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We found that the odds of return clinic visits for persistent non-gonococcal urethritis (NGU) were significantly lower (odds ratio: .4; 95% confidence interval: .3–.6; P < .0001) after implementing (1) testing for Mycoplasma genitalium during initial evaluations for NGU and (2) switching from azithromycin to doxycycline as first-line NGU treatment.

It is critical to understand what happens when PrEP patients are lost-to-follow-up (LTFU) and, where appropriate, attempt to re-engage them in care with the goal of preventing future human immunodeficiency virus (HIV) acquisition. We evaluated the benefits and limitations of using text-based outreach to re-engage with LTFU PrEP patients and offer re-initiation of PrEP care. Using text-messaging, we surveyed San Francisco City Clinic patients who started PrEP from January 2015 to October 2019 and were LTFU by October 1, 2020. Our goals were to better understand (1) whether our patients remained on PrEP through another provider or source, (2) why patients choose to discontinue PrEP, and (3) whether text-based outreach could successfully re-engage such patients in care. Multiple-choice survey questions were analyzed quantitatively to determine the proportion of respondents selecting each option; free-text responses were analyzed qualitatively using an inductive approach to identify any additional recurring themes. Of 846 eligible survey recipients, 130 responded (overall response rate 15.4%). Forty-two respondents (32.3%) were still on PrEP through another provider while 88 (67.7%) were not. Common reasons for stopping PrEP included: COVID-19–related changes in sex life (32.3% of responses), concerns regarding side effects (17.7%), and the need to take a daily pill (8.3%). Free text responses revealed additional concerns regarding risk compensation. While 32 participants agreed to be contacted by City clinic staff for PrEP counseling, only 6 were reached by phone and none of the six subsequently restarted PrEP. We learned that text messaging is a possible approach to survey certain PrEP program participants to determine who is truly LTFU and off PrEP, and to better understand reasons for PrEP discontinuation. While such information could prove valuable as programs seek to address barriers to PrEP retention, efforts to improve acceptability and increase response rates would be necessary. We were less successful in re-engaging LTFU patients in PrEP care, suggesting that text-messaging may not be the optimal strategy for this purpose.

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 Health departments utilize HIV surveillance data to identify people with HIV (PWH) who need re-linkage to HIV care as part of an approach known as Data to Care (D2C.) The most accurate, effective, and efficient method of identifying PWH for re-linkage is unknown. Methods We evaluated referral and care continuum outcomes among PWH identified using 3 D2C referral strategies: health care providers, surveillance, and a combination list derived by matching an electronic medical record registry to HIV surveillance. PWH who were enrolled in the re-linkage intervention received short-term case management for up to 90 days. Relative risks and 95% confidence intervals were calculated to compare proportions of PWH retained and virally suppressed before and after re-linkage. Durable viral suppression was defined as having suppressed viral loads at all viral load measurements in the 12 months after re-linkage. Results After initial investigation, 233 (24%) of 954 referrals were located and enrolled in navigation. Although the numbers of surveillance and provider referrals were similar, 72% of enrolled PWH were identified by providers, 16% by surveillance, and 12% by combination list. Overall, retention and viral suppression improved, although relative increases in retention and viral suppression were only significant among individuals identified by surveillance or providers. Seventy percent of PWH who achieved viral suppression after the intervention remained durably virally suppressed. Conclusions PWH referred by providers were more likely to be located and enrolled in navigation than PWH identified by surveillance or combination lists. Overall, D2C re-linkage efforts improved retention, viral suppression, and durable viral suppression.

