Penny S. Loosier

Objective: Case investigation and contact tracing (CI/CT) are fundamental public health efforts widely used during the COVID-19 pandemic to mitigate transmission. This study investigated how state, local, and tribal public health departments used CI/CT during the COVID-19 pandemic, including CI/CT methodology, staffing models, training and support, and efforts to identify or prioritize populations disproportionately affected by COVID-19. Methods: During March and April 2022, we conducted key informant interviews with up to 3 public health officials from 43 state, local, and tribal public health departments. From audio-recorded and transcribed interviews, we used the framework method to analyze key themes. Results: Major adjustments to CI/CT protocols during the pandemic included (1) prioritizing populations for outreach; (2) implementing automated outreach for nonprioritized groups, particularly during COVID-19 surges; (3) discontinuing contact tracing and focusing exclusively on case investigation; and (4) adding innovations to provide additional support. Key informants also discussed the utility of having backup staffing to support overwhelmed public health departments and spoke to the difficulty in “right-sizing” the public health workforce, with COVID-19 surges leaving public health departments understaffed as case rates rose and overstaffed as case rates fell. Conclusions: When addressing future epidemics or outbreaks, public health officials should consider strategies that improve the effectiveness of CI/CT efforts over time, such as prioritizing populations based on disproportionate risk, implementing automated outreach, developing models that provide flexible additional staffing resources as cases rise and fall among local public health departments, incorporating demographic data in laboratory reporting, providing community connections and support, and having a system of self-notification of contacts.

Objectives: We sought to (1) document how health departments (HDs) developed COVID-19 case investigation and contact tracing (CI/CT) interview scripts and the topics covered, and (2) understand how and why HDs modified those scripts. Design: Qualitative analysis of CI/CT interview scripts and in-depth key informant interviews with public health officials in 14 HDs. Collected scripts represent 3 distinct points (initial, the majority of which were time stamped May 2020; interim, spanning from September 2020 to August 2021; and current, as of April 2022). Setting: Fourteen state, local, and tribal health jurisdictions and Centers for Disease Control and Prevention (CDC). Participants: Thirty-six public health officials involved in leading CI/CT from 14 state, local, and tribal health jurisdictions (6 states, 3 cities, 4 counties, and 1 tribal area). Main Outcome Measure: Interview script elements included in CI/CT interview scripts over time. Results: Many COVID-19 CI/CT scripts were developed by modifying questions from scripts used for other communicable diseases. Early in the pandemic, scripts included guidance on isolation/quarantine and discussed symptoms of COVID-19. As the pandemic evolved, the length of scripts increased substantially, with significant additions on contact elicitation, vaccinations, isolation/quarantine recommendations, and testing. Drivers of script changes included changes in our understanding of how the virus spreads, risk factors and symptoms, new treatments, new variants, vaccine development, and adjustments to CDC's official isolation and quarantine guidance. Conclusions: Our findings offer suggestions about components to include in future CI/CT efforts, including educating members of the public about the disease and its symptoms, offering mitigation guidance, and providing sufficient support and resources to help people act on that guidance. Assessing the correlation between script length and number of completed interviews or other quality and performance measures could be an area for future study.

From 2020 to 2021, Marion County, Indiana, USA, saw an increase in early syphilis diagnoses, primarily among gay, bisexual, and other men who have sex with men (GBMSM). This rapid ethnographic assessment combines survey data from GBMSM with data from key informant interviews with multiple groups of stakeholders, including GBMSM, to describe how COVID-19 impacted sexual behaviors, sexual decision-making, and access to sexually transmitted disease (STD) services among GBMSM in Marion County, Indiana. A total of 62 virtual, semi-structured qualitative interviews with 72 key respondents including health department staff, medical providers, community-based organization staff, and GBMSM were conducted from October 14 to November 22, 2021. Modifications to partner-seeking and sexual behaviors attributable to the pandemic were associated with the way in which individuals reacted to the pandemic in general. Some GBMSM adopted mitigation strategies to avoid COVID-19 when meeting sex partners, such as creating a “sex pod.” Effects on mental health included increased loneliness, heightened anxiety, and a sense of hopelessness regarding the perceived inevitability of acquiring COVID-19. For some, the latter prompted decreased engagement in preventive measures when engaging in sexual activity. The pandemic decreased access to STD services and significantly curtailed public health outreach efforts, which may have limited access to needed STD treatment and care. Efforts focusing on ongoing public health concerns during extreme health events like COVID-19 may want to consider the many ways these events affect ancillary behaviors, such sexual decision-making and sexual behaviors. The role of mental health is key; messaging and guidance may benefit from a trauma-informed approach.

Social media forums provide a window into how gay, bisexual, and other men who have sex with men talk about pre-exposure prophylaxis for HIV prevention (PrEP) outside of research contexts. To examine information exchange about this important pillar of HIV prevention, discussions around PrEP were collected from the r/askgaybros subreddit of the social media site Reddit (2014–2019). Post titles and asks were qualitatively coded to identify themes describing the primary purpose of the post. In all, 1163 PrEP posts were identified, and a 23.3-fold increase in post volume was seen from 2014 (n = 20) to 2019 (n = 466). The most common post type was a mention of PrEP in a post primarily discussing: an assessment of risk after a sexual encounter (19.2%); a sexual or romantic relationship (6.0%); or other (29.3%). Access challenges (19.1%), information seeking (17.5%), and the cultural effects of PrEP on the gay community (16.3%) were other common themes. Posts regarding the initiation of PrEP (11.8%) and PrEP side-effects (9.4%) were moderately represented. Posts addressing promotion, shade, stigma, and usage were infrequent (≤ 5.5% of posts, respectively). Over time, discussion of PrEP has increased exponentially on r/askgaybros, which may reflect the normalization of PrEP. Qualitative analysis of these posts can be a rich source of data for scientists, practitioners, and healthcare providers interested in increasing uptake of PrEP and decreasing barriers to its use.

