Congenital syphilis: trends in mortality and morbidity in the United States, 1999 through 2013.

BACKGROUND: Congenital syphilis (CS) results when an infected pregnant mother transmits syphilis to her unborn child prior to or at delivery. The severity of infection can range from a delivery at term without signs of infection to stillbirth or death after delivery. OBJECTIVE: We sought to describe CS morbidity and mortality during 1999 through 2013. STUDY DESIGN: National CS case data reported to Centers for Disease Control and Prevention during 1999 through 2013 were analyzed. Cases were classified as dead (stillbirths and deaths up to 12 months after delivery), morbid (cases with strong [physical, radiographic, and/or nonserologic laboratory] evidence of CS), and nonmorbid (cases with a normal physical examination reported, without strong evidence of infection). Annual rates of these cases were calculated. Cases were compared using selected maternal and infant criteria. RESULTS: During 1999 through 2013, 6383 cases of CS were reported: 6.5% dead, 33.6% morbid, 53.9% nonmorbid, and 5.9% unknown morbidity; 81.8% of dead cases were stillbirths. Rates of dead, morbid, and nonmorbid cases all decreased over this time period, but the overall proportions that were dead or morbid cases did not significantly change. The overall case fatality ratio during 1999 through 2013 was 6.5%. Among cases of CS, maternal race/ethnicity was not associated with increased morbidity or death, although most cases (83%) occurred among black or Hispanic mothers. No or inadequate treatment for maternal syphilis, <10 prenatal visits, and maternal nontreponemal titer ≥1:8 increased the likelihood of a dead case; risk of a dead case increased with maternal nontreponemal titer (χ(2) for trend P < .001). Infants with CS born alive at <28 weeks' gestation (relative risk, 107.4; P < .001) or born weighing <1500 g (relative risk, 43.9; P < .001) were at greatly increased risk of death. CONCLUSION: CS remains an important preventable cause of perinatal morbidity and mortality, with comparable case fatality ratios during 1999 through 2013 (6.5%) and 1992 through 1998 (6.4%). Detection and treatment of syphilis early during pregnancy remain crucial to reducing CS morbidity and mortality.

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.

Traditional sexually transmitted disease prevention and control strategies: tailoring for African American communities.

African Americans carry the largest disease burden for bacterial sexually transmitted diseases (STDs) in the United States. These infections can have a devastating impact on sexual and reproductive health if they are not diagnosed and treated. Traditionally, public health efforts to prevent and control bacterial STDs have been through surveillance, clinical services, partner management, and behavioral intervention strategies. However, the persistence of disparities in STDs indicates that these strategies are not achieving sufficient impact in African American communities. It may be that factors such as limited access, acceptability, appropriateness, and affordability of services reduce the efficacy of these strategies for African American communities. In this article we describe the STD prevention strategies and highlight the challenges and implications of these strategies in addressing disparities in African American communities.

Heterosexual anal sex activity in the year after an STD clinic visit.

OBJECTIVES: To describe heterosexual anal sex activity during a year and to identify factors associated with heterosexual anal sex and condom use during anal sex. METHODS: Secondary analysis of data from a trial conducted in 3 public sexually transmitted disease (STD) clinics. Patients described sexual behaviors every 3-months for the year. Logistic regression models with generalized estimating equations were used to include multiple observations for each subject. RESULTS: Two thousand three hundred fifty-seven heterosexual subjects reported on 6611 3-month intervals that included 9235 partnerships. About 18.3% of subjects had anal sex in a particular 3-month interval and 39.3% in the year. About 23.5% of subjects had anal sex in at least two 3-month intervals in the year. Anal sex was associated with having more sex acts, 2 or more sex partners, unprotected vaginal sex, and a main partner. For anal sex in the past 3 months, 27.3% of subjects consistently used condoms, and 63% of subjects never used condoms. Consistent condom use for anal sex was associated with having consistent condom use for vaginal sex, 2 or more partners, and anal sex with casual or new partner. CONCLUSION: STD clinic patients were commonly engaged in heterosexual anal sex, and most of them never used condoms during anal sex. Patients who had anal sex tended to also engage in other risk behaviors that put them at risk of STD/human immunodeficiency virus. Clinicians should ask about anal sex, appropriately examine and test patients who have had anal sex, and recommend condom use for both anal and vaginal sex.