Publications by authors named "Cornelis A Rietmeijer"

75 Publications

The National Academies Report on Sexually Transmitted Infections: Implications for Clinical Training, Licensing, and Practice Guidelines.

Clin Infect Dis 2021 Jul 6. Epub 2021 Jul 6.

Rietmeijer Consulting, LLC, Denver, CO, USA.

STIs represent a sizable, longstanding, and growing challenge and a national public health priority. A recent National Academies report outlines new directions for STI prevention and control, including the adoption of a new sexual health paradigm and broader ownership and accountability for addressing sexual health and STIs among diverse clinical and nonclinical actors. These recommendations have important implications for infectious disease providers with STI and HIV expertise. As part of the envisioned shift toward greater prioritization of sexual health across systems for healthcare and health promotion, STI and HIV specialty providers will need to increasingly take on responsibilities as leaders in the provision of STI-related training; provision of technical assistance; and alignment of clinical training curricula, licensing criteria, and practice guidelines for healthcare generalists.
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http://dx.doi.org/10.1093/cid/ciab609DOI Listing
July 2021

Medicaid Expansion and Rates of Reportable Sexually Transmitted Infections in the United States A County-Level Analysis.

Sex Transm Dis 2021 Mar 16. Epub 2021 Mar 16.

1Rietmeijer Consulting, LLC 2Denver Public Health Department, Denver Health and Hospital 3Colorado School of Public Health, University of Colorado Denver.

Chlamydia, gonorrhea, and primary/secondary syphilis rates in 2018 were significantly higher in counties located in states without Medicaid expansion compared to those with Medicaid expansion. For STI combined, 59.9% of counties without Medicaid expansion were in the highest two STI rate quartiles compared to 42.2% of counties with Medicaid expansion (p<0.0001).
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http://dx.doi.org/10.1097/OLQ.0000000000001422DOI Listing
March 2021

Return of Positive Test Results to Participants in Sexually Transmitted Infection Prevalence Studies: Research Ethics and Responsibilities.

Sex Transm Dis 2021 Mar 19. Epub 2021 Mar 19.

Fogarty International Center, National Institutes of Health, Bethesda, Maryland, USA Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA Rietmeijer Consulting, Denver, Colorado, USA.

Background: In prevalence studies of sexually transmitted infections (STIs), investigators often provide syndromic management for symptomatic participants, but may not provide specific treatment for asymptomatic individuals with positive laboratory test results due to the delays between sample collection and availability of results as well as logistical constraints in re-contacting study participants.

Methods: To characterize the extent of this issue, 80 prevalence studies from the World Health Organization's Report on global sexually transmitted infection surveillance, 2018, were reviewed. Studies were classified as to whether clinically relevant positive results were returned or if this was not specified.

Results: More than half (56%) of the cited studies did not specify if participants were notified of clinically relevant positive STI test results. The percentages were similar for low- and middle-income country populations (57%) and high-income country populations (53%).

Conclusions: The absence of documentation of the provision of test results raises the possibility that in some instances, results may not have been communicated, with potential negative effects for participants, their sexual partners, and newborns. From an ethical perspective, clinically relevant results should be returned to study participants and treating clinicians in a timely fashion to ensure appropriate management of identified infections. Study authors should document if they returned test results to study participants and report on numbers lost to follow-up.
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http://dx.doi.org/10.1097/OLQ.0000000000001429DOI Listing
March 2021

Predicting Clinical Practice Change: An Evaluation of Trainings on Sexually Transmitted Disease Knowledge, Diagnosis, and Treatment.

Sex Transm Dis 2021 01;48(1):19-24

University of Colorado, Denver, CO.

Background: Sexually transmitted disease clinical training for working professionals requires substantial time and resources. Understanding the predictors of change in worksite practices and barriers to change will allow educators, learners, and clinical leadership to aid in ensuring learned practices are implemented and barriers are addressed.

Methods: Data for this analysis come from the first standardized national evaluation of a Centers for Disease Control and Prevention-funded clinical prevention training network, including precourse registration and responses to immediate postcourse (1-3 days) and 90-day postcourse evaluations from 187 courses. Univariate statistics describe the trainees and their workplace. Bivariate statistics describe their intention to change and actual change stratified by functional role and employment setting. Logistic regression identified predictors of self-reported changes in practice.

Results: The strongest predictors for practice change included an intention to change and attendance at a training lasting 4 hours or more. Functional role was a weaker predictor of change in practice; employment setting did not predict change. More than half of the trainees (65.9%; n = 912) stated their intention to make a change in their practice immediately after training. At 90 days after a course, 62.4% (n = 863) reported making a practice change. Trainees that took courses lasting 4 hours or more reported making a change more often (70%) compared with trainees from shorter courses (53%). We also report on trainees' barriers to practice change.

Conclusions: Results suggest that longer trainings may result in more practice change than shorter trainings, recruitment of trainees should focus on those more likely to make a change in their practice, and future trainings should focus on organizational capacity building and assessing change at the organizational level.
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http://dx.doi.org/10.1097/OLQ.0000000000001282DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7737854PMC
January 2021

Assessment of the Cost-Effectiveness of a Brief Video Intervention for Sexually Transmitted Disease Prevention.

