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OBJECTIVES: To estimate trends in the prevalence and comorbidities of diabetes mellitus (DM) in U.S. nursing homes from 1995 to 2004. DESIGN: SAS callable SUDAAN was used to adjust for the complex sample design and assess changes in prevalence of DM and comorbidities during the study period in the National Nursing Home Surveys. Trends were assessed using weighted least squares linear regression. Multiple logistic regressions were used to calculate predictive margins. SETTING: A continuing series of two-stage, cross-sectional probability national sampling surveys. PARTICIPANTS: Residents aged 55 and older: 1995 (n=7,722), 1997 (n=7,717), 1999 (n=7,809), and 2004 (n=12,786). MEASUREMENTS: DM and its comorbidities identified using a standard set of diagnosis codes. RESULTS: The estimated crude prevalence of DM increased from 16.9% in 1995 to 26.4% in 2004 in male nursing home residents and from 16.1% to 22.2% in female residents (all P<.05). Male and female residents aged 85 and older and those with high functional impairment showed a significant increasing trend in DM (all P<.05). In people with DM, multivariate-adjusted prevalence of cardiovascular disease increased from 59.6% to 75.4% for men and from 68.1% to 78.7% for women (all P<.05). Prevalence of most other comorbidities did not increase significantly. CONCLUSION: The burden of DM in residents of U.S. nursing homes has increased since 1995. This could be due to increasing DM prevalence in the general population or to changes in the population that nursing homes serve. Nursing home care practices may need to change to meet residents' changing needs. [ABSTRACT FROM AUTHOR]

Objectives: The objective of this study was to determine if Spanish language preference was significantly associated with barriers to healthcare services among a nationally representative sample of Hispanic persons in the United States. Design: Cross-sectional analysis of secondary data. Differences in outcomes between those responding in Spanish and those responding in English were tested using chi-square analyses and multiple logistic regression models. Setting: Nationally representative sample of US adults responding to the 2005 Behavioral Risk Factor Surveillance System survey. Participants: Respondents identifying them- selves as Hispanic (n=20,400). Main Outcome Measures: Four health care outcomes including health insurance coverage, having a personal health care provider, forgoing care because of cost, and having a routine check-up within the past five years. Results: Those responding in Spanish were less likely to have healthcare coverage, less likely to have a personal healthcare provider, and less likely to have had a routine check-up within the past five years. No difference was found for indicating that cost was a barrier to receiving care in this model. Conclusions: Disparities in healthcare access exist between Hispanic persons in the United States whose language preference is Spanish and those whose language preference is English. In an effort to achieve Healthy People 2010 goals and to provide care to all persons in the United States, barriers to care, such as language preference, should be addressed more fully in our healthcare system. [ABSTRACT FROM AUTHOR]

ObjectiveTo discover how community-based family physicians notify patients of test results and whether there are differences based on sex, length of time in practice, reimbursement status, employment status, or percentage of practice in managed care.MethodsWe mailed a survey to 500 randomly selected members of the South Carolina chapter of the American Academy of Family Physicians. All analyses were preformed using SASTM version 8.2. Both descriptive and inferential statistics were used to analyze the collected data.ResultsA total of 367 physicians responded (73% response rate). The main outcome variable was the time each physician spent notifying patients of test results: a mean of 20.86 18.3 minutes per day (range 0-120 minutes/day). Women physicians and those with more than 75% managed care were significantly more likely to spend more than the median time notifying patients of test results.ConclusionPhysicians vary in the amount of time they spend notifying patients of their test results, with female physicians and those with more than 75% of their practice in managed care spending more time than do male physicians and physicians with less managed care. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The purpose of this study was to determine whether a relationship exists between religious attendance and continuity of care. METHODS: We investigated this relationship in a large national database--the National Health and Nutrition Examination Survey III--which contains information on religious attendance, continuity of care, and potential confounders that might mediate the relationship such as health status and socioeconomic status. RESULTS: A total of 18,162 participants 17 years of age or older were included in the analysis. People who attended religious services were more likely to have continuity with a provider than people who did not attend such services (65% vs. 35%, p < .001). This association persisted after controlling for demographic, socioeconomic, and health status variables using regression analysis. CONCLUSION: This study documents a significant association between attendance at religious services and continuity with a usual provider. Continuity with a regular medical provider may influence the association of religious attendance and health outcomes. [ABSTRACT FROM AUTHOR]

Background: In the United States, most chlamydia cases are reported from non-sexually transmitted disease clinics, and there is limited information focusing on the reasons for chlamydia testing in private settings. These analyses describe clinical visits to primary care providers where chlamydia testing was performed to help discern between screening and diagnostic testing for chlamydia., Methods: Using the largest primary care clinical registry in the United States, the PRIME registry, chlamydia tests were identified using Current Procedural Terminology procedure codes and categorized as diagnostic testing for sexually transmitted infection (STI)-related symptoms, screening for chlamydia, or "other," based on Classification of Diseases, Tenth Revision Evaluation and Management codes selected for visits., Results: Of 120,013 clinical visits with chlamydia testing between January 1, 2019, and December 31, 2022, 70.4% were women; 20.6% were with STI-related symptoms, 59.9% were for screening, and 19.5% for "other" reasons. Of those 120,013 clinical visits with chlamydia testing, the logit model showed that patients were significantly more likely to have STI-related symptoms if they were female than male, non-Hispanic Black than non-Hispanic White, aged 15 to 24 years than aged ≥45 years, and resided in the South than in the Northeast., Conclusion: It is important to know what proportion of chlamydial infections is identified through screening programs and to have this information stratified by demographics. The inclusion of laboratory results could further facilitate a better understanding of the impact of chlamydia screening programs on the identification and treatment of chlamydia in private office settings in the United States., Competing Interests: Conflict of Interest and Sources of Funding: None declared., (Copyright © 2024 American Sexually Transmitted Diseases Association. All rights reserved.)

