Undiagnosed chlamydial and gonococcal infections in an emergency department

Chlamydial and gonococcal infections are the two most commonly reported sexually transmitted infections in the United States. Screening programs in clinics, schools, and communities detect a substantial burden of infection. Extension of current recommended guidelines has been suggested through expanding screening settings. Emergency departments have been proposed as potentially promising venues for screening interventions. The purpose of this dissertation is to investigate the utility and obstacles associated with chlamydial and gonococcal screening in an emergency department. To examine this issue, we analyzed data from a cross-sectional and short duration prospective cohort study of patients aged 18 to 35 years attending a busy urban emergency department. The overall prevalence of infection in this population was 9.6%. Separately for males and females, we developed predictive models and applicable clinical risk scores for chlamydial and gonococcal infections combined and for chlamydial infection alone. Age was the strongest predictor of infection in all four models. We then used the sensitivities and specificities of the clinical risk scores to examine the trade-off in misclassification errors across varying prevalence of infection. Results of this analysis suggest that the consequences of undetected chlamydial and/or gonococcal infection must substantially outweigh the costs of screening to justify incorporating routine screening into emergency department services. In independent models, we evaluated the influence of healthcare coverage status and reporting the emergency department as the main source for healthcare on the risk of not receiving treatment and follow-up services for infections identified in the emergency department. Antibiotic use in the three months prior to the emergency department visit appears to modify both of these associations. Lastly, we described the geospatial distribution of the detected infections and their treatment outcomes. As screening programs move into emergency departments, serious consideration must be given to the costs associated with unnecessarily screening a significant number of patients to detect infections. In addition, consideration must be given to ensuring appropriate treatment and follow-up for all detected infections

Descriptive and Injunctive Network Norms Associated with Nonmedical use of Prescription Drugs Among Homeless Youth

Background Nonmedical use of prescription drugs (NMUPD) among youth and young adults is being increasingly recognized as a significant public health problem. Homeless youth in particular are more likely to engage in NMUPD compared to housed youth. Studies suggest that network norms are strongly associated with a range of substance use behaviors. However, evidence regarding the association between network norms and NMUPD is scarce. We sought to understand whether social network norms of NMUPD are associated with engagement in NMUPD among homeless youth. Methods 1046 homeless youth were recruited from three drop-in centers in Los Angeles, CA and were interviewed regarding their individual and social network characteristics. Multivariate logistic regression was employed to evaluate the significance of associations between social norms (descriptive and injunctive) and self-reported NMUPD. Results Approximately 25% of youth reported past 30-day NMUPD. However, more youth (32.28%) of youth believed that their network members engage in NMUPD, perhaps suggesting some pluralistic ignorance bias. Both descriptive and injunctive norms were associated with self-reported NMUPD among homeless youth. However, these varied by network type, with presence of NMUPD engaged street-based and home-based peers (descriptive norm) increasing the likelihood of NMUPD, while objections from family-members (injunctive norm) decreasing that likelihood. Conclusions Our findings suggest that, like other substance use behaviors, NMUPD is also influenced by youths\u27 perceptions of the behaviors of their social network members. Therefore, prevention and interventions programs designed to influence NMUPD might benefit from taking a social network norms approach

Descriptive and injunctive network norms associated with nonmedical use of prescription drugs among homeless youth

This is an Accepted Manuscript of an article published by Elsevier in Addictive Behaviors in 2017. The published version is available at https://doi.org/10.1016/j.addbeh.2016.08.015Nonmedical use of prescription drugs (NMUPD) among youth and young adults is being increasingly recognized as a significant public health problem. Homeless youth in particular are more likely to engage in NMUPD compared to housed youth. Studies suggest that network norms are strongly associated with a range of substance use behaviors. However, evidence regarding the association between network norms and NMUPD is scarce. We sought to understand whether social network norms of NMUPD are associated with engagement in NMUPD among homeless youth.Funded by NIMH R01 MH09333

Pre-exposure Prophylaxis Awareness and Use Among Cisgender Men Who Have Sex With Men and Use Methamphetamine in 3 Western US Cities

