Older partners and STD prevalence among pregnant African American teens

BACKGROUND: Several recent studies have addressed the question of whether adolescent females who have sex with older partners have a greater risk of sexually transmitted disease (STD) acquisition. GOAL: The goal was to identify differences in STD prevalence and selected measures of behavioral risk between unmarried pregnant African American adolescent females reporting sex with older partners and those reporting sex with similar-age partners. STUDY DESIGN: Adolescents (n = 169) were recruited during their first prenatal visit. Adolescents completed a self-administered survey and a face-to-face interview and provided urine specimens for nucleic acid amplification assays. RESULTS: Approximately 65% of adolescents reported that their male sex partners were >/=2 years older, while 35% reported having similar-age male sex partners. In age-adjusted analyses, adolescents with older partners were four times more likely to test positive for chlamydia (P < 0.04) and were more than twice as likely to report that their partner was also having sex with other women (P < 0.04). With use of a 30-day recall period, the mean number of unprotected vaginal sexual encounters among adolescents with older partners was 4.1, as compared to a mean of 6.9 among those reporting similar-age partners; this difference approached significance (P = 0.051). Prevalence of trichomoniasis as well as scale measures of adolescents' self-efficacy for condom negotiation and frequency of sexual communication with partners did not differ between those adolescents with older or similar-age male sex partners. CONCLUSION: In resource-constrained clinical settings, one implication of these findings is that pregnant adolescents reporting older partners may be a priority for targeted delivery of partner services. More frequent screening for chlamydia may also be cost-effective for pregnant adolescents with older partners.     

Does partner selection contribute to sex differences in sexually transmitted infection rates among African American adolescents in San Francisco?

INTRODUCTION: Little is known regarding whether partner characteristics explain sex differences in sexually transmitted infection (STI) rates in nonclinic-based, school-aged African American youth. MATERIALS AND METHODS: A random digit dial household sample of 14- to 19-year-old youth in San Francisco reported the total number, age, race, and perceived history of incarceration, gang membership, and level of sexual activity of their partners. Youth were tested for gonorrhea and chlamydia. RESULTS: Female participants were more likely than male participants to have a partner who was older or had been incarcerated and less likely to have a non-African American partner. Controlling for partner number, female's odds ratio (OR) for having an STI was 1.39 (95% confidence interval [CI] = 0.98-1.98; P = 0.07). Controlling for partner incarceration and number of partners, the borderline sex difference was eliminated (OR = 1.07; 95% CI = 0.70-1.63). CONCLUSION: Sex differences in STI rates among African American adolescents may be determined more by the risk of the partner than the risk of the individual.     

Health indicators among low income women who report a history of sex work: the population based Northern California Young Women's Survey

OBJECTIVES: We examined differences in demographic characteristics, HIV related risk behaviour, prevalence of sexually transmitted infections (STI), and HIV and other health concerns among women with and without a history of sex work. METHODS: A secondary analysis of a population based, cross sectional survey of young, low income women in northern California. RESULTS: Of the 2543 women interviewed, 8.9% reported a history of sex work. These women reported more lifetime male sexual partners, were more likely to use drugs before sex, and were more likely to have a history of having sex with partners at high risk for HIV (that is, men who have sex with men, inject drugs, or were known to be HIV positive). They were significantly more likely to have positive serology for syphilis, herpes simplex virus type 2 (HSV-2), and hepatitis C regardless of their personal injecting drug use history; however, they were no more likely to have HIV, chlamydia, gonorrhoea, hepatitis A or hepatitis B infection compared to women without a history of sex work. Women with a history of sex work were significantly more likely to have a history of sexual coercion and tobacco use. CONCLUSIONS: These data measure the population prevalence of sex work among low income women and associated STI. Women with a history of sex work have health concerns beyond STI and HIV treatment and prevention.     

