Evidence Review: Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections

Population and Public Health BC Ministry of Health

September 2014

This is a review of evidence and best practice that should be seen as a guide to understanding the scientific and community-based research, rather than as a formula for achieving success. This review does not necessarily represent ministry policy, and may include practices that are not currently implemented throughout the public health system in BC. This is to be expected as the purpose of the Core Public Health Functions process—consistent with the quality improvement approach widely adopted in private and public sector organizations across Canada—is to put in place a performance improvement process to move the public health system in BC towards evidence-based best practice. Health authorities will develop public performance improvement plans with feasible performance targets and will develop and implement performance improvement strategies that move them towards best practice in the program component areas identified in the Model Program Paper. These strategies, while informed by the evidence in this review, will be tailored to local context.

This Evidence Review should be read in conjunction with the accompanying Model Core Program Paper.

Evidence Review accepted by: Population and Public Health, Ministry of Health (March 2014)

Edited by:

Gina Ogilvie, MD MSc FCFP DrPH Richard Lester, MD, FRCPC Former Medical Director Former Medical Head STI/HIV Control Clinical Prevention Services, BC Centre for Disease Control Clinical Prevention Services, BC Centre for Disease Control Associate Professor, Faculty of Medicine Clinical Assistant Professor University of British Columbia Division of Infectious Diseases, University of British Columbia Mark Gilbert, MD, FRCPC Former Physician Epidemiologist Bobbi Brownrigg, RN, BScN, MBA Leader, Epidemiology and Surveillance Leader Public Health Initiatives and Innovation Online Sexual Health Services Clinical Prevention Services, BC Centre for Disease Control Clinical Prevention Services, BC Centre for Disease Control Clinical Associate Professor Ciro Panessa, NP(F), MSN School of Population and Public Health Former Director Blood Borne Pathogens Faculty of Medicine, University of British Columbia Population and Public Health, BC Ministry of Health Adjunct Professor Darlene Taylor, RN MSc, PhD School of Nursing, University of British Columbia Research Program Manager Clinical Prevention Services, BC Centre for Disease Control Gina McGowan, MSc Director of Blood Borne Pathogens BC Ministry of Health

Prepared by:

Audrey Campbell, MD MHSc FRCPC Brian E. Ng, MD, MPH, CCFP* Clinical Research Associate, BC Centre for Disease Control Public Health Consultant and Family Physician Communicable Disease Control and Public Health Clinical Instructor, Department of Family Practice Emergency Management University of British Columbia Public Health Physician Consultant Course Director, Doctor, Patient, and Society 420, Course Director, Doctor, Patient, and Society 420 Vancouver-Fraser Medical Program Vancouver-Fraser Medical Program Site Faculty for Research and Evidence-based Medicine Clinical Instructor, Department of Pediatrics Vancouver-Fraser Family Practice Residency Program Faculty of Medicine, University of British Columbia *Denotes Professional Corporation

Paul Blasig, RN, BSN Community Health Nurse Nurse Consultant

Reviewed by:

James Blanchard, MD, MPH, PhD Ameeta Singh, BMBS (UK), MSc, FRCPC Professor, Department of Community Health Sciences Medical Director, AHS-Edmonton STI Clinic Director, Centre for Global Public Health Clinical Professor University of Manitoba Division of Infectious Diseases University of Alberta Colin Q-T Lee, MD, MSc, CCFP (EM), FRCPC Associate Medical Officer of Health Marc Steben, MD, Dess, CCFP, FCFP Simcoe Muskoka District Health Unit, Barrie Ontario Medical Advisor, STI Unit, Institut National de Santé Publique du Québec

Core Public Health Functions for BC: Evidence Review Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections

Table of Contents

Executive Summary ...... i 1.0 Overview/Setting the Context ...... 1 1.1 The Core Functions Framework ...... 1 1.2 Introduction to the Core Public Health Program of Communicable Disease ...... 2 1.3 Organization of this Report ...... 3 2.0 Methodology ...... 4 2.1 Primary Evidence Review ...... 5 2.1.1 Micro-level Interventions ...... 6 2.1.2 Meso- and Macro-level Interventions ...... 7 2.2 Supplemental Evidence Review: Youth ...... 7 2.3 Supplemental Evidence Review: MSM ...... 8 2.4 Strength of Evidence ...... 9 2.5 Expert Review Panel ...... 11 3.0 Background ...... 12 3.1 Health Implications...... 12 3.2 Special Considerations for Youth ...... 12 3.3 Special Considerations for MSM ...... 13 3.4 Review of Epidemiology of STI in BC ...... 13 3.4.1 Chlamydia ...... 14 3.4.2 Gonorrhea ...... 14 3.4.3 Infectious Syphilis ...... 14 3.4.4 Other Data from BC Studies ...... 14 4.0 Micro-Level Interventions ...... 16 4.1. STI/HIV Prevention Counselling and Behavioural Interventions ...... 16 4.1.1 General Behavioural Interventions ...... 17 4.1.2 Behavioural Interventions Stressing Ethnic Pride and Skill-building ...... 19 4.1.3 Youth-focused Behavioural Interventions (Youth Supplemental Review) ...... 20 4.1.4 MSM-focused Behavioural Interventions (MSM Supplemental Review) ...... 20 4.1.5 Cognitive-behavioural Interventions Aimed at Preventing STIs ...... 22 4.1.6 Brief Behavioural Interventions ...... 23 4.2 Small Group Sessions...... 25 4.3 Peer Education ...... 25 4.4 Online Interventions Targeting Youth (Youth Supplemental Review) ...... 26 4.5 Screening and Treating Chlamydia to Prevent Pelvic Inflammatory Disease ...... 28 4.5.1 Youth-focused Home-based STI Screening (Youth Supplemental Review) ...... 29 4.5.2 MSM-Focused STI Screening (MSM Supplemental Review) ...... 30 4.6 Abstinence and Reduction of Sexual Partners ...... 32 4.7 Male Condoms ...... 32 4.8 Female Condoms ...... 33 4.9 Cervical Diaphragms ...... 33 4.10 Topical Microbicides and Spermicides ...... 34 4.11 Male Circumcision ...... 34 4.11.1 Male Circumcision for MSM (MSM Supplemental Review) ...... 35

Population and Public Health, Ministry of Health Core Public Health Functions for BC: Evidence Review Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections

4.12 Syphilis Chemoprophylaxis for MSM (MSM Supplemental Review) ...... 35 4.13 Partner Management ...... 36 4.14 Provider referral ...... 37 4.15 Patient-delivered partner therapy (PDPT) ...... 37 4.16 CDC and PHAC: guidelines: Special populations ...... 39 4.17 CDC and PHAC Guidelines: Interventions ...... 39 4.18 Conclusion ...... 39 5.0 Meso-level Interventions ...... 40 5.1 Social Diffusion ...... 41 5.1.1 Community Opinion Leaders ...... 41 5.1.2 Peer Mentors within a Social Network...... 42 5.2 Group Education ...... 43 5.3 Parental Monitoring of Youth (Youth Supplemental Review) ...... 45 5.4 Worksite-based Programming for Parents of Youth (Youth Supplemental Review) ...... 47 5.5 Multi-component Programs Targeting Children/Younger Youth (Youth Supplemental Review) ...... 48 5.5.1 Multi-component Approach Involving Children, Parents and Teachers (Youth Supplemental Review) ...... 48 5.5.2 Multi-component Approach Involving Youth and Community Service (Youth Supplemental Review) ...... 49 Multi-component Approach Targeting Youth in High School (Youth Supplemental Review) 50 5.6 Peer Education (Youth Supplemental Review) ...... 51 5.6.1 Peer Education Combined with Outreach Screening (Youth Supplemental Review) . 51 5.7 Clinic-based Interventions ...... 52 5.7.1 Disease Intervention Specialists in Clinic Settings ...... 52 5.7.2 Electronic Technologies in the Clinic Setting ...... 52 5.7.3 Syphilis Testing during HIV Care in the Clinic Setting ...... 54 5.7.4 Clinic Guidelines on STI Screening ...... 54 5.7.5 Male clinics ...... 55 5.7.6 Mobile Clinics ...... 55 5.8 Outreach: Venue- or Group-based Screening ...... 56 5.8.1 School-based STI Screening and Treatment Programs ...... 56 5.8.2 Other Studies ...... 58 5.8.3 STI Screening in School-based Health Centres (Youth Supplemental Review) ...... 58 5.8.4 Sport-related Settings ...... 61 5.8.5 Occupational Groups ...... 62 5.8.6 Family Court System ...... 62 5.8.7 Prisons ...... 63 5.8.8 Shelter Residents ...... 63 5.8.9 STI Testing of Commercial Sex Workers in Outreach Settings ...... 64 5.8.10 MSM Sex on Premises Establishments, Saunas, Bathhouses ...... 64 5.8.11 Street ...... 65 5.8.12 Other Studies ...... 66 5.9 Home-based STI Testing ...... 67 5.10 Internet-based Campaigns and Services for MSM (MSM Supplemental Review) ...... 69 5.11 Online Initiatives to Promote STI Testing for Youth (Youth Supplemental Review) ...... 72 5.12 Contact Tracing and Social Networks ...... 74

5.13 Presumptive Treatment ...... 75 5.13.1 One-time Presumptive Treatment ...... 76 5.13.2 Periodic Presumptive Treatment (PPT) ...... 77 5.14 Targeted Mass Treatment ...... 78 5.15 Patient-delivered Partner Therapy (PDPT) ...... 79 5.16 Conditional Cash Transfers ...... 79 5.17 Community Mobilization ...... 80 5.17.1 Other Multi-component Interventions ...... 81 5.18 MSM-focused Community Partnerships and Events (MSM Supplemental Review) ...... 82 5.19 Conclusion ...... 82 6.0 Macro-level Interventions ...... 84 6.1 STI-specific Policy with an Evaluation of Impact on STIs ...... 84 6.1.1 Condom Use Policy ...... 84 6.1.2 Integrated Policy and Community Mobilization Interventions ...... 86 6.1.3 Performance Measures and Private Health Insurance ...... 87 6.1.4 Private Health Plan Reimbursement Law ...... 88 6.1.5 Sex Worker Registration ...... 88 6.2 STI-specific Policy without an Evaluation of Impact on STIs ...... 89 6.2.1 Screening Legislation ...... 89 6.3 Non-STI-specific Policy with an Evaluation of Impact on STIs ...... 90 6.3.1 Alcohol Policy ...... 90 6.3.2 Other Policy ...... 96 6.4 Funding and Fees ...... 96 6.4.1 STI Clinic Fees ...... 96 6.4.2 Federal Funding ...... 97 6.5 Clinic-based Systems Interventions Focused on Youth (Youth Supplemental Review) ...... 98 6.5.1 Clinical Practice Improvement Focused on Youth (Youth Supplemental Review) ..... 98 6.5.2 Primary Care Systems Intervention Focused on Youth (Youth Supplemental Review) ...... 98 6.6 Mass Media Targeting Youth (Youth Supplemental Review) ...... 99 6.7 Social Marketing and Public Awareness Campaigns for MSM (MSM Supplemental Review) ...... 101 6.8 CDC and PHAC Guidelines: Special Populations ...... 104 6.8.1 Pregnant Women ...... 105 6.8.2 Adolescents ...... 105 6.8.3 Children ...... 105 6.8.4 Inmates and Persons in Correctional Facilities...... 106 6.8.5 Men Who Have Sex with Men ...... 107 6.8.6 Women Who Have Sex with Women ...... 108 6.8.7 Sex Trade Workers ...... 108 6.8.8 Neonates ...... 108 6.8.9 Aboriginal People ...... 109 6.9 CDC and PHAC Guidelines: Interventions ...... 110 6.9.1 Counselling ...... 110 6.9.2 Abstinence ...... 112 6.9.3 Male Condoms ...... 112 6.9.4 Female Condoms ...... 112

6.9.5 Topical Microbicides and Spermicides ...... 112 6.9.6 Male Circumcision ...... 112 6.9.7 Patient-delivered Partner Therapy (PDPT) ...... 112 6.10 Evaluation of STI Control Strategies ...... 114 6.10.1 Evaluation of STI Control Strategies at the Level of Populations ...... 114 6.10.2 Evaluation of STI Control Strategies or Guidelines at the Institutional Level ...... 115 6.11 Conclusion ...... 116 7.0 STI Control Strategies ...... 118 7.1 World Health Organization ...... 118 7.2 England Department of Health ...... 124 7.3 European Centre for Disease Prevention and Control ...... 125 7.4 Department of Health and Ageing, Commonwealth of Australia ...... 127 7.5 Manitoba Health/Public Health, Communicable Disease Control Unit ...... 128 Appendix A: Summary of Database Search Results ...... 133 Appendix B: Summary of Reviewed Studies ...... 137 Appendix C: Summary of Evidence Ratings ...... 196 Appendix D: Descriptions of Selected Interventions ...... 210 Box 1: Philadelphia High School STD Screening Program (PHSSSP) ...... 210 Box 2: Family Court STD Screening Program ...... 211 Box 3: Shelter-based screening program ...... 211 Box 4: Description of the 100 % Condom Use Program (100% CUP) ...... 212 Box 5: Description of the CHAT intervention ...... 212 Box 6: The ImPACT intervention ...... 212 Box 7: Draw the Line/Respect the Line program ...... 212 Box 8: Safer Choices program ...... 213 Box 9: Clinical Practice Improvement Intervention ...... 213 Box 10: Example of a Florida SBHC program ...... 214 Box 11: Policy 123 ...... 215 Box 12: Features of the Get Tested Why Not program, Ottawa Public Health ...... 215 Box 13: Challenges related to STI screening in prison and suggested solutions ...... 216 Appendix E: Patient-Delivered Partner Therapy (PDPT)– The Policy and Legal Environment ...... 217 Appendix F: Examples of Social Marketing Campaigns...... 220 Appendix G: Recommended Knowledge Mobilization Partners ...... 224 Abbreviations and Acronyms ...... 236 References ...... 237

“In asking for strong evidence I would, however, repeat emphatically that this does not imply crossing every ‘t’, and swords with every critic, before we act.

All scientific work is incomplete – whether it be observational or experimental. All scientific work is liable to be upset or modified by advancing knowledge. That does not confer upon us a freedom to ignore knowledge we already have, or to postpone the action that it appears to demand at a given time.”

Austin Bradford Hill(1)

EXECUTIVE SUMMARY

In March 2005, the Ministry of Health released A Framework for Core Functions in Public Health (2) (Core Functions Framework), which clearly defined the core functions of the public health system and identified a comprehensive set of core public health programs intended to improve health and well- being, and/or reduce disease, disability and injury. This policy work formed the foundation of Promote, Protect, Prevent: Our Health Begins Here, BC’s Guiding Framework for Public Health (3) (Guiding Framework)—the 10-year directional document for the public health system released in March 2013. The Guiding Framework reinforces Core Functions as the framework for public health program and service delivery in the province, provides a strong foundation for all current public health efforts, and builds on the critical elements necessary to consider when identifying future priorities.

Communicable disease is a core public health program, which is aligned with the Communicable Disease Prevention goal in the Guiding Framework. Each core public health program is supported by an evidence review and model core program paper, quality improvement tools that help the Ministry of Health and health authorities ensure that public health policies, programs and services are based on evidence and best practice. This evidence review complements the existing Communicable Disease Secondary Transmission Evidence review, and fills a gap in the collation of evidence related to bacterial sexually transmitted infections (STIs).

Therefore, this document is a new evidence review under the communicable disease core public health program, and is intended to provide a foundation for effective prevention of STIs, given the unique aspects of STIs compared to other communicable diseases. The evidence review will inform the Ministry of Health’s work to develop a strategic framework on the prevention of STIs, which will support achievement of ten-year targets in the Guiding Framework.

The prevention and control of sexually transmitted infections (STI) has been a critical task of government agencies, health care practitioners, communities and individuals for decades. As STIs are non-randomly distributed, occur as a result of the most intimate behaviours, and are often disproportionately shouldered in certain communities, effective prevention and control programming requires consideration beyond the approaches used for the control of other non-sexually transmitted communicable diseases.

This evidence review identifies prevention interventions at the micro-, meso- and macro-levels that are specific to bacterial STIs as provincial strategic policy guidance is already in place for two sexually transmitted viral infections (HIV and hepatitis)(4)(5). The micro-level considers interventions between individuals; the meso level considers interventions among the broader community, among bridging groups and core networks; and the macro-level considers interventions such as legislation, regulation and policy. Settings where people live, learn, work and play are considered.

Policy-makers and program planners must also consider multi-outcome interventions that increase the cost-effectiveness of prevention approaches. A historically compartmentalized view of mental, social, educational, behavioural and legal issues means the evidence base to support efforts that simultaneously address common risk factors as they relate to STIs is not well developed. Yet it is the accumulation of outcomes across health and social domains that offer the most convincing arguments for investment in prevention (5). By addressing multiple outcomes, interventions can reduce the risk of

Population and Public Health, Ministry of Health Page i Core Public Health Functions for BC: Evidence Review Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections sexually transmitted infections, improve mental and physical health, and generate broader social and economic benefits.

Interventions identified through this review have been evaluated against the BC Ministry of Health Evidence Scale (see Figure 2) to determine which interventions have significant evidence for reducing the burden of STIs. A directed and comprehensive, but non-systematic, literature review was conducted in multiple phases to examine interventions at the micro-, meso-, and macro-levels with a special focus on youth, gay, bisexual and other men who have sex with men (MSM). In addition, STI control strategies from various jurisdictions were reviewed, with a focus on strategies from the World Health Organization (WHO). Evidence related to electronic and virtual technologies are included in both the micro- and meso-level sections of this report.

Resources dedicated to STI prevention and control efforts should be focused on interventions for which there is good evidence to support their dissemination—three star evidence rating according to the BC Ministry of Health Evidence Scale. Evidence for dissemination means these interventions have been shown to be effective in both research settings and “real world” applications, and follow-up has demonstrated sustained effects over time.

While no evidence with a three-star rating was found, the interventions that were assessed to be significantly effective in impacting STI incidence/prevalence using these criteria are presented in Box 1 below.

Box 1: Interventions with evidence of outcome effectiveness Prevention counselling and behavioural interventions Screening and treating for STI to prevent pelvic inflammatory disease (PID) Male condoms Partner management – patient referral and patient-delivered partner therapy (PDPT) Community mobilization, particularly in combination with other interventions (e.g., condom use policy, enhanced access to health services, etc.)

At the same time, this does not mean that interventions without evidence of outcome effectiveness need to be stopped, rather monitoring and evaluation efforts need to be improved, so that over time, we can better assess the wide array of STI prevention interventions currently in place. The micro-, meso- and macro-level findings below were found to be of key importance.

Micro-level interventions (individual-level) Micro-level interventions consider the interventions between individuals and how these impact the prevention and control of sexually transmitted infections. Interventions to prevent the transmission of STIs at the individual level, as well as those related to youth and MSM, are numerous. Appendix C lists these interventions and the corresponding evidence rating scale score.

Most interventions reviewed have some evidence for implementation. Prevention counselling and behavioural interventions have wide support for effectiveness in the literature. Topical microbicides and spermicides, which studies have largely shown to be ineffective and possibly carry an increased risk of STI transmission, are generally not recommended for use in STI prevention. Male condoms are an effective means of STI prevention. Female condoms and cervical diaphragms have been shown to be effective in preventing STI, but cost and safety concerns with anal intercourse limit recommendations

Population and Public Health, Ministry of Health Page ii Core Public Health Functions for BC: Evidence Review Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections for usage, especially when male condoms are available. However, in instances where the male partner refuses to use a male condom, female condoms and cervical diaphragms may be important to consider. Male circumcision, while recommended in developing nations with high HIV prevalence as a strategy to combat high STI and HIV rates, has had limited study in developed nations with typically lower HIV prevalence. As such, neither the US nor Canadian guidelines recommend for or against it as a strategy for STI control. Partner management remains a cornerstone of STI prevention and control. Various forms of partner management have been identified in the literature, and recommendations of specific strategies will vary according to local laws and regulation, resources, and cost.

New evidence shows promising results related to new electronic technologies (e.g., social media, short- message service [SMS], and other internet-enabled interventions) among youth, and reinforces that there is evidence for implementation, particularly for impact on sexual risk behaviour, while impact on STI rates is often uncertain. In addition, new evidence further supports the acceptance of these interventions among youth, and includes a caveat that the most recent technology should be utilized as youth may respond unfavourably to outdated modalities. Further, youth may use more than one type of technology and therefore there may be an advantage to offering multiple methods to reach youth. The evidence related to home-based STI screening among youth also supports the utility of this intervention for promoting uptake; a limited literature base suggests effectiveness for the detection of STIs.

Meso-level interventions (community or organizational level) Meso-level interventions occur at the level of communities and organizations, or among groupings such as family, peers or sub-populations. There are multiple preventive interventions to consider at these levels, including contact tracing using a social network approach for detection of STI cases, home-based STI testing to support screening uptake, and screening commercial sex workers to facilitate access to treatment. New evidence reinforces the importance of the long-established practice of group education, but suggests that group education should go beyond simply providing information, but rather include skill-building; this has been shown to be effective in decreasing STI positive test results.

Peer mentors providing informal education, specifically within their social network, have been found to be effective in decreasing risk behaviour, but further research is required to assess the impact on STI rates. Studies of community mobilization initiatives among sex trade workers in low- and middle-income countries, reveal significant decreases in the incidence of STIs. Note that these programs are generally multi-faceted in which community mobilization comprises an important but not sole component. The emerging use of social networks in contact tracing has been found to lead to a broader, more comprehensive identification of at-risk contacts, across settings and contexts, although long-term impact on STI burden is uncertain.

