The cost-effectiveness of a competitive voucher scheme to reduce sexually transmitted infections in high-risk groups in Nicaragua

Current evidence suggests that sexually transmitted infection (STI) interventions can be an effective means of human immunodeficiency virus (HIV) prevention in populations at an early stage of the epidemic. However, evidence as to their cost-effectiveness when targeted at high-risk groups is lacking. This paper assesses the cost-effectiveness of a competitive voucher scheme in Managua, Nicaragua aimed at high-risk groups, who could redeem the vouchers in exchange for free STI testing and treatment, health education and condoms, compared with the status quo (no scheme). A provider perspective was adopted, defined as: the voucher agency and health care providers from the public, NGO and private sectors. The cost of the voucher scheme was estimated for a 1-year period (1999) from project accounts using the ingredients approach. Outcomes were monitored as part of ongoing project evaluation. Costs and outcomes in the absence of the scheme were modelled using project baseline data and reports, and relevant literature. The annual cost of providing comprehensive STI services through vouchers was US$62 495, compared with an estimated US$17 112 for regular service provision in the absence of the scheme. 4815 vouchers were distributed by the voucher scheme, 1543 patients were tested for STIs and 528 STIs were effectively cured in this period. In the absence of the scheme, only an estimated 85 cases would have been cured from 1396 consultations. The average cost of the voucher scheme per patient treated was US$41 and US$118 per STI effectively cured, compared with US$12 per patient treated and US$200 per STI cured in its absence. The incremental cost of curing an STI through the voucher scheme, compared with the status quo, was US$103. A voucher scheme offers an effective and efficient means of targeting and effectively curing STIs in high-risk groups, as well as encouraging quality care practices.     

Neighborhood drug markets: a risk environment for bacterial sexually transmitted infections among urban youth

We hypothesized that neighborhoods with drug markets, as compared to those without, have a greater concentration of infected sex partners, i.e. core transmitters, and that in these areas, there is an increased risk environment for STIs. This study determined if neighborhood drug markets were associated with a high-risk sex partnership and, separately, with a current bacterial STI (chlamydia and/or gonorrhea) after controlling for individual demographic and sexual risk factors among a household sample of young people in Baltimore City, MD. Analyses also tested whether links were independent of neighborhood socioeconomic status. Data for this study were collected from a household study, systematic social observations and police arrest, public health STI surveillance and U.S. census data. Nonlinear multilevel models showed that living in neighborhoods with household survey-reported drug markets increased the likelihood of having a high-risk sex partnership after controlling for individual-level demographic factors and illicit drug use and neighborhood socioeconomic status. Further, living in neighborhoods with survey-reported drug markets increased the likelihood of having a current bacterial STI after controlling for individual-level demographic and sexual risk factors and neighborhood socioeconomic status. The results suggest that local conditions in neighborhoods with drug markets may play an important role in setting-up risk environments for high-risk sex partnerships and bacterial STIs. Patterns observed appeared dependent on the type of drug market indicator used. Future studies should explore how conditions in areas with local drug markets may alter sexual networks structures and whether specific types of drug markets are particularly important in determining STI risk.     

Human papillomavirus vaccine-related risk perceptions and subsequent sexual behaviors and sexually transmitted infections among vaccinated adolescent women

ObjectiveTo examine the association between risk perceptions after human papillomavirus (HPV) vaccination and sexual behaviors and sexually transmitted infection (STI) diagnosis over 30 months following vaccination.MethodsParticipants included 112 sexually experienced girls aged 13–21 years who were enrolled at the time of first HPV vaccination and completed ⩾2 of 4 follow-up visits at 2, 6, 18, 30 months and including 30 months. At each visit, participants completed surveys assessing risk perceptions (perceived need for safer sexual behaviors, perceived risk of STIs other than HPV) and sexual behaviors. STI testing was done at 6, 18, and 30 months. Outcomes were condom use at last intercourse with main male partner, number of sexual partners since last study visit, and STI diagnosis. Associations between risk perceptions and sexual behaviors/STIs were examined using generalized linear mixed models.ResultsMean age was 17.9 years; 88% were Black; 49% had a history of STI at baseline. Scale scores for perceived need for safer sexual behaviors did not change significantly over time. Scale scores for perceived risk of STIs other than HPV significantly changed (p = 0.027), indicating that girls perceived themselves to be more at risk of STIs other than HPV over 30 months following vaccination. Multivariable models demonstrated that greater perceived need for safer sexual behaviors following vaccination was associated with condom use (p = 0.002) but not with number of partners or STI diagnosis. Perceived risk of STIs other than HPV was not associated with the three outcomes.ConclusionsThe finding that perceived risk for STIs other than HPV was not associated with subsequent sexual behaviors or STI diagnosis is reassuring. The association between perceived need for safer sexual behaviors and subsequent condom use suggests that the HPV vaccination visit is an important opportunity to reiterate the importance of safer sexual behaviors to sexually experienced girls.     

