Leaving sex work: barriers, facilitating factors and consequences for female sex workers in northern Thailand.

Factors facilitating or inhibiting women's ability to leave sex work are still poorly characterized, and little is known about women's lives after they leave the profession. This paper presents findings from a qualitative study about factors affecting women's ability to leave sex work and influencing their lives after leaving. We interviewed 42 current and former female sex workers (FSWs) drawn from a cohort study of 500 FSWs in northern Thailand. All but one of the participants had quit sex work at least once. The majority experienced one or more quit-re-entry-quit cycles. Women's ability and decisions to leave sex work were determined primarily by four factors: economic situation, relationship with a steady partner, attitudes towards sex work and HIV/AIDS experience. Economic concerns, ranging from survival needs to materialistic desires, had the strongest influence. Most women perceived their risk for HIV infection to be lower after leaving sex work, but three of the 17 HIV-infected women acquired infection after having left, presumably from their steady partners. Prevention efforts should guide women as they transition out of commercial sex work. Interventions aimed at assisting women wanting to leave sex work need to address the role of economic factors.

An outbreak of syphilis in Alabama prisons: correctional health policy and communicable disease control.

OBJECTIVES: After syphilis outbreaks were reported at 3 Alabama State men's prisons in early 1999, we conducted an investigation to evaluate risk factors for syphilis infection and describe patterns of syphilis transmission. METHODS: We reviewed medical, patient interview, and prison transfer records and documented sexual networks. Presumptive source cases were identified. Odds of exposure to unscreened jail populations and transfer from other prisons were calculated for case patients at 1 prison. RESULTS: Thirty-nine case patients with early syphilis were identified from 3 prisons. Recent jail exposure (odds ratio [OR] = 8.0, 95% confidence interval [CI] = 0.3, 158.7, P = .14) and prison transfer (OR = 32.0, 95% CI = 1.6, 1668.1, P < .01) were associated with being a source case patient. CONCLUSIONS: Probable sources of syphilis introduction into and transmission within prisons included mixing of prisoners with unscreened jail populations, transfer of infected inmates between prisons, and multiple concurrent sexual partnerships. Reducing sexual transmission of disease in correctional settings is a public health priority and will require innovative prevention strategies.

Prevalence of genital chlamydial infection in young women entering a national job training program, 1990-1997.

OBJECTIVES: This analysis describes trends in the prevalence of genital chlamydial infection in economically disadvantaged young women entering a national job training program. METHODS: We examined chlamydia test data for May 1990 through June 1997 for women aged 16 to 24 years who enrolled in the program. The significance of trends was evaluated with the chi 2 test for trend. RESULTS: Prevalence of chlamydial infection declined 32.9%, from 14.9% in 1990 to 10.0% in 1997 (P < .001). Prevalence decreased significantly in all age groups, racial/ethnic groups, and geographic regions. CONCLUSIONS: The decrease in prevalence of chlamydial infection suggests that prevention activities have reached disadvantaged women across the United States; however, prevalence of chlamydial infection remains high, and enhanced prevention efforts in disadvantaged communities are urgently needed.

Characteristics of persons with syphilis in areas of persisting syphilis in the United States: sustained transmission associated with concurrent partnerships.

BACKGROUND AND GOAL: In areas with persistent syphilis, to characterize persons at higher risk for transmitting syphilis. STUDY DESIGN: Cohort study. Structured interviews of persons with early syphilis from four research centers were linked to outcomes of partner tracing. RESULTS: Of 743 persons with syphilis, 229 (31%) reported two or more partners in the previous month, and 57 (8%) received money or drugs for sex in the previous three months. Persons with at least one partner at an earlier stage of syphilis than themselves were defined as transmitters; 63 (8.5%) of persons with early syphilis met this definition. Having concurrent partners (two or more in one week in the last month) was independently associated with being a transmitter. CONCLUSION: Sexual network/behavioral characteristics of syphilis patients and their partners, such as concurrency, can help identify persons at higher risk for transmitting syphilis who should receive emphasis in disease prevention activities.

Syphilis among HIV-infected mothers and their infants in Texas from 1988 to 1994.

