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BACKGROUND: Reduced antibiotic susceptibility (RS) in Neisseria gonorrhoeae (GC) may increase treatment failure. Conducting tests of cure (TOC) for patients with RS-GC may facilitate identification of treatment failures. METHODS: We examined 2018 to 2019 data from 8 jurisdictions participating in the US Centers for Disease Control and Prevention’s Strengthening US Response to Resistant Gonorrhea project. Jurisdictions collected GC isolates and epidemiological data from patients and performed antimicrobial susceptibility testing. Minimum inhibitory concentrations of ceftriaxone, 0.125 μg/mL or greater; cefixime, 0.250 μg/mL or greater; or azithromycin, 2.0 μg/mL or greater were defined as RS. Patients with RS infections were asked to return for a TOC 8 to 10 days posttreatment. We calculated a weighted TOC return rate and described time to TOC and suspected reasons for any positive TOC results. RESULTS: Overall, 1165 patients were diagnosed with RS infections. Over half returned for TOC (weighted TOC, 61%; 95% confidence interval, 50.1%–72.6%; range by jurisdiction, 32%–80%). Test of cure rates were higher among asymptomatic (68%) than symptomatic patients (53%, P = 0.001), and men who have sex with men (62%) compared with men who have sex with women (50%; P < 0.001). Median time between treatment and TOC was 12 days (interquartile range, 9–16). Of the 31 (4.5%) TOC patients with positive results, 13 (42%) were suspected because of reinfection and 11 (36%) because of false-positive results. There were no treatment failures suspected to be due to RS-GC. CONCLUSIONS: Most patients with a RS infection returned for a TOC, though return rates varied by jurisdiction and patient characteristics. Test of cure can identify and facilitate treatment of reinfections, but false-positive TOC results may complicate interpretation and clinical management.

BACKGROUND We investigated differences in gonococcal antimicrobial susceptibility by anatomic site among cisgender men who have sex with men (MSM) using specimens collected through the Centers for Disease Control and Prevention's enhanced Gonococcal Isolate Surveillance Project and Strengthening the US Response to Resistant Gonorrhea. METHODS During the period January 1, 2018-December 31, 2019, 12 enhanced Gonococcal Isolate Surveillance Project and 8 Strengthening the US Response to Resistant Gonorrhea sites collected urogenital, pharyngeal, and rectal isolates from cisgender MSM in sexually transmitted disease clinics. Gonococcal isolates were sent to regional laboratories for antimicrobial susceptibility testing by agar dilution. To account for correlated observations, linear mixed-effects models were used to calculate geometric mean minimum inhibitory concentrations (MICs), and mixed-effects logistic regression models were used to calculate the proportion of isolates with elevated or resistant MICs; comparisons were made across anatomic sites. RESULTS Participating clinics collected 3974 urethral, 1553 rectal, and 1049 pharyngeal isolates from 5456 unique cisgender MSM. There were no significant differences in the geometric mean MICs for azithromycin, ciprofloxacin, penicillin, and tetracycline by anatomic site. For cefixime and ceftriaxone, geometric mean MICs for pharyngeal isolates were higher compared with anogenital isolates (P < 0.05). The proportion of isolates with elevated ceftriaxone MICs (≥0.125 μg/mL) at the pharynx (0.67%) was higher than at rectal (0.13%) and urethral (0.18%) sites (P < 0.05). CONCLUSIONS Based on data collected from multijurisdictional sentinel surveillance projects, antimicrobial susceptibility patterns of Neisseria gonorrhoeae isolates may differ among MSM at extragenital sites, particularly at the pharynx. Continued investigation into gonococcal susceptibility patterns by anatomic site may be an important strategy to monitor and detect the emergence of antimicrobial resistant gonorrhea over time.

BACKGROUND Initiating pre-exposure or post-exposure prophylaxis (PrEP/PEP) in the setting of undiagnosed acute HIV (AHI) could cause antiretroviral resistance. We sought to characterize clinical outcomes and drug resistance mutations among individuals prescribed PrEP/PEP with undiagnosed AHI at a San Francisco sexually transmitted disease clinic. SETTING In our PrEP/PEP program, patients are tested for HIV using a point-of-care antibody test. If negative, patients are started on prophylaxis and screened for AHI using pooled HIV RNA (5-10 days turn-around). We used 2-drug PEP until 05/2016. METHODS We identified patients who had as-yet-undiagnosed AHI on the day of PrEP/PEP start between 2011 and 2018, then used our clinical record and surveillance data to describe HIV resistance and clinical outcomes. RESULTS Of 1758 PrEP and 2242 PEP starts, there were 7 AHI cases among PrEP users (0.40%) and 6 among PEP users (0.30%). Median times for linkage to HIV care, initiation of HIV treatment, and viral suppression were 7, 12, and 43 days. On initiation of HIV care, 3 patients (23%) were found to have an M184 mutation 7-12 days after starting PrEP/PEP. All 3 had genotyping performed on stored serum available from the date of PrEP/PEP start, each of which demonstrated wild-type virus. All 3 patients achieved durable viral suppression. CONCLUSIONS Although rare (occurring