Background: Many underserved populations use Emergency Department (EDs) as primary sources of care, representing an important opportunity to provide infectious disease testing and linkage to care. We explored national ED testing trends and co-testing patterns for HIV, hepatitis C, and sexually transmitted infections (STIs)., Methods: We used 2010-2019 Healthcare Cost and Utilization Project, Nationwide Emergency Department Sample data to estimate ED visit testing rates for HIV, hepatitis C, chlamydia, gonorrhea, and syphilis infections, identified by Current Procedural Terminology codes. Trends and co-testing (visit with tests for > 1 infection) patterns were analyzed by sociodemographic, hospital, and visit characteristics. Trends were evaluated as the average annual percentage change (AAPC) using the Joinpoint Regression., Results: During 2010-2019, testing events per 1000 visits (AAPCs) increased for HIV from 1.3 to 4.2 (16.3 %), hepatitis C from 0.4 to 2.2 (25.1 %), chlamydia from 9.1 to 16.0 (6.6 %), gonorrhea from 8.4 to 15.7 (7.4 %), and syphilis from 0.7 to 2.0 (12.9 %). Rate increases varied by several characteristics across infections. The largest AAPC increases were among visits by groups with lower base rate testing in 2010, including persons aged ≥ 65 years (HIV: 36.4 %), with Medicaid (HIV: 43.8 %), in the lowest income quintile (hepatitis C: 36.9 %), living in the West (syphilis: 49.4 %) and with non-emergency diagnoses (hepatitis C: 44.1 %). Co-testing increased significantly for all infections except hepatitis C., Conclusions: HIV, hepatitis C, and STI testing increased in EDs during 2010-2019; however, co-testing patterns were inconsistent. Co-testing may improve diagnosis and linkage to care, especially in areas experiencing higher rates of infection., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 Published by Elsevier Inc.)

Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Increasing rates of bacterial sexually transmitted infections (STIs) may lead to increased HIV rates, as the STI and HIV epidemics are syndemic. Centers for Disease Control and Prevention guidelines recommend including extragenital (i.e., rectal and/or pharyngeal) STI screenings for certain populations at increased risk of STIs and concurrent infections with HIV., Methods: A descriptive study was conducted by interviewing staff members from 4 rural primary care clinics in areas of high need for STI and HIV services in South Carolina. Qualitative data about their clinical practices in 2021 were obtained. The primary outcome was to determine the awareness and availability of health care services associated with STI and HIV care in these locations., Results: Clinics in target counties provided limited STI and HIV testing and treatment services, especially for populations at risk of infection, indicating the need for additional clinical training and professional development for all clinic staff. Specifically, only 1 of 4 clinics provided extragenital STI testing, and no clinics reported prescribing preexposure prophylaxis., Conclusions: Rural primary care clinics can fill important gaps in the availability of STI and HIV services with appropriate support and incentives. Findings from this study may aid in facilitating policy (state Medicaid agency) and program (state health department) decisions related to STI and HIV testing and treatment., Competing Interests: Conflict of Interest and Sources of Funding: None declared., (Copyright © 2023 American Sexually Transmitted Diseases Association. All rights reserved.)

Competing Interests: Conflict of Interest and Sources of Funding: None declared.

Use of doxycycline to prevent sexually transmitted infections (STIs) may lead to antimicrobial resistance. We analyzed attitudes toward this practice between US providers who commonly and less commonly treat STIs. Providers who more commonly treat STIs are more likely to prescribe prophylactic doxycycline and believe that benefits outweigh potential for increased antimicrobial resistance.

The objective of this study was to determine the prevalence and predictors of testing for sexually transmitted infections (STIs) under an accountable care model of health care delivery. Data sources were claims and encounter records from the Massachusetts Medicaid and Children's Health Insurance Program (MassHealth) for enrollees aged 13 to 64 years in 2019. This cross-sectional study examines the one-year prevalence of STI testing and evaluates social determinants of health and other patient characteristics as predictors of such testing in both primary care and other settings. We identified visits with STI testing using procedure codes and primary care settings from provider code types. Among 740,417 members, 55% were female, 11% were homeless or unstably housed, and 15% had some level of disability. While the prevalence of testing in any setting was 20% (N = 151,428), only 57,215 members had testing performed in a primary care setting, resulting in an 8% prevalence of testing by primary care clinicians (PCCs). Members enrolled in a managed care organization (MCO) were significantly less likely to be tested by a primary care provider than those enrolled in accountable care organization (ACO) plans that have specific incentives for primary care practices to coordinate care. Enrollees in a Primary Care ACO had the highest rates of STI testing, both overall and by primary care providers. Massachusetts' ACO delivery systems may be able to help practices increase STI screening with explicit incentives for STI testing in primary care settings., Competing Interests: The authors have declared that no competing interests exist., (Copyright: This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.)

Background: Telehealth offers one approach to improving access to sexually transmitted infection (STI) prevention and care services. Therefore, we described recent telehealth use among those providing STI-related care and identified opportunities for improving STI service delivery., Materials and Methods: Using the DocStyles Web-based, panel survey conducted by Porter Novelli from September 14 to November 10, 2021, 1500 healthcare providers were asked about their current telehealth usage, demographics, and practice characteristics, and compared STI providers (≥10% of time spent on STI care and prevention) to non-STI providers., Results: Among those whose practice consisted of at least 10% STI visits (n = 597), 81.7% used telehealth compared with 75.7% for those whose practice consisted of less than 10% STI visits (n = 903). Among the providers with at least 10% STI visits in their practice, telehealth use was highest among obstetrics and gynecology specialists, those practicing in suburban areas, and those practicing in the South. Among providers whose practice consisted of at least 10% STI visits and who used telehealth (n = 488), the majority were female and obstetrics and gynecology specialists practicing in suburban areas of the South. After controlling for age, gender, provider specialty, and geographic location of their practice, providers whose practice consisted of at least 10% STI visits had increased odds (odds ratio, 1.51; 95% confidence interval, 1.16-1.97) of using telehealth compared with providers whose visits consisted of less than 10% STI visits., Conclusions: Given the widespread use of telehealth, efforts to optimize delivery of STI care and prevention via telehealth are important to improve access to services and address STIs in the United States., Competing Interests: Conflict of Interest and Sources of Funding: The authors declare no conflicts of interest in the completion of this work. This work was conducted as part of regular work for the Centers for Disease Control and Prevention., (Copyright © 2023 American Sexually Transmitted Diseases Association. All rights reserved.)