BackgroundSeventeen years into a sustained epidemic, early syphilis (ES) rates in San Francisco (SF) are continuing to increase and the demographics of the affected population are changing. We provide a historical overview of ES in SF among men who have sex with men (MSM) and describe trends in the

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 Rates of reported gonorrhea cases have increased in recent years among all groups in the U.S. Expanded screening, particularly extragenital screening among men who have sex with men (MSM), results in increased case finding, complicating interpretation of reported case rates. Monitoring trends in symptomatic presentation through enhanced surveillance may provide insight into changes in case rates. Methods Randomly sampled cases from 54 counties in 5 U.S. states 2010–2017 were interviewed; symptom status (patient report of ‘any STD symptoms’) and sex-of-sex partner(s) were elicited. Interviewed cases were weighted to be representative of all reported cases in participating jurisdictions. Proportion of cases presenting with symptoms and symptomatic rate per 100,000 were calculated, stratified by gender and sex-of-sex partners. Trends over time were evaluated by Cochran-Armitage and Pearson’s trend tests. Results During 2010–2017, 21,006 cases were interviewed, representing over 500,000 reported cases. Symptom status was available for 97.1%; the estimated number of symptomatic cases increased 125.9% (30,883 to 69,772). The proportion of women and non-MSM males reporting symptoms increased by 15.3% (48.3% to 55.7%) and 11.5% (80.1% to 89.3%), respectively. Conversely, the proportion of MSM cases reporting symptoms decreased by 23.2% (72.5% to 55.7%). Relative increase in estimated symptomatic case rate from 2010 to 2017 was 82.8% among women (56.0 to 102.4 per 100,000) , 82.8% among non-MSM males (67.0 to 122.5 per 100,000) and 185.9% among MSM (946.2 to 2705.2 per 100,000). All trends were significant at p Conclusion Decreases in the proportion of MSM cases reporting symptoms suggests increased case rates among MSM are partially attributable to expanded screening. Yet a significant, increasing trend in the symptomatic case rate among MSM suggests a real increase in gonorrhea transmission. The proportion symptomatic and symptomatic case rates for non-MSM males and females are also rising, suggesting more transmissions in these groups as well. Disclosure No significant relationships.

Background Little is known about the prevalence of lymphogranuloma venereum (LGV) among men who have sex with men (MSM) with symptomatic rectal chlamydia (CT) in US settings. Methods Clinicians at the San Francisco municipal STD clinic order an LGV PCR when evaluating rectal symptoms on a case by case basis. The LGV PCR is only run if the CT nucleic amplification test (NAAT) is positive. We compared characteristics of MSM found to have LGV with those who were infected with non-LGV CT. Results Rectal LGV testing was ordered at 666 patient-visits during 2016–2018, with 197 visits (29.6%) having a positive CT NAAT (169 individuals), and 94 visits a positive LGV PCR (47.7% of CT NAAT+ visits, 14.1% of all visits). Compared to visits at which the patient was CT+/LGV-, MSM with LGV were significantly (p Conclusion Almost 50% of MSM with rectal CT were positive for LGV in this clinic-based sample. In the absence of an LGV test, clinicians should have a low threshold for empiric LGV treatment in MSM with rectal symptoms and a positive rectal CT NAAT. Disclosure No significant relationships.

Background We assessed the impact of point of care (POC) testing for gonorrhea and chlamydia (GC/CT) on time to treatment in a HIV pre-exposure prophylaxis (PrEP) program in a STD clinic. Methods In May 2018, San Francisco City Clinic implemented express GC/CT testing using the GeneXpert™ for PrEP follow-up visits for men who have sex with men (MSM) and transwomen. PrEP patients who were symptomatic or a contact to GC or CT were empirically treated and excluded from express testing. We describe the population screened using GeneXpert™ and test positivity. We compared their time to treatment with asymptomatic PrEP follow-up visits during the same time frame one year prior. Differences in time to treatment were compared using a t-test. Results From May 2018-December 2018, there were 1623 visits by MSM and transwomen on PrEP at which GC/CT testing was conducted. The GeneXpert™ was used at 596 (36.7%) of visits. Of the 366 unique patients screened using the GeneXpert, the median age was 33; 40% were white, 30% Latino, 22% Asian and 6% black. Either GC or CT were positive at 87 (14.6%) of patient-visits. Positivity was higher at the rectum (10.8%) compared with throat (5.6%) and urine (1.5%). In comparison, from May 2017-December 2017, there were 611 visits by asymptomatic patients on PrEP who were tested for GC/CT but not empirically treated. Either GC or CT was positive at 90 (14.7%) visits. Median age and race/ethnicity did not differ between the groups. Mean and median time to treatment for GC/CT decreased from 6 and 4 days prior to implementing GeneXpert™, to 1.7 and 0 days for those tested with the POC test (p Conclusion Prevalence of GC and CT was high among asymptomatic patients on PrEP. The introduction of POC testing decreases time to treatment, reducing duration of infectivity and potentially preventing ongoing transmissions. Disclosure No significant relationships.

