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Background: Until 2005, national-level data on the sex of sex partners that describe how primary and secondary syphilis affects men who have sex with men (MSM) of different races or ethnicities were not reported. Objective: To present data from 27 states comparing trends in primary and secondary syphilis among MSM of different races or ethnicities. Design: Review of case report data and regression analysis. Setting: Federal database of case reports in the National Electronic Telecommunications System for Surveillance. Participants: Men reported to be MSM. Measurements: Cases of primary and secondary syphilis per 100 000 males of matching race or ethnicity ('rates'), determined by using population data from the National Center for Health Statistics as the denominator to compare age and racial and ethnic differences. Results: For each year during 2005 to 2008, 27 states from all U.S. census regions reported data on the sex of sex partners for 70% or more of male cases of primary and secondary syphilis. Regression analysis revealed significantly different trends in rates of primary and secondary syphilis: Absolute increases in rates among black MSM and Hispanic MSM were, respectively, 8.0 times and 2.4 times the absolute increase in rate among white MSM. By region, rates among MSM increased 30% in the Midwest, 48% in the South, 73% in the Northeast, and 77% in the West. By age group, the largest absolute increase in rates occurred among MSM aged 20 to 29 years. Limitation: Results from 27 states may not be generalizable to the United States as a whole. Conclusion: Rates of primary and secondary syphilis disproportionately increased among black and Hispanic MSM (compared with white MSM) and among young MSM. Care providers should offer counseling about safer sexual practices and screening for syphilis and other sexually transmitted infections when caring for MSM. Primary Funding Source: Centers for Disease Control and Prevention. [ABSTRACT FROM AUTHOR]

This article presents an update to "Sexually Transmitted Diseases Treatment Guidelines, 2006," put out by the U.S. Centers for Disease Control and Prevention, which explains that fluoroquinolones are no longer recommended to treat gonococcal infections. The article explains that previously, fluoroquinolones were used to treat gonorrhea because they were readily available and they were convenient because they could be taken orally. However, changes in treatment have become necessary because Neisseria gonorrhoeae is becoming more and more resistant to fluoroquinolones.

Abstract: The COVID-19 pandemic impacted sexually transmitted disease (STD) services. Of 59 US-funded STD programs, 91% reported a great deal to moderate impact from staff reassignment in April 2020, with 28% of respondents reporting permanent reassignment of disease intervention specialist staff. Telemedicine was implemented in 47%. Decreases in STD case reports were reported by most jurisdictions., Competing Interests: Conflict of Interest and Sources of Funding: None declared., (Copyright © 2021 American Sexually Transmitted Diseases Association. All rights reserved.)

Background: The prevalence of Neisseria gonorrhoeae (GC) isolates with elevated minimum inhibitory concentrations to various antibiotics continues to rise in the United States and globally. Genomic analysis provides a powerful tool for surveillance of circulating strains, antimicrobial resistance determinants, and understanding of transmission through a population., Methods: Neisseria gonorrhoeae isolates collected from the US Gonococcal Isolate Surveillance Project in 2018 (n = 1479) were sequenced and characterized. Whole-genome sequencing was used to identify sequence types, antimicrobial resistance profiles, and phylogenetic relationships across demographic and geographic populations., Results: Genetic characterization identified that (1) 80% of the GC isolates were represented in 33 multilocus sequence types, (2) isolates clustered in 23 major phylogenetic clusters with select phenotypic and demographic prevalence, and (3) common antimicrobial resistance determinants associated with low-level or high-level decreased susceptibility or resistance to relevant antibiotics., Conclusions: Characterization of this 2018 Gonococcal Isolate Surveillance Project genomic data set, which is the largest US whole-genome sequence data set to date, sets the basis for future prospective studies, and establishes a genomic baseline of GC populations for local and national monitoring., Competing Interests: Conflict of Interest and Sources of Funding: This work was supported by the Centers for Disease Control and Prevention (CDC) and in part made possible through support from CDC's Combating Antibiotic Resistant Bacteria and Advanced Molecular Detection programs. This project was also supported in part by an appointment to the Research Participation Program at the CDC administered by the Oak Ridge Institute for Science and Education through an interagency agreement between the Department of Energy and the CDC (to J.L.R. and V.L.C.). Authors declare no conflict of interest., (Copyright © 2021 American Sexually Transmitted Diseases Association. All rights reserved.)

Background: The most recent estimates of the number of prevalent and incident sexually transmitted infections (STIs) in the United States were for 2008. We provide updated estimates for 2018 using new methods., Methods: We estimated the total number of prevalent and incident infections in the United States for 8 STIs: chlamydia, gonorrhea, trichomoniasis, syphilis, genital herpes, human papillomavirus, sexually transmitted hepatitis B, and sexually transmitted HIV. Updated per-capita prevalence and incidence estimates for each STI were multiplied by the 2018 full resident population estimates to calculate the number of prevalent and incident infections. STI-specific estimates were combined to generate estimates of the total number of prevalent and incident STIs overall, and by sex and age group. Primary estimates are represented by medians, and uncertainty intervals are represented by the 25th (Q1) and 75th (Q3) percentiles of the empirical frequency distributions of prevalence and incidence for each STI., Results: In 2018, there were an estimated 67.6 (Q1, 66.6; Q3, 68.7) million prevalent and 26.2 (Q1, 24.0; Q3, 28.7) million incident STIs in the United States. Chlamydia, trichomoniasis, genital herpes, and human papillomavirus comprised 97.6% of all prevalent and 93.1% of all incident STIs. Persons aged 15 to 24 years comprised 18.6% (12.6 million) of all prevalent infections; however, they comprised 45.5% (11.9 million) of all incident infections., Conclusions: The burden of STIs in the United States is high. Almost half of incident STIs occurred in persons aged 15 to 24 years in 2018. Focusing on this population should be considered essential for national STI prevention efforts., Competing Interests: Conflict of Interest and Sources of Funding: The authors report no conflicts of interest., (Copyright © 2021 American Sexually Transmitted Diseases Association. All rights reserved.)

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

Background: Syphilis is a genital ulcerative disease caused by the bacterium Treponema pallidum that is associated with significant complications if left untreated and can facilitate the transmission and acquisition of HIV infection. The last prevalence and incidence estimates of the burden of syphilis in the United States were for 2008., Methods: We generate syphilis prevalence and incidence estimates for 2018 among adults aged 14 to 49 years. We fit a simple mathematical model to 2018 case report data to generate 10,000 sets of estimates for age and sex subpopulations and summarize our estimates by their median (50th percentile); uncertainty intervals are characterized by their 25th (Q1) and 75th (Q3) percentiles. We also used our methodology to reestimate 2008 prevalence and incidence estimates., Results: In 2018, there were an estimated 156,000 (Q1, 132,000; Q3, 184,000) prevalent and 146,000 (Q1, 126,000; Q3, 170,000) incident syphilitic infections in people aged 14 to 49 years. Men accounted for roughly 70% of prevalent infections and more than 80% of incident infections. In both sexes, there were more prevalent and incident infections in 25- to 49-year-olds than 14- to 24-year-olds. Using these methods to reanalyze 2008 data, syphilis prevalence and incidence estimates have increased 164% and 175%, respectively, between 2008 and 2018., Discussion: Although not as common as other sexually transmitted infections, syphilis should be monitored because of its devastating sequelae. As it continues to increase in frequency, it will be important for future work to continue to track its trajectory and burden., Competing Interests: Conflict of Interest and Sources of Funding: None declared., (Copyright © 2021 American Sexually Transmitted Diseases Association. All rights reserved.)

