Transmission risk behaviour at enrolment in participants in the INSIGHT Strategic Timing of AntiRetroviral Treatment (START) trial.

OBJECTIVES: A proportion of HIV-positive people have condomless sex. Antiretroviral treatment (ART) reduces infectiousness, but a substantial proportion of HIV-diagnosed people are not yet on ART. We describe baseline self-reported risk behaviours in ART-naïve Strategic Timing of AntiRetroviral Treatment (START) trial participants. METHODS: All START participants completed a risk behaviour questionnaire. Data were collected on sociodemographics, lifestyle factors, health and wellbeing status and clinical status. Recent sexual behaviour and HIV transmission beliefs in the context of ART were also assessed. The primary interest was in condomless sex with serodifferent partners (CLS-D) in the past two months. RESULTS: A total of 4601 of 4685 HIV-positive participants (98%) completed the questionnaire [2559 men who have sex with men (MSM), 803 heterosexual men and 1239 women]. Region of recruitment was Europe/Israel, 33%; South America/Mexico, 25%; Africa, 22%; other, 21%. Median age was 36 years [interquartile range (IQR) 29, 44 years]. Forty-five per cent reported white ethnicity and 31% black ethnicity. Two per cent had HIV viral load < 50 HIV-1 RNA copies/mL. Seventeen per cent (767 of 4601) reported CLS-D; 20% of MSM compared with 10% of heterosexual men and 14% of women. MSM were also more likely to report multiple CLS-D partners. Possible risk limitation measures (reported by more than half of those who had CLS-D) were seropositioning (receptive anal CLS-D only) or withdrawal (insertive anal CLS-D always without ejaculation). CLS-D was more commonly reported by participants from South America/Mexico and North America compared with Europe; among heterosexual men and women CLS-D was also more commonly reported among participants from Africa compared with Europe. Knowledge of ART impact on transmission risk was low. CONCLUSIONS: A substantial minority recruited to the START study reported CLS-D at baseline. CLS-D reporting was higher in MSM than heterosexuals and varied significantly according to region of recruitment. A substantial proportion of MSM reporting CLS-D appear to take transmission risk limitation measures.

Condom use problems during anal sex among men who have sex with men (MSM): findings from the Safe in the City study.

Our research aims were to: (1) assess the prevalence of two condom use problems: breakage or slippage and partial use (delayed application or early removal) among men who have sex with men (MSM) seeking services in urban US STD clinics; and (2) examine the association between these condom use problems and participant, partner and partnership characteristics. Analysis was restricted to HIV-negative MSM who reported having anal sex at least once in the preceding 3 months and who completed both the baseline and 3 month follow-up assessments. Two models were fitted using the generalized estimating equations (GEE) approach. A total of 263 MSM (median age=32 years) reported 990 partnerships. Partnerships with no condom use 422 (42.6%) were excluded. Thus, 207 MSM and 568 partnerships were included. Among condom users, 100% use was reported within 454 partnerships (79.9%) and <100% within 114 (20.1%), and 21(3.7%) reported both condom use problems, 25 (4.4%) reported only breakage, 67 (11.8%) reported only partial use, and 455 (80.1%) reported no errors. The breakage or slippage and partial use rates per condom used were 3.4% and 11.2%, respectively. A significantly higher rate of breakage or slippage occurred among non-main partnerships. Characteristics associated with increased odds for condom breakage or slippage were: lower education level (OR=2.78; CI: 1.1-7.5), non-main partner status (OR=4.1; CI: 1.5-11.7), and drunk or high during sex (OR=2.0; CI: 1.1-3.8), and for partial use: lower education level (OR=2.6; CI: 1.0-6.6), perceived partner sexually transmitted infections (STI) risk (OR=2.4; CI: 1.3-4.2), and inconsistent condom use (OR=3.7; CI: 2.0-6.6). A high percentage of MSM partnerships reported no condom use and among condom users, a sizable proportion did not use them consistently or correctly. MSM may benefit from interventions designed to increase proficiency for condom use with a particular focus on the behaviors of inconsistent and partial condom use.

Finding sex partners on the internet: what is the risk for sexually transmitted infections?