Factors associated with partner referral among patients with sexually transmitted infections in Bangladesh

Understanding the demographic, behavioural and psychosocial factors associated with partner referral for patients with sexually transmitted infections (STIs) is important for designing appropriate intervention strategies. A survey was conducted among STI clients in three government and three non-governmental organization-operated clinics in Dhaka and Chittagong city in Bangladesh. Demographic and psychosocial information was collected using a questionnaire guided by the Attitude-Social Influence-Self Efficacy model. Partner referral data were collected by verification of referral cards when partners appeared at the clinics within one month of interviewing the STI clients. Of the 1339 clients interviewed, 81% accepted partner referral cards but only 32% actually referred their partners; 37% of these referrals were done by clients randomly assigned to a single counselling session vs. 27% by clients not assigned to a counselling session (p < 0.0001). Among psychosocial factors, partner referral intention was best predicted by attitudes and perceived social norms of the STI clients. Actual partner referral was significantly associated with intention to refer partner and attitudes of the index clients. Married clients were significantly more likely to refer their partners, and clients with low income were less likely to refer partners. Intervention programmes must address psychosocial and socio-economic issues to improve partner referral for STIs in Bangladesh.     

Hormonal contraceptive use and risk of sexually transmitted infections: a systematic review

Previous research has suggested that hormonal contraceptive users, compared with nonusers, may be at increased risk for acquiring sexually transmitted infections (STIs). We searched the MEDLINE and EMBASE databases for all articles from January 1966 through February 2005 for evidence relevant to all hormonal contraceptives and STIs (including cervical chlamydial and gonococcal infection, human papillomavirus, trichomoniasis, herpes and syphilis). We used standard abstract forms and grading systems to summarize and assess the quality of 83 identified studies. Studies of combined oral contraceptive and depot medroxyprogesterone use generally reported positive associations with cervical chlamydial infection, although not all associations were statistically significant. For other STIs, the findings suggested no association between hormonal contraceptive use and STI acquisition, or the results were too limited to draw any conclusions. Evidence was generally limited in both amount and quality, including inadequate adjustment for confounding, lack of appropriate control groups and small sample sizes. The observed positive associations may be due to a true association or to bias, such as differential exposure to STIs by contraceptive use or increased likelihood of STI detection among hormonal contraceptive users.     

Prevention and control of sexually transmitted infections among adolescents: the importance of a socio-ecological perspective--a commentary

The sexually transmitted infection (STI) epidemic among adolescents in the USA is inextricably tied to individual, psychosocial and cultural phenomena. Reconceptualizing the epidemic within an expanded socio-ecological framework may provide an opportunity to better confront its challenges. In this article, we use a socio-ecological framework to identify determinants of adolescents' sexual risk and protective behaviours as well as antecedents of their STI acquisition. The goal is to provide a synthesis of several discrete categories of research. Subsequently, we propose an integrated strategy that addresses the STI epidemic among adolescents by promoting a socio-ecological perspective in both basic research and intervention design. This approach may expand the knowledge base and facilitate the development of a broader array of intervention strategies, such as community-level interventions, policy initiatives, institutionally based programmes, and macro-level societal changes. Although there are inherent challenges associated with such an approach, the end result may have reciprocal and reinforcing effects designed to enhance the adoption and maintenance of STI-preventive practices among adolescents, and further reduce the rate of STIs.     

