Improving the benefits of HIV testing and referrals in large household surveys through active linkages to care: lessons and recommendations from the Namibia population-based HIV impact assessment (NAMPHIA), 2017.

In household-based surveys that include rapid HIV testing services (HTS), passive referral systems that give HIV-positive participants information about how and where to access ART but minimal follow-up support from survey staff may result in suboptimal linkage. In the 2017 Namibia Population-based HIV Impact Assessment (NAMPHIA), we piloted a system of active linkage to care and ART (ALCART) that utilized the infrastructure of existing community-based partner organizations (CBPOs). All HIV-positive participants age 15-64 years not on ART were given standard passive referrals to ART plus the option to participate in ALCART. Cases were assigned to CBPOs in participants' localities. Healthcare workers from the CBPO's contacted cases and facilitated their linkage to facility-based ART. A total of 510 participants were eligible and consented to ALCART. The majority were new diagnoses (80.8%), while the remainder were previously diagnosed but not on ART (19.2%). Of the 510, 473 (92.7%) were successfully linked into care. Of these, all but one initiated ART. Our ALCART system used existing CBPOs and contributed to >90% linkage-to-care and >99% ART-initiation among linked participants in a large, nationally-representative survey. This approach can be used to improve the potential benefits of HTS in other large population-based surveys.

Identifying syphilis risk networks through venue attendance in San Francisco.

BACKGROUND: Prioritizing interventions for patients with syphilis who are part of large or interconnected sexual networks may be high yield for partner services, and identifying venues named by patients with syphilis who report high numbers of partners may help identify such networks. In this analysis, we explore differences between interviewed patients with early syphilis regarding where they met sex partners. METHODS: With a cross-sectional design, we examined the distribution of total reported sex partners from male index patients with early syphilis interviewed through the San Francisco Department of Public Health partner services program and the self-reported venues named as places they met sex partners. Based on the median number of total partners among male cases of syphilis who named each venue, we categorized venues into 3 levels of partner frequency: high (>15 partners reported), medium (6-15 partners reported), and low (<6 partners reported). Interviewed patients with early syphilis were then classified into these venue categories, and sociodemographic and risk behaviors from electronic medical records and interviews were compared using χ tests. RESULTS: In 2011, 433 male patients with early syphilis named 32 venues. One hundred forty-three (32.3%) patients were categorized as high, 226 (51.0%) as medium, and 74 (16.7%) as low partner frequency venue users. Patients with early syphilis who reported meeting partners at high partner frequency venues were generally older, more likely to be white, have a previous syphilis infection, use methamphetamines in the previous year, and be HIV infected (all P < 0.05) compared with those who reported meeting partners at medium-frequency and low-frequency venues. CONCLUSIONS: Venues where partners are met may be an appropriate proxy for network membership. Targeting additional resources, outreach, and services to clients who attend high-frequency venues may have a positive impact on syphilis prevention efforts.

Insurance among patients seeking care at a municipal sexually transmitted disease clinic: implications for health care reform in the United States.

INTRODUCTION: Limited data exist on insured patients who receive care at publically funded sexually transmitted disease (STD) clinics, despite having access to a primary care provider. In this analysis, we compare patients with and without health insurance who sought services at City Clinic, the San Francisco municipal STD clinic. METHODS: We analyzed San Francisco City Clinic patients between August 1, 2011, and December 31, 2012. Insurance was self-reported and included both private and public insurance. Variables from the clinic electronic medical record were examined and included basic demographic and risk behavior questions, as well as positivity among patients tested for chlamydial and gonoccocal infection. We compared the characteristics of insured and uninsured patients using χ test. RESULTS: There were 13,104 patients in this analysis, of whom 4981 (38%) were categorized as insured and 8123 (62%) as uninsured. Overall, insured patients were older, more likely to be male, more likely to be white, and less likely to be Hispanic compared with uninsured patients (all P < 0.05). In addition, insured patients were more likely to be among men who have sex with men and among HIV-infected individuals compared with uninsured patients (all P < 0.0001). Insured patients were less likely to have a diagnosis of chlamydia at any site or a diagnosis of rectal gonorrhea. CONCLUSIONS: In our municipal STD clinic, more than one-third of patients report currently having insurance, yet still choose to seek care at the STD clinic. The different characteristics between insured and uninsured patients may reflect reasons other than affordability; therefore, STD clinics remain an important source of care for at-risk populations. These data suggest that the expansion of access to insurance may not result in a reduced need for categorical STD services. Maintaining access to high-quality sexual health services should remain a priority in the era of expanded health care access.

Partner services as targeted HIV screening--changing the paradigm.

