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Background: Secondary transmission remains a significant concern among HIV-infected youth. Little is known, however, about how partner-specific sexual risk behaviors for the secondary transmission of HIV may differ between the 2 largest subgroups of HIV-positive youth, women-who-have-sex-with-men (WSM) and men-who-have-sex-with-men (MSM), Methods: During 2003-2004, a convenience sample of HIV-infected youth, 13 to 24 years of age, were recruited from 15 Adolescent Medicine Trials Network clinical sites. Approximately 10 to 15 youth were recruited at each site. Participants completed an ACASI survey including questions about sex partners in the past year. Cross-sectional data analyses, including bivariate and multivariable regressions, using generalized estimating equations, were conducted during 2008 to compare recent partner-specific sexual risk behaviors between WSM and MSM. Results: Of 409 participants, 91% (371) were included in this analysis, including 176 WSM and 195 MSM. Ninety-two percent (163 WSM. 177 MSM) provided information on characteristics of their sexual partners. There were significant differences between the 2 groups in recent partner-specific sexual risk behaviors including: lower rates of condom use at last sex among WSM (61% WSM vs. 78% MSM; P = 0.0011); a larger proportion of the sex partners of MSM reported as concurrent (56% MSM vs. 36% WSM; P = 0.0001); and greater use of hard drugs at last sex by MSM and/or their partner (18% MSM vs. 4% WSM; P = 0.0008). When measuring risk as a composite measure of sexual risk behaviors known to be associated with HIV transmission, both groups bad high rates of risky behaviors, 74.7% among young MSM compared to 68.1% of WSM. Conclusions: These data suggest that recent partner-specific sexual risk behaviors for HIV transmission are high among young infected MSM and WSM. These findings suggest the need to offer interventions to reduce the secondary transmission of HIV to all HIV-positive youth in care. However, differences in risk behaviors between young MSM and WSM supports population-specific interventions.

Background: Latino youth in the United States are at greater risk for contracting sexually transmitted infections (STIs) in comparison with non-Hispanic white youth. Methods: Sexually active heterosexual Latino youth aged 16 to 22 years (N = 647) were recruited for interviews through a large health maintenance organization or community clinics. Results: Adjusting for gender, age, ethnic heritage, and recruitment method, woman's consistent use of hormonal contraceptives, ambivalence about avoiding pregnancy, longer length of sexual relationship, and greater overall trust in main partner were independently associated with inconsistent condom use and engagement in a greater number of sexual intercourse acts that were unprotected by condom use. Perception that one's main partner had potentially been unfaithful, but not one's own sexual concurrency, was associated with consistent condom use and fewer acts of unprotected sexual intercourse. Sexually concurrent youth who engaged in inconsistent condom use with other partners were more likely to engage in inconsistent condom use and a greater number of unprotected sexual intercourse acts with main partners. Conclusions: Increasing attachment between youth may be a risk factor for the transmission of STIs via normative declines in condom use. Perception that one's partner has potentially been unfaithful may result in greater condom use. However, many Latino adolescents and young adults who engage in sexual concurrency may not take adequate steps to protect their partners from contracting STIs. Some youth may be more focused on the emotional and social repercussions of potentially revealing infidelity by advocating condom use than the physical repercussions of unsafe sex.

Background: Sexual networks play an important role in the transmission of sexually transmitted infections (STIs) and HIV. However, because of the challenges of collecting network data, relatively few empirical reports exist about the structure of sexual networks in general population samples. This study describes the structure of the sexual networks of a household sample of urban black adolescents living in an area with moderate endemic STI rates. Methods: Random digit dialing was used to recruit a household sample of black adolescents from the Bayview-Hunter's Point neighborhood of San Francisco. Participants' recent partners and partners of partners were recruited through snowball sampling. Biologic samples were tested for current infection with gonorrhea or chlamydia. Social network analysis methods were used to describe the characteristics of the resulting sexual networks. Results: One hundred and sixty-six sexually active participants were connected to 388 network members in 159 separate sexual network components. Despite relatively high prevalence of bacterial STIs (13%), components were small (3.5 people on average, and half involved only 2 people), linear and acyclic. Females were less central in their networks than males by local measures but just as central when overall structure was taken into account. Conclusions: Our results confirm, in a new setting, previous observations that sexual network structures necessary for endemic transmission of gonorrhea and chlamydia are sparsely connected.

Background: Chlamydia trachomatis (Ct) infection, especially repeat infection, is associated with serious sequelae among women, including pelvic inflammatory disease, ectopic pregnancy, and infertility. There are few reports evaluating repeat infection and predictors among men treated for Ct infection. Objective: To measure the predictors and incidence of repeat Ct infection among men. Methods: Men 15 to 35 years of age were screened for Ct infection in different venues in Baltimore, Denver, and San Francisco using urine-based nucleic acid amplification tests. Men with Ct infection were evaluated for repeat Ct infection from February 2001 until September 2003. Enrolled men had a baseline, 1-month, and 4-month follow-up visit and were tested for Ct infection at each visit. Project staff sought to locate and notify all female sex partners of infected men during the study to provide testing and treatment. We evaluated predictors of repeat Ct infection, time to infection, and incidence of infection. Results: Three hundred fifty-nine men were recruited into the study and 272 (76%) had at least 1 follow-up visit with Ct results. Repeat infection occurred in 13% of men with Ct infection; there was no significant difference in repeat infection by site (Denver 13%, Baltimore 13%, San Francisco 12%). Independent predictors of repeat infection were history of an STD and venue. Incidence of repeat infection was 45.4 infections per 100 person years. Conclusion: Repeat Ct infection is common among men and similar in geographically distinct cities. Incidence of repeat Ct infection support routine rescreening of men within the first 3 months after Ct infection.