Abstract: Most estimates of the combined burden and cost of sexually transmitted infections (STIs) in the United States have focused on 8 common STIs with established national surveillance strategies (chlamydia, gonorrhea, syphilis, trichomoniasis, genital herpes, human papillomavirus, and sexually transmitted human immunodeficiency virus and hepatitis B). However, over 30 STIs are primarily sexually transmitted or sexually transmissible. In this article, we review what is known about the burden of "other STIs" in the United States, including those where sexual transmission is not the primary transmission route of infection. Although the combined burden of these other STIs may be substantial, accurately estimating their burden due to sexual transmission is difficult due to diagnostic and surveillance challenges. Developing better estimates will require innovative strategies, such as leveraging existing surveillance systems, partnering with public health and academic researchers outside of the STI field, and developing methodology to estimate the frequency of sexual transmission, particularly for new and emerging STIs., Competing Interests: Conflict of Interest and Sources of Funding: None declared., (Copyright © 2021 American Sexually Transmitted Diseases Association. All rights reserved.)

During 2013-2017, the national annual rate of reported primary and secondary (P&S) syphilis cases in the United States increased 72.7%, from 5.5 to 9.5 cases per 100,000 population (1). The highest rates of P&S syphilis are seen among gay, bisexual, and other men who have sex with men (collectively referred to as MSM) (2), and MSM continued to account for the majority of cases in 2017 (1). However, during 2013-2017, the P&S syphilis rate among women increased 155.6% (from 0.9 to 2.3 cases per 100,000 women), and the rate among all men increased 65.7% (from 10.2 to 16.9 cases per 100,000 men), indicating increasing transmission between men and women in addition to increasing transmission between men (1). To further understand these trends, CDC analyzed national P&S syphilis surveillance data for 2013-2017 and assessed the percentage of cases among women, men who have sex with women only (MSW), and MSM who reported drug-related risk behaviors during the past 12 months. Among women and MSW with P&S syphilis, reported use of methamphetamine, injection drugs, and heroin more than doubled during 2013-2017. In 2017, 16.6% of women with P&S syphilis used methamphetamine, 10.5% used injection drugs, and 5.8% used heroin during the preceding 12 months. Similar trends were seen among MSW, but not among MSM. These findings indicate that a substantial percentage of heterosexual syphilis transmission is occurring among persons who use these drugs, particularly methamphetamine. Collaboration between sexually transmitted disease (STD) control programs and partners that provide substance use disorder services will be important to address recent increases in heterosexual syphilis., Competing Interests: All authors have completed and submitted the ICMJE form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

To estimate new human immunodeficiency virus (HIV) diagnosis rates among HIV negative men who have sex with men (MSM) who are repeatedly tested for HIV in sexually transmitted disease (STD) clinics and assess the impact of demographic and disease-specific characteristics that are associated with higher HIV diagnosis rates., Study Design: Retrospective analysis using 2010 to 2013 data from the STD Surveillance Network (SSuN), a sentinel surveillance system comprised of health departments in 12 cities conducting sentinel surveillance in 40 STD clinics. We analyzed data from all MSM repeatedly (≥2 times) tested for HIV, with an initial negative HIV test required for staggered cohort entry. Follow-up time was accrued from the date of the first negative HIV test to the most recent negative test or the first positive HIV test. The STD diagnoses during the follow-up period were reviewed. We estimated HIV diagnoses rates (number of HIV diagnoses/total number of person-years [PY] at risk) by demographic and clinical characteristics with 95% confidence intervals (CI) using an inverse variance weighted random effects model, adjusting for heterogeneity between SSuN jurisdictions., Results: Overall, 640 HIV diagnoses occurred among 14,824 individuals and 20,951.6 PY of observation, for an adjusted incidence of HIV diagnosis of 3.0 per 100 PY (95% CI, 2.6-3.4). Rates varied across race/ethnicity groups with the highest rate among Blacks (4.7/100 PY; 95% CI, 4.1-5.3) followed by Hispanics, whites, and persons of other races/ethnicities. Men who have sex with men having a diagnosis of primary or secondary (P&S) syphilis on or after the first negative HIV test had a higher new HIV diagnosis rate (7.2/100 PY; 95% CI, 5.8-9.0) compared with MSM who did not have a P&S syphilis diagnosis (2.8/100 PY; 95% CI, 2.6-3.1). Men who have sex with men who tested positive for rectal gonorrhea (6.3/100 PY; 95% CI, 5.7-6.9) or rectal chlamydia (5.6/100 PY; 95% CI, 4.6-6.6) had higher rates of new HIV diagnosis when compared to those with negative test results., Conclusions: Men who have sex with men attending SSuN STD clinics have high rates of new HIV diagnoses, particularly those with a previous diagnosis of P&S syphilis, rectal chlamydia, and/or gonorrhea. Sexually transmitted disease clinics continue to be important clinical setting for diagnosing HIV among MSM populations.

Preventing the emergence of ceftriaxone-resistant Neisseria gonorrhoeae can potentially avert hundreds of millions of dollars in direct medical costs of gonorrhea and gonorrhea-attributable HIV infections. In the illustrative scenario we examined, emerging ceftriaxone resistance could lead to 1.2 million additional N. gonorrhoeae infections within 10 years, costing $378.2 million.

Background: Men who have sex with men (MSM) in the United States experience an approximately 100-fold greater rate of primary and secondary (P&S) syphilis diagnoses compared with men who have sex with women only. As in the general population, racial/ethnic disparities in P&S syphilis diagnosis rates may exist among MSM, but MSM-specific P&S syphilis rates by race/ethnicity are unavailable. We enhanced a published modeling approach to estimate area-level MSM populations by race/ethnicity and provide the first estimates of P&S syphilis among black and white non-Hispanic MSM., Methods: We used data from the American Community Survey (ACS), published findings from the National Health and Nutrition Examination Survey (NHANES), and national syphilis surveillance data to estimate state-level rates of P&S syphilis diagnoses among MSM, overall and for black and white non-Hispanic MSM. We also used variability around ACS and NHANES estimates to calculate 95% confidence intervals for each rate., Results: Among 11,359 cases of P&S syphilis among MSM with known race/ethnicity in 2014, 72.5% were among white (40.3%) or black (32.2%) MSM. The national rate of P&S syphilis diagnosis was 168.4/100,000 for white MSM and 583.9/100,000 for black MSM. Regional rates for black MSM ranged from 602.0/100,000 (South) to 521.5/100,000 (Midwest) and were consistently higher than those for white MSM., Conclusions: Although white MSM accounted for more P&S syphilis diagnoses than black MSM in 2014, when evaluating diagnoses based on rate per 100,000, black MSM had consistently and markedly higher rates than white MSM, with the highest impacted states located in the US South.