Sex Transm Dis 2020 02;47(2):130-135

Centers for Disease Control and Prevention, Atlanta, GA.

Background: Cost-effective, scalable interventions are needed to address high rates of sexually transmitted diseases (STDs) in the United States. Safe in the City, a 23-minute video intervention designed for STD clinic waiting rooms, effectively reduced new infections among STD clinic clients. A cost-effectiveness analysis of this type of intervention could inform whether it should be replicated.

Methods: The cost-effectiveness of a brief video intervention was calculated under a baseline scenario in which this type of intervention was expanded to a larger patient population. Alternative scenarios included expanding the intervention over a longer period or to more clinics, including HIV prevention benefits, and operating the intervention part time. Program costs, net costs per STD case averted, and the discounted net cost of the intervention were calculated from a health sector perspective across the scenarios. Monte Carlo simulations were used to calculate 95% confidence intervals surrounding the cost-effectiveness measures.

Results: The net cost per case averted was $75 in the baseline scenario. The net cost of the intervention was $108,015, and most of the alternative scenarios found that the intervention was cost saving compared with usual care.

Conclusions: Single session, video-based interventions can be highly cost effective when implemented at scale. Updated video-based interventions that account for the changing STD landscape in the United States could play an important role in addressing the recent increases in infections.
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http://dx.doi.org/10.1097/OLQ.0000000000001109DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7590367PMC
February 2020

Improving care for sexually transmitted infections.

J Int AIDS Soc 2019 08;22 Suppl 6:e25349

Rietmeijer Consulting, Denver, CO, USA.

Introduction: Rising rates of reported sexually transmitted infections (STIs) in the US and Europe are a public health priority and require a public health response. The diagnosis and treatment of STIs have been the cornerstone of STI control and prevention for many decades and, historically, publicly funded STI clinics have played a central role in the provision of STI care. Innovations in non-invasive diagnostic techniques, especially nucleic acid amplification tests in the mid-1990s, have facilitated the expansion of STI testing and treatment outside traditional STI clinics, including primary care, family planning, school-based health, outreach, corrections, emergency departments and HIV prevention and care settings. As a result, the continued need for categorical STI clinics has been debated. In this Commentary, we discuss how practice can be improved at each level of STI care.

Discussion: STI practice improvement plans should be tailored to the strengths of each care setting. Thus, in primary care, the focus should be on improving STI screening rates, the provision of hepatitis B and human papillomavirus vaccines and, in jurisdictions where this is legal, expedited partner therapy for gonorrhoea and chlamydia. Extragenital (pharyngeal and rectal) testing for gonorrhoea and chlamydia should be available in settings serving populations more vulnerable to STI acquisition at these anatomical sites, including men who have sex with men. In family planning settings with a mostly female patient population, there are opportunities to serve male partners with both contraceptive and STI services. STI screening rates can also be improved in other settings serving populations at increased risk for STIs, including school-based clinics, emergency departments, correctional health facilities and providers of HIV care and prevention. These improvements are predominantly logistical in nature and not dependent on extensive STI clinical expertise. While some providers in these settings may have the clinical knowledge and skills to evaluate symptomatic patients, many do not, and STI speciality clinics must be available for consultation and referral and evolve from "safety net" providers of last resort to STI centres of excellence.

Conclusions: A tailored practice improvement plan can be envisioned to achieve an optimally functioning STI care continuum.
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http://dx.doi.org/10.1002/jia2.25349DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6715945PMC
August 2019

The National Network of Sexually Transmitted Disease Clinical Prevention Training Centers Turns 40-A Look Back, a Look Ahead.

Sex Transm Dis 2019 08;46(8):487-492

Centers for Disease Control and Prevention, Atlanta, GA.

Since 1979, the National Network of Sexually Transmitted Disease (STD) Clinical Prevention Training Centers (NNPTC) has provided state-of-the-art clinical and laboratory training for STD prevention across the United States. This article provides an overview of the history and activities of the NNPTC from its inception to present day, and emphasizes the important role the network continues to play in maintaining a high-quality STD clinical workforce. Over time, the NNPTC has responded to changing STD epidemiological patterns, technological advances, and increasing private-sector care-seeking for STDs. Its current structure of integrated regional and national training centers allows NNPTC members to provide dynamic, tailored responses to STD training needs across the country.
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http://dx.doi.org/10.1097/OLQ.0000000000001018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6713229PMC
August 2019

Performance of a Dual Human Immunodeficiency Virus/Syphilis Rapid Test Compared With Conventional Serological Testing for Syphilis and Human Immunodeficiency Virus in a Laboratory Setting: Results From the Zimbabwe STI Etiology Study.

Sex Transm Dis 2019 09;46(9):584-587

University of Washington School of Medicine, Seattle, WA.

Background: Dual human immunodeficiency virus (HIV)/syphilis rapid, point-of-care testing may enhance syphilis screening among high-risk populations, increase case finding, reduce time to treatment, and prevent complications. We assessed the laboratory-based performance of a rapid dual HIV/syphilis test using serum collected from patients enrolled in the Zimbabwe Sexually Transmitted Infections (STI) Etiology study.