Introduction: Rates of congenital syphilis cases are increasing, particularly among lower socioeconomic populations within the southern United States. Medicaid covers a significant portion of these births, which provides an opportunity to improve birth outcomes. This project sought to collect information from key stakeholders to assess facilitators of and barriers to Medicaid funding of prenatal syphilis screening and to provide insight into improving screening and lowering incidence through the Medicaid program., Methods: Seven southern states (Alabama, Georgia, Kentucky, Louisiana, North Carolina, South Carolina, and Tennessee) were identified for this assessment. Researchers conducted a legal and policy analysis for each state to gather information on factors affecting congenital syphilis prevention, identify knowledge gaps, and inform the development of interview guides. Seventeen structured interviews with 29 participants were conducted to gather information on facilitators and barriers to receiving timely prenatal syphilis screening through the Medicaid program. Interview transcripts were analyzed and compared to identify key themes., Results: Barriers to timely prenatal syphilis screening include varied laws among the states on the timing of screening, Medicaid reimbursement policies that may not adequately incentivize testing, Medicaid enrollment issues that affect both enrollment and continuity of care, and lack of clear understanding among providers on recommended testing., Conclusion: This work provides insight into systemic issues that may be affecting rates of prenatal syphilis screening and incidence among Medicaid enrollees and others in the U.S. South. To address rising congenital syphilis cases, policymakers should consider requiring third trimester syphilis screening, adopting policies to enhance access to prenatal care, adapting Medicaid payment and incentive models, and promoting collaboration between Medicaid and public health agencies., (Copyright © 2022 Jacobs Institute of Women's Health, George Washington University. All rights reserved.)

Background: Congenital syphilis can cause severe morbidity, including miscarriage and stillbirth, and rates are increasing rapidly within the United States. However, congenital syphilis can be prevented with early detection and treatment of syphilis during pregnancy. Current screening recommendations propose that all women should be screened early in pregnancy, whereas women with elevated risks for congenital syphilis should be screened again later in pregnancy. The rapid increase in congenital syphilis rates suggests that there are still gaps in prenatal syphilis screening., Objective: This study aimed to examine associations between the odds of prenatal syphilis screening and sexually transmitted infection history or other patient characteristics across 3 states with elevated rates of congenital syphilis., Study Design: We used the Medicaid claims data from Kentucky, Louisiana, and South Carolina for women with deliveries between 2017 and 2021. Within each state, we examined the log-odds of prenatal syphilis screening as a function of the mother's health history, demographic factors, and Medicaid enrollment history. Patient history was established using a 4-year lookback period of the Medicaid claims data; in state A, sexually transmitted infection surveillance data were used to improve the sexually transmitted infection history., Results: The prenatal syphilis screening rates varied by state, ranging from 62.8% to 85.1% of deliveries to women without a recent history of sexually transmitted infections and from 78.1% to 91.1% of deliveries to women with a previous sexually transmitted infection. For the main outcome of syphilis screening at any time during pregnancy, deliveries associated with previous sexually transmitted infections had 1.09 to 1.37 times higher adjusted odds ratios of undergoing screening. Deliveries to women with continuous Medicaid coverage throughout the first trimester also had higher odds of syphilis screening at any time (adjusted odds ratio, 2.45-3.15). Among deliveries to women with a previous sexually transmitted infection, only 53.6% to 63.6% underwent first-trimester screening and this rate was still just 55.0% to 69.5% when considering only deliveries to women with a previous sexually transmitted infection and full first-trimester Medicaid coverage. Fewer delivering women underwent third-trimester screening (20.3%-55.8% of women with previous sexually transmitted infection). Compared with deliveries to White women, deliveries to Black women had lower odds of first-trimester screening (adjusted odds ratio, 0.85 in all states) but higher odds of third-trimester screening (adjusted odds ratio, 1.23-2.03), potentially impacting maternal and birth outcomes. For state A, linkage to surveillance data doubled the rate of detection of a previous sexually transmitted infection because 53.0% of deliveries by women with a previous sexually transmitted infection would not have had sexually transmitted infection history detected using Medicaid claims alone., Conclusion: A previous sexually transmitted infection and continuous preconception Medicaid enrollment were associated with higher rates of syphilis screening, but Medicaid claims alone do not fully capture the sexually transmitted infection history of patients. The overall screening rates were lower than would be expected given that all women should undergo prenatal screening, but the rates in the third trimester were particularly low. Of note, there are gaps in early screening for non-Hispanic Black women who had lower odds of first-trimester screening when compared with non-Hispanic White women despite being at elevated risk for syphilis., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objectives: The purpose of this study was to measure sexually transmitted infection (STI) testing among Medicaid enrollees initiating preexposure prophylaxis (PrEP) to prevent human immunodeficiency virus. Secondary data are in the form of Medicaid enrollment and claims data in six states in the US South., Methods: Research partnerships in six states in the US South developed a distributed research network to accomplish study aims. Each state identified all first-time PrEP users in fiscal year 2017-2018 (combined N = 990) and measured the presence of STI testing for chlamydia, syphilis, and gonorrhea through 2019. Each state calculated the percentage of individuals with at least one STI test during 3-, 6-, and 12-month follow-up periods., Results: The proportion of first-time PrEP users that received an STI test varied by state: 37% to 67% of all of the individuals in each state who initiated PrEP received a test within the first 6 months of PrEP treatment and 50% to 77% received a test within the first 12 months., Conclusions: Although the Centers for Disease Control and Prevention recommends STI testing at least every 6 months for PrEP users, our analysis of Medicaid data suggests that STI testing occurs less frequently than recommended in populations at elevated risk of syphilis, gonorrhea, and chlamydia.