Background: Urine-based screening for Chlamydia trachomatis using highly sensitive and specific nucleic acid amplification tests offers a unique opportunity to screen men attending school-based health centers. Methods: As part of a large multicenter chlamydia screening project in men, 1434 students were enrolled; 1090 in high schools in Baltimore and 344 middle and high-school students in Denver. Students were screened for chlamydia using urine-based nucleic acid amplification tests at well adolescent visits, acute care visits, or visits for other reasons, such as sports physicals. A self-administered survey to ascertain sexual risk behaviors was used. Data were analyzed separately for Baltimore and Denver, with univariate and multivariate logistic regression analysis. Results: The overall prevalence in asymptomatic adolescent men was 6.8% (7.5% in Baltimore and 4.7% in Denver, P = n.s.). Students in Denver were older, more racially diverse, and more likely to have had intercourse in the previous 2 months than students in Baltimore. Students in Baltimore were more likely than those in Denver to have used a condom at last intercourse with casual and main partners. Among men in Denver but not Baltimore, condom use at last intercourse with both casual (OR 0.15, 95% CI, 0.03, 0.78) and main partners (OR 0.30, 95% CI, 0.10, 0.91) was protective against infection. The only risk factor for CT infection in Baltimore students was age (OR 1.47, 95% CI, 1.23, 1.75). In multivariate analysis that included age (as a continuous variable), race, history of an STI, any sex partner in the last 2 months, > 1 sex partner in the past 12 months, a new partner in the last 2 months, and condom use with last main and last casual partner, age (adjusted odds ratio 1.34, 95% CI, 1.11, 1.62) and black race (adjusted odds ratio 2.37, 95% CI, 1.21, 4.63) were the only variables associated with testing chlamydia positive. Conclusions: School-based health centers are important venues in which to perform urine-based screening for chlamydia in sexually active, asymptomatic males, especially in high prevalence communities, and such screening provides the opportunity to identify and treat substantial numbers of chlamydia infections.

Background: We examined 2 potentially important factors influencing successful treatment of Chlamydia trachomatis (Ct) and Neisseria gonorrhoeae (GC) infections identified in an emergency department (ED), health care coverage and reporting the ED as a primary source for health care. Methods: Adult patients aged 18 to 35 years attending an urban ED were screened for Ct and GC. Patients testing positive were contacted by Disease Intervention Specialists and notified of their infection status. Analyses focus on infected patients for whom we have treatment and follow-up information. We used generalized linear models with log link and binomial error distribution to estimate risk ratios (RRs) and 95% confidence intervals (CI). Results: Of 5537 patients screened in the ED, 348 (6.3%) tested positive for Ct, 143 (2.6%) tested positive for GC, and 43 (0.8%) tested positive for both. Overall, 20% of infected patients did not receive treatment. Among infected patients with no health care coverage 25% (n = 56) were untreated compared with 15% (n = 47) of patients reporting health care coverage (RR: 1.7, 95% CI: 1.2-2.3). Among patients reporting the ED as a primary source for health care 26% (n = 27) were untreated compared with the 18% (n = 77) reporting receiving health care from non-ED sources (RR: 1.4, 95% Ch 1.0-2.1). Conclusions: EDs often serve as primary care sites for difficult-to-reach populations. We were able to successfully locate and treat the greater part of ED-identified infections. However, one-fifth of infected patients did not receive treatment. ED-based screening programs can benefit from integration with local public health infrastructure to improve notification and treatment services.

Background: Syphilis incidence has been rising in the United States since 2000. Shifts in syphilis epidemic phases may be associated with changes between or within high-risk populations. Objectives/Goal: To determine whether shifts in syphilis epidemic phases are associated with changes between or within high-risk populations. Study Design: Using surveillance data collected from Baltimore, MD, 1994-2004, we retrospectively defined epidemic phases and compared epidemiologic profiles of syphilis cases infected during epidemic phase. Results: We defined 3 epidemic phases. The shift between hyperendemic and decline phases was not associated with demographic or behavioral changes among persons with syphilis. Compared to the decline phase, men infected with syphilis during the growth phase were 5 times [odds ratio (OR) 5.32 P 25 years of age (men: OR 0.60, P Conclusions: We verified that the shift from a decline to growth phase in Baltimore was mostly because of increases in morbidity among non-African American MSM and young, non-IDU women with [greater than or equal to] 5 recent sex workers. Although syphilis control activities have been targeted towards these groups, our analysis underscores the need for real-time investigation of potential tipping points to ensure interventions are properly focused at the beginning of any potential growth phase.

Objective: The objective of this study was to describe acceptability of urine chlamydia testing among asymptomatic men and providers' attitudes toward testing. Study Design: Asymptomatic men (no urethral discharge/dysuria) were offered free testing and characteristics of men who accepted were compared with those who declined. Acceptability logs tallied the proportion who accepted, and a standardized survey was administered to providers at study's end. Results: Median acceptance was 64% (range, 8-100%). Men accepting were younger and more likely to be in adolescent primary care or detention, to report higher numbers of recent partners, no prior sexually transmitted disease, time to last healthcare visit > 1 year, and to have received an incentive. Provider-reported barriers to testing included difficulty in conveying importance of testing to asymptomatic men (65%) and time constraints (24%). Conclusions: Asymptomatic men are likely to accept testing depending on venue and approach. However, barriers exist for men and providers, even when testing is free.

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.

Background: Sexual partnerships between people at higher and lower risk for sexually transmitted infections (STIs) (i.e., bridging) occur through dissortative mixing and concurrent partnerships, yet the relative effects of these network patterns on population STI spread are poorly understood. Goal: Using a stochastic model, the authors investigated the impact of mixing and concurrency on the spread of a persistent viral STI. Study Design: A total of 1050 populations were simulated of 1000 subjects over 400 weeks with varied concurrency levels and mixing patterns. STI prevalence and the average number of secondary transmissions per subject were analyzed with regression. Results: Mixing had a greater impact on prevalence for all groups, whereas concurrency was significant for only the lowest activity group. Mixing patterns moderated the magnitude of concurrency's impact on secondary transmissions. Conclusions: Through connecting subgroups of differential risk, sexual mixing facilitates dissemination of STIs throughout a population. Concurrency expedites transmission by shortening the time between sexual contacts among infected and susceptible persons, particularly during the highly infectious period.

