Presentations at 2008 CDC National STD Prevention Conference. CONFRONTING CHALLENGES, APPLYING SOLUTIONS March 10-13, 2008 Chicago, Illinois

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1 Presentations at 2008 CDC National STD Prevention Conference CONFRONTING CHALLENGES, APPLYING SOLUTIONS March 10-13, 2008 Chicago, Illinois COUNTY OF LOS ANGELES DEPARTMENT OF PUBLIC HEALTH SEXUALLY TRANSMITTED DISEASE PROGRAM 2615 South Grand Avenue, Room 500 Los Angeles, CA (213) Fax: (213)

2 Confronting Challenges, Applying Solutions Sexually Transmitted Disease Program Oral and Poster Presentations Page Number An Evaluation of New CDC Performance Measures on Timely Treatment of Females Diagnosed with Chlamydia or Gonorrhea in STD Clinics... 1 The Epidemiology of Anal Intercourse among STD Clinic Patients... 2 Using Choice-Based Conjoint to Assess Self-Reported Serosorting Among Men Who Have Sex with Men (MSM) Cruising the Internet for Sex... 3 Designing the I Know Social Marketing Campaign to Promote Chlamydia And Gonorrhea Testing Among Young Women of Color in Urban Los Angeles... 4 How Men Who Have Sex with Men Conceptualize and Manage Their Risk of Contracting Syphilis: Results from Qualitative Research... 5 Syphilis and HIV in Sexual Networks of Men Who Have Sex with Men (MSM) In Los Angeles County, California... 6 Testing Behavior and Perceived Risk for Syphilis in a Time-Space Sample of Men Who Have Sex with Men... 7 Perceptions of Chlamydia and Gonorrhea among Young Latina and African American Women: Findings from Qualitative Research... 8 Impact of a Hip-Hop Radio Outreach Collaboration to Promote Chlamydia and Gonorrhea Testing Among Youth in L.A. County... 9 Between Idea and Act Falls the Shadow: Discrepancies between Testing Attitudes And Behavior in a Survey of Young African American and Latina Women Prevalence of Rectal Chlamydia and Gonorrhea Before and After Implementation Of Routine Rectal Screening Methamphetamine Use and High Risk Sexual Risk Behaviors Among Incarcerated Female Adolescents with a Diagnosed STD STD Co-infection among Acute HIV Patients in Los Angeles County Vaccination of High Risk Inmates in Los Angeles County Men s Central Jail with Accelerated Schedule Hepatitis A/B Vaccine Self-collected Versus Provider-collected Rectal Screening for Gonorrhea and Chlamydia in Men Who Have Sex with Men Project Connect: Positive Effects of a Multi-level Social-Ecological Intervention for Adolescents... 16

3 An Evaluation of New CDC Performance Measures on Timely Treatment of Females Diagnosed with Chlamydia or Gonorrhea in STD Clinics Goldstein BY 1, Kerndt PR 1, Chien MW 1, and Aynalem GM 1, 1 Los Angeles County Department of Public Health, Sexually Transmitted Disease Program, Los Angeles,CA USA Learning Objectives: By the end of the presentation, participants will be able to (1) discuss the new CDC performance measures, (2) evaluate the utility of the new measures, and (3) identify potential improvements to the new measures. Background: In 2007, CDC added two new performance measures (PM) for STD clinics on the timely treatment (within 14 and 30 days of specimen collection) of females diagnosed with Chlamydia (CT) or Gonorrhea (GC). Objective: To evaluate the new PMs and to identify associated practices that impact the PMs. Methods: From January to June of 2007, time-to-treatment for females diagnosed with CT or GC in 13 Los Angeles STD clinics was analyzed including presumptive treatment on the day of specimen collection. Presumptive treatment was recorded on a clinic intake form and considered appropriate when signs/symptoms were present, patient was a known contact to a case, or had a positive test done elsewhere. Results: Of the 607 CT-positive females, 87% and 92% were treated within 14 and 30 days, respectively. Over 75% were presumptively treated on the day of presentation; of those with intake forms, an estimated 98% were appropriately treated. Of those not presumptively treated, 63% had justification for presumptive treatment. Of the 194 GC positive females, 77% and 84% were treated within 14 and 30 days, respectively. Nearly 65% were presumptively treated, of which 96% were appropriate. Of those not presumptively treated, 75% had justification for presumptive treatment. Conclusions: Most CT/GC was treated on presentation and more could have been identified and appropriately treated presumptively. These PMs should include a category for treatment at time of specimen collection. Implications: Presumptive treatment provides an opportunity for earlier treatment and minimization of loss-to-follow-up. Including a category for treatment on the day of specimen collection in the PMs would also allow STD clinics to assess their policy on presumptive treatment. Oral Presentation 1