Knowledge of partner risk and secondary transmission of HIV

BACKGROUND: The number and proportion of people living longer with HIV and the proportion of people infected heterosexually have increased. We measured the frequency with which people with heterosexually acquired AIDS knew their partners' risk behaviors, the extent of secondary heterosexual transmission of HIV, and characterized people at risk for secondary heterosexual transmission. METHODS: For each of five sites (Alabama, California, Florida, New Jersey, and Texas) and for New York City, a sample of adults with AIDS was interviewed. Primary heterosexual transmission was contact with a partner who had a known risk factor for HIV infection. Secondary transmission was contact with an HIV-positive partner not known to have a risk for HIV. RESULTS: Among men, 35% knew that a sexual partner was HIV infected, 56% of women knew that a sexual partner was HIV infected. Among women, 12% knew that a partner was bisexual. Overall, 79% (460 of 581) reported a partner with a primary risk for HIV; among men, 236 of 293 (81%), and among women, 224 of 288 (78%) reported a partner with a primary risk. People categorized with secondary transmission were significantly more likely to be black and never married. People categorized with secondary transmission were more frequently women (53%), had less than a high school education (48%), and a history of drug use (52%). Men categorized with secondary transmission of HIV had a mean of 22 heterosexual partners; women had a mean of 16 partners. CONCLUSIONS: We found that many heterosexuals with AIDS did not know their sexual partners' risk for HIV, and that secondary heterosexual transmission probably results in a small proportion of all AIDS cases in the U.S.     

Sexual health and sexually transmitted infections in the North American Arctic

Our objective was to describe the basic epidemiology of sexually transmitted infections for Arctic and sub-Arctic regions of North America. We summarized published and unpublished rates of chlamydial infection and gonorrhea reported from 2003 through 2006 for Alaska, Canada, and Greenland. In 2006, Alaska reported high rates of chlamydial infection (715 cases/100,000 population) compared with the United States as a whole; northern Canada reported high rates of chlamydial infection (1,693 cases/100,000) and gonorrhea (247 cases/100,000) compared with southern Canada; and Greenland consistently reported the highest rates of chlamydial infection (5,543 cases/100,000) and gonorrhea (1,738 cases/100,000) in the Arctic. Rates were high for both men and women, although the highest incidence of infection was predominantly reported for young women in their early twenties. We propose that community-based participatory research is an appropriate approach to improve sexual health in Arctic communities.     

Determinants of contraceptive method among young women at risk for unintended pregnancy and sexually transmitted infections

The objective of this study was to examine the relationship between contraceptive method choice, sexual risk and various demographic and social factors. Data were collected on 378, 15- to 24-year-old women, recruited from health clinics and through community outreach in Northern California. Logistic regression analysis was used to estimate the association of predictors with contraceptive method used at last sex. Asian and Latina women were less likely to use any method. Women who were raised with a religion, or thought they were infertile, were also less likely to use any method. Women with multiple partners were generally less likely to use any method, but were more likely to use barrier methods when they did use one. Few women (7%) were dual method users. Women appear to act in a rational fashion within their own social context and may use no methods at all or use methods that are less effective for pregnancy prevention but offer more protection from sexually transmitted infections.     

Post-training quality of syndromic management of sexually transmitted infections by chemists and druggists in Pokhara, Nepal: is it satisfactory?

OBJECTIVE: Using simulated client and provider interview methods, this study assessed chemists and druggists' post-training management quality of syndromic sexually transmitted infections focusing on the areas of privacy maintaining, encouraging, history taking, counseling, referral practice, partner notification, and drug prescribing and then compared the findings of two methods. DESIGN: Forty-five pharmacies from a list of 75 in Pokhara, who collected sexually transmitted infections data during 1999, were selected randomly. First simulated client successfully presented either urethral or vaginal discharge syndrome at 37 pharmacies and recorded the events of whole encounter into an observation form within 20 minutes. Later 39 chemists and druggists were interviewed by a pre-tested semi-structured questionnaire. MAIN MEASURE: Results were reported mainly by numbers and corresponding percentages. For comparative purpose, P values were also shown. RESULTS: Overall, interview method revealed satisfactory knowledge of chemists and druggists for management of sexually transmitted infections except drug prescribing but their actual behaviors, revealed by simulated client method, indicated lower quality and differed significantly in the areas of encouraging, history taking, counseling, referral practice, and partner notification. Both methods indicated very poor qualities of drug prescribing. CONCLUSION: Retained knowledge of chemists and druggists for syndromic management of sexually transmitted infections were not applied to simulated client in actual practice. They should not prescribe drugs for patients of sexually transmitted infections, except referring to the doctors/hospitals. Continuous monitoring and further motivations for them may improve syndromic management quality of sexually transmitted infections. Moreover, depending on the purpose of study, various methods should be applied simultaneously to reach a better conclusion.     