BACKGROUND: Syphilis was investigated in a group of HIV-infected women and their infants. GOAL: To assess syphilis morbidity among HIV-infected women and their infants. Among women with syphilis during pregnancy, the risks for delivering an infant with congenital syphilis were assessed. STUDY DESIGN: Through the Pediatric Spectrum of HIV Disease project, Texas infants born to HIV-infected women were identified. After the infants were matched with their mothers, it was determined which had been reported as syphilis cases. RESULTS: In this study 18% of the HIV-infected mothers were reported as syphilis cases, most during pregnancy. Half of these mothers delivered infants (n = 49) with congenital syphilis. Inadequate prenatal care was the only significant risk for delivering an infant with congenital syphilis. The congenital syphilis rate among Texas infants of HIV-infected mothers was 48.8 per 1,000 live births. CONCLUSION: The congenital syphilis rate among Texas infants born to HIV-infected mothers was almost 50 times that of the general population.

Molecular subtyping of Treponema pallidum in an Arizona County with increasing syphilis morbidity: use of specimens from ulcers and blood.

A molecular-based subtyping system for Treponema pallidum was used during an investigation of increasing syphilis in Maricopa County, Arizona. Genital ulcer or whole blood specimens from patients with syphilis were assayed by a polymerase chain reaction (PCR) amplification of a T. pallidum DNA polymerase I gene. Positive specimens were typed on the basis of PCR amplification of 2 variable genes. In all, 41 (93%) of 44 of ulcer specimens and 4 (27%) of 15 blood specimens yielded typeable T. pallidum DNA. Twenty-four (53%) of 45 specimens were subtype 14f; other subtypes identified included 4f, 4i, 5f, 12a, 12f, 14a, 14d, 14e, and 14i. Only 2 specimens were from epidemiologically linked patients. This investigation demonstrates that multiple subtypes of T. pallidum can be found in an area with high syphilis morbidity, although 1 subtype (14f) was predominant. Four typeable specimens were from blood, a newly identified specimen source for subtyping.

Sexually transmitted diseases of older persons in Washington State.

BACKGROUND: Sexually transmitted diseases (STDs) in persons older than 50 years are rarely studied because STDs are more common in young people. Understanding the epidemiology of STDs in older persons is important for reducing STD morbidity and for improving STD care. GOAL: To understand the epidemiology of STDs in older persons. METHODS: Washington State's STD surveillance data from 1992 to 1998 were analyzed to describe the burden of STDs and source of care for these diseases in older persons. RESULTS: From 1992 to 1998, 1535 episodes of STDs were reported for 50- to 80-year-olds in Washington State, accounting for 1.3% of all reported STDs. The most common STDs were nongonococcal urethritis in men and genital herpes in women. As compared with younger persons, older individuals more frequently sought care at private clinics and had symptoms at the time of the clinic visit. CONCLUSIONS: Sexually transmitted diseases are reported among older persons, although at lower rates than among younger persons. Services for STD and counseling regarding safe sex should be available to persons of all ages.

Syphilis outbreak assessment.

BACKGROUND: Syphilis rates began to decline in 1991 and have decreased every year since. In 1998, 6,993 cases of primary and secondary syphilis were reported in the United States, for a national incidence of 2.6 cases per 100,000 population. Although syphilis rates are at an historic low, focal outbreaks still occur. On October 7, 1999, the Division of Sexually Transmitted Disease Prevention of the Centers for Disease Control and Prevention, in collaboration with federal and community partners, presented the National Plan for Elimination of Syphilis from the United States. One of the five key strategies of the plan is rapid outbreak response. METHODS: Methods for outbreak assessment and response were reviewed in the literature, synthesized, and adapted for use in syphilis outbreaks. RESULTS: Key elements of outbreak assessment and response are detection, surveillance data review, hypothesis generation, intervention development, and the evaluation of clinical, public health, and laboratory services. CONCLUSIONS: Outbreak response necessitates community participation and a coordinated interdisciplinary effort to determine social and behavioral contributors to the outbreak and to develop targeted interventions.

Incidence of herpes simplex virus type 2 infection in the United States.

