Repeat Sexually Transmitted Infections Research Articles

Epidemiological Characteristics and Factors Associated with Repeat Sexually Transmitted Infections in Barcelona, Spain Over a Decade

In the last few years, the frequency of sexually transmitted infections (STI) has increased, as has the number of people with multiple infections. The aim of our study was to describe the epidemiological characteristics of persons with repeated bacterial STI and to determine the risk factors for these episodes in persons living in Barcelona during the period 2007–2018. We studied all cases of bacterial STI included in the STI registry of Barcelona. Repeated STI were defined as a diagnosis of gonorrhea, syphilis, or lymphogranuloma venereum (LGV) after a first episode of one of these infections. Analysis was stratified by sex and place of birth. The factors associated with time to reinfection were determined by Kaplan–Meier estimates, while the factors associated with risk of infection were determined by a Cox proportional hazards model. Of 9927 persons with a diagnosis of bacterial STI, 1690 (17.0%) had at least two episodes of STI during the study period. On multivariate analysis, repeat STI were independently associated with male sex assigned at birth (HR: 3.45; 95%CI 2.22–5.36), age less than 34 years (HR: 1.22; 95%CI 1.10–1.35); gay, bisexual, and other men who have sex with men, and transgender o transsexual woman (GBSMS/Trans) (HR: 4.03; 95%CI 3.24–5.03), having gonorrhea as first diagnosis (HR:1.49, 95%CI 1.34–1.66) or LGV (HR:1.75; 95%CI 1.47–2.08) and coinfection with HIV (HR:1.98; 95%CI 1.78–2.21). Sexual health programs should be strengthened to prevent STI and reinfection in key populations.

Sexually Transmitted Infections Among Men and Transgender Women Using HIV Pre-exposure Prophylaxis in a Large Integrated Health System-A Cohort Study.

Sexually transmitted infections (STIs) are common in people using pre-exposure prophylaxis (PrEP). We examined risk and factors associated with STIs in a cohort of PrEP users in an integrated health system in the United States. The Kaiser Permanente Southern California is a large integrated health system that provides comprehensive medical services to approximately 4.7 million demographically diverse members. We identified men and transgender women initiating PrEP between January 1, 2014, and June 1, 2018, and followed through December 31, 2018. Demographic and clinical factors potentially associated with the risk of bacterial STIs during PrEP use were evaluated using Poisson regression models. Among 5042 individuals tested for STIs with 7198 person-years of follow-up, 1709 (33.9%) had at least one new STI. The estimated incidence of STIs was 48.3 per 100 person-years, and the most common STI was rectal chlamydia. Most repeat STIs (61.4%) occurred <180 days apart. In a multivariable analysis, an history of STIs in the prior 6 months through 7 days after the PrEP initiation was the most prominent risk factor of STIs during PrEP use (adjusted risk ratio: 1.78, 95% confidence intervals: 1.65 to 1.93). Other risk factors included younger age (<35 years), being Hispanic, and having a history of alcohol use disorder or drug use disorder. Quarterly STI testing and targeted intervention to mitigate STI risk are warranted for young and racial minority PrEP users, particularly for those with prior history of STIs and substance use disorders.

Associations between Adverse Childhood Experiences and Sexual Risk among Postpartum Women.

Epidemiological evidence suggests that exposure to adverse childhood experiences (ACEs) is associated with sexual risk, especially during adolescence, and with maternal and child health outcomes for women of reproductive age. However, no work has examined how ACE exposure relates to sexual risk for women during the postpartum period. In a convenience sample of 460 postpartum women, we used linear and logistic regression to investigate associations between ACE exposure (measured using the Adverse Childhood Experiences Scale) and five sexual risk outcomes of importance to maternal health: contraceptive use, efficacy of contraceptive method elected, condom use, rapid repeat pregnancy, and incidence of sexually transmitted infections (STIs). On average, women in the sample were 25.55 years of age (standard deviation = 5.56); most identified as Black (60.4%), White (18%), or Latina (14.8%). Approximately 40% were exposed to adversity prior to age 18, with the modal number of experiences among those exposed as 1. Women exposed to ACEs were significantly less likely to use contraception; more likely to elect less-efficacious contraceptive methods; and used condoms less frequently (p = 0.041 to 0.008). ACE exposure was not associated with rapid repeat pregnancy or STI acquisition, p > 0.10. Screening for ACEs during pregnancy may be informative to target interventions to reduce risky sexual behavior during the postpartum period.