Background: Congenital syphilis (CS) results when an infected pregnant mother transmits syphilis to her unborn child prior to or at delivery. The severity of infection can range from a delivery at term without signs of infection to stillbirth or death after delivery., Objective: We sought to describe CS morbidity and mortality during 1999 through 2013., Study Design: National CS case data reported to Centers for Disease Control and Prevention during 1999 through 2013 were analyzed. Cases were classified as dead (stillbirths and deaths up to 12 months after delivery), morbid (cases with strong [physical, radiographic, and/or nonserologic laboratory] evidence of CS), and nonmorbid (cases with a normal physical examination reported, without strong evidence of infection). Annual rates of these cases were calculated. Cases were compared using selected maternal and infant criteria., Results: During 1999 through 2013, 6383 cases of CS were reported: 6.5% dead, 33.6% morbid, 53.9% nonmorbid, and 5.9% unknown morbidity; 81.8% of dead cases were stillbirths. Rates of dead, morbid, and nonmorbid cases all decreased over this time period, but the overall proportions that were dead or morbid cases did not significantly change. The overall case fatality ratio during 1999 through 2013 was 6.5%. Among cases of CS, maternal race/ethnicity was not associated with increased morbidity or death, although most cases (83%) occurred among black or Hispanic mothers. No or inadequate treatment for maternal syphilis, <10 prenatal visits, and maternal nontreponemal titer ≥1:8 increased the likelihood of a dead case; risk of a dead case increased with maternal nontreponemal titer (χ(2) for trend P < .001). Infants with CS born alive at <28 weeks' gestation (relative risk, 107.4; P < .001) or born weighing <1500 g (relative risk, 43.9; P < .001) were at greatly increased risk of death., Conclusion: CS remains an important preventable cause of perinatal morbidity and mortality, with comparable case fatality ratios during 1999 through 2013 (6.5%) and 1992 through 1998 (6.4%). Detection and treatment of syphilis early during pregnancy remain crucial to reducing CS morbidity and mortality., (Published by Elsevier Inc.)

Background: Pelvic inflammatory disease (PID) remains an important source of preventable reproductive morbidity, but no recent studies have singularly focused on US sexually transmitted disease (STD) clinics in relationship to established guidelines for diagnosis and treatment., Methods: Of the 83,076 female patients seen in 14 STD clinics participating in the STD Surveillance Network, 1080 (1.3%) were diagnosed as having PID from 2010 to 2011. A random sample of 219 (20%) women were selected, and medical records were reviewed for clinical history, examination findings, treatment, and diagnostic testing. Our primary outcomes were to evaluate how well PID diagnosis and treatment practices in STD clinic settings follow the Centers for Disease Control and Prevention (CDC) treatment guidelines and to describe age group-specific rates of laboratory-confirmed Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) in patients clinically diagnosed as having PID in the last 12 months, inclusive of the PID visit., Results: Among the 219 women, 70.3% of the cases met the CDC treatment case definition for PID, 90.4% had testing for CT and GC on the PID visit, and 68.0% were treated with a CDC-recommended outpatient regimen. In the last 12 months, 95.4% were tested for CT or GC, and positivity for either organism was 43.9% in women aged 25 years or younger with PID, compared with 19.4% of women older than 25 years with PID., Conclusions: Compliance with CDC guidelines was documented for many of the women with PID, though not all. Our findings underscore the need for continued efforts to optimize quality of care and adherence to current guidance for PID management given the anticipated expertise of providers in these settings.

National rates from human immunodeficiency virus (HIV) and sexually transmitted disease (STD) surveillance may not effectively convey the impact of HIV and STDs on American Indian/Alaska Native (AI/AN) communities. Instead, we compared average annual diagnosis rates per 100,000 population of HIV, chlamydia (CT), gonorrhea (GC), and primary and secondary (P&S) syphilis, from 2007 to 2010, among AI/AN aged ≥ 13 years residing in 625 counties in the 12 Indian Health Service Areas, all AI/AN, and all races/ethnicities to address this gap. AI/AN comprised persons reported as AI/AN only, with or without Hispanic ethnicity. Out of 12 IHS Areas, 10 had higher case rates for CT, 3 for GC, and 4 for P&S syphilis compared to rates for all races/ethnicities. Eight Areas had higher HIV diagnosis rates than for all AI/AN, but HIV rates for all IHS Areas were lower than national rates for all races/ethnicities. Two IHS Areas ranking highest in rates of CT and GC and four Areas with highest P&S syphilis also had high HIV rates. STD and HIV rates among AI/AN were greater in certain IHS Areas than expected from observing national rates for AI/AN. Integrated surveillance of overlapping trends in STDs and HIV may be useful in guiding prevention efforts for AI/AN populations.

U.S. surveillance for Neisseria gonorrhoeae antimicrobial susceptibilities is based exclusively on male urethral isolates. These data inform gonorrhea treatment guidelines, including recommendations for the treatment of extragenital infections, but data on the susceptibilities of extragenital isolates are limited. We compared the antimicrobial susceptibilities of pharyngeal, rectal, and urethral gonococcal isolates collected from men who have sex with men (MSM), at five sentinel sites throughout the United States. MICs were determined by the agar dilution method. Generalized linear models were used to compare (i) the proportions of isolates with elevated MICs and (ii) geometric mean MICs according to anatomic site, adjusted for city. In December 2011 to September 2013, totals of 205 pharyngeal, 261 rectal, and 976 urethral isolates were obtained. The proportions of isolates with elevated ceftriaxone MICs (≥ 0.125 μg/ml) did not differ according to anatomic site (0.5% of pharyngeal isolates, 1.5% of rectal isolates, and 1.7% of urethral isolates, with a city-adjusted odds ratio [aOR] of 0.4 [95% confidence interval {CI}, 0.0 to 3.9] for pharyngeal versus urethral isolates and an aOR of 0.9 [95% CI, 0.2 to 4.2] for rectal versus urethral isolates). The city-adjusted geometric mean ceftriaxone MICs of pharyngeal (0.0153 μg/ml) and rectal (0.0157 μg/ml) isolates did not differ from that of urethral isolates (0.0150 μg/ml) (ratios of geometric mean MICs of 1.02 [95% CI, 0.90 to 1.17] and 1.05 [95% CI, 0.93 to 1.19], respectively). Similar results were observed for other antimicrobials, including cefixime and azithromycin. These findings suggest that, at the population level, gonococcal antimicrobial susceptibility surveillance based on urethral isolates from MSM adequately reflects the susceptibilities of N. gonorrhoeae strains circulating among MSM., (Copyright © 2015, American Society for Microbiology. All Rights Reserved.)