Methods: Blood specimens were collected from patients presenting with STI syndromes in 6, predominantly urban STI clinics in different regions of Zimbabwe. All specimens were tested at a central research laboratory using the Standard Diagnostics Bioline HIV/Syphilis Duo test. The treponemal syphilis component of the dual rapid test was compared with the Treponema pallidum hemagglutination assay (TPHA) as a gold standard comparator, both alone or in combination with a nontreponemal test, the rapid plasma reagin test. The HIV component of the dual test was compared with a combination of HIV rapid tests conducted at the research laboratory following the Zimbabwe national HIV testing algorithm.

Results: Of 600 men and women enrolled in the study, 436 consented to serological syphilis and HIV testing and had specimens successfully tested by all assays. The treponemal component of the dual test had a sensitivity of 66.2% (95% confidence interval [CI], 55.2%-77.2%) and a specificity of 96.4% (95% CI, 94.5%-98.3%) when compared with TPHA; the sensitivity increased to 91.7% (95% CI, 82.6%-99.9%) when both TPHA and rapid plasma reagin were positive. The HIV component of the dual test had a sensitivity of 99.4% (95% CI, 98.4%-99.9%) and a specificity of 100% (95% CI, 99.9%-100%) when compared with the HIV testing algorithm.

Conclusions: Laboratory performance of the SD Bioline HIV/Syphilis Duo test was high for the HIV component of the test. Sensitivity of the treponemal component was lower than reported from most laboratory-based evaluations in the literature. However, sensitivity of the test increased substantially among patients more likely to have active syphilis for which results of both standard treponemal and nontreponemal tests were positive.
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http://dx.doi.org/10.1097/OLQ.0000000000001022DOI Listing
September 2019

Serological Markers for Syphilis Among Persons Presenting With Syndromes Associated With Sexually Transmitted Infections: Results From the Zimbabwe STI Etiology Study.

Sex Transm Dis 2019 09;46(9):579-583

University of Washington School of Medicine, Seattle, WA.

Background: Syphilis prevalence in sub-Saharan Africa appears to be stable or declining but is still the highest globally. Ongoing sentinel surveillance in high-risk populations is necessary to inform management and detect changes in syphilis trends. We assessed serological syphilis markers among persons with sexually transmitted infections in Zimbabwe.

Methods: We studied a predominantly urban, regionally diverse group of women and men presenting with genital ulcer disease (GUD), women with vaginal discharge and men with urethral discharge at clinics in Zimbabwe. Syphilis tests included rapid plasma reagin and the Treponema pallidum hemagglutination assay.

Results: Among 436 evaluable study participants, 36 (8.3%) tested positive for both rapid plasma reagin and Treponema pallidum hemagglutination assay: women with GUD: 19.2%, men with GUD: 12.6%, women with vaginal discharge: 5.7% and men with urethral discharge: 1.5% (P < 0.0001).

Conclusions: Syphilis rates in Zimbabwe are high in sentinel populations, especially men and women with GUD.
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http://dx.doi.org/10.1097/OLQ.0000000000001006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6885999PMC
September 2019

Rapid Syphilis Testing for Men Who Have Sex With Men in Outreach Settings: Evaluation of Test Performance and Impact on Time to Treatment.

Sex Transm Dis 2019 03;46(3):191-195

Colorado Department of Public Health and Environment, Division of Molecular Science and Public Health Microbiology, Denver, CO.

Background: Rapid syphilis tests (RST) may shorten time to syphilis diagnosis and treatment while enhancing access to testing in outreach settings. There are limited data on the performance of RST in outreach settings in the US.

Methods: We offered RST (Syphilis Health Check) at 6 outreach sites to men who reported having sex with men and no prior history of syphilis. Clients accepting RST were also tested with laboratory-based rapid plasma reagin (RPR) and reflex Treponema pallidum particle agglutination (TPPA) assay when RPR or RST were positive. Clients with positive RST were immediately referred to a sexually transmitted infection clinic. Those declining RST were screened with RPR and reflex TPPA only. The validity of the RST-based algorithm was compared with the RPR-based algorithm among participants receiving both. Time to treatment for those accepting RST was compared with those declining RST and to a historical control group screened in outreach settings with RPR and reflex TPPA before the availability of RST.

Results: Rapid syphilis test was accepted by 690 (64%) of 1081 eligible clients. Compared with RPR-based algorithm, RST sensitivity was 90%; specificity, 98.5%; positive predictive value, 47.4%; and negative predictive value, 98.5. The single false-negative case by RST was determined to be a late latent case by RPR/TPPA. Median time to treatment was 1 day (range, 0-6 days) for 9 of 690 accepting RST, compared to 9 days (range, 7-13 days) for 3 of 391 declining RST, and 9 days (range, 6-21 days) for 25 of 1229 historical controls (P < 0.0001).

Conclusion: Compared with an RPR-based algorithm, RST identified all early syphilis cases. Although RST had high specificity and negative predictive value, the low positive predictive value resulted in additional assessments in a sexually transmitted infection clinic for some patients. However, RST use in outreach settings significantly decreased time to treatment for new syphilis cases.
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http://dx.doi.org/10.1097/OLQ.0000000000000932DOI Listing
March 2019

Effects of a brief video intervention on treatment initiation and adherence among patients attending human immunodeficiency virus treatment clinics.