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

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. 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. 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. 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.

Detecting Spatial Cores and Temporal Trends of Repeat STIs to Plan Pre-exposure Prophylaxis (PrEP) Scale-up in DC.

Repeat sexually transmitted infections (STIs) in DC primarily results from untreated sexual partners. This analysis aims to identify high-risk areas and temporal trends of repeat STIs for pre-exposure prophylaxis scale-up and STI mitigation in DC. We identified repeat infections in the DC Department of Health STI and HIV data management systems, diagnosed from 2014 to 2018. The cases were geocoded and aggregated by census tracts. Poisson discrete scan statistic was implemented in SaTScan software to find clusters. Weighted moving average was used to compare temporal trends of repeat STIs. We used χ analysis to identify association with demographic variables. We identified 8535 repeat STIs from 2014 to 2018. Of these, 61.84% were among men, most cases were among blacks (34.75%) and 47.45% represented gonorrhea cases. The high-risk spatial clusters were identified as those tracts that had relative risk (relative risk > 1; P-value < 0.001). We identified one significant radius of risk covering tracts of wards 7 and 8 and parts of wards 5 and 6. We spotted positive temporal trends in cluster 1 and outside the cluster. We found significant associations of repeat STIs with gender (χ = 317.27, P < 0.001), age (χ = 539.26, P < 0.001), HIV coinfections (χ = 352.06, P < 0.001), and year of diagnoses (χ = 1.5, P < 0.01). Our findings indicate spatial disparities in DC for repeat STIs. This analysis is critical for pre-exposure prophylaxis planning, STI prevention strategies such as expedited partner therapies and condom distribution strategies in DC should prioritize the high-risk spatial cores.

\u201c[Repeat] testing and counseling is one of the key [services] that the government should continue providing\u201d: participants\u2019 perceptions on extended repeat HIV testing and enhanced counseling (ERHTEC) for primary HIV prevention in pregnant and lactating women in the PRIMAL study, Uganda

BackgroundThe ‘Primary HIV Prevention among Pregnant and Lactating Ugandan Women’ (PRIMAL) randomized controlled trial aimed to assess an enhanced counseling strategy linked to extended postpartum repeat HIV testing and enhanced counseling among 820 HIV-negative pregnant and lactating women aged 18–49 years and 410 of their male partners to address the first pillar of the WHO Global Strategy for the Prevention of Mother-to-Child HIV transmission (PMTCT). This paper presents findings of qualitative studies aimed at evaluating participants’ and service providers’ perceptions on the acceptability and feasibility of the intervention and at understanding the effects of the intervention on risk reduction, couple communication, and emotional support from women’s partners.MethodsPRIMAL Study participants were enrolled from two antenatal care clinics and randomized 1:1 to an intervention or control arm. Both arms received repeat sexually transmitted infections (STI) and HIV testing at enrolment, labor and delivery, and at 3, 6, 12, 18 and 24 months postpartum. The intervention consisted of enhanced quarterly counseling on HIV risk reduction, couple communication, family planning and nutrition delivered by study counselors through up to 24 months post-partum. Control participants received repeat standard post-test counseling. Qualitative data were collected from intervention women participants, counsellors and midwives at baseline, midline and end of the study through 18 focus group discussions and 44 key informant interviews. Data analysis followed a thematic approach using framework analysis and a matrix-based system for organizing, reducing, and synthesizing data.ResultsAt baseline, FGD participants mentioned multiple sexual partners and lack of condom use as the main risks for pregnant and lactating women to acquire HIV. The main reasons for having multiple sexual partners were 1) the cultural practice not to have sex in the late pre-natal and early post-natal period; 2) increased sexual desire during pregnancy; 3) alcohol abuse; 4) poverty; and 5) conflict in couples. Consistent condom use at baseline was limited due to lack of knowledge and low acceptance of condom use in couples. The majority of intervention participants enrolled as couples felt enhanced counselling improved understanding, faithfulness, mutual support and appreciation within their couple. Another benefit mentioned by participants was improvement of couple communication and negotiation, as well as daily decision-making around sexual needs, family planning and condom use. Participants stressed the importance of providing counselling services to all couples.ConclusionThis study shows that enhanced individual and couple counselling linked to extended repeat HIV and STI testing and focusing on HIV prevention, couple communication, family planning and nutrition is a feasible and acceptable intervention that could enhance risk reduction programs among pregnant and lactating women.Trial registrationClinicalTrials.gov registration number NCT01882998, date of registration 21st June 2013.