Screening, follow-up and treatment, remains a cornerstone of STI prevention efforts. This topic represented the largest area of study identified at the meso-level. Screening outreach efforts have been conducted with diverse populations in a range of settings. While each study has unique findings, generally a moderate to high proportion of most target populations were receptive to undergoing screening, and voluntarily accessed their results. As well, treatment rates for cases were generally high. Only a small selection of studies assessed STI rates over time, and the impact on incidence/prevalence varied between studies. In a recent review article, higher participation rates were noted when screening was delivered in existing “traditional” STI clinics, suggesting that conducting screening programs in such sites may be advisable. However, there is also a literature base that supports the effectiveness of promoting screening uptake in street-based settings were appropriate (e.g., with street-based sex trade

Population and Public Health, Ministry of Health Page iii Core Public Health Functions for BC: Evidence Review Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections workers). Home-based testing has demonstrated effectiveness in promoting testing uptake, with a limited literature base assessing STI rates over time; a randomized controlled trial (RCT) conducted among youth in Denmark found that a home testing strategy was associated with a lower prevalence of chlamydia and less reported PID.

There is evidence to support using school-based health centers (SBHC) as important venues for offering screening to youth in schools in US studies, and have demonstrated the ability to detect high rates of STIs. One study demonstrated that a chlamydia screening initiative that was widely advertised resulted in a high uptake of screening among a population that largely had no other source for reproductive health care. Another study suggests that this is an important way to engage asymptomatic young men in screening. Further, high rates of reinfection with chlamydia were detected through a SBHC in a single study, particularly among younger youth; this raises the question, however, of why reinfection rates remained high despite interaction with the SBHC.

At the same time, the STI clinic setting still remains a key venue for effective STI treatment and care. Strategies that operate within a clinic setting that have been shown to be effective in supporting screening include new electronic technologies that provide computer alerts and text message reminders, syphilis screening during HIV-related care, and electronic medical record alerts. Studies in the US revealed that partner notification and treatment may be facilitated by involving Disease Intervention Specialists (DIS) who have specialized expertise in STI-related outreach, counseling, contact tracing, etc. Male health clinics were suggested as an important way to promote access to male-focused STI care; the limited study identified on this topic, from a setting in India, reported a positive impact on STI knowledge and reduced risk behaviour, however the impact on STI rates is not reported. Further, a study of a mobile clinic in a US context revealed enhanced STI testing uptake and very high acceptability by community residents, but long-term impact on STI rates was uncertain.

Parents and teachers comprised key areas of focus for a number of behavioural interventions. There was consistent evidence of an association between parental monitoring and youth sexual risk behaviour, and the association between parental monitoring on STI incidence was demonstrated in one prospective cohort study. However, what is lacking is an assessment of parental monitoring interventions and their impact on STI rates in a population.

There are multi-component interventions seeking to effect behavioural change among youth that also have evidence for implementation. These included programs delivered to children/younger youth (i.e., elementary and middle school) as well as their parents and teachers, some of which also had community service elements. Despite having different components, these studies consistently demonstrated that comprehensive STI prevention interventions that attend to social context, delivered during earlier years, can reduce sexual risk behaviour long-term. The impact on STI rates was assessed in one study, which reported a significant impact only among African American youth. A similar multi-component intervention implemented among high school students demonstrated some positive effects on sexual risk behaviour, however impact on STI rates warrants further research.

The literature around group education involving risk reduction messages generally reports effectiveness in reducing sexual risk behaviour and STI rates. Group education involving abstinence-only messaging has had mixed results, and the impact on both behavioural and biological outcomes warrants further research. The first large, multi-national trial of community opinion leaders found that this intervention had little effect on STI rates; however the comparison control intervention itself incorporated a range of

Population and Public Health, Ministry of Health Page iv Core Public Health Functions for BC: Evidence Review Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections strategies shown to be effective in STI prevention and this may have decreased the ability to detect a difference between intervention and control groups.

Targeted presumptive STI treatment has also had mixed results in the literature; however, these are short-term, temporary measures and other control measures must be implemented in order to maintain STI reductions over the long-term.

While there have been many published studies on internet-based campaigns for MSM, most studies have been observational or provide only descriptive statistics. More rigorous, controlled studies are needed to determine if the many types of internet campaigns are indeed effective in decreasing STI rates and improving sexual health outcomes.

Macro-level interventions (laws, policies and regulations level) Macro-level interventions relate to policy instruments, including legislation, regulations, acts, resolutions, and guidelines. The literature on macro-level interventions, although relatively smaller than the micro- and meso-level literature base, contained a wide variety of policy-related interventions that have evidence for implementation, including both STI-specific and non-STI specific policy. Some of these interventions include STI Control Strategies and Guidelines and alcohol policy.

The majority of the macro-level literature is from outside of Canada (with many US-based studies as well as studies from low- and middle-income countries). In the US, evidence is supportive of the positive association between the amount of federal funding for syphilis elimination activities and a decrease in subsequent incidence rates of syphilis at the state level. Evidence also showed that implementation of co-payments had negative impacts on STI clinic visits and STI detection, particularly for higher risk populations in the US. The 100% Condom Use Program (CUP) - a government policy - was discussed widely in the literature, particularly in middle- and low-income countries. Studies have varied in the demonstration of impact on STI rates, with the turnover of sex trade workers and new sex trade workers thought to prevent challenges for program success.

Studies in low- and middle-income countries of combined community mobilization and policy initiatives revealed significant decreases in STIs and risk behaviours among female sex workers. By implementing a community solidarity project with a government policy intervention in commercial sex establishments there was a significant decrease in the proportion of individuals with one or more STIs (chlamydia, gonorrhea, Trichomoniasis) in the intervention site. In a single study, registration of sex workers with the municipal health department was not found to be associated with a lower risk of testing positive for STIs. Literature from private insurance contexts in the US suggests that performance measures matter and can have a significant influence on STI screening practices.

The literature on alcohol policy includes examination of multiple variables (e.g., alcohol pricing, minimum legal drinking age, zero-tolerance drunk driving laws) and finds that measures to reduce alcohol access are associated with lower STI rates. There is a well-established mechanism for the relationship between alcohol and STIs (i.e., the association between alcohol consumption and risky behaviour). Many of the studies identified for this review are ecological with subsequent limitations in establishing a causal relationship at the individual-level, however there is ample evidence corroborating an association and the potential impact of alcohol control policies on STI reduction at the population- level.

Population and Public Health, Ministry of Health Page v Core Public Health Functions for BC: Evidence Review Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections

Social marketing is a research-driven approach to behaviour change and consists of five components: branding, segmentation, price, placement, and promotion. Although various social marketing campaigns targeting MSM have shown promise in uncontrolled studies, the evidence from controlled studies for the use of social marketing campaigns for prevention of bacterial STIs is poor. More research is warranted before this intervention is recommended.

There is a noted absence of population-based evaluations of STI-related laws and jurisdiction-wide STI control strategies on the impact on STI incidence/prevalence among populations, in the academic literature, or publicly available grey literature, using the specified search terms. An unpublished evaluation of a provincial syphilis prevention campaign was identified and reviewed, as were evaluations of the dissemination of CDC STI guidelines among health care providers (without an evaluation of an impact on STI rates), and evaluation of STI guidelines/strategies at the level of local institutions.

Building the evidence base for STI control for future evaluation This evidence review has revealed that STI prevention interventions at the meso- and macro-level form key elements of a comprehensive STI prevention strategy across populations. It is important to note that most of the interventions have been evaluated on a foundation of the core elements of an STI control program, including surveillance, laboratory services, integrated and specialized clinic and public health follow up. This review has also revealed that much of the data on interventions at these levels, come from the US, Europe, Australia, or low- and middle-income countries. In addition, nascent endeavours, such as online technologies, are still too new to have a mature evidence base, but should continue to be examined given their potential role in STI prevention.

Overall, in the BC-context, without a population-based survey to be able to validate changes in behaviour, and biological outcomes (e.g., STI incidence/prevalence), the ability to evaluate many interventions at these levels is limited. This means that even well designed and implemented interventions may not be able to be rated beyond a “warrants further research” designation owing to a lack of evaluation data. As such, the existence of such a survey (that includes self-reported behavioural and STI data, ideally linked to biological data) would be highly advantageous to the future evaluation of programs and interventions delivered to populations within the province.

Effective prevention and control across the continuum of STIs and in whole populations requires more structured monitoring and evaluation, as well as research to further expand the spectrum of available interventions. Nevertheless, current evidence provides many options to program planners and policy makers. Some interventions are “stand-alone,” and fall within the scope and mandate of health authorities and primary care practitioners, while others require partnership and collaboration across sectors. Whether delivered directly by the health system, or in partnership with other sectors, sustainable implementation is enhanced by selecting programs that build on existing infrastructures and resources. Wherever possible, STI prevention efforts should be structurally integrated with existing health programs and social policies in schools, workplaces and communities (see knowledge mobilization Appendix G for further information).

Population and Public Health, Ministry of Health Page vi Core Public Health Functions for BC: Evidence Review Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections

1.0 OVERVIEW/SETTING THE CONTEXT

1.1 The Core Functions Framework In March 2005, the Ministry of Health released A Framework for Core Functions in Public Health (2)(Core Functions Framework) that clearly defined the core functions of the public health system and identified a comprehensive set of public health services, based on the best available evidence and best practices. This policy work formed the foundation of Promote, Protect, Prevent: Our Health Begins Here, BC’s Guiding Framework for Public Health (3) (Guiding Framework)—the 10-year directional document for the public health system released in March 2013. The Guiding Framework reinforces Core Functions as the framework for public health program and service delivery in the province, provides a strong foundation for all current public health efforts, and builds on the critical elements necessary to consider when identifying future priorities (See Figure 1).

The original Core Functions Framework has been revised to reflect the alignment with the Guiding Framework. It outlines the 20 core public health programs within the seven goal areas that health authorities provide as they seek to improve the overall health of their populations. Four strategies (health promotion; health protection; preventive interventions; and health assessment and disease surveillance) are used to guide implementation.

Communicable Disease is a core public health program, and it is aligned with the Communicable Disease Prevention goal (Goal 4) within the Guiding Framework.

Figure 1: Core Functions Framework

Population and Public Health, Ministry of Health Page 1 Core Public Health Functions for BC: Evidence Review Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections

Each core public health program is supported by quality improvement tools that help the Ministry of Health and health authorities ensure that public health policies, programs and services are based on evidence and best practice.  An evidence review, which identifies and ranks the evidence of effective public health interventions related to the core public health program.  A model core program paper, which identifies the core elements of a comprehensive program, including goals and objectives, principles, key components, best practices, and indicators and potential performance measures. The information in the evidence review provides the foundation for the main components and best practices outlined in the model core program paper.

Health authorities are expected to use these quality improvement tools to inform planning, policy development and delivery, and support ongoing quality improvement. Specifically to:  Ensure programs and services are evidence-based and address health inequities.  Develop and implement new public health priorities, as identified by the Guiding Framework and other public health directional documents.  Educate and inform internal and external stakeholders of the evidence and support them in implementing evidence-based practices.

1.2 Introduction to the Core Public Health Program of Communicable Disease This document is a new evidence review under the communicable disease core public health program, and is intended to provide a foundation for effective prevention of STIs, given the unique aspects of STIs compared to other communicable diseases. The evidence review will inform the Ministry of Health’s work to develop a strategic framework on the prevention of STIs, which will support achievement of ten- year targets in the Guiding Framework (3). This evidence review will ensure that any future, provincial strategic STI prevention policy is supported by updated evidence in the prevention of STIs.

While STI prevention and control programs are built on the foundations of communicable disease control, including legislation, surveillance, laboratory services, targeted and integrated clinical services, partner services and evaluation, careful evaluation of interventions and practices are needed to determine how to optimally disseminate and implement these interventions within these foundations, to ensure they impact positively on rates of sexually transmitted infections at a population level. In BC, as with many jurisdictions globally, STI rates have been increasing steadily again over the past few decades. Strengthening of existing practices may be required, as well as development of new, innovative ways to curb STI impact at the population level, both of which should be grounded in evidence.

Following initial dramatic declines in bacterial STI rates in the antibiotic era in the mid to late 1900s, rates of reportable STI have been increasing in recent decades in BC, as they have in most of Canada, the US, and other jurisdictions with STI control programs. In BC, chlamydia rates continue to rise steadily with a broad distribution that includes teenage girls and younger women; gonorrhea rates have also been increasing, albeit more concentrated among individuals with higher risk sexual behaviors. Rates of infectious syphilis, while fluctuant, have peaked in recent years to their highest levels since the 1970s, and have shifted from predominantly street involved and heterosexual populations in Vancouver to a highly concentrated provincial epidemic among MSM. Antimicrobial resistance remains a recurring challenge, particularly for gonorrhea control efforts. New technologies in testing and treatment support

Population and Public Health, Ministry of Health Page 2 Core Public Health Functions for BC: Evidence Review Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections are also emerging. These general trends and challenges are seen internationally. Historical core public health functions such as testing, treatment of cases, and partner notification are well established in BC where there is a strong integration of province-wide surveillance, laboratory support, clinical outreach and training; yet there may be room for improvements.

This evidence review describes prevention interventions specific to bacterial sexually transmitted infections as provincial strategic policy guidance is already in place for two sexually transmitted viral infections (HIV and hepatitis) (4,5). This work was identified as the first step to address the increasing rates of bacterial sexually transmitted infections identified in Promote, Protect, Prevent: Our Health Begins Here (3) and allows for identification of additional strategies or innovations within or in addition to these core functions that may ultimately help in reducing infection rates and the burden of STI in the population.

1.3 Organization of this Report This report is divided into four sections: micro-level (e.g., individuals, relationships) interventions; meso- level (e.g., institutions, society) interventions; macro-level (e.g., families, communities) interventions; and STI-control strategies, with an additional focus on youth and MSM populations. Some interventions do not clearly fit into one single intervention level category; therefore, these are discussed in multiple sections where appropriate (e.g., electronic new technologies).

Appendix A presents the results of the database searches conducted for the evidence reviews. Appendix B presents a summary of the reviewed studies that focus on STI incidence/prevalence or STI-related morbidity. Within the text, a summary box is provided after most interventions or group of interventions, containing an evidence rating scale and rationale for the assigned rating. Appendix C contains a summary of the evidence ratings for all of the interventions reviewed. Appendix D presents a description of selected interventions (e.g., programs, policies) that provide added context for some of the meso- and macro-level interventions in particular. Appendix E presents a discussion of policy and legal issues related to patient-delivered partner therapy (discussed in section 4.15). Appendix F provides examples of social marketing campaigns (discussed in section 6.7). Appendix G discusses knowledge mobilization.

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2.0 METHODOLOGY

This directed (non-systematic) evidence review is the product of an extensive search and critical appraisal of the published and unpublished literature on STI prevention and control interventions and strategies spanning micro (e.g., individuals, relationships), meso (e.g., institutions, society) and macro (e.g., families, communities) levels. Literature focused on the general population, as well as numerous other sub-populations nationally and internationally, including a special focus on youth and gay, bisexual and other men who have sex with men (MSM), as populations with a demonstrated high incidence/prevalence of STIs in BC was sought. The term “MSM” includes all men who have sex with other men, regardless of self-identified sexual orientation. The limitation of the term MSM is acknowledged as it overlooks important distinctions in sexual and gender identity, culture and behaviour between men in this group that are relevant for effective programming (for example, services for gay-identified men), this term and definition based on behaviour are more commonly used in the published literature (7).

‘Youth’, a term that is not consistently defined in the literature (8). A number of sources classify youth as 15-24 years (9), others as age 12-17 years (10) or age 15-29 years (11). For the purposes of this report, literature that states that the intervention targets “youth”, “adolescents”, “teenagers” or “young people”, and has a study population that includes (but is not necessarily limited to) individuals between the ages of 12-19 years (e.g., 10-19 years, 12-17 years, 15-24 years, <25 years, etc.), will be included in this review. The limitations of this approach are recognized, however to exclude studies that have a sample with an age range that is outside of the teenage years will result in the loss of many potentially valuable studies. While there were a number of studies that assessed youth in the general population, certain youth populations were the subject of increased study, including students in school and certain ethnic minority groups in the United States (US) such as African-American youth.

The review focuses on reportable bacterial STIs (chlamydia, gonorrhea, and syphilis) and other STIs (including viral infections) are not included. A number of terms and abbreviations are used in the literature to refer to the bacterial STIs, however within this report the terms ‘chlamydia’, ‘gonorrhea’, ‘syphilis’ and ‘LGV’ will be used to refer to these bacterial STIs. As noted previously, infectious syphilis is nationally reported, and therefore where this term is used in the literature, it will also be used in this report.

HIV is not specifically included in this review in part for feasibility and because of less pressing need due to the substantial efforts over the past few years at re-orienting HIV prevention and control through the provincial Seek and Treat for the Optimal Prevention of HIV/AIDS program. However, it is recognized that there will be considerable overlap between effective interventions for STI and HIV, particularly for interventions included in this report where changes in sexual behaviour are used as a proxy outcome for incidence of STI/HIV.

Evidence reviews of this nature are affected by publication lag for emerging and highly promising strategies for STI prevention, which have yet to be implemented in large scale studies. This is particularly relevant to emerging social media interventions and technology such as mobile health and online testing. This promising field offers important opportunities to decrease STI rates in both priority communities such as youth, MSM and in the general population, but given the nascent and dynamic nature of this field, it requires more time and will benefit from a rigorous evaluation of their impact at the population level.

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The report is structured by intervention types at micro-, meso- and macro-levels. While this approach provides comprehensive information permitting evaluation on an intervention by intervention basis, it does mask recent shifts within the field of STI prevention and control. The best example of this is the shift over the past decade to develop and implement interventions for delivery through new digital technologies, including through internet and mobile phones/text messaging, for which evidence is only just beginning to accumulate. Where such evidence exists, these have been included within the relevant intervention categories (for example, e-mail based partner notification programs included in the partner notification section). However, these interventions are considered to hold great promise in reaching populations at continued risk of STI and warrant further evaluation.

This evidence review occurred through multiple phases. First, a primary evidence review across all populations was prepared, primarily based on a directed but non-systematic search of the published and grey literature. Based on reviewer feedback, the review was expanded to include additional published and unpublished literature sources. In addition to the primary review, supplemental reviews were prepared specifically regarding youth and MSM populations which encompassed an additional search of the published and grey literature, and consultation with experts. Finally, an expert panel reviewed the primary evidence review, supplemental reviews and additional published and unpublished literature sources were suggested and incorporated. Findings from the supplemental youth and MSM reviews have been integrated with the primary review and have been identified as “Youth supplemental review” and “MSM supplemental review”.

2.1 Primary Evidence Review For the primary review, published and grey literature on the topic of bacterial STI prevention at the micro-, meso- and macro-levels was searched. Common search terms were utilized to search key databases (Medline, EMBASE, CINAHL, EBM Reviews and Health and Psychosocial Instruments - see Table 1). Articles were first scrutinized by title, and if deemed potentially relevant, the abstract was scrutinized. As previously mentioned, as the focus of this review was bacterial STIs, articles with HIV or other non-bacterial STI outcomes were included only if they also had bacterial STI outcomes (e.g., incident cases of bacterial STIs as well as HIV were measured pre- and post-intervention). Articles with outcomes that only focused on HIV or a focus on other non-bacterial STIs were excluded. RCTs, observational studies and other evaluation methodologies including ecological studies were included. Where relevant articles were identified, the reference lists were searched for additional articles.

Table 1 displays the search terms and search strategy. The results of the database searches are presented in Appendix A.

Table 1: Search Terms and Strategy for the Primary Evidence Review (micro-, meso- and macro-level interventions across populations) Category Search terms Combine within and between (Boolean) terms STI term Chlamydia STI term AND Population term AND OR Intervention term AND Prevention Gonorrhea term OR Syphilis OR Lymphogranuloma Venereum

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Category Search terms Combine within and between (Boolean) terms Sexually Transmitted Diseases, Bacterial/ OR Sexually transmitted infections (search as keyword, this is not an indexed term, it is a sub-set of STDs, bacterial). Population Child OR adolescent OR young adult OR aged OR middle term aged or aged, 80 and over OR High-risk population OR vulnerable populations OR vulnerable population OR marginalized population OR Disabled persons OR Inequity OR inequality OR Substance related disorders OR alcoholism Intervention Policy OR Health Policy OR Regulation OR Legislation term OR Strategies OR Programs OR Services OR Family OR Community OR Schools OR Workplaces OR Faith-based OR Interpersonal relations OR Partner OR Individual Prevention Prevention term OR Health promotion OR Harm reduction OR Control

While this general approach was utilized to identify literature at all three levels of intervention, due to the allotted time and large volume of STI prevention literature, the search for micro-level intervention topics was approached differently.

2.1.1 Micro-level Interventions Key documents The US CDC guidelines and the Public Health Agency of Canada (PHAC) guidelines were two key resources utilized in this review (12,13). This section of the review was structured based on the topics in these documents, with the inclusion of additional literature found through the search.

Previously identified systematic reviews Prior to conducting this review, three key systematic reviews on STI prevention and control were identified (14–16). Manhart and Holmes (14) conducted a systematic review of randomized controlled trials (RCTs) of micro-level interventions (in addition to population-level and multilevel interventions) for preventing STIs. This was updated in 2010 by Wetmore, et al. (16) who included all of the RCTs from

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Manhart and Holmes, and were the main focus of this review. These reviews also augment and complement the summary of the guidelines from the US CDC and PHAC.