Background Inequalities in Neisseria gonorrhoeae (gonorrhea) burden by sexual minority status in the United States are difficult to quantify. Sex of sex partner is not routinely collected for reported cases. Population estimates of men who have sex with men (MSM) necessary to calculate case rates have not been available until recently. For these reasons, trends in reported gonorrhea rates among MSM have not been described across multiple jurisdictions. Methods We estimated of the number of MSM cases reported in 6 jurisdictions continuously participating in the STD Surveillance Network 2010-2015 based on interviews with a random sample of cases. Data were obtained for Baltimore, Philadelphia, New York City, San Francisco, California (excluding San Francisco), and Washington State. Estimates of the MSM, heterosexual male (MSW) and female populations were obtained from recently published estimates and census data. Case rates and rate-ratios were calculated comparing trends in reported cases among MSM, heterosexual males and women. Results The proportion of male gonorrhea cases among MSM varied by jurisdiction (range: 20% to 98%). Estimated MSM rate increased from 1369 cases per 100,000 in 2010 to 3435 cases per 100,000 in 2015. Between 2010 and 2015, the MSM-to-Women gonorrhea rate ratio increased from 13:1 to 24:1, and the MSM-to-MSW gonorrhea rate ratio increased from 16:1 to 31:1. Conclusions Estimated gonorrhea rate among MSM increased in a network of 6 geographically diverse US jurisdictions. Estimating the size of this population, determining MSM among reported cases and estimating rates are essential first steps for better understanding the changing epidemiology of gonorrhea.

BACKGROUND The comparative effectiveness of pre- and post-exposure prophylaxis (PrEP and PEP) for men who have sex with men (MSM) is unclear. SETTING We conducted a case-control study of MSM who were initially HIV-uninfected during September 1, 2012-June 30, 2016 at San Francisco's only municipal sexually transmitted diseases (STDs) clinic. METHODS Each case was matched with up to 3 controls based on age, baseline visit date, and follow-up time. The primary dependent variable was HIV seroconversion; the primary independent variable was exposure to PrEP, PEP, or neither. Conditional logistic regression was used to calculate odds ratios and 95% confidence intervals. RESULTS Of 638 MSM (161 cases and 477 controls), 137 reported ever taking PrEP, 98 reported taking PEP-only, and 403 took neither. PrEP takers had more non-HIV sexually transmitted diseases during the analysis (72.3% vs. 55.1% vs. 42.4% P < 0.01) and were more likely to report receptive anal sex in the past 3 months (86.5% vs. 80.4% vs. 73.0%; P < 0.01). In the adjusted model, PrEP was associated with lower odds of HIV seroconversion (odds ratio 0.24; 95% confidence interval: 0.13 to 0.46) while PEP use had no effect on HIV acquisition compared with taking neither. CONCLUSIONS MSM who ever used PrEP demonstrated equal or higher sexual risk compared with those using neither PrEP nor PEP but had 76% lower odds of HIV seroconversion. MSM who used PEP but never PrEP were no less likely to seroconvert than those using neither. MSM should be offered PrEP. PEP users with ongoing risk of HIV infection should be connected to PrEP after PEP.

Background Transgender women and transgender men are disproportionately affected by human immunodeficiency virus (HIV) infection and may be vulnerable to other sexually transmitted diseases (STDs), but the lack of surveillance data inclusive of gender identity hinders prevention and intervention strategies. Methods We analyzed data from 506 transgender women (1045 total visits) and 120 transgender men (209 total visits) who attended 26 publicly funded clinics that provide STD services in 6 US cities during a 3.5-year observation period. We used clinical and laboratory data to examine the proportion of transgender women and transgender men who tested positive for urogenital and extragenital chlamydial or gonococcal infections and who self-reported or tested positive for HIV infection during the observation period. Results Of the transgender women tested, 13.1% tested positive for chlamydia and 12.6% tested positive for gonorrhea at 1 or more anatomic sites, and 14.2% were HIV-infected. Of transgender men tested, 7.7% and 10.5% tested positive for chlamydia and gonorrhea at 1 or more anatomic sites, and 8.3% were HIV-infected. Most transgender women (86.0% and 80.9%, respectively) and more than a quarter of transgender men (28.6% and 28.6%, respectively) with an extragenital chlamydial or gonococcal infection had a negative urogenital test at the same visit. Conclusions Publicly funded clinics providing STD services are likely an important source of STD care for transgender persons. More data are needed to understand the most effective screening approaches for urogenital, rectal, and pharyngeal Chlamydia trachomatis and Neisseria gonorrhoeae infections in transgender populations.

