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Treatment of Cases of Neisseria gonorrhoeae and Chlamydia trachomatis in Emergency Department Patients

imageBackground: The aim of this study was to determine the proportion of patients treated appropriately, both presumptively in the emergency department (ED), and at follow-up, among those patients who ultimately tested positive for either Neisseria gonorrhoeae (NG) or Chlamydia trachomatis (CT). Secondary aims were to characterize patients who received appropriate presumptive antibiotic treatment of both NG and CT at the time of ED visit and to compare them to patients who did not receive appropriate presumptive therapy. Methods: A retrospective chart review was performed on 500 patients randomly chosen from those that had positive NG or CT test results performed in the ED between January 10 and June 11. The Center for Disease Control and Prevention 2010 STD Treatment Guidelines were used to determine appropriate antibiotics. Results: We found 54% (95% confidence interval [CI], 49%–58%) of patients received appropriate antibiotics at ED visit and an additional 31% (95% CI, 27%–35%) were treated at our medical center on follow-up. Fifteen percent did not have documented treatment. Providers presumptively treated 46% (95% CI, 42%–50%) of patients studied with antibiotics appropriate for both NG and CT. The presence of behavioral risk factors and, for males, the presence of genital symptoms were the only factors independently associated with presumptive ED treatment. Conclusions: Among patients diagnosed as having NG or CT in this ED, a portion were not documented to ever receive appropriate antibiotics, although a call-back system is in place. Presumptive treatment was not commonly used in this ED but may be necessary given the high number of patients who never got treated. 07/01/2015 01:00 AM

Hydrogen Peroxide–Producing Lactobacilli Are Associated With Lower Levels of Vaginal Interleukin-1β, Independent of Bacterial Vaginosis

imageBackground: The presence of hydrogen peroxide (H2O2)–producing lactobacilli in the vagina is associated with decreased rates of preterm birth and HIV acquisition. We hypothesize that this is due to immunomodulatory effects of these species. Methods: Concentrations of interleukin (IL)-1β, IL-6, IL-8, secretory leukocyte protease inhibitor, and human β-defensin 2 were quantified from vaginal swabs from 4 groups of women: women with and without bacterial vaginosis (BV) by Nugent score, further stratified by detection of H2O2-producing lactobacilli by semiquantitative culture. Ten quantitative polymerase chain reaction assays characterized the presence and quantity of select Lactobacillus and BV-associated species in each group. Levels of immune markers and bacteria were compared between the 4 groups using analysis of variance, Kruskal-Wallis, Mann-Whitney U, or χ2 tests. Results: Swabs from 110 women from 4 groups were included: 26 had a normal Nugent score (BV−), and no H2O2-producing lactobacilli detected (H2O2−); 47 were BV−, H2O2+; 27 BV+, H2O2−; and 10 BV+, H2O2+. The groups were similar in age, marital status, and reproductive history, but not ethnicity: the BV−, H2O2− group had more white participants (P = 0.02). In women with and without BV, IL-1β was lower in the H2O2+ groups. Human β-defensin 2 was lowest in BV+ H2O2− women and highest in BV−, H2O2−. Secretory leukocyte protease inhibitor was lower in women with BV and did not differ by the presence of H2O2-producing lactobacilli. In regression analysis, higher quantities of Lactobacillus crispatus were associated with lower quantities of IL-1β. Detection and quantity of BV-associated species by quantitative polymerase chain reaction was significantly different between women with and without BV, but not between women with and without H2O2-producing lactobacilli within those groups. Conclusions: The presence of H2O2-producing lactobacilli is associated with lower levels of some vaginal proinflammatory cytokines, even in women with BV. 07/01/2015 01:00 AM

Contextual Factors Surrounding Anal Intercourse in Women: Implications for Sexually Transmitted Infection/HIV Prevention

imageBackground: Our objectives were to describe women's reasons for engaging in anal intercourse (AI), contextual factors surrounding AI, and how these vary by current rectal sexually transmitted infection (STI) status, and to assess women's knowledge and concerns about rectal infections. Methods: Between January 2011 and June 2013, we conducted semistructured, qualitative interviews among 40 women attending public sexually transmitted disease clinics in Los Angeles County, California. Women were eligible if they were at least 18 years of age, reported AI in the past 90 days, and were tested for rectal Chlamydia trachomatis and Neisseria gonorrhoeae. Interviews, which were guided by the theory of gender and power, were transcribed and coded to explore contextual factors surrounding AI. Results: On average, participants reported having 3 AI partners in their lifetime and most (n = 30) reported being in a serious relationship with a main/regular sex partner at the time of the interview. Motivations for engaging in AI and feelings about AI varied by rectal STI status. Women with a rectal STI more prominently conveyed the idea that AI was intended to please their sexual partner, whereas those who did not have a rectal STI reported AI more as a way to increase intimacy and personal sexual gratification. Almost all women (regardless of rectal STI status) reported limited to no knowledge about the risk of rectal STIs. Conclusions: Among women, risk of acquiring rectal STIs may vary by reason for engaging in unprotected AI as well as other contextual factors. Providers should consider addressing these contextual factors to reduce risk. 07/01/2015 01:00 AM