Examining the current incidence rates of HIV and STIs among racial and ethnic minority and rural residents is crucial to inform and expand initiatives and outreach efforts to address disparities and minimize the health impact of these diseases. A retrospective, cross-sectional study was conducted using Medicaid administrative claims data over a 2-year period (July 2019-June 2021) in South Carolina. Our main outcomes of interest were claims for chlamydia, gonorrhea, syphilis, and HIV. Any beneficiary with at least one claim for a relevant diagnosis throughout the study period was considered to have one of these diseases. Descriptive analyses and multivariable regression models were used to estimate the association between STIs, HIV, race and ethnicity, and rurality. Overall, 158,731 Medicaid beneficiaries had at least one medical claim during the study period. Most were female (86.6%), resided in urban areas (66.6%), and were of non-Hispanic Black race/ethnicity (42.6%). In total, 6.3% of beneficiaries had at least one encounter for chlamydia, 3.2% for gonorrhea, 0.5% for syphilis, and 0.8% for HIV. In multivariable models, chlamydia, gonorrhea, and HIV claims were significantly associated with non-Hispanic Black or other minority race/ethnicity compared to non-Hispanic white race/ethnicity. Rural residents were more likely to have a claim associated with chlamydia and gonorrhea compared to urban residents. The opposite was observed for syphilis and HIV. Providing updated evidence on disparities in STIs and HIV among racial/ethnic minority and rural populations in a southern state is essential for shaping state Medicaid policies to address health disparities., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Context: Sexually transmitted infections (STIs) continue to increase in the United States. Publicly funded sexually transmitted disease (STD) clinics provide important safety net services for communities at greater risk for STIs. However, creating financially sustainable models of STI care remains a challenge., Objective: Characterization of clinic insurance billing practices and patient willingness to use insurance., Design: Cross-sectional survey assessment of clinic administrators and patients., Setting: Twenty-six STD clinics and 4138 patients attending these clinics in high STD morbidity metropolitan statistical areas in the United States., Participants: Clinic administrators and patients of these clinics., Intervention: Survey assessment., Main Outcome Measure: Insurance billing practices of STD clinics and patient insurance status and willingness to use their insurance., Results: Fifteen percent of clinics (4/26) indicated that they billed only Medicaid, 58% (15/26) billed both Medicaid and private insurance, 27% (7/26) did not bill for any health insurance, and none (0%) billed only private health insurance companies. Of 4138 patients surveyed, just more than one-half of patients (52.6%) were covered by some form of health insurance. More than one-half (57.2%) of all patients covered by health insurance indicated that they would be willing to use their health insurance for that visit. After adjusting for patient demographics and clinic characteristics, the patients covered by government insurance were 3 times as likely (odds ratio: 3.16; 95% confidence interval, 2.44-4.10) than patients covered by private insurance to be willing to use their insurance for their visit., Conclusion: Opportunities exist for sustainable STI services through the enhancement of billing practices in STD clinics. The STD clinics provide care to large numbers of individuals who are both insured and who are willing to use their insurance for their care. As Medicaid expansion continues across the country, efforts focused on improving reimbursement rates for Medicaid may improve financial sustainability of STD clinics., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: The rates of syphilis among pregnant women and infants have increased in recent years, particularly in the U.S. South. Although state policies require prenatal syphilis testing, recent screening rates comparable across Southern states are not known. The purpose of this study is to measure syphilis screening among Medicaid enrollees with delivery in states in the U.S. South., Methods: A total of 6 state-university research partnerships in the U.S. South developed a distributed research network to analyze Medicaid claims data using a common analytic approach for enrollees with delivery in fiscal years 2017-2018 and 2018-2019 (combined N=504,943). In 2020-2021, each state calculated the percentage of enrollees with delivery with a syphilis screen test during the first trimester, third trimester, and at any point during pregnancy. Percentages for those with first-trimester enrollment were compared with the percentages of those who enrolled in Medicaid later in pregnancy., Results: Prenatal syphilis screening during pregnancy ranged from 56% to 91%. Screening was higher among those enrolled in Medicaid during the first trimester than in those enrolled later in pregnancy., Conclusions: Despite state laws requiring syphilis screening during pregnancy, screening was much lower than 100%, and states varied in syphilis screening rates among Medicaid enrollees. Findings indicate that access to Medicaid in the first trimester is associated with higher rates of syphilis screening and that efforts to improve access to screening in practice settings are needed., (Copyright © 2021 American Journal of Preventive Medicine. All rights reserved.)

This analysis was designed to determine if there existed differences by race in seeking sexually transmitted disease (STD) care in an emergency department (ED)., Methods: Data were collected from 4,138 patients attending 26 STD clinics across the United States (U.S.). The questionnaire asked where the patient would have sought care if the STD clinic had not been available that day. Responses were stratified by race and differences were tested for statistical significance., Results: Black/African American patients chose hospital emergency room as an alternative for STD clinic care at a rate approximately 2.5 times that of White patients (15.5% v. 5.8%, p &lt; .05). This difference persisted among Black/African American patients after controlling for demographic variables (adjusted OR 2.91; 2.21-3.82 95% CI)., Discussion: Receiving appropriate care is key to stemming the increases in sexually transmitted infections in the U.S. These findings suggest that disparities in access to STD care exist for Black/African American people.

Background: Although rural areas contain approximately 19% of the US population, little research has explored sexually transmitted infection (STI) risk and how urban-developed interventions may be suitable in more population-thin areas. Although STI rates vary across rural areas, these areas share diminishing access to screening and limited rural-specific testing of STI interventions., Methods: This narrative review uses a political ecology model of health and explores 4 domains influencing STI risk and screening: epidemiology, health services, political and economic, and social. Articles describing aspects of rural STI epidemiology, screening access and use, and intervention utility within these domains were found by a search of PubMed., Results: Epidemiology contributes to risk via multiple means, such as the presence of increased-risk populations and the at-times disproportionate impact of the opioid/drug use epidemic. Rural health services are diminishing in quantity, often have lesser accessibility, and may be stigmatizing to those needing services. Local political and economic influences include funding decisions, variable enforcement of laws/statutes, and systemic prevention of harm reduction services. Social norms such as stigma and discrimination can prevent individuals from seeking appropriate care, and also lessen individual self-efficacy to reduce personal risk., Conclusions: Sexually transmitted infection in rural areas is significant in scope and facing diminished prevention opportunities and resources. Although many STI interventions have been developed and piloted, few have been tested to scale or operationalized in rural areas. By considering rural STI risk reduction within a holistic model, purposeful exploration of interventions tailored to rural environments may be explored., Competing Interests: Conflict of Interest and Sources of Funding: The authors state they have no conflicts of interest., (Copyright © 2021 American Sexually Transmitted Diseases Association. All rights reserved.)