Objectives: Neisseria gonorrhoeae infections are the second most commonly reported disease in the United States and cause significant morbidity. We describe the prevalence of gonorrhea in a large sample of men tested for gonorrhea and Chlamydia trachomatis in Baltimore, Denver, San Francisco, and Seattle. Methods: Gonorrhea prevalence was measured among 17,712 men tested in a variety of non-sexually transmitted disease (STD) clinic venues using urine-based nucleic acid amplification tests. Results: Among 16,850 asymptomatic men, prevalence ranged from 0% to 1.5% by city (P = 0.20): Baltimore 1.3%, Denver 1.5%, San Francisco 1.5%, and Seattle 0%. Among 862 symptomatic men, the gonorrhea prevalence varied from 0.0% to 28.3% by city (P < 0.01). Conclusions: The high prevalence of gonorrhea in symptomatic men supports the importance of testing for symptomatic men. The prevalence of gonorrhea among asymptomatic men is low, and routine screening cannot be recommended when screening is performed for chlamydia, unless a substantial local prevalence of gonorrhea can be documented in specific targeted venues or population groups.

Goal: The goal of this study was to examine the risk for repeat sexually transmitted infections (STIs) associated with reducing the number of sex partners who come from within the social networks of males 13 to 25 years old in Baltimore, Maryland, and Denver, Colorado. Study: Asymptomatic males diagnosed with chlamydia and/or gonorrhea as part of an asymptomatic chlamydia and gonorrhea male screening project were recruited and interviewed about their sexual behaviors and their perceptions of social characteristics and sexual behaviors of their sex partners. We characterized the sex partners of each participant as belonging to or not belonging to his social network. We examined whether a decrease in percentage of sex partners who were in the participant's social network was associated with repeat infection. Results: There were 47 participants in Baltimore and 92 in Denver. In both cities, there was a trend toward a finding that decreasing the percentage of sex partners belonging to a participant's social network was protective for repeat STI. Conclusion: These data suggest that interventions may need to be designed to reduce the prevalence of infection in the social networks of infected men.

Objective: The objective of this study was to measure the prevalence of Chlamydia trachomatis (CT) infection among men in clinical and nonclinical settings across the United States. Goal: The goal of this study was to obtain data to inform recommendations regarding male CT screening. Study: The authors conducted a cross-sectional study of CT prevalence among adolescent and adult men in 4 U.S. cities (Baltimore, Denver, San Francisco, and Seattle). CT was detected using urine-based testing, and prevalence was calculated for first testing event. Results: Over 23,000 men were tested for CT over a 3 1/2-year period. The majority (96%) were asymptomatic. Overall, prevalence was 7% and varied significantly between cities (range: Seattle, 1%: Baltimore, 12%), by age (peak prevalence at age 20-24 years, 9%), and between venues where CT testing was offered. Conclusions: At 7%, the prevalence of CT is moderately high among men opportunistically tested in nonclinical and clinical settings.

Background: Geographic areas characterized by a high prevalence of sexually transmitted infections (STIs) are critical to the maintenance and persistence of STIs within populations. Sex partner concurrency has been shown to be associated with increased risk for individual-level STIs. Objectives: The objectives of this study were to determine whether gonorrhea rate per census block group and sex partner concurrency independently and interactively are associated with a current bacterial STI among adolescents. Study: Face-to-face interviews and urine testing for Chlamydia trachomatis and Neisseria gonorrhoeae were conducted among female, sexually active, 14- to 19-year-oids presenting for reproductive clinic care between August 2000 and June 2002. Results: Gonorrhea rate per census block group and sex partner concurrency were not independently but were interactively associated with a current bacterial STL Among participants with a main sex partner who practiced concurrency, living in high-prevalence geo. graphic areas was significantly associated with a current bacterial STI. Conclusions: The results suggest that geographic context may moderate an adolescent sex partner's behaviors. The research adds to the basic understanding of sexually transmitted disease transmission and acquisition in a high-prevalence inner-city setting.

Objectives: The objective of this study was to determine whether the syphilis epidemic in Baltimore City during the mid-1990s was associated with changes in sexual networks. Methods: Data on index cases of syphilis and their partners were collected from 1996 to 2000 and entered into CDC STD*MIS software. Unique pairs of dyads were used to create networks using SAS Interactive Matrix Language. PAJEK and UCINET were used to analyze the largest component from all years (1996-2000), during the epidemic (1997-1998), and after the epidemic (1999-2000). Results: Between 1996 and 2000, there were 3343 components containing 18,709 nodes. The 2 largest components were comprised of 1103 nodes and 125 nodes, respectively. From the period during the epidemic to after the epidemic, the average distance among reachable pairs, network centralization, number of n-cliques (n = 2, size = 3), and number of k-plexes (k = 2, n = 3) declined, whereas the block densities increased. Conclusions: Important differences exist between the sexual networks during and after the syphilis epidemic.

Background and Objectives: Adolescent females are frequently treated as a homogenous group but could differ on their sexually transmitted disease (STD) risk because of individual attitudes and exposure through sexual networks. Goal: The goal of this study was to determine if risk perceptions, condom use, and STD prevalence differs within sexual networks. Study Design: Three hundred three adolescent females participating in a longitudinal study of adolescent STD risk perceptions and condom use were categorized as 'core,' 'bridge,' and 'periphery' in a sexual network according to their and their main sex partner's risk information. Regression analysis determined differences in risk perceptions by network location. Results: We demonstrated an inverse relationship between STD risk perceptions and network location. Adolescents with higher risk perceptions were more likely to use condoms, irrespective of network location. Conclusion: Female adolescents are a heterogeneous group exhibiting different risk perceptions. Different intervention strategies for adolescents at higher risk could be necessary. Interventions designed to raise risk perceptions could be associated with condom use, even for those adolescents at greatest risk.

Background: Traditional syphilis control tools could be limited in high-risk groups in which the disease is concentrated. Novel programmatic methods such as tracking and targeting sex partner meeting venues could be valuable. Goal: The goals of this study were to determine if syphilis cases' sex partner meeting venues are geographically different than their residences and to determine the characteristics of identified meeting places. Results: For cases diagnosed from September 2001 to December 2002 with geocodable data, only 9% of meetings took place in the same census block group as residence, and mean and median distance from residence to meeting place was 1.73 and 1.03 miles. The most common meeting location type overall was a street or corner, but differed by risk behaviors. Conclusion: Baltimore syphilis cases in general met sex partners outside their immediate neighborhoods. Meeting locations could provide new targets for syphilis control interventions.