4 The Epidemiology of Anal Intercourse Among STD Clinic Patients Guerry SL 1, Javanbakht M 2, and Stirland A 1, 1 Los Angeles County Department of Public Health, Sexually Transmitted Disease Program, Los Angeles, CA USA, 2 Department of Epidemiology, University of California, Los Angeles, CA USA Background: Though the prevalence and epidemiology of anal intercourse (AI) are well described among men who have sex with men (MSM), less is known about heterosexual AI. Objective: To evaluate the epidemiology and risk factors of STD patients who report AI. Methods: This cross sectional study used demographic and risk behavior data collected from patients presenting at public STD clinics in Los Angeles. Current infection with an STD was determined using laboratory testing data. New patient visits from May 2006 June, 2007 were included in the analysis. Results: Among the 25,613 patients, the mean age was 31 years and 35% were women. Overall, 17% reported AI in the past 90 days. Among men with only female partners (MSW) 11% (1,528/13,422) reported AI and 12% (976/8,131) of women reported AI. Among men reporting sex with women and men (MSM/W) 53% reported insertive AI and 34% receptive AI (n=638). The overall prevalence of chlamydia and gonorrhea among women reporting AI was 13% and 2.4% respectively. Among MSW reporting AI, chlamydia and gonorrhea prevalence was 12% and 4.4%. MSM/W reporting AI had a chlamydia and gonorrhea prevalence of 6.5% and 5.9% respectively. Predictors of AI for heterosexuals included methamphetamine use (OR=3.20; 95% CI: ), exchanging sex for money/drugs in the past 12 months (OR=2.79; 95% CI: ) and recent incarceration (OR=1.71; 95% CI: ). Other predictors were heroin, ecstasy and anonymous sex. For MSW, MSM/W and women, the prevalence of chlamydia and gonorrhea was no different among those who practice AI and those who did not. Conclusion: The prevalence of AI was relatively high among this population of STD clinic patients. Though heterosexual patients practicing AI reported riskier behaviors, they were not more likely to have chlamydia or gonorrhea. Implications: There is a need for better understanding of the impact of anal intercourse on STD/HIV transmission in different populations. Oral Presentation 2

5 Using Choice-Based Conjoint to Assess Self-Reported Serosorting Among Men Who Have Sex with Men (MSM) Cruising the Internet for Sex Montoya JA 1, Plant A 1, McCullough PR 2, and PR Kerndt 1, 1 Los Angeles County Department of Public Health, Sexually Transmitted Disease Program, Los Angeles, CA USA, 2 Macro Consulting, Inc., Scotts Valley, CA USA Learning Objectives: By the end of this presentation, attendees will be able to describe the reliability of self-reported serosorting among MSM and the factors that influence serosorting decisions when cruising online. Background: Serosorting among HIV-positive men may be a promising harm reduction approach to prevent the spread of HIV. Profiles on cruising websites often include HIV status, allowing men to serosort. Indeed, several studies have reported high levels of serosorting among MSM. However, various factors may affect the likelihood of serosorting and furthermore, selfreported serosorting may differ from actual practice. Objective: To compare self-reported serosorting to serosorting in a conjoint trade-off exercise and describe factors that influence this behavior among MSM cruising the Internet for sex. Method: In 2006, 944 MSM were recruited from a popular cruising website and asked to engage in a choice-based conjoint (CBC) trade-off exercise where they were presented with a series of profiles that differed in partner attributes including appearance, serostatus, risk behavior, and condom use. Collecting these decisions in a CBC design produced a model of attributes MSM consider when choosing sex partners and the types of sexual practices they engage in. In addition, respondents were asked a series of self-reported questions around risk behaviors and serosorting. Result: 16% of respondents were HIV-positive, 72% HIV-negative, and 11% were unsure of their HIV status. In general, the CBC model predicts that men cruising the Internet for sex are influenced most by a potential partner s attractiveness. Among HIV-positive respondents who never used a condom with online partners, 74% reported always serosorting, however, the CBC model predicts that a lesser percentage (55%) always serosort. In addition, the CBC model predicts that the percentage of MSM who serosort drops when potential online partners are highly attractive. Conclusion: Self-reported serosorting by MSM may be substantially higher than their actual practice. Serosorting is affected by other factors including the attractiveness of a potential sexual partner. Implications: Harm reduction interventions that promote serosorting practices should incorporate strategies to help clients manage other factors that influence their decision-making. Poster Presentation 3