Background In the United States, cisgender men who have sex with men (MSM) who use methamphetamine are at substantial risk for HIV and can benefit from pre-exposure prophylaxis (PrEP). Methods We used data from the National HIV Behavioral Surveillance 2017 survey from Seattle, WA; Portland, OR; and Denver, CO, to estimate PrEP awareness and use in the past 12 months among MSM who use methamphetamine. We then compared these estimates with participants who do not use methamphetamine but meet other criteria for PrEP use (i.e., condomless anal sex or a bacterial sexually transmitted infection). We explored reasons for not using PrEP and challenges using PrEP. Results Of the 1602 MSM who participated in the 2017 National HIV Behavioral Surveillance survey in Seattle, WA; Portland, OR; and Denver, CO, 881 met the inclusion criteria for this study, of whom 88 (10%) reported methamphetamine use in the past 12 months. Most (95%) participants had heard of PrEP, and 35% had used it in the past 12 months. Pre-exposure prophylaxis awareness was lower among MSM who used methamphetamine (P = 0.01), but use was not different (P = 0.26). Among those who had not used PrEP, the most common reason for not using it was not thinking one\u27s HIV risk was high enough (51%). Men who have sex with men who used methamphetamine were more likely to report that they were not sure PrEP would prevent them from getting HIV (38% vs. 19%, P = 0.002). Conclusions These results highlight the need for continued efforts to educate and promote PrEP uptake among MSM, particularly those who use methamphetamine. Survey results from 3 cities showed that only 35% of preexposure prophylaxis (PrEP)–eligible cismen who have sex with men had used PrEP. Awareness and belief in PrEP efficacy were lower among methamphetamine users

Pre-exposure Prophylaxis (PrEP) Awareness and Use Among Cisgender Men Who Have Sex With Men (MSM) and Use Methamphetamine in Three Western US Cities

Background In the United States, cisgender men who have sex with men (MSM) who use methamphetamine are at substantial risk of HIV and can benefit from pre-exposure prophylaxis (PrEP). Methods We used data from the National HIV Behavioral Surveillance (NHBS) 2017 survey from Seattle, WA; Portland, OR; and Denver, CO to estimate PrEP awareness and use in the past 12 months among MSM who use methamphetamine. We then compared these estimates to participants who do not use methamphetamine but meet other criteria for PrEP use (i.e., condomless anal sex or a bacterial sexually transmitted infection). We explored reasons for not using PrEP and challenges using PrEP. Results Of the 1,602 MSM who participated in the 2017 NHBS survey in Seattle, WA; Portland, OR; and Denver, CO, 881 met inclusion criteria for this study, of whom 88 (10%) reported methamphetamine use in the past 12 months. Most (95%) participants had heard of PrEP, and 35% had used it in the past 12 months. PrEP awareness was lower among MSM who used methamphetamine (p=.01), but use was not different (p=.26). Among those who had not used PrEP, the most common reason for not using it was not thinking one’s HIV risk was high enough (50%). MSM who used methamphetamine were more likely to report that they were not sure PrEP would prevent them from getting HIV (38% vs 19%, p=.002). Conclusions These results highlight the need for continued efforts to educate and promote PrEP uptake among MSM, particularly those who use methamphetamine

Improving epidemiological surveys of sexual behaviour conducted by telephone

Background This study assesses the impact of Telephone Audio Computer-Assisted Self-Interviewing (T-ACASI) on the reporting of sensitive (mainly heterosexual) behaviours

Programmatic cost evaluation of nontargeted opt-out rapid HIV screening in the emergency department.

The Centers for Disease Control and Prevention recommends nontargeted opt-out HIV screening in healthcare settings. Cost effectiveness is critical when considering potential screening methods. Our goal was to compare programmatic costs of nontargeted opt-out rapid HIV screening with physician-directed diagnostic rapid HIV testing in an urban emergency department (ED) as part of the Denver ED HIV Opt-Out Trial.This was a prospective cohort study nested in a larger quasi-experiment. Over 16 months, nontargeted rapid HIV screening (intervention) and diagnostic rapid HIV testing (control) were alternated in 4-month time blocks. During the intervention phase, patients were offered HIV testing using an opt-out approach during registration; during the control phase, physicians used a diagnostic approach to offer HIV testing to patients. Each method was fully integrated into ED operations. Direct program costs were determined using the perspective of the ED. Time-motion methodology was used to estimate personnel activity costs. Costs per patient newly-diagnosed with HIV infection by intervention phase, and incremental cost effectiveness ratios were calculated.During the intervention phase, 28,043 eligible patients were included, 6,933 (25%) completed testing, and 15 (0.2%, 95% CI: 0.1%-0.4%) were newly-diagnosed with HIV infection. During the control phase, 29,925 eligible patients were included, 243 (0.8%) completed testing, and 4 (1.7%, 95% CI: 0.4%-4.2%) were newly-diagnosed with HIV infection. Total annualized costs for nontargeted screening were $148,997, whereas total annualized costs for diagnostic HIV testing were$31,355. The average costs per HIV diagnosis were $9,932 and$7,839, respectively. Nontargeted HIV screening identified 11 more HIV infections at an incremental cost of $10,693 per additional infection.Compared to diagnostic testing, nontargeted HIV screening was more costly but identified more HIV infections. More effective and less costly testing strategies may be required to improve the identification of patients with undiagnosed HIV infection in the ED

Program costs of emergency department nontargeted opt-out rapid HIV screening and physician-directed diagnostic rapid HIV testing from the Denver ED HIV Opt-Out Study.

<p>Abbreviations: N/A = not applicable; ED = emergency department; WB = western blot.</p><p>Includes personnel time for trainers, trainees, and training supplies.</p