Associations between internet sex seeking and STI associated risk behaviours among men who have sex with men

OBJECTIVE: This exploratory study identified associations between internet sex seeking and HIV associated risk behaviours among a high risk sample of men who have sex with men (MSM). METHODS: A cross sectional survey of men attending a sex resort was conducted. Of 164 men asked to participate, 91% completed a self administered questionnaire. The questionnaire assessed demographic variables and (using a 3 month recall period) men's HIV associated sexual risk behaviours. Potential confounding variables were assessed and controlled, as needed, by multivariate analysis. RESULTS: Men currently resided in 14 states. One sixth reported being HIV positive. 57% of the men reported using the internet to seek sex. Differences in critical behaviours (unprotected anal sex and number of partners) were not found. However, compared to those not seeking sex by internet, men using the internet to meet sex partners were more likely to report fisting (adjusted odds ratio = 3.3, p = 0.04), having group sex (prevalence ratio (PR) = 1.2, p = 0.0001), using poppers during sex (PR = 1.94, p = 0.0001), and using ecstasy during sex (PR = 2.7, p = 0.04). Internet sex seeking men were also significantly more likely to report meeting sex partners in bathhouses (PR = 2.2, p = 0.0001), bars (PR = 1.5, p = 0.001), parks (PR = 3.2, p = 0.006), and circuit parties (PR = 8.9, p = 0.007). CONCLUSION: Among MSM attending a sex resort, those using the internet to seek sex partners may have modestly elevated risks for acquiring or transmitting sexually transmitted infections. Subsequent studies should investigate the utility of using the internet as forum for promoting safer sex behaviours among high risk MSM.     

Prevalence and correlates of exchanging sex for drugs or money among adolescents in the United States

OBJECTIVE: This study examined the prevalence and correlates of exchanging sex for drugs or money among a nationally representative sample of 13,294 adolescents in the United States. METHODS: Data are from the National Longitudinal Study of Adolescent Health, waves I and II. The lifetime prevalence of exchanging sex was estimated and a cross sectional analysis of sociodemographic and behavioural correlates was conducted. Unadjusted odds ratios were obtained. RESULTS: 3.5% of adolescents had ever exchanged sex for drugs or money. Two thirds of these youths were boys. The odds of having exchanged sex were higher for youths who had used drugs, had run away from home, were depressed, and had engaged in various sexual risk behaviours. 15% of boys and 20% of girls who had exchanged sex reported they had ever been told they have HIV or another sexually transmitted infection (STI). CONCLUSIONS: Adolescents with a history of exchanging sex have engaged in other high risk behaviours and may experience poor health outcomes, including depression and HIV/STIs. These findings should help inform strategies to prevent this high risk sexual behaviour and its potential consequences.     

HIV risk profile of male street youth involved in survival sex

OBJECTIVES: To compare HIV risk factors of male street youth involved in survival sex with those of their never involved peers and to describe the sexual activities of the involved youths. METHODS: From 2001 to 2003, street youth aged 14-23 years were recruited from street youth agencies in Montreal, Canada. Information was collected on sociodemographic characteristics, substance use, and sexual behaviours. Involvement in survival sex was defined as having ever exchanged sex for money, gifts, drugs, shelter, or other needs. Logistic regression was used to identify HIV risk factors associated with involvement in survival sex. RESULTS: Among the 542 male participants recruited, 27.7% reported involvement in survival sex. HIV risk factors independently associated with such involvement were injection drug using partners (modulated by length of homelessness), unprotected oral sex with male partners, steroid injection, history of sexual abuse, and drug injection. Among involved youths, 32.0% had only female clients, 41.3% only male clients, and 26.7% had clients of both sexes. Unprotected sexual activities were common with clients. However, even more risks were taken with non-commercial sexual partners. CONCLUSIONS: Male street youth involved in survival sex are at higher risk for HIV than their non-involved peers not only because of their unprotected commercial sexual activities. They have multiple other HIV risks related to non-commercial sexual activities, drug injection, and sexual abuse. All these risks need to be addressed when providing sexual health interventions for this population.     

