A chlamydia education and training program for general practice nurses: reporting the effect on chlamydia testing uptake.

The long-term health consequences of untreated chlamydia are an increased risk of pelvic inflammatory disease, ectopic pregnancies and infertility among women. To support increased chlamydia testing, and as part of a randomised controlled trial of a chlamydia intervention in general practice, a chlamydia education and training program for general practice nurses (GPN) was developed. The training aimed to increase GPNs' chlamydia knowledge and management skills. We compared the difference in chlamydia testing between general practices where GPNs received training to those who didn't and evaluated acceptability. Testing rates increased in all general practices over time. Where GPNs had training, chlamydia testing rates increased (from 8.3% to 19.9% (difference=11.6%; 95% CI 9.4-13.8)) and where GPNs did not have training (from 7.4% to 18.0% (difference=10.6%; 95% CI 7.6-13.6)). By year 2, significantly higher testing rates were seen in practices where GPNs had training (treatment effect=4.9% (1.1 - 8.7)), but this difference was not maintained in year 3 (treatment effect=1.2% (-2.5 - 4.9)). Results suggest a GPN chlamydia education and training program can increase chlamydia testing up to 2 years; however, further training is required to sustain the increase beyond that time.

Awareness of Chlamydia trachomatis infection by people attending a sexual transmitted infection (STI) clinic and missed opportunities for screening in a primary health care setting.

OBJECTIVES: To characterize awareness of Chlamydia trachomatis infection among persons consulting in a screening center in Ille-et-Vilaine, France, as well as the missed opportunities for screening in a primary health care setting during the 6 months preceding a diagnosis. PATIENTS AND METHOD: Cross-sectional study including persons over 15 years of age consulting in the centers of Rennes and Saint-Malo between 4 April 2019 and 1 July 2019 with data collection by self-administered questionnaire and telephone interview. RESULTS: We included 723 persons with a median age of 22 years. A third of them (34%) had never heard of Chlamydia, while 36% thought that testing sexually active youth was recommended. Among the 37 infected persons we were able to contact and interview, 9 (24.3%) had missed at least one opportunity for screening. CONCLUSION: People's lack of awareness and failure to appropriate recent recommendations by professionals could constitute an obstacle to large-scale screening.

Sexually transmissible infections, partner notification and intimate relationships: a qualitative study exploring the perspectives of general practitioners and people with a recent chlamydia infection.

Background Individuals diagnosed with a chlamydia infection are advised to notify their sexual partners from the previous 6 months so that they too can get tested and treated as appropriate. Partner notification is an essential component of chlamydia management, helping to prevent ongoing transmission and repeat infection in the index case. However, partner notification can be challenging, particularly in circumstances where a relationship has ended or transmission has occurred beyond the primary relationship. METHODS: In this study we use data from 43 semistructured interviews with general practitioners (GPs) and people with a recent diagnosis of chlamydia. The interviews examined experiences of chlamydia case management in the general practice context. Here, we focus specifically on the effect of a chlamydia infection on intimate relationships in the context of the consultation and beyond.? RESULTS: A chlamydia infection can have significant consequences for intimate relationships. Although GPs reported speaking to their patients about the importance of partner notification and participants with a recent chlamydia infection reported notifying their sexual partners, both would appreciate further support to engage in these conversations. CONCLUSIONS: Conversations with patients should go beyond simply informing them of the need to notify their sexual partners from the previous 6 months, and should provide information about why partner notification is important and discuss strategies for informing partners, particularly for those in ongoing relationships. Ensuring GPs have the training and support to engage in these conversations with confidence is vital.

How to increase chlamydia testing in primary care: a qualitative exploration with young people and application of a meta-theoretical model.

