[Show abstract][Hide abstract] ABSTRACT: 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.
In 2013, we surveyed persons who used publicly funded STD clinics in 21 US cities with the highest STD morbidity.
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.
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. (Am J Public Health. Published online ahead of print October 8, 2015: e1-e6. doi:10.2105/AJPH.2015.302839).
Preview · Article · Oct 2015 · American Journal of Public Health
[Show abstract][Hide abstract] ABSTRACT: Presence of a sexually transmitted infection (STI) can increase 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 if private insurance beneficiaries who are HIV-positive were receiving recommended STI testing.
We used data from the 2011 and 2012 Marketscan datasets; a longitudinal, population-based database that collects claims from commercially-insured persons in private insurance and is conducted by Truven Health Analytics. Over a thirteen month period, we calculated rates of testing for chlamydia, gonorrhea and syphilis among an HIV-positive population and determined factors that contributed to differences in testing rates.
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 healthcare system, and geographic location. Most notably, persons receiving viral load testing were more likely to receive testing for chlamydia (1.72 OR; 1.63-1.81 95% CI), gonorrhea (1.72 OR; 1.64-1.81 95% CI) and syphilis (3.38 OR, 3.25 - 3.53 95% CI) compared to persons not receiving viral load testing.
Not all commercially-insured HIV-positive patients are receiving recommended testing for STIs. Presence of STIs could affect the transmission of HIV as well as have 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.
No preview · Article · Jun 2015 · JAIDS Journal of Acquired Immune Deficiency Syndromes
[Show abstract][Hide abstract] ABSTRACT: To estimate prenatal sexually transmitted disease-human immunodeficiency virus (HIV) screening rates among insured women with prenatal care and the association of chlamydia and gonorrhea screening with Pap testing.
We estimated prenatal screening rates for syphilis, hepatitis B, HIV, chlamydia, and gonorrhea among women aged 15-44 years using a 2009-2010 U.S. administrative claims database that captures information for health services provided for both Medicaid- and commercially insured persons. Procedural and diagnostic codes were used to identify pregnant women with a live birth in 2010 with continuous insurance coverage at least 210 days before delivery and at least one typical prenatal blood test. Strengths of association between chlamydia and gonorrhea screening and Pap testing were measured using a χ test of independence.
Among 98,709 Medicaid-insured pregnant women, 95,064 (96.3%) were screened for syphilis, 95,082 (96.3%) for hepatitis B, 81,339 (82.4%) for HIV, 82,047 (83.1%) for chlamydia, and 73,799 (74.8%) for gonorrhea. Among 266,012 commercially insured women, 260,079 (97.8%) were screened for syphilis, 257,675 (96.8%) for hepatitis B, 227,276 (85.4%) for HIV, 187,071 (70.3%) for chlamydia, and 182,400 (68.6%) for gonorrhea. Prenatal screening for chlamydia and gonorrhea among both groups of women was more likely to be performed if a Pap test was also done (P<.001).
Prenatal screening for syphilis and hepatitis B was nearly universal among Medicaid- and commercially insured women; HIV screening rates were much lower and varied by insurance type and demographic characteristics. Chlamydia screening was suboptimal and most often occurred with Pap testing.
No preview · Article · May 2015 · Obstetrics and Gynecology
[Show abstract][Hide abstract] ABSTRACT: Background:
Male circumcision confers protection against HIV, sexually transmitted infections, and urinary tract infections. Compared with circumcision of postneonates (>28 days), circumcision of neonates is associated with fewer complications and usually performed with local rather than general anesthesia. We assessed circumcision of commercially insured males during the neonatal or postneonatal period.
We analyzed 2010 MarketScan claims data from commercial health plans, using procedural codes to identify circumcisions performed on males aged 0 to 18 years, and diagnostic codes to assess clinical indications for the procedure. Among circumcisions performed in the first year of life, we estimated rates for neonates and postneonates. We estimated the percentage of circumcisions by age among males who had circumcisions in 2010, and the mean payment for neonatal and postneonatal procedures.
We found that 156,247 circumcisions were performed, with 146,213 (93.6%) in neonates and 10,034 (6.4%) in postneonates. The neonatal circumcision rate was 65.7%, and 6.1% of uncircumcised neonates were circumcised by their first birthday. Among postneonatal circumcisions, 46.6% were performed in males younger than 1 year and 25.1% were for nonmedical indications. The mean payment was $285 for a neonatal and $1885 for a postneonatal circumcision.
The large number of nonmedical postneonatal circumcisions suggests that neonatal circumcision might be a missed opportunity for these boys. Delay of nonmedical circumcision results in greater risk for the child, and a more costly procedure. Discussions with parents early in pregnancy might help them make an informed decision about circumcision of their child.
