Thomas L. Gift

Background: This article describes an updated spreadsheet tool that sexually transmitted infection (STI) prevention programs in the United States can use to estimate the health and economic benefits of their STI and HIV prevention activities. Methods: The development of the updated tool, Sexually Transmitted Infection Costs (STIC) Figure 2.0, involved 2 main components. First, we revised the tool to be more useful and user-friendly based on feedback from focus groups and usability testing. Second, we updated the mathematical model behind the calculations by (1) revising the model to reflect current STI and HIV prevention activities in the United States, (2) updating the epidemiological and economic parameters in the model using the best available evidence, and (3) including ranges (not just point estimates) in the model output. To demonstrate the use of STIC Figure 2.0, we applied it to estimate the impact of a hypothetical prevention program, consistent with that of a health department or large STI clinic in a metropolitan area. Results: STIC Figure 2.0 incorporated new features, including an interactive user interface to explore findings and create customized charts for use in reports and presentations. The hypothetical example we analyzed illustrated how providing STI treatment to 2680 people and HIV prevention services to 325 people could avert 1253 adverse outcomes and save more than $2 million in medical costs and productivity costs. Conclusions: Although subject to important limitations, STIC Figure 2.0 allows state and local programs, including STI clinics, to calculate evidence-based estimates of the impact of their program activities.

Rapid point-of-care tests that diagnose gonococcal infections and identify susceptibility to antibiotics enable individualized treatment. This could improve patient outcomes and slow the emergence and spread of antibiotic resistance. However, little is known about the long-term impact of such diagnostics on the burden of gonorrhea and the effective life span of antibiotics. We used a mathematical model of gonorrhea transmission among men who have sex with men in the United States to project the annual rate of reported gonorrhea cases and the effective life span of ceftriaxone, the recommended antibiotic for first-line treatment of gonorrhea, as well as 2 previously recommended antibiotics, ciprofloxacin and tetracycline, when a rapid drug susceptibility test that estimates susceptibility to ciprofloxacin and tetracycline is available. The use of a rapid drug susceptibility test with ≥50% sensitivity and ≥95% specificity, defined in terms of correct ascertainment of drug susceptibility and nonsusceptibility status, could increase the combined effective life span of ciprofloxacin, tetracycline, and ceftriaxone by at least 2 years over 25 years of simulation. If test specificity is imperfect, however, the increase in the effective life span of antibiotics is accompanied by an increase in the rate of reported gonorrhea cases even under perfect sensitivity.

Introduction: The COVID-19 pandemic changed the environment in which disease intervention specialists (DIS) operate, as their skills were in demand beyond STD control programs. Workforce conditions generally have changed in the last 2 years, imposing additional challenges. Retaining STD DIS has become more difficult in the changed environment. Materials and Methods: We conducted a landscape scan and obtained data from literature and personal observations to characterize current DIS workforce issues. We used published employment data to characterize current labor market conditions and described how cost-effectiveness analysis could be used to assess potential DIS retention interventions. An example illustrating cost-effectiveness concepts was developed. Results: Many STD control programs faced difficulties in retaining STD DIS, because competing positions often could be done without field work. Economic and crime issues posed additional challenges. General workforce turnover has increased 33% since 2016. Turnover varies by age, gender, and education. Cost-effectiveness analysis can be used to assess DIS retention interventions, but data on costs and outcomes are needed on an ongoing basis. Changes in the workforce environment could impact both retention and the effectiveness of retention interventions. Conclusions: Workforce changes have impacted employee retention. Increased federal funding makes expansion of the DIS workforce possible, but the labor market environment will continue to pose challenges to recruitment and retention.