6 Designing the I Know Social Marketing Campaign to Promote Chlamydia and Gonorrhea Testing Among Young Women of Color in Urban Los Angeles Montoya JA 1, O Leary CM 1, Plant A 1, Rotblatt H 1, and Kerndt PR, 1 Los Angeles County Department of Public Health, Sexually Transmitted Disease Program, Los Angeles, CA, USA Learning Objectives: By the end of this session, attendees will be able to understand the development of an empirically based social marketing campaign promoting STD testing among young Latinas and African American women in Los Angeles, CA. They will also better understand these women s barriers to testing and their feelings about STDs and sexuality in general. This will aid in development of any efforts to promote STD testing and awareness among young women of color (WOC). Background: Women under age 25 have disproportionate STD morbidity. In Los Angeles County, CA, this is particularly true among women of color (WOC). Latinas and African American women under age 25 account for 43% of chlamydia and gonorrhea cases, but only 10% of the population. A social marketing campaign was developed to promote routine chlamydia and gonorrhea testing among young WOC. Objectives: Describe the process undertaken to develop a targeted social marketing campaign promoting chlamydia and gonorrhea testing among WOC under age 25. Methods: A media campaign was developed according to commercial marketing principals. These included attention to theoretical principles, input from community partners, and a series of focus groups with young Latina and African-American women in English and Spanish. The results from these activities were used to create marketing concepts that were further tested with focus groups. Finally, the concepts were refined into a multimedia campaign. Results: WOC younger than 25 know little about STDs and maintain varied sexual relationships including monogamy, and friends with benefits (nonexclusive sexual relations). They believe that Pap smears provided a complete battery of STD tests and were impressed by STDs symptoms and effects on fertility. Some expressed negative feelings about regular testing for STDs. Finally, these women are easiest to reach via varied media including publications and electronic media. These lessons were combined into the I Know campaign. Conclusions: Commercial marketing techniques were incorporated from the beginning of the I Know social marketing campaign. This resulted in incorporation of young WOC s values and beliefs about sexuality, STDs, regular testing, fertility and idiomatic language in a campaign promoting regular STD testing. Implications: Techniques used in commercial marketing can provide insights for use in social marketing among WOC. Particularly useful insights include women s values, beliefs and language. Poster Presentation 4

7 How Men who have Sex with Men Conceptualize and Manage Their Risk of Contracting Syphilis: Results from Qualitative Research O Leary CM 1, Plant A 1, Montoya JA 1, Rotblatt H 1 and Kerndt PR 1, 1 Los Angeles County Department of Public Health, Sexually Transmitted Disease Program, Los Angeles, CA USA Learning Objectives: By the end of this session, attendees will be able to describe how Men who have Sex with Men (MSM) assess and manage their risk of contracting syphilis and HIV. They will also be able to list two barriers to syphilis partner disclosure, two ways in which MSM compare syphilis risk to HIV risk, and at least one barrier to syphilis testing. This knowledge will aid in developing more effective syphilis testing programs for MSM. Background: Despite ongoing prevention efforts, Men who have Sex with Men (MSM) continue experiencing disproportionately high syphilis rates. Regular testing could dramatically reduce infection rates. In spite of this many MSM do not test regularly. Objectives: To better understand how MSM conceptualize and manage their risk or contracting syphilis to improve the development of testing programs. Methods: To inform a syphilis prevention social marketing campaign, 27 ethnically diverse Los Angeles MSM were recruited into three focus groups in March-April Groups were divided by age and HIV serostatus. Each group had a professional moderator and a discussion guide designed by researchers and community advisors. Researchers watched the groups in person and analyzed video recordings using emergent codes and theory. Results: Syphilis was generally not on the minds of participants and was rarely discussed with sex partners. Nonetheless, it was considered a serious and even shameful disease, particularly by HIV-positive participants. These beliefs, however, were not enough to result in syphilis risk reduction strategies such as condom use. For instance, there was consensus that condoms are not used for oral sex. In fact, the possibility of contracting syphilis was considered an acceptable risk by all groups. Finally, all groups shared erroneous knowledge about syphilis testing, such as any STD or blood test screens for syphilis. Conclusions: Significant barriers to syphilis prevention exist in MSM of all HIV serostatuses because of beliefs about risk and misconceptions about testing. The reluctance to reduce risk may indicate that testing programs hold more promise for reducing syphilis rates among MSM than risk reduction programs. Implications: Efforts aimed at increasing syphilis testing among MSM must take into account their beliefs about the acceptability of syphilis risk and misconceptions regarding testing if they are to be effective. Poster Presentation 5

8 Syphilis and HIV in Sexual Networks of Men who Have Sex with Men (MSM) in Los Angeles County, California O Leary CM 1, and Kerndt PR 1, 1 Los Angeles County Department of Public Health, Sexually Transmitted Disease Program, Los Angeles, CA USA Learning Objectives: By the end of this presentation, participants will be able to describe some key differences in men who have sex with men s (MSM) sexual networks. Participants will also understand two ways these networks contribute to differential disease morbidity among MSM and how interrupting these networks dramatically lowers STD morbidity. Background: MSM online sex seeking creates sexual networks that facilitate dramatically higher syphilis and HIV rates than in other populations. Traditional venues such as bars also continue to thrive. These provide different sexual networks that also contribute to higher syphilis and HIV morbidity. Objectives: To describe two types of venue-specific sexual networks that contribute to high syphilis and HIV morbidity in MSM and discuss implications of interventions. Methods: A representative online network of a syphilis index case was compared to a representative bar syphilis case network using UCINet software. Demographic and partner data was extracted from data routinely collected as part of syphilis case investigation. Results: A syphilis patient with 63 partners met online led to a centralized network of 319 partners averaging 37.4 years old and 2 recent partners (range: 1-66). 9.1% had syphilis and/or HIV. But, 93% were directly exposed, and 100% had partners directly exposed to these diseases. The bar network began with a syphilis patient with 19 partners. It led to a denser centralized network of 123 averaging 24.3 years old, and 2 recent partners (range: 1-57). 3.1% had syphilis and/or HIV, but 50.9% were directly exposed and 100% had directly exposed partners. Both networks can be isolated into small groups incapable of spreading diseases by removing only 3 key members. Conclusions: The two networks are similar in demography and morbidity and centralization. Centralization is particularly apparent in the internet network, which can make it easier to interrupt. In contrast, the bar network has more contact between members and is more efficient at spreading infections as a result. Implications: More research on varied sexual networks will further our understanding of disease transmission, differential STD morbidity among MSM, and how to break chains of infections. Oral Presentation 6

