Screening for chronic hepatitis B and C virus infections in an urban sexually transmitted disease clinic: rationale for integrating services

BACKGROUND AND OBJECTIVES: Clients attending sexually transmitted disease (STD) clinics are at risk for multiple infections (e.g., STDs, HIV, and infectious viral hepatitis). Risk assessment and serosurveys can document the need for hepatitis screening and vaccination services. GOAL: To determine hepatitis C and B virus seroprevalence, identify predictive risk factors, and provide a rationale for integrating hepatitis services in an STD clinic. METHODS: During various periods in 1998, consecutive clients completed a self-administered risk assessment and were offered screening for markers of hepatitis B virus (HBV) and hepatitis C virus (HCV) infection (HBV core antibody and anti-HCV [enzyme-linked immunosorbent assay 3.0, confirmed by recombinant immunoblot assay 2.0]). RESULTS: Sixteen percent of 300 clients tested for an anti-HBV core were positive, with injecting-drug users (IDUs) and men who have sex with men (MSM) having higher prevalences (50% and 37%, respectively). Of 615 clients tested for anti-HCV, 21 (3.4%) were positive. Injecting-drug users (n = 34) had a 38% anti-HCV prevalence compared with 1.1% for non-IDUs. Of 66 non-IDU MSM tested, none was HCV infected. IDUs had a high prevalence of past STDs (> 50%) and unsafe sexual behavior. CONCLUSIONS: Injecting drug users and MSM are at high risk for STDs, HIV, and hepatitis infections and could benefit from a "one-stop" STD clinic that included hepatitis prevention services.     

Prevalence of and risk factors for hepatitis C virus infection among STD clinic clientele in Miami,Florida

Objectives: Hepatitis C virus (HCV) is the most common chronic blood borne viral infection in the United States. We assessed the HCV prevalence, risk factors, and sensitivity of the Centers for Disease Control and Prevention's (CDC) routine screening criteria among clients of a large urban sexually transmitted disease (STD) clinic.

Methods: Participants were recruited from a public STD clinic in Miami, Florida, and were interviewed regarding known and potential risk factors. The survey assessed CDC screening criteria, as well as other risk factors (for example, intranasal drug use, history of incarceration, exchanging sex for money, number of lifetime sex partners, and history of an STD). Testing was done by enzyme immunoassay (EIA) and confirmed by recombinant immunoblot assay (RIBA).

Results: The prevalence of anti-HCV positivity was 4.7%. Four variables were significantly associated with being anti-HCV positive, independent of confounding factors. These included injection drug use (odds ratio (OR) = 31.6; 95% confidence intervals (CI) 11.0 to 90.5); history of incarceration (OR = 3.0; 95% CI 1.1 to 8.1); sexual contact with an HCV positive person (OR 12.7; 95% CI 2.5 to 64.7); and older age (OR 1.4; 95% CI 1.2, 1.6). The sensitivity of CDC's routine screening criteria was 69% and specificity was 91%.

Conclusions: The prevalence of anti-HCV in this clinic was similar to that determined in studies of comparable populations. Having sexual contact with an HCV positive person and history of incarceration were independently associated with being anti-HCV positive. CDC's screening criteria identified approximately two thirds of the anti-HCV positive participants.

     

HIV infection and high risk behavior among patients attending an STD referral clinic in Prague, Czech Republic

