected STD. Fifty-five percent of respondents reported that they always or usually warn STD patients of their HIV risk, yet only 10% always or usually encouraged these patients to consent to HIV testing in their emergency department (RN = 7%, NP = 25%, PA = 0%, MD = 16%). Reasons for not offering HIV testing in their emergency department were follow-up concerns (51%), not certified to provide pretest/posttest counseling (45%), and too time consuming (19%). Twenty-seven percent of respondents indicated HIV testing was not available in their emergency department despite all hospital laboratories reporting HIV testing capability. Ninety-three percent of respondents were aware that confidential testing sites were available, but only 35% always or usually referred patients not tested in the emergency department elsewhere for testing. Emergency department health care professionals frequently fail to provide HIV counseling, testing, and/or referral for patients with suspected STD.

There is limited evidence from randomised controlled trials for STI control as an effective HIV prevention strategy. Improved STI treatment services have been shown to reduce HIV incidence in an environment characterised by an emerging HIV epidemic (low and slowly rising prevalence), where STI treatment services are poor and where STIs are highly prevalent. There is no evidence for substantial benefit from treatment of all community members. There are however other compelling reasons why STI treatment services should be strengthened and the available evidence suggests that when an intervention is accepted it can substantially improve quality of services provided. Further community based randomised controlled trials that test a range of alternative STI control strategies are needed in a variety of different settings. Such trials should aim to measure a range of factors that include health seeking behaviour and quality of treatment as well as HIV, STI and other biological endpoints.

Laboratory Industry Perspectives on the Role of Self-Collection and Self-Testing in Remote Care for Sexually Transmitted Infections: How Do We Bring These Services to Scale?

To the Editor: We published a 1999 review of studies exploring whether sexually transmitted infections (STIs) are causally associated with human immunodeficiency virus (HIV) infection among men who have sex with men (MSMs),1 finding few studies and no convincing evidence for associations. This contrasted with evidence then emerging of several STIs (especially ulcerative infections) being risk factors for HIV among the general population. We speculated that our findings might be explained by higher exposure to HIV among MSM and relatively higher transmission of HIV in anal than vaginal sex. A more recent review/meta-analysis by Freeman et al. focusing on herpes simplex virus (HSV)-22 reported a significant association of HSV-2 with HIV among MSMs [RR = 1.7; 95% confidence interval (CI) 1.2–2.4] but smaller than among the general population. This difference is plausible for the reasons above but does suggest STI control may nonetheless be important in MSM HIV prevention efforts. Another recent review/meta-analysis3 suggests other STIs, including syphilis, gonorrhoea, and chlamydia, may be risk factors for HIV among the general population but reports no findings for MSMs. We therefore decided to update our review to assess whether other STIs not merely HSV-2 might be important to address within HIV prevention for MSMs. We searched PubMed for relevant articles published 1998 to 2007 using MeSH/non-MeSH search terms covering STIs, HIV, and MSM; abstracts from the most recent International Acquired Immune Deficiency Syndrome conference and International Society for Sexually Transmitted Disease Research conference; and reference lists of found articles. We identified 10,681 potentially relevant articles. Titles and abstracts were reviewed for possible pertinence and where this was the case, full articles obtained (46 in all) and reviewed against criteria of reporting association(s) between HIV and one or more STIs, or between exposure/allocation to an STI control programme and HIV; assessing incident HIV infections serologically/via medical case notes; assessing prior STI infections serologically/via medical case notes; and adjusting, matching, or otherwise controlling for age and measure(s) of sexual risk behavior. Four adequate studies were identified. Two reported on data from the same cohort,4,5 so only the more complete of these was included. Three reported on HSV-25–7 and one on HSV-1.6 None examined other STIs. None reported the effects of STI control. One study5 did not appear in Freeman et al.'s review and this reported a significant association between HIV and HSV-2 detected >24 months previously (hazard ratio = 1.5, 95% CI 1.1–2.1) but not HSV-2 detected <24 months previously (hazard ratio = 1.7, 95% CI 0.8–3.3), i.e., in line with Freeman et al.'s meta-analysis. A further study reviewed by Freeman et al. regarding its findings for HSV-2 also included data on HSV-16 finding no association with HIV. Thus, current evidence suggests HSV-2 is a risk factor for HIV infection among MSMs but does not tell us whether STIs other than HSV-2 exert effects on HIV that are negligible; smaller than those found for the general population but not negligible; or possibly even comparable to the general population. Our review also identified an absence of research on STI control programmes effects on HIV among MSMs. This is surprising given the high prevalence of many STIs among MSMs worldwide. To assess the importance of addressing STIs other than HSV-2 within HIV prevention for MSMs we recommend further research on this question. Observational studies could be nested within studies of behavioural interventions or repeat clinic attenders. Alternatively, given the variability in contents, targeting, and intensity of STI control for MSMs as well as the uncertainty regarding impact on HIV incidence, it would be ethical and useful for experimental evaluations of pilot-enhanced STI control programmes targeting MSM to assess effects on HIV incidence.