The state of Alaska had a sharp increase in cases of primary and secondary syphilis among gay, bisexual, and other men who have sex with men (GBMSM) in 2018, centered in Anchorage. A rapid ethnographic assessment was conducted in October 2018 to examine contextual factors contributing to local increases in syphilis. The assessment team conducted qualitative interviews with 64 (N=49 interviews) key informants in Anchorage and Matanuska-Susitna Valley identified through the STD/HIV program at the Alaska Department of Health and Social Services, Division of Public Health (ADPH): ADPH staff (n = 11; 22%) Medical Providers (n = 18; 37%), Community-Based Organizations/Partners (n = 9; 18%), and GBMSM Community Members (n = 11; 22%). This project was deemed exempt from IRB review. Primary factors affecting syphilis transmission, care, and treatment among GBMSM were: (1) Low awareness about the current syphilis outbreak and ambivalence about syphilis and other STIs; (2) Aspects of sexual partnering such as travel, tourism, and the use of online sites and apps to facilitate anonymous sex and multiple (both sequential/concurrent) partnering; (3) The synergistic effects of substance use, homelessness, and transactional sex; (4) Choosing condomless sex; and (5) Challenges accessing healthcare, including the ability to find appropriate and culturally competent care. Syphilis increases may have been influenced by factors which spanned multiple sectors of the Anchorage community, including individual behavior, community-level risk and protective factors, and use of and interactions with resources offered by ADPH, community-based organizations, and medical providers.

Food insecurity is linked to poor sexual health outcomes, especially among persons engaged in sexual behaviors that are associated with the risk of acquiring sexually transmitted infections (STIs). We examined this link using nationally representative data. We used data on adolescents and adults aged 15-44 who reported sexual activity in the past year from 6 years (September 2011–September 2017) of cross-sectional, weighted public-use data from the National Survey of Family Growth. We compared data on persons who did and did not report food insecurity, accounting for demographic characteristics, markers of poverty, and past-year STI risk indicators (ie, engaged in 1 of 4 high-risk activities or diagnosed with chlamydia or gonorrhea). Respondents who reported at least 1 past-year STI risk indicator were significantly more likely to report food insecurity (females: adjusted risk ratio [ARR] = 1.63; 95% confidence interval [CI], 1.35-1.97; P < .001; males: ARR = 1.46; 95% CI, 1.16-1.85) than respondents who did not report food insecurity. This finding was independent of the association between food insecurity and markers of poverty (≤100% federal poverty level [females: ARR = 1.46; 95% CI, 1.23-1.72; P < .001; males: ARR = 1.81; 95% CI, 1.49-2.20; P < .001]; if the respondent or someone in the household had received Special Supplemental Nutrition Program for Women, Infants, and Children or Supplemental Nutrition Assistance Program benefits in the past year [females: ARR = 3.37; 95% CI, 2.81-4.02; P < .001; males: ARR = 3.27; 95% CI, 2.76-3.87; P < .001]). Sex with opposite- and same-sex partners in the past year was significantly associated with food insecurity (females: ARR = 1.44; 95% CI, 1.11-1.85; P = .01; males: ARR = 1.99; 95% CI, 1.15-3.42; P = .02). Food insecurity should be considered a social determinant of health independent of poverty, and its effect on persons at highest risk for STIs, including HIV, should be considered when planning interventions designed to decrease engagement in higher-risk sexual behaviors.

In 2008, the $1.2 M sexually transmitted disease (STD) services line item supporting STD clinical services by the Massachusetts Department of Public Health was eliminated, forcing the cessation of all state-supported STD service delivery. To determine the impact on community provision of STD services after the elimination of state funds supporting STD service provision. Rapid ethnographic assessments were conducted in May 2010 and September 2013 to better understand the impact of budget cuts on STD services in Massachusetts. The rapid ethnographic assessment teams identified key informants through Massachusetts's STD and human immunodeficiency virus programs. Fifty providers/clinic administrators in 19 sites (15 unique) participated in a semistructured interview (community health centers [n = 10; 53%], hospitals [n = 4; 21%], and other clinical settings [n = 5; 26%]). Results clustered under 3 themes: financial stability of agencies/clinics, the role insurance played in the provision of STD care, and perceived clinic capacity to offer appropriate STD services. Clinics faced hard choices about whether to provide care to patients or refer elsewhere patients who were unable or unwilling to use insurance. Clinics that decided to see patients regardless of ability to pay often found themselves absorbing costs that were then passed along to their parent agency; the difficulty and financial strain incurred by a clinic's parent agency by providing STD services without support by state grant dollars emerged as a primary concern. Meeting patient demand with staff with appropriate training and expertise remained a concern. Provision of public health by private health care providers may increase concern among some community provision sites about the sustainability of service provision absent external funds, either from the state or from the third-party billing. Resource constraints may be felt across clinic operations. Provision of public health in the for-profit health system involves close consideration of resources, including those: leveraged, used to provide uncompensated care, or available for collection through third-party billing.