Under the influence: risky sexual behavior and substance abuse among driving under the influence offenders

BACKGROUND AND OBJECTIVES: The purpose of this study was to examine the associations between alcohol and drug abuse and risky sexual practice in a sample of 366 driving under the influence (DUI) offenders. STUDY DESIGN: Data were collected from a sample of participants at a university-operated drunk driving intervention program. Specific indicators included established or severe alcohol/drug use problems, multiple drugs used, multiple alcohol/drug related arrests, and early regular alcohol use. Multiple sexual partners, condom use, and having sex while under the influence of alcohol or drugs were used to measure risky sexual behavior patterns. Correlation and logistic regression analyses examined associations between these substance abuse and sexual risk taking measures. RESULTS: Substance abuse in general was unrelated to risky sexual behavior such as multiple sexual partners or lack of condom use. However, having sex while high from alcohol or drugs was significantly associated with substance abuse. Moreover, having sex while high was significantly related to both risky sex and a history of sexually transmitted disease. CONCLUSIONS: Having sex while high may be an important behavior to address to prevent STDs in the DUI population. Assessing relationships between substance abuse and risky sexual behavior poses a challenge to researchers because any estimates about this association may be dependent on the measure of sexual behavior that is used. An integrated intervention approach that addresses both substance abuse prevention and safe sexual practice appears crucial and effective for educating "risk takers" such as DUI offenders. However, these data caution that for those who are dependent upon alcohol and/or other drugs, education solely emphasizing risk reduction procedures is likely to be inefficient until their chemical dependency is addressed.     

Associations between sexually transmitted disease diagnosis and subsequent sexual risk and sexually transmitted disease incidence among adolescents

BACKGROUND: Empiric evidence is lacking in regard to the subsequent sexually transmitted disease (STD)-associated risk behaviors of adolescents diagnosed and treated for an STD. GOAL: The goal of this study was to prospectively identify associations between STD diagnosis and subsequent sexual risk and STD incidence among a sample of U.S. adolescents. STUDY DESIGN: A cohort of 455 adolescents (age 15-21 years) was followed for 3 months. Adolescents were recruited from primary care clinics and through outreach activities. RESULTS: A total of 10.8% were initially diagnosed with at least one STD. After adjusting for observed covariates, these adolescents (compared with those testing negative) were 2.8 times (P = 0.0001) more likely to be abstinent from sex and 2.2 times more likely to report always using condoms (P = 0.04). However, during the ensuing 3 months, they were approximately 2.4 times more likely to report having sex with multiple partners (P = 0.01), 8.9 times more likely to test positive for trichomonas (P = 0.009), and 3.0 times more likely to test positive for chlamydia (P = 0.04). CONCLUSIONS: Compared with those testing negative, adolescents diagnosed with an STD may subsequently adopt safer sex behaviors, including abstinence. However, perhaps in part as a result of having sex with multiple partners, they might fail to practice safer sex behaviors stringently enough to avoid subsequent STD acquisition.     