Background: Bacterial sexually transmitted infections may facilitate HIV transmission. Bacterial sexually transmitted infection testing is recommended for sexually active HIV-infected patients annually and more frequently for those at elevated sexual risk. We estimated percentages of HIV-infected patients in the United States receiving at least one syphilis, gonorrhea, or chlamydia test, and repeat (≥2 tests, ≥3 months apart) tests for any of these sexually transmitted infections from mid-2008 through mid-2010., Design: The Medical Monitoring Project collects behavioral and clinical characteristics of HIV-infected adults receiving medical care in the United States using nationally representative sampling., Methods: Sexual activity included self-reported oral, vaginal, or anal sex in the past 12 months. Participants reporting more than 1 sexual partner or illicit drug use before/during sex in the past year were classified as having elevated sexual risk. Among participants with only 1 sex partner and no drug use before/during sex, those reporting consistent condom use were classified as low risk; those reporting sex without a condom (or for whom this was unknown) were classified as at elevated sexual risk only if they considered their sex partner to be a casual partner, or if their partner was HIV-negative or partner HIV status was unknown. Bacterial sexually transmitted infection testing was ascertained through medical record abstraction., Results: Among sexually active patients, 55% were tested at least once in 12 months for syphilis, whereas 23% and 24% received at least one gonorrhea and chlamydia test, respectively. Syphilis testing did not vary by sex/sexual orientation. Receipt of at least 3 CD4+ T-lymphocyte cell counts and/or HIV viral load tests in 12 months was associated with syphilis testing in men who have sex with men (MSM), men who have sex with women only, and women. Chlamydia testing was significantly higher in sexually active women (30%) compared with men who have sex with women only (19%), but not compared with MSM (22%). Forty-six percent of MSM were at elevated sexual risk; 26% of these MSM received repeat syphilis testing, whereas repeat testing for gonorrhea and chlamydia was only 7% for each infection., Conclusions: Bacterial sexually transmitted infection testing among sexually active HIV-infected patients was low, particularly for those at elevated sexual risk. Patient encounters in which CD4+ T-lymphocyte cell counts and/or HIV viral load testing occurs present opportunities for increased bacterial sexually transmitted infection testing.

Azithromycin, administered with ceftriaxone, is recommended by the CDC for the treatment of gonorrhea. Many experts have expressed concern about the ease with which Neisseria gonorrhoeae can acquire macrolide resistance. We sought to describe gonococcal azithromycin susceptibility in the United States and to determine whether azithromycin susceptibility has changed over time. We analyzed data from 2005 to 2013 from the Gonococcal Isolate Surveillance Project, a CDC-supported sentinel surveillance network that monitors gonococcal antimicrobial susceptibility. A total of 44,144 N. gonorrhoeae isolates were tested for azithromycin susceptibility by agar dilution methods. The overall azithromycin MIC50 was 0.25 μg/ml, and the MIC90 was 0.5 μg/ml. There were no overall temporal trends in geometric means. Isolates from men who had sex with men had significantly higher geometric mean MICs than isolates from men who had sex exclusively with women. The overall prevalence of reduced azithromycin susceptibility (MIC, ≥2 μg/ml) was 0.4% and varied by year from 0.3% (2006 and 2009) to 0.6% (2013). We did not find a clear temporal trend in gonococcal azithromycin MICs in the United States, and the prevalence of reduced azithromycin susceptibility remains low. These findings support the continued use of azithromycin in a combination therapy regimen for gonorrhea., (Copyright © 2015, American Society for Microbiology. All Rights Reserved.)

Background: Ceftriaxone is the foundation of currently recommended gonorrhea treatment. There is an urgent need for backup treatment options for patients with cephalosporin allergy or infections due to suspected cephalosporin-resistant Neisseria gonorrhoeae. We evaluated the efficacy and tolerability of 2 combinations of existing noncephalosporin antimicrobials for treatment of patients with urogenital gonorrhea., Methods: We conducted a randomized, multisite, open-label, noncomparative trial in 5 outpatient sexually transmitted disease clinic sites in Alabama, California, Maryland, and Pennsylvania. Patients aged 15-60 years diagnosed with uncomplicated urogenital gonorrhea were randomly assigned to either gentamicin 240 mg intramuscularly plus azithromycin 2 g orally, or gemifloxacin 320 mg orally plus azithromycin 2 g orally. The primary outcome was microbiological cure of urogenital infections (negative follow-up culture) at 10-17 days after treatment among 401 participants in the per protocol population., Results: Microbiological cure was achieved by 100% (lower 1-sided exact 95% confidence interval [CI] bound, 98.5%) of 202 evaluable participants receiving gentamicin/azithromycin, and 99.5% (lower 1-sided exact 95% CI bound, 97.6%) of 199 evaluable participants receiving gemifloxacin/azithromycin. Gentamicin/azithromycin cured 10 of 10 pharyngeal infections and 1 of 1 rectal infection; gemifloxacin/azithromycin cured 15 of 15 pharyngeal and 5 of 5 rectal infections. Gastrointestinal adverse events were common in both arms., Conclusions: Gentamicin/azithromycin and gemifloxacin/azithromycin were highly effective for treatment of urogenital gonorrhea. Gastrointestinal adverse events may limit routine use. These non-cephalosporin-based regimens may be useful alternative options for patients who cannot be treated with cephalosporin antimicrobials. Additional treatment options for gonorrhea are needed. Clinical Trials Registration. NCT00926796., (Published by Oxford University Press on behalf of the Infectious Diseases Society of America 2014. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Background: Because of the decreasing susceptibility of Neisseria gonorrhoeae to cephalosporin therapy, the Centers for Disease Control and Prevention recommends test of cure (TOC) 1 week after gonorrhea (GC) treatment if therapies other than ceftriaxone are used. In addition, the Centers for Disease Control and Prevention asks clinicians, particularly those caring for men who have sex with men (MSM) on the west coast, to consider retesting all MSM at 1 week. However, it is unclear if this is acceptable to providers and patients or if nucleic acid amplification tests (NAATs) are useful for TOC at 7 days., Methods: Between January and July 2012, MSM with GC were advised to return 1 week after treatment for TOC using NAAT. A multivariate logistic regression model was used to determine demographic and behavioral differences between MSM who returned for follow-up and MSM who did not., Results: Of 737 men with GC, 194 (26.3%) returned between 3 and 21 days of treatment. Individuals who returned were more likely to have no GC history (P = 0.0001) and to report no initial symptoms (P = 0.02) when compared with individuals who did not return for TOC. Of those who returned, 0% of urethral samples, 7.4% of rectal samples, and 5.3% of pharyngeal samples were NAAT positive at TOC., Conclusions: Although TOC may be an important strategy in reducing complications and the spread of GC, low return rates may make implementation challenging. If implemented, extra efforts should be considered to enhance return rates among individuals with a history of GC. If TOCs are recommended at 1 week and NAATs are used, the interpretation of positive results, particularly those from extragenital sites, may be difficult.