BACKGROUND. Approximately 90% of genital warts are caused by human papillomavirus (HPV) types 6 and 11. In the United States, HPV vaccination has been recommended for girls and women aged ≤26 years, and since 2011, for boys and men aged ≤21 years and for gay, bisexual, and other men who have sex with men (MSM) aged ≤26 years. METHODS. Data were obtained from 27 clinics participating in the STD Surveillance Network. Trends in the annual prevalence of anogenital warts (AGW) from 2010–2016 were described by sex and by the sex of sex partners. RESULTS. During 2010–2016, significant declines in the prevalence of AGW were observed in women aged

Early syphilis, gonorrhea, and chlamydia but not HIV infections have increased in San Francisco, primarily among men.We linked records of persons reported with early syphilis, gonorrhea, and chlamydia to records of persons reported with HIV to measure the proportion and characteristics of San Francisco residents with HIV-sexually transmitted disease (STD) coinfection between 2007 and 2014. We measured trends in HIV coinfection separately for men and women for each STD.From 2007 to 2014, of the 5745 early syphilis, 18,037 gonorrhea, and 37,224 chlamydia diagnoses that were reported, 66%, 28%, and 15%, respectively, were among persons coinfected with HIV. Men accounted for most persons with early syphilis, gonorrhea, and chlamydia HIV coinfection. For early syphilis and HIV coinfection, among men who have sex with men (MSM), Latinos were more likely and Asian/Pacific Islanders were less likely to have HIV coinfection compared with whites. Older age at diagnosis and history of an STD were both also significantly associated with early syphilis and HIV coinfection. Transgender persons, older ages, Latino MSM compared with white MSM, and those with a history of STD were more likely to have HIV coinfection, whereas Asian/Pacific Islander MSM were less likely to have HIV coinfection for both gonorrhea and chlamydia, CONCLUSIONS: Our findings highlight the high burden of HIV-STD coinfection in San Francisco. To maintain the current declines in HIV incidence and turn the curve in rising STD incidence, there is an urgent need for collaborative HIV and STD prevention and control efforts.

The number of reported early syphilis cases in San Francisco has increased steadily since 2005. It is not yet clear what factors are responsible for such an increase. A recent analysis of the sexual contact network of men who have sex with men with syphilis in San Francisco has discovered a large connected component, members of which have a significantly higher chance of syphilis and HIV compared to non-member individuals. This study investigates whether it is possible to exploit the existence of the largest connected component to design new notification strategies that can potentially contribute to reducing the number of cases. We develop a model capable of incorporating multiple types of notification strategies and compare the corresponding incidence of syphilis. Through extensive simulations, we show that notifying the community of the infection state of few central nodes appears to be the most effective approach, balancing the cost of notification and the reduction of syphilis incidence. Additionally, among the different measures of centrality, the eigenvector centrality reveals to be the best to reduce the incidence in the long term as long as the number of missing links (non-disclosed contacts) is not very large The work of J.S. and D.J. has been partially supported by the research grants MTM2014-52402-C3-3-P of the Spanish Government (MINECO) and MPCUdG2016/047 of the Universitat de Girona. J.S. and D.J. are members of the research groups 2014SGR-1083 and 2014SGR-555 of the Generalitat de Catalunya, respectively

BACKGROUND: Since 2001, San Francisco has experienced a sustained syphilis epidemic that has been nearly exclusively limited to men who have sex with men. We examined the characteristics associated with changes in the syphilis epidemic in San Francisco. METHODS: All primary and secondary (P&S) syphilis cases reported to the San Francisco Department of Public Health between 2001 and 2011 were examined using joinpoint analysis to identify periods within the broader epidemic. Characteristics of the index cases were compared across the periods using χ(2) statistics and t tests. RESULTS: Three distinct periods were identified, an acute increase, decline, and then period of resurgence. In the most recent period of resurgence, compared with earlier periods, patients with P&S syphilis were more likely to have a prior syphilis infection, were older, were more likely to meet partners online, and were more likely to have a partner from outside San Francisco. CONCLUSIONS: In an analysis of 11 years of P&S syphilis data, several factors were associated with declines or resurgences. Innovative prevention measures are needed to reduce syphilis morbidity among men who have sex with men.

We describe the molecular epidemiology of syphilis in San Francisco (SF) using Treponema pallidum specimens obtained from patients examined at the SF municipal sexually transmitted diseases clinic during 2004-2007. Of 69 specimens, 52 (75%) were subtype 14d9. Single subtype predominance might reflect a closely linked sexual network in SF.