Background: Pelvic inflammatory disease (PID) is an infection of the upper genital tract that has important reproductive consequences to women. We describe the burden of and trends in PID among reproductive-aged women in the United States during 2006-2016., Methods: We used data from 2 nationally representative probability surveys collecting self-reported PID history (National Health and Nutrition Examination Survey, National Survey of Family Growth); 5 datasets containing International Classification of Diseases, Ninth/Tenth Revision codes indicating diagnosed PID (Healthcare Utilization Project; National Hospital Ambulatory Medical Care Survey, emergency department component; National Ambulatory Medical Care Survey; National Disease Therapeutic Index; MarketScan); and data from a network of sexually transmitted infection (STI) clinics (Sexually Transmitted Disease Surveillance Network). Trends during 2006-2016 were estimated overall, by age group and, if available, race/ethnicity, region, and prior STIs., Results: An estimated 2 million reproductive-aged women self-reported a history of PID. Three of 4 nationally representative data sources showed overall declines in a self-reported PID history, and PID emergency department and physician office visits, with small increases observed in nearly all data sources starting around 2015., Conclusions: The burden of PID in the United States is high. Despite declines in burden over time, there is evidence of an increase in recent years., (Published by Oxford University Press for the Infectious Diseases Society of America 2021.)

Background: Chlamydia, gonorrhea, and syphilis are common, treatable sexually transmitted infections (STIs) that are highly prevalent in the general US population. Costs associated with diagnosing and treating these conditions for individual states' Medicaid participants are unknown. The purpose of this study was to estimate the cost of screening and treatment for 3 common STIs for state Medicaid program budgets in Maryland and South Carolina., Methods: A retrospective, cross-sectional study was conducted using Medicaid administrative claims data over a 2-year period. Claims were included based on the presence of one of the 3 study conditions in either diagnosis or procedure codes. Descriptive analyses were used to characterize the participant population and expenditures for services provided., Results: Total Medicaid expenditures for STI care in state fiscal years 2016 and 2017 averaged $43.5 million and $22.3 million for each year in Maryland and South Carolina, respectively. Maryland had a greater proportion of costs associated with outpatient hospital and laboratory settings. Costs for care provided in the emergency department were highest in South Carolina., Conclusions: Diagnosis and treatment of commonly reported STIs may have a considerable financial impact on individual state Medicaid programs. Public health activities directed at STI prevention are important tools for reducing these costs to states., Competing Interests: Conflict of Interest: None declared., (Copyright © 2021 American Sexually Transmitted Diseases Association. All rights reserved.)

Background: The Centers for Disease Control and Prevention recommends initial and follow-up sexually transmitted infection (STI) and HIV testing when taking HIV preexposure prophylaxis (PrEP). We assessed frequencies of STIs and HIV testing and rates of STIs before and after PrEP initiation among men aged ≥18 years., Methods: We used the OptumLabs database for this cohort study. We measured STI/HIV testing rates and prevalence in 2 time intervals: (1) within 90 days before and on the date of PrEP initiation and (2) within 45 days of the 180th day after the date of PrEP initiation., Results: Of 4210 men who initiated PrEP in 2016 to 2017 and continuously used PrEP for ≥180 days, 45.7%, 45.7%, and 56.0% were tested for chlamydia, gonorrhea, and HIV, respectively, at the second time interval. These percentages were significantly lower than those at the first time interval (58.3%, 57.9%, and 73.5%, respectively; P < 0.01). Chlamydia and gonorrhea prevalence rates at the second time interval were 6.5% and 6.2%, respectively, versus 5.0% and 4.7%, respectively, at the first time interval. Most gonorrhea or chlamydia infections at the second time intervals seem to be new infections new infections., Conclusions: Sexually transmitted infection/HIV testing for PrEP users in the real-world private settings is much lower than in clinical trials. High STI prevalence before and after PrEP initiation in this study suggests that patients taking PrEP have an increased risk of acquiring STI. Interventions to improve provider adherence for PrEP users are urgently needed., Competing Interests: Conflict of Interest and Sources of Funding: The authors declare no conflict of interest. No external funding sources were used to assist in the preparation of this article., (Copyright © 2021 American Sexually Transmitted Diseases Association. All rights reserved.)

Reports of bacterial sexually transmitted infections are at the highest levels ever reported in the United States, and state and local budgetary issues are placing specialized sexually transmitted disease (STD) care at risk. This study collected information from 4138 patients seeking care at 26 STD clinics in large metropolitan areas across the United States with high levels of reported STDs to determine patient needs and clinic capabilities. Surveys were provided to patients attending these STD clinics to assess their demographic information as well as reasons for coming to the clinic and surveys were also provided to clinic administrators to determine their operational capacities and services provided by the clinic. For this initial study, we conducted univariate analyses to report all data collected from these surveys. Patients attending STD clinics across the country indicated that they do so because of the relative ease of getting an appointment; including walk-in and same-day appointments as well as the welcoming environment and expertise of the staff at the clinic. Additionally, STD clinics provide specialized care to patients; including HIV testing and counseling as well as on-site, injectable medications for the treatment of gonorrhea and syphilis in an environment that helps to reduce the role of stigma in seeking this kind of care. Sexually transmitted disease clinics continue to play an important role in helping to curb the rising epidemic of sexually transmitted infections., (Published by Elsevier Inc.)