[Show abstract][Hide abstract] ABSTRACT: Chlamydia is a sexually transmitted infection caused by the bacterium Chlamydia trachomatis. Chlamydia is the most commonly reported notifiable disease in the United States, with 1.4 million cases reported in 2012. Chlamydia is usually asymptomatic in both men and women, and as a result, infections often are undiagnosed. Approximately 3 million new infections are estimated to occur each year. Among sexually active females aged 14-19 years, chlamydia prevalence has been estimated to be 6.8%. In a recent study involving approximately 1 million tests conducted among both privately insured and Medicaid-insured females aged 15-21 years, chlamydia positivity ranged from 6.9% to 10.7% among those with chlamydial symptoms and from 6.1% to 9.6% among those who were asymptomatic.
No preview · Article · Sep 2014 · MMWR. Surveillance summaries: Morbidity and mortality weekly report. Surveillance summaries / CDC
[Show abstract][Hide abstract] ABSTRACT: Background:
In the United States, chlamydia screening has been recommended for all pregnant women by the Centers for Disease Control and Prevention (CDC) but only for pregnant women who are at increased risk by the US Preventive Services Task Force (USPSTF). Very limited evidence, such as age-specific chlamydia positivity in pregnant women, has been used to develop these recommendations.
We analyzed data from a large commercial laboratory corporation in the United States in 2013. At the first prenatal visit made by women aged 15 to 44 years for whom a chlamydia test was performed between June 2008 and July 2010, we estimated positivity of chlamydia by age, insurance coverage, geographic region, and test type.
Of 601,001 pregnant women aged 15 to 44 years who had routine prenatal care, 62.9% had private insurance and 32.9% had Medicaid coverage, 60.3% resided in the South region, and 43.2% were aged 15 to 24 years, 26.8% were aged 25 to 29 years, and 19.1% were aged 30 to 34 years. Chlamydia positivity was 3.6% overall, and significantly decreased as age increased (15-19 years: 9.6 %; 20-24 years: 5.2%; 25-29 years: 1.8%; 30-34 years: 0.9%; and 35-44 years: 0.6%; P < 0.05).
Our findings of higher positivity among younger pregnant women suggest that the yield is likely to be greater from screening younger pregnant women than from screening older pregnant women to identify chlamydia infection. The benefits of harmonizing CDC and USPSTF recommendations for pregnant women could be explored by reviewing age-specific positivity data and estimating the frequency of prenatal adverse health outcomes caused by chlamydia to develop consensus regarding the age limit for pregnant women who should be screened.
[Show abstract][Hide abstract] ABSTRACT: The Affordable Care Act of 2010 (ACA) contains a provision requiring private insurers issuing or renewing plans on or after September 23, 2010, to provide, without cost sharing, preventive services recommended by US Preventive Services Task Force (grades A and B), among other recommending bodies. As a grade A recommendation, chlamydia screening for sexually active young women 24 years and younger and older women at risk for chlamydia falls under this requirement. This article examines the potential effect on chlamydia screening among this population across private and public health plans and identifies lingering barriers not addressed by this legislation. Examination of the impact on women with private insurance touches upon the distinction between coverage under grandfathered plans, where the requirement does not apply, and nongrandfathered plans, where the requirement does apply. Acquisition of private health insurance through health insurance Marketplaces is also discussed. For public health plans, coverage of preventive services without cost sharing differs for individuals enrolled in standard Medicaid, covered under the Medicaid expansion included in the ACA, or those enrolled under the Children's Health Insurance Program or who fall under Early, Periodic, Screening, Diagnosis and Treatment criteria. The discussion of lingering barriers not addressed by the ACA includes the uninsured, physician reimbursement, cost sharing, confidentiality, low rates of appropriate sexual history taking by providers, and disclosures of sensitive information. In addition, the role of safety net programs that provide health care to individuals regardless of ability to pay is examined in light of the expectation that they also remain a payer of last resort.