9 Testing Behavior and Perceived Risk for Syphilis in a Time-Space Sample of Men who Have Sex with Men Plant A 1, Montoya JA 1, Rotblatt H 1, O Leary CM 1, and Kerndt PR 1, 1 Los Angeles County Department of Public Health, Sexually Transmitted Disease Program, Los Angeles, CA USA Learning Objectives: By the end of this session, attendees will be able to describe various determinants of syphilis testing behavior and perceived risk for syphilis infection in MSM. Background: Men who have sex with men (MSM) experience disproportionately high syphilis morbidity, making up 66% of cases in Los Angeles County. Regular testing can reduce this burden, but many MSM fail to routinely test. Objectives: To better understand MSM s perceived risk for syphilis and influences on testing behavior, in order to improve testing programs. Methods: In May 2007, a baseline survey to evaluate a syphilis prevention social marketing campaign was conducted with 203 ethnically diverse MSM in Los Angeles. The survey utilized a time-space sampling methodology and contained questions about demography, knowledge, beliefs, risk and testing behavior. Results: Only 53% of respondents reported getting tested for syphilis every 6 months. A logistic regression was conducted to investigate influences on syphilis testing. Overall, ethnicity had a strong effect on testing. African Americans were 3.1 times as likely to test as whites (p=0.021) and Latinos were 2.6 times as likely to test (p=0.026). Similarly, HIV positive men were 5.7 times as likely to test (p=0.006) as HIV negative men. Those who perceived themselves at risk were 2.2 times as likely to test (p=0.026). However, when self-reported risk behavior was examined, 72% of MSM who never use condoms for anal sex did not perceive themselves to be at risk for syphilis infection. Conclusions: Regular syphilis testing was associated with HIV-positive serostatus, non-white ethnicity, and higher perceived risk. Furthermore, there is a disconnect between high risk behaviors and low perceived risk among some surveyed MSM. Implications: Efforts aimed at reducing syphilis among MSM must find ways to target those who do not test regularly, such as HIV negative men and those who report risky behaviors yet do not see themselves at risk. Additionally, further research into the contribution of ethnicity to syphilis testing is necessary. Poster Presentation 7

10 Perceptions of Chlamydia and Gonorrhea among Young Latina and African-American Women: Findings from Qualitative Research Plant A 1, O Leary CM 1, Rotblatt H 1 Montoya JA 1, and Kerndt PR 1, 1 Los Angeles County Department of Public Health, Sexually Transmitted Disease Program, Los Angeles CA USA Learning Objectives: By the end of this session, attendees will be able to describe different ways in which young African-American and Latina women conceptualize their personal risk for chlamydia and gonorrhea infection. They will also be able to list two possible effects of the stigma that surrounds these diseases. Background: Young African-American and Latina women experience disproportionately high rates of chlamydia (CT) and gonorrhea (GC). These groups have over four times their expected rates in Los Angeles. Regular testing could dramatically reduce these disparities. Objectives: To better understand young African-American and Latina women s perceptions of CT and GC to help create more effective testing programs. Methods: 32 Los Angeles women participated in five focus groups (three African-American, two Latina) in March-April 2007 to inform a social marketing campaign promoting STD testing. Groups were run by a professional moderator using a discussion guide designed by researchers and a community advisory board. Researchers observed the groups and later analyzed videotapes using emergent codes and theory. Results: CT and GC were highly stigmatized in all groups. The diseases were seen as nasty and scary. Patients were seen as stupid, irresponsible, or promiscuous. These beliefs made it difficult for many to discuss STDs with sex partners or friends. While all groups conceded that anyone could potentially get infected, infection was usually related to blame for themselves, or more often, for an unfaithful partner. While participants discussed a wide range of relationship types, from monogamous to casual, even those with multiple partners believe their risk of infection stems from a partner s infidelity. Many would only test if they found out about a partner s cheating. Conclusions: Participants distanced themselves from feelings of personal vulnerability for CT and GC by stigmatizing the diseases and those who get infected and by externalizing their vulnerability. These are significant barriers for regular testing. Implications: Chlamydia and gonorrhea prevention and testing efforts must address the ways young women conceptualize the diseases. High levels of stigma and varying concepts of perceived vulnerability may affect the propensity to test. Sustained social marketing and education are needed to de-stigmatize CT and GC. Poster Presentation 8