Estimating the Public Health Burden Associated With Adverse Pregnancy Outcomes Resulting From Syphilis Infection Across 43 Countries in Sub-Saharan Africa

imageBackground: Untreated syphilis in pregnancy is associated with adverse clinical outcomes to the infant. The study aimed to estimate the public health burden resulting from adverse pregnancy outcomes due to syphilis infection among pregnant women not screened for syphilis in 43 countries in sub-Saharan Africa. Methods: Estimated country-specific incidence of syphilis was generated from annual number of live births, the proportion of women with at least 1 antenatal care (ANC) visit, the syphilis prevalence rate, and the proportion of women screened for syphilis during ANC. Adverse pregnancy outcome data (stillbirth, neonatal death, low birth weight, and congenital syphilis) were obtained from published sources. Disability-adjusted life-year (DALY) estimates were calculated using undiscounted local life expectancy, the neonatal standard loss function, and relevant disability weights. The model assessed the potential impact of raising ANC coverage to at least 95% and syphilis screening to at least 95% (World Health Organization targets). Results: For all 43 sub-Saharan Africa countries, the estimated incidence of adverse pregnancy outcomes was 205,901 (95% confidence interval [CI], 113,256–383,051) per year, including stillbirth (88,376 [95% CI, 60,854–121,713]), neonatal death (34,959 [95% CI, 23,330–50,076]), low birth weight (22,483 [95% CI, 0–98,847]), and congenital syphilis (60,084 [95% CI, 29,073–112,414]), resulting in approximately 12.5 million DALYs. Countries with the greatest burden are (in DALYs, millions) Democratic Republic of the Congo (1.809), Nigeria (1.598), Ethiopia (1.466), and Tanzania (0.961). Attaining World Health Organization targets could reduce the burden by 8.5 million DALYs. Conclusions: Substantial infant mortality and morbidity results from maternal syphilis infection concentrated in countries with low access to ANC or low rates of syphilis screening. 07/01/2015 01:00 AM

A Phase 3, Multicenter, Randomized, Double-Blind, Vehicle-Controlled Study Evaluating the Safety and Efficacy of Metronidazole Vaginal Gel 1.3% in the Treatment of Bacterial Vaginosis

imageBackground: Bacterial vaginosis (BV), a prevalent infection in women of reproductive age, is associated with increased risk of upper genital tract and sexually transmitted infections, and complications in pregnancy. Currently approved treatments include metronidazole, which requires once or twice daily intravaginal administration for 5 days or twice daily oral administration for 7 days. This phase 3 study determined the safety and efficacy of single-dose metronidazole vaginal gel (MVG) 1.3%. Methods: In this double-blind, vehicle-controlled study, 651 women with clinical diagnosis of BV were randomized 1:1 to receive MVG 1.3% or vehicle vaginal gel. Primary efficacy measure was clinical cure (normal discharge, negative “whiff test,” and <20% clue cells) at day 21. Secondary measures included therapeutic cure (both clinical and bacteriological; day 21) and bacteriologic cure (Nugent score <4), clinical cure, and time to resolution of symptoms (day 7). Results: A total of 487 participants were included in the primary analysis. Clinical and therapeutic cure rates (day 21) were higher in participants treated with MVG 1.3% compared with vehicle gel (37.2% vs. 26.6% [P = 0.010] and 16.8% vs. 7.2% [P = 0.001], respectively). Clinical and bacteriologic cure rates (day 7) were also higher in the MVG 1.3% group (46.0% vs. 20.0% [P < 0.001] and 32.7% vs. 6.3% [P < 0.001], respectively). The median time to resolution of symptoms was shorter in the MVG 1.3% (day 6) than vehicle group (not reached). No serious adverse events were reported, and incidence was similar across treatment groups. Conclusions: Single-dose MVG 1.3% was safe and superior to vehicle gel in producing cure among women with BV. 07/01/2015 01:00 AM