Between the time that two large, national surveys were conducted, the Second National Health and Nutrition Examination Survey (1976-1980) and the Third National Health and Nutrition Examination Survey (1988-1994), prevalence of herpes simplex virus type 2 (HSV-2) infection in the United States increased by 30%. From these survey data, the authors estimated the incidence of HSV-2 infection in the civilian, noninstitutionalized population aged > or = 12 years by means of a mathematical model that allowed overall incidence to increase linearly with time but required the shape of the age-specific incidence curve to remain constant. From 1970 to 1985, annual incidence of HSV-2 infection in HSV-2-seronegative persons increased by 82%, from 4.6 per 1,000 (95% confidence interval: 4.2, 5.0) to 8.4 per 1,000 (95% confidence interval: 7.7, 9.1). Incidence in 1985 was higher in women than in men (9.9 vs. 6.9 per 1,000), higher in Blacks than in Whites (20.4 vs. 6.3 per 1,000), and highest in the group aged 20-29 years (14.6 and 22.5 per 1,000 in men and women, respectively). Thus, by 1985, approximately 1,640,000+/-150,000 persons (730,000 men and 910,000 women) were being infected annually with HSV-2.

Determinants of persistent and recurrent Chlamydia trachomatis infection in young women: results of a multicenter cohort study.

BACKGROUND: Sequelae of genital Chlamydia trachomatis infection in women are more strongly linked to repeat infections than to initial ones, and persistent or subsequent infections foster continued transmission. OBJECTIVE: To identify factors associated with persistent and recurrent chlamydial infection in young women that might influence prevention strategies. METHODS: Teenage and young adult women with uncomplicated C trachomatis infection attending reproductive health, sexually transmitted disease, and adolescent medicine clinics in five US cities were recruited to a cohort study. Persistent or recurrent chlamydial infection was detected by ligase chain reaction (LCR) testing of urine 1 month and 4 months after treatment. RESULTS: Among 1,194 women treated for chlamydial infection, 792 (66.4%) returned for the first follow-up visit, 50 (6.3 %) of whom had positive LCR results. At that visit, women who resumed sex since treatment were more likely to have chlamydial infection (relative risk [RR], 2.0; 95% CI, 1.03-3.9), as were those who did not complete treatment (RR, 3.4; 95% CI, 1.6-7.3). Among women who tested negative for C trachomatis at the first follow-up visit, 36 (7.1%) of 505 had positive results by LCR at the second follow-up visit. Reinfection at this visit was not clearly associated with having a new sex partner or other sexual behavior risks; new infection was likely due to resumption of sex with untreated partners. Overall, 13.4% of women had persistent infection or became reinfected after a median of 4.3 months, a rate of 33 infections per 1,000 person months. CONCLUSIONS: Persistent or recurrent infection is very common in young women with chlamydial infection. Improved strategies are needed to assure treatment of women's male sex partners. Rescreening, or retesting of women for chlamydial infection a few months after treatment, also is recommended as a routine chlamydia prevention strategy.

Screening for sexually transmitted infections among economically disadvantaged youth in a national job training program.

PURPOSE: To evaluate results of screening for syphilis, gonorrhea, and chlamydia among youth in a federally funded job training program. METHODS: Data were evaluated from medical records of 12,881 randomly selected students in 54 U.S. job training centers during 1996. The intake medical evaluation includes serologic testing for syphilis. The policy was for females to receive a pelvic examination with gonorrhea and chlamydia testing and for males to be first screened with a urine leukocyte esterase (LE) assay, with follow-up gonorrhea and chlamydia testing for those with positive LE results. RESULTS: Adjusting for our sampling strategy, among females, an estimated 9.2% had a positive chlamydia test, 2.7% a positive gonorrhea test, and 0.4% had a positive syphilis test. Gonorrhea and chlamydia rates among females were highest in African-American followed by Native American students. Chlamydia infection was most common in younger women < or = 17 years of age. An estimated 0.1% of males had a positive syphilis test, and 4.8% of males a positive urine LE test. Of 103 LE-positive males tested for gonorrhea and chlamydia, only 27 (26%) had a positive test for one of these STDs. CONCLUSIONS: Our study supports routine screening of adolescents for gonorrhea and chlamydia, including those youth from socioeconomically disadvantaged backgrounds. Because individuals from such backgrounds may not regularly interact with traditional clinical health care systems, screening and treatment should be offered in alternative settings, such as the job training program described in this study.