PLoS One 2018 5;13(10):e0204599. Epub 2018 Oct 5.

University of California-Los Angeles, Los Angeles, CA, United States of America.

Background: Persons with human immunodeficiency virus (HIV) who get and keep a suppressed viral load are unlikely to transmit HIV. Simple, practical interventions to help achieve HIV viral suppression that are easy and inexpensive to administer in clinical settings are needed. We evaluated whether a brief video containing HIV-related health messages targeted to all patients in the waiting room improved treatment initiation, medication adherence, and retention in care.

Methods And Findings: In a quasi-experimental trial all patients (N = 2,023) attending two HIV clinics from June 2016 to March 2017 were exposed to a theory-based, 29-minute video depicting persons overcoming barriers to starting treatment, taking medication as prescribed, and keeping medical appointments. New prescriptions at index visit, HIV viral load test results, and dates of return visits were collected through review of medical records for all patients during the 10 months that the video was shown. Those data were compared with the same variables collected for all patients (N = 1,979) visiting the clinics during the prior 10 months (August 2015 to May 2016). Among patients exposed to the video, there was an overall 10.4 percentage point increase in patients prescribed treatment (60.3% to 70.7%, p< 0.01). Additionally, there was an overall 6.0 percentage point improvement in viral suppression (56.7% to 62.7%, p< 0.01), however mixed results between sites was observed. There was not a significant change in rates of return visits (77.5% to 78.8%). A study limitation is that, due to the lack of randomization, the findings may be subject to bias and secular trends.

Conclusions: Showing a brief treatment-focused video in HIV clinic waiting rooms can be effective at improving treatment initiation and may help patients achieve viral suppression. This feasible, low resource-reliant video intervention may be appropriate for adoption by other clinics treating persons with HIV.

Trial Registration: http://www.ClinicalTrials.gov (NCT03508310).
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0204599PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6173379PMC
March 2019

The Etiology of Vaginal Discharge Syndrome in Zimbabwe: Results from the Zimbabwe STI Etiology Study.

Sex Transm Dis 2018 06;45(6):422-428

Zimbabwe Ministry of Health and Child Care, Harare, Zimbabwe.

Introduction: Symptomatic vaginal discharge is a common gynecological condition managed syndromically in most developing countries. In Zimbabwe, women presenting with symptomatic vaginal discharge are treated with empirical regimens that commonly cover both sexually transmitted infections (STIs) and reproductive tract infections, typically including a combination of an intramuscular injection of kanamycin, and oral doxycycline and metronidazole regimens. This study was conducted to determine the current etiology of symptomatic vaginal discharge and assess adequacy of current syndromic management guidelines.

Methods: We enrolled 200 women with symptomatic vaginal discharge presenting at 6 STI clinics in Zimbabwe. Microscopy was used to detect bacterial vaginosis and yeast infection. Nucleic acid amplifications tests were used to detect Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, and Mycoplasma genitalium. In addition, serologic testing was performed to detect human immunodeficiency virus (HIV) infection.

Results: Of the 200 women, 146 (73%) had an etiology detected, including bacterial vaginosis (24.7%); N. gonorrhoeae (24.0%); yeast infection (20.7%); T. vaginalis (19.0%); C. trachomatis (14.0%) and M. genitalium (7.0%). Among women with STIs (N = 90), 62 (68.9%) had a single infection, 18 (20.0%) had a dual infection, and 10 (11.1%) had 3 infections.Of 158 women who consented to HIV testing, 64 (40.5%) were HIV infected.The syndromic management regimen covered 115 (57.5%) of the women in the sample who had gonorrhea, chlamydia, M. genitalium, or bacterial vaginosis, whereas 85 (42.5%) of women were treated without such diagnosis.

Conclusions: Among women presenting with symptomatic vaginal discharge, bacterial vaginosis was the most common etiology, and gonorrhea was the most frequently detected STI. The current syndromic management algorithm is suboptimal for coverage of women presenting with symptomatic vaginal discharge; addition of point of care testing could compliment the effectiveness of the syndromic approach.
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http://dx.doi.org/10.1097/OLQ.0000000000000771DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6879447PMC
June 2018

The Etiology of Genital Ulcer Disease and Coinfections With Chlamydia trachomatis and Neisseria gonorrhoeae in Zimbabwe: Results From the Zimbabwe STI Etiology Study.

Sex Transm Dis 2018 01;45(1):61-68

From the *Zimbabwe Ministry of Health and Child Care; †Department of Community Medicine, University of Zimbabwe, College of Health Sciences, Harare, Zimbabwe; ‡US Centers for Disease Control and Prevention, Zimbabwe and Division of Global HIV/AIDS, CDC, Atlanta, GA; §Fogarty International Center, National Institutes of Health, Bethesda, MD; ¶Zimbabwe Community Health Intervention Research (ZiCHIRe) Project, Harare, Zimbabwe; ∥Western Sydney Sexual Health Centre, Parramatta; **Marie Bashir Institute for Infectious Diseases and Biosecurity & Sydney Medical School-Westmead, University of Sydney, Sydney, New South Wales, Australia; ††School of Medicine, University of Washington, Seattle, WA; ‡‡Colorado School of Public Health, University of Colorado Denver, Denver, CO; §§Rietmeijer Consulting LLC, Denver, CO.