Factors Associated With Hepatitis C Infection Among HIV-Infected Men Who Have Sex With Men With No Reported Injection Drug Use in New York City, 2000–2010

imageBackground: Hepatitis C (HCV) infection is a major source of morbidity and mortality among HIV-infected patients. Despite decreasing HCV incidence in the United States, the proportion of cases among men who have sex with men (MSM) without history of injection drug use (IDU) in New York City has more than tripled between 2000 and 2010. Methods: Using matched surveillance data, we identified non-IDU HIV-infected MSM with and without diagnosed HCV. Differences in continuous variables were assessed with Mann-Whitney U tests, and Pearson χ2 tests were used for categorical variables. Poisson regression was used to compare HCV diagnosis rates by race/ethnicity and sexual transmitted disease history. Results: There were 41,303 non-IDU MSM diagnosed as having HIV before 2010 alive as of 2000, of whom 2016 (4.9%) were diagnosed as having HCV after HIV diagnosis. The HCV diagnosis rate was 605/100,000 person-years. Adjusting for birth year and age at HIV diagnosis, Hispanics (rate ratio [RR], 1.4; 95% confidence interval [CI], 1.2–1.5) and non-Hispanic blacks (RR, 1.6; 95% CI, 1.4–1.8) had higher HCV diagnosis rates than did non-Hispanic whites. Adjusting for race/ethnicity, birth year, and age at HIV diagnosis, MSM diagnosed as having syphilis (RR, 2.5; 95% CI, 2.3–2.8) had higher HCV diagnosis rates than did those without syphilis. Conclusions: We found a racial/ethnic disparity in HCV diagnosis rates and an association between HCV and syphilis, which is consistent with sexual transmission of HCV. With curative HCV treatment available, emphasis should be placed on adherence to guidelines recommending annual HCV screening for HIV-infected MSM, and education and outreach to MSM to prevent sexually transmitted HCV infections. 07/01/2015 01:00 AM

Intimate Partner Violence and Correlates With Risk Behaviors and HIV/STI Diagnoses Among Men Who Have Sex With Men and Men Who Have Sex With Men and Women in China: A Hidden Epidemic

imageBackground: Intimate partner violence (IPV) research has primarily focused on heterosexual couples but has largely ignored IPV among men who have sex with men (MSM). We examined IPV prevalence among MSM and men who have sex with men and women (MSMW) in China. Methods: Men who have sex with men older than 16 years were recruited through 3 MSM-focused Web sites in China. An online survey containing items on sociodemographics, risk behaviors, IPV, and self-reported HIV or sexually transmitted infection diagnosis was completed. Multivariate regression was used to examine associations between IPV and risk behaviors and an HIV or sexually transmitted infection diagnosis. Results: Among 610 participants, 182 (29.8%) reported experiencing at least 1 type of IPV. Men who have sex with both men and women were at significantly greater risk for IPV (adjusted odds ratio [AOR], 1.65; 95% confidence interval [CI], 1.08–2.53) compared with MSM. Men who had experienced IPV were more likely to have participated in group sex (AOR, 1.86; 95% CI, 1.08–3.21), to have had sex in exchange for gifts or money (AOR, 5.06; 95% CI, 2.47–10.35), and to report a positive HIV diagnosis (AOR, 2.59; 95% CI, 1.22–5.51). Conclusions: There is a hidden epidemic of IPV among MSM in China, especially among MSMW. The hidden nature of MSM and MSMW suggests the need for a clinical environment more conducive to disclosure. Research is needed to understand the pathways linking IPV and HIV risk among MSM to optimize the design of effective interventions. 07/01/2015 01:00 AM

Consistency of Condom Use During Receptive Anal Intercourse Among Women and Men Who Have Sex With Men: Findings From the Safe in the City Behavioral Study

imageBackground: Unprotected receptive anal intercourse poses HIV risk for men who have sex with men (MSM) and heterosexual women. Little is known about differences in consistent condom use during anal intercourse among these populations. Methods: Data were analyzed from a nested study conducted from 2004 to 2005 within a behavioral intervention trial of approximately 40,000 urban US sexually transmitted disease clinic patients. Analyses were restricted to women and MSM who reported receptive anal intercourse with at least 1 partner in the prior 3 months at baseline, or 3-month follow-up surveys. Condom use was categorized as consistent (100% of receptive acts) or inconsistent/nonuse (0–99% of receptive acts). Multivariable regression with general estimating equations was used to identify factors associated with consistent condom use within each population. Results: Approximately 31% of women and 70% of MSM reported receptive anal intercourse at least once in the past 3 months. Men who have sex with men were significantly more likely to report consistent condom use compared with women. For women, intention to use condoms, partner support for condom use, the belief they could stop having sex when condoms were unavailable, and believing their partner had not given them a sexually transmitted infection (STI) were associated with using condoms consistently. For MSM, intention to use condoms, condom use self-efficacy, perceived partner support for condom use, having a nonmain partner, believing their partner had not given them an STI, and fewer sex acts were associated with consistent condom use. Conclusions: Findings confirm the importance of considering anal intercourse when assessing STI/HIV risk in MSM and heterosexual women. 07/01/2015 01:00 AM