Background: Latino youth suffer disproportionately from unintended pregnancy and sexually transmitted infections (STIs), but studies of the social context of their sexual behaviors are lacking. Goal: Our qualitative assessment of recruitment venues in a Latino neighborhood had 3 objectives: to identify venues where youth at risk of unintended pregnancy and STIs could be found; to describe different youth 'crowds'; and to investigate how and where youth meet their sex partners. Study Design: We conducted ethnographic interviews with 62 youth recruited primarily from street sites. Mapping of venues was conducted with Map-Info. Results: Youth crowds included the Regulars, gang-related crowds, street-economy affiliated crowds, and female crowds. Maps demonstrated the dominance of the venues in the Mission by gang members. Street sites are important venues for meeting sexual partners. Conclusion: The qualitative assessment produced insights and hypotheses that can contribute to the planning of research, outreach, testing, and interventions with Latino youth.

Background: Although physical attributes have been shown to be associated with sexually transmitted disease (SD) rates, there is little information about the association between social attributes and STD rates. Goal: The objective of this study was to determine the association between gonorrhea prevalence and perceptions of social cohesion in impoverished, urban neighborhoods. Study Design: We conducted a street-based survey of 18- to 24-year-olds residing in selected census block groups in Baltimore City, Maryland. Census block groups eligible for selection were defined as impoverished (greater than 20% in poverty) and unstable (lowest 25th percentile for stability). From the eligible census block groups, 5 from high gonorrhea rate (greater than the 75th percentile) census block groups and 5 from the lower gonorrhea rate (lowest 25th percentile to equal or greater than the 75th percentile) census block groups were randomly selected. Participants within the 10 selected census block groups were recruited using a street-intercept method. Participants were asked about perceived social cohesion and control. Results: Results showed that for young adults 18 to 24 years of age residing in high gonorrhea census block groups, the mean social cohesion index scores were 1.7 points lower than mean social cohesion index scores of the participants residing in the low gonorrhea census block groups (P Conclusion: Future research needs to be conducted to determine the temporal association between gonorrhea prevalence and local social cohesion dynamics.

Background: Effective syphilis control and elimination require community effort and innovative case-finding techniques, especially to identify infected persons from core transmission groups. Goal: To summarize the implementation and outcomes of a community-oriented response to a localized outbreak of syphilis directed at sex partner meeting places. Study Design: Syphilis surveillance and rapid response data from a 7-month period were analyzed for risk behaviors, sex partner meeting locations, field investigation outcomes, and social and sexual network connections. Results: Four (6%) of the sixty-nine persons tested were confirmed syphilis reactors, of whom three were new cases. A sexual and needle-sharing network of 15 persons was identified that included two of the new syphilis cases. These two had not been found through standard field investigation. Conclusions: Targeting interventions to sex partner meeting places may effectively complement traditional syphilis control tools and find previously unidentified syphilis cases in high-morbidity areas.

Background: In sexual networks, bridge members engaging in discordant partnering play key roles in maintaining and transmitting sexually transmitted infections (STIs) within a population. Goal: The goal was to characterize adolescents likely to engage in discordant sexual relationships with main and casual sex partners. Study Design: Egocentric data about adolescents and their most recent sex partner(s) collected over 6 months were analyzed with use of logistic regression. Results: History of STI, drug use, and meeting venue were significantly associated with discordant sexual partnering among high-risk adolescents. Participants with histories of high-risk behavior, e.g., hard drug use or STI, were more likely to have had a recent, dissimilar partner than those with lower-risk profiles. Particular meeting venues, such as clubs and street locations, were more likely to be associated with age-discordant, race-discordant, and drug use--discordant partnerships for females. Conclusion: Bridge members of adolescent sexual networks were more likely to have a history of STI, hard drug use, or meeting their sex partner through particular venues.

Background: The authors' previous research has shown that in cross-sectional analysis, partner-specific perceptions of risk for gonorrhea and chlamydial and HIV infection correlated with partner-specific intentions to use condoms. Goal: The goal was to determine whether partner-specific measures of perception of risk for STDs (PRSTD) predict partner-specific condom use 6 months later among high-risk and low-risk youth. Study Design: Youths aged 14 to 19 years were recruited from an STD clinic (n = 236) and an HMO teen clinic (n = 306) and were interviewed at baseline and at 6 months about PRSTD, attitudes about condoms, self-efficacy, normative expectations, and condom use. Results: PRSTD with a main sex partner was an independent predictor of condom use with a main sex partner in the STD clinic cohort (odds ratio = 2.5; 95% CI = 1.1-6.2). There was no association between PRSTD with a casual sex partner and condom use in this cohort or between PRSTD for main or casual sex partners and condom use in the HMO teen clinic cohort. Conclusion: Interventions that target high-risk adolescents should focus on PRSTD with a main sex partner.

Who gets sick and who doesn't? Why do some apparently healthy children develop serious diseases later in life while others do not? These questions propel the work we do to [...]

Background and Objectives: African-American adolescents have the highest rates of sexually transmitted diseases (STDs) of any racial/ethnic group of adolescents. The objective of this study was to determine the degree to which racial/ethnic differences in sexual behaviors account for African-American adolescents' higher rates of STDs. Study Design: A secondary analysis of data collected as part of the Youth Risk Behavior Survey supplement to the 1992 National Health Interview Survey was conducted. The sample included 5,189 nationally representative civilian noninstitutionalized sexually experienced United States adolescents 14 to 21 years of age. Results: The age- and sex-adjusted odds ratio (OR) for a reported history of an STD for African-American adolescents was 3.86 (95% confidence interval [CI] = 1.57,9.50). The STD risk for African-American youth increased with the adjustment for other sociodemographic factors (OR - 4.13; CI = 1.71,9.99) and decreased with the adjustment for sexual behaviors (OR = 3.67; CI = 1.55, 8.66). Conclusions: Differences in sexual behaviors do not fully account for African-American adolescents' increased risk for STDs. Interventions designed to reduce sexual risk taking among African- American adolescents may not ameliorate racial/ethnic differences in rates of STDs., Differences in sexual behaviors do not completely explain the higher rate of sexually transmitted diseases (STDs) in African American teenagers. Sexual behaviors that might put a teen at risk of contracting an STD include more than one partner, inconsistent condom use, and the rate of STDs in the pool of prospective partners. Researchers studied the link between behavior and STDs in 5,189 teenagers. African-Americans were over three times more likely to have an STD and this increased risk remained after adjusting for sexual behaviors.