Search For this section of the report, the databases mentioned above were searched as well as the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials. Articles that were included in the previous reviews by Wetmore, et al. (16) and Manhart and Holmes (14) were not analyzed again but are included as part of the summary. Because RCTs were included in these two reviews, RCTs that were found in this search that were included in the previous reviews were not included. RCTs that were not included in the previous review, as well as any other relevant non-RCTs, were included.

2.1.2 Meso- and Macro-level Interventions The search strategy described above was utilized for the micro-, meso-, and macro-level interventions; however, the search for the meso-level interventions was supplemented by additional searches surrounding specific topics that were felt to be informative (e.g., the legal and policy environment related to patient-delivered partner therapy [PDPT]). Furthermore, in order to expand the review to the topic of alcohol policy and STIs, an expert at the BC Ministry of Health identified published and unpublished literature for review in the area of alcohol policy.

A search for STI Control Strategies was conducted using GoogleTM using the following search terms: sexually, transmitted, diseases, illnesses, STI, STD, guidelines, policies, strategy, and strategies. Selected STI Control Strategies were reviewed in detail, prioritizing strategies from the World Health Organization (WHO), Canadian strategies, and strategies from other high-income countries. Further, in order to specifically search for existing evaluations of jurisdiction-wide control strategies, the following terms, or combination, were searched: strategic, evaluation, impact, review, guidelines, control, strategy, strategies, sexually, transmitted, diseases, illnesses, STI, STD, government, governmental. Results were reviewed until the hits were no longer relevant to the topic.

2.2 Supplemental Evidence Review: Youth Database search Published and grey literature was searched on the topic of bacterial STI prevention among youth at the micro-, meso- and macro-levels. Key databases include Medline, EMBASE, CINAHL and EBM Reviews, using a search strategy that combined a youth term, bacterial STI term, and prevention term (see Table 2). The same approach taken for the primary evidence review was followed for the assessment of evidence for the supplemental evidence review focused on youth (i.e., scrutiny of titles, followed by abstracts and full text, if relevant). Diverse study designs were included, and reference lists of included articles were searched.

Expert consultation Different from the primary evidence review, given the large amount of STI literature and in order to ensure that key published papers on the topic of youth STI prevention were identified, along with very current research and unpublished literature, experts were sought in the area of youth sexual health, and requested their literature suggestions. These articles were reviewed per the process previously outlined.

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Table 2 displays the youth-focused search terms and search strategy. The results of the database searches are presented in Appendix A.

Table 2: Search Terms and Strategy for the Supplemental Evidence Review Focused on Youth Category Search terms Combine within and between terms STI term Chlamydia infections or Chlamydia trachomatis STI term AND Population term OR AND Prevention term Gonorrhea OR Syphilis OR Lymphogranuloma Venereum OR Sexually Transmitted Diseases, Bacterial/ OR Sexually transmitted infections (search as keyword, this is not an indexed term, it is a sub-set of STDs, bacterial). Population Youth OR Adolescent term Prevention Primary prevention term Secondary prevention Tertiary prevention Health promotion Harm reduction

2.3 Supplemental Evidence Review: MSM Database search Key content experts were consulted and a literature search of Pubmed, EMBASE, CINAHL, EBM Reviews, the Cochrane Central Register of Controlled Trials, and Health and Psychosocial Instruments was conducted. Articles were limited to the English language. Three search terms were combined with the Boolean operator AND: an STI term, a prevention and control term, and a term specifying MSM. Appendix A details the search strategy and results for each search engine. References of articles were also reviewed and articles were included that were relevant to preventive interventions for MSM. A summary of reviewed studies is presented in Appendix B.

Expert consultation As with the supplemental evidence review for youth, key content experts were consulted and a literature search of key databases, along with reviewing the reference lists of included articles was conducted.

Table 3 presents the MSM-focused search terms and search strategy. The results of the database searches are presented in Appendix A.

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Table 3: Search Terms and Strategy Category Search terms Combine within and between terms STI term Chlamydia infections or Chlamydia trachomatis STI term AND Population term OR AND Prevention term Gonorrhea OR Syphilis OR Lymphogranuloma Venereum OR Sexually Transmitted Diseases, Bacterial/ OR Sexually transmitted infections (search as keyword, this is not an indexed term, it is a sub-set of STDs, bacterial). Population Homosexuality, male OR men who have sex with men term Prevention Primary prevention term Secondary prevention Tertiary prevention Control OR Communicable Disease Control Health promotion Harm reduction

2.4 Strength of Evidence Nutley, Powell & Davies state that there is no simple answer to the question of what counts as good evidence, as it depends on what we want to know, for what reason and in what contexts the information will be used (17). RCTs are often considered the gold standard among study designs. Although it is common to base hierarchies of evidence on study design, there are a number of challenges inherent in this approach:  Hierarchies based on study design tend to underrate the value of good observational studies.  Insufficient attention is paid to what works, for whom, in what circumstances, and why.  There may be ethical and logistical challenges associated with conducting RCTs for some public health interventions.

The application of the traditional hierarchy of evidence poses challenges particularly for macro-, and in some cases meso-level, STI prevention interventions. RCTs, and even observational cohort studies involving a control group, are often not conducted. Yet the value of the available non-RCT evidence should not be minimized.

The BC Core Programs Steering Committee supports the evidence scale presented in Figure 2. This scale considers both theoretical and empirical studies as well as other factors of relevance in population level health interventions. The scale was used to rate the level of evidence available for the various topics covered in the current document.

The application of the evidence rating scale was guided by the detailed description of components that comprise each evidence rating (e.g., corroboration of literature sources, sound theoretical rationale, operational details, acceptance, etc.). The intervention evidence scale considers theoretical and

Population and Public Health, Ministry of Health Page 9 Core Public Health Functions for BC: Evidence Review Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections empirical grounds, corroboration of findings, as well as other factors of relevance in population-level interventions. This review is directed but non-systematic, and therefore it is possible that some literature sources have been missed (particularly unpublished literature). The evidence has been rated based only on identified studies; therefore there may be literature that is potentially relevant, and would influence the rating scale if included. This might particularly affect the criteria related to ‘corroboration of evidence’.

Figure 2: Evidence Scale Symbol Evidence Rating Definition 0 Limited investigation No relevant effectiveness studies were located and there were no empirical or theoretical grounds suggesting the intervention might potentially impact the outcome; may also indicate that the evidence is inconsistent or contradictory.  Evidence is contra- Evidence is contra-indicative for the use of this strategy to prevent the indicative targeted outcome; consistent null or negative findings in well-controlled evaluation studies.  Warrants further Applied to strategies that appeared theoretically sound or have some research promising evidence for their implementation or outcome, but the operational specifics of the delivery format are not clearly resolved or have been investigated only in small scale or inadequately controlled studies. Policies and programs utilizing these strategies might be considered priority targets for future research funding on innovations to better define service delivery.  Evidence for Published studies reported a sound theoretical rationale, a clearly implementation specified service delivery format, acceptance within service delivery organizations, target population recruitment on a scale sufficient to usefully contribute to population health impacts, and adequate consumer approval measured using indicators such as program retention. The proportion of positive demonstrations of impacts on risk factors, protective factors or outcome behaviours was reported.

Although this rating requires a clear service delivery format, in some cases, not all other criteria are satisfied and in such cases this is indicated in the summaries. Policies and programs utilizing these strategies might be supported for implementation where there are few costs and obvious benefits. In other cases, wider implementation may await rigorously controlled outcome evaluation to better establish benefits.  Evidence for outcome Applied where positive outcomes were consistently published in well effectiveness controlled interventions. Interventions were required to be of sufficient scale to ensure outcomes within the constraints imposed by large-scale population health frameworks. Policies and programs utilizing these strategies might be carefully monitored for their impacts while being supported for wide-scale dissemination.  Evidence for Published reports of impacts where programs were delivered on a large dissemination scale, not by research teams, but rather by government auspice bodies or other service delivery agents. Evidence for dissemination was only sought for strategies demonstrating evidence for outcomes. Policies and programs utilizing these strategies might be accorded some priority for dissemination. Initial Canadian dissemination trials should monitor for impacts. Where possible, cost-effectiveness has been considered for programs using these strategies.

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2.5 Expert Review Panel Once the review was complete, feedback from established experts in the field of STI prevention and control was solicited. This group consisted of Dr. James Blanchard (Professor, Department of Community Health Sciences; Director, Centre for Global Public Health University of Manitoba), Dr. Colin Lee (Associate Medical Officer of Health, Simcoe Muskoka District Health Unit, Barrie Ontario), Dr. Ameeta Singh (Medical Director, AHS-Edmonton STI Clinic; Clinical Professor, Division of Infectious Diseases, University of Alberta), and Dr. Marc Steban (Medical Advisor, STI Unit, Institut National de Santé Publique du Québec ). This group conducted a comprehensive review of the document, identified any critical interventions missed and provided review and input of the evidence ratings.

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3.0 BACKGROUND

3.1 Health Implications The bacterial STIs, gonorrhea, chlamydia and syphilis constitute a significant source of morbidity provincially, nationally and globally, and are reportable infections in BC and Canada. The potential health implications of bacterial STIs (i.e., signs and symptoms, and complications of untreated infection) have common elements across age groups. Complications of chlamydia and gonorrhea can include infertility, PID, ectopic pregnancy, urinary tract infections, and chronic pelvic pain (18). Pregnant females with untreated chlamydia may transmit chlamydia to their babies during childbirth, and this may cause neonatal conjunctivitis and pneumonia (19). Complications of chlamydia in males may include conditions such as epididymoorchitis (19). If untreated, lymphogranuloma venereum (LGV) can cause serious sequelae such as lymphatic obstruction or anogenital ulcerations (20). Among females, complications of untreated gonorrhea may include PID, infertility, ectopic pregnancy, and among males complications of gonorrhea may include epididymitis (21). Further, although rare, gonorrhea can also affect the joints and blood (19). Syphilis, if left untreated, can progress through stages of infections (i.e., primary, secondary, early latent stages and late latent phases), and the late latent phase may lead to complications including damage to the central nervous system, cardiovascular system, eyes, skin and other internal organs (19). In addition, untreated syphilis causes a multitude of symptoms, can extend through several stages and may result in paralysis, numbness, blindness, dementia and death (18).

3.2 Special Considerations for Youth Among youth, the consequences of STIs “can last a lifetime” (22), and STIs in youth raise concerns about reproductive health throughout the reproductive years. A special focus on youth is important for a number of reasons. First, the burden of STIs is disproportionately high among this population (described below). Further, adolescence is often a period of multiple transitions (e.g., biological, cognitive, psychological, social, etc.), and adolescents may be more sensitive to influences related to their social context (8). Guidance may be sought and/or required from multiple and diverse sources, such as parents, peers, schools and other institutions, providing potentially unique considerations for preventive interventions (8). As well, health behaviours that are developed during adolescence can have long-term health implications throughout subsequent life-stages (8). Finally, adolescents are not “little adults” and therefore understanding STI risk and effective prevention may be “relatively unique to this life-stage” (8). DiClemente et al. (23) summarized a complex web of factors related to sexual risk and protective behaviors, and assert that these diverse factors that affect adolescents’ STI-related risk behaviour should influence the design and implementation of risk reduction interventions. These factors include

 Individual characteristics (e.g., personality traits, psychological states, self-efficacy, and individual cognitions)  Relational factors (e.g., length of relationship and age of partner)  Familial characteristics (e.g., parental monitoring and support)  Community factors (e.g., school connectedness, poverty, and condom availability)  Societal factors (e.g., media exposure)

The authors assert that a reliance on individual-level models is not sufficient, and advocate for a broader, ecological perspective that includes interventions at the family-level, school/workplace-level, media-level, etc.

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Similarly, Ethier & Orr (8) in their chapter on prevention and control of STIs among adolescents, highlight the importance of social environmental factors and social context (i.e., “the important people [e.g., peers, parents], places [e.g., neighbourhoods], institutions [e.g., schools, health care organizations], and social processes [e.g., culture and policy] that can influence adolescent behaviour and health.” These factors are key considerations for STI preventive interventions.

A common theme in most of the youth-specific literature is that social and community context, including relationships with parents, peers, teachers and others, are essential components of youth STI prevention. Interventions of this nature should form a key part of any STI control strategy among this population.

3.3 Special Considerations for MSM In addition to HIV, certain STIs remain more prevalent among MSM. The disproportionate burden of STI borne by MSM exists within a larger context of health inequities rooted in a profound legacy of social marginalization and discrimination which persists to this day (24). To effectively deal with STI epidemics in this population, this broader inequity needs to be acknowledged and a more comprehensive approach to STI control is warranted, where both interventions to reduce sexual health inequities at the level of individuals, relationships, communities, and within society are necessary.

Wolitski and Fenton (24) describe sexual health among MSM as much more than just the presence or absence of disease. They state that

It is a holistic concept that includes how MSM approach their sexual behavior and relationships, how they feel about them, and how their physical and mental health are affected by them. Good sexual health is important not only for MSM, but is an essential component of the overall health and well-being of all people.

The focus in this report parallels the thoughts of Wolitski and Fenton (24). Although specific interventions are presented and the evidence for each of these preventive interventions summarized, sexual health for MSM is more than the sum of parts, and to achieve optimal health, we require “a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination, and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected, and fulfilled” (25).

As most of the literature on sexual health and MSM involve HIV to some degree, most of the interventions reviewed have specifically been designed to address HIV but are included here as the behavioural risk factor outcomes and secondary outcomes of STI testing were relevant to this review.

3.4 Review of Epidemiology of STI in BC In general, during the past few decades there have been increased rates of diagnosed chlamydia, gonorrhea, and infectious syphilis. In this section, surveillance trends for these infections are reviewed at a high level, and key findings summarized from other BC studies. Please refer to the most recent Annual Surveillance Report for Sexually Transmitted Infections in BC for more detailed information (26).

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3.4.1 Chlamydia Chlamydia is the most common reportable STI in BC, and rates have been increasing since 1998 among both males and females. In BC, in 2012, the rate of genital chlamydia was 267.9 per 100,000 population. Genital chlamydia infection rates are higher among females compared to males, and the highest rates are among individuals aged 20-24 years followed by individuals aged 15-19 years.

The reasons for the increase in the rates of chlamydia are not entirely understood, but are likely related to a number of factors including increased screening, introduction of more sensitive and acceptable tests, and possibly changes in behaviour. Rates may be higher in females due to greater screening for asymptomatic infection as a result of routine gynaecologic and contraceptive care. Increased chlamydia rates may also be a paradoxical result of improved public health control programs where improved, timelier treatment and partner notification may be affecting the development of immunity to chlamydia infection and increasing susceptibility to reinfection (27).

3.4.2 Gonorrhea Gonorrhea rates have also increased since 1998 in BC, although recently provincial rates appear to be stabilizing, particularly among females (28). In 2012, the rate of genital gonorrhea in BC was 28.1 per 100,000 population, with higher rates of infection among young adult males in their twenties. As with chlamydia, increasing rates are likely due to a number of factors related to screening, changes in tests, and possibly changes in behaviour. A possible explanation for higher rates of gonorrhea infection among men include the fact that gonorrhea infections are more likely to be symptomatic in men (and trigger testing). A greater number of infections among MSM may also explain increasing rates and has been observed in some US regions (29) (30).

3.4.3 Infectious Syphilis Rates of infectious syphilis in BC began increasing in 1997, and while rates decreased in 2009-2010, the provincial rate is dramatically increasing to the highest annual rates observed in past decades (8.1 per 100,000 in 2012) (28). In BC, the resurgence of infectious syphilis initially began among individuals who were street-involved, sex workers or their patrons. Cases peaked among these populations in 2003 and have declined steadily since. Infectious syphilis cases in individuals who acquired infection through heterosexual sex also increased, and have remained relatively stable.

However, currently MSM are disproportionately represented among BC cases of infectious syphilis, accounting for 84% of all cases in 2012, and the number of new infections in this population is continuing to increase (preliminary figures for 2013 are over 470 cases, up from 313 in 2012) representing the highest rate in more than 30 years (31). Infectious syphilis among MSM is concentrated among HIV positive men (66% of all MSM cases in 2012), and the increase in syphilis may in part reflect changes in sexual networks among HIV positive MSM, and synergy between HIV and syphilis transmission.

3.4.4 Other Data from BC Studies Further information regarding self-reported STI diagnosis is available from a regional analysis of the 2005 Canadian Community Health Survey, which found that 5.5% (95% CI 3.5, 7.0) of individuals aged 15-24 years in BC reported ever being diagnosed with a STI, with approximately half of the proportion seen among individuals age 25-49 years (32). This proportion was 6.7% (95% CI 4.2, 9.3) in Metropolitan

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The Adolescent Health Survey (AHS) (33) provides a comprehensive picture of the physical and emotional health of BC youth, including information related to sexual health. In 2008, over 29,000 BC public school students in grades 7-12 completed the survey, with 78% of BC youth reporting never having had sexual intercourse. Among the 22% of male and female youth who reported having sexual intercourse, the most common age for first having sex was 15. Of sexually active students, 47% of males and 55% of females reported having had sexual intercourse with one person in the past year; 13% of males and 5% of females indicated having had sex with six or more people in the past 12 months. Overall, 1% of students reported they had been told by a doctor or nurses that they had an STI; this rate was 4% for sexually active students. The rates of STI among sexually active students was 2% who had one partner in the past year and 22% for those who had six or more sexual partners in the past year.

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4.0 MICRO-LEVEL INTERVENTIONS

The aim of this section is to consider STI interventions that occur between individuals. Limited literature was found that had morbidity as an outcome (e.g., Pelvic Inflammatory Disease [PID], etc.), and no papers were identified that had mortality as an outcome. This is not surprising since mortality due to bacterial STIs is rare, and therefore to detect any measurable difference resulting from interventions would require a very large sample size and be prohibitively expensive and resource intensive. Moreover, because of the rarity of mortality as an outcome, even if one were able to detect a significant difference with a large enough sample, the intervention would not be cost-effective. Appendix B provides a summary of reviewed studies of the micro-level interventions.

4.1. STI/HIV Prevention Counselling and Behavioural Interventions The review conducted by Wetmore, et al. (16) reported that two-thirds of the 27 published RCTs showed significant behavioural effects and effects on STI rates, with 16 showing positive results and relevant to this review (trials reporting on non-bacterial STIs as the only outcomes (34–49) were excluded here but were not excluded in the original review by Wetmore, et al.). Only one study (50) showed an increased risk for STIs in a subgroup analysis. All of the behavioural interventions identified by Wetmore et al. included risk reduction counselling, while more than half also included a skills-building component (e.g., condom use, negotiation, communication skills). These interventions were found to have varied effectiveness in reducing the risk of gonorrhea and/or chlamydia infection (9-83% reduction in risk), probably owing to the fact that the interventions’ outcome measures were not homogeneous across the studies. In general, behavioural interventions delivered in a small group setting were more successful than interventions delivered one-on-one (79% of studies showing significant effects on STI risk versus 42%) and interventions that included skills building were more often effective than those that did not (73% of studies versus 50%). Most of the trials Wetmore, et al. (16) found were conducted in the US (22/27 [81]%).

There were limited studies addressing cost or cost-effectiveness. Given that many studies have components that vary, it would be difficult to estimate cost-effectiveness for the different types of behavioural interventions.

Sixteen RCTs and three additional studies were found that looked at behavioural interventions (see below). Of the 15 RCTs that reported behavioural outcomes, nine studies (51–59) demonstrated a positive effect on behavioural risk modification for participants and five (60–64) showed no significant differences. Of the five RCTs that reported on risk of STI acquisition, four (57,59,65,66) reported decreases in transmission rates and one (60) reported no significant differences. Effect estimates for the positive trials ranged from a reduction of 38% of incident non-viral STIs (59) (OR 0.62, 95% CI 0.40-0.96) to a 63% (65) reduction in incident STIs over 12 months (4.8 versus 13.2%, p < 0.01). Strathdee, et al. (66) reported a 50% reduction in HIV/STI rates and Thurman, et al. (57) reported 52% and 39% reductions (52%, p = 0.04; 39%, p = 0.04, respectively) in gonorrhea and chlamydia infections at 6 months.

Because of the wide range of behavioural intervention types, each specific intervention will be reviewed separately. Some interventions presented in the studies could rightfully fall in more than one category; for ease of comparison these are included in only one category.

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4.1.1 General Behavioural Interventions General behavioural interventions include interventions based on knowledge transfer, risk reduction counselling, skill development, and motivational support, without an emphasis on any particular element. Effect sizes for STI acquisition ranged from a reduction of 20-75%, with a non-significant 11% increase in one trial. Of the trials examined, there were three trials with significant differences between intervention and control groups in health behaviours including increased reported condom use (OR 2-3), decreases in total episodes of vaginal sex, decreases in total number of sex partners, and increases in condom carrying. An additional three trials however, found no significant differences between intervention and control groups in health behaviours. This is discussed in more detail below.

Kamali, et al. (35) looked at behavioural and STI interventions (information giving, education, and communication activities) in rural Uganda and found that the incidence of active syphilis and prevalence of gonorrhea were lower in the behavioural and STI intervention group than in the control group (RR for syphilis: 0.52, 95% CI 0.27 – 0.98; prevalence ratio for gonorrhea: 0.25, 95% CI 0.10-0.64).