OBJECTIVE: To assess the association between sexual encounters with internet partners and current Chlamydia trachomatis (Ct) and Neisseria gonorrhoeae (GC) infections. METHODS: Between August 2006 and March 2008, patients at the Denver Metro Health Clinic were routinely asked about sexual encounters with internet partners. This retrospective case-control study was limited to patients who tested for Ct/GC at their visit. Analyses were stratified by sexual orientation to account for differences in baseline risk behaviours. RESULTS: Of 14 955 patients with a valid Ct/GC test result, 2802 (19%) were infected with Ct/GC. Stratified by sexual orientation, the prevalence of Ct/GC infection was 17% for men who have sex with men (MSM), 21% for men who have sex with women (MSW) and 16% for women. A total of 339 (23%) MSM, 192 (3%) MSW and 98 (2%) women reported having a sexual encounter with a person they met on the internet in the past 4 months. The estimates of the association between recent internet sex partner and current Ct/GC infection were not significant for MSM (risk ratio (RR): 1.12, 95% confidence interval (CI): 0.84 to 1.49) and women (RR: 0.81, 95% CI 0.45 to 1.48). However, the association appeared to be significantly protective among MSW (RR: 0.66, 95% CI 0.44 to 0.98). CONCLUSIONS: Sexual encounters with internet partners did not appear to be associated with increased risk of current Ct/GC infection among people seeking care at a sexual health clinic. Seeking sexual partners on the internet is a complex behaviour and its implications for STI/HIV infection are not fully understood.

Risk reduction counselling for prevention of sexually transmitted infections: how it works and how to make it work.

Prevention research in the past decade has proved the efficacy of risk reduction counselling in reducing the risks for sexually transmitted infections (STIs). The question currently facing STI service providers is therefore not so much whether counselling should be part of the standard of STI care but rather how this intervention can be implemented given the logistical and resource constraints of a busy practice setting. After a brief introduction of the history and an overview of the models for risk reduction counselling and their theoretical and scientific underpinnings, the focus of this paper will be on the extent to which individual prevention models have been adopted in different clinical settings, the impediments to implementation and suggestions for improvement.

[Infectious disease prevention and occupational-disability insurance for medical students]. / Infectiepreventie en arbeidsongeschiktheidsverzekering voor studenten geneeskunde.

OBJECTIVE: To gain insight into the rate of immunization for hepatitis B and the status of infectious-disease prevention among Dutch medical students working in areas where HIV is endemic. Additionally, to provide an overview of the preparedness of medical schools in the Netherlands to collaborate in the development of a collective occupational disability insurance for their students. DESIGN: Literature review and survey. METHOD: A questionnaire was sent to all 8 Dutch medical schools in 2003 and a follow-up telephone interview was conducted in July 2005. The results of this survey were compared with the international scientific literature, which was systematically searched using PubMed, Web of Science and Picarta up to and including March 2005. RESULTS: There was a great deal of international variation in the proven degree of immunization against hepatitis B. Infectious-disease prevention measures for students on rotation in HIV-endemic areas left much to be desired. Occupational-disability insurance for students who started their clinical rotations was described, particularly in the United States, but details on participation and costs were lacking. In 2003 there were considerable differences between medical schools in the Netherlands regarding hepatitis-B immunization. However, in 2005, all schools reported the implementation of a new national hepatitis-B immunization protocol. Compared to 2003, most schools reported higher safety standards for electives in HIV-endemic areas and post-exposure prophylaxis was more frequently made available at no cost. Individual preparation for these electives still occurred infrequently. None of the medical schools were pursuing a policy of providing occupational disability insurance for students from the beginning of their clinical rotations.

Recruitment and retention of an online sample for an HIV prevention intervention targeting men who have sex with men: the Smart Sex Quest Project.

There is an increasing interest in developing interventions for HIV and STD prevention that can be delivered on the Internet. However, we know little about what it takes to identify, recruit and retain participants in interventions so that we can test their efficacy and effectiveness. Objectives for this investigation were to evaluate rates of recruitment and retention in an Internet-based randomized controlled trial (RCT) to increase sexually transmitted disease (STD) prevention among men who have sex with men (MSM). The Smart Sex Quest study was a RCT conducted online. Eligible participants were MSM, at least 18 years old and US residents. After completing a baseline risk assessment, participants were exposed to tailored or control messages and asked to return to the site at three months for a follow-up interview. From January 2002 through June 2003, 3,625 persons logged on as potential study participants; of these, 563 were not eligible, while 1,286 left the site without filling out a baseline survey. Complete baseline data were available for 1,776 participants, all of whom were eligible to complete a follow-up. Complete follow-up data were available for 270 (15.2%) participants. While the Internet is a valuable tool for conducting research, conducting this longitudinal research online was severely affected by a loss to follow-up, and analyzing outcome data was hampered by significant differences between those who did and did not complete the study. Alternate ways to recruit for and evaluate online trials must be considered.