We describe the epidemiology of Trichomonas vaginalis (TV) among San Francisco County Jail inmates using APTIMA TV analyte-specific reagents on remnant urine. We detected TV in 15/713 (2.1%) men and 95/297 (32.0%) women. Among women, increased age was significantly associated with TV. The benefits of TV screening should be determined.

Background: Syphilis incidence has increased dramatically in the United States since 2000, occurring primarily among men who have sex with men (MSM) and disproportionately affecting those with human immunodeficiency virus (HIV) infection. The continued increases in syphilis rates among MSM signals the need for enhanced prevention methods. We undertook a study to examine the rate of repeat syphilis infection among MSM in San Francisco and to identify risk factors associated with syphilis reinfection that may inform additional prevention strategies. Methods: We developed a retrospective cohort of all cases of primary, secondary, and early latent syphilis among MSM diagnosed in San Francisco in 2001 and 2002. We evaluated data through the end of 2003 to determine all cases of syphilis reinfection, defined as a new infection that occurred within 1 year after prior syphilis infection and treatment. Results: We found that 6.7% (42/624) of cases had a repeat syphilis infection within 1 year. HIV infection was associated with an increased risk of repeat infection (OR 4.7; CI, 1.8‐12.0). No differences in age, race, number of period sex partners, illicit substance use, or partner meeting venues were observed between cases with and without repeat infection. Conclusions: Our study revealed that HIV-infected MSM with syphilis represent an at-risk group for repeat syphilis infection. Targeting increased screening and risk reduction interventions to HIV-infected MSM in care could reduce the overall incidence of syphilis among MSM.

Although acute HIV infection contributes disproportionately to onward HIV transmission, HIV testing has not routinely included screening for acute HIV infection. To evaluate the performance of an HIV antigen/antibody (Ag/Ab) combination assay to detect acute HIV infection compared with pooled HIV RNA testing. Multisite, prospective, within-individual comparison study conducted between September 2011 and October 2013 in 7 sexually transmitted infection clinics and 5 community-based programs in New York, California, and North Carolina. Participants were 12 years or older and seeking HIV testing, without known HIV infection. All participants with a negative rapid HIV test result were screened for acute HIV infection with an HIV Ag/Ab combination assay (index test) and pooled human immunodeficiency virus 1 (HIV-1) RNA testing. HIV RNA testing was the reference standard, with positive reference standard result defined as detectable HIV-1 RNA on an individual RNA test. Number and proportion with acute HIV infections detected. Among 86,836 participants with complete test results (median age, 29 years; 75.0% men; 51.8% men who have sex with men), established HIV infection was diagnosed in 1158 participants (1.33%) and acute HIV infection was diagnosed in 168 participants (0.19%). Acute HIV infection was detected in 134 participants with HIV Ag/Ab combination testing (0.15% [95% CI, 0.13%-0.18%]; sensitivity, 79.8% [95% CI, 72.9%-85.6%]; specificity, 99.9% [95% CI, 99.9%-99.9%]; positive predictive value, 59.0% [95% CI, 52.3%-65.5%]) and in 164 participants with pooled HIV RNA testing (0.19% [95% CI, 0.16%-0.22%]; sensitivity, 97.6% [95% CI, 94.0%-99.4%]; specificity, 100% [95% CI, 100%-100%]; positive predictive value, 96.5% [95% CI, 92.5%-98.7%]; sensitivity comparison, P < .001). Overall HIV Ag/Ab combination testing detected 82% of acute HIV infections detectable by pooled HIV RNA testing. Compared with rapid HIV testing alone, HIV Ag/Ab combination testing increased the relative HIV diagnostic yield (both established and acute HIV infections) by 10.4% (95% CI, 8.8%-12.2%) and pooled HIV RNA testing increased the relative HIV diagnostic yield by 12.4% (95% CI, 10.7%-14.3%). In a high-prevalence population, HIV screening using an HIV Ag/Ab combination assay following a negative rapid test detected 82% of acute HIV infections detectable by pooled HIV RNA testing, with a positive predictive value of 59%. Further research is needed to evaluate this strategy in lower-prevalence populations and in persons using preexposure prophylaxis for HIV prevention.

Background: The San Francisco Department of Public Health conducts HIV third-party partner notification in the following populations based on standard Centers for Disease Control and Prevention (CDC) guidelines: (1) persons with acute and nonacute incident HIV infection tested at the municipal sexually transmitted disease (STD) clinic and the county hospital and (2) all county residents with early syphilis and long-standing HIV infection. Methods: We reviewed routinely collected demographic and partner notification outcome data among acute and nonacute cases between 2004 and 2006 and among long-standing cases between July 2005 and December 2006. Outcomes were examined among the 3 case types. Results: Most acute (n = 30), nonacute (n = 398), and long-standing cases (n = 335) occurred in gay/bisexual men (89%), and most case-patients were interviewed (80%). In acute and nonacute cases, 13% of partners tested for HIV were newly identified as HIV-infected. The number of patients interviewed per new HIV infection identified was 25 for acute cases, 21 for nonacute cases, and 39 for long-standing cases; however, half of recent new HIV infections were identified among partners of long-standing patients. Few patients or partners refused partner notification services. Conclusions: Partner notification was acceptable and successfully identified new HIV infections. Other jurisdictions should consider implementing or expanding partner notification for HIV infection. More evaluation is needed of the effectiveness of partner notification among HIV-infected persons with other STDs.