Evaluation of nucleic acid amplification tests as reference tests for Chlamydia trachomatis infections in asymptomatic men.

Urine ligase chain reaction (LCR) and PCR tests and urethral swab culture were compared for their abilities to detect Chlamydia trachomatis infection in 3,639 asymptomatic men by using one-, two-, and three-test reference standards. Frozen urine at four of five participating centers was also tested by a transcription-mediated amplification assay which was used as a reference test. LCR increased the yield of positive results by 27% and PCR increased the yield of positive results by 26% over the yield of positive results by culture (n = 295). LCR and PCR sensitivities were similar, ranging from 80.4 to 93.5%, depending on the reference standard. Culture sensitivity was substantially less. A multiple-test standard yielded LCR, PCR, and culture specificities of 99.6%, with or without discrepant analysis. Test performance varied among centers partly due to different interpretations of the testing protocols. The study confirms that urine LCR and PCR for the detection of C. trachomatis have substantially improved sensitivities over that of urethral swab culture for testing of asymptomatic men, enabling screening of this important target group. These tests, perhaps in combination, are also candidate reference tests for the conduct of test evaluation studies.

Repeat Chlamydia trachomatis infection in women: analysis through a surveillance case registry in Washington State, 1993-1998.

Repeat infections with Chlamydia trachomatis are associated with increased risk for long-term sequelae. The authors analyzed the frequency and predictors of repeat chlamydial infection by using a population-based chlamydia registry in Washington State and evaluated whether women would seek care at the same clinic for repeat infections. Among 32,698 women with an appropriately treated initial chlamydial infection during 1993-1998, 15% developed one or more repeat infections during a mean follow-up time of 3.4 years. Among women less than age 20 years at the time of initial infection, 6% were reinfected by 6 months, 11% by 1 year, and 17% by 2 years. Young age was the strongest predictor for one and two or more repeat infections after controlling for the length of follow-up and other variables. Only 36% of the repeat infections were diagnosed at the same clinical setting as the initial infection, and 50% were diagnosed at the same type of clinic. Adolescent girls had the least consistency in the source of care for chlamydia. This study suggests that efforts to prevent repeat chlamydial infection in young women remain an urgent public health priority and that the burden of repeat infection may be substantially higher than estimates from clinic-based studies.

Sexually transmitted diseases among female prisoners in Brazil: prevalence and risk factors.

BACKGROUND: Sexually transmitted diseases (STDs) have become an important medical problem in prisons. GOAL: To determine the prevalence of and risk factors for STDs among female inmates in a Brazilian prison. STUDY DESIGN: All female prisoners at the Espírito Santo State Prison were offered enrollment in this cross-sectional study. An interview exploring demographics, criminal charges, and risk behavior was conducted. Blood and genital specimens were collected for STD testing. RESULTS: Of 122 eligible women, 121 (99%) agreed to participate. Prevalence rates were: HIV 9.9%, human T-cell lymphotrophic virus type I 4.1%, hepatitis B virus 7.4%, hepatitis C virus 19%, syphilis 16%, gonorrhea 7.6%, chlamydial infection 11%, human papillomavirus-related cytologic changes 9.3%, trichomoniasis 30%, and bacterial vaginosis 15%. Previous or current drug abuse (54%), injection drug use (11%), and blood transfusion (16%) were associated with at least one STD. Condom use was infrequent. CONCLUSION: The prevalence of STDs and of behaviors leading to ongoing transmission are high among female inmates in Vitória, Brazil, and demonstrate the potential importance of prevention activities targeting this population.

Implementing a syphilis elimination and importation control strategy in a low-incidence urban area: San Diego County, California, 1997-1998.