The process of seeking sex partners online and implications for STD/HIV prevention.

Research has shown that online sex-seeking among men who have sex with men (MSM) is related to elevated risk for sexually transmitted diseases (STDs), including HIV infection; however, the process of seeking sex online is not well understood. It is important to understand the process of seeking sex partners in order to determine the best method for reaching MSM at high risk for infection. We report on baseline data from the Smart Sex Quest, an Internet-based STD prevention intervention targeting MSM (n = 1,776, 79% white, mean age = 33 years). Results indicate that older, white, college-educated men solicited sex partners on AOL, whereas Gay.com was a more frequent choice among younger men. Yahoo was named as a solicitation site more frequently by those with no college education, as were 'bareback' websites devoted to facilitating anal sex without the use of condoms. Following online solicitation, men tended to meet in public restrooms (86%), partners' homes (74%) and their own home (57%). Though results are limited by the self-selected nature of the sample, the data have important implications for online outreach, study recruitment and intervention.

Reaching homeless youths for Chlamydia trachomatis and Neisseria gonorrhoeae screening in Denver, Colorado.

BACKGROUND AND RATIONALE: The availability of urine based testing for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) provides a unique opportunity to screen for these pathogens outside traditional clinical settings. The researchers investigated the feasibility of street based CT/GC screening in the context of an outreach programme among street/homeless adolescents in Denver. OBJECTIVES: To describe the integration of urine based CT/GC screening into an existing outreach programme among street/homeless youths and the yield of CT/GC testing in this setting. METHODS: The Denver Department of Public Health (DPH) collaborated with outreach staff from Urban Peak (a community based organisation serving street/homeless youths in Denver) to offer urine based CT/GC testing to males and females in street settings. Tests were conducted on the street in areas where street/homeless youths congregate. RESULTS: Urban Peak outreach staff were trained by DPH staff to conduct CT testing, process urine specimens, and provide test results to participating youths. DPH remained responsible for treatment of people with CT or GC infection as well as CT/GC case reporting. CT testing started in January 2000; GC testing was added in July 2000. Throughout April 2002 a total of 414 CT and 302 GC tests were conducted, respectively 11.6% and 2.7% of which were positive. Among first testers, 13.0% were positive for CT and 3.7% for GC. CONCLUSIONS: CT/GC urine testing can be incorporated into existing outreach programmes without considerable extra effort. Overall CT rates were high and suggest the need for ongoing screening in this manner. LEARNING OBJECTIVE: To understand the role of CT/GC screening in the context of services provided to street/homeless youths in outreach settings.

Developing standards in behavioral surveillance for HIV/STD prevention.

HIV/STD prevention programs are increasingly guided by behavioral rather than by disease indicators. Relevant HIV/STD-related behavioral information is currently available from a variety of surveys and surveillance systems at three levels: general population, infected populations, and high-risk populations. However, the utility of these systems for local program development is limited due to lack of standardization. In 1997 a Centers for Disease Control and Prevention working group was formed to develop a core set of items for HIV/STD behavioral surveillance for use across surveys. Core items were chosen on the basis of existing surveys and surveillance systems, relevant literature, testing in a cognitive laboratory, and field pilot-testing. A draft of the core set of sexual behavior questions is available on the web at http://www.cdc.gov/nchstp/od/core-workgroup for review and feedback. Questions on drug use, including drug injection practices, as well as questions on HIV testing and sexually transmitted diseases are in preparation and will also be posted on the web site for review.

Screening for Chlamydia trachomatis in an anonymous and confidential HIV counseling and testing site: feasibility and prevalence rates.