Self-treatment for sexually transmitted diseases (STD) is common, but little studied, in Thailand, and its influence on human immunodeficiency virus (HIV) infection is unknown. To assess STD self-treatment and self-prophylaxis behaviors as well as HIV risks and serostatus among northern Thai men. Cross-sectional report from a cohort of military conscripts (N = 869). HIV and STD seroprevalence and reported risk behaviors, including STD history and antibiotic self-treatment, were obtained. Associations between STDs and self-treatment or prophylaxis and HIV infection were analyzed using t-tests, odds ratios, and logistic regression. The prevalence rate for HIV was 12.3%, and for syphilis it was 2.2%. Men who were seropositive for HIV were more likely to report having sex with commercial sex workers (OR 9.1), to have had an STD (OR 5.96) and to report inconsistent condom use with commercial sex workers (OR 3.13). Of 282 men reporting any STD, 65.2% treated themselves with antibiotics, and 8.5% used them before commercial sex. Among those who frequented commercial sex workers, 98.7% took preventive steps after sex by increasing urine output (69.2%), washing the genital area (28.9%), and using antibiotics (0.9%). Men reporting STD self-treatment were less likely to be HIV infected (OR 0.53; 95% CI 0.31, 0.93). These men are attempting to prevent HIV and STDs. Self-treatment with antibiotics may lower HIV risks associated with bacterial STD in a high-prevalence population.

National guidelines regarding sexually transmitted infections recommend Human Immunodeficiency Virus (HIV) screening for all patients evaluated for sexually transmitted infections (STI). At our institution, compliance with HIV screening in the Emergency Department (ED) for these patients was noted to be suboptimal. Human Immunodeficiency Virus screening was limited because of HIV screening and confirmatory antigen/antibody assay being transported to another location, which caused result delays and led ED providers to defer testing to Primary Care Managers (PCMs). Rapid HIV testing was implemented in our ED as a quality improvement initiative in an effort to improve compliance with guideline recommended HIV screening for these encounters. Rapid HIV testing for patients undergoing Neisseria gonorrhea and Chlamydia trachomatis (GC/CT) testing was implemented in the ED beginning in December 2021. Three months of pre-intervention data (August-October 2021) and 3 months of post-intervention data (December 2021-February 2022) were collected. Before the post-intervention period, ED providers received education regarding the initiative and were encouraged to include rapid HIV testing for patients presenting with STI complaints. Chart review was performed for all patients tested for GC/CT during the study period; date collected included demographic, clinical, and laboratory data to assess HIV screening practices. A total of 571 patients underwent GC/CT testing across the study period (303 pre-intervention and 268 post-intervention). Rates of bacterial STIs were similar between the 2 periods (13.5% vs. 10.8%, pre- vs. post-intervention, respectively, P = .324). Additionally, empiric treatment for GC/CT was similar in the pre-intervention period (38.3% vs. 34.3%, P = .327) compared to the post-intervention period. Screening for HIV significantly increased following the introduction of rapid HIV testing (4.3% vs. 19.8%, P = .001). Human Immunodeficiency Virus screening rates were also assessed at primary care follow-up for those not screened in the ED. Human Immunodeficiency Virus screening at primary care follow-up remained low in the pre- and post-intervention periods (6.2% vs. 8.4%, P = .35). Sexually transmitted infections are considered biologic markers of HIV risk, including acquisition and forward transmission. Implementation of rapid HIV testing in the ED resulted in a nearly 5-fold increase in HIV screening in patients evaluated for GC/CT. Despite this increase, the overall rate of HIV screening in the ED remained low. HIV screening during PCM follow-up remained expectedly low across the study period, given that our intervention did not target PCM follow-up. This study demonstrates the success of a relatively easy-to-implement intervention for increasing HIV screening for STI encounters in our ED. Further studies are needed to explore barriers to HIV screening at primary care follow-up and methods to improve compliance with guideline recommended screening.