OBJECTIVE: The objective of this study was to explore young people's perspectives barriers to chlamydia testing in general practice and potential intervention functions and implementation strategies to overcome identified barriers, using a meta-theoretical framework (the Behaviour Change Wheel (BCW)). METHODS: Twenty-eight semistructured individual interviews were conducted with 16-24 year olds from across the UK. Purposive and convenience sampling methods were used (eg, youth organisations, charities, online platforms and chain-referrals). An inductive thematic analysis was first conducted, followed by thematic categorisation using the BCW. RESULTS: Participants identified several barriers to testing: conducting self-sampling inaccurately (physical capability); lack of information and awareness (psychological capability); testing not seen as a priority and perceived low risk (reflective motivation); embarrassment, fear and guilt (automatic motivation); the UK primary care context and location of toilets (physical opportunity) and stigma (social opportunity). Potential intervention functions raised by participants included education (eg, increase awareness of chlamydia); persuasion (eg, use of imagery/data to alter beliefs); environmental restructuring (eg, alternative sampling methods) and modelling (eg, credible sources such as celebrities). Potential implementation strategies and policy categories discussed were communication and marketing (eg, social media); service provision (eg, introduction of a young person's health-check) and guidelines (eg, standard questions for healthcare providers). CONCLUSIONS: The BCW provided a useful framework for conceptually exploring the wide range of barriers to testing identified and possible intervention functions and policy categories to overcome said barriers. While greater education and awareness and expanded opportunities for testing were considered important, this alone will not bring about dramatic increases in testing. A societal and structural shift towards the normalisation of chlamydia testing is needed, alongside approaches which recognise the heterogeneity of this population. To ensure optimal and inclusive healthcare, researchers, clinicians and policy makers alike must consider patient diversity and the wider health issues affecting all young people.

What do young women living in regional and rural Victoria say about chlamydia testing? A qualitative study.

Background Chlamydia trachomatis is the most commonly notified sexually transmissible infection in Australia, with almost 100000 cases diagnosed in 2018. Chlamydia is easy to diagnose and treat, but infections are underdiagnosed. Eighty per cent of chlamydia cases are asymptomatic. Without testing, infections will remain undetected. Several barriers to testing have been identified in previous research, including cost, privacy concerns for young rural people, knowledge gaps, embarrassment and stigma. The aim of this study was to investigate young regional and rural women's understanding of chlamydia and factors that may prevent or delay testing. METHODS: Semistructured interviews were conducted with 11 women aged between 18 and 30 years residing in north-east Victoria, Australia. Interviews were transcribed verbatim and analysed thematically. RESULTS: Themes were grouped under four categories: (1) chlamydia and stigma; (2) the application of stigma to self and others; (3) factors affecting testing; and (4) knowledge. A chlamydia infection was associated with stigma. The young women in this study anticipated self-stigma in relation to a positive diagnosis, but resisted stigmatising others. Increased knowledge about chlamydia prevalence was associated with reduced self-stigma. The most consistent factor affecting testing decisions was personal risk assessment. Knowledge gaps about symptoms, testing and treatment were also identified, with participants not always accessing information from reputable sources. CONCLUSION: Chlamydia testing was viewed as a positive activity among this cohort. However, there is considerable perceived stigma about being diagnosed with an infection. Interventions that communicate prevalence, reduce stigma and provide factual information about testing and risk are still needed. Clinicians have an opportunity to convey this information at consultation. Health promotion workers should continue to develop and run campaigns at a community level to encourage regular screening.

Factors associated with unsuccessful follow-up in patients undertreated for gonorrhea and chlamydia infections.

INTRODUCTION: Neisseria gonorrhea (GC) and Chlamydia trachomatis (CT) are two commonly encountered sexually transmitted infections in the Emergency Department (ED). METHODS: The study was a single-center, retrospective cohort of patients screened for GC/CT infections at an urban, academic medical center ED. Participants were identified through electronic medical record reports. Patients were excluded if they absconded, were discharged against medical advice, or had a chief complaint of sexual assault. Patients were classified as having tested positive or negative for GC/CT and further classified as having received adequate treatment, overtreatment, or undertreatment. The undertreatment group was further assessed for successful versus unsuccessful follow-up. The primary aim was to determine factors associated with unsuccessful follow-up in patients undertreated. Secondary aims included rate of overtreatment, rate of undertreatment, and method of contact in patients with successful follow-up. RESULTS: A total of 10,452 patients were included. Of the 456 undertreated patients, follow-up was successful in 425 (93.2%) patients and unsuccessful in 31 (6.8%) patients. No history of STIs was associated with a higher rate of unsuccessful follow-up in patients undertreated for GC/CT infections (52.9% versus 74.2%, difference = -21.3%, 95% CI -37.4%, -5.1%). Rate of overtreatment was 19.1%, and rate of undertreatment was 46.5%. Phone contact was the most frequent method of successful contact, which occurred in 98.6% of patients. CONCLUSIONS: GC/CT infections continue to be overtreated in the ED. Based on this study, no history of prior sexually transmitted infections was associated with unsuccessful follow-up in patients undertreated for GC/CT infections after discharge from the ED.

