Trial marriage: Florida's experience in consolidating HIV/AIDS, STD, and TB programs.

After a three-year experiment in consolidating services, the Florida Department of Health has again separated programs for the prevention and control of HIV/AIDS, sexually transmitted diseases (STDs), and tuberculosis. The authors report that while there were some clear advantages to consolidating services, especially programs dealing with HIV and other STDs, the individual programs suffered in some important ways. The authors describe Florida's effort to preserve the positive programmatic and administrative aspects of the consolidated approach and to apply the lessons learned.

Human immunodeficiency virus partner notification. Cost and effectiveness data from an attempted randomized controlled trial.

OBJECTIVE: Determine the cost and effectiveness of partner notification for human immunodeficiency virus (HIV) infection. METHODS: Persons testing HIV positive in three areas were randomly assigned one of four approaches to partner notification. Analysis plans changed because disease intervention specialists notified many partners from the patient referral group. We dropped the patient referral group and combined the others to assess the cost and effectiveness of provider referral. RESULTS: The 1,070 patients reported 8,633 partners. Of those 1,035 were located via record search or in person. A previous positive test was reported by 248 partners. Of the 787 others, 560 were tested: 438 were HIV negative and 122 were newly identified as HIV positive. The intervention specialist's time totaled 197 minutes per index patient. The cost of the intervention specialist's time, travel, and overhead was $268,425: $251 per index patient, $427 per partner notified, or $2,200 per new HIV infection identified. No demographic characteristic of the index patient strongly predicted the likelihood of finding an infected partner. CONCLUSION: We could not compare the effectiveness of different partner notification approaches because of frequent crossover between randomized groups. The cost of partner notification can be compared with other approaches to acquired immunodeficiency syndrome prevention, but the benefits are not easily measured. We do not know the number of HIV cases prevented or the value of fulfilling the ethical obligation to warn partners of a potential threat to their health.

Partner notification for syphilis: a randomized, controlled trial of three approaches.

OBJECTIVE: To determine the cost and effectiveness of three approaches to partner notification for infectious syphilis. STUDY DESIGN: People with syphilis were randomly assigned to: (1) notification of partners by patients themselves within 2 days or disease intervention specialists would notify them; (2) immediate notification by intervention specialist; or (3) immediate notification by intervention specialists, who had the option of drawing blood in the field. Costs of intervention specialists' time, travel, and overhead were measured. Intention-to-treat analysis measured outcomes per randomized index patient. RESULTS: From December, 1990 through March, 1993, 1,966 index patients with syphilis (primary 9%; secondary 18%; and early latent 73%) were randomized in Broward County (Ft. Lauderdale), Florida (1,191); Tampa, Florida (569); and Paterson, New Jersey (206). Index patients reported 11,272 potentially exposed partners and sufficient information to initiate investigations for 2,761. Of these, 2,236 were located, 367 had newly identified infections, and 870 others received preventive treatment. The three partner notification approaches had similar success locating partners (1.1-1.2 per index patient) and treating partners (0.61-0.67 per index). The cost was $317 to $362 per partner treated; the optimal strategy differed by study site. CONCLUSIONS: Partner notification identified many infected and potentially infected people. The cost and effectiveness of the three types of provider notification were similar. Alternative approaches are needed to reach infected partners who could not be notified.

Trends in the acquisition of sexually transmitted diseases among HIV-positive patients at STD clinics, Miami 1988-1992.