OBJECTIVES: The San Francisco Department of Public Health (SFDPH) has the goal of offering HIV partner services (PS) to all individuals newly diagnosed with HIV in San Francisco. However, measuring the potential impact of these services is challenging. Building on an existing syphilis partner notification program, we developed a framework for expanding and monitoring HIV PS in San Francisco. METHODS: We identified process and outcome measures to evaluate HIV PS in San Francisco, including the number of index patients interviewed, the proportion of named partners who had previously diagnosed HIV infection, the proportion of HIV-uninfected partners who tested through HIV PS, and the positivity rate among the partners tested. Results were recorded in a locally developed electronic surveillance and case-management system at SFDPH. RESULTS: We examined HIV PS data from 2005-2011. In 2011, 426 new HIV diagnoses were reported, and 178 were assigned for HIV PS; of these, 124 (69.7%) patients were successfully interviewed, naming a total of 109 sex partners. Of the named partners, 34 (31.2%) had been previously diagnosed with HIV. Among the remaining named partners not known to be HIV infected, 31 (32.3%) were tested, for a positivity of 22.6% (n=7). The proportion of HIV that was newly diagnosed by a provider who participated in the citywide HIV PS program increased from 15.4% in 2005 to 69.5% in 2011. CONCLUSIONS: As HIV PS expand, locally relevant outcome measures are increasingly important. Using these criteria, HIV PS as a targeted screening activity resulted in the identification of newly diagnosed HIV cases.

Exploring sexual health among female sexually transmitted disease clinic patients, San Francisco 2010.

BACKGROUND: Current data on sexual health in the United States is limited, in part, because of a lack of measurement tools. It is difficult for programs to develop a holistic approach to improving sexual health that is data-driven and evaluable without a tool that encompasses sexual health beyond the absence of disease. The objective of this study was to understand possible factors associated with sexual health and reported differences in sexual health among women. METHODS: We conducted a survey measuring sexual health among women seeking care at the municipal sexually transmitted disease (STD) clinic in San Francisco between January 25, 2010, and June 15, 2010. Records were matched on variables including basic demographics, reason for visit, symptoms at visit, history of an STD, and STD diagnosis at the visit. RESULTS: A total of 822 women completed the questionnaire during the study period. Women reporting no recent sexual activity reported feeling more insecure, angry, isolated, and limited because of health compared with women with recent sexual activity. However, few differences were seen among women based on symptoms and diagnosis at visit. DISCUSSION: Given the minimal differences based on symptoms and disease, this suggests that there are other factors that impact the quality of life and sexual health. Creating tools that can be used to measure sexual health is a necessary first step for programs to understand the sexual health of a community. More broad-based assessments of sexual health in a variety of populations will be critical to identifying points of intervention and progress toward success.

Epidemiologic characteristics of an ongoing syphilis epidemic among men who have sex with men, San Francisco.

BACKGROUND: Since 2001, San Francisco has experienced a sustained syphilis epidemic that has been nearly exclusively limited to men who have sex with men. We examined the characteristics associated with changes in the syphilis epidemic in San Francisco. METHODS: All primary and secondary (P&S) syphilis cases reported to the San Francisco Department of Public Health between 2001 and 2011 were examined using joinpoint analysis to identify periods within the broader epidemic. Characteristics of the index cases were compared across the periods using χ(2) statistics and t tests. RESULTS: Three distinct periods were identified, an acute increase, decline, and then period of resurgence. In the most recent period of resurgence, compared with earlier periods, patients with P&S syphilis were more likely to have a prior syphilis infection, were older, were more likely to meet partners online, and were more likely to have a partner from outside San Francisco. CONCLUSIONS: In an analysis of 11 years of P&S syphilis data, several factors were associated with declines or resurgences. Innovative prevention measures are needed to reduce syphilis morbidity among men who have sex with men.

Disentangling screening and diagnostic Chlamydia test positivity among females testing at title x-funded and adolescent health clinics, san francisco 2009.

By using a reason-for-test code, we compared positivity for female chlamydia and gonorrhea. At family planning clinics, there were no statistically significant differences in screening versus diagnostic positivity for either chlamydia or gonorrhea among women. However, at adolescent health clinics, diagnostic positivity was higher than screening positivity for chlamydia and gonorrhea.

Male to female and female to male transgender persons have different sexual risk behaviors yet similar rates of STDs and HIV.

The epidemiology of STDs and HIV among male-to-female (MTF) and female-to-male (FTM) transgender persons is limited, which makes prevention for transgender populations challenging. We examined data collected at visits for all self-identified MTF and FTM patients at the municipal STD clinic in San Francisco from January 1, 2006 to December 31, 2009. We compared demographic and socio-behavioral characteristics, as well as STD and HIV positivity and history of previous STD. Despite demographic and behavioral risk differences, there were no differences in STD positivity or HIV prevalence between MTF and FTM. A more complete understanding of the prevention needs for transgender persons is needed.

Can case reports be used to identify trends in pelvic inflammatory disease? San Francisco, 2004-2009.