[Show abstract][Hide abstract] ABSTRACT: To examine rates of ectopic pregnancy (EP) among American Indian and Alaska Native (AI/AN) women aged 15-44 years seeking care at Indian Health Service (IHS), Tribal, and urban Indian health facilities during 2002-2009. We used 2002-2009 inpatient and outpatient data from the IHS National Patient Information Reporting System to identify EP-associated visits and obtain the number of pregnancies among AI/AN women. Repeat visits for the same EP were determined by calculating the interval between visits; if more than 90 days between visits, the visit was considered related to a new EP. We identified 229,986 pregnancies among AI/AN women 15-44 years receiving care at IHS-affiliated facilities during 2002-2009. Of these, 2,406 (1.05 %) were coded as EPs, corresponding to an average annual rate of 10.5 per 1,000 pregnancies. The EP rate among AI/AN women was lowest in the 15-19 years age group (5.5 EPs per 1,000 pregnancies) and highest among 35-39 year olds (18.7 EPs per 1,000 pregnancies). EP rates varied by geographic region, ranging between 6.9 and 24.4 per 1,000 pregnancies in the Northern Plains East and the East region, respectively. The percentage of ectopic pregnancies found among AI/AN women is within the national 1-2 % range. We found relatively stable annual rates of EP among AI/AN women receiving care at IHS-affiliated facilities during 2002-2009, but considerable variation by age group and geographic region. Coupling timely diagnosis and management with public health interventions focused on tobacco use and sexually transmitted diseases may provide opportunities for reducing EP and EP-associated complications among AI/AN women.
Full-text · Article · Jul 2014 · Maternal and Child Health Journal
[Show abstract][Hide abstract] ABSTRACT: Background: CDC sexually transmitted disease (STD) treatment guidelines recommend that all persons presenting with a genital, anal or perianal ulcer (GUD) be tested for herpes simplex virus (HSV), syphilis, and HIV and receive empiric treatment while awaiting diagnostic tests. It is unknown what proportion of patients with GUD are appropriately managed according to these guidelines.
Methods: We analyzed administrative claims data from the 2011 MarketScan database. The database included enrollment and claims data for inpatient and outpatient encounters and prescription services for approximately 15 million privately insured persons in the United States. We included all initial encounters with an ICD-9 code for genital herpes, primary or secondary syphilis, or unspecified genital, anal, or perianal ulcer. We used CPT and NDC codes to identify laboratory testing and prescribed pharmacotherapy, respectively. We defined appropriate management as testing for syphilis and HIV, and testing for HSV or provision of antivirals, within 30 days of initial presentation. Either testing or provision of antivirals was considered appropriate management for HSV because it can recur.
Results: Among initial encounters by 84,919 patients with GUD, 78.3% were for HSV, 20.8% for unspecified ulcers, and 0.9% for syphilis; 0.1% were for both HSV and syphilis. Among all GUD patients, only 5.3% (n=4520) were tested for syphilis and managed for HSV, and only 0.2% (n=174) were also tested for HIV. The percentage of patients receiving appropriate management for HSV and syphilis was not significantly different by sex (both 5.3%, p=0.89). When considering HIV testing, men were significantly more likely to be managed appropriately than women (0.32% v. 0.16%, respectively, p≤0.0001).
Conclusions: Despite CDC GUD management guidelines, few patients with GUD received appropriate care. Patients with GUD have an increased risk of HIV transmission and acquisition. Interventions are needed to assure high quality healthcare services for patients with GUD.
[Show abstract][Hide abstract] ABSTRACT: HIV-infected men who have sex with men (MSM) are at increased risk for transmitting and acquiring sexually transmitted diseases (STDs). Guidelines recommend at least annual screening of HIV-infected MSM for syphilis and for chlamydia and gonorrhea at exposed anatomical sites, to protect their health and their sexual partners' health. Despite these guidelines, STD screening has been suboptimal, with very low nongenital chlamydia and gonorrhea testing rates. Our objective was to better understand barriers encountered by HIV care providers in adhering to STD screening guidelines for HIV-infected MSM.
We conducted 40 individual semistructured interviews with health care providers (physicians, midlevel providers, nurses, and health educators) of HIV-infected MSM at 8 large HIV clinics in 6 US cities. Providers were asked about their STD screening practices and barriers to conducting sexual risk assessments of their patients. Emerging themes were identified by qualitative data analysis.
Although most health care providers reported routine syphilis screening, screening for chlamydia and gonorrhea at exposed anatomical sites was less frequent. Obstacles that prevented routine chlamydia and gonorrhea screening included time constraints, difficulty obtaining a sexual history, language and cultural barriers, and patient confidentiality concerns.
Providers reported many obstacles to routine chlamydia and gonorrhea screening. Interventions are needed to help to mitigate barriers to STD screening, such as structural and patient-directed health services models that might facilitate increased testing coverage of these important preventive services.
