Repeat Infections among Adolescents and Young Adults: Findings From Philadelphia STD Clinics Nicole Liddon, PhD 1 Michael Eberhart, BS 2 Jami Leichliter, PhD 1 Martin Goldberg, BS 2 Lenore Asbel, MD 2 1 National Centers for Disease Control and Prevention, NCHSTP, DSTP, BIRB 2 City of Philadelphia Health Department

Background: Repeat Infections Studies estimate between 5%-20% of STD clinic clients reinfected within the following 2 years. As much as 40% of annual chlamydia and gonorrhea incidence occurs in previously infected patients. Health and financial consequences.

Objective To use clinic intake records and morbidity reports to identify factors associated with repeat infection among Philadelphia STD clinic clients. Can observations commonly used by clinics be used to recognize individuals at risk of returning with reinfection? Are there any clinic-level protective factors (e.g. didactic messages)?

Methods Retrospective study of records: City of Philadelphia morbidity files (n=79,989) Matched clinic patient records (n=17,929) Lab diagnosed gc and/or ct infection

Preliminary inquiry (Eberhart et al., 2002) 16.3% reinfected with gc and/or ct (within 30 days to 2 years) Relatively little of the difference in risk of repeat infections explained by demographics or behavior. Repeaters more likely to be African-American, younger, present initially with dual infection. History of Gonorrhea and/or Chlamydia strongest predictors of repeat infections.

Methods  Age 14-19, no previous dx (n=1,909)  To identify risks of re-infection at initial dx for patients by using demographics, behaviors, and provider actions.  Chi-square, difference of means tests, univariate logistic regression  Separate analyses by gender

Methods Demographics (race, age) Sexual Risk Behaviors Condom use last sexual encounter Condom use regular partners (never, some/always) Condom use other partners (never, some/always) New sex partner last 90 days # of sex partners last 90 days (none, one, two, three or more)

Provider Actions Self reported message delivery (yes or no) re: Partner notification Risk reduction Future Disease Suspicion Medication Follow-up Patient Handouts Contraception

Patients Females (n=1302) Males (n=607) Mean age17.1 years18.0 years Race/Ethnicity AA White Other 88.0% 4.4% 8.6% 94.2% 1.5% 4.3% Repeat infection20.0%4.0%

Significant correlates of repeat infection--females RepeatNo repeatOR (CI) Diagnosis Single Dual 19.1% 25.0% 80.9% 75.0% 1.92 (1.38, 2.69)

Significant correlates of repeat infection—males RepeatNo repeat OR (CI) Diagnosis Single Dual 3.6% 11.5% 96.4% 88.5% 3.74 (1.09, 12.51) Condoms-other partners sometimes/always never 4.0% 23.5% 96.0% 76.5% 7.08 (1.98,15.27) Provider risk reduction2.8%5.6%.49 (.21,.98)

Limitations-- Use of morbidity data Unclear if there are other dx outside of reported cases. Use of clinic files Not designed for in-depth behavior measurement Self-report Retrospective design Behaviors occurred before initial dx Individuals not randomly assigned to receive message from provider or not.

Conclusions  Current clinic-level observation does little to identify individuals at risk of reinfection, and new methods of assessing this risk may need to be developed.  However, some specific factors clinics currently measure that do associate with increased risk of re-infection and suggest possibilities for focused prevention at the first diagnosis.

Conclusions  For both males and females, individuals presenting with multiple diagnoses may benefit from increased follow-up and case management techniques.  Provider-delivered risk reduction messages may protect patients from repeat infection, but should be explored further.