Population attributable fractions (PAF) from observational studies may under- or overestimate the contribution of cofactor sexually transmitted disease (STD) to human immunodeficiency virus (HIV) spread. Empirical PAF estimates from the Mwanza and Rakai trials indicated the proportion of HIV infections attributable to STDs was higher in Mwanza than Rakai. Estimate the "true" proportion (PAFM) of HIV infections attributable to STDs in the Mwanza and Rakai STD trial populations and explore how the evaluated interventions prevented HIV infections. The STDSIM model was used to simulate the 2 populations at the baseline of the trials (with no STD treatment interventions) and counterfactual scenarios in which STD cofactor effects on HIV spread were removed either at the start of the trials or 2, 10, and 20 years into the HIV epidemics. Similar methods were used to quantify the contribution of the cure of each STD to overall HIV impact in each site. : In Mwanza, the highest PAFM for the effect of any single STD over the 2 years of the trial was due to chancroid (40%). The PAFM for all curable STD was 65%. In Rakai, herpes simplex virus type 2 (HSV-2) was the most important STD (PAFM = 23%); the PAFM for curable STD was 20%. In both sites, the proportion of new infections due to treatable STD decreased over time. The decrease was greater for Rakai, where a behavioral risk reduction that preceded the trial reduced STD prevalence. In both sites, the importance of HSV-2 increased later in the HIV epidemics and STD increased transmission of HIV more than acquisition of HIV. In the Mwanza trial, treatment of chancroid contributed most to preventing new HIV infections. PAFs calculated from empirical data underestimated the contribution of STD to HIV spread in the Mwanza and Rakai trial populations because STD effects on HIV transmission (as opposed to acquisition) were not captured in the observationally based studies.

It's Time to Act: Contextualizing the Prevalence of Sexually Transmitted Infections in Adolescents and Young Adults with Sickle Cell Disease

The objective of this study was to test the effect of a brief educational and counseling intervention on increasing the uptake of free testing for Chlamydia trachomatis (chlamydia) and Neisseria gonorrhea (gonorrhea) among young female emergency department (ED) patients. Women are particularly vulnerable to more serious consequences of these infections due to asymptomatic presentation. Increased testing is important to detect, treat, and halt the spread of these infections among asymptomatic women. This was a randomized controlled trial. Research assistants (RAs) approached female patients in two EDs. Eligible patients were between 18 and 35 years of age, who reported having sex with males, but were not attending the ED for either treatment of sexually transmitted infection (STI) or testing for possible STI exposure. Participants responded to survey questions about their lifetime and past 3-month substance use, number of recent sexual partners, condom use, and perception of risks for chlamydia and gonorrhea infections. Following the survey, the RAs randomized participants into study control or treatment arms. Each treatment arm participant received a brief educational/counseling intervention from the RA. The brief intervention focused on the woman's personal risks for chlamydia and gonorrhea and condoms attitudes and usage. As the primary outcome of this study, participants were offered free urine tests for chlamydia and gonorrhea infection postintervention or post-survey completion, depending on group assignment. A total of 171 women completed the baseline assessment and were offered chlamydia and gonorrhea testing. The mean (±SD) age was 26 (±4.76) years, 18% were Hispanic, and 12% were Spanish-speaking only. The brief intervention that was offered to increase these women's awareness of their STI risk did not result in increased acceptance of testing; 48% in the brief intervention group accepted testing (95% confidence interval [CI] = 32% to 64%) versus 36% in the control group (95% CI = 19% to 53%). In a multivariable logistic regression, only self-identifying as being Hispanic was associated with greater willingness to be tested. Of the asymptomatic women tested (n = 71), five tested positive for chlamydia. This represents a positivity rate of 7%. There were no positive test results for gonorrhea. Women who reported high-risk factors for STI, such as younger age (≤25 years), having sex in the past 90 days without using condoms, identified substance use, or previous STI, were not more likely to accept the offer of chlamydia and gonorrhea testing. The brief intervention used in this study did not increase the uptake of testing for chlamydia and gonorrhea infections in this sample, in comparison to receiving no intervention. Although Hispanic women were more likely to accept chlamydia and gonorrhea testing, it is concerning that those women who report STI risk factors were not more likely to accept the offer of chlamydia and gonorrhea testing. Future research should focus on the refinement of an intervention protocol to focus on prior STI and lack of condom use to increase the uptake of testing among this high-risk group.

Neisseria gonorrhoeae and Chlamydia trachomatis among human immunodeficiency virus-infected women.