Background: The Centers for Disease Control and Prevention (CDC) recommends specific regimens for chlamydia and dual therapy for gonorrhea to mitigate antimicrobial-resistant gonorrhea in the CDC 2015 sexually transmitted disease treatment guidelines. Only limited studies examining adherence to these recommendations have been conducted at private practices in the United States., Methods: We used the OptumLabs Data Warehouse, a comprehensive, longitudinal data asset with deidentified persons with linked commercial insurance claims and clinical information, to identify persons aged 15 to 60 years who had valid nucleic acid amplification testing results demonstrating urogenital or extragenital gonorrhea or chlamydia in 2016 to 2018. We defined valid laboratory results as positive or negative. We then assessed the time of their first positive test result and the type of treatment within 30 days to determine if there was evidence in the claims record that the CDC-recommended treatment was provided. We defined presumed treatment if the date of treatment was before the date of the positive test result within 30 days., Results: Among 6476 patients with positive gonorrhea test results and 26,847 patients with positive chlamydia test results only, 34.8% and 64.2% had evidence of receiving the CDC-recommended therapy, respectively. Approximately 11.6% of patients with positive gonorrhea test results with recommended dual treatment and 7.1% of patients with positive chlamydia test results only with recommended chlamydia treatment were presumptively treated., Conclusion: Analysis of treatment claims and medical records from private settings indicated low rates of recommended gonorrhea and chlamydia treatment. Validation of treatment claims is needed to support further quality of care interventions based on these data., Competing Interests: Conflict of Interest and Sources of Funding: Neither authors' conflict of interest nor financial source was involved in this article., (Copyright © 2020 American Sexually Transmitted Diseases Association. All rights reserved.)

Introduction: Access to health care services such as screening, testing, and treatment of sexually transmitted diseases is vital for those who engage in high-risk behaviors. Studies examining the relationship between high-risk behaviors and health care access and utilization are crucial for determining whether persons at risk are receiving appropriate health services., Methods: We examined 2016 data from the Behavioral Risk Factor Surveillance System. Our study population included persons aged 18 to 65 years. χ and logistic regression analyses were used to examine relationships between high-risk behaviors including drug use and high-risk sexual behaviors, and access to and utilization of health care services., Results: Among our study population, 6.2% engaged in a high-risk behavior in the past year. Those engaging in high-risk behaviors were more likely to have no health insurance coverage (odds ratio [OR], 1.23; 95% confidence interval [CI], 1.13-1.34), have no personal health care provider (OR, 1.14; 95% CI, 1.06-1.21), have foregone care because of cost (OR 1.54; 95% CI, 1.42-1.65), or have had no routine check-up in the past 2 years (OR 1.16; 95% CI, 1.09-1.25)., Conclusions: Those who engaged in high-risk behaviors had poorer health care access and utilization outcomes. Future studies should incorporate the relationships between changes in behaviors, health care access and utilization, and resulting sexually transmitted disease morbidity.

Introduction: Chlamydia and gonorrhea are the most commonly reported notifiable infections in the U.S., with direct medical costs for the treatment of these infections exceeding $700 million annually. Medicaid currently covers approximately 80 million low-income Americans, including a high percentage of racial and ethnic minorities. Studies have shown that racial and ethnic minority populations, particularly those with low SES, are at an increased risk of acquiring a sexually transmitted disease. Therefore, as Medicaid expands, there will likely be a greater demand for sexually transmitted disease services in community-based physician offices. To determine demand for these services among Medicaid enrollees, this study examined how often Medicaid was used to pay for sexually transmitted disease services received in this setting., Methods: This study combined 2014 and 2015 data from the National Ambulatory Medical Care Survey and tested for differences in the proportion of visits with an expected payment source of Medicaid when sexually transmitted disease services were and were not provided. All analyses were conducted in October 2018., Results: During 2014-2015, an estimated 25 million visits received a sexually transmitted disease service. Medicaid paid for a greater percentage of sexually transmitted disease visits (35.5%, 95% CI=22.5%, 51.1%) compared with non-sexually transmitted disease visits (12.1%, 95% CI=10.8%, 13.6%). Logistic regression modeling, controlling for age, sex, and race of the patient, showed that visits covered by Medicaid had increased odds of paying for a sexually transmitted disease service visit (OR=1.97, 95% CI=1.12, 3.46), compared with other expected payment sources., Conclusions: Focusing sexually transmitted disease prevention in Medicaid populations could reduce sexually transmitted disease incidence and resulting morbidity and costs., (Copyright © 2019. Published by Elsevier Inc.)

Background Violent crime rates are often correlated with the hard-to-measure social determinants of sexually transmissible infections (STIs). In this study, we examined whether including violent crime rate as an independent variable can improve the quality of ecological regression models of STIs., Methods: We obtained multiyear (2008-12) cross-sectional county-level data on violent crime and three STIs (chlamydia, gonorrhoea, and primary and secondary (P&S) syphilis) from counties in all the contiguous states in the US (except Illinois and Florida, due to lack of data). We used two measures of STI morbidity (one categorical and one continuous) and applied spatial regression with the spatial error model for each STI, with and without violent crime rate as an independent variable. We computed the associated Akaike's information criterion (AIC) and Bayesian information criterion (BIC) as our measure of the relative goodness of fit of the models., Results: Including the violent crime rate as an independent variable improved the quality of the regression models after controlling for several sociodemographic factors. We found that the lower calculated AICs and BICs indicated more favourable goodness of fit in all the models that included violent crime rates, except for the categorical P&S syphilis model, in which the violent crime variable was not statistically significant., Conclusion: Because violent crime rates can account for the hard-to-measure social determinants of STIs, including violent crime rate as an independent variable can improve ecological regression models of STIs.

Objective: Chlamydia, gonorrhoea and syphilis (primary and secondary) are at high levels in the USA. Disparities by race, gender and sexual orientation have been characterised, but while there are indications that rural poor populations may also be at distinct risk this has been subjected to little study by comparison. The federally designated Delta Regional Authority, similar in structure to the Appalachian Regional Commission, oversees 252 counties within eight Mississippi Delta states experiencing chronic economic and health disparities. Our objective was to identify differences in infection risk between Delta Region (DR)/non-DR counties and examine how they might vary by rurality, population density, primary care access and education attainment., Methods: Reported chlamydia/gonorrhoea/syphilis data were obtained from the Centers for Disease Control and Prevention AtlasPlus, county demographic data from the Area Health Resource File and rurality classifications from the Department of Agriculture. Data were subjected to analysis by t-test, χ 2 and linear regression to assess geographical disparities in incidence and their association with measures of rurality, population and primary care density, and education., Results: Overall rates for each infection were significantly higher in DR versus non-DR counties (577.8 vs 330.1/100 000 for chlamydia; 142.8 vs 61.8 for gonorrhoea; 3.6 vs 1.7 for syphilis; all P<0.001) and for nearly every infection for every individual state. DR rates for each infection were near-universally significantly increased for every level of rurality (nine levels) and population density (quintiles). Regression found that primary care and population density and HS graduation rates were significantly associated with each, though model predictive abilities were poor., Conclusions: The nearly 10 million people living in the DR face significant disparities in the incidence of chlamydia, gonorrhoea and syphilis-in many instances a near-doubling of risk. Our findings suggest that resource-constrained areas, as measured by rurality, should be considered a priority for future intervention efforts., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2018. No commercial re-use. See rights and permissions. Published by BMJ.)