Understanding the attitudes and acceptability of extra-genital Chlamydia testing in young women: evaluation of a feasibility study.

BACKGROUND: Chlamydia trachomatis (C. trachomatis) is the most common bacterial sexually transmitted infection in the UK. Recent studies suggest that in addition to the genital tract, C. trachomatis is found in the throat and rectum, suggesting the number of infections is under-reported. There is an urgent need to study the impact of extending diagnosis to include extra-genital samples; however, there is a lack of evidence on the acceptability of asking young women to provide these samples. METHOD: A mixed methods single group feasibility study explored the acceptability of combined genital and extra-genital testing in young women aged 16-25 years consecutively attending a sexual health centre in Edinburgh, Scotland. Young women were asked to complete a self- administered anonymous questionnaire whether they would be willing to give self-taken throat and ano-rectal samples. Interviews with women (n = 20) willing to self-sample were conducted before and after self-sampling, and these explored the underlying reasons behind their decision, and feelings about the tests. RESULTS: Of 500 women recruited to the study, 422 (84.4%) women provided sufficient data for analysis. From completed questionnaires, 86.3% of respondents reported willingness to self-sample from the throat. Willingness of ano-rectal self-sampling was lower (59.1%), particularly in women under 20 (< 20 years: 44.4%; ≥20 years, 68.2%). Willingness of ano-rectal self-sampling was higher in women who had more sexual partners in the last 6 months (0 partners, 48.3%, n = 14, 3 or more partners, 67.4%, n = 60) and in those who have previous experience of a positive test for a sexually transmitted infection (STI) (positive: 64.5%; negative: 57%). Interviewed women suggested that a lack of knowledge of STIs, embarrassment and lack of confidence in the ability to carry out the sampling were barriers towards acceptability. CONCLUSIONS: In this study, self-sampling of throat samples is largely acceptable; however, the acceptability of taking an ano-rectal sample for C. trachomatis testing in young women was lower in younger women. The study suggests further research to investigate the acceptability of extra-genital testing as an addition to routine C. trachomatis testing, and whether this increases detection and prevents infective sequelae for women.

Who drops out and when? Predictors of non-response and loss to follow-up in a longitudinal cohort study among STI clinic visitors.

INTRODUCTION: Response rates in health research are declining, and low response rates could result in biased outcomes when population characteristics of participants systematically differ from the non-respondents. Few studies have examined key factors of non-response beyond demographic characteristics, such as behavioral and psychological factors. The aim of the current study was to identify predictors of non-response and loss to follow-up in a longitudinal sexual health study. MATERIALS AND METHODS: A longitudinal cohort study (iMPaCT) was conducted from November 2016 to July 2018 among heterosexual STI clinic visitors aged 18-24 years. At four different time points in one year, data was collected on sexual behavior, psychological determinants and chlamydia infections. The national STI surveillance database provided data on demographic, behavioral and sexual health-related characteristics for non-respondents. Predictors of non-response at baseline and of loss to follow-up were identified using multivariable logistic regression analyses. RESULTS: In total, 13,658 STI clinic visitors were eligible to participate, of which 1,063 (8%) participated. Male gender, low/medium education level, young age (≤ 20 years) and having a non-Dutch migration background were significant predictors of non-response at baseline. Furthermore, non-respondents at baseline were more likely to report STI-related symptoms, to have been notified by a partner, to have had condomless sex, and to have had ≤ 2 partners in the past six months, compared to participants. Psychological predictors of loss to follow-up differed between STI clinic regions, but low perceived importance of health at baseline was associated with loss to follow-up in all regions. The baseline chlamydia positivity rate was significantly higher in the non-respondents (17%) compared to the participants (14%), but was not a predictor of loss to follow-up. DISCUSSION: Targeted recruitment aimed at underrepresented groups in the population based on demographic, behavioral and psychological characteristics, might be necessary to decrease loss to follow-up, and to prevent non-response bias in health research.