Background: Congenital syphilis (CS) is a potentially life-threatening yet preventable infection. State and local public health jurisdictions conduct investigations of possible CS cases to determine case status and to inform public health prevention efforts. These investigations occur when jurisdictions receive positive syphilis test results from pregnant women or from infants., Methods: We extracted data from Louisiana's electronic case management system for 328 infants investigated as possible CS cases in 2010 to 2011. Using date stamps from the case management system, we described CS investigations in terms of processes and timing., Results: Eighty-seven investigations were prompted by positive test results from women who were known to be pregnant by the health jurisdiction, and 241 investigations were prompted by positive syphilis test results from infants. Overall, investigations required a median of 101 days to complete, although 25% were complete within 36 days. Investigations prompted by positive test results from infants required a median of 135 days to complete, and those prompted by positive test results from pregnant women required a median of 41 days., Conclusions: Three times as many CS investigations began with reported positive syphilis test results from infants as from pregnant women, and these investigations required more time to complete. When CS investigations begin after an infant's birth, the opportunity to ensure that women are treated during pregnancy is missed, and surveillance data cannot inform prevention efforts on a timely basis. Consistently ascertaining pregnancy status among women whose positive syphilis test results are reported to public health jurisdictions could help to assure timely CS prevention efforts.

Antimicrobial drug resistance can hinder gonorrhea prevention and control efforts. In this study, we analyzed historical ciprofloxacin resistance data and gonorrhea incidence data to examine the possible effect of antimicrobial drug resistance on gonorrhea incidence at the population level. We analyzed data from the Gonococcal Isolate Surveillance Project and city-level gonorrhea incidence rates from surveillance data for 17 cities during 1991-2006. We found a strong positive association between ciprofloxacin resistance and gonorrhea incidence rates at the city level during this period. Their association was consistent with predictions of mathematical models in which resistance to treatment can increase gonorrhea incidence rates through factors such as increased duration of infection. These findings highlight the possibility of future increases in gonorrhea incidence caused by emerging cephalosporin resistance.

Background: Neisseria gonorrhoeae has progressively developed resistance to sulfonamides, penicillin, tetracycline and fluoroquinolones, and gonococcal susceptibility to cephalosporins has been declining worldwide., Methods: We described trends in gonococcal antimicrobial susceptibility in the USA from January 2006 through June 2012. Susceptibility data for cefixime, ceftriaxone, azithromycin, penicillin, tetracycline and ciprofloxacin were obtained from the Gonococcal Isolate Surveillance Project (GISP), a sentinel surveillance system that monitors antimicrobial susceptibility in urethral gonococcal isolates collected from symptomatic men at 25-30 sexually transmitted disease clinics throughout the USA., Results: The percentage of isolates with elevated cefixime minimum inhibitory concentrations (MICs) (≥ 0.25 µg/mL) increased from 0.1% in 2006 to 1.4% in 2010-2011 and was 1.1% in the first 6 months of 2012. The percentage with elevated ceftriaxone MICs (≥ 0.125 µg/mL) increased from 0.1% in 2006 to 0.3%-0.4% during 2009 through the first 6 months of 2012. There were no temporal trends in the prevalence of elevated azithromycin MICs (≥ 2 µg/mL) (0.2%-0.5%). The prevalence of resistance remained high for penicillin (11.2%-13.2%), tetracycline (16.7%-22.8%) and ciprofloxacin (9.6%-14.8%)., Conclusions: The proportion of gonococcal isolates with elevated cephalosporin MICs increased from 2006 to 2010, but plateaued during 2011 and the first 6 months of 2012. Resistance to previously recommended antimicrobials has persisted. As the number of antimicrobials available for gonorrhoea treatment dwindles, surveillance systems such as GISP will be critical to detect emerging resistance trends and guide treatment decisions.

Background: Trichomonas vaginalis is the most prevalent nonviral sexually transmitted infection in the United States, affecting 3.1% of women of reproductive age. Infection is associated with HIV acquisition and pelvic inflammatory disease. In the United States, Centers for Disease Control and Prevention guidelines recommend testing all women with vaginal discharge for T. vaginalis, but except for HIV-infected women, there are no national guidelines for screening asymptomatic persons. The objective of this analysis is to assess testing and screening practices for T. vaginalis among symptomatic and asymptomatic women in the sexually transmitted disease (STD) clinic setting., Methods: We analyzed data on demographics, clinical presentation, and laboratory testing for all women visiting a clinician in 2010 to 2011 at any of 15 STD clinics participating in the STD Surveillance Network. Prevalence of laboratory-confirmed T. vaginalis infection was calculated among symptomatic women tested and among asymptomatic women screened., Results: A total of 59,176 women visited STD clinicians: 39,979 were considered symptomatic and 19,197 were considered asymptomatic for T. vaginalis infection, whereas 211 were HIV-infected. Diagnostic practices varied by jurisdiction: 4.0% to 96.1% of women were tested or screened for T. vaginalis using any laboratory test. Among 17,952 symptomatic women tested, prevalence was 26.2%. Among 3909 asymptomatic women screened, prevalence was 6.5%. Among 92 HIV-infected women tested/screened, prevalence was 29.3%., Conclusions: Trichomoniasis is common among STD clinic patients. In this analysis, most STD clinics tested symptomatic women seeking care, in accordance with national guidelines. All HIV-infected women should be screened annually. Additional evidence and national guidance are needed regarding potential benefits of T. vaginalis screening in other asymptomatic women.

Background: Congenital syphilis is a serious, preventable, and nationally notifiable disease. Despite the existence of a surveillance case definition, congenital syphilis is sometimes classified differently using an algorithm on the Centers for Disease Control and Prevention's case reporting form., Methods: We reviewed Louisiana's congenital syphilis electronic reporting system for investigations of infants born from January 2010 to October 2011, abstracted data required for classification, and applied the surveillance definition and the algorithm. We calculated the sensitivities and specificities of the algorithm and Louisiana's classification using the surveillance definition as the surveillance gold standard., Results: Among 349 congenital syphilis investigations, the surveillance definition identified 62 cases. The algorithm had a sensitivity of 91.9% and a specificity of 64.1%. Louisiana's classification had a sensitivity of 50% and a specificity of 91.3% compared with the surveillance definition., Conclusions: The differences between the algorithm and the surveillance definition led to misclassification of congenital syphilis cases. The algorithm should match the surveillance definition. Other state and local health departments should assure that their reported cases meet the surveillance definition.

Using data from a nationally representative survey, we identified predictors of chlamydial infection in women aged 26 to 39 years. Chlamydia prevalence was low overall but varied by sociodemographics and sexual behaviors. Findings support current recommendations that women older than 25 years should not be routinely screened for chlamydial infection.