Chlamydia trachomatis (CT) and Neisseria gonorrhea (GC) are the most frequently reported notifiable diseases in the United States and costs for diagnosis and treatment of these two infections are approximately $700 million per year. A proposed new method for screening for these two infections is self-tests; similar to at-home pregnancy and HIV tests which do not include sending collected specimens to a laboratory for diagnosis. However, no such self-tests for sexually transmitted diseases (STD) have been approved by the Food and Drug Administration (FDA). To determine the acceptability of such a test, we used three surveys, conducted in 2017, including the American Men's Internet Survey, the SummerStyles survey, and the DocStyles survey to ask potential users about their interest in this type of test and how they might use it. Among our sampled population of men who have sex with men, 79.5% said they would prefer to take this type of test at home and 73.9% said they would be willing to pay at least $20 for the test. Among young adults (18-29 years), 54.1% indicated that they would like to take this test at home and 64.5% were willing to pay more than $10 for such a test. Among sampled physicians, 85.1% were "likely" or "very likely" to use an FDA-approved STD self-test in their office to screen for CT or GC. Self-tests for STDs are on our horizon and we need to be prepared to integrate these tests into our healthcare systems., (Published by Elsevier Inc.)

Objective: To describe the array of sexual health care services provided at US colleges and universities., Participants: During 2014-2015, 885 colleges were surveyed about their provision of sexual health services., Methods: 55% of colleges responded. Data were weighted and stratified by minority-serving institutions (MSIs), 2-year and 4-year institutions., Results: 70.6% of colleges reported having a health center (HC), of which 73.0% offered STI diagnosis/treatment (4 years vs. 2 years; 77.9% vs. 53.1%) and contraceptive services (70.1% vs. 46.4%), all p < .001. HCs less frequently offered LARC (19.7%), express STI testing (24.4%) and self-collection (31.4%). Condoms were available on 66.8% of campuses. HPV vaccination was available at more 4-year colleges (73.7% vs. 48.5%, p < .003) and non-MSIs (74.4% vs. 58.5, p = .019). Regarding MSM-targeted services, 54.6% offered pharyngeal and 51.8% rectal STI testing., Conclusions: 2-year colleges may require additional support with providing sexual health care. Improvements could entail increasing express testing, extra-genital STI testing, and LARC.

New technology may soon allow individuals to test themselves for chlamydia and gonorrhea. These new self-tests might help increase screening, but they will also bring new issues for treatment, prevention, and surveillance. Providers will need to decide how to respond to patients who present after a positive screening test and how to approach partner testing and treatment. Research will be needed to identify approaches to increase screening using these tests. Laboratory-based surveillance will not capture infections if testing does not involve a laboratory, so new surveillance techniques will be needed. Self-tests are new tools that will soon be available. We should be prepared to use them.

Surveillance data show that there is an increase in the incidence of sexually transmitted infections (STI) and we believe that because of this increased incidence, coupled with a deteriorating public health infrastructure, these STIs are being seen more often in emergency departments. Therefore, we used six years of the most recently available nationally-representative emergency department data to show an increase in the number of emergency department visits where a sexually transmitted infection was treated. We further described the population for these visits., (Published by Elsevier Inc.)

Purpose: We used a combination of hot spot analysis (HSA) and spatial regression to examine county-level hot spot correlates for the most commonly reported nonviral sexually transmitted infections (STIs) in the 48 contiguous states in the United States (US)., Methods: We obtained reported county-level total case rates of chlamydia, gonorrhea, and primary and secondary (P&S) syphilis in all counties in the 48 contiguous states from national surveillance data and computed temporally smoothed rates using 2008-2012 data. Covariates were obtained from county-level multiyear (2008-2012) American Community Surveys from the US census. We conducted HSA to identify hot spot counties for all three STIs. We then applied spatial logistic regression with the spatial error model to determine the association between the identified hot spots and the covariates., Results: HSA indicated that ≥84% of hot spots for each STI were in the South. Spatial regression results indicated that, a 10-unit increase in the percentage of Black non-Hispanics was associated with ≈42% (P < 0.01) [≈22% (P < 0.01), for Hispanics] increase in the odds of being a hot spot county for chlamydia and gonorrhea, and ≈27% (P < 0.01) [≈11% (P < 0.01) for Hispanics] for P&S syphilis. Compared with the other regions (West, Midwest, and Northeast), counties in the South were 6.5 (P < 0.01; chlamydia), 9.6 (P < 0.01; gonorrhea), and 4.7 (P < 0.01; P&S syphilis) times more likely to be hot spots., Conclusion: Our study provides important information on hot spot clusters of nonviral STIs in the entire United States, including associations between hot spot counties and sociodemographic factors., (Published by Elsevier Inc.)