Results from e-KISS: electronic-KIOSK Intervention for Safer Sex: A pilot randomized controlled trial of an interactive computer-based intervention for sexual health in adolescents and young adults.

IntroductionInteractive computer-based interventions (ICBI) are potentially scalable tools for use in real-world settings to promote sexual health and prevent sexually transmitted infections (STIs) and unintended pregnancies. We developed and assessed the feasibility and acceptability of an ICBI for promoting adolescent and young adult sexual health, and the effectiveness of the intervention in reducing unprotected sex, STIs, and unintended pregnancy.MethodsThis pilot randomized controlled trial enrolled STI Clinic patients, in Seattle, Washington, who were 14–24 years old and reported unprotected vaginal sex during the last 2 months. Both the control and intervention group used a computerized survey to enter their sexual health and only the intervention group received the ICBI. The ICBI included personalized sexual health feedback from a physician avatar; instructive video modules advocating sexual health; and identification of one behavior to change. At 3-month follow-up, participants reported on interim sexual and pregnancy histories and underwent repeat STI testing. We assessed intervention impact on unprotected vaginal sex, number of sexual partners, incident STIs, and unintended pregnancy.ResultsOf 272 participants, 242 (89%) completed the study, of whom 65% were female. While these findings did not reach statistical significance, at 3-month follow-up, the intervention group reported a 33% lower rate of unprotected vaginal sex (no condom use) [IRR = 0.67, 95% CI: 0.44–1.02]; 29% fewer sex partners [IRR = 0.71, 95% CI: 0.50–1.03]; and 48% fewer STIs [IRR = 0.52, 95% CI: 0.25–1.08] when compared to the control group. Similarly, as compared to the control group, intervention females reported a lower rate of unprotected vaginal sex (no birth control) [IRR = 0.80, 95% CI: 0.47–1.35] and half as many unintended pregnancies (n = 5) versus control females (n = 10) [IRR = 0.51, 95% CI: 0.17–1.58]. In exploratory analyses, intervention females reported fewer partners [IRR = 0.71, 95% CI: 0.50–1.00] and a significantly lower rate of vaginal sex without condoms [IRR = 0.50, 95% CI: 0.30–0.85].ConclusionThe intervention was acceptable to both males and females, and at 3-month follow-up, there were non-significant reductions in risk behavior for all outcomes. Among females, exploratory analysis showed a significant reduction in vaginal sex without condoms.