BACKGROUND AND OBJECTIVES: To assess trends in the acquisition of new sexually transmitted diseases (STDs) among patients who test positive for human immunodeficiency virus (HIV) at STD clinics. STUDY DESIGN: Cohorts of HIV-positive and HIV-negative persons were compared using computerized records from Miami STD clinics for 1988-1992. Persons were assigned to cohorts according to their first positive or first negative HIV test results. New STDs were defined if persons had new diagnoses of gonorrhea, primary or secondary syphilis, chancroid, or lymphogranuloma venereum; were undergoing treatment as contacts for syphilis or gonorrhea; or were undergoing epidemiologic treatment for syphilis or gonorrhea. RESULTS: Of the 103,549 persons who visited the clinics, 53,467 were tested for HIV, and 5,615 had results that were positive. The percentages returning with new STDs were similar for the HIV-positive and HIV-negative cohorts, and both decreased over time. For the 1988 cohorts, 26% of those testing positive and 30% of those testing negative for HIV returned with at least one STD within 5 years. Returns with STD within 1 year decreased from 16% in 1988 to 3% in 1992. CONCLUSIONS: Returns decreased dramatically among HIV-positive cohorts; however, there were similar decreases of new STDs among HIV-negative cohorts, so the decrease may have been caused by the decreasing prevalence of bacterial STD in the community rather than by behavioral changes among HIV-positive persons.

Syphilis and gonorrhea in Miami: similar clustering, different trends.

During the second half of the 1980s, Miami had a syphilis epidemic while gonorrhea rates decreased. To determine whether the direction of these trends truly differed within all population subgroups or whether they resulted from aggregating groups within which trends were similar, records from four sexually transmitted disease clinics from 1986 to 1990 and census data from 1990 were used to compare race-, sex-, age-, and zip code-specific groups. Syphilis and gonorrhea clustering was similar; 50% of cases occurred in the same zip codes, representing 10% of the population. In all groups, gonorrhea decreased (aggregate 48%) while syphilis first increased (aggregate 47%) and then decreased. Determining reasons for these different trends may facilitate controlling these diseases.

Incubating syphilis in patients treated for gonorrhea: a comparison of treatment regimens.

Dade County sexually transmitted disease clinic records were reviewed to estimate the relative effectiveness of gonorrhea treatment regimens for eradicating incubating syphilis. Records were searched to see if persons treated for gonorrhea returned with primary syphilis 3-45 days after treatment or secondary syphilis 15-90 days after treatment. The number of persons treated was adjusted for the prevalence of syphilis in the year of treatment. Between 1985 and 1992, 98,441 persons were treated for gonorrhea. Syphilis was diagnosed in an interval that suggested it was incubating at the time of the treatment for 5.6/10(4) (adjusted number) persons treated with spectinomycin alone (a regimen not expected to eradicate syphilis); 2.9/10(4) persons treated with spectinomycin plus tetracycline, doxycycline, or erythromycin; and 2.1/10(4) persons treated with ceftriaxone plus tetracycline, doxycycline, or erythromycin (P > .1). Incubating syphilis was rare despite a syphilis epidemic. The effectiveness of a regimen for eradicating incubating syphilis should not be a major consideration when choosing gonorrhea therapy.

A method for identifying persons at high risk for sexually transmitted infections: opportunity for targeting intervention.

OBJECTIVES: The purpose of this study was to develop a method to identify persons at high risk for acquiring new sexually transmitted infections. METHODS: Computerized medical records from sexually transmitted disease clinics in Dade County, Florida, were used to conduct a retrospective cohort study. For all patients who visited in 1987, risk factors were identified for returning to the clinics within a year with a new sexually transmitted infection. Predictor variables were derived from the index visit and any visits in the year prior to the index visit. Logistic regression was used to develop a model that was applied to all patients who attended in 1989. RESULTS: Of 24,439 patients attending in 1987, 18.5% returned within a year with a new infection. Return rates were highest for 15- to 19-year-old Black males (31.8%). The highest odds ratios for returning were a diagnosis or treatment for an infection in the previous year and a diagnosis or treatment for infection at the index visit. The patients predicted to be at highest risk had a 39% return rate. There were as many new infections among the 2893 patients at highest risk as there were among the 13,326 patients at lowest risk. CONCLUSIONS: We developed a model that identifies persons at very high risk for sexually transmitted infection. These persons should be targeted for intensive intervention to reduce their risk.