Background and Objectives: To determine whether personal and/or a partner's use of crack cocaine is associated with the diagnosis of early syphilis or gonorrhea independent of high-risk sex behaviors, and to determine whether the relationships between crack cocaine and associated sexually transmitted diseases (STDs) are similar for adolescents and adults. Study Design: A cross-sectional behavioral survey of heterosexual males and females attending public STD clinics in three cities. Logistic regression was used to identify risk behavior patterns associated with each STD compared with no STD. Results: Multivariate analysis revealed that men who were high on drugs, including crack cocaine, before or during sex were more likely to be diagnosed with syphilis (Odds Ratio [OR] = 1.49; Confidence Intervals [CI] = 1.06, 2.13). Males more likely to be diagnosed with gonorrhea were younger (OR = 0.94; CI = 0.92, 0.96), had sex with a crack cocaine user (OR = 1.99; CI = 1.36, 2.91), did not use condoms last time they had sex with a nonmain partner (OR = 1.59; CI = 1.09, 2.13), and did not have sex with an intravenous drug user (OR = 0.45; CI = 0.22, 0.95). For women, there were no independent risk factor for syphilis but younger age was a risk factor for gonorrhea (OR = 0.95; CI = 0.91, 0.99). The associations between crack cocaine and syphilis and gonorrhea in men and between crack cocaine and syphilis in women were not significant among adolescents in this study. Conclusion: The results of this study highlight the differences in the crack cocaine-related behaviors of adults and adolescents at risk for gonorrhea and syphilis. The nature of these differences support the use of distinct intervention strategies for each STD and for adolescents and adults., Linkages between use of crack cocaine and contracting syphilis or gonorrhea may vary. Researchers analyzed behavior among 1,442 heterosexual patients attending sexually transmitted disease clinics in Philadelphia, Tampa, or San Diego. Men contracting syphilis were more likely to use drugs while having sex. Men contracting gonorrhea were more likely to be younger, to have sex with a crack user, and not to use condoms with a casual partner. No behavioral associations were found for women contracting syphilis, but women contracting gonorrhea were younger. None of these associations held true for adolescents.

Purpose: To examine how interpersonal factors are associated with family, peer, and partner social support among urban female adolescents in sexual relationships.Design: Secondary data analysis of cross-sectional data.Setting: Two urban health clinics and community sites in Baltimore, Maryland.Participants: One hundred sixteen female adolescents (ages 16-19) with 131 heterosexual relationships from the Perceived Risk of Sexually Transmitted Diseases cohort.Measures: Interpersonal factors included parental monitoring, friend–partner connectedness, and feelings of intimacy for partner. Social support was measured using the Multidimensional Scale of Perceived Social Support with family, peer, and partner subdomains.Analysis: Multivariable linear regression models using baseline data and accounting for clustering of partners.Results: Adolescents perceived high levels of family, peer, and partner support, with the greatest coming from partners (range: 1-5; family mean: 4.0 [95% confidence interval, CI: 3.83-4.18]; peer mean: 4.2 [95% CI: 4.05-4.33]; partner mean: 4.5 [95% CI: 4.36-4.60]). Parental monitoring and friend–partner connectedness were significantly associated with greater family (b= 0.11, standard error [SE] = 0.03, P= 0.001; b= 0.15, SE = 0.06, P= .02) and peer support (b= 0.06, SE = 0.02, P= .01; b= 0.29, SE = 0.07, P< .001). Feelings of intimacy for partner was significantly associated with greater partner support (b= 0.08, SE = 0.03, P= .02).Conclusion: Feeling connected to one’s social network and having a connected network is an important contribution to social support for urban female adolescents in sexual relationships. Future research targeting interpersonal factors is warranted, as it may result in increased social support and promote positive sexual health behaviors in an urban female adolescent population.

* Objectives To determine the proportion of sexually experienced African American adolescents who report having been screened for sexually transmitted diseases and to determine the proportion who report having been screened for these diseases among adolescents who have had a preventive primary health care visit in the past 2 years. * Methods A telephone survey of a population-based sample of African American adolescents aged 12 to 17 years residing in a low-income neighborhood in San Francisco with a high prevalence of sexually transmitted diseases. * Results Of the 302 adolescents surveyed, 118 (39.1%) reported a history of sexual intercourse. Of these, 17 (26.2%) of 65 males and 31 (58.5%) of 53 females had been screened for a sexually transmitted disease in the previous 12 months. Twenty (30.8%) of the males and 32 (60.4%) of the females had been screened for a sexually transmitted disease in the previous 24 months. Of the 93 participants who had had a preventive primary care visit since their first episode of sexual intercourse, 14 (26.4%) of the 53 males and 24 (60.0%) of the 40 females had been screened for a sexually transmitted disease in the previous 24 months. * Conclusions Sexually experienced African American adolescents in San Francisco are being screened for sexually transmitted diseases at rates well below those recommended by current clinical guidelines. A low rate of screening was found even in adolescents who had been seen for a preventive primary care visit since they had first had sex. This suggests that the preventive primary care visit is not being used to its full potential as an opportunity to screen and treat adolescents for sexually transmitted diseases. Capitalizing on this opportunity to screen may increase the number of cases of sexually transmitted diseases diagnosed and, thus, decrease rates of these diseases in this population., A study of low-income African American adolescents in San Francisco, California INTRODUCTION A cornerstone of prevention and control of sexually transmitted diseases (STDs) is the early diagnosis and treatment of [...]

