1. Repeat STDs: Why Are STD Clinic Patients Refractory to Clinic- Based Interventions? Emily J. Erbelding, MD, MPH Johns Hopkins University Baltimore, Maryland

2. Background Repeat STDs account for a substantial proportion of STD clinic visits in most sites Individuals who acquire STDs repeatedly suffer serious health consequence and are responsible for sustained transmission within the wider community Though client-centered risk reduction counseling has proven effectiveness in clinical trials, patients with repeat STDs may still have unmet needs

3. Study Aims To describe the range of underlying cultural, psychosocial, and contextual factors contributing to repeat STDs among patients seen in Baltimore STD clinics

4. Study Methods Eligible participants recruited from STD Clinics: –Men and women age >18 years presenting with 2 documented treated episodes of STD (any combination of GC, CT, syphilis) occurring in interval of 30 days - 2 years

5. Study Methods In-depth semi-structured interviews on following major domains: –Relationship status, persons they talk to about sex and context, scenarios and venues for meeting sex partners, relationship context, condom negotiation, scenarios for partner notification of STDs, family and social support, interactions with healthcare system

6. Study Methods Interviews were recorded and transcribed Narrative analysis by 2 separate investigators to identify major themes Structured analysis (Nudist) also performed separately to identify specific recurrent themes

7. Results 21 interviews completed and content analyzed from 9 female and 12 male participants –Predominantly African American and resided in inner city Baltimore –Self-identified as heterosexual –Age range 18-53 years, mean 25 years

8. Common themes, Male/Female: Accurate perception of HIV/STD risk 24 yr old woman with 3 episodes of GC and 1 episode of CT in past 2 years who is waiting for HIV post-test counseling “I already got my three strikes of being burned. If I get burned again, well see I just got my warning right now…I’m waiting for her to give the results and stuff so then my first strikes is up my mother got AIDS yam’ saying. I ain’t trying to go that way…”

9. Common Male/Female themes: Risk perception 40 yr old man view on same-- “I mean, the more…. When you think about it, the better a person looks, more people are attracted to them sexually so they’re having more sex, they’re more active.” 19 yr old woman on view of most risky partners-- “Like them big time, them big time drug dealers… that got that big time money, lawyers and all that. You can tell they got somethin’ because they…..all they do is they got money and don’t know what to do with their money…The ones that got a lot of money they the ones that basically catch a lot of stuff.”

10. Common Themes: Relationship as response to crisis 21 yr old woman on a boyfriend who is in prison, and who was better than the current one who gave her gonorrhea “..he was there for me when my mother passed away…like I found out when she… passed away that she had AIDS….” 20 yr old man describes why he cares for and stays with girlfriend who gave him gonorrhea “When I got locked up … she stuck by me. You know how some girls will break up with you while you locked up? She didn’t do that. She helped me pay for my lawyer and everything.”

11. Common Male/Female Themes: Relationship as response to crisis 24 yr old woman describes fight with father when boyfriend intervened. She was pregnant and old boyfriend had been shot, then locked up, leaving her homeless and forcing her to move in with her violent father. “My father bitchin’ I’m like aight’. They get fightin’. My father pushed him, he fell off the railing, you know the metal railing that got like the hearts that do like this, his finger got caught in there and it pop all the way back. So I’m sitting up the hospital with him all morning all night…I goes back home, my father was like where you been, at up the hospital with him with that monkey. I said I ain’t been up the hospital with no monkey…I moved in with him.”

12. Female Themes: STD signals of loss of hope for relationship 21 yr old woman on how she has broken it off with her current boyfriend after getting gonorrhea “Because it’s like he lie, every time it’s like, every time like say I don’t want to mess with him or something go wrong… He come back and say, ‘I’m sorry, I want to be with you’ and all this stuff.”

13. Male Themes: Life circumstances won’t allow hope for relationship they want 20 yr old man lives with his girlfriend but pretends to be her brother to not cause problems when other men in the neighborhood pay to have sex with her “because she still be messing with them… and getting money from them. She can go to, she got a couple of them, look… my college tuition need to be paid or something like that, she got a couple that’ll do that for her, you know what I mean? Any time she need something I know she can call and get it…”

14. Male themes: Resignation that they have to tolerate infidelity 21 yr old man on parole, has no steady income, currently lives in his girlfriend’s apartment and off her public assistance checks. He describes how he tolerates her outside partners-- “I mean she gonna see who she wanna see regardless of me sayin’ whatever. And she know that’s probably the same way wit me, if I wanna see somebody I’ma see em. So the only thing I tell is, don’t let me see it, you know, don’t have that person ‘round my son trying to tell my son and stuff what to do, I’m his daddy. Other than that, ‘long as you don’t bring it in my face, I have no problem. What I can’t see or what I don’t hear, it would not hurt me.”

15. Common themes: Lack of hope for the future 24 yr old woman is asked about what she sees for herself in the future--- “I don’t see I have no future that’s the whole point I’m trying to say. I know for a fact… I’m not gonna make it pass like 28 yam sayin’ ? I don’t see myself after that, and usually I….. when I was younger I seen myself 18, 19, 20 dadadada. But now.. I don’t see myself, you know what I’m sayin’...?

16. Common themes: Conscious decision to not have goals for future 21 yr old man talks about his feelings for his future— “I had ambition, it’s just my ambition it’s like … being held down right now. I mean, I can settle for good it ain’t got to be the best, but I’d like to have you know I’d just like to have my own house, my family, and a nice job. Something that’s gonna … get me by. I ain’t gonna say I don’t see nothin’ for myself, but things is hard right now so what I see for myself is whatever I get, whatever I reach in life, …that’s where I see myself. So if, if I’m right here and I had right now I had my family, I had my house, but I don’t have a car, that’s where I see myself. When I get my car, that’s where I see myself. If things start to get better, that’s where I see myself. I try not to put my standards too far ahead because if I don’t reach my standards I don’t want to feel like I failed or something. So, I mean…my future is gonna be alright. ”

17. STD Repeaters: Challenges Broad social context of impoverished life in inner city makes clinic-based interventions difficult Approach to prevention counseling involves focus on client’s perception of risk with goal of enhancing risk perception –STD repeaters communicated very keen perception of risks Prevention counseling is future-oriented exercise –Common theme for STD repeaters was lack of hope for their own future, and even a conscious decision to not focus on a future for themselves

18. STD Repeaters, Phase 2: Intervention Plans Eligibility criteria: STD clinic patients with new episode of GC, CT, syphilis occurring after report of prior episode in past 2 years Intervention: Individualized assessment, referrals, multi-session counseling –Counselor will be social worker (MSW) –Depressive symptom screen –Addictions counseling, drug treatment referral as needed –Referrals for other social services (housing, domestic violence) –Five semi-structured counseling sessions based upon individualized assessments Outcomes: –Client acceptance of intervention, rates of kept follow-up with sessions –Client self-report of whether intervention helped them –Counselor self-report of whether client engaged

19. Collaborators Johns Hopkins Bloomberg School of Public Health Lori Leonard, Sc.D. Jessica Greene, M.H.S. Aaron Goodfellow, Ph.D. Centers for Disease Control and Prevention Jami Leichliter, Ph.D. Michelle Esterberg, B.S.