OBJECTIVE: This survey was conducted to determine the prevalence of HIV infection and associated risk behaviour in a high risk population of clients attending an STD clinic in Prague, Czech Republic. METHODS: Between September 1994 and January 1995, clients entering the Apolinar STD clinic in Prague, Czech Republic, were enrolled in a blinded, unlinked HIV antibody seroprevalence study. Non-identifying demographic characteristics, STD diagnoses, HIV risk exposures, and voluntary HIV testing experience were extracted from medical charts. RESULTS: Of 1394 patients for whom serum was available for testing, one was positive for HIV (HIV prevalence 0.07%, 95% confidence interval (CI) 0.01, 0.41%). This person was one of 28 men having sex with men (MSWM) (HIV prevalence among MSWM 3.6%, 95% CI 0.6, 17.7%). Among the 775 male clients, 75.5% had heterosexual unprotected sex, 11.1% had sex with high risk partners or prostitutes, 3.6% were MSWM, 1.0% were injecting drug users (IDUs), 0.7% were both MSWM and IDUs, and 6.8% and 1.8% had other or no recognized risk for HIV/STDs, respectively. Among the 619 female clients, 74.5% had heterosexual unprotected sex, 11.6% were prostitutes, 7.8% had sex with high risk partners, 1.1% were IDUs, and 3.9% and 2.3% had other or no recognised risk, respectively. The 304 adolescent patients (age 11-19 years) differed significantly (p < 0.05) in risk behaviour and STD diagnoses from the 1090 patients who were 20 years and older. Adolescents were significantly more likely to be female (58.6% v 40.5%, OR = 2.1), IDUs (3.6% v 0.4%, OR = 10.2), prostitutes (8.9% v 4.7%, OR = 2.0), and have sex partners with STDs (7.6% v 4.4%, OR = 1.8). The adolescent patients were also significantly more likely to be diagnosed with gonorrhoea (21.1% v 12.3%, OR = 1.9) and non-gonococcal urethritis (27.6% v 17.2%, OR = 1.8), and significantly less likely to have been tested previously for HIV (19.1% v 31.9%, OR = 0.5). CONCLUSIONS: HIV infection is currently uncommon in this population. However, the high rates of unprotected sex, prostitution, injecting drug use, and STDs, especially among adolescents, provide the basis for an epidemic in this population. Aggressive prevention education should be started before adolescence.


     

Sexually transmitted disease clinic clients at risk for subsequent gonorrhea and chlamydia infections: possible 'core' transmitters

BACKGROUND: From an sexually transmitted disease (STD) intervention perspective, developing a practical way to identify persons in core transmitter groups has been difficult. However, persons who have repeated STD infections may be in such groups. GOAL: To evaluate a self-administered risk assessment approach that would identify STD clinic clients who were at an increased risk of being involved in gonorrhea (GC) or chlamydia (CT) transmission in the subsequent year. STUDY DESIGN: Prospective cohort of consecutive STD clinic clients with a 1-year follow-up period. RESULTS: During a 6-month period in 1995, 2576 STD clinic clients in San Diego completed a risk assessment. Of those clients, 204 (7.9%) had a subsequent STD and 79 (3.1%) had a subsequent GC or CT infection during the 1-year follow-up period. The strongest predictor of a subsequent GC/CT was having a recent history or current clinic visit diagnosis of GC or CT (6.1% subsequent GC/CT rate). The more past episodes of GC or CT, the higher the subsequent GC/CT rate. Unsafe sexual behavior had little effect on further increasing subsequent GC/CT risk. CONCLUSION: STD clinic clients with a recent history of GC or CT and a high risk of subsequent GC/CT may be core transmitters who could likely benefit from risk reduction, periodic screening for GC/CT, symptom recognition counseling, and preventive treatment-the essential elements of STD-prevention case management.     

Screening for Chlamydia trachomatis in an anonymous and confidential HIV counseling and testing site: feasibility and prevalence rates

BACKGROUND: Chlamydia trachomatis is the most common bacterial sexually transmitted disease (STD) in the United States. The development of nucleic acid amplification tests for C trachomatis in urine specimens allows for screening outside traditional clinic settings. Persons visiting an HIV counseling and testing site may be at increased risk for STDs, including C trachomatis. GOAL: To measure the acceptance of C trachomatis urine screening and the prevalence of C trachomatis infection among clients at an HIV counseling and testing site. STUDY DESIGN: Site HIV counselors offered urine C trachomatis screening to clients, administered a questionnaire, and collected urine samples. RESULTS: Of 808 counseling and testing site clients approached for C trachomatis screening, 572 (71%) accepted. The most common reasons for declining screening were absence of symptoms (33%) and recent STD testing (32%). Men were more likely to accept urine screening than women (risk ratio, 1.31; 95% CI, 1.06-1.62), as were clients who practiced oral sex, had a history of STD, or who had never been screened for STD. Of 560 urine specimens processed, only 8 (1.43%; 95% CI, 0.66-2.91%) were infected with C trachomatis. CONCLUSIONS: Sites offering HIV testing and counseling are a feasible alternative to clinical settings for C trachomatis screening. Prevalence may be too low for screening to be cost effective unless higher-risk subpopulations can be identified.     