11 Impact of a Hip-Hop Radio Outreach Collaboration to Promote Chlamydia and Gonorrhea Testing among Youth in L.A. County Rotblatt H 1, Boudov M 1, Mercado C 1, Montoya JA 1, Plant A 1, O Leary CM 1, and Kerndt PR 1, 1 Los Angeles County Department of Public Health, Sexually Transmitted Disease Program, Los Angeles, CA USA Learning Objectives: By the end of this session, attendees will be able to describe key components and issues in developing a social marketing program using mass media and direct outreach to increase youth STD testing, describe advantages and limitations of the outcome measure used, and discuss possible explanations for lower than expected measures of project impact on chlamydia and gonorrhea testing. Background: Despite innovations in detecting and treating chlamydia and gonorrhea, youth ages in Los Angeles County (LAC) continue to experience high rates of these STDs, including disproportionately high rates among youth of color. Objectives: To describe the impact of an LAC STD Program (STDP) project with a top-ranked youth radio station to promote chlamydia and gonorrhea testing among youth of color. Methods: The project used radio spots, a website, text messaging, mass s, and direct outreach to promote chlamydia and gonorrhea testing by youth. Flyers distributed at outreaches or downloaded from the project website could be redeemed for incentives at participating clinics. Redeemed flyers were tallied to measure project impact on testing. Other impact measures included the number of flyers distributed or downloaded, text messages received, website visits, recipients, radio spot audience, and clinic participation. Results: During the project s initial 12 weeks, 195 radio spots were each heard by, on average, over 16,000 targeted youth. This same period saw 2,411 visits to the website, 91 incentiveredeemable flyer downloads, distribution of 19,340 flyers at 46 outreaches, 155 text messages received, and 4 s sent to 130,000 listeners. Thirty-eight clinics participated in flyer redemptions. However, only 25 flyers were redeemed at clinics. An additional 28 individuals tested at 4 project-linked mobile testing events. Conclusions: The project successfully reached target populations with STD testing messages. The project also attracted substantial clinic partnerships. However, direct impact on testing was surprisingly low. Interpretation of this result is complicated by the unforeseen availability of comparable incentives through an unrelated commercial promotion. Implications: The project s low measure on testing impact demonstrates possible unsuitability of the redeemed flyers model to incentivize STD testing or measure program impact, especially when easier means of obtaining the same incentive are available. Nonetheless, combined media/outreach programs can effectively deliver STD testing messages to high risk youth. Oral Presentation 9

12 Between Idea and Act Falls the Shadow: Discrepancies between STD Testing Attitudes and Behavior in a Survey of Young African American and Latina Women Rotblatt H 1, O Leary CM 1, Montoya JA 1, Plant A 1, and Kerndt PR 1, 1 Los Angeles County Department of Public Health, Sexually Transmitted Disease Program, Los Angeles, CA USA Learning Objectives: By the end of this session, attendees will be able to discuss discrepancies between STD testing beliefs and actual testing behavior in a sample of young African American and Latina women in areas of high chlamydia and gonorrhea morbidity. Attendees will also be able to understand concrete ways in which these findings can inform STD social marketing campaigns and programs. Background: African American and Latina women under age 26 have disproportionately high chlamydia and gonorrhea rates in Los Angeles County, CA. Higher levels of routine testing by at-risk women could dramatically reduce the STD burden in these populations. Objectives: To describe results of a survey of African American and Latina women under age 26 regarding STD testing attitudes and practices. Methods: To evaluate a social marketing campaign, a baseline survey of 150 African American women and 150 Latina women ages was conducted in areas of L.A. County with high chlamydia and gonorrhea morbidity. Forty-eight Latinas were Spanish speakers. The survey utilized street-intercept interviews at selected venues and asked questions about demography, behavior and beliefs. Results: Overall awareness of chlamydia and gonorrhea was high, at 80% and 87% respectively. Of those who had heard of chlamydia and gonorrhea, 78% and 65%, respectively, believed they are curable; 83% and 71% believed a person could not always tell if she had them; and 85% and 86% believed they should be tested annually. Yet at least 72% did not perceive themselves at risk for chlamydia or gonorrhea, and only 55% reported being tested for chlamydia and 48% for gonorrhea in the past year. Testing was significantly higher among women who were older, had multiple partners, had health insurance, or were African American. Conclusions: Despite substantial knowledge that should encourage testing (e.g., regarding curability), and perceived desirability of annual testing, the majority of respondents did not perceive themselves at risk for these STDs, and nearly half or more did not report annual testing. Implications: Efforts to promote chlamydia and gonorrhea testing among young women of color should address discrepancies between desired and actual testing behavior, and the lack of perceived risk among many at-risk women. Increased testing with health insurance also suggests benefits from promoting the availability of free services. Poster Presentation 10