OBJECTIVES: This study assessed a strategy designed to contain imported cases of syphilis and prevent reestablishment of ongoing transmission. METHODS: Reported syphilis cases during an endemic period (1990-1992) and an elimination period (1997-1998) were compared in San Diego, Calif. The elimination strategy, which focuses on rapid reporting of infectious syphilis cases by clinicians, prompt partner and sexual network management, outreach to marginalized populations, and implementation of an outbreak containment plan, was evaluated. RESULTS: Infectious syphilis incidence rates declined from 18.3 per 100,000 in 1998 to 1.0 per 100,000 in 1998. Of the 46 cases involving probable infection during 1997-1998, 19 (41%) were imported, mostly (79%) from Mexico. Outbreak containment procedures were implemented successfully for 2 small clusters. Outreach workers provided sexually transmitted disease information to a large number of individuals; however, no cases of infectious syphilis were identified, suggesting that syphilis transmission was not occurring among marginalized groups. CONCLUSIONS: This syphilis elimination and importation control strategy will require monitoring and adjustments. Controlling syphilis along the US-Mexico border is a necessary component of syphilis elimination in the United States.

The effect of treating sexually transmitted diseases on the transmission of HIV in dually infected persons: a clinic-based estimate. Ad Hoc STD/HIV Transmission Group.

BACKGROUND: The effect of sexually transmitted disease (STD) treatment on HIV transmission is a topic of considerable current interest and controversy. GOAL: To assess the potential effect of STD treatment on HIV transmission in persons who are dually infected with STD and HIV. STUDY DESIGN: Using data from eight STD clinic sites in the United States, the authors estimate the actual achievable reduction in HIV transmission by multiplying the prevented fraction associated with treatment of STDs (set at an average of 0.8) by the maximum potential reduction in HIV transmission achieved by treating STDs (using an average relative risk of 3.0 for increased HIV transmission in the presence of STDs). Subgroup analysis assessed infection proportions for genital ulcer disease, nonulcerative STDs, and any STD by sex, ethnicity, age, and sexual orientation. RESULTS: The maximum achievable reduction in HIV transmission from dually infected persons to their partners is approximately 33%. The actual achievable reduction is approximately 27% (range, 10.0-38.1%) at the eight clinic sites. If each of the 4,516 dually infected persons in this cohort experienced a single sexual exposure with an uninfected person, 28 HIV infections would occur in the absence of STD treatment whereas 16 infections would occur with STD treatment. CONCLUSIONS: The estimate of a 27% reduction provides a qualitative assessment of the potential impact of STD treatment on HIV transmission in the absence of any other behavioral intervention. Identification of dually infected persons in STD clinics is an important mechanism for targeting interventions to a social milieu with high risk for HIV infection and other STDs.

Duration of untreated genital infections with chlamydia trachomatis: a review of the literature.

BACKGROUND: Estimates of the duration of untreated genital infections with Chlamydia trachomatis vary. Accurately estimating the distribution of the duration of infection would be useful in the counseling patients, and is essential when modeling the burden of chlamydial disease and the potential impact of prevention programs. GOAL: The authors review the scientific literature to summarize what is known about the duration of genital chlamydial infection and the factors that affect it. STUDY DESIGN: Literature review of animal and human studies. RESULTS: Animal studies document a longer duration of infection in primates than in mice or guinea pigs. Although animals spontaneously become culture negative over time, numerous studies document persistent nonculture evidence of chlamydiae in the upper genital tract. Studies in which women have been serially cultured suggest that most untreated infections remain culture positive for more than 60 days. Small series report that some infections may persist for years. Most infections eventually become culture negative; however, non-culture evidence of chlamydiae often persist in women with negative cultures. The duration of chlamydial infection is reduced in animals previously exposed to chlamydiae and in older humans, suggesting that partial immunity may result from exposure. Data are inadequate to define the median duration of untreated infection or to derive a curve that describes the natural history of untreated genital chlamydial infections. CONCLUSION: Current data do not allow one to reliably estimate the duration of genital infections with C trachomatis. Systematic retesting could help to better define the duration of infection in patients who, against medical advice, delay treatment for genital chlamydial infections.