Harvey, et al. (61) looked at a health behaviour change model among heterosexual couples but found no significant intervention effect found among couples at 3 months or among women at 6 months.

Chacko, et al. (60) looked at a client-centered motivational behavioural intervention to increase uptake of STI check-ups in young women. They found no significant difference between study groups in seven risk behaviours including: consistent condom use and movement along the stages of change compared to baseline.

Kalichman, et al. (53) conducted a study involving a three-hour behavioural skills building intervention that included educating women about the female condom, motivation of female condom use, and behavioural skills building relevant to the female condom among African American women. Those who received the intervention used the female condom to a greater extent at three months than the control group (for those with one partner, 18.9% in the intervention group versus 16.6% in the health skills comparison; and for those with two or more partners, 4.3% versus 1.4% used the female condom; p < 0.05).

Morrison-Beedy, et al. (55) looked at a sexual risk-reduction intervention, supplemented with post intervention booster sessions for low-income, urban, teenage girls. Those receiving the sexual risk- reduction intervention showed significant decreases in total episodes of vaginal sex at all follow-up visits (mean number of episodes 15.94 at baseline, 10.94 at three months, 10.75 at six months, and 14.54 at 12 months for the intervention versus 14.68 at baseline, 13.13 at three months, 15.64 at six months, and 16.02 at 12 months, respectively for the control group, p < 0.05). A similar effect was seen in the number of unprotected vaginal sex acts at three and 12 months (mean number of episodes for the intervention 6.68 at baseline, 4.47 at three months, and 7.03 at 12 months versus 6.37 at baseline, 5.17 at three months, and 8.09 at 12 months in the non-intervention women). Finally the total number of sex partners at six months was also lower in the intervention arm (0 versus 1, OR 0.536, 95% CI 0.311-0.926; 0 versus 2 or more, OR 0.368, 95% CI (0.191-0.706). Kamb, et al. (36) compared two interactive HIV/STD counselling interventions (enhanced counselling and brief counselling) to didactic prevention messages typical of current practice in heterosexual, HIV- negative patients aged 14 years or older. At three and six month follow-up visits, self-reported condom use was 100% higher in both the enhanced counselling and brief counselling arms compared to those in the didactic messages arm. At 12-month follow-up, there was a 20% absolute reduction of STI incident

Population and Public Health, Ministry of Health Page 17 Core Public Health Functions for BC: Evidence Review Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections infections compared to the didactic messages arm (p = 0.008). During the second six months, rates of infection were 9.1 versus 17.7% (p = 0.008). Over the entire 12 months, rates of infection were 16.8 in the counselling arms versus 26.9% in the didactic messages arm (p = 0.004).

James, et al. (52) looked at an individually-focused counselling and skills training intervention, that included three intervention arms: 1) participants receiving written materials with counseling 2) participants receiving written materials only and 3) a control group in a genitourinary clinic in the United Kingdom (UK). Participants in Arm 1 were significantly more likely than Arms 2 and 3 to report carrying condoms when anticipating sexual intercourse with new partner (71% (Arm 1) versus 49% (Arm 2) versus 63% (Arm 3), p < 0.05). There were no significant effects on levels of knowledge about correct condom use, attitudes to condoms, self-reported condom use or incidence of STI.

Thurman, et al. (57) looked at the Sexual Awareness For Everyone (SAFE) behavioural intervention in African- or Mexican-American adolescents and adults who were had been diagnosed with an STI. They found that adults and teens randomized to the SAFE intervention had significant decreases in high-risk sexual behaviours such as unprotected sex with an untreated partner (adjusted OR 10.53, 95% CI 4.37- 25.42) and in rapid (less than three months) partner turnover (adjusted OR 3.28, 95% CI 1.23-8.76).

Witte, et al. (64) studies an enhanced behavioural intervention based on social cognitive theory and a relationship-oriented ecological perspective but did not find any significant differences in behavioural outcomes between groups.

The one trial that had a behavioural intervention associated with an increased risk of STIs was in the RESPECT-2 Trial (50). They looked at risk reduction counselling with rapid HIV testing among male and female attendees aged 15-39 years of STI clinics in three US cities. They reported a non-significant difference in incident STIs: 19% in the rapid HIV testing group and 17.1% of the standard testing group (RR 1.11, 95% CI 0.96-1.29). In a subgroup analysis, this difference was significant among men (RR 1.35, 95% CI 1.06-1.70).

In a retrospective chart review of non-RCTs, In-iw, et al. (67) reported that those having health education counselling were less likely to have recurrent STIs (adjusted OR 2.24, p = 0.041). In a pre-post intervention study conducted by Ulibarri, et al. (68) the rate of unprotected sex that female Mexican sex workers had with their clients was 2.23 times than the rate at follow-up p=<0.001) following a behavioural intervention promoting condom use.

Summary: Results for trials looking at general behavioural interventions and risk reduction counseling have been mixed. There is some evidence to support implementation of this strategy in limited settings but further studies should be done evaluating the impact of this intervention on a wider scale.

Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence General behavioural   Results of trials looking at general behavioural interventions and interventions have been mixed. There is some risk reduction evidence to support implementation of this counselling strategy in limited settings but further studies should be done evaluating the impact of this intervention on a wider scale.

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4.1.2 Behavioural Interventions Stressing Ethnic Pride and Skill-building Studies involving interventions stressing ethnic pride and skill-building were reviewed. These types of interventions were generally found to be most effective for reducing the risk of acquiring STIs in ethnic minorities (reduction of 40-83%). The first is a behavioural intervention (38) that involved four, four- hour group sessions for African American girls aged 14-18 years. The sessions emphasized ethnic and gender pride, HIV knowledge, communication, condom use skills, and healthy relationships. Here the rate of new chlamydia infections was significantly reduced (OR:0.17; 95% CI, 0.03-0.92, p = 0.04). However, the results did not reach significance for trichomonas (OR: 0.37, 95% CI, 0.09-1.46, p = 0.16) or gonorrhea (OR 0.14, 95% CI, 0.01-3.02, p = 0.21). Although the decreased rates or trichomonas and gonorrhea were not significant there was a trend toward a reduction in risk.

Another study by Wingood, et al. (39) showed a large reduction in infection risk. They looked at a behavioural intervention targeting mostly African American women (85%) emphasizing gender pride, maintaining current and identifying new network members, HIV transmission knowledge, communication and condom use skills, and healthy relationships in women with HIV in Alabama and Georgia. They found that women in the intervention arm reported fewer episodes of unprotected vaginal intercourse (1.8 versus 2.5, p = 0.022), and were less likely to report never using condoms (OR = 0.27, p = 0.008). They also found that women in the intervention group had a lower incidence of chlamydia and gonorrhea (OR = 0.19, p = 0.006).

Other skills building interventions targeting ethnic minorities in the US included studies by Jemmott, et al. (42,43) and Marion, et al (49). In 2005, Jemmott, et al. (42) looked at a skill-based HIV/STI risk- reduction intervention in African American and Latino adolescent girls. Skills-intervention participants reported significantly fewer episodes of unprotected sex at 12 months (mean [Standard Error], 2.27 [0.81] versus 4.04 [0.80], p = 0.03), and fewer sexual partners (mean 0.91 [0.05] versus 1.04 [0.05], p = 0.04). There was also fewer reports of new STIs (chlamydia, gonorrhea, and trichomonas) among the skills-intervention participants (10.5% [2.9] versus 18.2% [2.8%], p = 0.05).

In 2007, Jemmott, et al. (43) looked at a brief HIV/STI risk reduction intervention in African American women. Those in the skill-building interventions reported less unprotected sexual intercourse (Cohen’s d[d] = 0.23, p = 0.02), and a greater proportion of protected sex (d = 0.21, p = 0.05). Intervention participants were also less likely to test positive for an STI than control participants (d = 0.20, p = 0.03). Marion, et al. (49) looked at a nurse practitioner directed, culturally specific, intensive intervention in African American women having past STIs. Here, the probability of an intervention participant having an STI at 15 months was 20% less than a control participant.

Summary: Behavioural interventions stressing ethnic pride and skill-building have been shown to be effective in African- and Latino-American populations.

Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence Behavioural   Behavioural interventions stressing ethnic interventions stressing pride and skill-building have been shown to ethnic pride and skill- be effective in African- and Latino-American building populations.

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4.1.3 Youth-focused Behavioural Interventions (Youth Supplemental Review) Downs et al. (69) conducted a RCT involving a computer-based education initiative, that included a skill- building component, with a six month follow-up period. The intervention arm involved an interactive video that was intended to increase the ability of young females to make fewer risky sexual decisions, and was implemented among a sample of 300 adolescent girls (75% African American) in an urban setting in Pittsburgh. The video included information about negotiation with sexual partners to reduce STI risk, information about STIs, and condom access and use, and was intended to stand-alone (i.e., not requiring a facilitator). The first control arm had the same content but in book form, and the second control arm used brochures. These interventions were delivered at baseline, and had booster sessions at one, three and six months. Adolescents in the intervention arm were significantly less likely to report having been diagnosed with a STI (OR 2.79, p 0.05). However, the STI data was underpowered and objective chlamydia diagnostic data did not detect a significant difference (OR -2.79, p = 0.56). Further, based on self-report, females in the intervention arm were more likely to be abstinent in the first three months following initial exposure to the intervention (OR -2.50, p = 0.027), however this did not continue at the six month point. There were no significant differences in how frequently participants reported using condoms, however between three and six months, intervention arm participants reported significantly fewer condom failures.

Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence Computer-based   Note that the review of this study is intended to education and skill complement the previous discussion of individual- building level behavioural interventions, and not stand on behavioural its own. This particular computer-based program intervention for that combined education and skill-building had youth some positive behavioural outcomes (while others did not differ from traditional print-based materials) as well as lower rates of self-reported STIs. However, objective STI data is uncertain.

4.1.4 MSM-focused Behavioural Interventions (MSM Supplemental Review) The European Centre for Disease Control (ECDC) published a systematic review looking at behavioural interventions in MSM (70). They looked at four RCTs and two controlled before-after studies. One of the RCTs found significant differences in risk behaviours while the other three RCTs and two before-after studies did not. The RCT that did find significant differences was that by Amirkhanian, et al. (71) They looked at an educational session for Russian MSM in which a social network leader attended a group training program which taught the leaders how to effectively communicate HIV prevention messages and personal risk reduction advice to those in their network. They found that there was a significant reduction in unprotected anal intercourse (UAI) at three months (RR 0.62, 95% CI 0.47-0.81), and UAI with multiple partners at 12 months (RR 0.47, 95% CI 0.22-0.99). The other studies were by Harding, et al. (72), Imrie, et al. (73), van Kesteren, et al. (74) (unpublished), Elford, et al. (75), and Flowers, et al. (75). Harding, et al. looked at four group sessions about safer sex led by volunteers at a community- based, volunteer-led organization. Imrie, et al. looked at standard 20 minute sexual risk behaviour counselling plus one day of cognitive behavioural group workshop delivered by trained counsellors, while van Kesteren, et al. looked at a self-help booklet with a face-to-face and telephone motivational interviews delivered by specialist nurses. Elford, et al. looked at HIV risk-reduction education by trained popular opinion leaders and Flowers, et al. looked at gay-specific services with a sexual health

Population and Public Health, Ministry of Health Page 20 Core Public Health Functions for BC: Evidence Review Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections information hotline and bar-based sexual health promotion by trained peers. Only Imrie, et al. reported on STI rates; all of the rest of these studies reported UAI with steady and casual partners with no significant differences found for any of the reported outcomes. Imrie, et al. found that 58% (53/91) of men in the intervention group and 43% (35/81) of men in the control group (adjusted odds ratio 1.84, 95% CI 0.99-3.40) were diagnosed with a new STI.

Herbst, et al. (76) looked at data from 33 studies and 65 citations. In their meta-analysis, they found that overall interventions were associated with a significant decrease in unprotected anal intercourse (OR 0.77, 95% CI 0.65-0.92), reduction in number of sexual partners (OR = 0.85, 95% CI 0.61-0.94), and a significant increase in condom use during anal intercourse (OR 1.61, 95% CI 1.16-2.22). They found several intervention characteristics that were associated with effectiveness:  Theoretical models—based on diffusion of peer norms or relapse prevention  Interpersonal skills training—training MSM on negotiation and communication of safer sex and assertiveness training  More than four delivery methods, including counselling, group discussions, lectures, live demonstrations, and role plays/practice  Exposure complexity, including having more than one session, greater than four hours of total exposure and more than a three week time span.

Johnson, et al. (77) published a Cochrane Review looking at behavioural interventions aimed at reducing the risk of sexual transmission of HIV. They found 44 studies evaluating 58 interventions with a total of 18,585 participants. Forty interventions that compared to minimal or no HIV prevention intervention reduced occasions for UAI by 27% (95% CI 15-37%). The other 18 interventions reduced UAI by 17% when compared with other standard therapies (95% CI 5-27%). They included 26 small group interventions, 21 individual-level interventions, and 11 community-level interventions. Studies found to be most effective were:  Those with a shorter intervention span, suggesting that a clear and focused risk reduction message may be most effective  Those that include efforts to promote personal skills, such as keeping condoms readily available, avoiding excess intoxicants, self-reinforcement for behaviour change, and behavioural self- management  Those that focus on losses rather than gains, i.e., the discussion of the adverse effects of risky sexual behaviour and HIV/STI infection are important

MSM who were classified as “non-gay” were found to be more responsive to behavioural interventions than MSM who identified as “gay”. The authors postulate that this may be due to non-gay MSM having less knowledge about STI and HIV prevention so that their initial exposure may have had greater impact. It is interesting to note that although the reviews by Herbst, et al. (76) and Johnson, et al. (77) both report findings from similar studies, the inclusion of newer studies by Johnson altered their findings that interventions with a shorter intervention span were found to be more effective. Summary: There is evidence to suggest that behavioural interventions are effective in reducing sexual risk behaviours among MSM. However, there is a paucity of data for effectiveness in reducing STI and HIV transmission risk. Interventions that were found to be most effective are those based on theoretical models, interpersonal skills training, with multiple delivery methods, and a focus on the adverse effects of risky sexual behaviour and HIV/STI infections.

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Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence Behavioural   There is evidence to suggest that interventions for behavioural interventions are effective in MSM reducing sexual risk behaviours among MSM. However, there is a paucity of data for effectiveness in reducing STI and HIV transmission risk. Interventions that were found to be most effective are those based on theoretical models, interpersonal skills training, with multiple delivery methods, and a focus on the adverse effects of risky sexual behaviour and HIV/STI infections.

4.1.5 Cognitive-behavioural Interventions Aimed at Preventing STIs Boyer, et al. (40) looked at a cognitive-behavioural intervention on preventing STIs and unintended pregnancies in female marine recruits. They found a higher risk of post-intervention STI or unintended pregnancy among the control group compared to the intervention group (OR 1.41, 95% CI 1.01-1.98). Among participants with no history of STIs or pregnancy but who engaged in risky sexual behaviours, the control group was more likely to acquire an STI (OR 3.24, 95% CI 1.74-6.03).

Champion and Collins (65) looked at cognitive behavioral interventions versus enhanced counselling among abused ethnic minority adolescent women. Although they did not report on any behavioural outcomes, they reported that the cognitive behavioral intervention group had fewer STIs at 0-6 months (0 versus 6.6%), 6-12 months (3.6 versus 7.8%) and 0-12 months (4.8 versus 13.2%) (all p < 0.01).

Peipert, et al. (45) looked at a transtheoretical model-tailored expert system intervention. Intervention group participants were more likely to report use of dual contraceptive methods during follow-up (adjusted hazard ratio, 1.7, 95% CI 1.09-2.66) but there were no differences among rates of STIs. They also reported fewer sexual partners (2.06 versus 4.15, p < 0.001) and fewer acts of unprotected sex (12.3 versus 29.4, p = 0.045). Those receiving the intervention were also less likely to acquire subsequent STIs (50.4% versus 31.9%, p = 0.002).

Scholes, et al. (56) looked at a theory-based tailored minimal self-help intervention in women aged 18- 24 years. The intervention group reported significantly more condom use overall (adjusted OR 1.86, 95% CI 1.32-2.65) and with recent primary partners (OR 1.97, 95% CI 1.37-2.86). They also reported using condoms for a higher proportion of intercourse episodes, carried condoms, discussed condoms with partners, and had higher self-efficacy to use condoms with primary partners.

Summary: There is some evidence that cognitive-behavioural interventions can help reduce the risk of STIs and improve health behaviours.

Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence Cognitive-   There is some evidence that cognitive- behavioural behavioural interventions can help reduce the interventions risk of STIs and improve health behaviours.

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4.1.6 Brief Behavioural Interventions Brief behavioural interventions consist of interventions that are intended to be delivered over a short period of time (less than half an hour). Generally, these interventions have shown to be effective in decreasing the risk of STI acquisition by 40-50% and in reducing risky sexual behaviours.

Patterson, et al. (44) looked at a brief behavioural intervention to promote condom use among Mexican female sex workers. They addressed four main areas: (1) motivations for practicing safer sex; (2) barriers to condom use; (3) techniques for negotiating safer sex with clients; and (4) enhancement of social supports. There were increases in the number and percentage of protected sex acts with clients (p < 0.05). Cumulative STI incidence in the intervention versus control groups was 13.8 versus 24.92 per 100 person-years (p = 0.034); a 40% decline.

Warner, et al. (46) looked at brief STI prevention messages in a video shown at a high volume STI clinic. Patients assigned to the intervention had significantly fewer STIs compared with the control group (hazard ratio, 0.91, 95% CI 0.84-0.99).

Crosby, et al. (47) looked at a brief, clinic-based safer sex program administered by a lay health adviser in young African American men newly diagnosed with an STI. Those receiving the intervention were more likely to report using condoms during last sexual intercourse than the control group (72.4% versus 53.9%, p = 0.008).

Grimley and Hook (48) looked at a brief face-to-face behavioural intervention among African Americans. The intervention consisted of a computer program designed to assess risk behaviours and generate brief, tailored counselling messages. In the intervention group, 32% reported consistent condom use versus 23% in the comparison group (p = 0.03). Moreover, the combined gonorrhea and chlamydia incidence declined to 6% in the intervention group versus 13% in the comparison group (p = 0.04).

Guilamo-Ramos, et al. (51) looked at a parent-based intervention delivered to Latino and African American mothers in a pediatric clinic. They found statistically significant, reduced rates of transitioning to sexual activity and frequency of sexual intercourse at 9-month follow-up in the control versus intervention group (22.2 versus 6.8%, p < 0.05).

Krauss, et al. (54) looked at a brief one pretest assessment session intervention for female partners of male injection drug users aimed at influencing perceptions of partner risk, HIV knowledge, correct condom usage, and self-reported consistent safer sex. Women were randomly assigned to three education modalities. They found that a higher proportion of women who took the pretest assessment reported consistent safer sex (66.7%) versus those who did not (55.6%). The adjusted OR was 0.22 (95% CI 0.06-0.78). Among women who did not take pretests, 76.9% of women who were randomized to an interactive education session reported consistent safer sex versus 33.3% of women who received a non- interactive safer sex pamphlet.

Proude and D’Este (62) looked at the impact of a brief advice intervention initiated in routine consultations in family practice settings for young adults. Self-reported behaviour did not change significantly.

Senn, et al. (63) looked at a motivational brief intervention and provision of condoms. There was no significant difference among the groups in terms of condom use.

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Strathdee, et al. (66) looked at brief combination interventions with four different groups: Group A was defined as didactic injection risk intervention and didactic sexual risk intervention; Group B was defined as an interactive injection risk intervention and didactic sexual risk intervention; Group C was defined as an interactive sexual risk intervention and didactic injection risk intervention; Group D was defined as an interactive injection risk intervention and interactive sexual risk intervention. They found that the adjusted RR for HIV/STI incidence for group B was 0.88 (95% CI 0.40-1.94), for group C, 0.38 (95% CI 0.16-0.89), for group D, 0.37 (95% CI 0.16-0.89), relative to group A. HIV/STI incidence decreased by over 50% in the interactive sex intervention compared to didactic controls.

Trent, et al. (58) looked at a brief behavioural intervention provided at the time of diagnosis of pelvic inflammatory disease (PID) in young adolescents aged 15-21 years. The intervention groups had higher rates of PID at 72-hour follow-up (32 versus 16%) and higher rates partner treatment (71 versus 53%), p = 0.1. There were no differences in medication completion, sexual abstinence or partner notification.

Laughon, et al. (78) conducted a study examining the impact of an intervention consisting of a 10 minute counselling session with intimate partner violence information, danger assessment, safety planning and options and reviewing resources as components. They reported no significant difference in behavioural outcomes.

Gold, et al. (79) looked at youth and young adults aged 16-29 years recruited from a music festival in Melbourne, Australia. Participants completed a survey and provided their mobile phone numbers. They then received SMS messages every two weeks relating to sexual health for four months, and then completed an online follow-up survey. With 40% follow-up, 80% found the SMS entertaining, 68% found it informative, and 73% showed the SMS to others. There was a significant increase in knowledge (p < 0.01) and STI testing (p < 0.05) over time in both males and females.