13 Prevalence of Rectal Chlamydia And Gonorrhea Before And After Implementation Of Routine Rectal Screening Rudy ET 1, Wigen C 1, Clay E, Guerry SL 1, Hall J, Bolan B, and Kerndt PR 1, 1 Los Angeles County Department of Public Health, Sexually Transmitted Disease Program, Los Angeles, CA USA Learning Objectives: Participants will learn about the impact that rectal screening for CT and GC has on disease detection. Background: The Centers for Disease Control and Prevention (CDC) recommends rectal chlamydia (CT) and gonorrhea (GC) screening for men who report receptive anal sex. Despite the availability of nucleic acid amplification tests (NAAT) validated for rectal specimens, compliance with rectal screening in sexual health clinics often remains sub-optimal. Objectives: To compare the prevalence of rectal CT and GC before and during implementation of a rectal screening evaluation and to compare with other anatomic site infections with CT and GC within and across evaluation periods. Methods: As part of an ongoing evaluation to compare results of provider-collected versus selfcollected rectal specimen for GC/CT NAAT, men who reported receptive anal sex were routinely offered rectal GC/CT testing at a sexual health clinic. Rectal results were compared to other anatomical sites within the study period as well as with rectal results for the three months previously when the evaluation was not implemented. Specimens were tested using previously validated NAATs. Results: Between August 1, 2007 and October 15, 2007, there were 1584 clinic visits from men who have sex with men (MSM); 260 (16.4%) were tested for rectal CT and GC. The prevalence of rectal CT was 17.6% (46/260) and rectal GC was 16.9% (44/260). The prevalence of urethral CT was 5.2%; urethral GC 5.9% and pharyngeal GC was 7.5% during the evaluation period. Compared with results from May 1, 2007 through July 15, 2007, there were 1882 MSM clinic visits; 215 (11.4%) were tested for rectal CT and GC. The prevalence of rectal CT was 13.6% (29/214); rectal GC was 15.3% (33/215); urethral CT was 5.0%; urethral GC was 4.0% and pharyngeal GC was 8.2%. Conclusion: Compliance with CDC MSM screening guidelines resulted in a 29% increase in the detection of rectal CT. Implications: Strategies to implement guidelines should be emphasized in STD clinic settings. Oral Presentation 11

14 Methamphetamine Use and High Risk Sexual Risk Behaviors Among Incarcerated Female Adolescents With a Diagnosed STD Steinberg J 1, Boudov M 1, Kerndt PR 1, Grella C 2, and Kadrnka C 3, 1 Los Angeles County Department of Public Health, Sexually Transmitted Disease Program, Los Angeles, CA USA, 2 Integrated Substance Abuse Program, UCLA, Los Angeles, CA USA, 3 Juvenile Court Health Services, LA County Department of Health Services, Los Angeles, CA USA Background: The use of methamphetamine (MA) is associated with high risk sexual behaviors, yet little is known about its use and attendant risk behaviors among incarcerated female adolescents. Objective: By the end of the presentation participants will be able to identify demographic characteristics and risk factors associated with methamphetamine use among incarcerated adolescents. Method: Self-reported drug use, sexual risk behaviors and demographic data were examined from 478 interviews of confirmed chlamydia or gonorrhea cases diagnosed in juvenile hall in Bivariate analyses were conducted and logistic regression was used to determine predictors of methamphetamine use. Results: Mean results are as follows: age at arrest (16.0), age of first sexual experience (13.0) and number of lifetime sexual partners (6.0). The sample was African American (49%), Hispanic (37%), White (7%) and Other (7%). STD diagnoses were: chlamydia (72%), gonorrhea (11%) or both (17%). Other sexual behaviors were: no condoms used at last sex (63%), prior pregnancy (26.2%), prior STD (25.3%), prior sexual abuse (20%), ever traded sex (17%), have children (11%), and currently pregnant (6.3%). Daily or weekly substance use was reported for any drug (51%), marijuana (36%), alcohol (21%), polydrug use (20%) and methamphetamine (15%). In multivariate analysis, methamphetamine users were more likely to be Hispanic (OR=6.30, CI: 3.6, 11.40) and report marijuana use (OR=2.00, CI: 1.18, 3.62) and less likely to report condom use at last sexual encounter (OR=.56, CI:.32,.96). Conclusion: This is the one of the few studies of MA use among STD positive, incarcerated adolescents. Ethnic differences, drug use, and risky sexual behavior remained significant after adjusting for demographic and behavioral factors. Implications: Recognition of methamphetamine use among incarcerated female adolescents increases the need to provide interventions that address their drug use and risky sexual behaviors through screening, referrals to drug treatment and post-release case management. Oral Presentation 12