Background: Given the strong relation between sexually transmitted diseases (STDs) and the spread of HIV infection, recent outbreaks of syphilis in the United States could lead to increased rates of new HIV infection. STD clinics serving persons at risk for syphilis would be logical sites to monitor rates of acute HIV infection. The detection of acute HIV infection, however, is not routine and requires the use of HIV RNA testing in combination with HIV antibody testing. Methods: To determine the rate of acute HIV infection, we performed HIV RNA testing on pooled HIV antibody-negative specimens from persons seeking care at San Francisco City Clinic (SFCC) and from men seeking care at 3 STD clinics in Los Angeles. We compared prevalence of acute HIV infection among those groups. Results: From October 2003 to July 2004, we tested 3075 specimens from persons at the SFCC, of which 105 (3%) were HIV antibody-positive and 11 were HIV RNA-positive/HIV antibody-negative, resulting in a prevalence of acute HIV infection of 36 per 10,000 (95% confidence interval [CI]: 26 to 50 per 10,000) and increasing by 10.5% the diagnostic yield of HIV RNA testing compared with standard testing. From February 2004 to April 2004, 1712 specimens were tested from men at 3 Los Angeles STD clinics, of which 14 (0.82%) were HIV-positive by enzyme immunoassay testing and 1 was HIV RNA-positive/HIV antibody-negative, resulting in a prevalence of 6 per 10,000 (95% CI: 3 to 13 per 10,000) and increasing the diagnostic yield for HIV infection by 7.1%. Conclusions: In our study, the addition of HIV RNA screening to routine HIV antibody testing in STD clinics identified a substantial increased proportion of HIV-infected persons at high risk for further HIV transmission, who would have been missed by routine HIV counseling and testing protocols. Further evaluation of the addition of HIV RNA screening to routine HIV antibody testing is warranted.

Worldwide, studies of men who have sex with men (MSM) report increases in HIV risk-related behavior. Less is known about trends within minority subpopulations of MSM, particularly those of Asian and Pacific Islander (A&PI) ethnicity. A&PI MSM are underrepresented among AIDS cases (2.7%) with respect to their estimated makeup in the gay community of San Francisco (4.5%). However, recent trends in unprotected anal intercourse (UAI) and sexually transmitted diseases suggest a reversal in the relative risk for HIV among A&PI MSM compared with White MSM. Starting from lower levels in 1999, UAI with multiple partners, UAI with multiple partners of unknown HIV serostatus, the incidence of male rectal gonorrhea, and the incidence of early syphilis among A&PI MSM surpassed levels among White MSM by 2002. A window of opportunity to prevent further spread of HIV among A&PI MSM may be closing.

In a retrospective analysis of asymptomatic men who have sex with men visiting an urban municipal sexually transmitted disease clinic, 83.8% of chlamydial and gonococcal infections would have been missed by urethral screening, compared with 9.8% by screening the rectum and pharynx. Extragenital screening is critical to the provision of comprehensive sexual health services for men who have sex with men.

The authors compared temporal trends in the prevalence and incidence of human immunodeficiency virus (HIV) infection based upon 34,866 specimens from patients who attended the San Francisco, California, municipal sexually transmitted disease clinic between 1989 and 1998. HIV infection data were collected during annual blinded HIV serologic surveys. Incidence was determined by applying a serologic testing algorithm for recent HIV seroconversion that uses both a sensitive and a less sensitive enzyme immunoassay to stored HIV positive sera. The HIV seroprevalence declined from 15.2% in 1989 to 7.2% in 1998 (odds ratio per year = 0.92, 95% confidence interval (CI): 0.91, 0.94). Among homosexual men, the HIV prevalence declined from 50.9% in 1989 to 19.9% in 1998 (odds ratio per year = 0.86, 95% CI: 0.85, 0.88). The pooled seroincidence was 1.6% and did not change significantly over time (odds ratio per year = 1.0, 95% CI: 0.98, 1.1). The pooled seroincidence among homosexual men was 6.6% per year and remained steady between 1989 and 1998 (odds ratio per year = 0.99, 95% CI: 0.92, 1.1). During a dramatic, 10-year decline in seroprevalence of HIV infection, the incidence of HIV infection remained remarkably stable.