Objective: To determine the relative importance of various features of health clinics when African American adolescents consider seeking care for sexually transmitted diseases (STDs). Design: Confidential interviewer-administered telephone survey. Setting: A predominantly low-income, African American neighborhood in San Francisco, Calif. Participants: Random sample of African American adolescents aged 12 to 17 years; 302 (76.6%) of 394 identified eligible adolescents participated. Main Outcome Measures: Items and scales measuring adolescents' sense of the importance of the attributes of the provider ([Alpha] = .58), availability of services ([Alpha] = .61), and perceived confidentiality of health services from family ([Alpha] = .72) when deciding where to seek care for possible STDs. Results: More than 90% (90.4%) of subjects rated items relating to provider attributes as being highly important when they consider where they would seek care for an STD; between 62.5% and 82.7% rated availability items as being highly important; and between 38.6% and 60.8% rated items pertaining to confidentiality as being highly important. Greater importance was placed on provider attributes and confidentiality by female than male adolescents. The importance placed on provider attributes and confidentiality increased as adolescents aged. Conclusions: Low-income, African American adolescents place great importance on provider attributes, less importance on availability, and even less importance on confidentiality when deciding where to seek health care for a possible STD. Health care providers and organizations need to be aware of these adolescent preferences to better promote screening and treatment of STDs in this population. Arch Pediatr Adolesc Med. 1999; 153:829-833, When seeking health care services for a possible sexually transmitted disease (STD), low income African-American adolescents place the greatest importance on the personal qualities of the doctor and/or nurse. As they define them, those qualities are that the clinicians will tell them exactly what's wrong, will answer questions about STDs, explain what they're doing during the examination and that they understand teenage medical problems Less important to the adolescents is availability and confidentiality, although confidentiality increases in importance as they get older as do the personal qualities.

ObjectivesFeelings of intimacy, perceptions of partner concurrency (PPC) and perceptions of risk for an STD (PRSTD) are meaningful and dynamic attributes of adolescent sexual relationships. Our objective was to examine whether variations in these STI-associated feelings and perceptions predicted incident Chlamydia trachomatisand/or Neisseriagonorrhoeaeinfection within a prospective cohort of urban adolescent women.MethodsA cohort of clinic-recruited women aged 16–19 completed daily surveys on feelings and risk perceptions about each current sex partner on a smartphone continuously for up to 18 months. Urine was tested for C. trachomatisand N. gonorrhoeaeevery 3 months. Daily responses were averaged across the week. As overall means for trust, closeness and commitment were high, data were coded to indicate any decrease in feelings from the previous week. PRSTD and PPC were reverse coded to indicate any increase from the previous week. An index was created to examine the cumulative effect of variation in these feelings and perceptions. Generalised linear models were used to account for correlation among repeated measures within relationships.ResultsFor each week that there was a decrease in trust, there was a 45% increase in the risk of being infected with an STI at follow-up (relative risk (RR) 1.45, 95% CI 1.18 to 1.78, P=0.004). Neither a decrease in closeness or commitment, nor an increase in PRSTD or PPC was associated with an STI outcome. Cumulatively, the index measure indicated that a change in an additional feeling or perception over the week increased the odds of an STI by 14% (RR 1.14, 95% CI 1.02 to 1.29, P=0.026).ConclusionsA decrease in feelings of trust towards a main partner may be a more sensitive indicator of STI risk than PRSTD, PPC or commitment. The next generation of behavioural interventions for youth will need strategies to address feelings of intimacy within adolescent romantic relationships.

IMPORTANCE: Youths aged 13 to 24 years old living with human immunodeficiency virus (HIV) are less likely than adults to receive the health and prevention benefits of HIV treatments, with only a small proportion having achieved sustained viral suppression. These age-related disparities in HIV continuum of care are owing in part to the unique developmental issues of adolescents and young adults as well as the complexity and fragmentation of HIV care and related services. This article summarizes a national, multiagency, and multilevel approach to HIV care for newly diagnosed youths designed to bridge some of these fragmentations by addressing National HIV/AIDS Strategy goals for people living with HIV. DESIGN, SETTING, AND PARTICIPANTS: Three federal agencies developed memoranda of understanding to sequentially implement 3 protocols addressing key National HIV/AIDS Strategy goals. The goals were addressed in the Adolescent Trials Network, with protocols implemented in 12 to 15 sites across the United States. Outcome data were collected from recently diagnosed youth referred to the program. MAIN OUTCOMES AND MEASURES: Cross-agency collaboration, youth-friendly linkage to care services, community mobilization to address structural barriers to care, cooperation among services, proportion of all men who have sex with men who tested, and rates of linkage to prevention services. RESULTS: The program addressed National HIV/AIDS Strategy goals 2 through 4 including steps within each goal. A total of 3986 HIV-positive youths were referred for care, with more than 75% linked to care within 6 weeks of referral, with almost 90% of those youths engaged in subsequent HIV care. Community mobilization efforts implemented and completed structural change objectives to address local barriers to care. Age and racial/ethnic group disparities were addressed through targeted training for culturally competent, youth-friendly care, and intensive motivational interviewing training. CONCLUSIONS AND RELEVANCE: A national program to address the National HIV/AIDS Strategy specifically for youths can improve coordination of federal resources as well as implement best-practice models that are adapted to decrease service fragmentation and systemic barriers at local jurisdictions.