Jones, et al. (80) examined the influence of a Facebook page that addressed the signs, symptoms, treatment, screening, and prevention of chlamydia infection. Educational components included: reasons adolescents and young adults have unprotected intercourse; signs, symptoms, and complications of chlamydia infection; treatment and testing information with links to area providers; myths and facts about chlamydia contagion; STI prevention and transference, including correct condom application and safe sex practices, and how to talk to one’s partner and parents once a diagnosis occurs. Video links and links to other website (US CDC) were on the page. Participants “friended” on the site were invited to complete a follow-up survey. The authors found a 23% increase in self-reported condom use and a 54% reduction in positive chlamydia cases among 15- to 17-year olds.

Summary: There is evidence that cognitive-behavioural interventions can help reduce the risk of STIs and improve health behaviours. Many of these studies were done in African- and Latino-American populations and young adults.

Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence Brief   There is evidence that brief behavioural behavioural interventions can help reduce the risk of STIs and interventions improve health behaviours. Many of these studies were done in African- and Latino-American populations and young adults.

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4.2 Small Group Sessions Small group sessions generally have been found to be effective in reducing the risk of STIs by 30-40%. Shain, et al.(37) looked at three small-group sessions, lasting three to four hours each, designed to help women recognize personal susceptibility, acquire necessary skills and commit to changing their behavior. This study was conducted with Mexican American and African American females with non- viral STIs. During the first six months, rates of subsequent infection among the intervention group was 11.3% compared to 17.2% in the control group (p = 0.05).

Shain, et al. (34) looked at standard and enhanced support small group interventions that were gender- and culture-specific for Hispanic American and African American women. Adjusted chlamydia and/or gonorrhea infection rates were higher in controls than in the enhanced in year one, year two, and cumulatively (26.8 versus 15.4% (p = 0.004), 23.1 versus 14.8% (p < 0.03), 39.8 versus 23.7% (p < 0.001), respectively) and in the standard arm (26.8 versus 15.7% (p = 0.006), 23.1 versus 14.7% (p = 0.03), 39.8 versus 26.2% (p < 0.008), respectively).

Summary: Small group sessions have been shown to positively affect risk behaviours and reduce the risk of STIs in African- and Latino-American women.

Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence Small group   Small group support sessions have shown to sessions positively affect risk behaviours and reduce the risk of STIs in African- and Latino-American women.

4.3 Peer Education Feldblum, et al. (41) looked at peer education supplemented by individual risk reduction counselling by a clinician compared to condom promotion by peer educators among female sex workers in Madagascar. The OR for chlamydia, gonorrhea, Trichomoniasis and aggregate STI were 0.7 (95% CI, 0.4-1.0), 0.7 (95% CI, 0.5-1.0), 0.8 (95% CI, 0.6-1.2) and 0.7 (95% CI,0.5-0.9), respectively.

Ramesh, et al. (81) looked at the impact of a large-scale HIV prevention program for female sex workers in India. Over 85% of female sex workers reported contact by a peer educator and having visited a project STI clinic. Compared with baseline, there were reductions in high-titre syphilis (adjusted OR 0.53, 95% CI 0.37-0.77, p = 0.001) and chlamydia and/or gonorrhea (adjusted OR 0.72, 95% CI 0.54-0.94, p = 0.02). Reported condom use at last sex increased significantly for repeat clients (adjusted OR 1.98, 95% CI 1.58-2.48, p < 0.001).

Bhattacharjee, et al. (82) looked at the role of membership in peer groups in reducing HIV-related risk and vulnerability among female sex workers. They found that peer group members participating in the integrated biological and behavioural assessments had a lower prevalence of chlamydia and/or gonorrhea (5.2 versus 9.6%, p > 0.001) and of syphilis (8.2% versus 10.3%, p < 0.05) compared to non- members.

Summary: Peer education sessions have been shown to be effective in reducing STI rates and increasing condom usage among female sex workers in developing nations.

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Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence Peer   Peer education sessions have been shown to be education effective in reducing STI rates and increasing condom usage among female sex workers in developing nations.

4.4 Online Interventions Targeting Youth (Youth Supplemental Review) The importance of STI screening and treatment in detecting STIs (including asymptomatic infection) and preventing STI sequelae, is well recognized. However, barriers exist to accessing screening in traditional health care facility settings, including for individuals age 15-24 years (e.g., lack of transportation, cost, and confidentiality issues) (83). Online (internet-based) sexual health interventions are proposed as a potential intervention to promote access for young populations. Online/computer-based interventions may offer advantages over face-to-face interventions, in that access can be anonymous, repeated and utilized at convenient times (84). Such services may include those described in box 2 below.

Box 2: Internet-based sexual health services (85)  Testing services (e.g., online risk assessment questionnaires, lab test requisition forms)  Counseling and education services (e.g., online counseling delivered through chat, forums or emails, as well as referrals to services elsewhere)  Partner notification (e.g., online documents sent “peer-to-peer” either with personal identifiers or anonymously)

Acceptance for online services has been studied by Shoveller et al. (85) who explored the perspectives of sexually active individuals age 15-24 years in the Vancouver, BC area (n = 38 males and 14 females) on online STI/HIV risk assessment, testing, and online sexual health counseling and education. Participants felt that online testing allowed for immediate access to testing, rather than waiting for clinic appointments, which was rated favourably in terms of convenience. The anonymity of the online environment, rather than having to deal with health professionals face-to-face, was also rated favourably by many participants, while a small number expressed concern that an online service may not be as comprehensive as an in-person assessment. The opportunity to receive counseling and education online (e.g., chatting live with a nurse) was rated favourably for potentially prompt responses while maintaining anonymity. Email communication was rated less favourably due to less expediency. Similarly, there were apprehensions expressed about posting questions on a forum that could be read by others, although reading the posts by others was more acceptable. Generally it was important to participants that technologies should be up-to-date (e.g., printing lab requisition forms was viewed unfavourably).

The online interventions identified among youth are categorized in their appropriate intervention category where applicable (e.g., screening outreach). Where the intervention does not fall into a specific category, or it crosses multiple categories, it is presented below.

Guse et al. (86) conducted a systematic review of the impact of “new digital media” (i.e., the internet, text messaging, social networking, etc.) on sexual health knowledge, attitudes and/or behaviours of youth age 13-24 years. With respect to behaviour, three included studies demonstrated a significant impact of new digital media on youth behaviours (e.g., lower likelihood of sex initiation and changes public profiles including the removal of references to sex). Impacts on self-efficacy for condom use were

Population and Public Health, Ministry of Health Page 26 Core Public Health Functions for BC: Evidence Review Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections inconsistent, and a number of other psychosocial variables (e.g., perceived susceptibility, intention to engage in sex) also had inconsistent results. The feedback about the new digital media interventions themselves were generally positive.

A 2010 Cochrane Review by Bailey et al. (84) examined RCTs of interactive computer-based interventions (ICBI) for sexual health promotion. For the purpose of this review, interactive was defined as “packages that require contributions from users (e.g., entering data, making choices) to produce tailored material and feedback that is personally relevant.” This review included participants of any age and therefore was not limited to youth; however young people are identified as a higher risk group and it is acknowledged that the internet is a particularly appropriate way to deliver sexual health promotion to young people in high-income countries because they are often frequent and are confident users of internet technology. A number of studies focused on youth. Results from the meta-analysis showed that ICBI had a statistically significant effect on sexual knowledge and behaviour, however, there was insufficient data to conduct a meta-analysis of biological outcomes. Implications for youth specifically were difficult to ascertain given the broad population inclusion criteria.

Among individuals age 15-24 years in a community in the US Midwest, an STD prevention education intervention was disseminated through Facebook (80). The site was named Caryn Forya to reflect a focus on caring for youth (“caring for ya”), and to resemble the name of an actual Facebook user. The site contained information about the reasons youth have unprotected intercourse, information about chlamydia infection, testing information and links to testing sites, STI prevention information, how to talk to partners and parents if an individual is diagnosed with a STI, etc. Although a number of encouraging findings were reported, concerns about study limitations make interpretation difficult. Based on self-reports by individuals who accessed the Facebook site and were willing to complete the questionnaire, the reported proportion of participants testing positive for chlamydia declined from 26% in 2008 to 14% in 2010, and there was a there was a 23% increase in condom utilization. Yet it appears that of over 800 individuals who “friended” the site, and an unknown number of others who viewed the site but did not “friend” it, only 70 completed a study questionnaire (70% female and 30% male). Summary: Evidence suggests that there is acceptability among youth to utilize online/computer based interventions to access information related to sexual health and to test for STI, which can have a positive impact on behavioural outcomes.

Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence Online interventions   Systematic review/meta-analysis data targeting youth (general suggests that “new digital media/interactive or multiple computer-based” interventions, can have a interventions) positive impact on behavioural outcomes. Determining impact on STI rates would benefit from further research.

Acceptance is high among youth.

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4.5 Screening and Treating Chlamydia to Prevent Pelvic Inflammatory Disease Gottlieb, et al. (87) conducted a systematic review on screening and treating for chlamydia infection to prevent PID. They evaluated four RCTs:

 Scholes, et al. (88) randomly assigned women enrollees in a US health maintenance organization to either receive testing for chlamydia trachomatis or to receive usual care. The women were followed for one year. Sixty-four percent of the 645 women in the screening group were tested for chlamydia; 7% tested positive and were treated. At the end of one year, nine verified cases of PID occurred in the screening group, while 33 occurred in the group receiving usual care for a RR of 0.44 (95% CI, 0.20-0.90).  Ostergaard, et al. (89) compared the effectiveness of a screening program for urogenital chlamydia infections based on home sampling with that of a screening program based on conventional swab sampling performed at a physician’s office (control group) in Denmark. At one year, 51.1% of the 867 women in the intervention group and 58.5% of the women in the control group were followed up. Nine women (2.1%) in the intervention group, and 20 (4.2%) in the control group required treatment for PID (p = 0.045).  Andersen, et al. (90) conducted a study involving 4000 women and 5000 men in a county in Denmark. Participants were offered an opportunity to be tested for chlamydia trachomatis by means of a home sample that was mailed directly back to the laboratory. The control group was the rest of the population living in the county (11,459 women and 9980 men). All were followed for nine years by Danish health registers. At the end of the study period, among women, there were no significant differences between the intervention group and control group in terms of PID, ectopic pregnancy, infertility, IVF treatment, or births. In men, there was no significant difference in epididymitis.  The most methodologically rigorous of these studies, the POPI trial conducted by Oakeshott (91), involved female college students in the United Kingdom. They found that the incidence of PID in screened women was 1.3% compared with 1.9% in controls (RR 0.65, 95% CI 0.34-1.22).

Taken together, although these results demonstrate direct evidence that chlamydia screening and treatment can reduce the risk of PID, the effect of interventions ranges form no significant difference to 45%. This has caused some research to state that the benefits of screening may be overstated (87).

Several other articles were found that looked at various forms of screening with behavioural outcomes. Scholes, et al. (92) examined the use of chart prompts for health care providers to screen for chlamydia. The chart prompt intervention had no significant effect on screening among participants. Furthermore, Walker, et al. (93) looked at computer reminders for chlamydia screening in Australian general practices. In this cluster randomized trial, chlamydia testing increased from 8.3% to 12.2% in the intervention group and from 8.8% to 10.6% in the control group (both p < 0.01). Overall the intervention group had a 27% (OR 1.3, 95% CI 1.1-1.4) greater increase in testing. Short messaging service (SMS) has been looked at in several settings as reminders for youth to get screened, and also as a health promotion tool. Dokkum, et al. (94) evaluated a chlamydia screening reminder program that used email and SMS. This study was conducted in the Netherlands in which a register and internet-based Chlamydia Screening Implementation (CSI) was started in 2008 in several regions among 16-29 year old sexually active youth and young adults. Automated respondent reminders were sent by letter, email and SMS, in sequential order. Forty-two percent of all package requests were made after the reminder letter. There was a

Population and Public Health, Ministry of Health Page 28 Core Public Health Functions for BC: Evidence Review Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections significant increase of invitees returning a sample (10 – 14%) after email/SMS reminders. STI rates were not reported.

Summary: Taken together, although these results demonstrate direct evidence that chlamydia screening and treatment can reduce the risk of PID, the effect of interventions ranges from no significant difference to 45%. Chart and computer prompts and reminders for STI screening may increase testing but more research on this intervention is warranted.

Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence Screening and N/A  RCTs have shown a decreased risk of PID in treating for STI to those screened for chlamydia in studies in prevent PID developed nations, but the benefits of screening may be overstated.

4.5.1 Youth-focused Home-based STI Screening (Youth Supplemental Review) Using screening tests at home, rather than attending a health clinic may address the barriers of privacy, embarrassment, clinic accessibility, time and finances associated with health care visits (95).

Cook et al. (95) conducted a RCT (the Detection Acceptability Intervention for STDs in Youth [DAISY] study) among females age 15-24 years who had a recent STI (chlamydia, gonorrhea or Trichomoniasis) or had certain risk factors including age <20 years, African American, monthly douching, >1 sexual partner in the past year or living in a neighbourhood with higher chlamydia rates (n = 403); 70% of the sample was African American. The intervention group received a home testing kit for testing at 6, 12 and 18 months (serial home screening tests) that the majority received by mail, while a small number picked up the kit from their neighbourhood clinic. The comparison group received a postcard invitation to attend a medical clinic for testing during the same intervals (serial clinical attendance invitations). The home testing group mailed samples directly to the study laboratory. Seventy-one percent of the intervention group returned at least one home test, and 10% of these tests were positive for chlamydia and/or gonorrhea. Although significantly more chlamydia and gonorrhea tests overall were completed per year by the home testing group (1.94 vs. 1.41 test per women-year, p <0.001), and more specifically asymptomatic tests (1.18 vs. 0.7 tests per woman-year, p<0.001), there was no significant difference in the incidence rate of STIs detected (20.4 vs. 24.1 infections per 100 woman-years, p = 0.28) as well as when disaggregated for chlamydia or gonorrhea.

A RCT conducted in Denmark by Østergaard et al. (89) involved a sample of students in highschool. The intervention group (n = 867) were tested for chlamydia by home sampling and the control group (n = 833) were tested in a physician’s office. At one year, 2.9% of the intervention group had a new chlamydia infection, compared to 6.6% of the control group (p = 0.026). Furthermore, significantly fewer women in the intervention group reported being treated for PID compared to the control group (2.1% vs. 4.2%, p = 0.045). Therefore, this study suggests that a home sampling screening strategy for youth is associated with a lower prevalence of chlamydia and less reported PID.

Similarly, Østergaard et al. (96) conducted a cluster RCT to evaluate home testing for chlamydia. Seventeen highschools in Denmark were randomized to a home sampling intervention arm (approximately 188 students), or standard of care testing (i.e., students were offered testing at their doctors or at the local clinic) as a control arm (approximately 1400 students). Significantly higher testing

Population and Public Health, Ministry of Health Page 29 Core Public Health Functions for BC: Evidence Review Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections rates were observed among the intervention group (93.4%) compared with 7.6% in the control group (p < 0.001); a similar effect was seen among males (97.3% vs.1.6%) (p < 0.001). Forty-three women were found to be infected with chlamydia (4.6%) compared with five in the control group (0.6%), representing a significantly higher detection rate in the intervention group (p <0.001). A similar increase in detection rates were seen among the males (11 [2.5%] and 1 [0.4%), (p < 0.05). Note that among those that presented for testing, a significantly higher proportion of control group participants reported symptoms.

Finally, a large population-based RCT in Denmark (97) among individuals age 21-23 years (n = 30,439) also found a significantly higher chlamydia testing rate with home sampling. This study involved three groups: Group 1 was mailed a home sampling kit directly to their residence address; Group 2 was mailed a reply card to their home address that participants could use to order a home sampling kit; and Group 3 had access to usual care (i.e., participants could visit a physician for usual testing). The two intervention groups (Groups 1 and 2) also had the opportunity to receive usual care in a physician’s office. The rate of testing for female participants in Groups 1 and 2 was three to four times higher than the rate in Group 3 (relative risk [RR] 4.1 [959% CI 3.8-4.4] and 3.5 [95% CI 3.2-3.9], respectively). A similar difference was observed among males (RR 19.1 [95% CI 16.0-22.8] and 11.8 [95% CI, 9.8-14.2] in Groups 1 and 2, respectively). Among the women in Groups 1 and 2 that submitted samples, 6.5% and 8.0% tested positive for chlamydia, respectively (p = 0.37); in Group 1, 54.8% of infections were asymptomatic and in Group 2, 50.0% (21/42) were asymptomatic. Among males, 5.9% and 5.7% tested positive for chlamydia in Groups 1 and 2, respectively; 76.3% and 77.3% of infections in Groups 1 and 2 were asymptomatic, respectively. Note that the prevalence of chlamydia was higher among those who sought testing in a physician’s office (both among intervention participants who also sought care in a physician office and for the control group – 12.6%, 9.0% and 10.0% for females, and 27.0%, 19.4% and 19.3% for males, respectively). More women in Group 1 disliked the intervention strategy of having the kit mailed directly to their home, which suggests that the use of a reply card (Group 2) may be preferred among female participants. However, for men, more infections were detected using the direct kit mailing strategy which suggests this might be preferred over sending a card to initiate kit distribution.

Summary: Using screening tests at home rather than attending a health clinic may address some barriers to STI screening that youth experience. Some studies suggest that home STI screening for youth is associated with a higher uptake and detection of STI testing.

Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence Home-based For promoting  Although not all studies have found a differential STI testing for testing and STI impact on STI detection, the bulk of the evidence youth detection suggests that home-based STI testing has advantages over traditional face-to-face/clinic testing in promoting testing uptake among youth, as well as detecting STIs.

4.5.2 MSM-Focused STI Screening (MSM Supplemental Review) Despite the recommendations of selective testing by US and Canadian public health bodies, there is evidence to suggest that such screening will miss many STIs. Van Liere, et al. (98) found that the sensitivity of selective symptom- and sexual history-based testing for anorectal chlamydia and gonorrhea was 52% for homosexual MSM, 40% for bisexual MSM, 43% for bisexual male swingers (defined as heterosexual couples who have sex with other heterosexual couples and their self-identified

Population and Public Health, Ministry of Health Page 30 Core Public Health Functions for BC: Evidence Review Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections heterosexual sex partners), 40% for heterosexual male swingers, and 47% for female swingers. Cachay, et al. (99) also looked at the sensitivity for self-reported exposure to predict anorectal STI. They found the sensitivity for self-reported exposure to be 86-100% in a primary care clinic, but only 12-35% in a high resolution anoscopy clinic. Thus, certainly in high risk patients, screening based on sexual history alone will miss many infections.

Sexton, et al. (100) looked at self-collection testing for pharyngeal and rectal chlamydia and gonorrhea in a sample of patients in a large US city. They randomized patients to either self-sampling first or to have provider-collected testing. Instructions as to how to collect samples at the two sites were given to patients. The Kappa coefficient in comparing provider and patient test results were significant in testing for rectal and pharyngeal gonorrhea (0.76 and 0.79, respectively). In 23 cases the patient identified a positive result when the provider’s result was negative and in only one case did a provider identify a positive result when the patient’s result was negative. One limitation of this study is that the four providers who performed the testing were not physicians (one was a nursing student, one was a medical student, and two were clinical research assistants), although they were all previously trained in STI testing techniques.

Chesson, et al. (101) looked at two different mathematical models for rectal chlamydia and gonorrhea screening to prevent HIV infection in MSM—a base case, in which only benefits to those screened were included; and a dynamic version, in which the population impacts were also looked at. The cost per quality-adjusted life year (QALY) gained through screening MSM for rectal chlamydia and gonorrhea was $16,300 in the static version of the model and the cost per quality adjusted life year gained was less than $0, meaning the measure was cost-saving. Future costs and benefits were discounted at 3% annually to arrive at a present value in 2011 US dollars. It is important to note that this analysis looked only at the costs associated with HIV, as the authors note that those with a recent history of rectal chlamydia and/or gonorrhea are at increased risk of acquiring HIV than MSM with no history of rectal chlamydia or gonorrhea (102–104).

Tuli, et al. (105) looked at three different mathematical models to examine the cost effectiveness of a screening, treatment, and condom provision intervention for MSM inmates at the Los Angeles County Men’s Jail. In the first scenario, in which no sex occurs in the jail, the costs of the screening program over 10 years is estimated to be about $180,000 in March 2000 US dollars, assuming a 3% discount rate. The program would be cost saving in two scenarios: those in which men continue to have sex with other men as before incarceration, and in a scenario in which men continue to have sex with other men but with 20% condom use.

Vriend, et al. (106) used a mathematical model to compare anorectal chlamydia screening among MSM in care at HIV treatment centres. Costs were discounted at 4% per year. They found that once yearly, routine screening in MSM for anorectal chlamydia was cost saving if they did not seek care elsewhere. Costs included in this analysis included referral to an STI clinic for further testing, treatment, counselling, and partner notification. They also added a delay for the start of costs of HIV treatment with combination antiretroviral drug therapy. The authors took into account costs associated with chlamydia treatment, partner notification, and counselling, unlike the study by Chesson, et al. (101). Summary: While one study showed some promise in self-screening, limitations in the control group mean that this strategy cannot yet be recommended and more research is needed. There is evidence for once yearly anorectal screening for chlamydia and gonorrhea among MSM and that selective screening based on history may miss many infections.

Population and Public Health, Ministry of Health Page 31 Core Public Health Functions for BC: Evidence Review Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections

Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence Self-screening N/A  While one study showed some promise in self- screening, limitations in the control group mean that this strategy cannot yet be recommended. More research is needed. Universal anorectal N/A  There is evidence for once yearly universal screening for anorectal screening for chlamydia and gonorrhea chlamydia and among MSM. This recommendation rests on the gonorrhea for MSM fact that three studies have shown this to be cost- savings and the fact that selective screening based on history may miss many infections.