Sexually transmitted infections: incidence and awareness among German adolescents

Despite the fact that they are largely preventable and curable, sexually transmitted infections (STIs) present a major global public health problem disproportionally affecting young persons aged 15-25 years. Several STIs can occur without, or only with mild and passing symptoms over long periods of time, leading to delayed diagnosis and treatment, and also increasing the chance of the infections being passed on during unprotected sexual intercourse. According to reports, many adolescents get information on STIs such as chlamydia and human papillomavirus only after getting infected.     

大连市不同人群性病知识知晓情况调查

目的 了解辽宁省大连市不同人群对性病防治知识的知晓程度,为制定性病防治工作规划及策略、有针对性地开展性病宣传教育提供科学依据.方法 采取一对一访谈和问卷调查的方式对大连市4个县区的8类人群进行性病相关知识调查,调查问卷及性病知识知晓率计算方法采用中国CDC性病防制中心推荐的题目和知晓率计算方法.结果 本次共回收调查问卷4 222份,大连市人群整体性病知识知晓率为55.12%,不同人群的性病知识知晓率有明显差异(X~2=584.47,P<0.001),重点人群性病知晓率水平由低到高分别是流动人群28.80%、学生46.97%、男男同性性接触者47.20%、暗娼55.90%.结论 不同人群对性病防治知识知晓率不同,对于重点人群应侧重于宣传如何规范的治疗性病,对于普通公众应侧重于宣传性病的病种及如何预防.     

Knowledge,attitudes and behaviours in relation to safe sex,sexually transmitted infections (STI) and HIV/AIDS among remote living north Queensland youth

Objective: To assess the knowledge, attitudes and behaviours of remote Aboriginal and Torres Strait Islander youth living in far north Queensland in relation to sexually transmitted infections, HIV/AIDS and safe sex. Methods: Community consultation followed by local recruitment of a sample of young people who, in a facilitated same gender focus group setting, completed a questionnaire followed by open discussion of the issues in a range of remote locations during 2007. Results: The remote living Indigenous youth demonstrated lower levels of knowledge in relation to STI and HIV and higher levels of partner change than was demonstrated in the 2002 national secondary school survey. Despite the high rates of bacterial STI in the region, there was an extremely low level of awareness of personal risk in relation to STI and HIV. Conclusion: There is an urgent need to strengthen school‐based sex education and to develop innovative approaches to sexual health promotion in addition to improving clinical sexual health service provision.     

Observations of sexually transmitted disease consultations in India

Objectives: To assess the quality of sexually transmitted disease (STD) case management provided in public and private health facilities in selected areas of Madras, Tamil Nadu, India, in order to make recommendations for improving the quality of care and promote the syndromic approach to STD treatment.Methods: Structured observations of consultations for STDs in health care facilities. Scoring of the observations according to standards for history taking, examination, treatment and provision of basic health promotion advice allows evaluation of STD case management.Results: With STD treatment adequacy scored against Indian national guidelines (which recommend aetiologic treatment), history taking, examination and treatment were satisfactory in 76 out of 108 (70%) of observed consultations. However, if STD treatment adequacy is scored with respect to the syndromic approach towards selected STD (male urethritis and non herpetic genital ulcer for both sexes), only 8 out of 81 (10%) of the patients were satisfactorily managed. During 32 out of 108 (30%) of the consultations, advice on the use of condoms in order to prevent STD or HIV/AIDS was given. Instructions regarding how to use condoms were offered to seven (6%) patients and condoms were only provided to one patient (1%). Patients were urged to refer their partner(s) for treatment during 29 (27%) of consultations. A criterion of adequate use of the STD consultation for health promotion, requiring both promotion of condoms and encouragement to refer partner(s) for treatment, was met during 13 (12%) of consultations.Conclusions: Monitoring and improving the standards of care at facilities at which STDs are treated have become key roles of STD/HIV/AIDS programmes. The present report suggests that in Madras the activities of medical practitioners who treat STD patients are far from ideal at present. Improvements would involve simplifying existing treatment guidelines by promoting the syndromic approach to STD management, continuing education programmes for health care providers in the public and private sectors and repeat assessments and feedback of the quality of STD care.     