Factors associated with anorectal Chlamydia trachomatis or Neisseria gonorrhoeae test positivity in women: a systematic review and meta-analysis.

OBJECTIVES: There has been considerable discussion about anorectal Chlamydia trachomatis (CT) in women, with some calling for anorectal CT screening, but little about anorectal Neisseria gonorrhoeae (NG). Given that urogenital NG is more strongly associated with pelvic inflammatory disease, this is an evidence gap. This systematic review and meta-analysis investigates the associations between anorectal CT in women and CT positivity at other sites (urogenital/oropharyngeal) and with anal intercourse, and compares these with anorectal NG within the same study populations. METHODS: Electronic databases were searched for English-language studies published to October 2018 using the following terms: ("Chlamydia" OR "Chlamydia trachomatis") AND (("anal" OR "rect*" OR "anorect*") OR ("extra?genital" OR "multi?site")). Studies were included if anorectal NG data were available. Random-effects meta-analyses calculated pooled estimates; heterogeneity was investigated using meta-regression. RESULTS: 25 studies were eligible. Anorectal CT positivity ranged from 0% to 17.5%, with a summary estimate of 8.0% (95% CI 7.0 to 9.1; I2=88.5%). Anorectal NG positivity ranged from 0% to 17.0%, with a summary estimate of 2.1% (95% CI 1.6 to 2.8; I2=92.7%). The association between urogenital and anorectal positivity was stronger for NG than CT (summary prevalence ratio (PR)=89.3 (95% CI 53.1 to 150.3; I2=80.1%), PR=32.2 (95% CI 25.6 to 40.7; I2=70.3%), respectively), and between oropharyngeal and anorectal positivity it was stronger for NG than CT (PR=34.8 (95% CI 10.2 to 118.2; I2=89.9%), PR=8.8 (95% CI 6.8 to 11.5; I2=58.1%), respectively). Anal intercourse was associated with anorectal NG (PR=4.3; 95% CI 2.2 to 8.6; I2=0.0%) but not with anorectal CT (PR=1.0; 95% CI 0.7 to 1.4; I2=0.0%). CONCLUSIONS: Anorectal CT is more common than anorectal NG, but anorectal NG is more strongly associated with anal intercourse, urogenital and oropharyngeal NG, suggesting that ongoing discussion about anorectal CT should also include NG. Longitudinal data are required to further understanding of the aetiology of anorectal STIs and assess whether anorectal screening is needed in women. TRIAL REGISTRATION NUMBER: CRD42df017080188.

Sexual network characteristics of men who have sex with men with syphilis and/or gonorrhoea/chlamydia in Lima, Peru: network patterns as roadmaps for STI prevention interventions.