BACKGROUND: Chlamydia trachomatis is the most common bacterial sexually transmitted disease (STD) in the United States. The development of nucleic acid amplification tests for C trachomatis in urine specimens allows for screening outside traditional clinic settings. Persons visiting an HIV counseling and testing site may be at increased risk for STDs, including C trachomatis. GOAL: To measure the acceptance of C trachomatis urine screening and the prevalence of C trachomatis infection among clients at an HIV counseling and testing site. STUDY DESIGN: Site HIV counselors offered urine C trachomatis screening to clients, administered a questionnaire, and collected urine samples. RESULTS: Of 808 counseling and testing site clients approached for C trachomatis screening, 572 (71%) accepted. The most common reasons for declining screening were absence of symptoms (33%) and recent STD testing (32%). Men were more likely to accept urine screening than women (risk ratio, 1.31; 95% CI, 1.06-1.62), as were clients who practiced oral sex, had a history of STD, or who had never been screened for STD. Of 560 urine specimens processed, only 8 (1.43%; 95% CI, 0.66-2.91%) were infected with C trachomatis. CONCLUSIONS: Sites offering HIV testing and counseling are a feasible alternative to clinical settings for C trachomatis screening. Prevalence may be too low for screening to be cost effective unless higher-risk subpopulations can be identified.

The Internet as a newly emerging risk environment for sexually transmitted diseases.

CONTEXT: Transmission of sexually transmitted diseases (STDs) such as human immunodeficiency virus (HIV) infection is associated with unprotected sex among multiple anonymous sex partners. The role of the Internet in risk of STDs is not known. OBJECTIVE: To compare risk of STD transmission for persons who seek sex partners on the Internet with risk for persons not seeking sex partners on the Internet. DESIGN: Cross-sectional survey conducted September 1999 through April 2000. SETTING AND PARTICIPANTS: A total of 856 clients of the Denver Public Health HIV Counseling and Testing Site in Colorado. MAIN OUTCOME MEASURES: Self-report of logging on to the Internet with the intention of finding sex partners; having sex with partners who were originally contacted via the Internet; number of such partners and use of condoms with them; and time since last sexual contact with Internet partners, linked to HIV risk assessment and test records. RESULTS: Of the 856 clients, most were white (77. 8%), men (69.2%), heterosexual (65.3%), and aged 20 to 50 years (84. 1%). Of those, 135 (15.8%) had sought sex partners on the Internet, and 88 (65.2%) of these reported having sex with a partner initially met via the Internet. Of those with Internet partners, 34 (38.7%) had 4 or more such partners, with 62 (71.2%) of contacts occurring within 6 months prior to the client's HIV test. Internet sex seekers were more likely to be men (P<.001) and homosexual (P<.001) than those not seeking sex via the Internet. Internet sex seekers reported more previous STDs (P =.02); more partners (P<.001); more anal sex (P<.001); and more sexual exposure to men (P<.001), men who have sex with men (P<.001), and partners known to be HIV positive (P<.001) than those not seeking sex via the Internet. CONCLUSIONS: Seeking sex partners via the Internet was a relatively common practice in this sample of persons seeking HIV testing and counseling (representative of neither Denver nor the overall US population). Clients who seek sex using the Internet appear to be at greater risk for STDs than clients who do not seek sex on the Internet. JAMA. 2000;284:443-446

Practice patterns for the elicitation of sexual history, education, and counseling among providers of STD services: results from the gonorrhea community action project (GCAP).

BACKGROUND: The frequently asymptomatic nature and high incidence of severe complications of sexually transmitted diseases (STD) calls for targeted efforts to identify those at greatest risk. Earlier studies have shown inconsistencies regarding STD evaluation by primary care clinicians and physicians. However, the literature regarding the consistency of practice patterns regarding elicitation of sexual history is limited. We examined practice patterns for the elicitation of sexual history among providers across seven sites nationwide. METHODS: As part of a multisite study to encourage health seeking for populations specifically at risk for gonorrhea (GC) and other STDs, semistructured interviews that included questions regarding sexual history elicitation were conducted with 208 service providers in a total of 121 publicly and privately funded clinics, managed care organizations (MCOs), hospital clinics, community- and school-based clinics in Denver, New York, Los Angeles, Birmingham, St. Louis, Indianapolis, and Prince Georges County, MD. RESULTS: Among the providers interviewed, practice patterns for the elicitation of sexual history were inconsistent. Sexual histories were described as routine (i.e., solicited from every client regardless of reason for visit) in 57% of sites. Providers most frequently asked clients their number of sex partners (57%), their contraceptive history (55%), and STD history (34%). Client discomfort among 46% and provider discomfort among 13% was cited as barriers to the elicitation of sexual history. A quarter (26%) of providers agreed that the elicitation of sexual history can be fostered by improved provider communication skills and 16% agreed increasing training and experience for providers is needed. CONCLUSIONS: These findings suggest that interventions with providers to standardize sexual history elicitation can help to reduce barriers to prevention, diagnosis, and treatment of STD.

