Normalizing HIV testing in a busy urban sexually transmitted infections clinic.

BACKGROUND: Increased awareness of HIV serostatus is a cornerstone of HIV prevention efforts. Thus, routine HIV testing in clinical settings has been identified as a priority. We report on our experience with making rapid HIV testing a routine procedure in a large STI clinic. METHODS: A series of logistical changes were implemented to enhance HIV testing uptake, including introduction of rapid testing, changes in sequence of clinical procedures, and an opt-out consent process. The impact of these changes on HIV testing was measured by the ratio of HIV testing and syphilis RPR testing, with the latter defined as the gold standard of routine testing in an STI clinic setting. RESULTS: Over time and in relationship to the introduction of clinic changes, the HIV/RPR ratio increased from 0.79 at baseline to 0.96 after full implementation. Overall HIV positivity rates did not vary significantly over time. CONCLUSION: After the introduction of several changes in clinic procedures, we experienced an increase HIV testing uptake relative to routine syphilis testing. In STI clinics, HIV testing can be made as normal as other routine STI testing.

Economic benefits of hepatitis B vaccination at sexually transmitted disease clinics in the U.S.

OBJECTIVE: This study assessed the long-term economic implications of a national program to vaccinate all adults treated at sexually transmitted disease (STD) clinics in a single year. METHODS: A model was developed to track the long-term disease outcomes and costs among a hypothetical cohort of 2 million STD clinic clients accessing services in one year, using data from published sources and demonstration projects at STD clinics in San Diego (California), Illinois, and Denver (Colorado). The model estimated net economic benefits of a routine hepatitis B vaccination policy at STD clinics nationwide compared with no vaccination. RESULTS: Without a vaccination program, an estimated 237,021 new hepatitis B virus (HBV) infections would occur over the lifetimes of the 2 million STD clinic clients seen in a single year. HBV-related medical costs and productivity losses would be $1.6 billion. In a national program for routine vaccination at STD clinics, 1.3 million adults would be expected to receive at least one vaccine dose, and an estimated 45% of the new HBV infections expected without vaccination would be prevented. The vaccination program would cost $138 million, HBV infections occurring despite the program would cost $878 million, and clients' time and travel would cost $45 million. The net economic benefit (savings) of routine vaccination would be $526 million. If the indirect costs of lost productivity due to HBV infection are not considered, routine vaccination would have a net cost of $28 million. CONCLUSIONS: Estimates from this model suggest a national program for routine hepatitis B vaccination of adults at STD clinics would be a cost saving to society.

Evaluation of a testing-only "express" visit option to enhance efficiency in a busy STI clinic.

OBJECTIVE: To evaluate the use of a testing-only "express" visit option to enhance efficiency in a busy STI clinic. METHODS: At the Denver Metro Health Clinic, clients at low risk for sexually transmitted infections (STI) are offered an express visit comprised of a urine test for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) as well as optional syphilis and human immunodeficiency virus (HIV) testing, but no physical examination. Higher risk clients (STI-related symptoms, contact to STI, men having sex with men, injection drug use, exchange of sex for money or drugs) are offered a comprehensive visit that includes a physical examination. The triage system was evaluated for the period April 2005--July 2006 by comparing rates of CT, GC, syphilis, and HIV between the 2 visit options. RESULTS: Of 13,447 clients with new visits, 3284 (24.4%) were express visits. When compared with clients with comprehensive visits, express visit clients had lower rates of CT (8.1% vs. 17.2%), GC (0.9% vs. 7.4%), syphilis (0.7% vs. 1.2%), and HIV (0.1% vs. 0.2%). Of 2969 STI cases, only 10.8% were diagnosed among clients with express visits. Express visits resulted in a 39% time saving for men and a 56% for women. With the possible exception of asymptomatic urethritis among men, underdiagnosis of STI beyond CT, GC, syphilis, and HIV among express visit clients appeared to be low. CONCLUSION: The triage system at DMHC effectively selects clients at highest risk for STI and increases clinic efficiency.

Integrating viral hepatitis prevention services into an urban STD clinic: Denver, Colorado.

The Centers for Disease Control and Prevention recommends integrating viral hepatitis prevention services with services for adults evaluated for sexually transmitted diseases (STDs). The Denver Public Health STD clinic began hepatitis B vaccination in 1999, hepatitis C virus (HCV) antibody (anti-HCV) testing in 2000, and hepatitis A vaccination in 2002. Rapid human immunodeficiency virus (HIV) testing began in late 2004. Hepatitis B vaccinations peaked in 2003 (31/100 client visits) when a full-time nurse was hired to vaccinate and eligibility was expanded. The proportion of clients documented to have received their anti-HCV test results declined from an average of 71% in 2000-2003 to 22% in 2004-2005, coinciding with the introduction of rapid HIV testing. Viral hepatitis prevention services can be incorporated into a busy STD clinic if staff and resources are available. Rapid HIV testing may be associated with lower receipt of anti-HCV test results.