OBJECTIVE: While men who have sex with men (MSM) are disproportionately affected by Peru's overlapping HIV and STI epidemics, there are few data on how partnership-level and network-level factors affect STI transmission in Peru. We explored partnership-level and network-level factors associated with gonorrhoea/chlamydia (Neisseria gonorrhoeae and/or Chlamydia trachomatis (NG/CT)) and/or syphilis infection among MSM in Peru. METHODS: We present the results of a cross-sectional secondary analysis of MSM (n=898) tested for syphilis and NG/CT infection as part of the screening process for two STI control trials in Lima, Peru. Participants completed questionnaires on demographics, sexual identity and role, characteristics of their three most recent sexual partners (partner sexual orientation, gender, role, partnership type, partner-specific sexual acts) and 30-day sexual network characteristics (number of sexual partners, partnership types, frequency of anal/vaginal intercourse). Participants were tested for syphilis and urethral, rectal and oropharyngeal NG/CT. Differences in network characteristics were analysed with χ2 and Kruskal-Wallis tests. RESULTS: Approximately 38.9% of participants had a new STI diagnosis (syphilis (rapid plasma reagin ≥16): 10.6%; NG/CT: 22.9%; syphilis-NG/CT coinfection: 5.4%). Condomless anal intercourse (CAI) was not significantly associated with an STI diagnosis. Gay-identified participants with exclusively homosexual networks had a higher prevalence of STIs (47.4%) than gay-identified MSM with only heterosexual/bisexual partners (34.6%, p=0.04), despite reporting fewer sexual partners (any partners: 2, 1-4 vs 3, 2-6; p=0.001; casual partners: 1, 0-3 vs 2, 1-4; p=0.001) and more stable partnerships (1, 0-1 vs 0, 0-1; p=0.003) in the last month. CONCLUSIONS: Network size and the number of casual sexual partners were associated with NG/CT infection among MSM in Peru. Despite reporting fewer sexual risk behaviours (smaller network size, more stable partnerships, less CAI), MSM with homosexual-only sexual networks had a higher prevalence of NG/CT and syphilis. These findings suggest network composition among MSM in Peru plays an important role in the risk for STI acquisition.

Application of the COM-B model to barriers and facilitators to chlamydia testing in general practice for young people and primary care practitioners: a systematic review.

BACKGROUND: Chlamydia is a major public health concern, with high economic and social costs. In 2016, there were over 200,000 chlamydia diagnoses made in England. The highest prevalence rates are found among young people. Although annual testing for sexually active young people is recommended, many do not receive testing. General practice is one ideal setting for testing, yet attempts to increase testing in this setting have been disappointing. The Capability, Opportunity, and Motivation Model of Behaviour (COM-B model) may help improve understanding of the underpinnings of chlamydia testing. The aim of this systematic review was to (1) identify barriers and facilitators to chlamydia testing for young people and primary care practitioners in general practice and (2) map facilitators and barriers onto the COM-B model. METHODS: Qualitative, quantitative, and mixed methods studies published after 2000 were included. Seven databases were searched to identify peer-reviewed publications which examined barriers and facilitators to chlamydia testing in general practice. The quality of included studies was assessed using the Critical Appraisal Skills Programme. Data (i.e., participant quotations, theme descriptions, and survey results) regarding study design and key findings were extracted. The data was first analysed using thematic analysis, following this, the resultant factors were mapped onto the COM-B model components. All findings are reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS: Four hundred eleven papers were identified; 39 met the inclusion criteria. Barriers and facilitators were identified at the patient (e.g., knowledge), provider (e.g., time constraints), and service level (e.g., practice nurses). Factors were categorised into the subcomponents of the model: physical capability (e.g., practice nurse involvement), psychological capability (e.g.: lack of knowledge), reflective motivation (e.g., beliefs regarding perceived risk), automatic motivation (e.g., embarrassment and shame), physical opportunity (e.g., time constraints), social opportunity (e.g., stigma). CONCLUSIONS: This systematic review provides a synthesis of the literature which acknowledges factors across multiple levels and components. The COM-B model provided the framework for understanding the complexity of chlamydia testing behaviour. While we cannot at this juncture state which component represents the most salient influence on chlamydia testing, across all three levels, multiple barriers and facilitators were identified relating psychological capability and physical and social opportunity. Implementation should focus on (1) normalisation, (2) communication, (3) infection-specific information, and (4) mode of testing. In order to increase chlamydia testing in general practice, a multifaceted theory- and evidence-based approach is needed. TRIAL REGISTRATION: PROSPERO CRD42016041786.

Health-related quality of life and psychosocial impacts of a diagnosis of non-specific genital infection in symptomatic heterosexual men attending UK sexual health clinics: a feasibility study.