15 STD Co-infection Among Acute HIV Patients in Los Angeles County Chein M 1, Stirland A 1, Uniyal A 1, Kerndt PR 1, 1 Los Angeles County Department of Public Health, Sexually Transmitted Disease Program, Los Angeles, CA USA Background: Sexually transmitted diseases (STDs) in HIV-positive individuals increases the risk of HIV transmission. Detecting acute HIV infection and treating STDs in the earliest stage of an HIV infection will prevent further HIV transmission. Objective: To examine the prevalence of STDs among a cohort of acutely infected HIV patients in Los Angeles County (LAC). Method: Acute HIV cases were identified through pooled testing using Roche Amplicor Monitor HIV-1 or the GenProbe Aptima assays of HIV Ab negative (Vironostika HIV1) persons in 14 STD clinics and an incarcerated MSM population in LAC. Test results for gonorrhea (GC), syphilis and chlamydia (CT) were obtained from medical charts and STD surveillance data. Result: From February 2006 through October 2007, 34 persons with acute HIV were identified; 32 were tested for at least one other STD. Of these, 29 were MSM; two were MSW; and one was a M-to-F transgender who had sex with men. All 32 acute HIV cases were tested for CT and GC; 30 patients were additionally tested for syphilis. Overall, 18 (56.3%) acute HIV patients were coinfected with at least one other STD: 7 (21.9%) had CT, 14 (43.8%) had GC and 6 (20%) had syphilis. Of these, 2 had CT only; 7 GC only; 2 syphilis only; 3 CT/GC; 2 syphilis/gc; and 2 with syphilis/ct/gc. Conclusion: STD co-infection in the acute stage of HIV infection is common. Any MSM with an STD and a negative HIV Ab test should be tested for acute HIV infection with a more sensitive test. Implications: Prevention efforts should include testing to detect acute HIV among persons with STDs. Individuals with acute HIV and an STD co-infection provide a target for intervention to reduce HIV transmission. Oral Presentation 13

16 Vaccination of High Risk Inmates in Los Angeles County Men's Central Jail with Accelerated Schedule Hepatitis A/B Vaccine Stirland A 1, Munoz M 1, Mendoza R 1, Chien M 1, Malek M 2, and Guerry SL 1, 1 Los Angeles County Department of Public Health, Sexually Transmitted Disease Program, Los Angeles, CA USA, 2 Los Angeles Sheriff s Department, Los Angeles, CA USA Background: Guidelines recommend hepatitis A and B vaccination for incarcerated persons and men who have sex with men (MSM). Objectives: To describe the implementation of a hepatitis A and B vaccination demonstration project in a unit housing 500 MSM and transgendered persons in a Los Angeles County Jail. Methods: In August 2007, the STD Program, in collaboration with the Sheriff's Department and Immunization Program, implemented a one year hepatitis vaccination program using the newly FDA-approved accelerated (4 dose) schedule of combination A/B vaccine (0, 7 days, days and 12 months). Data were collected from immunization and STD screening medical records. Inmates were entered onto LINK, a web-based immunization registry. Results: From 8/1/2007 to 10/12/2007, 607 doses of Hepatitis A/B combination vaccine were given to 277 inmates. So far 125 have received 3 doses, 80 had 2 doses and 72 inmates had 1 dose. Two inmates received one dose of Hepatitis A vaccine. 30% of inmates (83/227) were unable to continue the series in jail either because they were released (56) or sent to prison (27). 4 inmates declined further vaccination due to side effects. Of the inmates vaccinated: 249 (90%) were male and 28 (10%) were transgender; 53 (19%) had sex for drugs or money, 59 (21%) injected drugs and 67 (24%) reported being HIV positive. Only one inmate opted out of the registry. Conclusion: Providing vaccination to inmates at high risk of hepatitis A and B is feasible and the accelerated schedule enables the majority of vaccines to receive 2 or more doses during their short jail stay. Implications: Accelerated schedule hepatitis A/B vaccine can be used in the jail setting. Oral Presentation 14