Background: Gonorrhea treatment has been complicated by antimicrobial resistance in Neisseria gonorrhoeae. Gonococcal fluoroquinolone resistance emerged more rapidly among men who have sex with men (MSM) than men who have sex exclusively with women (MSW)., Objective: To determine whether N. gonorrhoeae urethral isolates from MSM were more likely than isolates from MSW to exhibit resistance to or elevated minimum inhibitory concentrations (MICs) of antimicrobials used to treat gonorrhea., Design: 6 years of surveillance data from the Gonococcal Isolate Surveillance Project., Setting: Publicly funded sexually transmitted disease clinics in 30 U.S. cities., Patients: Men with a total of 34 600 episodes of symptomatic urethral gonorrhea., Measurements: Percentage of isolates exhibiting resistance or elevated MICs and adjusted odds ratios for resistance or elevated MICs among isolates from MSM compared with isolates from MSW., Results: In all U.S. regions except the West, isolates from MSM were significantly more likely to exhibit elevated MICs of ceftriaxone and azithromycin than isolates from MSW (P < 0.050). Isolates from MSM had a high prevalence of resistance to ciprofloxacin, penicillin, and tetracycline and were significantly more likely to exhibit antimicrobial resistance than isolates from MSW (P < 0.001)., Limitations: Sentinel surveillance may not be representative of all patients with gonorrhea. HIV status, travel history, and antimicrobial use data were missing for some patients., Conclusion: Men who have sex with men are vulnerable to the emerging threat of antimicrobial-resistant N. gonorrhoeae. Because antimicrobial susceptibility testing is not routinely done in clinical practice, clinicians should monitor for treatment failures among MSM diagnosed with gonorrhea. Strengthened prevention strategies for MSM and new antimicrobial treatment options are needed.

Background: Prevalence estimates from population-based surveys do not suffer from the same biases as case-report and clinic positivity data and may be better to monitor sexually transmitted disease morbidity over time., Methods: We estimated the prevalence of Neisseria gonorrhoeae in a nationally representative sample of persons aged 14 to 39 years participating in the National Health and Nutrition Examination Survey., Results: From 1999 to 2008, the overall prevalence of gonorrhea was 0.27% (95% confidence interval, 0.13%-0.47%). In the 2005 to 2006 and 2007 to 2008 cycles, prevalence approached 0% and was based on too few positive sample persons to obtain reliable estimates. In 2004, most infections were found in 1 survey location., Discussion: Given the low prevalence and geographic clustering of disease, gonorrhea estimates from national probability surveys are often imprecise and unstable. In 2008, gonorrhea testing in National Health and Nutrition Examination Survey was discontinued. Continued surveillance of gonorrhea should include case reporting and prevalence estimates from local surveys and sentinel surveillance systems.

Nitroimidazoles (metronidazole and tinidazole) are the only recommended drugs for treating Trichomonas vaginalis infection, and previous samples that assessed resistance of such isolates have been limited in geographic scope. We assessed the prevalence of in vitro aerobic metronidazole and tinidazole resistance among T. vaginalis isolates from multiple geographic sites in the United States. Swab specimens were obtained from women who underwent routine pelvic examinations at sexually transmitted disease clinics in 6 US cities. Cultured T. vaginalis isolates were tested for nitroimidazole resistance (aerobic minimum lethal concentration [MLC] >50 µg/mL). Of 538 T. vaginalis isolates, 23 (4.3%) exhibited low-level in vitro metronidazole resistance (minimum lethal concentrations 50-100 µg/mL). No isolates exhibited moderate- to high-level metronidazole resistance or tinidazole resistance. Results highlight the possibility that reliance on a single class of antimicrobial drugs for treating T. vaginalis infections may heighten vulnerability to emergence of resistance. Thus, novel treatment options are needed.

We investigated the feasibility of monitoring trends in prevalence of vaccine-preventable human papillomavirus (HPV) types in different clinic populations. We collected cervical specimens from women presenting to family planning, primary care, and sexually transmitted disease (STD) clinics for routine pap smears in five US cities during 2003-2005. We performed HPV genotyping and calculated annual type-specific prevalences; pre-vaccine era prevalence was highest for HPV 16 (6.0; 95% confidence interval [CI] 5.5-6.6%) and annual prevalences for vaccine-preventable types were stable, with few exceptions, after controlling for clinic type, age group, and city. With sufficient sample size and stable population characteristics, clinic-based surveillance systems can contribute to monitoring HPV vaccine impact in the cervical screening population., (Published by Elsevier Ltd.)

Objective: We investigated factors associated with high rates of congenital syphilis among Hispanic infants in Maricopa County, AZ., Methods: Using 2004-2008 syphilis case report data from the state and county health departments, we examined characteristics of pregnant and nonpregnant women with syphilis and their male partners., Results: During 2004-2008, 970 women were reported to have syphilis: 49% were Hispanic (of whom 49% were non-US citizens), 27% were white, 13% were black, and 8% were American Indian/Alaskan Native. Although 16% of Hispanic noncitizens reported drug use or high-risk sexual behaviors, 64% of these women had a male sex partner who reported drug use or anonymous sex. Hispanic women with syphilis were more likely to be pregnant (37%) than white (15%) or black women (13%) (P < 0.05), and were overrepresented among pregnant women with syphilis. Pregnant Hispanic noncitizens were treated later than pregnant Hispanic citizens (median 28 weeks gestation vs. 21 weeks, P = 0.01)., Conclusions: Innovative congenital syphilis prevention strategies that are relevant to Hispanic women are warranted. Strategies should address the reproductive health and prenatal care needs of Hispanic women, and may include interventions for their male partners.

Background: We explored the utility of using insurance claims data for surveillance of pelvic inflammatory disease (PID). PID rates are an important indicator of population level trends in reproductive morbidity; however, data available to monitor PID trends are limited. National survey data are currently used to estimate PID rates in the United States, but a declining number of cases threaten their future usefulness., Methods: We performed a retrospective analysis of PID diagnosis rates using administrative claims data from 2001 to 2005. Diagnostic codes were used to identify women aged 15 to 44 in the study population that were diagnosed with acute PID as inpatients, in emergency departments, and in outpatient ambulatory settings., Results: Rates of PID diagnoses among privately insured women declined significantly from 2001 to 2005 among all age groups examined and within all geographic regions. Annual PID diagnosis rates decreased from 317.0 to 236.0 per 100,000 enrollees, representing a 25.5% decline over the study period. The highest rates of PID were among 25- to 29-year-olds (352.8 per 100,000 in 2005) and among those residing in the South (314.3 per 100,000 in 2005). Most women (70.1%) received PID care through physician offices and other outpatient facilities; of these women, approximately 40% were treated by an obstetrician/gynecologist., Conclusions: The decline in PID diagnoses corresponds with previous reports from national surveys. Claims data offer a much needed new data source that will allow for continued monitoring of PID among a broad population in both inpatient and outpatient clinical settings.