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.

Objective: Passive retrospective cohorts composed of persons who have tested 2 or more times for a sexually transmitted infection (STI) of interest during clinical visits have been used to estimate STI incidence. We hypothesized that the analytic period of a passive cohort might affect the estimate of STI incidence, with shorter periods yielding higher estimates of incidences of infection. Study: We analyzed data collected from women, 12 to 24 years of age, tested for chlamydia 2 or more times at 6 sites in San Francisco between January 1997 and December 2000. Incidence was calculated for 10 different analytic periods. Results: The calculated incidence of chlamydial infection during 1997 was 16.8 (95% confidence interval [CI], 10.9 ‐24.0) per 1000 person-months of follow up. The calculated incidence dropped markedly as the analytic period lengthened, with the incidence estimated to be 9.7 (95% CI, 8.6 ‐10.9) using a study period of 4 years (1997‐2000). Estimates of incidence were similar when using the same analytic period, regardless of calendar year, and there was a similar decline in estimated incidence using longer analytic periods. Conclusions: Estimates of STI incidence based on passive cohort data may have limited epidemiologic value because incidence measures may be highly dependent on the analytic period.

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.

Background Chlamydia screening programs have been shown to reduce the incidence of pelvic inflammatory disease (PID), which can lead to ectopic pregnancy, tubal infertility, and chronic pelvic pain. However, few reliable data exist on the population-level burden of PID and the utility of passive case-based surveillance of this important infertility-related outcome. Methods We conducted a descriptive analysis of all case reports of PID in San Francisco from 2004 to 2009 through our passive case reporting surveillance system. We examined demographics as well as sexually transmitted disease history. Pearson χ and Fisher exact tests were used to assess significance in the trend analysis. Results There were 245 case reports over the 6-year period examined. There were no statistically significant differences over this period based on demographics. However, an increasing proportion of cases were diagnosed at the municipal sexually transmitted disease clinic. Discussion PID is an important intermediary to assess the impact in reducing infertility in areas where chlamydia screening programs have been implemented. As the locus of PID care has shifted from inpatient to outpatient settings, passive PID surveillance has not adjusted. Efforts should be made to increase provider awareness that pelvic inflammatory disease is a notifiable condition and improve reporting among providers by devoting resources to either improving current passive surveillance or to the development of new innovative ways to conduct PID surveillance.

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.

Introduction Due to the potential emergence of cephalosporin-resistant Neisseria gonorrhoeae (NG), some public health agencies recommend a test of cure (TOC) using nucleic acid amplification tests (NAATs). NAATs can remain positive after the infection has been effectively eradicated; the optimal time to obtain a TOC is unclear. To inform TOC recommendations, we conducted NAATs for 21 days following treatment for men who have sex with men (MSM) NG-infected at the urethra, rectum or pharynx. Methods MSM with untreated urethral, rectal or pharyngeal gonorrhoea were eligible. At enrollment, prior to provision of antibiotics, infection-site specimens were collected by a clinician for culture and NAAT testing. Participants whose enrollment-day specimens were negative were excluded. Participants self-collected daily infection-site specimens (rectal or pharyngeal swabs or urine) for 3 weeks and returned on days 7, 14, and 21 to submit their self-collected specimens for NAAT testing and provide clinician-collected specimens for culture and NAAT testing. We planned to follow at least 10 participants for at least 7 days in each of the urethral (U), rectal (R), and pharyngeal (P) study arms. Results We enrolled 46 MSM. Eleven participants had negative enrollment-day specimens, and 4 did not return after enrollment. Of the 31 included in the analysis (11U, 11R, 9P), 22 (71%) provided all 21 days of specimens; another 6 provided nearly all study specimens. The majority (94%) were negative on Day 7 (11U, 11R, 7P), though 4 (2U, 1R, 1P) had subsequent positive results. Conclusion A high proportion of participants had a negative NAAT before antibiotics, despite a prior positive result, indicating either an original false positive result or natural clearance of infection. Additional analyses will determine the effectiveness of other TOC time-points, including median time to: first negative result, 3 consecutive negative results, and clearance (consistently negative results through follow-up); and clearance at Days 14 and 21. Disclosure of interest statement No pharmaceutical grants were received in the development of this study.