No preview · Article · Feb 2014 · Sexually transmitted diseases
[Show abstract][Hide abstract] ABSTRACT: Background Automated immunoassays (AI) for detection of T. pallidum antibodies are increasingly used for syphilis screening in the United States. These assays demonstrate fast performance, reduced labour requirements, and high throughput with walk-away capability. Limited data are available about the relative seroreactivity among commercial treponemal assays, especially in low risk populations. Additionally, it is unknown to what extent the AI signal strength values, used to assess reactivity, are associated with non-AI treponemal reactivity. We compared concordance of seroreactivity among 7 treponemal tests and assessed AI signal strength values associated with reactivity.
Methods Previously identified reactive and nonreactive sera (n = 566) were obtained from Kaiser Northern and Southern California regional laboratories. All sera were tested with AIs: BioPlex 2200 Syphilis IgM/IgG (BioRad), treponemal LIAISON (DiaSorin), Advia-Centaur syphilis (Siemens), and non-AIs (INNOLIA syphilis score (INNOGENETICS), TrepSure (Phoenix Biotech), Treponemal Pallidum Particle Agglutination (TP-PA) (Fujirebio), and Fluorescent Treponemal Antibody-Absorption (FTA-ABS) (Zeus Scientific) tests. Reactivity was interpreted according to manufacturers’ instructions.
Results Seroreactivity ranged from 40.5 – 43.9% for AIs, and 33.0–42.2% for non-AIs. In all 7 tests, 30% (167/566) were reactive, and positive agreement among assays was 82.3%. The overall seroreactivity among AIs was 38.9% (220/566) and positive agreement was 92.6%. Minimum signal strength values of 11.72 (Centaur, range: 1.1–45), 4.4 (BioPlex, range: 1.1–8) and 9.4 (Liaison, range: 1.1–70) correlated 100% with TPPA reactivity. The proportion of AI-seroreactive specimens that were also TP-PA reactive were: 86.5% (198/229) for BioPlex, 85.2% (202/237) for ADVIA-Centaur, and 81.6% (200/245) for LIAISON.
Conclusion Although there is some variation in seroreactivity among the 7 tests, there is good correlation. A large proportion of AI tests with a minimal signal-to-cutoff ratio were associated with a positive TP-PA, suggesting that a second treponemal test may not be necessary to confirm AI-reactive, RPR-nonreactive sera.
[Show abstract][Hide abstract] ABSTRACT: Unlabelled:
Background Men who have sex with men (MSM) experience disparities in access to healthcare and have specific healthcare needs.
We analysed data from the 2006-10 National Survey of Family Growth (NSFG) to examine differences in access to healthcare and HIV and sexually transmissible infection (STI) related health services by MSM and non-MSM among men in the United States aged 15-44 years who have ever had sex. MSM and sexually active MSM were identified in the NSFG as men who had ever had oral or anal sex with another man, or who had sex in the past 12 months with another man, respectively. Access was measured by the type of health insurance, having a usual place for receiving healthcare and type of usual place.
Of men aged 15-44 years who have ever had sex, there were no significant differences between MSM and non-MSM in the three access measures. MSM were more likely than non-MSM to receive HIV counselling (22.5% v. 8.3%) and STI testing (26.2% v. 15.6%) in the past 12 months, or to ever have had HIV testing (67.8% v. 44.6%). STI testing in the past 12 months was reported by 38.7% of sexually active MSM.
Our findings show no significant differences in access to healthcare between MSM and non-MSM. MSM were more likely to receive HIV- and STI-related preventive services than non-MSM. However, the low STI testing rate among MSM highlights the need for interventions to increase STI testing, and HIV and STI counselling for MSM.
[Show abstract][Hide abstract] ABSTRACT: We assessed sexually transmitted infection risk behaviours and desire to discuss mental health, as reported by 426 HIV-infected men who have sex with men receiving HIV care in eight urban clinics. Most of these patients (90%) had begun HIV care >1 year ago. In the past year, 74% had multiple sexual partners, 75% engaged in anal intercourse, 48% had >1 HIV-uninfected partner and 82% used illegal psychoactive drugs. Among those reporting anal intercourse, approximately 61% reported using a condom during the most recent episode. Among all patients, 70% wanted to talk with their clinicians about how they felt mentally or emotionally. Using a two-tailed chi-squared test, we found that patients who engaged in unprotected receptive anal sex were more likely to want such a conversation than those who did not (80% versus 62%, P < 0.01); and those who engaged in unprotected insertive anal sex were also more likely to want such a conversation (81% versus 63%, P < 0.01). The findings highlight the prevalence of risky sexual behaviour and of mental health concerns in the participating patient population. Patients reporting risky sexual behaviour were more likely to want to discuss how they felt mentally or emotionally than those not reporting such behaviour.
No preview · Article · Mar 2013 · International Journal of STD & AIDS