HIV prevalence and risk behaviour among prostitutes and clients in Amsterdam: migrants at increased risk for HIV infection.

OBJECTIVES--To study groups of prostitutes and clients of prostitutes in order (i) to determine HIV prevalence and sexual risk behaviour, (ii) to determine differences between samples recruited within and outside a clinic for sexually transmitted diseases (STD) and (iii) to determine correlates of inconsistent condom use (ICU) among both groups. DESIGN--Participants were interviewed and anonymously tested for HIV-antibody; approximately half were recruited at a clinic for sexually transmitted diseases (STD) and half at prostitute working places. SETTING--An STD clinic and prostitute working places in Amsterdam in 1991. SUBJECTS--201 female prostitutes without a history of injecting drugs and 213 male clients of female prostitutes. MAIN OUTCOME MEASURES--antibodies to HIV, consistency of condom use in commercial vaginal contacts in the preceding 6 months. RESULTS--HIV prevalence was low: three prostitutes (1.5%; 95% CI 0.5-4.6%) and one client (0.5%; 95% CI 0.1-3.3%) were infected. All three HIV positive prostitutes originated from AIDS-endemic countries, came to the Netherlands only recently and were recruited outside the STD clinic. Large differences between subgroups resulted from the two recruitment methods: while clients of prostitutes with relatively high risk behaviour were strongly represented among the STD clinic sample, high risk prostitutes were underrepresented in this sample. Consistent condom use (with 100% of contacts) was reported by 66% of prostitutes and 56% of clients of prostitutes. Inconsistent condom use was found to be high among prostitutes who had migrated from Latin America and among migrant clients of prostitutes. CONCLUSIONS--When monitoring HIV infection one must take into account imported cases. HIV prevention efforts should be particularly focused at prostitutes from Latin America and at clients of prostitutes who migrated to the Netherlands.     

Development and evaluation of screening strategies for Chlamydia trachomatis infections in an STD clinic.

OBJECTIVES--To identify predictors for Chlamydia trachomatis infection among visitors of an STD clinic in Amsterdam in 1986-1988. To design predictor-based screening programmes for C trachomatis. To evaluate the chosen screening strategy in 1993. METHODS--In 1986-1988, 947 heterosexual men and 648 women participated in the study. A medical history was recorded, a physical examination took place and samples were taken for laboratory diagnostics. Information for 1993 was available from routine databases. RESULTS--C trachomatis infections in heterosexual men in 1986-1988 (prevalence 15.8%) were independently associated with: age under 26 years, being an STD contact, coitarche below 13, last sexual contact with a non-prostitute, (muco)-purulent urethral discharge and ten or more leukocytes per microscopic field of urethral smear or urine. For women (prevalence 21.5%) independent predictors were age under 26, no history of STD, being an STD contact, cervical friability, (muco)purulent cervical discharge, presence of clue cells and ten or more leukocytes per field of urethral smear. Screening men with one anamnestic predictor for C trachomatis and ten or more leukocytes in smear or urine (59% of men) would detect 93% of the cases in 1986-1988. For females only universal screening proved to be suitable. After the introduction of a screening strategy in 1989 (universal for women, indicated by urethritis for men), a strong decline was found in the C trachomatis prevalence for all subgroups in 1993, excluding prostitute's clients and Turkish men. CONCLUSIONS--In 1993 the overall C trachomatis prevalence had declined among the attendants of the STD clinic. It seems likely that this fall was caused both by the screening programme and the reduction of risk behaviour.     

