1. Enhanced Behavioral Surveillance Lessons Learned for Gonorrhea Control 2004 National STD Prevention Conference Philadelphia, PA March 2004

2. Why Enhance GC Behavioral Surveillance? Gonorrhea rates in the United States reached historic lows in the mid 90s

3. Endemic Gonorrhea Relative stability in GC rates since 1997 suggests that gonorrhea transmission may now be concentrated in ‘core’ groups Maximum possible reduction in rates using traditional GC control methods appears to have been reached US Gonorrhea rate of 125 per 100,000 in 2002 masks considerable regional variation Sporadic outbreaks have been observed among MSM in mid and large-sized urban areas

4. Regional Variation in GC Rates 2002 Gonorrhea Rate/100,000 0 – 20 20 – 100 100 – 200 200 +

5. Objectives of OASIS Enhanced GC Surveillance National surveillance data include only very limited, often incomplete demographics (i.e. age, sex, geography) Additional behavioral data are being collected to better characterize GC morbidity in 8 participating sites Replicable methodologies and validated core behavioral data elements found through OASIS will be used to strengthen future national gonorrhea surveillance activities

6. Enhanced Data Elements Sexual history Gender, number of sex partners Hx of STDs HIV Status/Testing Hx Condom use Socio-demographics Education Hx of Incarceration Risk Behaviors Internet use for finding partners Commercial sex worker/use Recreational drug use Clinical/Provider Symptoms Site(s) of infection Provider type

7. Enhanced Surveillance Methods Sampling Population based California (all GC cases interviewed in 15 LHJs) Washington (all GC cases interviewed in 4 LHJs) New York (all GC cases) Site based Michigan (all patients at 3 LHJ STD clinics) Virginia (all patients at Richmond STD Clinic) Ohio (All STD/IPP patients in 7 clinics) Other San Francisco (high-risk adolescents, venue-based) Baltimore (all repeat GC infections, city STD clinics)

8. Methods (Cont.) DIS or Staff Administered (phone and in-person) Washington California New York Baltimore San Francisco Self-Administered Michigan Ohio Virginia

9. IRB/Consent Issues Many sites exempt from IRB review CA, MI, NY, SF, WA Several sites required IRB approval Baltimore, OH, VA Written consent Baltimore & OH Incentives offered for patient participation Baltimore, CA, SF, VA, WA

10. Data Systems MS Access databases for enhanced surveillance data: CA, MI, VA, WA STD*MIS in use: NY, WA, OH Variety of analyses tools including SAS, SPSS, etc.

11. Selected Preliminary Findings California

12. Selected Preliminary Findings California (cont.)

14. Selected Preliminary Findings Michigan Ingham County STD Clinic 27 cases (136 retrospective) Washtenaw County STD Clinic 3 cases (27 retrospective) Genesee County STD Clinic 59 cases Kent County 213 retrospective

15. Selected Preliminary Findings Michigan (cont.) Risk Behavior

16. Selected Preliminary Findings Michigan (cont.) Where Met Sex Partners

17. Selected Preliminary Findings Michigan (cont.) HIV Testing/HIV Status

18. Selected Preliminary Findings Michigan (cont.) HIV Testing/HIV Status

19. Selected Preliminary Findings Virginia 2,603 interviews completed (response rate of 92%) 66% of respondents tested for CT (15% positive) 88% of respondents tested for GC (24% positive) 95% of respondents tested for syphilis (2.5% reactive) 78% of respondents tested for HIV (0.9% positive) See poster # P162

20. Selected Preliminary Findings Washington N=235 Gender of Sex Partners Reported

21. Selected Preliminary Findings Washington (cont.) N= 232 MalesFemales Males are 6.9 times more likely to report anonymous sex partners in the previous 3 months than females (95% CI 3.16 – 15.77, p<.0001) Anonymous Partners Reported in Previous 3 Months

22. Selected Preliminary Findings Washington (cont.) 7.6% of males and 1.8% of females report being HIV+ 80% of all respondents report having ‘ever’ had an HIV test Persons 20 years of age and older are 2.6 times more likely than those under 20 to report ever having had an HIV test (95% CI 1.5 – 4.6, p <.001) Persons reporting more than 1 partner in the previous 3 months were 2.4 times more likely to report having ever had an HIV test than those reporting 0 or 1 partner (p =.018) HIV Status / Testing History

23. Selected Preliminary Findings Washington Reported HIV Positivity by Age & Gender Age GroupFemalesMales 29 and under1.7%0% 30 and over5.3%12.8%

24. Selected Preliminary Findings Washington Interview Method Findings No statistically significant difference in the proportion refusing to participate in the interview when contacted by phone vs. in-person Persons contacted by telephone were significantly more likely to provide contact information for at least one period partner than those interviewed in person (adjusted OR=2.5, 95% CI 1.3 - 4.8)

25. OASIS Next Steps Continue piloting behavioral surveillance methods and instruments Develop ‘core’ set of behavioral/clinical data elements Explore integration of ‘core’ behavioral elements into STD PAM and NEDSS requirements planning Create cross-site dataset for combined analyses

26. Other OASIS Presentations at the 2004 National STD Prevention Conference Poster: “Enhancing Surveillance to Better Understand STD risks and demographics”, Jennifer Bissette Poster: “Effects of Partner Notification on Reducing Gonorrhea Morbidity” Todd Gerber, P101, ID#1365 Poster: "Risk Factors Associated with Sexual Behaviors and STDs in San Francisco High School Students" Kate Steiner, P131. Demonstration/Roundtable: “Analysis, Visualization and Reporting Methods for STD*MIS Data”, Todd Gerber Poster: "Locally Acquired Quinolone-Resistant Neisseria gonorrhea in Michigan." Katie MacComber, Poster # LB11, Poster: “Behavioral Characteristics of Gonorrhea Morbidity: Selected Findings of a Behavioral Surveillance Project in Washington State,” Mark Stenger, P022

27. For more Information Contact: Mark Stenger, MA Washington State Dept of Health 360-236-3446 Mark.Stenger@doh.wa.gov