Objectives: To describe trends in the occurrence and frequency of HIV testing among men who have sex with men (MSM) receiving care in 4 US sexually transmitted disease (STD) clinics and to define factors associated with HIV testing frequency and positivity., Study Design: Routine clinical encounters during 57,131 visits by MSM to STD clinics in 4 cities (Seattle-King County, San Francisco, Denver, and District of columbia), 2002-2006, were examined., Results: From 2002 to 2006, a city-specific median of 69.1% of presumptive HIV-uninfected MSM were tested for HIV, of which, a median of 86.7% had previously tested (4.5% unknown) and a median of 3.9% were newly diagnosed with HIV. Between 2002 and 2006, the median percentage of tested MSM who reported no previous HIV testing decreased from 9.4% to 5.4% (P = 0.01) and the city-specific median intertest interval decreased from 302 to 243 days (P = 0.03). Among MSM with newly diagnosed HIV, the median intertest interval decreased from 531 days in 2002 to 287 days in 2006 (P = 0.001). Predictors of newly diagnosed HIV infection included the following: younger age, longer intertest interval, black or Hispanic race/ethnicity, clinic in San Francisco, and concurrent diagnosis with a bacterial STD., Conclusions: In MSM seen at 4 STD clinics, the percentage of never previously HIV tested is decreasing and MSM are testing more frequently.

Objectives: To evaluate factors associated with recurrent chlamydial infection and failure to return for retesting in socioeconomically disadvantaged women (aged 16-24 years) entering the National Job Training Program, 1998--2005., Goal: To evaluate sociodemographic characteristics of young women associated with recurrent chlamydial infection., Study Design: We computed chlamydia prevalence at initial visit and recurrent infection (defined as a positive chlamydia test 1-2 months after completing treatment) and percent of infected women who were retested by sociodemographic variables., Results: At entrance, women had a high prevalence of chlamydia infection (10.7%). Chlamydia prevalence varied by age, race/ethnicity, and place of residence (South, Midwest, Northeast, and West), year of test, and type of test. Among women infected at initial visit, younger aged women (16-17 years), blacks and Hispanics, those who resided in the South and Midwest, and those tested in 1998--2000 were less likely to be retested. Of the 13,550 infected women, 5,892 (43.5%) were retested. Of those retested, 332 (5.6%) had recurrent infection 1-2 months after completing treatment. Although chlamydia prevalence at retesting did not differ significantly by sociodemographic characteristics, the pattern of the prevalence was similar to the pattern at the initial test. Multivariate logistic regression analyses showed similar findings., Conclusions: The high prevalence of recurrent infection in these women may be due to reinfection and/or treatment failure. The findings of this analysis underscore the need for retesting infected women regardless of their demographic characteristics.

Objectives: We assessed the epidemiology of primary and secondary syphilis in the United States and estimated the percentages of cases occurring among men who have sex with men (MSM)., Methods: We reviewed US syphilis surveillance data from 1990 through 2003. We estimated the number of cases occurring among MSM by modeling changes in the ratio of syphilis cases among men to cases among women., Results: During 1990 through 2000, the rate of primary and secondary syphilis decreased 90% overall, declining 90% among men and 89% among women. The overall rate increased 19% between 2000 and 2003, reflecting a 62% increase among men and a 53% decrease among women. In 2003, an estimated 62% of reported cases occurred among MSM., Conclusions: Increasing syphilis cases among MSM account for most of the recent overall increase in rates and may be a harbinger of increasing rates of HIV infection among MSM. National efforts are under way to improve monitoring of syphilis trends, better understand factors associated with the observed increases, and improve efforts to prevent syphilis transmission.

Objective/goal: The objective of this study was to identify characteristics associated with subsequent infection in patients attending a sexually transmitted disease (STD) clinic., Study Design: Records were retrospectively reviewed for patients from public STD clinics in 4 cities for 12 months after their initial visit to assess subsequent infection with gonorrhea, chlamydia, mucopurulent cervicitis, nongonococcal urethritis, pelvic inflammatory disease, primary or secondary syphilis, or trichomoniasis., Results: Among 64,463 patients, 33.9% had an initial STD and 7.0% had a subsequent STD. Patients with an initial STD had significantly higher probability of a subsequent STD than patients without (12.0% vs. 4.4%). A subsequent STD was significantly more likely for both sexes for those with an initial STD, who were symptomatic at initial visit, reporting exchange of sex, or under age 20 as well as for men reporting sex with men., Conclusions: Patients with an initial STD were more likely to return with a subsequent STD. Routinely collected information such as initial diagnosis or age can help identify patients at increased risk of a subsequent STD.

Background: The prevalence and characteristics of persons with newly diagnosed human immunodeficiency virus (HIV) infections with or without evidence of mutations associated with drug resistance have not been well described., Methods: Drug-naive persons in whom HIV had been diagnosed during the previous 12 months and who did not have acquired immune deficiency syndrome were sequentially enrolled from 39 clinics and testing sites in 10 US cities during 1997-2001. Genotyping was conducted from HIV-amplification products, by automated sequencing. For specimens identified as having mutations previously associated with reduced antiretroviral-drug susceptibility, phenotypic testing was performed., Results: Of 1311 eligible participants, 1082 (83%) were enrolled and successfully tested; 8.3% had reverse transcriptase or major protease mutations associated with reduced antiretroviral-drug susceptibility. The prevalence of these mutations was 11.6% among men who had sex with men but was only 6.1% and 4.7% among women and heterosexual men, respectively. The prevalence was 5.4% and 7.9% among African American and Hispanic participants, respectively, and was 13.0% among whites. Among persons whose sexual partners reportedly took antiretroviral medications, the prevalence was 15.2%., Conclusions: Depending on the characteristics of the patients tested, HIV-genotype testing prior to the initiation of therapy would identify a substantial number of infected persons with mutations associated with reduced antiretroviral-drug susceptibility.

Increases in the number of infections with fluoroquinolone-resistant Neisseria gonorrhoeae in Asia and the United States threaten the efficacy of fluoroquinolones as inexpensive, single-dose, orally administered treatments for gonorrhea. This report describes the findings of a field investigation of an increase in the number of infections with ciprofloxacin-resistant N. gonorrhoeae (CipRGC) in Hawaii in 2001. We conducted a case review of 53 patients with CipRGC, who constituted 20% of the 267 patients with cultures positive for N. gonorrhoeae during this period. Nearly one-half of patients with CipRGC were seen by clinicians in private practice, one-third were seen by clinicians at a sexually transmitted diseases (STD) clinic, and only 2% were seen by clinicians in the military. Among the 117 patients with culture-confirmed gonorrhea who attended the public STD clinic, we found a prevalence of infection with CipRGC of 17%. The demographic and clinical characteristics of patients with CipRGC were similar to those of patients with gonorrhea that was not resistant to ciprofloxacin, suggesting that fluoroquinolone-resistant gonorrhea has become endemic in Hawaii.

We report 4 urogenital Neisseria gonorrhoeae isolates recovered from 3 patients that demonstrated resistance to penicillin, tetracycline, and ciprofloxacin and reduced susceptibility to cefixime. This report of the first 3 patients in the United States identified with this multidrug-resistant strain may portend an emerging problem for clinicians and public health officials.