High prevalence of genital Chlamydia trachomatis infection in women presenting in different clinical settings in Jamaica: implications for control strategies

OBJECTIVE: To determine the prevalence of genital Chlamydia trachomatis infection and risk factors in women attending family planning, gynaecology, and sexually transmitted disease (STD) clinics in Jamaica. METHODS: Endocervical specimens from 645 women including 238 family planning, 170 gynaecology, and 237 STD clinic attendees were examined for C trachomatis using a direct fluorescence assay (DFA) and culture. Investigations were carried out for the presence of other STD pathogens and demographic, behavioural, historical, and clinical data recorded for each participant. RESULTS: The prevalence of C trachomatis infection was 35%, 47%, and 55% in family planning, gynaecology, and STD clinic clients, respectively. The performance of the DFA was comparable to that of culture in screening for C trachomatis. Logistic regression analysis revealed that the independent risk factors for C trachomatis infection were non-barrier contraceptive methods in family planning clients (OR = 2.1; 95% confidence interval (CI) = 1.2-3.9; p = 0.0110), cervical ectopy in gynaecology clients (OR = 3.9; 95% CI = 1.4-10.6; p = 0.0076) and concomitant Trichomonas vaginalis infection in STD clients (OR = 3.5; 95% CI = 1.8-6.8; p = 0.003). Age, number of sex partners, and reason for visit were not identified as risk factors for C trachomatis infection. CONCLUSIONS: Consistently high prevalence of C trachomatis infection occurs in Jamaican women. Universal screening or presumptive treatment should be evaluated as prevention and control measures for C trachomatis infection in this population where all women appear to be at risk.     

Syphilis serologic prevalence monitoring among STD clinic clients: correlation with reported syphilis incidence, San Diego, CA, 1985-2004

OBJECTIVE: To describe the serologic test for syphilis (STS) prevalence among STD clinic clients, determine the correlation between STS prevalence trends and reported community-diagnosed primary and secondary (P&S) case incidence, and evaluate the usefulness of STS prevalence monitoring as a component of syphilis surveillance. STUDY: During the period 1985-2004, 21,4336 STS were done among STD clinic clients and a variety of STS prevalence measures were evaluated. RESULTS: From 1985-1991, 10.2% of STS were positive, which declined to 5.6% during 1992-2004. Overall, STS positivity (>or=1:8) and male positivity (>or=1:8) trends were correlated with reported community-diagnosed P&S case incidence and case incidence in men (r = 0.58 and r = 0.81, respectively). Male STS positivity (>or=1:8) began increasing in 2001, 1 year before the increase in syphilis incidence in men, which began in the latter half of 2002 and occurred mostly among men who have sex with men. CONCLUSION: In a syphilis outbreak in men who have sex with men, STS prevalence (>or=1:8) among male STD clinic clients was a useful measure of syphilis case incidence trends and may provide an early warning for a subsequent increase in community-diagnosed case incidence.     

Hepatitis B virus infection risk factors and immunity among sexually transmitted disease clinic clients

BACKGROUND AND OBJECTIVES: Hepatitis B virus (HBV) infection is a sexually transmitted infection that can be prevented with hepatitis B vaccination. GOAL: The goal was to determine prevalence and risk factors for HBV infection and immunity among sexually transmitted disease (STD) clinic clients. STUDY DESIGN: In this cross-sectional study, consenting adult STD clinic clients were interviewed regarding HBV risk factors and vaccination history, and blood was drawn for HBV serologic testing. RESULTS: Of the 682 participants, 154 (22.6%) had antibody to hepatitis B core antigen, indicating previous infection, and 64 (9.4%) had only antibody to hepatitis B surface antigen, indicating immunity as a result of hepatitis B vaccination. Only 130 (19.1%) of all participants reported receiving at least one dose of hepatitis B vaccine. CONCLUSION: The majority of clients were susceptible to HBV, were at high risk for HBV infection, and would benefit from hepatitis B vaccination.     

Sexually transmitted disease testing protocols, sexually transmitted disease testing, and discussion of sexual behaviors in HIV clinics in Los Angeles County

OBJECTIVE/GOAL: The objective of this study was to evaluate the use of written protocols for sexually transmitted disease (STD) screening, the frequency and types of STD tests performed, and the occurrence and frequency of obtaining sexual risk assessments among HIV clinics. STUDY: A survey was administered to 36 medical directors, clinic directors, and HIV providers representing 48 HIV healthcare clinics in Los Angeles. RESULTS: The use of a written or electronic protocol for STD testing was reported by 50% of clinics. Clinics with written or electronic STD protocols were significantly more likely to report questioning patients at each visit regarding their sexual practices (prevalence ratio, 2.2; 95% confidence interval, 1.4-3.4). Clinics with written or electronic protocols were not more likely to report more frequent STD testing. CONCLUSIONS: Written or electronic protocols for STD testing may promote sexual risk assessment questioning among HIV healthcare providers and may help to ensure STD testing per Centers for Disease Control and Prevention/IDSA guidelines for HIV-positive persons at sexual risk.     