INTRODUCTION: Non-specific genital infection (NSGI; non-Chlamydia trachomatis, non-Neisseria gonorrhoeae-associated urethritis) is a common diagnosis in symptomatic heterosexual men attending UK sexual health clinics (SHCs). but little is known about the psychosocial impact of this diagnosis. METHODS: We conducted an observational study among symptomatic heterosexual men attending SHCs to evaluate the psychosocial impact of an NSGI diagnosis compared with a diagnosis of Chlamydia trachomatis (CT), Neisseria gonorrhoeae or no abnormalities detected focusing on the feasibility of our study methodology. Participants completed a computer-assisted self-interviewing (CASI) including two validated measures of psychosocial impact: the EQ-5D-5L health-related quality of life and Rosenberg Self-Esteem Scale, before diagnostic testing and 2 weeks after receiving test results (follow-up 1 (FU-1)) and a qualitative interview. We compared scores between diagnostic groups using paired t-tests, qualitative data were analysed thematically and feasibility was assessed by process analysis. RESULTS: 60 men completed the baseline CASI (75% response rate). 46 (76.6%) were eligible for follow-up; 11/46 (23.9%) completed the follow-up CASI, and 3/11 (27.3%) completed the qualitative interview. 81.7% of all participants left CASI feedback at baseline: 73.5% reported the questionnaire as 'fine' or 'very good'. Qualitative interview participants reported the study was acceptable. Compared with baseline, among patients completing FU-1, only patients with a diagnosis of NSGI (p<0.05) or CT (p<0.05) showed increased EQ-5D-5L Index, whereas patients with a diagnosis of NSGI (p=0.05) showed decreased mean Rosenberg Self-Esteem Scale score. CONCLUSIONS: Although most participants indicated study acceptability at baseline, and we employed measures to increase retention (CASI questionnaires, reminder messages and a focus on men's health), we experienced high loss to follow-up. We found that heterosexual men attending SHCs with symptoms of urethritis experience both positive and negative psychosocial impacts following their clinic attendance, which warrants further investigation.

Gender differences in the well-being of patients diagnosed with Chlamydia trachomatis: a cross-sectional study.

OBJECTIVES: We aimed to investigate how an infection with Chlamydia trachomatis (CT) influenced patients' well-being and whether there were differences due to gender, age or relationship status, in an effort to strengthen preventive measures and provide better healthcare for patients with CT. METHODS: Patients diagnosed with CT in the county of Västerbotten, Sweden, were asked to fill out a questionnaire about their feelings, thoughts and actions after CT diagnosis. The patients were also asked to fill in the validated questionnaires Hospital Anxiety and Depression Scale and Alcohol Use Disorder Identification Test. Between February 2015 and January 2017, 128 patients (74 women and 54 men) were included in the study. RESULTS: After being diagnosed with CT, men were generally less worried than women (P<0.001). Women worried more about not being able to have children (P<0.001) and about having other STIs (P=0.001) than men did. Men felt less angry (P=0.001), less bad (P<0.001), less dirty (P<0.001) and less embarrassed (P=0.011) than women did. Nineteen per cent of men and 48% of women reported symptoms of anxiety. The majority of both men (60%) and women (72%) had a risk consumption of alcohol. CONCLUSION: Women and men reacted differently when diagnosed with CT. Women worried more about complications and more often blamed themselves for being infected. Being aware of these gender differences may be important when planning preventive measures and during counselling of CT-infected patients. Persons working with patients with CT must also be aware of the high frequency of harmful alcohol consumption among their patients.

Using the eSexual Health Clinic to access chlamydia treatment and care via the internet: a qualitative interview study.