Objectives: This study measured age-specific seroprevalence of HIV, hepatitis B virus, and hepatitis C virus (HCV) infection among injection drug users (IDUs) admitted to drug treatment programs in 6 US cities., Methods: Remnant sera collected from persons entering treatment with a history of illicit drug injection were tested for antibodies to HIV, hepatitis C (anti-HCV), and hepatitis B core antigen (anti-HBc)., Results: Prevalence of anti-HBc and anti-HCV increased with age and reached 80% to 100% among older IDUs in all 6 cities. Although overall age-specific HIV prevalence was lower than anti-HCV or anti-HBc, this prevalence was greater in the Northeast than in the Midwest and West., Conclusions: The need continues for effective primary prevention programs among IDUs specifically targeting young persons who have recently started to inject drugs.

To investigate the epidemiology and clinical spectrum of neurosyphilis in a population with high rates of coexisting syphilis and human immunodeficiency virus (HIV) infection, a retrospective analysis of cases in all San Francisco hospitals from 1985 to 1992 was conducted. Neurosyphilis was defined by a newly reactive cerebrospinal fluid VDRL; 117 patients with neurosyphilis were identified. The median age was 39 years, 91% were male, 74 (63%) were white, and 75 (64%) were HIV-infected. Thirty-eight (33%) presented with an early symptomatic neurosyphilis syndrome. Six (5%) had late neurosyphilis. Thirty-eight (32%) patients were asymptomatic, and 35 (30%) had findings attributable to coexisting neurologic diseases. Patients demonstrated high serum nontreponemal (VDRL) titers (median, 1:128) at neurosyphilis presentation. In contrast to the findings from the preantibiotic era, neurosyphilis was identified in young patients most often with HIV coinfection, and early symptomatic syndromes were identified more frequently than late neurosyphilis syndromes.

Trends in seroprevalence of the human immunodeficiency virus (HIV) were examined among patients attending sentinel clinics for sexually transmitted diseases (STDs) throughout the United States. Cross-sectional, unlinked (blinded) surveys of HIV seroprevalence were conducted annually within clinics in 40 metropolitan areas. From 1988 to 1992, 552,665 specimens were tested in 80 STD clinics. The overall HIV seroprevalence was 33% (range among metropolitan areas: 5-52%) among gay and bisexual men, 3% (range: 0.3-11%) among heterosexual men, 2% (range: 0.1-11%) among women, and 10% (range: 0.5-45%) among heterosexual injecting drug users (IDUs). Controlling for clinic, age, and race/ethnicity, HIV seroprevalence decreased among all gay and bisexual men, but especially among white gay and bisexual men from 32% in 1989 to 22% in 1992. Among heterosexual men and women, HIV seroprevalence decreased among whites and, to a lesser degree, Hispanics, but remained essentially stable among African-Americans over time. Among heterosexual IDUs, seroprevalence was also unchanged. These results reflect changes in the HIV epidemic, which is becoming increasingly characterized by infected heterosexuals and IDUs, especially within minority populations.

Patients were assigned to one of two vaccine schedules to assess the feasibility of vaccinating a sexually transmitted disease clinic population against hepatitis B virus. Of 1386 patients entering an inner-city clinic between June and July 1990, 611 (44%) accepted a first dose of vaccine. Twenty-one percent of all susceptible patients received at least two doses of vaccine. Annualizing these findings shows that an ongoing program could prevent 636 hepatitis B virus infections per year. Although a significant proportion of sexually transmitted disease clinic patients can be successfully vaccinated, strategies for preventing hepatitis B virus infections in this high-risk population must consider patient behavior as well as vaccine efficacy.

Objective: To evaluate the association between hepatitis C virus (HCV) infection and sexual behavior in a sexually active population., Design: Cross-sectional study., Setting: Inner-city clinic for sexually transmitted diseases., Subjects: The study included 1292 patients attending the clinic for care during a 1-month period and having syphilis serologic tests performed., Outcome Measures: Antibody to HCV (anti-HCV) positivity as defined by a repeatedly-reactive enzyme immunoassay and a positive neutralization enzyme immunoassay (Abbott Laboratories, Chicago, Ill)., Results: Of 1292 patients screened for anti-HCV, 99 (7.7%) were positive. Logistic regression analysis found that patients who reported intravenous drug use, were positive for antibody to hepatitis B core antigen, reported a history of a blood transfusion, were black, or reported crack cocaine use were more likely to be anti-HCV-positive. Forty-five percent of patients who were anti-HCV-positive reported intravenous drug use. Sex with an intravenous drug user and a history of gonorrhea and syphilis were associated with anti-HCV positivity in a univariate analysis, but after controlling for confounding variables, no such associations remained. While having multiple sexual partners in the previous 3 months, being homosexual or bisexual, and engaging in receptive anal intercourse were associated with being positive for antibody to hepatitis B core antigen, those behaviors were not associated with anti-HCV positivity., Conclusions: While these results cannot exclude a role for the sexual transmission of HCV, they do suggest that, in this sexually active population, the sexual transmission of HCV occurs infrequently and that HCV is largely associated with intravenous drug use.

The use of condoms has been advocated as a means of preventing the transmission of the human immunodeficiency virus and other sexually transmitted agents. To better understand factors that may influence condom use, 300 heterosexuals were enrolled in a cross-sectional study of patients attending San Francisco's only public sexually transmitted disease clinic. Interviewer-administered questionnaires were conducted. Condom use at last sexual intercourse was examined by logistic regression analysis. Men who used drugs or alcohol at last intercourse and whose partners did not want to use condoms were less likely to have used them; women who were black or Hispanic, who reported difficulty getting their partners to use condoms, or who reported that condoms decrease sexual pleasure also were less likely to have used them. Efforts to increase condom use in this population should target minorities, assist women to negotiate their use, emphasize the dangers of using alcohol and other drugs with sex, and address the perception that condoms interfere with sexual pleasure.

Chlamydia trachomatis is the most prevalent sexually transmitted bacterial pathogen. Nevertheless, selective, rather than universal, screening for chlamydia has been recommended, largely because testing is expensive and requires considerable technical expertise. A total of 1,348 women in four family planning clinics in San Francisco, California, were screened from March 1987 to January 1988 to identify criteria for selective screening. Of these, 9.2% had a positive chlamydia test using direct fluorescence. Logistic regression analysis identified five factors associated with infection: age less than 25 years, cervical friability, single marital status, a new sexual partner within the past 3 months, and lack of barrier contraceptive use. No single risk factor or combination of risk factors had both a high sensitivity and a high positive predictive value for infection. While screening all women who were unmarried would detect 93% of those with chlamydia, the positive predictive value of 10.7% was not much higher than the overall prevalence. Conversely, screening all women with cervical friability, which had a positive predictive value of 23.2%, would only detect 11% of those with chlamydia. On the basis of the authors' findings, selective screening should not be used in high prevalence populations in which all women are at risk and should be screened for chlamydia.