Comparison of health status, socioeconomic characteristics, and knowledge and use of HIV-related resources between HIV-infected women and men.

OBJECTIVES: The authors compared socioeconomic characteristics, and knowledge and use of human immunodeficiency virus (HIV)-related resources and health status measures between HIV-infected women and men registered within the Denver Health and Hospitals health care system. METHODS: Data collected through two Centers for Disease Control-funded surveillance initiatives (Adult Spectrum of Disease and Supplement to HIV/AIDS Surveillance) were linked. Health status measures were obtained using the Medical Outcomes Study (MOS-20) questionnaire. To compare health status measures between genders, men were matched to women based on disease stage, intravenous drug use, race, years of education, employment status, and age. RESULTS: Among all patients interviewed (n = 419), women (n = 52) were more likely to be minority, uneducated, intravenous drug users, and at earlier stages of HIV-disease than men (n = 367). Employment status was not significantly different. Knowledge of available services was generally good among both genders. Women received public assistance and had health insurance (Medicaid) more often than men. Women used support services, social work, and shelter assistance less often than men. The matched pairs analysis (n = 46 pairs) showed no significant differences between genders in physical and social function, mental health, pain, or general health perceptions; however, role function was better in women than in men (P<0.02). CONCLUSIONS: When controlling for factors that may influence health and access to health care, HIV disease generally impacts the health status of both genders similarly. Women scored higher in role function which may reflect family caretakers' responsibilities. Although knowledge of HIV-related resources was similar by gender, men made contact more often suggesting areas for enhanced outreach toward women.

Patterns of general health care and STD services use among high-risk youth in Denver participating in community-based urine chlamydia screening.

BACKGROUND: In the United States, youth are at highest risk for STDs, and innovative programs have been called for to increase their access to essential STD-related services. To guide the development of such programs, locally relevant information is needed on current use of general health care and STD services in this population. GOAL: To study access to and use of general health care and STD services in a purposive sample of high-risk youth in inner-city Denver. STUDY DESIGN: An interview-based survey conducted as part of a community program for urine chlamydia screening targeting black and Hispanic youth 13 years to 25 years. RESULTS: Of 221 sexually experienced youth in the survey, 72% had accessed general health services in the past year and 39% reported an STD evaluation at any time in the past. Community and school clinics were reported by 50% as a source for general health care and by 62% as a source for STD services. STD clinics were reported by only 14% as a source for STD services. Routine checkups were the most important reasons to seek general health care, yet of those who went for a routine checkup, only 34% reported an STD evaluation. Although few barriers appeared to exist in accessing general health care, anticipated anxiety about procedures and results formed the major barrier to accessing STD services. CONCLUSIONS: Use of general health services was common in this population of high-risk adolescents; however, the provision of STD services as part of general health care visits appeared to be low. On the basis of these findings, a comprehensive STD prevention strategy may be envisioned, which would include provider interventions to increase the provision of STD prevention services in general health care settings; community interventions to enhance access to general health care and STD services; and community-based screening programs for those not able or willing to seek clinic-based services.