OBJECTIVE: We developed the eSexual Health Clinic (eSHC), an innovative, complex clinical and public health intervention, embedded within a specialist sexual health service. Patients with genital chlamydia access their results online and are offered medical management via an automated online clinical consultation, leading to antibiotic collection from community pharmacy. A telephone helpline, staffed by Sexual Health Advisers, is available to support patients and direct them to conventional services if appropriate. We sought to understand how patients used this ehealth intervention. METHODS: Within exploratory studies of the eSHC (2014-2015), we conducted in-depth interviews with a purposive sample of 36 patients diagnosed with chlamydia, who had chosen to use the eSHC (age 18-35, 20 female, 16 male). Thematic analysis was conducted. RESULTS: Participants described choosing to use this ehealth intervention to obtain treatment rapidly, conveniently and privately, within busy lifestyles that hindered clinic access. They described completing the online consultation promptly, discreetly and with ease. The information provided online was considered comprehensive, reassuring and helpful, but some overlooked it in their haste to obtain treatment. Participants generally described being able to collect treatment from pharmacies discreetly and promptly, but for some, poor awareness of the eSHC by pharmacy staff undermined their ability to do this. Those unsuitable for remote management, who were directed to clinic, described frustration and concern about health implications and clinic attendance. However, the helpline was a highly valued source of information, assistance and support. CONCLUSION: The eSHC is a promising adjunct to traditional care. Its users have high expectations for convenience, speed and privacy, which may be compromised when transitioning from online to face-to-face elements of the eSHC. Managing expectations and improving implementation of the pharmacy process, could improve their experiences. Positive views on the helpline provide further support for embedding this ehealth intervention within a specialist clinical service.

Repeat testing for chlamydia trachomatis, a "safe approach" to unsafe sex? a qualitative exploration among youth in Stockholm.

BACKGROUND: Chlamydia trachomatis testing is offered to youth in Sweden, through a network of Youth Health Clinics, free at the point of care, in an attempt to bring down the prevalence and incidence of the infection. Nevertheless, infections rates have continued to rise during the past two decades and re-testing rates among youth for Chlamydia trachomatis has been reported to be high in Stockholm County. A few literature reports suggest that testing for sexually transmitted infections and the test result itself can have an undesirable impact on the sexual behaviour for the individual, i.e. increase sexual risk-taking. METHODS: This qualitative study aimed to explore the motives for repeated testing for Chlamydia trachomatis among youth using the services of the Youth Health Clinics in Stockholm, and how testing affects their subsequent risk-taking. We interviewed 15 repeat testers aging 18-22 years. RESULTS: Our main findings were that the fear of social stigma related to infecting a peer was a major driver of the re-testing process. The repetitive testing process, the test result, and the encounter with personnel did not decrease sexual risk-taking among this group. CONCLUSIONS: While testing and treatment services are an important part of Chlamydia trachomatis prevention it must not take the focus away from primary prevention strategies. Testing should be encouraged, but not to the exclusion of risk reduction measures. The testing services must be complemented with stronger emphasis on safe sex, especially for those who attend the clinics repeatedly, otherwise the easy accessible testing services risk counteracting its own purpose. Future research should focus on developing and evaluating youth appropriate interventions to increase condom use, taking into consideration factors which youth perceive as important to drive this behaviour change.

Iterative Design and Testing for the Development of a Game-Based Chlamydia Awareness Intervention: A Pilot Study.

OBJECTIVES: Herein we describe a methodology for developing a game-based intervention to raise awareness of Chlamydia and other sexually transmitted infections among youth in Boston's underserved communities. MATERIALS AND METHODS: We engaged in three design-based experiments. These utilized mixed methods, including playtesting and assessment methods, to examine the overall effectiveness of the game. In this case, effectiveness is defined as (1) engaging the target group, (2) increasing knowledge about Chlamydia, and (3) changing attitudes toward Chlamydia testing. These three experiments were performed using participants from different communities and with slightly different versions of the game, as we iterated through the design/feedback process. RESULTS: Overall, participants who played the game showed a significant increase in participants' knowledge of Chlamydia compared with those in the control group (P = 0.0002). The version of the game, including elements specifically targeting systemic thinking, showed significant improvement in participants' intent to get tested compared with the version of the game without such elements (Stage 2: P > 0.05; Stage 3: P = 0.0045). Furthermore, during both Stage 2 and Stage 3, participants showed high levels of enjoyment, mood, and participation and moderate levels of game engagement and social engagement. During Stage 3, however, participants' game engagement (P = 0.0003), social engagement (P = 0.0003), and participation (P = 0.0003) were significantly higher compared with those of Stage 2. Thus, we believe that motivation improvements from Stage 2 to 3 were also effective. Finally, participants' overall learning effectiveness was correlated with their prepositive affect (r = 0.52) and their postproblem hierarchy (r = -0.54). CONCLUSION: The game improved considerably from its initial conception through three stages of iterative design and feedback. Our assessment methods for each stage targeted and integrated learning, health, and engagement outcomes. Lessons learned through this iterative design process are a great contribution to the games for health community, especially in targeting the development of health and learning goals through game design.