Sexual behaviour of young people in international tourist resorts

BACKGROUND/OBJECTIVES: Increasingly, young people travel abroad to experience nightlife in international resorts. Although media coverage of such resorts suggests high levels of sexual activity, little empirical data are currently available. We have measured: 3 year trends in sexual behaviour of young people visiting Ibiza, levels of sexual risk taking, and their relation to substance use. Additionally, in 2002 we identified levels of homosexual sex and sexual interactions between UK residents and individuals from other countries. METHODS: Data were collected from visitors to Ibiza between 2000 and 2002 just before they left the island. Information on sexual health was surveyed using a short anonymous questionnaire. RESULTS: Over half of individuals (56.0%) visiting Ibiza had sex with at least one person, with 26.2% of males and 14.5% of females having sex with more than one individual. However, of those arriving without sexual partners (75.5%) just under half (47.5%) have sex in Ibiza and most of these (62.4%) always used condoms. Having any sex abroad was associated with using illicit drugs and having more sexual partners in the 6 months before visiting Ibiza. However, having unprotected sex or sex with more than one person was associated with smoking as well as having higher numbers of sexual partners before their visit. Overall, 8.6% of individuals had sex with a non-UK resident in Ibiza although such individuals were no more likely to have sex without condoms. CONCLUSIONS: Substantial numbers of individuals visiting international nightlife resorts have unprotected sex with people they meet while abroad. This poses an increasing threat to the sexual health of UK residents but as yet little attention has been paid to developing interventions that might reduce sexual risk taking among young people holidaying abroad.     

Sexual risk behaviors associated with having older sex partners: a study of black adolescent females.

BACKGROUND: Volunteer black adolescent females from neighborhoods characterized by high rates of unemployment, substance abuse, violence, and sexually transmitted disease were studied to determine the frequency of condom use and unprotected vaginal sex with steady, older partners during various time periods over the previous 6 months. GOAL: To examine associations between having male sex partners who were typically older (by at least 2 years) and adolescent females' sexually transmitted disease (STD)/HIV-associated sexual risk behaviors. STUDY DESIGN: In this cross-sectional study, 522 sexually active black adolescent females completed a questionnaire and a structured interview, of which a portion assessed the age difference between the adolescents and their typical sex partners. The adolescents' ages, length of relationship and their use of hormonal contraception were identified as covariates. Adjusted odds ratios (AOR), their 95% confidence intervals, and respective P values were calculated to detect significant associations. RESULTS: Sixty-two percent of the adolescents reported their typical sex partners were at least 2 years older. These adolescents were more likely to report never using condoms during the most recent sexual encounter (AOR = 2.0), during the last five sexual encounters (AOR = 2.0), and during the past month (AOR = 2.2). Similarly, having older partners was associated with greater odds of reporting any unprotected vaginal sex in the past 30 days (AOR = 1.7) or the past 6 months (AOR = 1.5). CONCLUSION: Our findings suggest that many adolescent females have sex partners who are at least 2 years older and that their relationship dynamics do not favor the adoption and maintenance of behavior protective against STD or HIV infection. Prevention programs could include training designed to help adolescent females overcome barriers to safer sex with older male partners.     

Adjudication history and African American adolescents' risk for acquiring sexually transmitted diseases: an exploratory analysis

BACKGROUND: Little is known about sexually transmitted disease (STD) risk behavior among adjudicated African American adolescents. GOAL: The goal of the study was to compare STD-associated risk profiles of African American adolescents reporting a history of adjudication and those not reporting adjudication. STUDY DESIGN: A cross-sectional survey of 304 African American adolescent males and females (aged 15-21 years) was conducted. Adolescents were recruited from primary care clinics and through outreach activities. RESULTS: Twenty-six percent of the adolescents reported adjudication. After adjusting for gender, adjudicated adolescents were about 3.6 and 4.5 times, respectively, more likely than nonadjudicated adolescents to report ever having one of three STDs (gonorrhea, chlamydia, and trichomoniasis) or to report having one of these in the past 90 days. Reporting recent sex with someone known or suspected of having an STD was about nine times more likely among adjudicated adolescents, and they were about 2.6 times more likely than their nonadjudicated counterparts to report using drugs or alcohol during their last sexual experience and 2.2 times more likely to report frequent sex in the past 90 days. CONCLUSIONS: African American adolescents with a history of adjudication may have greater risk for acquisition of STDs than their peers not reporting adjudication.     

Early sexual debut among young men in rural South Africa: heightened vulnerability to sexual risk?