To determine whether there were core groups of transmitters of gonorrhea and chlamydial infection among 14- to 35-year-olds in San Francisco during 1989-1993, sociodemographic risk factors for repeat gonorrhea and chlamydial infection were examined. During those 5 years, 8613 cases of gonorrhea were reported among males and 3893 among females; the proportions with repeat infection were 17.0% and 19.0%, respectively. There were also 2465 reported cases of chlamydial infection among males and 6996 among females; the proportions with repeat infection were 8.6% and 15.1%, respectively. Multivariate analyses reveal that for males, city planning region 5 was an independent risk factor for both repeat gonorrhea (relative hazard [RH] = 1.22; 95% confidence interval [CI] = 1.05-1.43) and repeat chlamydial infection (RH = 1.78; 95% CI = 1.23-2.57). For females, city planning region 4 was an independent risk factor for repeat gonorrhea (RH = 1.50; 95% CI = 1.12-1.98), and there was no high-risk planning region for repeat chlamydial infection. In San Francisco, there appear to be male and female core transmitters for gonorrhea but there may not be core transmitters for chlamydial infection.

In this retrospective review of cases of clinical proctitis, we identified the frequency of common sexually transmitted diseases (STDs) among men who have sex with men on the basis of reports from the municipal STD clinic in San Francisco. Of note, gonorrhea and chlamydia were the most common STDs, followed by herpes and syphilis. Current STD treatment guidelines recommend empiric treatment for gonorrhea and chlamydia, but treatment for herpes should also be considered. The implications for human immunodeficiency virus (HIV) transmission are also discussed.

The authors analyzed temporal trends in human immunodeficiency virus (HIV) infection among men and women who visited the San Francisco municipal sexually transmitted disease clinic between 1989 and 1992, using blinded HIV seroprevalence data. Temporal changes in sexual behavior were evaluated by abstracting self-reported information on sexual behaviors from a random sample of charts of men who visited the clinic between 1990 and 1992. From 1989 to 1992, HIV seropositivity declined from 2.0% to 1.0% among women (p = 0.06) and from 18.9% to 12.0% (p < 0.001) among men. The percentage of patients who reported having anal intercourse in the previous year did not change significantly during the study period. The percentage of male patients who reported having vaginal intercourse during the previous year decreased from 82.9% to 78.6% (p < 0.05), and the percentage of male patients who reported engaging in receptive oral sex during the previous year increased from 24.0% to 41.6% (p < 0.001). The percentage of male patients who reported that they always used condoms increased from 31.8% to 49.2% for anal sex, from 8.7% to 19.5% for vaginal sex, and from 1.4% to 6.3% for oral sex (p < 0.05). Among patients visiting the sexually transmitted disease clinic, there was a steady and significant decline in HIV seroprevalence. The decline in HIV seroprevalence was accompanied by a significant trend toward safer sexual practices. However, by the end of the study period, less than half of the patients reported using condoms all of the time, which suggests that there is a need to expand behavioral interventions to focus on high-risk persons. Am J Epidemiol 1995 ;142 :314-22.

We evaluated self-sampling to detect pharyngeal Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infection among men who have sex with men attending a San Francisco STD clinic. The prevalence of pharyngeal NG and CT infection was 6.7% (32/480) and 1.3% (6/480), respectively. The percent agreement between self-collected and clinician-collected NG and CT specimens using nucleic acid amplification testing was 96.6% with a κ of 0.766 (95% confidence interval: 0.653-0.879) and 99.4% with a κ of 0.766 (95% confidence interval: 0.502-1.000), respectively. Acceptability was high among participants.

To compare the seroprevalence of and risk factors for human immunodeficiency virus infection (HIV) among patients attending a public sexually transmitted disease clinic, the authors conducted both voluntary and blinded seroprevalence surveys between June 1989 and August 1990. For the voluntary survey, every twenty-fifth patient attending the clinic for a new problem was invited to receive anonymous testing for HIV antibody. For the blinded survey, sera obtained for syphilis serologies from 2,297 (86%) of the 2,682 patients attending the clinic for a new problem were tested for HIV antibody after all personal identifiers were removed. Of the 946 eligible patients, 631 (66.7%) agreed to participate in the voluntary survey. Black men were significantly less likely to participate than other men and women (p < 0.0001). The prevalence of HIV antibody was 25% greater in the blinded survey than in the voluntary survey (15.2% and 11.4%, respectively, p < 0.05). This difference was due primarily to black homosexual/bisexual men, who had a 12.7-fold greater risk of HIV infection in the blinded survey than in the voluntary survey. These results suggest that blinded seroprevalence surveys may provide a better prevalence estimate of HIV infection than voluntary surveys. The greater risk for HIV infection observed among homosexual and bisexual black men, who were tested only in the blinded serosurvey, suggests that efforts to increase voluntary testing for HIV infection in this group should be developed.