Background: In many countries, sexually transmitted infections (STIs) are treated syndromically. Thus, patients diagnosed as having genital ulcer disease (GUD) in Zimbabwe receive a combination of antimicrobials to treat syphilis, chancroid, lymphogranuloma venereum (LGV), and genital herpes. Periodic studies are necessary to assess the current etiology of GUD and assure the appropriateness of current treatment guidelines.

Materials And Methods: We selected 6 geographically diverse clinics in Zimbabwe serving high numbers of STI cases to enroll men and women with STI syndromes, including GUD. Sexually transmitted infection history and risk behavioral data were collected by questionnaire and uploaded to a Web-based database. Ulcer specimens were obtained for testing using a validated multiplex polymerase chain reaction (M-PCR) assay for Treponema pallidum (TP; primary syphilis), Haemophilus ducreyi (chancroid), LGV-associated strains of Chlamydia trachomatis, and herpes simplex virus (HSV) types 1 and 2. Blood samples were collected for testing with HIV, treponemal, and nontreponemal serologic assays.

Results: Among 200 GUD patients, 77 (38.5%) were positive for HSV, 32 (16%) were positive for TP, and 2 (1%) were positive for LGV-associated strains of C trachomatis. No H ducreyi infections were detected. No organism was found in 98 (49.5%) of participants. The overall HIV positivity rate was 52.2% for all GUD patients, with higher rates among women compared with men (59.8% vs 45.2%, P < 0.05) and among patients with HSV (68.6% vs 41.8%, P < 0.0001). Among patients with GUD, 54 (27.3%) had gonorrhea and/or chlamydia infection. However, in this latter group, 66.7% of women and 70.0% of men did not have abnormal vaginal or urethral discharge on examination.

Conclusions: Herpes simplex virus is the most common cause of GUD in our survey, followed by T. pallidum. No cases of chancroid were detected. The association of HIV infections with HSV suggests high risk for cotransmission; however, some HSV ulcerations may be due to HSV reactivation among immunocompromised patients. The overall prevalence of gonorrhea and chlamydia was high among patients with GUD and most of them did not meet the criteria for concomitant syndromic management covering these infections.
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http://dx.doi.org/10.1097/OLQ.0000000000000694DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5994235PMC
January 2018

The Etiology of Male Urethral Discharge in Zimbabwe: Results from the Zimbabwe STI Etiology Study.

Sex Transm Dis 2018 01;45(1):56-60

From the *Surveillance, Evaluation, Assessment, and Monitoring (SEAM) Project, Department of Community Medicine, College of Medicine, University of Zimbabwe, Harare, Zimbabwe; †Colorado School of Public Health, University of Colorado Denver; ‡Rietmeijer Consulting, Denver, CO; §Zimbabwe Ministry of Health and Child Care; ¶Zimbabwe Community Health Intervention Research (ZiCHIRe) Project; ∥US Centers for Disease Control and Prevention, Harare, Zimbabwe, Zimbabwe; **Western Sydney Sexual Health Centre, Sydney, Australia; and ††School of Medicine, University of Washington, Seattle, WA.

Introduction: Sexually transmitted infections (STIs) are managed syndromically in most developing countries. In Zimbabwe, men presenting with urethral discharge are treated with a single intramuscular dose of kanamycin or ceftriaxone in combination with a week's course of oral doxycycline. This study was designed to assess the current etiology of urethral discharge and other STIs to inform current syndromic management regimens.

Methods: We conducted a study among 200 men with urethral discharge presenting at 6 regionally diverse STI clinics in Zimbabwe. Urethral specimens were tested by multiplex polymerase chain reaction testing for Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium, and Trichomonas vaginalis. In addition, serologic testing for syphilis and HIV was performed.

Results: Among the 200 studied men, one or more pathogens were identified in 163 (81.5%) men, including N. gonorrhoeae in 147 (73.5%), C. trachomatis in 45 (22.5%), T. vaginalis in 8 (4.0%), and M. genitalium in 7 (3.5%). Among all men, 121 (60%) had a single infection, 40 (20%) had dual infections, and 2 (1%) had 3 infections. Among the 45 men with C. trachomatis, 36 (80%) were coinfected with N. gonorrhoeae. Overall, 156 (78%) men had either N. gonorrhoeae or C. trachomatis identified. Of 151 men who consented to HIV testing, 43 (28.5%) tested positive. There were no differences in HIV status by study site or by urethral pathogen detected.

Conclusions: Among men presenting at Zimbabwe STI clinics with urethral discharge, N. gonorrhoeae and C. trachomatis are the most commonly associated pathogens. Current syndromic management guidelines seem to be adequate for the treatment for symptomatic men, but future guidelines must be informed by ongoing monitoring of gonococcal resistance.
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http://dx.doi.org/10.1097/OLQ.0000000000000696DOI Listing
January 2018

STI Versus STD: Coda.