4.6 Abstinence and Reduction of Sexual Partners Abstinence-related literature, while intended to affect individual behaviour, is often implemented in a group setting (e.g., through a group education program). Therefore, the published literature on this topic is presented in the meso-level interventions section. Furthermore, among individuals who are currently being treated for an STI, counselling that encourages abstinence until completion of the entire course of medications is recommended (CDC, 2010). For those starting a mutually monogamous relationship, screening for common STIs before initiation of sex might reduce the risk for future disease transmission.

4.7 Male Condoms Latex condoms use can lower the risk of recurrent PID, chronic pelvic pain or infertility, following an initial episode of PID (107). Ness (107) conducted a cohort study among African American females aged 24 years or younger who had an initial episode of PID. After adjusting for confounders, the RR was 0.5 (95% CI, 0.3-0.9) for recurrent PID, 0.4 (95% CI 0.2-0.9) for infertility, and 0.7 (95% CI, 0.5-1.2) for chronic pelvic pain. Holmes, et al. (108) conducted a systematic review looking at the effectiveness of condoms in preventing bacterial STIs. They found four studies (109–112) addressing condom usage in preventing bacterial STIs. Ahmed, et al. (109) found that in a cohort study in Uganda, consistent condom use reduced the risk of syphilis (OR 0.71, 95% CI 0.53-0.94), and gonorrhea/chlamydia (OR 0.50, 95% CI 0.25- 0.97). Crosby, et al. (110) conducted a study among American youth aged 14-18 years. They found that the RR of acquiring chlamydia gonorrhea or Trichomoniasis among youth with non-consistent condom use compared to those reporting 100% condom use was 1.69 (95% CI, 1.16-2.46). Macaluso, et al. (112) found that among American female patients at STI clinics who were considered to be at high-risk for STIs, consistent and correct use of latex male or female condoms was associated with a statistically significant reduction in combined incidence of gonorrhea, chlamydia or syphilis compared to use of less than 50% (effect size not available). Sánchez, et al. (111) conducted a study among Peruvian female sex workers at two STI clinics. Compared with women who did not report consistent condom use, there was a statistically significant 62% reduction in the risk of acquiring gonorrhea and 26% reduction in the risk of acquiring chlamydia. Taken together, these studies show that, at least for self-reported consistent condom use, there likely is a clinically significant reduction in risk of transmission (30-70%) of bacterial STIs.

Population and Public Health, Ministry of Health Page 32 Core Public Health Functions for BC: Evidence Review Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections

Summary: Male condoms have been shown to be highly effective in preventing the transmission of STIs. Studies have been done in a variety of settings in North America and in developing nations.

Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence Male N/A  Male condoms have been shown to be highly effective condoms in preventing the transmission of STIs. Studies have been done in a variety of settings in North America and in developing nations.

4.8 Female Condoms Female condoms have been shown to be an effective mechanical barrier to viruses and to semen (113). Wetmore, et al. (16) found three trials (114–117) looking at female condoms; in comparison to male condoms, none of the three trials found any significant reduction in the risk of STI acquisition. Follow-up rates were over 75% in these trials, but uptake of the female condom was low. There is also a lack of safety data on anal intercourse. Although female condoms are costly, a female condom is recommended when a male condom cannot be used properly or when male condom use cannot be negotiated.

Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence Female N/A  Although the female condom, as a technology, is condoms effective as a mechanical barrier to viruses and semen, poor uptake of the female condom and cost limit its recommendation for wide dissemination. However, it should be noted that there is a lack of safety data on usage during anal intercourse.

4.9 Cervical Diaphragms The cervical diaphragm is a barrier form of birth control and has been shown to protect against cervical gonorrhea, chlamydia and Trichomoniasis in observational studies (113). The diaphragm has not been shown to be more effective than male condoms. Wetmore, et al. (16) found one study done in Southern Africa (117) that examined the use of a cervical diaphragm, lubricant gel and male condoms in women, compared to male condoms alone; there was no significant difference in the rate of acquisition of chlamydia or gonorrhea.

It should also be noted that the use of the diaphragm and nonoxynol-9 (N-9) spermicide has been associated with an increased risk for urinary tract infections in women (118).

Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence Cervical N/A  The use of diaphragms for STI prevention is as diaphragms effective as male condoms, as a technology. However, poor uptake may limit its recommendation for wide dissemination.

Population and Public Health, Ministry of Health Page 33 Core Public Health Functions for BC: Evidence Review Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections

4.10 Topical Microbicides and Spermicides Wetmore, et al. (16) found 10 trials looking at the spermicide, N-9. Each trial assessed the impact of gonococcal infection. Three early trials (119–121) demonstrated marked reductions in risk of acquiring a gonococcal infection of 74% and 60% among female sex workers in Thailand (119) and Kenya (120) respectively, and 25% among female STI clinic attendees in the US (121). However, two subsequent trials (122,123) demonstrated 50-80% increases in the risk of gonococcal infections. The results of other studies were equivocal, with some demonstrating non-significant increases or decreases in risk of gonococcal or chlamydial infection (124,125). In two of the RCTs that Wetmore, et al. (16) analyzed, they found two studies (120,126) that reported an increased risk of HIV acquisition among N-9 users. Kreiss, et al. (120) also found decreased risk for gonococcal cervicitis (RR 0.4, p < 0.0001) but an increased risk of genital ulcers (RR 3.3, p < 0.001) and vulvitis (RR 3.3, p < 0.0001). For cellulose sulfate gels, two recent trials (127,128) reported trends toward reduced risk of chlamydia and/or gonorrhea acquisition. However, both of these trials were stopped early due to a significant increase in risk of HIV that was noted in one trial (127).

Finally, Obiero, et al. (129) published a Cochrane Review looking at topical microbicides for the prevention of STIs. Their conclusion was that there is some evidence that vaginal tenofovir microbicides may reduce the risk of HIV and HSV-2 infection acquisition in women but that other types of topical microbicides have not shown the same effect on HIV or STI acquisition.

Summary: Topical spermicides have not been shown to be effective in reducing the transmission of STI, and in fact may facilitate the transmission of STI, especially in the case of N-9. Topical tenofovir has shown promise in preventing the transmission of HIV only. More research is needed into whether other microbicides is effective in preventing STI acquisition.

Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence Topical N/A  Topical spermicides have not been shown to be spermicides effective in reducing the transmission of STI, and in fact may facilitate the transmission of STI, especially in the case of N-9. Topical N/A  Topical tenofovir has shown promise in preventing the microbicides transmission of HIV only. More research is needed into whether other microbicides is effective in preventing STI acquisition.

4.11 Male Circumcision Male circumcision has been shown to reduce the risk of HIV and other STIs among heterosexual men. Wetmore, et al. (16) looked at three RCTs involving male circumcision as the intervention and bacterial STI endpoints (130–132). They also looked at one additional trial that assessed the risk of STI among the female partners of the men randomized to circumcision (133). Mixed results were obtained for the acquisition and transmission of trichomonas. One trial in Kenya (130) failed to demonstrate reduced rates of acquisition of STIs. Equivocal results were reported for chlamydia infection (130,131). For syphilis and gonorrhea, none of the trials that reported results showed a protective effect.

Population and Public Health, Ministry of Health Page 34 Core Public Health Functions for BC: Evidence Review Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections

Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence Male N/A  There is evidence to suggest that male circumcision is circumcision effective in preventing transmission of STIs but most studies have been done in developing nations with high HIV prevalence. Limited evidence exists for a policy of recommending male circumcision in developed nations. Accordingly, the US CDC and Canadian guidelines have not recommended for or against this strategy in developed nations.

4.11.1 Male Circumcision for MSM (MSM Supplemental Review) Although African trials have shown success in reducing HIV acquisition among heterosexuals, the data are lacking for MSM (134). Templeton, et al. (135) conducted a systematic review, and found that, as of 2010, no RCTs of circumcision in MSM were in progress. For bacterial STIs, they found six studies looking at the association between circumcision and STIs in MSM. For gonorrhea and chlamydia, two studies found no significant association between circumcision status and urethral gonorrhea or chlamydia (135,136). For syphilis, Templeton, et al. (134) found that only one study (135) reported a significantly reduce risk of incident syphilis (OR 0.36, 95% CI 0.15-0.89). However, four other cross-sectional studies did not find a difference (137–140).

Wiysonge, et al. (2011) completed a Cochrane Review looking at male circumcision for the prevention of homosexual acquisition of HIV in men (141). They found one completed RCT and 21 observational studies. For syphilis outcomes, eight pooled studies showed no significant association between male circumcision and syphilis.

Summary: There is very limited evidence to support male circumcision in the prevention of bacterial STIs. The quality of evidence is low hence randomized trials of MSM in the prevention STIs are warranted.

Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence Male   There is very limited evidence to support male circumcision circumcision in the prevention of bacterial STIs in for MSM MSM. The quality of evidence is low hence randomized trials of MSM in the prevention of both HIV and STIs are warranted.

4.12 Syphilis Chemoprophylaxis for MSM (MSM Supplemental Review) One article was found that looked at chemoprophylaxis for syphilis among gay men. Wilson, et al. (142) conducted a mixed-methods study utilizing an online survey, focus groups, and a mathematical model that simulated a population of Australian gay men to explore the potential impact of introducing chemoprophylaxis for syphilis. They surveyed 2095 gay men; 52.7% of them (95% CI 50.6-54.8%) indicated that they would be very likely or slightly likely to use chemoprophylaxis to reduce their chances of acquiring syphilis. When told it would help reduce infections in the gay community, that number rose to 75.8% (95% CI 74.0-77.6%). Their mathematical model showed that this could reduce the number of syphilis cases by 50% after 12 months of use and 85% after 10 years.

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Intervention Behavioural STI incidence/ Contextual considerations and comments outcomes prevalence Syphilis   One mixed-methods study has shown acceptability among chemoprophylaxis gay men to use chemoprophylaxis to reduce the for MSM transmission of syphilis. Running this through a model shows the potential to reduce syphilis transmission rates by 85% over 10 years. More research is needed to demonstrate that this would be an effective intervention, especially balanced against the risks of antibiotic treatment.

4.13 Partner Management Partner treatment is a cornerstone of STI control. When partners are treated there is a decreased risk of reinfection for the index patient. The exact process by which partners are notified vary from jurisdiction to jurisdiction but may involve health care providers of the index patient and/or the partner, the public health agency where the index patient resides, or some other means. US CDC guidelines note, however, that the data are limited in regards to whether partner notification actually decreases exposure and the prevalence and incidence of STIs in a community. However, evaluations of partner notification and contact tracing have shown that when partners are treated, index patients have a decreased risk of reinfection (see below) (143). Health care providers can ask their infected patients about recent sexual contacts and directly contact the sexual contacts and arrange for testing and treatment. Or, providers can encourage patients to contact their sex partners themselves to notify them of an exposure and to get tested and treated. Wilson, et al. (144) showed that when a health care provider spends time with index patients counselling them on the importance of notifying partners, outcomes on notification are improved (OR 1.8, 95% CI, 1.02-3.0).

The National Collaborating Centre on Infectious Diseases recently published an evidence review on outcomes related to STI partner notification (145)(Box 3).

Box 3: A summary of the types of partner management strategies Patient referral Occurs when the index case and his or her health care provider agree that the index case will inform all of his or her sexual partners and ask them to seek testing and treatment. Taylor (145) found that this is generally less effective than provider referral but is practiced more frequently as it is less resource intensive. This review also found that in the literature, most patients prefer this form of partner notification as it felt to be more private and confidential. Provider referral Occurs when a physician or public health practitioner (usually nurses) contact sexual partners and notify them of possible exposure to an STI. Contact slips Occurs when a clinician provides a slip, containing information about the type of infection, for the index case to give to his or her sexual partners. Email Occurs when the health care provider or public health nurse sends an email to sexual partners of notification the index case advising them of a possible STI exposure. This is done without identifying the index case, although in some cases in which there is only one sexual partner, the identity of the index case may be inferred. Text message Similar to email notification, occurs when the index case or health care provider or public health notification nurse notifies sexual partners of exposure via short message service (SMS). Patient delivered Occurs when partners of infected persons are treated without any medical evaluation, prevention partner therapy or medication counselling by a health care provider. (PDPT)

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Taylor (145) found that rates of reinfection range from 6-24%, and varies according to disease. Most of the studies in this review did not address the effects of partner notification on reinfection rates, aside from those addressing PDPT, reviewed below. Patient referral is generally less effective than provider referral, as reviewed in the section below.

Internet-based partner notification (IPN) strategies were evaluated by Ehlman, et al (146). They looked at internet partners (defined as sex partners for whom syphilis exposure notification was initiated by email because no other locating information existed). From 361 early syphilis patients, they investigated a total of 888 sex partners, of which 381 (43%) were done via IPN. There was an increase of 8% in the overall number of syphilis patients with at least one treated sex partner, and 26% more partners being medically examined and treated if necessary, and 83% more sex partners notified of their STI exposure.

Summary: Studies of partner notification and contact tracing have shown that when partners are treated, index patients have a decreased risk of reinfection. When a health care provider spends time with index patients counselling them on the importance of notifying partners, outcomes on notification are improved. Other methods of partner notification show varying levels of efficacy.

Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence Patient N/A  Patient referral is generally less effective than referral provider referral and PDPT.

Contact slips N/A  More research is warranted into whether contact slips can be used as a partner notification technique.

4.14 Provider referral Low, et al. (147) looked at partner notification at a general practice immediately after diagnosis of an STI. This study involved: 1) trained nurses contacting the index case by telephone follow-up by a health advisor and 2) referral to a specialist health advisor at a genitourinary medicine clinic. A total of 65.3% of participants receiving practice nurse-led partner notification had at least one partner treated compared with 52.9% of those referred to a genitourinary medicine clinic (risk difference 12.4%, 95% CI -1.8% to 26.5%).

Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence Provider N/A  Although provider referral has shown some promise, referral more research is needed before this strategy can be recommended.

4.15 Patient-delivered partner therapy (PDPT) US CDC guidelines recommend that when index patients indicate that their partner is not likely to seek evaluation and treatment, PDPT, which is a form of expedited partner therapy (EPT), may be effective, where legal. US CDC guidelines cite three trials (148–150) and a systematic review (151) that included heterosexual men and women with chlamydia or gonorrhea in making these recommendations. Across all the trials, there were reductions of 20% to 50% in chlamydia and gonorrhea at follow-up, respectively. Six RCTs evaluated PDPT (148–154) with half of the participants demonstrating significant protective effects against reinfection of the index patient. Results showed 1) relapse rate reduction of

Population and Public Health, Ministry of Health Page 37 Core Public Health Functions for BC: Evidence Review Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections trichomonas of 78% for those in the PDPT group (p = 0.01) (152), 2) recurrent or persistent infection of gonorrhea of 3% in the EPT group versus 11% in the non-EPT group (p = 0.01) (148) 3) increased testing for chlamydia and/or gonorrhea in PDPT with booklet-enhanced partner referral) (151); (23.0% versus 14.3% versus 42.7%, p < 0.001).

Two additional RCTs (155,156) were found that looked at PDPT. The review by Trelle, et al. (150) identified only one other article (157)that was not identified by the CDC, Wetmore et al. (16) or by our search. Nuwaha, et al. (157) found that PDPT was more effective than patient-based partner referral in treating their partners. For women, 86 of 103 partners were considered treated (83%) compared with 22% in the patient-based partner referral group (RR 4.55; 95% CI 2.92-7.08). For casual partners, the RR was 1.43 (95% CI, 1.40-2.65). Kerani, et al. (155) found the number of partners treated per original patient was 2.33 in the PDPT arm and 1.52 in the non-PDPT arms. They found that PDPT assignment increased the mean number of partners treated per original patient by 54% (ratio of means 1.54, 95% CI, 1.01-2.34). Further, Schwebke and Desmond (156) randomized women diagnosed with Trichomoniasis to self-referral of partners (PR), PDPT, or public health disease intervention (DIS), locating partners and delivering medication in the field, if needed. They randomized 484 women, and found no significant difference in repeat rates of infection at one and three month follow-up visits when PDPT and DIS were compared to the reference PR. However, when PDPT was compared to DIS or PR/DIS combined, at one month, the PDPT group had lower repeat infection rates (5.8 versus 15% and 5.8 versus 12.5%, respectively).

Stephens, et al. (158) conducted a PDPT program evaluation in San Francisco. They found no significant differences in one-year reinfection risk for chlamydia or gonorrhea (aRR 0.99, 95% CI 0.86-1.14; aRR 0.90, 95% CI 0.72-1.11, respectively). Interestingly, subgroup analysis did not find any significant differences among MSM or men who have sex with women (MSW), or females.

Summary: PDPT has been shown in multiple studies, including randomized controlled trials, particularly in chlamydia and gonorrhea, to reduce reinfection rates. Some caution, however, should be exercised given that gonorrhea is becoming a multi-drug resistant organism and may require parenteral treatment. PDPT should only be implemented for chlamydia in the heterosexual population. For MSM, because there is a higher risk for HIV infection, PDPT may only be cautiously offered, if at all, to ensure appropriate testing and counselling.

Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence PDPT N/A  PDPT has been shown in multiple studies, including randomized controlled trials, particularly in chlamydia and gonorrhea, to reduce reinfection rates Some caution, however, should be exercised given that gonorrhea is becoming a multi-drug resistant organism and may require parenteral treatment. PDPT should only be implemented for chlamydia in the heterosexual population. For MSM, because there is a higher risk for HIV infection, PDPT may only be cautiously offered, if at all, to ensure appropriate testing and counselling.

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4.16 CDC and PHAC: guidelines: Special populations As part of the primary search strategy for this review, evidence identified for special populations is integrated throughout, particularly in the meso- and macro-level interventions sections (e.g., venue- based STI screening and treatment programs for youth and MSM, presumptive treatment, etc.). However, not all special populations were covered and it was felt that there was outstanding information that should be included for all populations. Therefore, information was identified by completing a review of the CDC and PHAC guidelines. This review is presented in the macro-level intervention section of this report. No evaluation of these guidelines was identified.

4.17 CDC and PHAC Guidelines: Interventions In addition to the reviews and primary research presented in the micro-level interventions section of this review, interventions discussed in the CDC and PHAC guidelines are also reviewed in the macro-level intervention section of this report.

4.18 Conclusion Interventions to prevent the transmission of STIs at the individual level, as well as those related to youth and MSM, are numerous. Appendix C lists these interventions and the corresponding evidence rating scale score. Most interventions reviewed have some evidence for implementation. Prevention counselling and behavioural interventions have wide support for effectiveness in the literature. Topical microbicides and spermicides, which studies have largely shown to be ineffective and possibly carry an increased risk of STI transmission, are generally not recommended for use in STI prevention. Male condoms are an effective means of STI prevention. Female condoms and cervical diaphragms have been shown to be effective in preventing STI, but cost and safety concerns with anal intercourse limit recommendations for usage, especially when male condoms are available. However, in instances where the male partner refuses to use a male condom, female condoms and cervical diaphragms may be important to consider. Male circumcision, while recommended in developing nations with high HIV prevalence as a strategy to combat high STI and HIV rates, have had limited study in developed nations with typically lower HIV prevalence. As such, neither the US nor Canadian guidelines recommend for or against it as a strategy for STI control. Partner management remains a cornerstone of STI prevention and control. Various forms of partner management have been identified in the literature, and recommendations of specific strategies will vary according to local laws and regulation, resources, and cost.

New evidence shows promising results related to new electronic technologies (e.g., social media, short- message service, and other internet-enabled interventions) among youth, and reinforces that there is evidence for implementation, particularly for impact on sexual risk behaviour, while impact on STI rates is often uncertain. In addition, new evidence further supports the acceptance of these interventions among youth, and includes a caveat that the most current technology should be utilized as youth may respond unfavourably to outdated modalities. Further, youth may use more than one type of technology and therefore there may be an advantage to offering multiple methods to reach youth. The evidence related to home-based STI screening among youth also supports the utility of this intervention for promoting uptake; and a limited literature base suggests effectiveness for the detection of STIs.

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5.0 MESO-LEVEL INTERVENTIONS

Meso-level interventions occur at the level of communities and organizations, or among groupings such as family, peers or sub-populations (159). This evidence review has identified a number of meso-level interventions, implemented in diverse settings and among a variety of target populations, that have been assessed for impact on sexual behaviour, knowledge, or other outcomes such as screening uptake or the identification of contacts. A lesser number of articles examined STI incidence/prevalence outcomes. Similar to the micro-level intervention section, limited literature was found that had morbidity as an outcome, and no papers were identified that had mortality as an outcome

For this section of the report, a description of the results of selected studies is supplemented by a detailed description of the programs described in the studies (see Appendix D). Many of the programs involve novel and unique elements, specific to the screening venue and/or population that might be of interest to fully understand the intervention. This detail is intended to support a consideration of applicability to the BC context. The studies that examine an impact on STI incidence or prevalence are of particular interest; Appendix B contains a summary of reviewed studies. Appendix C is a summary of evidence ratings for all interventions reviewed and specifies interventions that have and have not been evaluated for direct impact on STI rates.

Application of the Rating Scale The evidence rating scale was applied per the specification identified in the text portion of Figure 2. The limitation of this approach in this directed, non-systematic review, is that often there were a limited number of studies of a given meso-level intervention, which meant that corroboration (a component within the scale) was not present. This meant that corroboration had to be weighed against the strength of the theoretical rationale and other criteria.