P024 Reducing repeated chlamydia and gonorrhoea infections

IntroductionThe role of Sexual Health Services (SHS) is not only to treat sexually transmitted infections (STIs) but also to reduce repeat infection through appropriate antimicrobials, health education and partner notification (PN). We reviewed the management of patients with repeat infections.MethodsA retrospective case-note review of patients attending the SHS with more than one episode of chlamydia and/or gonorrhoea, July 2015 – June 2016.Results156 patients were identified of which a random sample of 30 (20%) were reviewed. All were male; median age 29.5 (range 21-58). 70% (21) were MSM, 23% (7) heterosexual, 7% (2) bisexual. 30% (9) were HIV positive. Risk-factors for unsafe sex (e.g. substance misuse/sex-work/mental-health diagnosis) were noted in 77% (23). 77% (23) had 2 infective episodes; 23% (7) had 3 episodes. Of the 67 infective episodes all were treated appropriately; 40% (27) were treated the same day, 9% (6) within 1-week, 24% (16) within 2-weeks, and 22% (15) within 2–4 weeks. Patients reported 1–100 partners in the 6-months prior to review. 73% (48) saw a health advisor (HA); in the remaining 28% the most common reason for not seeing a HA was being managed in non-sexual health clinics e.g. PEP/HIV-research/general HIV. PN was undertaken in 82% (55) of episodes although only completed in 52% (35) largely due to untraceable partners.DiscussionFocusing on addressing risk factors for unsafe sex may facilitate a reduction in repeat STIs. While most patients were able to access HA support, referral pathways from non-SHS clinics need improving. PN remains challenging in the context of multiple casual partners and novel strategies such as electronic PN should be urgently explored.

Sexually Transmitted Infections

High prevalence of sexually transmitted infections (STI) among adolescents is a significant public health concern. New and repeat STI acquisition in teens and young adults remains disproportionate to other age groups. Conversations with adolescent patients should include education about abstinence, use of barrier protection, reducing number of sexual partners, STI screening recommendations, how to access services for testing and treatment, partner treatment, and availability of effective vaccines against STIs such as human papillomavirus and hepatitis B virus. As early detection and prompt intervention is critical to decreasing disease complications, transmission, and overall community prevalence, it is essential to provide greater access to testing and treatment.

P29 Audit of re-testing and reinfection in london men who have sex with men with acute stis in a large gum outpatient clinic

Background Men who have sex with men (MSM) in the UK are at relatively high risk of acquiring new STIs. The British Association of Sexual Health and HIV recommend active recall of MSM diagnosed with sexually transmitted infections (STIs) for retesting after 3 months. Objectives An audit was undertaken to assess the incidence of bacterial STIs, and rates of re-screening and re-infection amongst MSM attending a large genitourinary (GU) outpatient clinic in London. Methods A retrospective audit of GU coding data on MSM attendees aged >18 years between January and December 2014 was performed. Data was collected on patient demographics, STI tests performed and diagnoses. Results 397 MSM were diagnosed with 826 new bacterial STIs during the audit period (762 STIs over 534 episodes occurred in the initial 9 month period). 145 (37%) patients were HIV infected. In 98/534 (18%) episodes, a repeat screen was performed within 3 months (excluding screening within the initial 6 weeks after an STI was diagnosed); in 21 (21%) of these episodes, a further 1 ≥ STI was diagnosed. Overall, the mean time to re-screening during the study period was 108 days (excluding initial 6 weeks; range 43–282). In 149/534 (28%) of STI episodes, no repeat STI screen was performed within the period analysed. Conclusion The incidence of STIs and re-infection in this high risk group is high, however prompt re-screening rates are low, highlighting the need for active recall. Routine 3 month text recall of MSM with an STI has since been implemented.