Trends in HIV prevalence among young populations (15-24 years) are held to approximate trends in HIV incidence. Using the Serological Testing Algorithm for Recent HIV Seroconversion (STARHS) to estimate HIV incidence, we were able to demonstrate that this assumption was true for young patients at San Francisco's public sexually transmitted infection clinic from 1989 to 1998. However, the trend in prevalence among young people did not mirror trends in incidence in the overall population.

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.

Background A variety of sex-themed events draw crowds from across the USA and provide opportunities for sex partner recruitment, potentially amplifying local sexual networks and complicating disease prevention and control. We examined the frequency of attendance at such events and the association between attendance and incident STD diagnosis among patients visiting a municipal STD clinic. Methods During 21 September 10–1 November 10, patients seeking services at San Francisco City Clinic were invited to complete a survey about their attendance at local and national events in the prior 12 months, including street fairs, gay pride events, Burning Man, leather events, and circuit parties. Survey results were linked with data from the clinic visit, including self-reported risk behaviours and STD diagnoses. Analyses were stratified by sexual orientation. Events traditionally associated with sex partner recruitment (sex events) were combined. χ 2 and Wilcoxon rank-sum statistics were used to compare patients who attended sex events with all other patients completing the survey. Results Of the 246 completed surveys, 106 (43.1%) were among heterosexual patients and 140 (56.9%) were among men who have sex with men (MSM). Twenty per cent of heterosexual patients and 47% of MSM patients reported attending a sex event in the prior 12 months. Among heterosexual patients, those attending a sex event were of younger age (median 25 vs 29 years, p=0.014), reported fewer sex partners in the prior 12 months (median 1 vs 2, p=0.021) and were more likely to be at their first visit to the STD clinic (71.4% vs 47.1%, 0.045). There was no association between STD diagnosis and event attendance among heterosexuals. Among MSM, those attending sex events reported more sex partners in the prior 12 months (median 10 vs 5, p=0.019), were more likely to be residents of San Francisco (83.3% vs 66.2%, p=0.021), and were more likely to be diagnosed with chlamydia (15.2% vs 4.1%, p=0.024) or any STD (29.0% vs 14.9%, p=0.045) at that visit. Conclusions Attendance at sex events was common among patients at an urban STD clinic. Among MSM, attendance was associated with more sex partners and STD diagnosis. The ability of local programs to successfully prevent and control STDs may be complicated by recruitment of new sex partners at such events. Innovative collaborative prevention interventions at sex events and for residents returning from such events should be explored.

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.