Background: Current guidelines recommend that all sexually active human immunodeficiency virus (HIV)-infected persons be tested at least annually for syphilis, chlamydia, and gonorrhea. We examined temporal trends in syphilis, chlamydia, and gonorrhea testing among sexually active HIV-infected adults receiving medical care in the United States during 2009-2013., Methods: Using medical record data from the Medical Monitoring Project, a population-based HIV surveillance system, we assessed the proportion of adults receiving HIV medical care who were tested for syphilis, chlamydia, and gonorrhea in the past 12 months by year and stratified by sex and sexual behavior, age, and race/ethnicity., Results: During 2009-2013, the proportion of sexually active HIV-infected adults receiving medical care who were tested in the past year for all 3 examined sexually transmitted diseases (STDs) increased from 20% to 36% (PTREND < .01). Overall testing for syphilis increased from 55% to 65% (PTREND < .01), and significant increases were noted for the following subgroups: men who have sex with men (58% to 69%), non-Hispanic whites (48% to 64%), and all age groups with the exception of persons aged 18-29 year. Overall testing for chlamydia and gonorrhea increased from 22% to 42% (PTREND < .01), and significant increases were noted for most subgroups., Conclusions: STD testing significantly increased among sexually active HIV-infected adults receiving medical care; however, the majority of persons were not tested for all 3 STDs in 2013. While increased testing indicates progress, testing remained far below recommended guidelines. Our findings suggest enhanced efforts may be warranted to screen all sexually active HIV-infected adults for syphilis, chlamydia, and gonorrhea., (Published by Oxford University Press for the Infectious Diseases Society of America 2016. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

During 2010-2014, urgent care centers saw a ≈2-fold increase in the number of visits for chlamydia and gonorrhea testing and a >3-fold increase in visits by persons with diagnosed sexually transmitted infections. As urgent care becomes more popular, vigilance is required to ensure proper management of these diseases.

Objectives: To survey patients of publicly funded sexually transmitted disease (STD) clinics across the United States about their willingness to use health insurance for their visit., Methods: In 2013, we identified STD clinics in 21 US metropolitan statistical areas with the highest rates of chlamydia, gonorrhea, and syphilis according to Centers for Disease Control and Prevention surveillance reports. Patients attending the identified STD clinics completed a total of 4364 surveys (response rate = 86.6%)., Results: Nearly half of the insured patients were willing to use their health insurance. Patients covered by government insurance were more likely to be willing to use their health insurance compared with those covered by private insurance (odds ratio [OR] =  3.60; 95% confidence interval [CI] = 2.79, 4.65), and patients covered by their parents' insurance were less likely to be willing to use their insurance compared with those covered by private insurance (OR = 0.72; 95% CI = 0.52, 1.00). Reasons for unwillingness to use insurance were privacy and out-of-pocket cost., Conclusions: Before full implementation of the Affordable Care Act, privacy and cost were barriers to using health insurance for STD services., Public Health Implications: Barriers to using health insurance for STD services could be reduced through addressing issues of stigma associated with STD care and considering alternative payment sources for STD services.

Chlamydia trachomatis (CT) is the most commonly reported sexually transmitted infection (STI) in the US and timely, correct treatment can reduce CT transmission and sequelae. Emergency departments (ED) are an important location for diagnosing STIs. This study compared recommended treatment of CT in EDs to treatment in physician offices. Five years of data (2006-2010) were analyzed from the National Ambulatory Medical Care Survey, and the National Hospital Ambulatory Medical Care Surveys (NHAMCS), including the Outpatient survey (NHAMCS-OPD) and Emergency Department survey (NHAMCS-ED). All visits with a CT diagnosis and those with a diagnosis of unspecified venereal disease were selected for analysis. Differences in receipt of recommended treatments were compared between visits to physician offices and emergency departments using Chi square tests and logistic regression models. During the 5 year period, approximately 3.2 million ambulatory care visits had diagnosed CT or an unspecified venereal disease. A greater proportion of visits to EDs received the recommended treatment for CT compared to visits to physician offices (66.1 vs. 44.9 %, p < .01). When controlling for patients' age, sex and race/ethnicity, those presenting to the ED with CT were more likely to receive the recommended antibiotic treatment than patients presenting to a physician's office (OR 2.16; 95 % CI 1.04-4.48). This effect was attenuated when further controlling for patients' expected source of payment. These analyses demonstrate differences in the treatment of CT by ambulatory care setting as well as opportunities for increasing use of recommended treatments for diagnosed cases of this important STI.

Background: Presence of a sexually transmitted infection (STI) can increase the likelihood of HIV transmission, and current treatment guidelines indicate that HIV-positive persons should be screened yearly for STIs. Therefore, we examined recent insurance claims data to determine whether private insurance beneficiaries who are HIV-positive were receiving recommended STI testing., Methods: We used data from the 2011 and 2012 MarketScan data sets, a longitudinal population-based database that collects claims from commercially insured persons in private insurance and is conducted by Truven Health Analytics. Over a 13-month period, we calculated rates of testing for chlamydia, gonorrhea, and syphilis among an HIV-positive population and determined the factors that contributed to differences in testing rates., Results: Overall testing rates were 22.2% for chlamydia, 21.9% for gonorrhea, and 51.1% for syphilis. Significant predictors of STI testing were sex, age, type of health plan, engagement with the health care system, and geographic location. Most notably, persons receiving viral load testing were more likely to receive testing for chlamydia [odds ratio (OR): 1.72; 95% confidence interval (CI): 1.63 to 1.81], gonorrhea (OR: 1.72; 95% CI: 1.64 to 1.81), and syphilis (OR: 3.38; 95% CI: 3.25 to 3.53) compared with persons not receiving viral load testing., Discussion: Not all commercially insured HIV-positive patients are receiving recommended testing for STIs. Presence of STIs could affect the transmission of HIV and has deleterious effects on health outcomes of the patients. Targeted efforts based on demographics, health plan type, and other quality-of-care measures could help identify populations for whom testing rates for STIs among HIV-positive persons could be improved.

Objectives: We assessed the characteristics of sexually transmitted disease (STD) clinic patients, their reasons for seeking health services in STD clinics, and their access to health care in other venues., Methods: In 2013, we surveyed persons who used publicly funded STD clinics in 21 US cities with the highest STD morbidity., Results: Of the 4364 STD clinic patients we surveyed, 58.5% were younger than 30 years, 72.5% were non-White, and 49.9% were uninsured. They visited the clinic for STD symptoms (18.9%), STD screening (33.8%), and HIV testing (13.6%). Patients chose STD clinics because of walk-in, same-day appointments (49.5%), low cost (23.9%), and expert care (8.3%). Among STD clinic patients, 60.4% had access to another type of venue for sick care, and 58.5% had access to another type of venue for preventive care. Most insured patients (51.6%) were willing to use insurance to pay for care at the STD clinic., Conclusions: Despite access to other health care settings, patients chose STD clinics for sexual health care because of convenient, low-cost, and expert care. Policy Implication. STD clinics play an important role in STD prevention by offering walk-in care to uninsured patients.