The Efficacy of Clinic-Based Interventions Aimed at Increasing Screening for Bacterial Sexually Transmitted Infections Among Men Who Have Sex With Men

In many countries, the prevalence of bacterial sexually transmitted infections (STIs) among men who have sex with men (MSM) is high. We undertook a systematic review to identify clinic-based strategies for increasing screening and detection of bacterial STIs among MSM. We reviewed studies that compared screening for or detection of gonorrhea, chlamydia, and syphilis in the presence and the absence of an intervention. The primary end points were STI screening, rescreening, or detection rates. Of 1809 studies identified, 8 fulfilled the inclusion criteria; of these, 4 studies demonstrated significant increases in screening rates for gonorrhea and chlamydia using different strategies (odds ratio range, 1.4-1.9). These included the following: use of a computer alert on an electronic medical record; the introduction of clinic guidelines on STI screening; and short text messaging reminders for repeat STI screening. A further 4 studies demonstrated increases in syphilis testing (odds ratio range, 2.3-21.4), with increased detection of asymptomatic early syphilis in 2 studies. Strategies used included regular serological screening for syphilis during routine human immunodeficiency virus (HIV) care, syphilis serology included with blood tests performed as part of HIV monitoring, use of a computer alert on an electronic medical record, and an electronic medical record system to enhance syphilis retesting after syphilis treatment. A range of interventions has been used, including the application of newer technologies targeting clinicians and patients that appear to be efficacious at increasing screening of MSM for bacterial STIs. Wider application of such interventions could improve STI screening and control in this high-risk population.

P1-S1.07 Multiple bacterial sexually transmitted infections in Ontario, Canada

BackgroundIn 2009, there were 33 000 reported cases of chlamydia, gonorrhoea and infectious syphilis in Ontario. These reportable bacterial sexually transmitted infections (STIs) represented approximately 48% of all reportable disease...

Sexual Behaviors After Universal Screening of Sexually Transmitted Infections in Healthy Young Women

To prospectively study the relationship between diagnosis of sexually transmitted infections (STIs) at entry to U.S. Marines recruit training and subsequent sexual behaviors during vacation. Of all women entering recruit training (June 1999-June 2000), 2,157 (94%) voluntarily enrolled. At baseline, women received universal screening for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis and treatment and counseling for positive STIs. Recruit training (13 weeks) precluded any social activities. Unrestricted vacation followed (median 10 days). After training resumed (3 weeks), questionnaires and repeat STI screening were administered. Multivariable logistic regression examined STI diagnosis at baseline as a predictor for risky sexual behaviors at vacation and STI-positive diagnosis after vacation. The study was completed by 1,712 (79%) women (median age 18 years); 1,038 reported sexual activity during vacation; 71% used condoms inconsistently; 19% had casual partners. At baseline, 152 (15%) tested STI-positive. Baseline STI diagnosis was unrelated to inconsistent condom use, nonmonogamous partnerships, or multiple partnerships. However, women testing STI-positive at baseline were more likely to test STI-positive after vacation (adjusted odds ratio 3.74, 95% confidence interval 2.10-6.65). Baseline STI diagnosis predicted casual partnerships among women aged 19-21 years (adjusted odds ratio 2.48, 95% confidence interval 1.12-5.50). Substantial numbers of women engaged in risky sexual behaviors after universal STI screening and counseling. Compared with STI-negative women, STI-positive women were at increased risk for subsequent STI acquisition regardless of their similar behaviors. As universal STI screening is increasingly implemented, follow-up care will likely be required to further reduce risky behaviors and address network-level factors. II.

Increasing the confidence of nursing staff to address the sexual health needs of people living with HIV: the use of motivational interviewing

The need to promote safer sexual behaviour has taken on new urgency in the UK because of large increases in the number of sexually transmitted infections (STIs). The sexual health needs of people living with HIV and AIDS (PLHA) also require attention as part of health promotion efforts. Many sexual health clinics are however struggling with high demand and limited resources. Within this context, this paper describes an innovate attempt at STI prevention with PLHA. Specifically, nursing staff were trained in the use of motivational interviewing to address sexual health issues and safer sexual behaviour in PLHA. We describe the training package and the impact upon participants. We conclude that by providing a positive training experience, front-line health staff that see the highest volume of PLHA with repeat STIs, can be assisted in developing their skills and confidence in prevention work with clients.