A range of programs targeting various populations have been implemented and evaluated, with many examining behavioural outcomes, as well as other outcomes such as promoting uptake of STI testing and identification of contacts. A lesser proportion of the literature examines biological outcomes (i.e. STI rates). Recognizing that self-reported behavioural endpoints are valuable in revealing the impact of diverse interventions on sexual risk behaviour, of clear relevance to the discourse on STI prevention, it is recognized that it may be difficult to control for variables that can affect self-report data (e.g., social desirability biases). In the rating of evidence, where biological endpoints (e.g., STI incidence/prevalence or morbidity) are not assessed, or are assessed to a limited degree, two ratings are offered: evidence of impact on sexual risk behaviours, and evidence of impact on STI burden (unless otherwise indicated).

Distinguishing Level of Intervention As previously mentioned, the distinction between micro-, meso- and macro-levels of interventions is not always clear-cut. In particular, it was found that the distinction between micro- and meso-level interventions was sometimes challenging to delineate. For example, an intervention that is intended to be used at the individual level but is delivered as part of a community-wide program. Therefore, for the purposes of this report, this distinction is determined as follows. Where there is an outcome at the individual level of a study design that looks at specific individual-level outcomes, this is classified as a micro-level intervention. Whereas, where there are interventions that look at outcomes of a specific group or population, or uptake of an intervention by a group or population, this is classified as a meso- level intervention.

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Some studies evaluate a single intervention, while others evaluate a combination of activities (e.g., condom promotion, community mobilization, increased STI services and educational interventions all implemented at once). For the latter, it is difficult to disaggregate the relative contribution of each intervention to the observed outcome; however, more importantly, such interventions suggest the value of a combined approach.

5.1 Social Diffusion A key question in the discourse on STI prevention is how does prevention knowledge and behaviour, once it occurs in at least one person, diffuse through a given population, particularly when the main method of spread is via person-to-person interaction (160). The literature that examines this area has been classified as ‘social diffusion’ interventions for the purpose of this report. Clearly this topic has elements of both micro- and meso-level prevention, however these are distinguished from the individual (one-to-one) level in that while these interventions also aim to influence individual behaviour, they specifically operate at the community-level or level of social networks. Two key interventions in this category are the use of community popular opinion leaders, and peer mentors that operate within their social network.

5.1.1 Community Opinion Leaders “Popular opinion leaders” personally endorse HIV and other STI-risk prevention through messaging to members of the community, with the intent that this changes norms for risk behaviour in the population (161). This intervention is based on the diffusion of innovation theory which suggests that innovations and changes often originate with a subset of the population who are opinion leaders and whose views are adopted by others in the community (161).

The first large, international, multisite study to evaluate a Community Popular Opinion Leader (C-POL) intervention was conducted between 2002-2007 by the National Institute of Mental Health Collaborative HIV/STD Prevention Trial Group (161). Study sites were located in China, India, Peru, Russia and Zimbabwe, and in each site a common protocol was followed, targeting at-risk population(s). Study settings were community venues that were social gathering points for high-risk populations (e.g., school dormitories, wine shops and vendor markets, as well as neighbourhood settings), as the C-POL intervention required informal conversation opportunities through which prevention messages were shared (161). Venues were matched within each country and randomly assigned within matched pairs to the C-POL intervention or a control condition. At both intervention and control sites, STI testing, pre- and post-test counseling, referral for treatment of incident STI cases, provision of educational materials, as well as free or inexpensive condoms, were implemented. Additionally, among the C-POL sites, trained community opinion leaders (identified through ethnographic observations, nominations by venue gatekeepers and other key informants, nominations by other population members, or self-nomination) conveyed STI prevention messages during informal conversations with friends and acquaintances (161). Results among longitudinal cohorts in 20-40 community sites per country (n = 18,000+) over a 2-year period, revealed that there was little effect of the C-POL intervention on STI rates, and mixed results for risk behavior (161).

Chlamydia rates were compared in four countries, HSV-2 in all countries, and Trichomoniasis in three countries. No significant differences in chlamydia incidence were found between intervention and control venues in any of the four countries; nor for Trichomoniasis incidence in women in any of the three countries (161). There were significantly decreased rates of HSV-2 among the intervention venues in China

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(average difference -1.26, p=0.012 across venues) and Russia (-1.50, p = 0.016) but this was not observed in the other three countries (note however that there were a low number of incident cases of HSV-2 in most countries). Comparison of gonorrhea and syphilis between intervention and control venues were not performed due to low incidence rates in all countries (161). The proportion of participants reporting unprotected sex with non-spousal/non-live in partners was lower among intervention sites in China, Russia and Zimbabwe, while in India and Peru there was a greater reduction among comparison sites. Therefore, overall, the C-POL intervention and control program had a similar effect on STI incidence and self-reported unprotected extramarital sex acts (approximately 20% and 30% reduction, respectively) (161). The authors speculated that this may have been because the comparison intervention was itself quite comprehensive (i.e., community-wide education, counseling and testing, risk-assessment interview, access to condoms and treatment in all sites) thus making it difficult to detect a difference.

Another study examined the impact of a community popular opinion leader HIV/STI intervention on stigma in Peru and found that it had a positive impact on reducing STI/HIV-related stigma that, where present, can be a barrier to engaging in HIV testing and treatment (162).

Summary: In a larger, randomized, multi-site study examining the effect of community opinion leaders, no significant differences in chlamydia incidence were found between intervention and control venues in any of the four countries; nor for Trichomoniasis incidence in women in any of the three countries studied. Evidence related to sexual risk behaviour was also not conclusive.

Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence Community opinion   Community opinion leaders, based on leaders diffusion of innovation theory, are postulated to influence community norms. A large, randomized, multi-site study did not demonstrate reduced STI incidence, yet a comprehensive comparison intervention may have made it difficult to detect a difference.

Evidence related to sexual risk behaviour was also not conclusive.

A small study suggests a beneficial effect on reducing HIV/STI-related stigma.

Studies were from China, Russia, India, Peru and Zimbabwe, thus no North American studies were included.

5.1.2 Peer Mentors within a Social Network A peer mentor intervention within a social network approach involves individuals that are trained in STI risk reduction conducting outreach to people within their social network (40,163). This approach is intended to bring about behavior change at the individual level (among individuals within the social network), among the peer mentor, as well as serve as a bridge to change social network level norms and affect a wider range of people (163).

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Davey-Rothwell et al. (163) evaluated the CHAT intervention, focused on the social networks of women at high-risk of STI transmission, living in urban neighborhoods in Baltimore (see Appendix D). The CHAT intervention consisted of five small group sessions and one individual session. Peer mentors were encouraged to talk to their family, friends, and sex partners about a range of risk reduction options. They conducted a randomized clinical trial (RCT) among 169 women, where a standard of care involving voluntary counseling and testing and a single didactic session delivered by a female facilitator, was compared to the peer mentor intervention. The majority of the sample were adult African American heterosexual females, and 95% reported at least one risky sexual behavior in the past 90 days (163). At six-months follow-up, the peer mentor group were significantly less likely to have multiple sex partners (adjusted odds ratio [AOR]: 0.28, 95% CI: 0.13, 0.63); at 12 months, had lower odds of having unprotected sex with a non-main sex partner (AOR: 0.36, 95%CI: 0.16, 0.84); and at 18 months had lower odds of having unprotected anal or vaginal sex, unprotected sex with a main sex partner, and unprotected sex with a non-main sex partner (163). Reductions of any sexual risk behavior were also seen at 18 months. There was also an overall increase in having conversations with friends about HIV/STIs among intervention group participants (AOR: 1.65, 95%CI: 1.04, 2.61) (163).

Intervention Behavioural STI Contextual considerations and outcomes incidence/prevalence comments Peer mentors   The single identified study (RCT) on within a social the topic of a peer mentor network operating within their social network, revealed encouraging reductions of risky sexual behaviour.

However impact on STI rates is uncertain.

The majority of the sample group were African American women.

5.2 Group Education Individual (one-to-one) education has the potential benefits of delivery in a shorter timeframe and being tailored to the individual, while group interventions can allow participants to learn from each other, build group norms and provide opportunities for support (43). Group education may focus on different ways of preventing STIs, including risk-reduction and abstinence.

Systematic reviews conducted by Chin et al. (164) examined the effectiveness of group-based risk- reduction education, and group-based abstinence education, on the prevention of STIs among adolescents as well as other outcomes (164). Comprehensive risk-reduction interventions resulted in a 31% decrease in the prevalence of STIs (risk ratio [RR] = 0.69); as well as a 12% decrease in sexual activity (RR = 0.88), 14% decrease in the number of sexual partners (RR = 0.86); 25% decrease in unprotected sexual activity (RR = 0.75) and a 13% increase in the use of protection (164). With respect to abstinence education, the authors reported difficulty in assessing effectiveness because of too few studies and weak study designs, as well as heterogeneity in the curriculum and implementation (164). There was also found to be differential effects when stratified by study design. However, it is

Population and Public Health, Ministry of Health Page 43 Core Public Health Functions for BC: Evidence Review Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections noteworthy that after completion of the abstinence education review, the authors identify the publication of another key study (described below) that would have contributed to the analysis (164).

Jemmott et al. (165) evaluated the impact of an abstinence-only intervention among African American students in grades six and seven (n = 662) in preventing sexual involvement (165). They conducted an RCT in urban public schools, involving the following arms: eight-hour abstinence-only intervention encouraging abstinence to eliminate the risk of pregnancy and HIV/STI (designed to increase HIV/STI knowledge, behavioral beliefs supporting abstinence including the belief that abstinence can prevent STI/HIV and that abstinence can foster attainment of future goals, and increase skills to negotiate abstinence and resist pressure to have sex); eight-hour safer sex-only intervention targeting increased condom use; eight-hour and twelve-hour comprehensive interventions targeting sexual intercourse and condom use; and an eight-hour health promotion control intervention targeting health issues that are unrelated to sexual behavior (165). The abstinence-only intervention was found to significantly reduce sexual initiation (RR = 0.67, 95% CI: 0.48,0.96); and there were fewer reports of having sex in the previous three months during follow-up compared to control participants. A model was used to estimate the probability of ever having sexual intercourse by the 24-month follow-up, and this was estimated to be 33.5% among the abstinence-only intervention and 48.5% in the health-promotion control group. The safer sex and comprehensive intervention groups did not differ from the control group regarding sexual initiation (165).

Kohler, et al. (166) studied a sample of 1719 adolescents age 15-19 years who were part of the National Survey of Family Growth in the US, and reported their formal sex education that they received before their first sexual intercourse. Compared to adolescents that received no formal sex education, neither abstinence-only education nor comprehensive sex education, significantly reduced the likelihood of engaging in vaginal intercourse, or reported STD diagnoses. For abstinence-only education, the adjusted OR for engaging in vaginal intercourse was 0.8 (95% CI 0.51-1.31, p = 0.40), and for reported STD diagnoses was 1.7 (95% CI 0.57-34.76, p = 0.36). For adolescents that received comprehensive sex education, the adjusted ORs were 0.7 (95% CI 0.49-1.02, p = 0.06), and 1.8 (95% CI 0.67-5.0, p = 0.24), respectively.

Trenhold et al. (167) examined the impact of four abstinence education programs delivered to adolescents. A study sample of 2057 adolescents that had participated in the treatment arm in one of these four programs was compared to those that had been assigned to control arms. The follow-up period was fairly long, at 42-78 months. There were no significant differences between the intervention and control participants regarding abstaining from sex, number of sexual partners, mean age at first sexual intercourse (only among youth who had sex), and having unprotected sex (without a condom). The intervention group did demonstrate a significantly higher level of knowledge related to identification of STIs. One program in particular, called My Choice, My Future! demonstrated consistently improved knowledge of the risks of unprotected sex and STIs.

Jemmott et al. (43) suggest that just providing information is not enough to induce sexual behaviour change; rather, skill-building is important (e.g., condom use skills, condom-use negotiation skills, etc.). They conducted a RCT among African American women (n = 564) in an inner city women’s health clinic called “Sister-to-Sister: The Black Women’s Health Project”. Participants were randomly assigned to one of five arms: 20-minute one-to-one HIV/STD behavioural skill building intervention; 200-minute group HIV/STD behavioural skill building interventions; 20-minute one-to-one HIV/STD information intervention; 200-minute group HIV/STD information intervention; or a 200-minute general health

Population and Public Health, Ministry of Health Page 44 Core Public Health Functions for BC: Evidence Review Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections promotion intervention control group. At baseline, 20.3% tested positive for a STI (T vaginalis 11.3%, chlamydia 8.9%, gonorrhea 2.6%). At 12-months post-intervention, those in the individual or group skill- building interventions were significantly less likely to test positive for a STI (i.e., chlamydia, gonorrhea, or T vaginalis) compared to controls. The skill-building groups also reported significantly less unprotected sex, and a higher proportion of protected sex, than participants in the information groups. With respect to the group intervention specifically, compared to the individual intervention, the only significant difference was that there was a greater increase in the proportion of protected sexual acts at 12-month follow-up.

Summary: Both individual-and group-level skill building interventions have contributed to decreased STI rates and risky sexual behaviour. Studies demonstrating effects of abstinence-based and risk-reduction interventions have shown some positive impacts.

Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence Group   Group education involving risk reduction has been education – risk shown to be effective in impacting STI rates in some, reduction but not all, studies.

This intervention has also been shown to impact sexual risk behaviour outcomes in some, but not all, studies. Group   Group education with an abstinence message has education - revealed a positive impact on sexual initiation in a abstinence recent study. However a meta-analysis suggests that conclusions cannot be drawn and some other studies have not found an impact.

Impact on STI rates is uncertain based on the reviewed literature. Skill building in   As a general principle, in group education, beyond group just providing information, skill-building is an education important element. Both individual-and group-level skill building interventions have contributed to decreased STI rates and risky sexual behaviour.

5.3 Parental Monitoring of Youth (Youth Supplemental Review) Parental monitoring, or youth perceptions of parental monitoring (i.e. that their parents know where they are and who they are with), is inversely associated with sexual risk behaviours and STIs. However, what is lacking is literature that evaluates a parental monitoring intervention on behavioural or biological outcomes.

The association between parental monitoring and STI incidence was explored in an prospective cohort study by Crosby et al. (168) involving a sample of sexually active African American female youth aged 14- 18 years (n = 217). In this study, testing for chlamydia, gonorrhea and trichomonas was performed at baseline, as well as at 6-, 12- and 18-months. Youth that tested positive for a STI at baseline were treated. Note that participants in this study were from the control arm of a HIV prevention program, and received information related to health but unrelated to sexual behaviours. Youth who perceived that

Population and Public Health, Ministry of Health Page 45 Core Public Health Functions for BC: Evidence Review Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections parental monitoring was infrequent at baseline were significantly more likely to acquire chlamydia or Trichomoniasis during the study period, compared to youth who perceived greater levels of monitoring (adjusted odds ratio [AOR] – adjusted for STI at baseline: 1.8 [95% CI 1.01-3.21] and 2.4 [95% CI 1.22- 4.87], respectively). This inverse effect was not observed for gonorrhea. Similarly, over the entire 18- month study period, youth that perceived that parental monitoring was infrequent were twice as likely to test positive for a STI (OR 2.1 [95% CI 1.16-3.74).

Crosby et al. (168) examined the association between mother-daughter communication and other family support-related factors, and STI history among pregnant African American females age 14-20 years. The sample included females that were sexually active in the past two months and lived in an urban area in the southern US. Sexual risk behaviours were assessed through interviews, conducted by young adult African American female interviewers. Perceived family support (i.e. receipt of emotional support, family efforts to help, being able to talk about problems), mother-daughter communication (i.e. having discussions about sex, prevention of HIV/AIDS, and prevention of STIs), and STI history were assessed through a survey. Urine samples were collected for STI testing. At baseline, 51.2% of participants reported a past STI, and of these, 45% reported being treated for a STI within the past six months. With respect to mother-daughter communication, only less frequent communication about the prevention of AIDS was associated with self-reported STIs. Low perceived family support was not found to be significant, nor was less frequent communication about STI prevention or less frequent discussion about sex. The other significant association with reported STIs was not residing with a family member/relative

Stanton et al. (169) conducted a randomized controlled trial (RCT) among pairs of low-income African American parents/guardians and youth aged 12-16 years (n = 237 dyads) who lived in urban public housing developments. This study assessed the impact of parental monitoring on sexual behaviours; however, impact on STIs is not known. Ninety-six percent of parents in the study sample were female, while a mix of male and female youth were included (51% and 49%, respectively). The intervention centered on parental monitoring, described as including both parental supervision and communication with youth, and was termed “Informed Parents and Children Together (ImPACT)”. This 60-90-minute home-based intervention included a parental monitoring video with associated discussion, role-play and other activities, as described in Appendix D. This intervention included but was not limited to sexual risk behavior. The control condition involved a program called “Goal for IT!”, which involved a video that was also produced by the researchers that described planning for education and career training. At 6- months post-intervention, a significantly greater proportion of youths and parents were performing condom skills correctly overall (among youth intervention vs. control, 3.77% vs. 3.00 %, p < 0.001; among parents intervention vs. control, 3.80% vs. 3.33%, p < 0.01). It is also important to note that generally, across various risk behaviours, parents underestimated the actual risk behaviour that their child was engaging in. Further, ImPACT increased the concordance of parent-youth reports of risk and protective behaviours.

Crosby et al. (170) conducted a study among 522 sexually active African American female adolescents to explore the joint influence of living with the mother within a supportive family environment. Data on family support, living arrangements and sexual behaviour, were collected through a self-administered survey and structured interview. Adolescents that lived with their mothers in a perceived supportive family (46% of the sample) were compared with those who did not report this situation (54% of the sample) with respect to various sexual risk behaviours. After adjusting for parent-adolescent communication about sex-related issues, parental monitoring and age, adolescents living with their mothers in a perceived supportive family were significantly less likely to have had any unprotected sex

Population and Public Health, Ministry of Health Page 46 Core Public Health Functions for BC: Evidence Review Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections with a steady partner in the past 30 days (OR 0.52, 95% CI 0.33, 0.82; p=0.005), any unprotected sex with any partner in the past 30 days (OR 0.55, 95% CI 0.35,0.85; p=0.008), and any sex with a non-steady partner in the past six months (OR 0.51, 95% CI 0.30, 0.86; p=0.01); as well as having significantly more frequent communication with sex partner(s) (OR 1.53, 95% CI 1.04, 2.53; p=0.03). No significant differences were noted with respect to higher condom negotiation self-efficacy and more positive attitudes towards condom use (although the latter was subsequently found to be significant when dichotomous variables were converted to continuous variables).

Summary: Parental monitoring, or youth perceptions of parental monitoring is inversely associated with sexual risk behaviours and STIs. Literature is lacking that evaluates a parental monitoring intervention on behavioural or biological outcomes.

Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence Parental   An association between parental monitoring and monitoring of sexual risk behaviours has been consistently youth identified, and in one prospective cohort study, an association between parental monitoring and STI incidence was identified. Literature is lacking that evaluates a parental monitoring intervention.

5.4 Worksite-based Programming for Parents of Youth (Youth Supplemental Review) Talking Parents, Healthy Teens is a parenting program, delivered in the workplace, that is intended to help parents address sexual health with their adolescent children (grades six to 10) (171,172). This program, which involved eight weekly one-hour sessions, was evaluated through a RCT conducted by Schuster et al. (172) in 13 worksites in California (n = 569 parent participants as well as their children n = 683), with follow-up surveys at one week, three months and nine months after the program. At baseline, 4% of parents reviewed how to use a condom with their adolescent child, however at nine months, a significantly higher proportion of parents in the intervention group had reviewed how to use a condom compared with parents in the control group (29% vs. 5%, 95% CI for the difference 13%-36%, p <0.001). Parents and adolescents in the intervention group reported a significantly greater ability to communicate with each other about sex, and reported more openness in their communication about sex, compared to control dyads. As well, intervention parents were more likely to discuss more new sexual topics with their adolescent children.

Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence Worksite based   A single identified study examining a workplace- programming for based program for parents of adolescent children, parents of youth and demonstrated positive impact on parent-child communication about sexual behaviour, but it is uncertain how this impacts subsequent adolescent sexual behaviour and STI rates.

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5.5 Multi-component Programs Targeting Children/Younger Youth (Youth Supplemental Review) Coyle et al. (173) evaluated a program specifically targeted to children in middle school (grades six through eight), based on the rationale that it is important that younger youth be targeted with prevention messages before they begin to have sexual intercourse with the aim of effecting delayed intercourse or avoidance of unprotected intercourse. Draw the Line/Respect the Line is school-based HIV/STD and pregnancy prevention program, aimed at reducing the number of students who initiate or have sexual intercourse, and to increase condom use (see Appendix D). A cluster RCT was conducted involving 19 middle schools in California, with a sample of 2829 students in grade six over a period of three years (60% Hispanic). Ten intervention schools received the Draw the Line program, while the control condition had usual classroom activities related to HIV/STD and pregnancy prevention that were determined by the school. The study revealed significant impact on sexual risk behaviour specifically for males. From grade six through grade nine, boys in the intervention arm were significantly less likely to report ever having sex compared to boys from the control schools (p<0.01). Further, at each follow-up measurement time (i.e., grades seven, eight and nine), significantly fewer boys in the intervention schools reported having sex compared to boys in the control arm (p < 0.04, p < 0.01 and p < 0.02, respectively). There were no significant effects regarding reports of having sex among girls. With respect to having sexual intercourse in the past 12 months, while there was not a significant difference for either males or females overall, when each follow-up assessment period was viewed separately (i.e., at the seventh, eighth and ninth grades), males were significantly less likely to report having had sex in the 12 months before the survey compared to the control arm. There were no significant differences in condom use for either males or females. With respect to knowledge there were a number of significant differences, including that males in the intervention arm had stronger sexual limits (p = 0.004), higher HIV and condom knowledge (p < 0.001), more positive attitudes towards not having sex (p = 0.003), fewer situations where sexual behaviours might occur (p< 0.001), and perceived fewer peer norms supporting sex (p = 0.001). Among females, intervention arm girls had significantly higher HIV and condom knowledge (p < 0.05) and fewer incidents of unwanted sexual advances (p = 0.02).