The theoretical impact and cost-effectiveness of vaccines that protect against sexually transmitted infections and disease

Sexually transmitted diseases, a source of widespread morbidity and sometimes mortality, are caused by a diverse group of infections with a common route of transmission. Existing vaccines against hepatitis B virus (HBV) and human papilloma virus 16, 18, 6 and 11 are highly efficacious and cost effective. In reviewing the potential role for other vaccines against sexually transmitted infections (STIs) a series of questions needs to be addressed about the burden of disease, the potential characteristics of a new vaccine, and the impact of other interventions. These questions can be viewed in the light of the population dynamics of sexually transmitted infections as a group and how a vaccine can impact these dynamics. Mathematical models show the potential for substantial impact, especially if vaccines are widely used. To better make the case for sexually transmitted infection vaccines we need better data and analyses of the burden of disease, especially severe disease. However, cost effectiveness analyses using a wide range of assumptions show that STI vaccines would be cost effective and their development a worthwhile investment.     

In sickness and in health: Same-sex marriage laws and sexually transmitted infections

This paper analyzes the relationship between same-sex marriage laws and sexually transmitted infections in the United States using state-level data from 1981 to 2008. We hypothesize that same-sex marriage laws may directly affect risky homosexual behavior; may affect or mirror social attitudes toward gays, which in turn may affect homosexual behavior; and may affect or mirror attitudes toward non-marital sex, which may affect risky heterosexual behavior. Our findings may be summarized as follows. Laws banning same-sex marriage are unrelated to gonorrhea rates, which are a proxy for risky heterosexual behavior. They are more closely associated with syphilis rates, which are a proxy for risky homosexual behavior. However, these estimates are smaller and less statistically significant when we exclude California, the state with the largest gay population. Also, laws permitting same-sex marriage are unrelated to gonorrhea or syphilis, but variation in these laws is insufficient to yield precise estimates. In sum, the findings point to a modest positive association-if any at all-between same-sex marriage bans and syphilis.     

The global roadmap for advancing development of vaccines against sexually transmitted infections: Update and next steps

In 2014, the World Health Organization, the US National Institutes of Health, and global technical partners published a comprehensive roadmap for development of new vaccines against sexually transmitted infections (STIs). Since its publication, progress has been made in several roadmap activities: obtaining better epidemiologic data to establish the public health rationale for STI vaccines, modeling the theoretical impact of future vaccines, advancing basic science research, defining preferred product characteristics for first-generation vaccines, and encouraging investment in STI vaccine development. This article reviews these overarching roadmap activities, provides updates on research and development of individual vaccines against herpes simplex virus, Chlamydia trachomatis, Neisseria gonorrhoeae, and Treponema pallidum, and discusses important next steps to advance the global roadmap for STI vaccine development.     

云南省德宏州无抗病毒治疗史的成年HIV感染者机会性感染相关症状发生及其处理

目的 了解云南省德宏州无抗病毒治疗史的成年HIV感染者机会性感染相关症状发生及处理.方法 回顾性调查德宏州≥18岁无抗病毒治疗史的HIV感染者于2012年1～9月间机会性感染相关症状发生及处理.结果 共有1 416例参加调查,以男性(75.3％)、≤40岁(74.2％)、少数民族(70.1％)、小学及以下文化程度(70.0％)为主;经性传播及静脉吸毒传播感染HIV者各占约50％;CD4细胞计数平均为478个/μL.133例(9.4％)调查对象观察期间至少出现过一种机会性感染相关症状,以呼吸系统症状罹患率最高(6.0％,85例).其中,85例(63.9％)仅出现1个系统症状,26例(19.5％)出现2个系统症状,22例(16.5％)则出现≥3个系统症状.多因素Logistic回归分析显示,CD4细胞计数＞200个/μl的患者机会性感染相关症状罹患率低于CD4细胞计数较低者.大多数出现机会性感染相关症状患者自购药物处理或不做任何处理.结论 德宏州无抗病毒治疗成年HIV感染者特别是CD4细胞计数水平低的患者机会性感染发生率较高,应加强机会性感染防治.