Background Internet partner services (IPS) is the process of notifying named sexual partners to a newly diagnosed syphilis or HIV patient, where the only contact information for that partner is an email address or website handle. Although IPS is recommended by the Centers for Disease Control and Prevention, limited data are available regarding outcomes and the benefits to public health. San Francisco STD Prevention and Control Services has implemented IPS for over a decade. IPS data collected between 2006 and 2011 from newly diagnosed HIV and syphilis index patients and the outcomes of their partner investigations were examined. Methods The proportion of partners with only internet contact information who, through IPS, had more contact information gathered was calculated. Additionally, the proportion of these partners who were presumptively treated or brought to treatment (for syphilis investigation) or who were tested for HIV (for HIV investigation) was also examined. Results Between 2006 and 2011, 4,255 partners were elicited from syphilis cases and 3,607 partners from HIV cases. Of these partners, 645 from syphilis index cases and 691 from HIV index cases only had internet contact information. Overall, 47.1% and 46.6% of the syphilis and HIV internet partners, respectively, were successfully contacted and resulted in more contact information being gathered. Of the syphilis internet partners with updated contact information, 129 (42.4%) were either presumptively treated or brought to treatment and represented an increase of 7.2% in successful partner service outcomes. Among the HIV internet contacts, 55 (17.1%) were tested for HIV; a 7.9% increase in successful partner outcomes. Conclusions By developing and maintaining IPS infrastructure in San Francisco, a substantially larger proportion of partners were able to be contacted by Disease Intervention Specialists (DIS) and successful outcomes of partner services increased for both syphilis and HIV.

Background Data addressing the question of whether HIV-positive patients respond as well to the recommended treatment for syphilis as HIV-negative patients are sparse. We examined data from reported early syphilis cases in San Francisco to identify factors related to serologic response to treatment. Methods San Francisco early syphilis cases diagnosed between 2006 and 2012 were analysed in terms of serologic response to treatment. Cases were excluded if the patient had any prior syphilis diagnosis reported, and only cases with an initial reactive serologic test for syphilis (STS) titer of 1:4 or higher were included. A successful serologic response to treatment was defined by a record of a non-reactive STS or a four-fold titer decrease within 12 months from treatment. Survival analysis and proportional hazards models were used to examine the relationship between demographic and risk factor data, including HIV status, and number of days until successful serologic response was documented. Results A total of 1664 first-time cases were examined. HIV-positive patients were significantly more likely to have a follow-up STS than other patients (p Conclusion Analysis of routine interview data found no evidence that HIV-positive patients failed to respond to standard syphilis treatments. However, the limits of surveillance data suggest the need for further research examining the relationship between immune status and response to treatment among HIV-positive patients.

Background In 2009, African American women 15 to 19 years of age had the highest rate of chlamydia of any population in San Francisco (10 762.13 cases per 100 000 residents per year). Screening and education efforts had not succeeded in lowering rates in this population. Previous research suggests that adolescents may have fewer partners and fewer anonymous encounters than other patients with whom we conduct partner notification. We evaluated a pilot program of contact tracing aimed at male partners of adolescents women diagnosed with chlamydia living in selected neighbourhoods. Methods Residential addresses for all reported females under 20 years of age reported with a Chlamydia infection were geocoded. Cases residing in neighbourhoods with the highest rates of Chlamydia in 2009 were assigned to a health worker for partner notification. Cases were interviewed at least two weeks after being tested in order to give providers time to disclose the results. Names of male partners during the previous three months were collected along with locating information. The total number of partners for each woman (including unnamed partners) was also recorded. Male partners were contacted by the health worker; if partners had not been tested or prophylactic ally treated, they were tested for Chlamydia and treated if positive. Results Between 1 June 2010 and 31 December 2010, 296 Chlamydia cases were reported among women under 20 years of age. Of these, 106 (35.8%) resided in the priority neighbourhoods. Only 64 cases (60.4%) were located and interviewed; all but one of the remaining cases were not locatable. The cases claimed a total of 96 male partners, with 66% claiming just one partner in the previous 3 months, and only two cases claiming more than three partners. However, only 39 partners (40%) were named, including 11 partners residing out of jurisdiction, and 4 who had already been treated by the time they were located. Eleven (11) male partners were tested, and only 2 were positive for Chlamydia. The greatest barrier to contacting the cases and their male partners was cell phones numbers that were disconnected by the time we needed to use them. Conclusion While women in this population have fewer anonymous encounters than other populations targeted using partner notification, few cases among male partners were brought to treatment. Partner notification for adolescent females will likely have minimal impact on chlamydia transmission.

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)