Is Patient-Reported Exposure a Reliable Indicator for Anogenital Gonorrhea and Chlamydia Screening in Young Black Men Who Have Sex With Men?

Among 485 young black men who have sex with men recruited in Jackson, MS, 90-day anal sexual exposure significantly predicted rectal infection, but 19.4% of rectal infections would have been missed among men denying receptive anal sex. Reports of consistent condom use were associated with lower infection rates only in men reporting insertive anal sex.

Biological and Behavioral Factors Associated With Positive Chlamydia Retests.

BACKGROUND: Repeat chlamydia detection after treatment is common, and there is concern that treatment failure may be a cause. METHODS: Within a randomized trial, we established a prospective cohort of 600 participants with anogenital chlamydia diagnoses (200 each of women, heterosexual men, and men who have sex with men [MSM]). Participants were invited for repeat testing at 3 months and to complete a behavioral survey at 4 months. Positive samples were analyzed for organism DNA load and genovar. We estimated repeat chlamydia positivity, reinfection and treatment failure rates, and investigated the biological and behavioral factors associated with a repeat positive test. RESULTS: A total of 290 participants (100 women, 89 heterosexual men, 101 MSM) were retested at 1 to 4 months, with 43 repeat positives, including 26 classed as reinfection and 9 as treatment failures. Comparing MSM with heterosexual men and women combined, repeat positivity was higher (20.8% vs 11.6%, P = 0.04), and treatment failure was higher (6.9% vs 1.1%, P = 0.01), but there was no difference in reinfection rates (11.9% vs 7.4%, P = 0.21). Among MSM, the odds of repeat positivity increased by 90% with each additional log organism load in the original specimen (baseline) (adjusted odds ratio, 1.9; 95% confidence interval, 1.1-3.2). Among heterosexuals, the odds of repeat positivity decreased by 10% with each additional week delay in being retested for chlamydia (adjusted odds ratio, 0.9; 95% confidence interval, 0.8-0.9). CONCLUSIONS: Positive retests were more common among MSM than heterosexuals. Treatment failure was more common in MSM with rectal chlamydia, reinforcing concerns about azithromycin treatment failure.

"Men don't think that far" - Interviewing men in Sweden about chlamydia and HIV testing during pregnancy from a discursive masculinities construction perspective.

OBJECTIVES: We used qualitative research design to discursively explore expectant fathers' perceptions of chlamydia and HIV, and their masculinity constructions about testing, and explored how they talked about their potential resistance towards testing and their pre-test emotions. STUDY DESIGN: Twenty men were offered chlamydia and HIV testing at the beginning of their partner's pregnancy. Those who agreed to be tested were interviewed in-depth; those who declined testing were also interviewed. The interviews were tape recorded and transcribed verbatim. The analysis was inspired by discourse analysis on masculinity. MAIN OUTCOME: Three discursive themes: Men prefer to suppress their vulnerability to STIs, Body and biology differ between men and women and Men have mixed emotions around STI testing underscore the informants' conversations and sometimes conflicting thoughts about STI testing. CONCLUSION: The majority of men talked about pregnancy as a feminine territory, raised uncertainties about men's roles in the transmission of STIs, and talked about women's and men's essentially different bodies and biology, where few men realised that they could infect both their partner and the unborn child. This knowledge gap that men have must become apparent to healthcare providers, and policy makers must give men equal access to the reproductive arena.