Sex Transm Dis 2017 11;44(11):712-713

From the *Division of Allergy and Infectious Diseases, Department of Medicine, and the Center for AIDS and STD, University of Washington School of Medicine, Seattle, WA; and †Denver Public Health, Colorado School of Public Health, University of Colorado, and Rietmeijer Consulting, Denver, CO.

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http://dx.doi.org/10.1097/OLQ.0000000000000717DOI Listing
November 2017

Dependency Traits, Relationship Power, and Health Risks in Women Receiving Sexually-Transmitted Infection Clinic Services.

Behav Med 2017 Jul-Sep;43(3):176-183

f STD Control Program , Rietmeijer Consulting.

In prior research, having traits consistent with a personality disorder has been shown to be related to substance use and high-risk sexual activity; however, few studies have examined relationships between dependency traits and health-jeopardizing behaviors. Individuals with traits consistent with dependent personality disorder may be more likely to be in a primary relationship characterized by unhealthy conditions, including physical abuse from a partner, low assertiveness in sexual situations, and partner infidelity. In addition, dependency traits may be associated with unhealthy coping (e.g., through substance use). To examine associations between dependent personality traits and these types of health-related behaviors, 198 women seeking sexually transmitted infection clinic services completed a computer-assisted assessment of dependent personality traits, substance use, unhealthy conditions in primary relationships, perceived sexual and relationship power, and sexual risk related to condom use. Dependency trait scores were correlated with the use of cocaine, heroin, and methamphetamine. Participants high in dependency traits reported low perceived power within their relationships and less say in sexual behaviors, including condom use. In a series of multivariate analyses, dependency traits significantly predicted having been hit by a partner, staying with a partner after he cheated, having sex because of threats, and fear of asking a partner to use a condom. Dependency traits were also associated with lower past condom use and lower future condom use intentions. Results suggest that dependent personality traits may place women at higher risk for physical abuse and harmful health behaviors.
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http://dx.doi.org/10.1080/08964289.2017.1297291DOI Listing
April 2018

A New Resource for STD Clinical Providers: The Sexually Transmitted Diseases Clinical Consultation Network.

Sex Transm Dis 2017 08;44(8):510-512

From the *Denver Public Health Department, Denver Health and Hospital, Denver, CO; †Division of Infectious Diseases, Department of Medicine, University of Colorado-Anschutz Medical Campus, Aurora, CO; ‡Gilead Sciences, Foster City, CA; §Denver Public Health, Denver, CO; ¶Colorado School of Public Health, University of Colorado, Denver, CO; ∥Rietmeijer Consulting, Denver, CO.

An online consultation tool, the Sexually Transmitted Diseases Clinical Consultation Network is a new resource for sexually transmitted disease clinicians and clinic managers. An initial evaluation shows that most requests (29%) were from medical doctors, followed by nurse practitioners (22%). Syphilis queries comprised 39% of consults followed by gonorrhea (12%) and chlamydia (11%).
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http://dx.doi.org/10.1097/OLQ.0000000000000632DOI Listing
August 2017

The Diagnosis of Nongonococcal Urethritis in Men: Can There Be a Universal Standard?

Sex Transm Dis 2017 03;44(3):195-196

From the *Denver STD Prevention Training Center, Denver Public Health Department, Denver Health and Hospital, Denver, CO; †Community and Behavioral Health, Colorado School of Public Health, University of Colorado, Denver; and ‡Public Health Informatics, Denver Public Health, Department Denver Health and Hospital, Denver, CO.

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http://dx.doi.org/10.1097/OLQ.0000000000000594DOI Listing
March 2017

Variations in Clinical Presentation of Ocular Syphilis: Case Series Reported From a Growing Epidemic in the United States.

Sex Transm Dis 2016 08;43(8):519-23

From the *Denver Public Health Department, Denver Prevention Training Center, Denver, CO; †Division of Infectious Diseases, Department of Medicine, University of Colorado, Aurora, CO; ‡Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA; §Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, AL; ¶Division of Infectious Diseases, Department of Medicine, Bayview Medical Center, Johns Hopkins University, Baltimore, MD; ∥Division of Infectious Disease, Department of Medicine, University of North Carolina, Chapel Hill, NC; **Division of Infectious Diseases, Department of Medicine, Johns Hopkins University, Baltimore, MD; and ††Colorado School of Public Health, Aurora, CO.

Ocular syphilis, a form of neurosyphilis, has been increasingly diagnosed in the United States. This case series summarizes the course of 6 patients recently diagnosed with ocular syphilis, emphasizing the varied sociodemographic factors and the wide range of symptoms and outcomes that are seen in patients with this disease.
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http://dx.doi.org/10.1097/OLQ.0000000000000477DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5755588PMC
August 2016

Assessing Patient Exposure to a Video-Based Intervention in STD Clinic Waiting Rooms: Findings From the Safe in the City Trial.

Health Promot Pract 2016 09 18;17(5):731-8. Epub 2016 Apr 18.

Centers for Disease Control and Prevention, Atlanta, GA, USA.