Background: Chlamydia remains a significant public health problem that contributes to adverse reproductive health outcomes. In the United States, sexually active women 24 years and younger are recommended to receive annual screening for chlamydia. In this study, we evaluated the impact of estimated current levels of screening and partner notification (PN), and the impact of screening based on guidelines on chlamydia associated sequelae, quality adjusted life years (QALYs) lost and costs. Methods: We conducted a cost-effectiveness analysis of chlamydia screening, using a published calibrated pair formation transmission model that estimated trends in chlamydia screening coverage in the United States from 2000 to 2015 consistent with epidemiological data. We used probability trees to translate chlamydial infection outcomes into estimated numbers of chlamydia-associated sequelae, QALYs lost, and health care services costs (in 2020 US dollars). We evaluated the costs and population health benefits of screening and PN in the United States for 2000 to 2015, as compared with no screening and no PN. We also estimated the additional benefits that could be achieved by increasing screening coverage to the levels indicated by the policy recommendations for 2016 to 2019, compared with screening coverage achieved by 2015. Results: Screening and PN from 2000 to 2015 were estimated to have averted 1.3 million (95% uncertainty interval [UI] 490,000–2.3 million) cases of pelvic inflammatory disease, 430,000 (95% UI, 160,000–760,000) cases of chronic pelvic pain, 300,000 (95% UI, 104,000–570,000) cases of tubal factor infertility, and 140,000 (95% UI, 47,000–260,000) cases of ectopic pregnancy in women. We estimated that chlamydia screening and PN cost $9700 per QALY gained compared with no screening and no PN. We estimated the full realization of chlamydia screening guidelines for 2016 to 2019 to cost $30,000 per QALY gained, compared with a scenario in which chlamydia screening coverage was maintained at 2015 levels. Discussion: Chlamydia screening and PN as implemented in the United States from 2000 through 2015 has substantially improved population health and provided good value for money when considering associated health care services costs. Further population health gains are attainable by increasing screening further, at reasonable cost per QALY gained.

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Background: With the potential impact of the COVID-19 pandemic on HIV preexposure prophylaxis (PrEP) care management, we assessed the number of PrEP users and sexually transmitted infection (STI) testing–eligible PrEP users, STI testing rates, and prevalence between prepandemic (January 1, 2018–March 31, 2020) and early-pandemic (April 1, 2020–September 30, 2020) periods. Methods: In this retrospective cohort study, a PrEP user for a given quarter is defined as either a previous PrEP user or a PrEP initiator who has at least 1-day coverage of tenofovir/emtricitabine in the given quarter. The STI testing–eligible PrEP users for a given quarter were defined as those persons whose runout date (previous dispense date + days of tenofovir/emtricitabine supply) was in the given quarter. Results: The quarterly number of PrEP users increased from the first quarter of 2018 to the first quarter of 2020 and then decreased in the second and third quarter of 2020. Among STI testing–eligible PrEP users who had ≤14 days between runout and next refill date, gonorrhea and chlamydia screening testing rates were 95.1% for prepandemic and 93.4% for early pandemic (P = 0.1011). Among all STI testing–eligible PrEP users who were tested for gonorrhea and chlamydia, gonorrhea prevalence was 6.7% for prepandemic and 5.7% for early pandemic (P = 0.3096), and chlamydia prevalence was 7.0% for prepandemic and 5.8% for early pandemic (P = 0.2158). Conclusions: Although the early COVID-19 pandemic resulted in lower numbers of PrEP users and PrEP initiators, individuals who remained continuous users of PrEP maintained extremely high rates of bacterial STI screening. With high STI prevalence among PrEP users, assessments of PrEP care management are continuously needed.

This report describes the impact of sexual networks in the transmission of Monkeypox virus among gay, bisexual, and other men who have sex with men

Background: During the COVID-19 pandemic, disruptions were anticipated in the US health care system for routine preventive and other nonemergency care, including sexually transmitted infection care. Methods: Using a large national laboratory data set, we assessed the impact of the COVID-19 pandemic on the weekly numbers and percent positivity of chlamydia and gonorrhea tests ordered from the 5th week of 2019 to the 52nd week of 2020 in the United States. We compared weekly 2020 values for test volume, percent positive, and number of positives with the same week in 2019. We also examined the potential impact of stay-at-home orders for the month of April 2020. Results: Immediately after the declaration of a national emergency for COVID-19 (week 11, 2020), the weekly number of gonorrhea and chlamydia tests steeply decreased. Tests then rebounded toward the 2019 pre–COVID-19 level beginning the 15th week of 2020. The weekly percent positive of chlamydia and gonorrhea remained consistently higher in 2020. In April 2020, the overall number of chlamydia tests was reduced by 53.0% (54.1% in states with stay-at-home orders vs. 45.5% in states without stay-at-home orders), whereas the percent positive of chlamydia and gonorrhea tests increased by 23.5% and 79.1%, respectively. Conclusions: To limit the impact of the pandemic on control of chlamydia and gonorrhea, public health officials and health care providers can assess measures put in place during the pandemic and develop new interventions to enable care for sexually transmitted infections to be delivered under pandemic and other emergency conditions. The assessment like this study is continuously needed.