AbstractBackground:Sickle cell disease (SCD) is a common hemoglobinopathy characterized by debilitating vaso-occlusive crises (VOCs) that can require hospitalization for treatment. Despite optimization of multimodal allopathic inpatient treatment, pain burden remains high. Narcotics, the mainstay of therapy, incur adverse side effects, tolerance, and the potential for addiction. Adjunctive treatments are sorely needed and patients' families have reported openness to complementary modalities to fill this need.Objectives:The aim of this pilot study was to assess initial feasibility and acceptability of inpatient adjuvant acupuncture and its potential impact on pediatric VOC-related pain.Materials and Methods:This prospective, single-center study at an urban children's center sought to recruit 13–17-year-old patients with either HbSS (2 mutated sickle hemoglobin copies, each denoted HbS, are inherited, one from each parent) or HbSC (1 sickle hemoglobin variant, or HbS, is inherited from one parent and another hemoglobin variant, HbC, from the other) disease being admitted for VOC management. The patients were recruited within 24 hours of admission. Upon enrollment, a trained acupuncturist evaluated and treated patients according to Worsley Classical Five-Element Acupuncture daily while they required patient-controlled analgesia pumps.Results:Over a 9-month period in 2004, ∼40 patients were identified for possible participation. Of 13 patients interested in the study and eligible, 2 (5% of total; 15% of eligible and interested) ultimately completed it. Both patients conveyed openness to acupuncture, achieved some pain reduction and/or relaxation through it, and indicated that they would want repeated treatments. Care providers were also impressed favorably with the pain attenuation and functional gains achieved.Conclusions:In the total sample, there were some barriers to feasibility and acceptability. However, the 2 patients who received adjuvant acupuncture treatment, their families, and providers alike perceived clinical benefit. Adjuvant inpatient acupuncture for pediatric SCD VOC pain control merits further study.

The principal purposes of residency training are the care of patients and the teaching and training of young physicians. The educational process is under the direction of physicians who are usually younger faculty and more senior residents. Senior physicians, who should be the line supervisors of residents, are frequently only slightly involved with residency training programs. This may be due to the fact that senior physicians are not up to date in the latest techniques, are too busy with their own practices, or feel that the residents should 'learn as you go'. However, senior attending physicians should participate in these programs. They bring experience, diagnostic acumen (intelligence), subtle insights and other fine detailing unavailable from the senior residents or junior staff. They have greater skills in determining what to do, and when to do it, and likewise, the wisdom of knowing when doing nothing is the best care. It may be a wise teaching tactic to let residents make their own decisions and mistakes, but under appropriate guidance. The senior physicians have weathered the fads and fancies of treatments, and know the durable, more effective and successful treatment modalities. They bring to the training classroom the confidence of years of practice, and recognize the first principle of care: first, do no harm. The skills of the senior attending staff are an essential component in developing the skills of young residents. (Consumer Summary produced by Reliance Medical Information, Inc.)

IMPORTANCE: With the emphasis on structural-level interventions that target social determinants of human immunodeficiency virus (HIV) transmission to curb the HIV epidemic, there is a need to develop evaluation models that can detect changes in individual factors associated with HIV-related structural changes. OBJECTIVE: To describe whether structural changes developed and achieved by community coalitions are associated with an effect on individual factors associated with the risk of contracting HIV. DESIGN, SETTING, AND PARTICIPANTS: In this serial cross-sectional survey design, data were collected from 8 cities during 4 rounds of annual surveys from March 13, 2007, through July 29, 2010. Study recruitment took place at venues where the population of focus was known to congregate, such as clubs, bars, community centers, and low-income housing. The convenience sample of at-risk youth (persons aged 12-24 years) included 5337 individuals approached about the survey and 3142 (58.9%) who were screened for eligibility. Of the 2607 eligible participants, 2559 (98.2%) ultimately agreed to participate. INTERVENTIONS: Achievement of locally identified structural changes that targeted public and private entities (eg, federal agencies, homeless shelters, and school systems) with the goal of fostering changes in policy and practice to ultimately facilitate positive behavioral changes aimed at preventing HIV. MAIN OUTCOMES AND MEASURES: Number of sexual partners, partner characteristics, condom use, and history of sexually transmitted infections and HIV testing. RESULTS: Exposure to structural changes was not statistically significantly associated with any of the outcome measures, although some results were in the direction of a positive structural change effect (eg, a 10-unit increase in a structural change score had an odds ratio of 0.88 [95% CI, 0.76-1.03; P = .11] for having an older sexual partner and an odds ratio of 0.91 [95% CI, 0.60-1.39; P = .39] for using a condom half the time or less with a casual partner). CONCLUSIONS AND RELEVANCE: This study evaluated a broad representation of at-risk individuals and assessed the effect of numerous structural changes related to various HIV risk factors. No structural changes as measured in this study were associated with a statistically significant reduction in risk behaviors. These null findings underscore the need for a long-term approach in evaluating structural interventions and the development of more nuanced methods of quantifying and comparing structural-change initiatives and determining the appropriate strategies for evaluating effect.

To describe the HIV viral load and CD4cell counts of youth (12–24 years) in 14 cities from March 2010 through November 2011.

Objectives. The social determinants of health (SDH) include factors apart from genes and biology that affect population health. Zoning is an urban planning tool that influences neighborhood built environments. We describe the methods and results of a health impact assessment (HIA) of a rezoning effort in Baltimore, Maryland, called TransForm Baltimore. We highlight findings specific to physical activity, violent crime, and obesity.Methods. We conducted a multistage HIA of TransForm Baltimore using HIA practice guidelines. Key informant interviews identified focus areas for the quantitative assessment. A literature review and a zoning code analysis evaluated potential impacts on neighborhood factors including physical activity, violent crime, and obesity. We estimated potential impacts in high- and low-poverty neighborhoods. The findings resulted in recommendations to improve the health-promoting potential of TransForm Baltimore.Results. Mixed-use and transit-oriented development were key goals of TransForm Baltimore. Health impacts identified by stakeholders included walkability and healthy communities. For Baltimore residents, we estimated that (1) the percentage of people living in districts allowing mixed-use and off-premise alcohol outlets would nearly triple, (2) 18% would live in transit-oriented development zones, and (3) all residents would live in districts with new lighting and landscaping guidelines. Limiting the concentration of off-premise alcohol outlets represented an opportunity to address health promotion.Conclusions. Changes to Baltimore's zoning code could improve population health including decreasing violent crime. HIAs are an important platform for applying SDH to public health practice. This HIA specifically linked municipal zoning policy with promoting healthier neighborhoods.