Rectal gonorrhea cases among males remained stable in San Francisco during 2005-2008, but rectal chlamydia increased 38 percent. While testing increased, rectal gonorrhea positivity declined at the STD clinic, and both infections remained stable elsewhere. Sentinel surveillance provides a better understanding of disease trends than case reporting alone.

Background Limited data exist on the risk of Chlamydia trachomatis and Neisseria gonorrhoeae transmission from oropharynx to urethra. We examined urethral C. trachomatis and N. gonorrhoeae positivity among men who have sex with men (MSM) seen at San Francisco City Clinic (San Francisco, CA) during 2007. Methods All patients who sought care at the San Francisco City Clinic (the only municipal sexually transmitted disease clinic in San Francisco) received a standardized interview conducted by clinicians. We estimated urethral C. trachomatis and N. gonorrhoeae positivity for 2 groups of visits by MSM who visited during 2007: (1) men who reported their only urethral exposure was receiving fellatio in the previous 3 months and (2) men who reported unprotected insertive anal sex in the previous 3 months. Additionally, urethral C. trachomatis and N. gonorrhoeae positivity was estimated, stratified by human immunodeficiency virus infection status, urogenital symptom history, and whether the patient had been a contact to a sex partner with either chlamydia or gonorrhea. Results Among MSM who reported only receiving fellatio, urethral C. trachomatis and N. gonorrhoeae positivity were 4.8% and 4.1%, respectively. These positivity estimates were similar to positivity found among MSM who reported unprotected insertive anal sex. Conclusions A more complete understanding of the risks of transmission of C. trachomatis and N. gonorrhoeae from oropharynx to urethra will help inform prevention and screening programs.

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

SEXUALLY TRANSMITTED INFECTIONS (STI), such as Chlamydia trachomatis, Neisseria gonorrhoeae, herpes simplex virus (HSV), and Treponema pallidum are common causes of proctitis among gay men and other men who have sex with men (MSM).1,2 Inflammatory proctitis caused by an STI may increase the suscepti

Background Recent experimental evidence has demonstrated the benefits of male circumcision for the prevention of human immunodeficiency virus (HIV) infection. Studies have also shown that male circumcision is cost-effective and reduces the risk for certain ulcerative sexually transmitted diseases (STDs). The epidemiology of male circumcision in the United States is poorly studied and most prior reports were limited by self-reported measures. The study objective was to describe male circumcision trends among men attending the San Francisco municipal STD clinic, and to correlate the findings with HIV, syphilis and sexual orientation. Methods and Findings A cross sectional study was performed by reviewing all electronic records of males attending the San Francisco municipal STD clinic between 1996 and 2005. The prevalence of circumcision over time and by subpopulation such as race/ethnicity and sexual orientation were measured. The findings were further correlated with the presence of syphilis and HIV infection. Circumcision status was determined by physical examination and disease status by clinical evaluation with laboratory confirmation. Among 58,598 male patients, 32,613 (55.7%, 95% Confidence Interval (CI) 55.2–56.1) were circumcised. Male circumcision varied significantly by decade of birth (increasing between 1920 and 1950 and declining overall since the 1960's), race/ethnicity (Black: 62.2%, 95% CI 61.2–63.2, White: 60.0%, 95% CI 59.46–60.5, Asian Pacific Islander: 48.2%, 46.9–49.5 95% CI, and Hispanic: 42.2%, 95% CI 41.3–43.1), and sexual orientation (gay/bisexual: 73.0%, 95% CI 72.6–73.4; heterosexual: 66.0%, 65.5–66.5). Male circumcision may have been modestly protective against syphilis in HIV-uninfected heterosexual men (PR 0.92, 95% C.I. 0.83–1.02, P = 0.06). Conclusions Male circumcision was common among men seeking STD services in San Francisco but has declined substantially in recent decades. Male circumcision rates differed by race/ethnicity and sexual orientation. Given recent studies suggesting the public health benefits of male circumcision, a reconsideration of national male circumcision policy is needed to respond to current trends.

Background The effectiveness of postexposure prophylaxis (PEP) following occupational exposure to HIV has prompted advocacy for PEP following sexual or drug-use exposures. Objective To evaluate the concern that the availability of PEP for sexual or drug-use exposures might result in behavioral disinhibition. Design Non-randomized trial of 397 adults with high-risk sexual or drug-use exposures within the prior 72 h. Interventions Antiretroviral medication for 4 weeks and five counseling sessions. Main outcome measurements Participants were followed for 12 months for repeat request for PEP and for changes compared with pre-enrollment in overall high-risk behavior and the acquisition of sexually transmitted diseases (STD) and HIV. Results After 12 months following receipt of PEP, the majority of participants (83%) did not request a repeat course of PEP. At 12 months after exposure, 73% of participants reported a decrease compared with baseline in the number of times they had performed high-risk sexual acts; 13% reported no change, and 14% had an increase. Most participants (85%) had no change in the incidence of STD; 8.5% had a decrease and 6.8% an increase. Three homosexual men seroconverted for HIV (none associated with the presenting exposure) for a rate of 1.2/100 person-year, equivalent to rates in San Francisco among all homosexual men. Conclusions After receipt of PEP consisting of antiretroviral medication and behavioral counseling following a potential sexual exposure to HIV, most individuals do not increase high-risk behavior. Coupled with prior safety and feasibility data, this lack of behavioral disinhibition suggests that use of PEP should be routinely considered following high-risk sexual exposures.