BACKGROUND: Chlamydia screening programs have been shown to reduce the incidence of pelvic inflammatory disease (PID), which can lead to ectopic pregnancy, tubal infertility, and chronic pelvic pain. However, few reliable data exist on the population-level burden of PID and the utility of passive case-based surveillance of this important infertility-related outcome. METHODS: We conducted a descriptive analysis of all case reports of PID in San Francisco from 2004 to 2009 through our passive case reporting surveillance system. We examined demographics as well as sexually transmitted disease history. Pearson χ and Fisher exact tests were used to assess significance in the trend analysis. RESULTS: There were 245 case reports over the 6-year period examined. There were no statistically significant differences over this period based on demographics. However, an increasing proportion of cases were diagnosed at the municipal sexually transmitted disease clinic. DISCUSSION: PID is an important intermediary to assess the impact in reducing infertility in areas where chlamydia screening programs have been implemented. As the locus of PID care has shifted from inpatient to outpatient settings, passive PID surveillance has not adjusted. Efforts should be made to increase provider awareness that pelvic inflammatory disease is a notifiable condition and improve reporting among providers by devoting resources to either improving current passive surveillance or to the development of new innovative ways to conduct PID surveillance.

The effectiveness of patient-delivered partner therapy and chlamydial and gonococcal reinfection in San Francisco.

BACKGROUND: Patient-delivered partner therapy (PDPT) has been evaluated in randomized trials. No analysis has examined the impact of PDPT once implemented programmatically. METHODS: We examined the association between receiving PDPT and Chlamydia trachomatis and Neisseria gonorrhoeae reinfection within 1 year in patients diagnosed at San Francisco City Clinic between October 31, 2005 and March 31, 2008. Propensity score modeling was used to control for the difference between persons who did and did not receive PDPT. RESULTS: There was no significant difference between patients who received PDPT and those that did not in the crude cumulative risk for repeat infection with C. trachomatis or N. gonorrhoeae. Using propensity score analysis, the adjusted relative risk was 0.99 (0.86-1.14) for chlamydial reinfection and 0.90 (0.72-1.11) for gonococcal reinfection. Further analysis looking at men who have sex with men, men who have sex with women, and females showed no significant reductions in relative risk of reinfection for C. trachomatis or N. gonorrhoeae in these sub populations. CONCLUSIONS: Continued evaluation of PDPT on reinfection rates in real world settings as well as cost-effectiveness analyses of PDPT are needed to assess this alternative method of partner treatment.

Sentinel surveillance of rectal chlamydia and gonorrhea among males--San Francisco, 2005-2008.

Rectal gonorrhea cases among males remained stable in San Francisco during 2005-2008, but rectal chlamydia increased 38 percent. While testing increased, rectal gonorrhea positivity declined at the STD clinic, and both infections remained stable elsewhere. Sentinel surveillance provides a better understanding of disease trends than case reporting alone.

Dogs Are Talking: San Francisco's social marketing campaign to increase syphilis screening.

To promote regular syphilis testing among men who have sex with men in San Francisco, a social marketing campaign, Dogs Are Talking, was created. An evaluation of the campaign found no difference in syphilis testing among men who recalled the campaign and those that did not. A significant difference was seen among HIV-infected men.

Chlamydia trachomatis and Neisseria gonorrhoeae transmission from the oropharynx to the urethra among men who have sex with men.

BACKGROUND: Limited data exist on the risk of Chlamydia trachomatis and Neisseria gonorrhoeae transmission from oropharynx to urethra. We examined urethral C. trachomatis and N. gonorrhoeae positivity among men who have sex with men (MSM) seen at San Francisco City Clinic (San Francisco, CA) during 2007. METHODS: All patients who sought care at the San Francisco City Clinic (the only municipal sexually transmitted disease clinic in San Francisco) received a standardized interview conducted by clinicians. We estimated urethral C. trachomatis and N. gonorrhoeae positivity for 2 groups of visits by MSM who visited during 2007: (1) men who reported their only urethral exposure was receiving fellatio in the previous 3 months and (2) men who reported unprotected insertive anal sex in the previous 3 months. Additionally, urethral C. trachomatis and N. gonorrhoeae positivity was estimated, stratified by human immunodeficiency virus infection status, urogenital symptom history, and whether the patient had been a contact to a sex partner with either chlamydia or gonorrhea. RESULTS: Among MSM who reported only receiving fellatio, urethral C. trachomatis and N. gonorrhoeae positivity were 4.8% and 4.1%, respectively. These positivity estimates were similar to positivity found among MSM who reported unprotected insertive anal sex. CONCLUSIONS: A more complete understanding of the risks of transmission of C. trachomatis and N. gonorrhoeae from oropharynx to urethra will help inform prevention and screening programs.