Urine screening for gonococcal and chlamydial infections at community-based organizations in a high-morbidity area

BACKGROUND: Increasing availability of urine testing for Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT) offers expanded opportunities to collaborate with community-based organizations (CBOs) to screen high-risk populations for sexually transmitted diseases (STDs). GOAL: To determine the prevalence and correlates of genital tract gonococcal and chlamydial infection among CBO clients, and to assess the feasibility of implementing widespread community-based STD screening programs. DESIGN: Free, voluntary, confidential first-catch urine screening was conducted at 20 CBOs serving disadvantaged populations in St. Louis, MO. Brief demographic, behavioral, and sexual contact data were obtained from all participants. Urine samples were tested by ligase chain reaction (LCR). Persons testing positive were promptly notified and directed to seek treatment. RESULTS: A GC and/or CT infection was identified in 24 of 277 persons (8.7%) screened; 2 persons were infected with GC only, 17 with CT only, and 5 with GC and CT. Treatment was documented for 22 persons (91.7%) testing positive. The highest rates of infection were found at shelters (12.3%) and residence facilities (11.1%). Costs of screening were $38 per sample collected and $453 per case identified. CONCLUSION: Community-based urine testing successfully identified GC and CT infections, and was well accepted by community members and CBOs. Community-based screening can significantly impact STD epidemiology by facilitating early detection, treatment, and interruption of transmission.     

Signs and symptoms of urethritis and cervicitis among women with or without Mycoplasma genitalium or Chlamydia trachomatis infection

OBJECTIVES: To study the prevalence, symptoms, and signs of Mycoplasma genitalium and Chlamydia trachomatis infections in women attending a Swedish STD clinic, accessible for both sexes, and in a group of young women called in the cervical cancer screening programme. METHODS: A cross sectional study among female STD clinic attendees in Orebro and a study among women called for Papanicolaou smear screening. Attendees were examined for urethritis and cervicitis. First void urine and endocervical samples were tested for M genitalium and C trachomatis. RESULTS: The prevalence of C trachomatis and M genitalium in the STD clinic population was 10% (45/465) and 6% (26/461), respectively. Dual infection was diagnosed in four women. In the cancer screening group of women the corresponding prevalence was 2% (1/59) and 0%, respectively. Among the STD clinic attendees there were no significant differences in symptoms (32% v 23%, RR 1.4, 95% CI 0.6 to 3.4) or signs (71% v 50%, RR 1.4, 95% CI 0.9 to 2.3) between C trachomatis and M genitalium infections. Microscopic signs of cervicitis were significantly more common among M genitalium and C trachomatis infected women than in the cancer screening group of women. 56% (15/27) of male partners of M genitalium infected women were infected with M genitalium compared to 59% of male partners of C trachomatis infected women who were infected with C trachomatis (p = 0.80). CONCLUSIONS: M genitalium is a common infection associated with cervicitis and with a high prevalence of infected sexual partners supporting its role as a cause of sexually transmitted infection.     

Hepatitis B vaccination of men who have sex with men attending an urban STD clinic: impact of an ongoing vaccination program, 1998-2003

OBJECTIVE: To evaluate the impact of an ongoing hepatitis B vaccination service offered in an urban sexually transmitted disease (STD) clinic. STUDY DESIGN: During the period 1998-2003, hepatitis B vaccine acceptance, series completion, and vaccine coverage rates were evaluated among men who have sex with men (MSM) and other clients attending the main STD clinic in San Diego County, California. RESULTS: Among 21,631 STD clinic attendees, 81% were eligible to start and 69% accepted hepatitis B vaccination. Among a cohort of MSM starting vaccination in 1998, 76% and 55% received 2 doses and 3 doses, respectively, after 1 year follow-up and coverage then increased 1-2 percentage points annually to a final 2-dose and 3-dose coverage of 80% and 62%, respectively. Vaccine coverage (>=1 prior vaccine dose) among STD clinic attendees in 2003 was 45% compared to only 11% in 1998, the first year of the program. CONCLUSIONS: Hepatitis B vaccination can be integrated into STD clinic services with reasonable levels of vaccine acceptance and series completion. The increase in vaccination coverage over time indicates that a sustained hepatitis B immunization program can achieve acceptable vaccine coverage in high-risk populations.     

Prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae among at-risk women, young sex workers, and street youth attending community organizations in Quebec City, Canada

BACKGROUND: Despite a relatively recent decline in the global incidence of Chlamydia trachomatis and Neisseria gonorrhoeae it seems that some segments of the population such as street youth, sex workers, and individuals with social problems or delinquent behavior could be part of a core group for STDs. These persons may be reluctant to undergo STD diagnosis in traditional medical settings. GOALS: To determine the prevalence of C trachomatis and N gonorrhoeae infection using polymerase chain reaction on urine samples among subjects attending an anonymous HIV testing clinic and four community organizations in Quebec City, and to identify associated risk factors. STUDY DESIGN: A cross-sectional study of 626 street youth, sex workers, and women with social problems or delinquent behavior was conducted. RESULTS: The prevalences of N gonorrhoeae and C trachomatis were, respectively, 1.1% (95% CI, 0.5%--2.3%) and 5.8% (95% CI, 4.1%--7.9%). No significant difference was found between men and women, but the sexually transmitted disease (STD) prevalence was much higher in subjects younger than 20 years: 11.4% versus 3.6% (P < 0.01). In a logistic regression model, factors independently associated with STD infection were age younger than 20 years (OR, 2.6; P = 0.007), occasional sex partners (OR, 2.9; P = 0.007), and injection of drugs (OR, 2.8; P = 0.002) in the preceding 6 months. CONCLUSIONS: A moderate STD prevalence was found in the study population. The prevalence, however, can be considered high (>10%) among street youth and young sex workers. Providing community-based STD screening and treatment services appear to be an efficient method for reaching these high-risk groups.     

Hepatitis B vaccination in sexually transmitted disease (STD) clinics: a survey of STD programs

BACKGROUND: Hepatitis B virus infection causes substantial morbidity and mortality in the United States. Sexual activity is the most commonly reported risk factor among persons with acute hepatitis B, yet hepatitis B vaccine coverage among adolescents and adults with high-risk sexual practices is low. Sexually transmitted disease (STD) clinics are potentially efficient settings for vaccine administration to persons with high-risk sexual practices; however, little is known about hepatitis B vaccination activities in these settings. GOAL: To gain information about policies and activities for vaccinating against hepatitis B in STD clinic settings. STUDY DESIGN: In April 1997, a questionnaire was sent to managers of 65 federally funded STD programs in state and local health departments. A similar survey was sent to 89 STD clinic managers in November 1997. RESULTS: The response rate among program managers was 97% (63/65). Forty-eight percent considered hepatitis B prevention a program responsibility; 21% had developed and distributed written policies to prevent hepatitis B through vaccination; and 27% had developed policies to encourage hepatitis B education activities. The response rate among clinic managers was 82% (73/89). Forty-five percent reported that their STD clinics had implemented policies recommending hepatitis B vaccination and health education activities. Program managers and clinic managers reported that lack of funding to cover the cost of the vaccine, and lack of resources to provide prevaccination counseling, administer vaccine, and track clients for vaccine series completion were the primary barriers to the implementation of hepatitis B vaccination programs. CONCLUSIONS: To enhance hepatitis B vaccination in STD clinics, existing funding sources must be accessed more effectively. Supplemental funding mechanisms for the cost of vaccine and resources for implementing vaccination programs also need to be identified. Additionally, STD clinics and programs should continue to propose and implement hepatitis B vaccination policies.     

Sexually transmitted disease prevalence and characteristics of market vendors in eastern China

BACKGROUND AND OBJECTIVES: Sexually transmitted diseases (STDs) have soared in China. To address the impact, we studied market stall vendors in eastern China. GOAL: The goal was to determine STD prevalence and predictors. STUDY DESIGN: A total of 1536 randomly selected market stall vendors were interviewed and tested for STDs. RESULTS: The prevalence of any STD was 20.1% among those reporting sexual intercourse and 5.5% among those reporting never having sexual intercourse. Among those reporting sexual intercourse, chlamydia was most common (9.4%), followed by herpes (9.3%). A total of 4.5% of those reporting never having sexual intercourse had herpes infection, but none had chlamydia. Prevalence of all STDs was higher among females, and those with low education and multiple partners. The pharmacy was the major source of health care (48.8%). CONCLUSION: Generalizing from the results, targeting only STD clinic patients and persons reporting multiple partners for intervention will exclude a high proportion of those with STDs. More effective, less stigmatized sources of STD treatment should be developed.     