17 Self-Collected Versus Provider-Collected Rectal Screening for Gonorrhea and Chlamydia in Men Who Have Sex with Men Wigen CL 1 ; Rudy E 1 ; Clay E,2 ; Bolan R,2, Hall J,2, Guerry SL 1 ; and Kerndt PR 1, 1 Los Angeles County Department of Public Health, Sexually Transmitted Diseases Program, Los Angeles, CA USA, 2 Los Angeles Gay and Lesbian Center, Los Angeles, CA USA Learning Objective: Participants will learn about an alternative rectal screening method for gonorrhea and Chlamydia. Background: The Centers for Disease Control and Prevention (CDC) recommend rectal Chlamydia (CT) and gonorrhea (GC) screening for men who report receptive anal sex. Inadequate staffing at STD/HIV screening sites may limit compliance with rectal screening recommendations. Objective: To compare results of self-collected versus provider-collected rectal specimens for GC/CT nucleic acid amplification testing (NAAT). Methods: MSM who reported receptive anal sex were offered rectal GC/CT screening at a sexual health clinic. 220 paired provider-collected and self-collected rectal specimens were obtained between August and October A validated NAAT assay was used to test specimens. The results were recorded and analyzed using SAS v.9.0. We calculated the percent agreement and Kappa statistic to measure the pair-wise concordance of provider-collected and self-collected results. Improper samples were excluded from the final analysis. To assess sensitivity we used the composite reference as the standard. Results: Of the 220 paired specimens collected, 2 GC/CT provider samples and 1 self-collected CT specimen were deemed indeterminate by the lab. The overall prevalence of rectal CT was 18% (40/217); rectal GC was 19% (42/218). Percent agreement for detection of rectal CT and GC was 97% and 95%, respectively. Rectal CT was found in 37 of the paired specimens; 39 from the self-collected and 40 from the provider-collected specimens. Rectal GC was found in 34 of the paired specimens; 42 from the self-collected and 37 from the provider-collected specimens. Kappa coefficient and 95% confidence limits (CL) for rectal CT and GC were 0.92 (95% CL: 0.86, 0.99) and 0.83 (95% CL: 0.73, 0.93), respectively. Self-collected rectal CT and GC sensitivity were Provider-collected CT and GC sensitivity were 0.95 and 0.82, respectively. Conclusion: Self-collected rectal swabs performed as well as provider-collected rectal swabs. Implication: The self collection-method is a feasible alternative in understaffed settings to increase screening. Poster Presentation 15

18 Project Connect : Positive Effects of a Multi-level Social-Ecological Intervention for Adolescents Dittus P 1, DeRosa C 2, Ethier K 1, Chung E 2, Martinez S 2, Wong K 2, and Kerndt PR 2,3 1 Centers for Disease Control and Prevention 2 Health Research Association 3 Los Angeles County Department of Public Health Summary: Promising data from Project Connect point to the utility of employing a socialecological approach to adolescent STD prevention. Background/Purpose: Intervening at social-ecological levels is increasingly recognized as important and appropriate for adolescent health promotion. The goal of Project Connect is to develop and evaluate a multi-level social-ecological approach to adolescent STD prevention, including interventions for parents and structural changes to school programs and health care. Objectives of Symposium: To present intervention-specific outcome data supporting the utility of this approach. Implications for Programs, Policy and/or Research: Changing the social environment in which adolescents are embedded may have a powerful impact on their behavior and subsequent risk for STD. Descriptions An Overview of Project Connect, a multi-level social-ecological intervention to improve adolescent health through the prevention of STDs, including HIV, and teen pregnancy (Kathleen Ethier) Adolescents are uniquely influenced by their social context, including families, schools, and health care systems. Project Connect s purpose is to evaluate a multi-level social-ecological approach to adolescent STD prevention, including interventions for parents and structural changes to school programs and health care. It is currently implemented in 12 high schools and 14 middle schools (half are intervention, half control schools) in an urban California school district with a quasi-experimental design. Intervention activities are designed to increase parental monitoring, health care utilization, and use of school programs. Three cross-sectional waves of data, including more than 25,000 data points, have been collected thus far. Measures include intervention specific outcomes, sexual behavior and Chlamydia prevalence in participating schools. Positive impact of a structural intervention on knowledge of and use of school-based condom availability programs by urban high school students (Emily Chung) Description: Project Connect worked with school health personnel to fully implement districtmandated condom availability programs (CAPs) in six intervention high schools. Activities included increasing awareness and education of school nurses and administrators about the policy and its rationale, recruitment of additional school staff to implement the program, and provision of tools to streamline program implementation. Among students in intervention and their matched comparison schools, knowledge about CAPs increased significantly from baseline 16

19 to Time 3 among both groups (p<.001 for both groups) but the increase was larger for interventions students. Among sexually experienced students, there was a significant increase among intervention students in the percent who used the CAP (p<.05) but not for comparison students. Increase in reproductive health care, STD screening and HIV testing among high school students following school-based health care intervention. (Christine DeRosa) Description: Enhancements were made to reproductive health care referral systems for students in intervention high schools. Activities included development of community-based provider referral network, educational and policy meetings with school nurses, and work with school administrators to reduce barriers and increase access to confidential services. Among students in intervention schools, significant increases from baseline to Time 3 occurred in the percent who received reproductive health care in the last year (p<.03), the percent who had ever been tested for an STD (p<.001), and the percent of students who had ever been tested for HIV (p<.001). There were no changes in these variables among the students in the six matched comparison high schools. A practical, feasible parental monitoring intervention increases parents use of rules about friends and dating for urban middle and high school students (Patricia Dittus) Print materials designed to improve parental monitoring were distributed to 33,000 parents of intervention middle and high school students. Additional distribution to parents of incoming 6 th and 9 th graders occurred between Time 2 and Time 3. Among all students, reports of specific monitoring strategies (e.g., having rules about friends and dating) increased significantly (p<.0001 for both groups) from baseline to Time 3. Although the increase from baseline to Time 2 was significant among comparison students (p<.05), the change from time 2 to time 3 was not. In contrast, among intervention students the increase was more pronounced (p <.05), with a significant increase at each wave. Symposium Presentation 17