OBJECTIVE: This report examines early sexual debut ( or = 3 partners in the past 3 years (OR = 10.26, p<0.01). CONCLUSIONS: Men who initiate sex before age 15 form a distinct risk group in this setting. Specific interventions are needed for young men in the pre-teen years, before sexual debut.     

Commercial sex venues: a closer look at their impact on the syphilis and HIV epidemics among men who have sex with men

OBJECTIVE: To provide insight into the role of commercial sex venues in the spread of syphilis and HIV among men who have sex with men (MSM). Study: A cross sectional study of 1351 MSM who were diagnosed with early syphilis who did and did not encounter sexual partners at commercial sex venues. RESULTS: Overall, 26% MSM diagnosed with syphilis had sexual encounters at commercial sex venues. Of these, 74% were HIV positive, 94% reported anonymous sex, and 66% did not use a condom. Compared to those who did not have a sexual encounter at these venues, they were twice as likely to be HIV positive (OR = 1.91, 95% CI 1.36 to 2.68), six times more likely to have anonymous sex (OR = 6.18, 95% CI 3.37 to 11.32), twice as likely not to use condom (OR = 2.02, 95% CI 1.71 to 2.38), and twice as likely to use non-injecting drugs (OR = 1.65, 95% CI 1.21 to 2.37). CONCLUSIONS: MSM diagnosed with syphilis who frequent commercial sex venues are engaging in high risk behaviours for syphilis and HIV transmission and acquisition. Thus commercial sex venues are one of the focal points of syphilis and HIV transmission and acquisition.     

Predictors of syphilis seroreactivity and prevalence of HIV among street recruited injection drug users in Los Angeles County, 1994-6

OBJECTIVES: To describe HIV prevalence and the association between syphilis incidence and sexual and drug injection risk behaviours in a cohort of street recruited injecting drug users (IDUs) in Los Angeles County, between 1994 and 1996. METHODS: During the study period, 513 street recruited African-American and Latino IDUs were screened for syphilis and antibodies to HIV. Subjects were administered a risk behaviour survey at baseline and followed up at 6 month intervals for 18 months with repeated interviews and serological screening. Rate ratios were used to examine associations between syphilis incidence and demographic characteristics and risk behaviours. A proportional hazard model was used to identify predictors of syphilis incidence independent of demographic characteristics. RESULTS: 74% of the sample were male, 70% African-American, 30% Latino; and the median age was 43 years. Overall baseline serological prevalence of HIV was 2.5% and of syphilis 5.7%. None of the participants were co-infected for HIV and syphilis at baseline or at any of the 6 month follow ups. Among 390 eligible IDUs retained for analysis of incidence data, the overall syphilis incidence was 26.0 per 1000 person years. Higher syphilis incidence was found for women compared with men (RR = 2.70; 95% CI 1.60, 4.55), and for those 44 years of age or younger compared with those 45 years of age and older (RR = 2.26; 95% CI 1.25, 4.08). African-Americans were more likely to be syphilis incident cases when compared with Latinos, although the difference did not reach statistical significance (RR = 1.27; 95% CI 0.72, 2.23). In bivariate analysis, risk behaviours significantly associated with higher syphilis incidence included injection of cocaine, "speedball" and heroin, "crack" smoking, recency of first injection event, backloading of syringes, injecting with others, exchanging drugs or money for sex, multiple sex partners, and non-heterosexual sexual preference. Variables that significantly predicted syphilis infection at follow up in the multivariate analysis included multiple sex partners (RR = 7.8; 95% CI 2.4, 25.0), exchanging money for sex (RR = 3.0; 95% CI 0.9, 9.6), and recent initiation to injection drug use (RR = 4.6; 95% CI 1.1, 18.8). CONCLUSION: Syphilis transmission among IDUs in Los Angeles County remains a serious public health concern, particularly among IDUs who engage in trading of sex for money or drugs. Although low, the prevalence of HIV observed in this study constitutes a serious concern because of the potential for expanded HIV transmission in this susceptible population of IDUs with high syphilis incidence. Enhanced case finding screening efforts and prevention of transmission of sexually transmitted infections should specifically target hard to reach IDUs and their sexual partners.     