Chlamydia, gonorrhea, and HIV-1 prevalence among five populations of women in the Czech and Slovak Republics

BACKGROUND: Five populations at risk for sexually transmitted diseases (STDs) in the Czech and Slovak Republics were sampled. GOAL: To estimate prevalence of Chlamydia trachomatis, Neisseria gonorrhoeae, and HIV-1 infections. STUDY DESIGN: Urine specimens were collected serially from women at a Prague prenatal clinic (n = 134), a Prague dermatovenerealogy clinic (n = 91), sex workers from northern and central Bohemia (n = 35), students from a northern Bohemian school (n = 217), and Gypsies from Jarovnice, Slovakia (n = 128). These specimens were tested for chlamydia and gonorrhea using a ligase chain reaction pooling algorithm, and for HIV using an enzyme immunoassay confirmed by Western blot. RESULTS: The prevalence of chlamydia was 2.2% (95% CI, 0.4-6.4) in the prenatal clinic, 5.5% (95% CI, 1.8-12.4) in the STD clinic, 22.9% (95% CI, 10.4-40.1) among street sex workers, 8.2% (95% CI, 3.6-15.6) among sexually active female high school students, and 3.9% (95% CI, 1.3-8.9) among Gypsy women. Gonorrhea was found in only two populations: 2.2% (95% CI, 0.3-7.7) in the STD clinic, and 2.9% (95% CI, 0.1-14.9) among sex workers. No HIV-1 infection was detected. CONCLUSIONS: Urine screening was an efficient and accurate method for identifying groups at risk for STDs in the Czech Republic and Slovakia because sample collection was fast and noninvasive, and potential participation bias was reduced by high acceptability.     

Screening for sexually transmitted diseases in an HIV testing clinic; uptake and prevalence.

OBJECTIVE: To estimate the prevalence of sexually transmitted diseases (STDs) and the acceptability of STD screening among people seeking an HIV antibody test in an established free standing HIV testing clinic. DESIGN: A 9 month period prevalence study conducted between August 1993 and April 1994. SETTING: The Same Day Testing Clinic (SDTC) for HIV antibodies at the Royal Free Hampstead NHS Trust Hospital, London. SUBJECTS: 242 males and 160 females attending the Same Day Testing Clinic. OUTCOME MEASURES: The prevalence of STDs including gonorrhoea, chlamydia, syphilis and hepatitis B and the percentage of clinic attenders accepting an STD screen. RESULTS: Of those invited to take part in the study 69% of the males (242/350) and 59% (160/269) of the females agreed to be screened although for a variety of reasons not everyone agreed to a full screen. Two cases of untreated syphilis, no cases of gonorrhoea and six cases of chlamydia were detected. Four people had active, previously undiagnosed herpes while three had genital warts. Evidence of previously unknown hepatitis B infection was found in 26 people. Despite a high level of previous contact with genitourinary medicine services, uptake of hepatitis B vaccination among those homosexual men eligible for immunisation was low (28%; 23/83). Nine (4%) of the males, but none of the females screened for STD were found to be HIV antibody positive. CONCLUSION: Among people seeking an HIV antibody test in an established free standing HIV testing clinic, the prevalence of acute STDs was low. However, evidence of previously undiagnosed hepatitis B infection was found in a number of subjects and uptake of vaccination among those most at risk had been low. While opportunistic screening for STD was acceptable to almost two thirds of HIV testing clinic attenders, a substantial minority nonetheless declined this offer. Selective STD screening could be offered to those people seeking an HIV test who report never having been screened before, as both cases of positive syphilis serology and all those of chlamydia were in people who had not previously been screened. All those at risk for hepatitis B infection should be encouraged to establish their infection status and be immunised where appropriate.     

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.