Changes in sexually transmitted disease rates after HIV testing and posttest counseling, Miami, 1988 to 1989.

OBJECTIVES: The effects of posttest counseling on acquisition of sexually transmitted diseases in patients at a large urban sexually transmitted disease clinic were studied. METHODS: Comparisons were made of the percentage of patients who had a positive gonorrhea culture (or any sexually transmitted disease) in the 6 months before and after human immunodeficiency virus (HIV) counseling and testing. RESULTS: For 331 patients counseled about a positive HIV test, the percentage with gonorrhea was 6.3 before and 4.5 after posttest counseling (29% decrease). For 666 patients counseled about a negative test, the percentage with gonorrhea was 2.4 before and 5.0 after posttest counseling (106% increase). With any sexually transmitted disease as the outcome, patients who tested positive for HIV had a 12% decrease and patients who tested negative had a 103% increase after counseling. CONCLUSIONS: HIV counseling and testing was associated with a moderate decrease in sexually transmitted diseases among patients who tested positive for the virus, but risk increased for patients who tested negative. This suggests a need to improve posttest counseling in this clinic and to assess the effects of counseling and testing in other clinics.

Characteristics of mothers of live infants with congenital syphilis in Florida, 1987-1989.

The incidence of congenital syphilis in Florida increased sixfold from 1985 through 1989, and more than 80% of the cases occurred in metropolitan areas of southern Florida. To characterize the population of pregnant women in Florida at high risk of delivering an infant with congenital syphilis, the authors conducted a case-control study using birth certificates. Birth certificates were obtained for 256 of the 344 live infants reported as having congenital syphilis from 1987 through 1989 (74%); the 246 of these infants born in hospitals were matched for hospital and week of birth with an equal number of controls. In conditional multiple logistic regression, the following maternal characteristics were independent risk factors for congenital syphilis: young age, black race, single marital status, absence of a father's name on the birth certificate, previous pregnancy, substance abuse, and lack of prenatal care. Although the national origin of the mother was not a significant risk factor, the infants of black mothers born in the United States were at greater risk than the infants of black mothers born outside the United States. Mothers who had < or = 3 prenatal visits had an increased risk of delivering an infant with congenital syphilis as compared with mothers who had > 3 visits. This study suggests that targeted outreach efforts are necessary to control congenital syphilis and provides guidance for public health intervention activities.

Gonococcal infection of the newborn in Florida, 1984-1989.

An increase in neonatal gonococcal infections was recorded in Florida between 1984 and 1988. By reviewing Florida sexually transmitted disease surveillance case records between 1984 and 1989, 68 cases of neonatal gonococcal infections were identified state-wide. Those 68 cases included 55 (81%) cases of gonococcal ophthalmia neonatorum, 4 genital infections, 1 nasal infection, 1 ear infection, 1 skin infection, and 1 scalp infection. At birth, positive culture results were demonstrated in 3 gastric and 2 respiratory aspirate cultures. A case-control study using birth certificates as the source of information showed that mothers of infected infants were more likely to be younger, black (odds ratio [OR] = 6.2; 95% confidence interval [CI] 2.3, 16.2), and less educated (less than a high school education, OR = 2.9, CI 1.0,8.8) in comparison to mothers of control subjects. Although mothers of infected newborns were less likely to have received prenatal care than were mothers of control subjects, this difference was not statistically significant. Maternal substance abuse was documented among 19% of the mothers of the infected infants. The rate of clinical gonococcal ophthalmia neonatorum in Florida hospitals from which cases had been reported was 1.7 per 10,000 live births, and tended to be higher in hospitals using erythromycin than in hospitals using any other prophylactic eye treatment. This study suggests that the rate of neonatal gonococcal infection, in particular ophthalmia neonatorum, may have increased in Florida among high-risk populations between 1984 and 1988, and underscores the need for targeted prevention efforts and surveillance.