Risk factors for sexually transmitted diseases and casual sex among Chinese patients attending sexually transmitted disease clinics in Hong Kong

BACKGROUND: The risk factors for sexually transmitted diseases (STDs) and having casual sex among the Chinese people are unknown. GOAL: The goal of the study was to estimate the prevalence of STDs and to develop a profile of risk behavior among patients attending STD clinics in Hong Kong. STUDY DESIGN: In a clinic-based, cross-sectional study, 448 patients attending two government STD clinics were randomly sampled and interviewed by means of a structured questionnaire. RESULTS: The prevalence of STDs was 51% (70% of men and 35% of women). Attendees who had STDs diagnosed were more likely to be male, never married, and smokers and alcohol users (ever) and to have had casual sex or sex during travel with someone not their usual partner. Those who did not always use condoms were more likely to be male and never married. Having had casual sex was reported by 63% of the respondents. Those who reported having had casual sexual encounters were more likely to have the following characteristics: male; never married; no religious belief; ever smoker and alcohol user; current STD; had sex during travel; history of STD; inconsistent condom user; and perception of being at low risk for STD. After adjustment, only male gender was associated with casual sexual encounters. CONCLUSION: The results of this study indicated several risk factors among Chinese patients for the acquisition of STDs, for not using condoms, and for having casual sex. This information is useful in strengthening and evaluating currently available STD prevention and control strategies for the Chinese population in Hong Kong and elsewhere.     

Understanding male sexual behaviour in planning HIV prevention programmes: lessons from Laos, a low prevalence country

METHODS: Focus group discussions were conducted with a range of young men in Vientiane, Laos; interviews were conducted with male sex workers. A questionnaire survey was conducted with a purposive sample of 800 young men. RESULTS: Most young men initiate sex at an early age and have multiple sex partners. Married men are more likely to pay for sex and most sex for money is negotiated in non-brothel settings. Despite high reported condom use for last intercourse with a casual partner, decisions on condom use are subjective. Many men have extramarital sex when their partner is pregnant and post partum. 18.5% of men report having had sex with another man; most of these men also report having sex with women. Moreover, more men report having had anal sex with a woman than with a man. CONCLUSIONS: Although not a probability sample survey, this study of a broad range of young men in Vientiane reveals sexual behaviours that could lead to accelerated HIV transmission. Education should emphasise the need to use condoms in all sexual encounters outside the primary relationship. This needs special emphasis when the partner is pregnant or post partum. Advice on safe sex with other men needs to be integrated into all sexual health education for young men.     

High-risk sexual behavior in the general population. Results from a national survey, 1988-1990.

The responses of 2,896 adults who completed the General Social Survey (1988-1990), a nationally representative household probability sample of the United States adult population, were analyzed. Three outcome variables were examined: engaging in sexual intercourse with two or more partners, with five or more partners, or with a stranger in the past year. Age, marital status, gender, pattern of alcohol consumption, and race have the strongest and most consistent relationship with having multiple sexual partners or sex with a stranger. Marriage reduces the odds of having 5 or more sexual partners by a factor of 90% (odds ratio, OR, = 0.10). For each single year increase in age, the odds of having multiple partners or sex with a stranger also decrease (OR = 0.95). Alcohol consumption, on the other hand, increases the odds of sexual risk behavior by a factor of 2 to 3 in the three models. Men are more likely to have 5 or more sexual partners (OR = 7.17) and sex with a stranger (OR = 5.62) than women; and blacks are more likely to have multiple partners (OR = 2.82) than members of other racial or ethnic groups. In the United States last year, an estimated 3 to 6 million adults had sex with 5 or more partners and an estimated 5 to 8 million had sex with a stranger.     