Background/Objectives: A large percentage of sexually active adolescents have multiple sex partners and are at high risk of acquiring sexually transmitted diseases (STDs). Little is known about adolescents' patterns of sexual partnerships (e.g., concurrent versus serial) and how these patterns influence STD risk. Goal of the Study: To determine the frequency with which adolescents have concurrent partners during a main relationship and the association between having concurrent partners and STD risk. Study Design: Adolescents seeking care at a public STD clinic were recruited from March, 1996, to May, 1998. Demographic and behavioral data were obtained during an interviewer-administered questionnaire. Sexually transmitted disease testing and physical exams were performed by clinicians. Results: Of those adolescents who reported having at least one main partner during the previous 6 months (n = 245), 110 (44.9%) had multiple partners, and 76 (31%) had at least one concurrent partner during a main relationship. Greater number of concurrent partners was associated with STD diagnosis/ exposure after controlling for number of sex partners (OR = 1.6; 95% CI, 1.1-2.4). Conclusions: A significant percentage of adolescents have concurrent partners during a main relationship, and having concurrent partners increases STD risk., Sexually active teenagers are likely to have more than one sexual partner, increasing their risk of sexually transmitted infections. Researchers evaluated 245 teenagers who reported at least one partner. Of these, 45% had had multiple sexual partners, and 31% had more than one partner during the same period. Having multiple sexual partners was associated with a 60% increase in the risk of sexual infections or exposure to sexually transmitted disease.

OBJECTIVES To examine the feasibility and acceptability of a friendship-based network recruitment strategy for identifying undiagnosed human immunodeficiency virus (HIV) infection within young women's same-sex friendship networks and to determine factors that facilitated and hindered index recruiters (IRs) in recruiting female friendship network members (FNMs) as well as factors that facilitated and hindered FNMs in undergoing HIV screening. DESIGN A cross-sectional study design that incorporated dual incentives for IRs and their female FNMs. SETTING The IRs were recruited through 3 Adolescent Trials Network for HIV/AIDS Interventions sites within their Adolescent Medicine Trials Units. Data were collected from January 1, 2009, through June 30, 2010. PARTICIPANTS The IRs self-identifying as HIV positive, negative, or status unknown were enrolled to recruit FNMs to undergo HIV screening. MAIN OUTCOME MEASURES Self-reports of HIV risk and facilitators and barriers to network recruitment and HIV screening were assessed using an audio-computer-assisted self-interview. Participants were identified as HIV negative or positive on the basis of an OraQuick HIV test with confirmatory enzyme-linked immunosorbent assay and/or Western blot tests. RESULTS Nearly all (156 [98.1%]) eligible IRs agreed to participate and most (78.4%) recruited 1 or more FNMs. Of the 381 FNMs, most (342 [89.8%]) agreed to HIV screening. Although a high acceptance of HIV screening was achieved, the HIV prevalence was low (0.26%). CONCLUSION Our findings provide compelling evidence to suggest that use of a female friendship network approach is a feasible and acceptable means for engaging at-risk young women in HIV screening, as shown by their high rates of agreement to undergo HIV screening.

AbstractBackground:Television viewing is associated with an increased risk for obesity in children. Latino children are at high risk for obesity and yet little is known about differences in television viewing habits within this population. The purpose of this study is to determine if hours of television viewed by young children with low-income Latina mothers differs by maternal ethnic subgroup and English language proficiency.Methods:This was a cross-sectional analysis of data from the Welfare, Children, & Families: A Three City Study.Participants were 422 low-income Latina mothers of Mexican and Puerto Rican descent with children ages 0–4 years old. The dependent variable was hours of daily television viewed by the child. The independent variable was maternal ethnic subgroup and English language proficiency. Analyses involved the use of multiple negative binomial regression models, which were adjusted for demographic variables.Results:Multivariable regression analyses showed that compared to children with mothers of Mexican descent, children of mothers of Puerto Rican descent watch more daily television (<2 years old, incidence rate ratio (IRR)=4.18, 95% confidence interval (CI) 1.68, 10.42; 2–4 years, IRR=1.54, 95% CI 1.06, 2.26). For children with mothers of Mexican descent, higher maternal English language proficiency was associated with higher amounts of child television viewing (IRR=1.29, 95% CI 1.04, 1.61). No relationship was found for children of Puerto Rican descent.Conclusions:Child television viewing varies in low-income Latino children by maternal ethnic subgroup and English language proficiency. Interventionists must consider the varying sociocultural contexts of Latino children and their influence on television viewing.

To investigate whether educational modules presented on a touchscreen computer increase immediate nutrition and feeding knowledge in low-income, Spanish-speaking Latino immigrant parents.

OBJECTIVES To examine methamphetamine use and its association with sexual behavior among young men who have sex with men. DESIGN Cross-sectional observational analysis. SETTING Eight US cities. PARTICIPANTS As part of the Adolescent Trials Network for HIV/AIDS Interventions, adolescent boys and young men who have sex with men, aged 12 to 24 years, were recruited from social venues (eg, clubs, parks, and street corners) between January 3, 2005, and August 21, 2006, to complete a study survey. MAIN OUTCOME MEASURES Reported methamphetamine use in the past 90 days and reported sexual risk behavior compared with individuals reporting no hard drug use and individuals reporting hard drug use in the past 90 days. RESULTS Among 595 adolescent boys and young men, 64 reported recent methamphetamine use, and 444 reported no recent hard drug use (87 reported use of hard drugs other than methamphetamine). Recent methamphetamine use was associated with a history of sexually transmitted diseases (51.6%), 2 or more sex partners in the past 90 days (85.7%), sex with an injection drug user (51.6%), and sex with someone who has human immunodeficiency virus (32.8%) compared with individuals reporting no recent hard drug use (21.1%, 63.1%, 10.7%, and 11.1%, respectively; P &lt; .05 for all [n = 441]). Recent users of methamphetamine were more likely to have a history of homelessness (71.9%) and were less likely to be currently attending school (35.9%) compared with individuals reporting no recent hard drug use (28.4% and 60.4%, respectively; P &lt; .001 for both). CONCLUSIONS Adolescent boys and young men who have sex with men and use methamphetamine seem to be at high risk for human immunodeficiency virus. Prevention programs among this age group should address issues like housing, polydrug use, and educational needs.