In a sexually transmitted disease clinic-based sample of men who have sex with women, positivity for urethral Chlamydia trachomatis and Neisseria gonorrhoeae was 3.5% and 3.1%, respectively, among patients whose only urethral exposure in the previous 3 months was receiving fellatio from a woman. Urethral infections acquired by fellatio might contribute to ongoing disease spread.

In contrast to rates for the United States as a whole, the incidence rate of gonorrhea increased 11% in San Francisco between 1986 and 1988, with substantial increases observed among black adolescents. Reports by health department personnel and police suggested that crack cocaine use, specifically the exchange of sex for drugs, contributed to this increase. To test this hypothesis, the authors conducted a case-control study from August 1988 to October 1988 that compared 68 prospectively identified adolescent gonorrhea patients with 136 neighborhood control patients. Thirty-two percent of the female gonorrhea patients had received money or drugs in exchange for sex, while none of the control patients reported having done so (P = 0.0001). Most of the female patients (89%) who had received money or drugs in exchange for sex had used crack. Crack use was less common among female patients who denied receiving money or drugs in exchange for sex (11%) and among control patients (6%). Crack use and providing money or drugs in exchange for sex were not risk factors for gonorrhea among the male patients, but were reported frequently by both gonorrhea patients and control patients. Not living with parents was a risk factor for male patients (odds ratio 4.9, 95% confidence limit 1.4 to 19.5). For all patients, a history of a sexually transmitted disease appeared to be an independent risk factor for gonorrhea. The conclusion is made that crack-related exchange of sex for money or drugs is a risk factor for gonorrhea among black adolescent girls in San Francisco.(ABSTRACT TRUNCATED AT 250 WORDS)

Background Racial/ethnic minorities and men who have sex with men (MSM) represent populations with disparate sexually transmitted infection (STI) rates. While race-specific STI rates have been widely reported, STI rates among MSM is often challenging given the absence of MSM population estimates. We evaluated the race-specific rates of chlamydia and gonorrhea among MSM and non-MSM in San Francisco between 1999-2008. Methods 2000 US Census data for San Francisco was used to estimate the number of African-American, Asian/Pacific Islander, Hispanic, and white males. Data from National HIV Behavioral Surveillance (NHBS) MSM 1, conducted in 2004, was used to estimate the total number of MSM in San Francisco and the size of race/ethnic sub-populations of MSM. Non-MSM estimates were calculated by subtracting the number of estimated MSM from the total number of males residing in San Francisco. Rates of MSM and non-MSM gonorrhea and chlamydia reported between 1999 and 2008 were stratified by race/ethnicity. Ratios of MSM and non-MSM rates of morbidity were calculated by race/ethnicity. Results Between 1999-2008, MSM accounted for 72% of gonorrhea cases and 51% of chlamydia cases. Throughout the study period, African-American MSM had the highest chlamydia rate with 606 cases per 100,000 in 1999 increasing to 2067 cases per 100,000 in 2008. Asian/Pacific Islander MSM consistently had the lowest rate among MSM with1003 cases per 100,000 in 2008. The ratio of MSM/non-MSM for chlamydia was highest among whites 11.6 (95% CI: 8.8-14.4) and Asian/Pacific Islanders 8.6 (95% CI: 6.2-11), and lowest among African-Americans 1.53 (95% CI: 1.2-1.9) and Hispanics 4.43 (95% CI: 2.8-6.0). Gonorrhea rates were similar for African-American, white, and Hispanic MSM between 2137-2441 cases per 100,000 in 2008. Asian/Pacific Islander MSM had the lowest gonorrhea rate with 865 cases per 100,000 in 2008. The ratio of MSM/non-MSM for gonorrhea was highest among whites 11.6 (95% CI: 8.8-14.4) and Asian/Pacific Islanders 8.6 (95% CI: 6.2-11), and lowest among African-Americans 1.53 (95% CI: 1.2-1.9) and Hispanics 4.43 (95% CI: 2.8-6.0). Conclusions For all racial/ethnic groups in San Francisco, MSM carried a substantially higher burden of STIs compared to non-MSM except among African-American men. These racial and sexual behavior disparities warrant further public health attention and resources.