Safe in the City, a video intervention for clinic waiting rooms, was previously shown to reduce sexually transmitted disease (STD) incidence. However, little is known about patients' recall of exposure to the intervention. Using data from a nested study of patients attending clinics during the trial, we assessed whether participants recalled Safe in the City, and, if so, how the intervention affected subsequent attitudes and behaviors. Analyses were restricted to responses to a 3-month follow-up questionnaire among participants who were exposed to the video (n = 708). Impact was measured as participants' reports of the video's effect on behaviors and attitudes. Associations were evaluated using multivariable logistic regression. Of participants who were exposed, 685 (97%) recalled viewing the video, and 68% recalled all three vignettes. After watching the video, participants felt more positive about condoms (69%) and comfortable acquiring condoms (56%), were reminded of important information about STDs and condoms (90%), and tried to apply what they learned to their lives (59%). Compared with those who recalled viewing one or two vignettes, participants who recalled viewing all three vignettes reported more positive attitudes toward condoms and peer/provider communication. These findings demonstrate that a low-resource video intervention for waiting rooms can provide sufficient exposure to positively influence STD-related attitudes/behaviors.
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http://dx.doi.org/10.1177/1524839916631537DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4980150PMC
September 2016

An Opportunity Too Good to Miss: Implementing Human Immunodeficiency Virus Preexposure Prophylaxis in Sexually Transmitted Diseases Clinics.

Sex Transm Dis 2016 Apr;43(4):266-7

From the *Department of Infectious Diseases, University of Colorado; †Denver Public Health, Denver Prevention Training Center, Denver, CO; ‡Division of STD/HIV, Chicago Department of Public Health; §Department of Preventative Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; and ¶Colorado School of Public Health, Aurora, CO.

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http://dx.doi.org/10.1097/OLQ.0000000000000439DOI Listing
April 2016

Sexual abstinence and other behaviours immediately following a new STI diagnosis among STI clinic patients: Findings from the Safe in the City trial.

Sex Transm Infect 2016 May 15;92(3):206-10. Epub 2015 Dec 15.

Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.

Background: Few studies have assessed patients' sexual behaviours during the period immediately following a new diagnosis of a curable sexually transmitted infection (STI).

Methods: Data were analysed from a behavioural study nested within the Safe in the City trial, which evaluated a video-based STI/HIV prevention intervention in three urban STI clinics. We studied 450 patients who reported having received a new STI diagnosis, or STI treatment, 3 months earlier. Participants reported on whether they seriously considered, attempted and succeeded in adopting seven sex-related behaviours in the interval following the diagnostic visit. We used multivariable logistic regression to identify, among men, correlates of two behaviours related to immediately reducing reinfection risk and preventing further STI transmission: sexual abstinence until participants were adequately treated and abstinence until their partners were tested for STIs.

Results: Most participants reported successfully abstaining from sex until they were adequately treated for their baseline infection (89%-90%) and from sex with potentially exposed partners until their partners were tested for HIV and other STIs (66%-70%). Among men who intended to be abstinent until they were adequately treated, those who did not discuss the risks with a partner who was possibly exposed were more likely not to be abstinent (OR, 3.7; 95% CI 1.5 to 9.0) than those who had this discussion. Similarly, among men who intended to abstain from sex with any potentially exposed partner until the partner was tested for HIV and other STIs, those who reported not discussing the risks of infecting each other with HIV/STIs were more likely to be sexually active during this period (OR, 3.5; 95% CI 1.6 to 8.1) than were those who reported this communication.

Conclusions: Improved partner communication could facilitate an important role in the adoption of protective behaviours in the interval immediately after receiving a new STI diagnosis.

Trial Registration Number: NCT00137670.
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http://dx.doi.org/10.1136/sextrans-2014-051982DOI Listing
May 2016

The Program Cost of a Brief Video Intervention Shown in Sexually Transmitted Disease Clinic Waiting Rooms.

Sex Transm Dis 2016 Jan;43(1):61-4

From the *Centers for Disease Control and Prevention, Atlanta, GA; †Education Development Center, Waltham, MA; ‡Rietmeijer Consulting, LLC, Denver, CO; §California State University, Long Beach, Long Beach, CA; and ¶University of California, Los Angeles, Los Angeles, CA.

Background: Patients in sexually transmitted disease (STD) clinic waiting rooms represent a potential audience for delivering health messages via video-based interventions. A controlled trial at 3 sites found that patients exposed to one intervention, Safe in the City, had a significantly lower incidence of STDs compared with patients in the control condition. An evaluation of the intervention's cost could help determine whether such interventions are programmatically viable.

Materials And Methods: The cost of producing the Safe in the City intervention was estimated using study records, including logs, calendars, and contract invoices. Production costs were divided by the 1650 digital video kits initially fabricated to get an estimated cost per digital video. Clinic costs for showing the video in waiting rooms included staff time costs for equipment operation and hardware depreciation and were estimated for the 21-month study observation period retrospectively.

Results: The intervention cost an estimated $416,966 to develop, equaling $253 per digital video disk produced. Per-site costs to show the video intervention were estimated to be $2699 during the randomized trial.

Conclusions: The cost of producing and implementing Safe in the City intervention suggests that similar interventions could potentially be produced and made available to end users at a price that would both cover production costs and be low enough that the end users could afford them.
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http://dx.doi.org/10.1097/OLQ.0000000000000388DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6752031PMC
January 2016

You Say STD…..