Heterosexual transmission of HIV in China: a systematic review of behavioral studies in the past two decades

OBJECTIVE: The objective of this study was to address the role of heterosexual transmission of HIV in China. GOAL: The goal of this study was to explore the prevalence of unsafe sex and the likelihood of HIV spread heterosexually from core populations to others. STUDY: The authors conducted a review of behavioral studies. RESULTS: Drug users were more likely to be involved in higher-risk sexual behaviors than were those who abstained from using drugs. Most female drug users (52-98%) reported having engaged in commercial sex. Most female sex workers (FSWs) and individuals with sexually transmitted diseases (STDs) had concurrent sexual partners. Many continued to have unprotected sex after noticing STD symptoms in themselves or their sexual partners. From 5% to 26% of rural-to-urban migrants had multiple sexual partners and 10% of males patronized FSWs during migration. CONCLUSIONS: Factors such as high rates of FSW patronage, low rates of condom use during commercial sex, having sex with both commercial and noncommercial sexual partners, and high rates of STD infection may promote a heterosexual epidemic in China.     

HIV related behaviours and attitudes among Chinese men who have sex with men in Hong Kong: a population based study

OBJECTIVE: This study was conducted in order to determine the prevalence of men having sex with men (MSM) and their HIV related behaviours and attitudes among Chinese men in Hong Kong. METHODS: A large scale, random, population based, anonymous telephone survey of 14 963 men between the ages of 18-60 was conducted. The overall response rate was approximately 57%. RESULTS: Of the respondents, 4.6% had ever engaged in MSM activity. In the 6 months preceding the survey, 2.0% had engaged in MSM behaviours (active MSM) and 0.5% reported having engaged in anal sex MSM behaviours. Among anal sex MSM, consistent condom use was 42.9% with male non-commercial sex partners and even lower with male commercial sex partners (35.7%). Approximately 11% of anal sex MSM and 4.1% of the non-anal sex MSM had contracted an STD in the last 6 months. The prevalence of HIV testing was only 20.6% among anal sex MSM and 11.9% among non-anal sex MSM. CONCLUSIONS: Active MSM in Hong Kong are at high risk of HIV infection. The belief of low vulnerability to HIV is prevalent among active MSM in Hong Kong with only 2.0% believing that their chances of HIV infection as being "very likely."     

Gonorrhoea reinfection in heterosexual STD clinic attendees: longitudinal analysis of risks for first reinfection

OBJECTIVES: Gonorrhoea is associated with adverse reproductive health outcomes, including pelvic inflammatory disease and increased HIV transmission. Our objective was to determine the association of demographic factors, sexual risk behaviours, and drug use with incident gonorrhoea reinfection among public STD clinic clients. METHODS: A retrospective cohort study conducted from January 1994 through October 1998, of heterosexual public STD clinic attendees age >/=12 years having at least one gonorrhoea infection in Baltimore, MD. The outcome was first incident gonorrhoea reinfection over a maximum 4.8 years, compared in STD clinic clients with or without sexual risk behaviours and drug use at initial gonorrhoea infection. RESULTS: 910 reinfections occurred among 8327 individuals and 21 246 person years of observation, for an overall incidence of 4.28 reinfections per 100 person years (95% CI 4.03 to 4.53). Median time to reinfection was 1.00 year (95% CI 0.91 to 1.07 years). In multivariate Cox regression, increased reinfection risk was associated with male sex, younger age, greater number of recent sex partners, and having a sex partner who is a commercial sex worker. Injection drug use and coming to the clinic as an STD contact were protective. Among risk factors that differed significantly between men and women, injection drug use was protective of reinfection in men, and "any" condom use was a risk factor for reinfection in women CONCLUSIONS: Reinfection represents a significant proportion of STD clinic visits for gonorrhoea. Prevention counselling and routine screening for patients at high risk for reinfection should be considered to maximally reduce transmission and resource utilisation.