PIP: To guide the development of innovative programs to increase the access of US adolescents and young adults to sexually transmitted disease (STD) prevention and treatment services, data should be obtained at the local level from nonclinic-based samples comprised of those at greatest risk. Such a survey was conducted in Denver, Colorado, in 1996-97 by Youth in Action--a community-level chlamydia urine screening program. Questionnaires were completed by 221 of the 277 predominantly Black and Hispanic inner-city youth 13-25 years of age who underwent urine analysis during the study period. 25 (11%) reported a history of an STD. On urine screening, 10.7% of males and 12.9% of females tested positive for chlamydia. 72% had accessed general health services in the past year, primarily for routine checkups, and 39% reported an STD evaluation at any time in the past. Community and school clinics were identified by 50% as a source for general health care and by 62% as a source for STD services. Only 14% of respondents attended STD clinics. In multivariate analysis, the following factors were associated with an STD evaluation: recruitment in field settings, female gender, age above 16 years, non-Hispanic ethnicity, vaginal sex in the past 30 days, presence of chlamydia on urine screening, and a general health visit in the past year. Of concern was the finding that only 34% of youth who went for a general checkup reported an STD evaluation. These findings indicate needs for interventions to increase the provision of STD prevention services in general health care settings and community-based screening programs for those unable or unwilling to seek clinic-based services.

HIV serostatus disclosure among gay and bisexual men in four American cities: general patterns and relation to sexual practices.

The present study examined patterns of serostatus disclosure among previously untested HIV-seropositive and HIV-seronegative gay and bisexual men recruited from four American cities (n = 701). Six months after learning their HIV serostatus, 97% of study participants had disclosed their test results to at least one other individual. Consistent with earlier studies, test results were most frequently shared with friends and the respondent's primary partner. HIV serostatus was disclosed less frequently to family members, co-workers, and non-primary sex partners. Compared with HIV-seronegative men, HIV-seropositive men were more likely to have disclosed their status to a health care provider and less likely to have shared this information with family members. Of seropositive men, 11% did not disclose their serostatus to their primary partner and 66% did not disclose to a non-primary sex partner. Of HIV-seropositive men with one or more non-primary partners, 16% of those who did not disclose their serostatus reported inconsistent condom use during anal intercourse with these partners. No significant differences in self-reported sexual practices were observed for HIV-seropositive disclosers versus non-disclosers. Compared with HIV-seronegative men who did not disclose, seronegative men who shared information about their serostatus were more likely to have had receptive anal intercourse with their primary partner (p < 0.05) and to have engaged in mutual masturbation (p < 0.005), receptive oral sex (p < 0.005) and insertive anal intercourse (p < 0.05) with non-primary partners. No significant differences were observed between disclosers and non-disclosers with regard to condom use. Implications of the findings for future research and HIV prevention programmes are discussed.

Long-term outcomes of treatment of Mycobacterium avium complex bacteremia using a clarithromycin-containing regimen.

OBJECTIVES: To describe the long-term outcomes of treatment of AIDS-related Mycobacterium avium complex (MAC) bacteremia using a standard clarithromycin-based regimen. DESIGN: Retrospective study of patients with MAC bacteremia diagnosed between April 1992 and April 1995. SETTING: An urban AIDS clinic SUBJECTS: One hundred seventy-six consecutive patients with MAC bacteremia. INTERVENTIONS: Clarithromycin 500 mg twice daily, ethambutol 800 or 1200 mg daily, and clofazimine 100 mg daily. MAIN OUTCOME MEASURES: Late treatment failure (defined as a positive blood culture more than 90 days after starting treatment), clarithromycin susceptibility of initial and treatment-failure isolates, DNA fingerprinting of isolates from treatment failures. RESULTS: Two out of 176 (1.1%) baseline isolates were resistant to clarithromycin. One hundred and fifty-one patients were treated for MAC bacteremia, 144 (95%) with the standard regimen. Of the 117 patients who survived > 90 days after starting therapy, 25 (21%) met the criteria for late treatment failure. Of the 22 treatment-failure isolates available for susceptibility testing, 19 (86%) were resistant to clarithromycin. Therefore, 13% of patients treated using the standard regimen (19 out of 144) had treatment failure associated with the emergence of clarithromycin resistance. Using logistic regression, non-compliance was associated with treatment failure (P = 0.02). Fourteen out of the 17 (82%) evaluable paired isolates had identical DNA fingerprint patterns, whereas three pairs showed that a different strain of MAC was present at the time of treatment failure. CONCLUSIONS: Initial resistance to clarithromycin was rare during this period. However, late treatment failure associated with the emergence of clarithromycin resistance was relatively common during long-term follow-up. Most late treatment failures represented emergence of clarithromycin resistance in the initial strain.