BackgroundGuidelines recommend that human immunodeficiency virus (HIV) screening be performed for all patients evaluated for sexually transmitted infections (STIs). The current practice for STI evaluation in the Brooke Army Medical Center (BAMC) emergency department (ED) is to defer HIV testing to Primary Care Managers (PCMs), however PCM follow-up and HIV screening may not occur. This project evaluated HIV screening practices before and after implementation of rapid HIV testing in the ED.MethodsThe pre-intervention period (Aug – Oct 2021) included usual practice in the BAMC ED followed by the post-intervention period (Dec 2021 – Feb 2022) after implementation of rapid testing with the Determine™ HIV-1/2 Ag/Ab Combo test. ED providers were educated to include HIV rapid testing for patients with STI complaints. Patients with Neisseria gonorrhea/Chlamydia trachomatis (GC/CT) tests ordered in the ED pre-intervention (n=303) and post-intervention (n=268) were selected for chart review and demographic, clinical, and laboratory data were used to assess HIV screening practices.ResultsA similar proportion of patients in the pre-intervention period presented with an STI chief complaint (13.5% vs. 17.2%), tested positive for GC/CT (13.5% vs. 10.8%), and received empiric treatment for GC/CT (38.3% vs. 34.3%) compared to the post-intervention period (Table 1). HIV screening in the ED significantly increased both overall (4.3% vs. 19.8%; P< 0.001) and in the subgroup treated empirically for GC/CT (9.7% vs. 30.4%; P< 0.001, Table 2). Among patients treated empirically for GC/CT who did not receive HIV screening in the ED, PCM follow-up was low in both the pre- and post-intervention periods (20.7% and 34%, respectively; P< 0.001) and HIV screening was not commonly performed by PCMs during those visits (6.2% vs. 8.4%, respectively; P=0.350).ConclusionSTIs are considered biologic markers of HIV risk, including acquisition and forward transmission. Implementation of a rapid screening protocol in the ED resulted in a nearly 5-fold increase in HIV screening, however HIV screening by PCMs remained low. Although rapid HIV testing can be a useful tool, continued education and training of ED providers and PCMs is also needed to improve uptake of HIV screening.DisclosuresAll Authors: No reported disclosures.

The incidence of human immunodeficiency virus (HIV) infection in the United States is higher among persons with other sexually transmitted diseases (STDs), and the incidence of other STDs is increased among persons with HIV infection (1). Because infection with an STD increases the risk for HIV acquisition and transmission (1-4), successfully treating STDs might help reduce the spread of HIV among persons at high risk (1-4). Because health department STD programs provide services to populations who are at risk for HIV, ensuring service integration and coordination could potentially reduce the incidence of STDs and HIV. Program integration refers to the combining of STD and HIV prevention programs through structural, service, or policy-related changes such as combining funding streams, performing STD and HIV case matching, or integrating staff members (5). Some STD programs in U.S. health departments are partially or fully integrated with an HIV program (STD/HIV program), whereas other STD programs are completely separate. To assess the extent of provision of HIV services by state and local health department STD programs, CDC analyzed data from a sample of 311 local health departments and 56 state and directly funded city health departments derived from a national survey of STD programs. CDC found variation in the provision of HIV services by STD programs at the state and local levels. Overall, 73.1% of state health departments and 16.1% of local health departments matched STD case report data with HIV data to analyze possible syndemics (co-occurring epidemics that exacerbate the negative health effects of any of the diseases) and overlaps. Similarly, 94.1% of state health departments and 46.7% of local health departments performed site visits to HIV care providers to provide STD information or public health updates. One fourth of state health departments and 39.4% of local health departments provided HIV testing in nonclinical settings (field testing) for STD contacts, and all of these programs linked HIV cases to care. STD programs are providing some HIV services; however, delivery of certain specific services could be improved.

BackgroundThere are 1.14 million people infected with human immunodeficiency virus (HIV) in the United States, and only about 86% are diagnosed. HIV diagnosis is the first step to care and expanded testing is essential to reduce transmission. Individuals with undiagnosed HIV have a transmission rate 3.5 times higher than those aware of their infection. Individuals seeking testing and treatment for sexually transmitted infections (STIs) represent a higher risk population for HIV infection. Despite revised Centers for Disease Control and Prevention (CDC) recommendations to expand HIV testing in healthcare settings, testing remains low. A significant obstacle to expanded testing, especially in emergency departments (EDs), is concern about ensuring appropriate HIV test tracking and follow-up.MethodsWe performed a retrospective chart review of patients presenting with symptoms of an STI between January 1, 2015 and July 8, 2019 at eight Beaumont Health EDs in Southeast Michigan. De-identified data was collected from the electronic health record (EHR) for patients aged 10 and older who had testing for one or more STIs including gonorrhea, syphilis, and chlamydia. Patients were evaluated for concurrent HIV testing during the encounter, and patients known to be HIV infected were excluded.ResultsOf 32,640 encounters during which patients not known to be HIV infected were tested for STIs, only 68 (0.21%) included HIV antibody/antigen screening. Of those tested, only one (1.47%) returned reactive. The remaining 67 screenings returned non-reactive. Applying only 10% of this diagnosis rate to the total number of STI encounters suggests an opportunity to diagnose 47 additional individuals; applying 50% of this rate and the corresponding value is 239 individuals.ConclusionThese results highlight the need for expanded HIV screening in EDs. Systematic HIV test tracking and follow-up removes this burden from ED providers and enables expanded HIV testing in these settings.DisclosuresAll Authors: No reported disclosures