Gonorrhea in male adolescents and young adults in Newark, New Jersey: implications of risk factors and patient preferences for prevention strategies.

BACKGROUND: Although the national rate of gonorrhea declined 68% from 1975 to 1995, rates remain high in many inner-city areas. In 1995, the gonorrhea rate in Newark, NJ, was five times the US rate. OBJECTIVE: To determine factors associated with acquisition of gonorrhea by men in Newark. STUDY DESIGN: A case-control study conducted at the sexually transmitted disease (STD) clinic in Newark, comparing males 15 to 29 years with culture-confirmed gonorrhea to controls with no STD. RESULTS: Compared with controls, males with gonorrhea more frequently reported at least 1 casual sex partner within the preceding month (adjusted odds ratio [OR], 3.2; 95% CI, 1.8-5.7), sex after using marijuana during the preceding month (OR, 2.4; 95% CI, 1.1-5.3), and a history of incarceration (OR, 2.1; 95% CI, 1.2-3.7). Of males with casual partners, having a new casual sexual relationship (onset within the past month) was particularly risky for gonorrhea (OR, 3.9; 95% CI, 1.2-12.7). Incorrect condom use was highly prevalent for both cases and controls. Many persons with gonorrhea reported that they were not willing to consistently use condoms or to have only one partner. CONCLUSIONS: Sex with casual partners is associated with gonorrhea in males, and may be a difficult practice to change. Condoms are often used incorrectly, if at all, in this population. Prevention strategies, in addition to the promotion of condom use and monogamy, may be necessary.

Geographic variation of HIV infection in childbearing women with syphilis in the United States.

OBJECTIVES: Substantial biologic and epidemiologic data indicate the importance of syphilis as a potential cofactor for sexual transmission of HIV infection, but few detailed data exist on the geographic covariation of these two important sexually transmitted infections. DESIGN: HIV prevalence in childbearing women and primary and secondary (P&S) syphilis data from 29 states were examined to explore the importance of the epidemiology of syphilis as a factor in facilitating HIV transmission. METHOD: The spatial relationship between P&S syphilis and HIV infection in the health districts of 29 states was analyzed and adjusted for demographic and socioeconomic factors such as racial composition, income, housing, education levels, and access to medical services using the 1990 US census, and geographic location. RESULTS: In 29 states and the District of Colombia, 448 health districts, representing more than 75% of the US population, reported HIV prevalence rates for mothers' district of residence. The HIV seroprevalence ranged from 0 to 1258/10 000 in these health districts. The incidence of P&S syphilis from 1984-1994 in these districts ranged from 0 to 87/100 000. The P&S syphilis incidence was positively associated with the prevalence of HIV infection among childbearing women (P < 0.0001). CONCLUSIONS: Syphilis that persists in communities in the United States appears to represent a 'sentinel public health event' reflecting risk for sexual HIV transmission. These findings, along with other biologic and epidemiologic information, reinforce the importance of syphilis as an indicator for targeting HIV prevention efforts generally, as well as syphilis control as a specific HIV-prevention strategy.

HIV prevalence in patients with syphilis, United States.

BACKGROUND: Among persons with a sexually transmitted disease (STD), the proportion who are also infected with HIV is a major factor influencing the public health impact of that STD on HIV transmission. GOAL: To assess HIV infection in persons with syphilis in the United States. STUDY DESIGN: A systematic literature review was conducted of U.S. studies with HIV seroprevalence data in patients with syphilis. RESULTS: Thirty studies were identified and analyzed. The median HIV seroprevalence in men and women infected with syphilis was 15.7% (interquartile range [IQR]: 13.6-21.8%), among men was 27.5% (23.1-29.6%), and among women was 12.4% (8.3-20.5%). Median odds ratios for men and women, men only, and women only were 4.5, 8.5, and 3.3, respectively. Seroprevalences among men who have sex with men (MSM) and injecting drug users (IDU) ranged from 64.3-90.0% and 22.5-70.6%, respectively. CONCLUSIONS: Despite substantial variability, HIV seroprevalence is high among patients with syphilis in the United States, identifying them as a critical target group for HIV prevention efforts.