Sex Transm Dis 2015 Sep;42(9):469

From Rietmeijer Consulting, LLC, Denver, CO.

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http://dx.doi.org/10.1097/OLQ.0000000000000324DOI Listing
September 2015

You Say STD…..

Sex Transm Dis 2015 Sep;42(9):469

From Rietmeijer Consulting, LLC, Denver, CO.

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http://dx.doi.org/10.1097/OLQ.0000000000000324DOI Listing
September 2015

Sexually transmitted infection clinics as safety net providers: exploring the role of categorical sexually transmitted infection clinics in an era of health care reform.

Sex Transm Dis 2015 May;42(5):286-93

From the *New York City Department of Health and Mental Hygiene, Queens, NY; †Los Angeles County Department of Public Health, Los Angeles, CA; ‡San Francisco Department of Public Health, San Francisco, CA; §Public Health-Seattle & King County and University of Washington Center for AIDS and STD Research, Seattle, WA; ¶Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA; ║Baltimore City Health Department, Baltimore, MD; **Chicago Department of Public Health, Chicago, IL; and ††Denver Public Health Department, Denver, CO.

Background: For many individuals, the implementation of the US Affordable Care Act will involve a transition from public to private health care venues for sexually transmitted infection (STI) care and prevention. To anticipate challenges primary care providers may face and to inform the future role of publicly funded STI clinics, it is useful to consider their current functions.

Methods: Data collected by 40 STI clinics that are a part of the Sexually Transmitted Disease Surveillance Network were used to describe patient demographic and behavioral characteristics, STI diagnoses, and laboratory testing data in 2010 and 2011.

Results: A total of 608,536 clinic visits were made by 363,607 unique patients. Most patients (61.9%) were male; 21.9% of men reported sex with men (MSM). Roughly half of patients were 20 to 29 years old (47.1%) and non-Hispanic black (56.2%). There were 212,765 STI diagnoses (mostly nonreportable) that required clinical examinations. A high volume of chlamydia, gonorrhea, and HIV testing was performed (>350,000 tests); the prevalence was 11.5% for chlamydia, 5.8% for gonorrhea, 0.9% for HIV, and varied greatly by sex and MSM status. Among MSM with chlamydia or gonorrhea, 40.1% (1811/4448) of chlamydial and 46.2% (3370/7300) of gonococcal infections were detected at extragenital sites.

Conclusions: Sexually Transmitted Disease Surveillance Network clinics served populations with high STI rates. Given experience with diagnoses of both nonreportable and reportable STIs and extragenital chlamydia and gonorrhea testing, STI clinics comprise a critical specialty network in STI diagnosis, treatment, and prevention.
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http://dx.doi.org/10.1097/OLQ.0000000000000255DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6737524PMC
May 2015

Relationship between social cognitive theory constructs and self-reported condom use: assessment of behaviour in a subgroup of the Safe in the City trial.

BMJ Open 2014 12 30;4(12):e006093. Epub 2014 Dec 30.

Division of HIV/AIDS, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.

Objectives: Previous studies have found social cognitive theory (SCT)-framed interventions are successful for improving condom use and reducing sexually transmitted infections (STIs). We conducted a secondary analysis of behavioural data from the Safe in the City intervention trial (2003-2005) to investigate the influence of SCT constructs on study participants' self-reported use of condoms at last intercourse.

Methods: The main trial was conducted from 2003 to 2005 at three public US STI clinics. Patients (n=38,635) were either shown a 'safer sex' video in the waiting room, or received the standard waiting room experience, based on their visit date. A nested behavioural assessment was administered to a subsample of study participants following their index clinic visit and again at 3 months follow-up. We used multivariable modified Poisson regression models to examine the relationships among SCT constructs (sexual self-efficacy, self-control self-efficacy, self-efficacy with most recent partner, hedonistic outcome expectancies and partner expected outcomes) and self-reported condom use at last sex act at the 3-month follow-up study visit.

Results: Of 1252 participants included in analysis, 39% reported using a condom at last sex act. Male gender, homosexual orientation and single status were significant correlates of condom use. Both unadjusted and adjusted models indicate that sexual self-efficacy (adjusted relative risk (RRa)=1.50, 95% CI 1.23 to 1.84), self-control self-efficacy (RRa=1.67, 95% CI 1.37 to 2.04), self-efficacy with most recent partner (RRa=2.56, 95% CI 2.01 to 3.27), more favourable hedonistic outcome expectancies (RRa=1.83, 95% CI 1.54 to 2.17) and more favourable partner expected outcomes (RRa=9.74, 95% CI 3.21 to 29.57) were significantly associated with condom use at last sex act.

Conclusions: Social cognitive skills, such as self-efficacy and partner expected outcomes, are an important aspect of condom use behaviour.

Trial Registration Number: clinicaltrials.gov (NCT00137370).
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http://dx.doi.org/10.1136/bmjopen-2014-006093DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4281534PMC
December 2014

Structural interventions for sexually transmitted infection prevention and sexual health.

Sex Transm Dis 2013 Aug;40(8):655-6

Colorado School of Public Health, University of Colorado Denver, Denver, CO 80218, USA.

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http://dx.doi.org/10.1097/OLQ.0000000000000018DOI Listing
August 2013
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