5.5.1 Multi-component Approach Involving Children, Parents and Teachers (Youth Supplemental Review) Hawkins et al. (174) conducted a non-randomized controlled trial examining an intervention that combined teacher training, parent education, and social competence training. This intervention was somewhat unique in its duration; it was implemented among children in elementary school and participants were followed for six years to determine the impact on adolescent health risk behaviours at age 18 years, including sexual risk behaviours (n = 598). The intervention consisted of five days of in- service training for teachers of grades one through six; parenting classes for parents of children in grades one through three and five through six; and social competence/skill-building training for children in grades one through six (see a description of the intervention in Appendix D). A ‘late intervention’ arm involved the same program, but it was implemented in grades five and six only; and the control arm received no specific intervention. Participants were drawn from schools in high-crime areas in Washington. Significantly fewer participants in the intervention group reported having sexual intercourse (72.1% vs. 83.0%, p = 0.02) and multiple sex partners (49.7% vs. 61.5%, p = 0.04) at age 18 years, compared to the control group. Numerous other health risk behaviours were also significantly lower among intervention students (e.g., violence and heavy drinking) while others showed no difference (ie. drug use) and protective behaviours were significantly higher (e.g., commitment and attachment to school) at age 18 years. Further, a dose effect was seen for many of the outcomes (i.e.

Population and Public Health, Ministry of Health Page 48 Core Public Health Functions for BC: Evidence Review Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections the full intervention group demonstrated the most positive outcomes, followed by the late intervention group, followed by the control group).

Lonczak et al. (175) examined the long-term impact of the program described previously by Hawkins et al. (174), termed the Seattle Social Development Project, over a longer period to age 21 years. With respect to STI diagnosis, although a significant difference was not found overall, after controlling for poverty there was a significant difference among African Americans in the intervention versus control arms: 7% vs. 34% reported being diagnosed with a STI in their lifetime (OR 0.11, p < 0.01) or a difference of 27%. For non-African Americans, this difference was 3%. Participants in the full intervention group had their first sexual experience significantly later than individuals in the control arm (15.8 years vs. 16.3 years, p <0.05), reported significantly fewer sexual partners in their lifetime (p < 0.05). While there was no significant difference in reported condom use during first intercourse, individuals in the full intervention group were significantly more likely to report condom use during last intercourse (among African Americans, 79% vs. 36%, and among non-African Americans, 56% vs. 47%).

5.5.2 Multi-component Approach Involving Youth and Community Service (Youth Supplemental Review) O’Donnell et al. (176) conducted a RCT to evaluate the Reach for Health Community Service intervention among children/younger youth in middle school, aimed at helping youth gain the knowledge, attitudes and skills to avoid high-risk behaviours and make healthy choices. This program involved two components: community field placements (e.g., service provision in nursing homes, senior centers, daycare centers, etc). followed by reflection including sharing their experiences in their class and reinforcing what they contributed to their community and why their community counted on them to stay healthy and succeed; and health curriculum delivered in the classroom (e.g., risks related to early and unprotected sex, violence and substance abuse, as well as healthy development and sexuality), with interactive classroom activities to help students make healthy choices, communicate their needs and avoid risk behaviours. Reflection is an integral part of the community services component. The target population was African American and Latino youth, low socio-economic status, in a middle school; classrooms were randomly assigned to the intervention and control arms. All students received a classroom health curriculum, while the intervention students received the Reach for Health Community Service intervention during grades seven and eight. Follow-up evaluation was conducted during grade 10. Individuals in the intervention arm were significantly less likely to have initiated sex at the time of follow-up compared to controls; this was the case after two years of the intervention (OR 0.32, 95% CI 0.14-0.73) and one year of the intervention (OR 0.49, 95% CI 0.25-0.99), as well as less likely to report recent sex (OR 0.39, 95% CI 0.20-0.76 after two years, and OR 0.48, 95% CI 0.24-0.96 after one year).

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Intervention Behavioural STI incidence/ Contextual considerations and comments outcomes prevalence Multi-component   Interventions delivered to target populations of approaches children/young youth, varied in their components and targeting scope (e.g., involvement of parents and teachers, children/younger community service elements). However, the studies in youth this area all suggest that the period of childhood/early adolescence is an important time for STI prevention interventions and can reduce sexual risk behaviour over the long-term. These studies also highlight the importance of the social and community context for youth.

Impact on STI incidence/prevalence was only assessed in one study, and a significant difference was only found among African American individuals. Further study is warranted.

Multi-component Approach Targeting Youth in High School (Youth Supplemental Review) Coyle et al. (177) conducted a RCT to evaluate a program called Safer Choices in 20 highschools in California and Texas (n = 3869 grade nine students), with a 31-month follow-up period. Safer Choices is a school-based HIV/STI and pregnancy prevention program that is implemented over a two year period in grades nine and 10. The aim is to reduce the number of students that begin to have sexual intercourse during highschool and in doing so reduce student engagement in unprotected intercourse. As well, to increase condom use among students who are sexually active. The program involves five components (see Appendix D), and engage youth, teachers, parents and members of the wider community. The results of this evaluation revealed that although there was no significant difference in the incidence of sexual initiation between intervention and comparison arms, sexually experienced students reported a significantly lower frequency of having intercourse without a condom during the three months preceding the survey (OR 0.63, p = 0.05), and fewer partners with whom they had sexual intercourse without using a condom in the prior three months (OR 0.73, p = 0.02). Further, intervention students reported significantly more positive attitudes about condoms (p = 0.01), greater condom use self- efficacy (p = 0.00), fewer barriers to condom use (p = 0.01) and higher levels of self-perceived risk for HIV and other STIs (p = 0.02 and p = 0.04, respectively), while there were no significant differences in self-efficacy to refuse sex and to communicate with a partner about sexual limits.

Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence Multi-component   Similar to the multi-component school- approach targeting based interventions delivered to younger youth in highschool students, along with their teachers and parents, a multi-component intervention among highschool students had numerous positive impacts on sexual risk behaviour. In this single study however, the intervention did not seem to impact sexual initiation, but did decrease sexual risk behaviours.

Impact on STI incidence/prevalence is uncertain.

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5.6 Peer Education (Youth Supplemental Review) The Youth United Through Health Education (YUTHE) is a peer-led outreach program that aims to increase awareness and improve STI screening among youth (target population age 12-22 years) (178). YUTHE is a collaboration between the San Francisco Department of Public Health and the Department of Pediatrics at the University of California, San Francisco, consisting of a 15-minute standardized protocol that consisted of: a recruitment script; STI/HIV risk assessment; STI/HIV prevention messages, including information on non-invasive STI screening; condom distribution, if desired; and information on ‘youth- friendly’ STI services. Ozer et al. (178) evaluated the program among 1487 sexually experienced youth that lived in two communities in San Francisco that historically have high youth STI rates (one YUTHE intervention community where 46.5% reported participating in the YUTHE program, and one comparison community matched by ethnicity and socioeconomic status); 81% of participants were African American (178). In the intervention community, YUTHE was implemented in popular areas where youth congregated (e.g., schools, recreation centers, public housing facilities, after-school programs, etc.). Peer educations wore distinctive clothing with the YUTHE logo. Among participants in the intervention compared to the comparison community, there was not a significant difference in the intention to get an STI test in the next six months (OR 1.19, 95% CI 0.95-1.51), or having sought STI testing in the prior year (OR 1.06, 95% CI 0.84-1.34). However, participants in the YUTHE outreach community were significantly more likely to know that STI infections could be asymptomatic, know about urine-based STI screening tests; perceive themselves to be at risk for acquiring a STI; and worried about acquiring a STI. As well, participants that reported having contact with the YUTHE outreach staff, were more likely to report receiving a STI test in the previous year (OR 2.21, 95% CI 1.62-3.01) as well as the previous six months (OR 2.12, 95% CI 1.11-4.03 for a single contact with the YUTHE program, and OR 2.78, 95% CI 1.81-4.26 for multiple contacts) compared to those who reported having no contact with the program.

5.6.1 Peer Education Combined with Outreach Screening (Youth Supplemental Review) The focus of the article by Moss et al. (179) is the YUTHE initiative of the San Francisco Department of Public Health, described previously. This initiative was further expanded to include STI screening, and delivered in partnership with a local faith-based organization affiliated with the Baptist Church with a longstanding history of helping the low-income residents of the target neighbourhoods. In addition to peer education described previously, the program was expanded to include field-based STI screening for youth (<25 years). This intervention was implemented in low-income neighbourhoods with high youth STI rates, and predominantly African American populations. A partnership was established with a faith- based organization that provided staff to 1) help reach local youth, 2) secure local venues where education and screening were conducted (e.g., YMCA, eateries, employment program, after-school program, etc.), and 3) organize six youth rallies (including food and entertainment) to raise STI awareness and offered STI screening and education. As well, outreach workers set up along four geographic routes to cover separate gang turf areas. Participants provided urine samples. The YUTHE staff notified individuals if they tested positive, provided therapy, and offered treatment packs for partner therapy. Four hundred and seventy individuals were screened, 85% of whom were African American and under 25 years of age. Thirty five percent of screened individuals came from other neighbourhoods, suggesting success in outreach staff’s encouragement to bring friends and sexual partners to screening sessions. Four percent of those screened tested positive for chlamydia or gonorrhea and received treatment (delivered in the field). Twenty-six percent took treatment for their sexual partners. The cost per person educated, counseled and screened for chlamydia and gonorrhea is approximately $320, and cost per new case detected is $7900.

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Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence Peer education alone   Peer education alone demonstrated and combined with improvements in STI-related knowledge and outreach screening for undergoing STI testing. This was expanded to youth in partnership include outreach screening, in partnership with with a faith-based a faith-based organization, which demonstrated organization further positive impact in engaging youth in STI screening

Impact on STI incidence/prevalence warrants further research.

5.7 Clinic-based Interventions A number of strategies that are implemented in clinic settings have been studied in the literature.

5.7.1 Disease Intervention Specialists in Clinic Settings Taylor et al. (180) examined the impact of Disease Intervention Specialists (DIS) on partner elicitation as part of contact tracing. DIS are a defined job category in the US with specialized expertise in STI-related outreach, counseling, contact tracing, etc. (181) (190)(189)(188)(174). DIS were placed in three clinics with providers that reported the highest number of syphilis cases outside of public STI clinics (these clinics were all HIV clinics). DIS were placed in these clinics for one-half day per week, or on an on-call basis, to conduct partner elicitation interviews with patients and to provide penicillin. A number of positive outcomes were noted during the period of DIS placement, including a significantly greater proportion of patients participating in the partner elicitation interview (94% vs. 81%); increased number of partners located (1.1 vs. 0.6); increase in the average number of exposed or infected partners that were brought to treatment (0.6 vs. 0.3); and there was a 9 day decrease in the time to interview (18 days vs. 9 days) (180).

Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence Disease Intervention  To support  Limited study suggests a positive impact on Specialists (DIS) partner partner elicitation. within a clinic setting elicitation Research on the impact of DIS on STI rates is needed (note that there is also a study of a combined DIS and electronic technologies intervention that demonstrates promising results).

5.7.2 Electronic Technologies in the Clinic Setting Zou et al. (182) conducted a systematic review to examine clinic-based strategies for increasing the screening and detection of bacterial STIs among MSM. The results of this review revealed a number of strategies for increasing screening, many of which involved the application of electronic technologies. Among four studies that demonstrated significant increases in screening rates for gonorrhea and chlamydia, strategies included the use of a computer alert on an electronic medical record, and short text messaging reminders for repeat STI screening. Four studies revealed increases in syphilis testing,

Population and Public Health, Ministry of Health Page 52 Core Public Health Functions for BC: Evidence Review Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections and strategies included the use of a computer alert on an electronic medical record; and an electronic medical record system to enhance syphilis retesting after syphilis treatment of MSM (182). These studies are examined in greater detail below.

Lister et al. (183) conducted a study at a sexual health clinic in Australia, and evaluated the dual intervention of implementing screening guidelines for MSM, with a computer reminder/alert. This initiative was undertaken due to awareness that screening MSM for rectal gonorrhea and chlamydia was not being adequately implemented. At the one year point after introducing the guidelines and electronic reminder system, there was a significant increase in rectal chlamydia testing (28% to 65%, p <0.001) and significant reduction in pharyngeal chlamydia (65% to 28%, p <0.001) and gonorrhea testing (83% to 76%, p = 0.015). There was no difference in the proportion of positive tests at either the rectal or pharyngeal sites, before vs. after implementation (7% vs. 7%).

Hotton et al. (184) found that after implementing electronic medical records, and enhanced follow-up from DIS, timely follow up of MSM after diagnosis with early syphilis (i.e., return clinic visit within 6 months of the initial syphilis diagnosis) increased from 53% to 76%. Further, rescreening at the follow- up visit increased from 64% to 81%, and among patients that had timely follow-up, 70% were rescreened.

Bourne et al. (185) examined how the use of a short message service (SMS) reminder system affected HIV/STI re-testing rates among MSM in a sexual health clinic in Australia. The study population was HIV- negative males who had had previous HIV/STI tests and received a SMS reminder about re-testing (recommended to occur 3-6 monthly for individuals considered high-risk based on self-reported sexual behaviour). The intervention group (SMS reminder) was compared to a control group during the same period, as well as retrospectively to the pre-SMS reminder period. It was found that in the intervention (SMS) group, 64% were re-tested within 9 months; this was significantly higher than the control group (30%, p < 0.001) and the pre-SMS group (31%, p <0.001). After controlling for baseline differences between the groups, the SMS group was 4.4 times more likely to undergo retesting (95% CI 3.5-5.5) compared to the comparison group, and 3.1 times more likely to be re-tested compared to the pre-SMS group (95% CI 2.5-3.8).

Bissessor et al. (186) examined the impact of a computer alert that reminded health care providers to test MSM that were at higher risk for syphilis, on syphilis testing. There was a significant increase in the proportion of high-risk MSM who were tested for syphilis (from 77% to 89%, p > 0.001). There was also an increase in the percentage of men diagnosed with asymptomatic syphilis (16% to 53%, p = 0.001).

Summary: Among four studies that demonstrated significant increases in screening rates for gonorrhea and chlamydia, strategies included the use of a computer alert on an electronic medical record, and short text messaging reminders for repeat STI screening. Four studies revealed increases in syphilis testing, and strategies included the use of a computer alert on an electronic medical record; and an electronic medical record system to enhance syphilis retesting after syphilis treatment of MSM.

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Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence Electronic  To support  The evidence is supportive of electronic technologies in testing STI technologies, sometimes in conjunction with STI clinic screening, another intervention (such as the introduction of settings diagnosis, re- guidelines, or intensive DIS follow-up) being testing effective in improving various outcomes related to STI diagnosis and follow-up care (e.g., STI screening, timely follow-up post-diagnosis, rescreening).

Impact on STI rates over time is uncertain.

Studies are from high-income countries and utilize technology that is of considerable interest in a North American setting, such as electronic medical records and SMS.

5.7.3 Syphilis Testing during HIV Care in the Clinic Setting The systematic review by Zou et al. (182), discussed previously, also found that regular serological screening for syphilis during routine HIV care, and syphilis serology included with blood tests performed as part of HIV monitoring, were effective in increasing syphilis testing among MSM. Looking at the original studies, Bissessor et al. (187) examined the effect of including routine syphilis testing with every blood test performed as part of HIV monitoring, on the detection of early syphilis. This intervention was compared to the traditional policy in the clinic of annual syphilis screening. A significantly higher proportion of HIV-positive asymptomatic MSM were diagnosed with early syphilis in the 18 months following the intervention compared to the 18 months before the intervention (85% vs. 21%, p = 0.006), and there was a significantly shorter median time between the midpoint since last syphilis serology and the diagnosis of syphilis after the intervention (45 days [range 23-235 days] vs. 107 days [range 9-362 days]).

Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence Syphilis testing  To support  Including routine syphilis testing with every blood during routine HIV syphilis test that is collected as part of HIV monitoring monitoring detection resulted in a significant increase in early syphilis detection, among HIV-positive MSM in an Australian study.

Impact on STI rates is uncertain.

5.7.4 Clinic Guidelines on STI Screening The systematic review by Zou et al. (182), discussed previously, also found that the introduction of clinic guidelines on STI screening was effective in increasing screening rates for gonorrhea and chlamydia among MSM. These are discussed later in this report in the section on evaluating STI control strategies/guidelines.

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5.7.5 Male clinics Sharma et al. (188) suggest that men may not feel comfortable seeking STI and other sexual health services from family planning clinics, particularly young men, and that men need clinic services and staff to provide confidential and non-judgmental care. The authors evaluated a men’s health clinic that was established in a government health centre in India. At six months, there was a significant increase in STI knowledge, and increase in the high-risk sexual activity score (which is presented as a positive change but is difficult to interpret as the criteria for the score could not be accessed in the source journal).

Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence Male clinics   Male health clinics are suggested as an important way to promote male access to STI care. The limited study identified on this topic reported positive impact on STI knowledge and suggests positive impacts on sexual risk behaviour; impact on STI detection and STI rates was not reported.

The single study on this topic is from India.

5.7.6 Mobile Clinics The previous clinic-based interventions discussed in this section have all described interventions offered in a standing facility. At the intersection of clinic-based initiatives and outreach is the mobile clinic. Kahn et al. (189) evaluated the STI yield, and community acceptance, of a mobile clinic that set up at various sites throughout a Louisiana area in neighbourhoods known to have high STI incidence. Screening sites included stores, bars, restaurants, churches, vacant lots, and public housing facilities. The clinic offered STI screening and treatment, and in order to avoid stigmatizing clients, it was advertised as the “Community Health Outreach Project” in which various other free health promotion activities took place (e.g., blood pressure testing and pregnancy testing). Individuals that tested positive for chlamydia, gonorrhea or syphilis were notified of their results by telephone or home visits and referred to the local health department for treatment. They were also instructed to refer their sexual partners to the local health department for testing and treatment. During a three-year period, the rate of syphilis, chlamydia and gonorrhea detection was 1.2%, 8.3% and 4.9%, respectively. Ninety-seven percent of respondents to a survey assessing acceptability felt that neighborhood STI testing was a “good” or “very good” idea.

Intervention Behavioural outcomes STI Contextual considerations and comments incidence/prevalence Mobile  To support screening  A single US study revealed mobile clinics as a clinics uptake feasible and acceptable way to reach community members and test for STIs. Note that general health services were also offered in order to decrease stigma.

Impact on STI rates over time is not examined.

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5.8 Outreach: Venue- or Group-based Screening STI screening allows for the identification of an unrecognized infection (including asymptomatic infection) and referral for follow-up investigation and treatment. Screening, a form of secondary STI prevention, can therefore improve STI detection, facilitate the interruption of STI transmission and improve control (182), and is a key group- and population-level intervention that is discussed at length in the literature. Traditionally, screening has largely relied on individuals presenting to clinical settings (190). However, many populations do not regularly access health care facilities for STI testing, with barriers including a lack of transportation, concerns about confidentiality, stigma, lack of knowledge about STIs, etc. The availability of nucleic acid amplification technology (NAAT) and the ability to test urine and self-collected swabs for chlamydia and gonorrhea, has made the conduct of screening in non- clinical settings more feasible (190). As Johnson et al. (191) assert, a non-clinical STI screening program is a convenient forum to serve a high-risk population.

There are a number of publications discussing STI screening outreach to specific populations within established venues in the community, outside of traditional healthcare facilities (e.g., secondary schools, Family Court, shelters, sports-related venues, bathhouses, etc.). There are also examples of screening outreach outside of existing venues, such as on the street or in public areas. In a recent review by Hengel et al. (190) outreach programs were identified in a variety of settings among diverse populations and participation was found to be particularly high where screening was offered within existing venues (e.g., community centre, homeless shelter, parenting centre) or a sporting club, rather than on the street or in public areas within the community.

5.8.1 School-based STI Screening and Treatment Programs School-based STI screening, coupled with school-based treatment or referral for treatment, has been studied in a number of settings with encouraging although not uniform results. The rationale for such programs that take place within the school setting, include that adolescents and young adults are disproportionately affected by chlamydia and gonorrhea, most chlamydia infections are asymptomatic, particularly in females, and gonorrhea is typically asymptomatic in males; therefore active screening and treatment programs are essential in order to prevent complications; adolescents are less likely than some other age groups to seek or receive preventive health services and STI screening; and the availability of urine-based nucleic acid amplification tests (NAAT) facilitates testing in non-clinical settings (192). There were high rates of treatment for students with identified infection, however those studies that evaluated the impact of school-based screening on STI rates over time produced mixed results. The resource-intensive nature of such screening programs is consistently recognized.

The Philadelphia Department of Public Health (PDPH), with the support of the School District of Philadelphia (SDP), established a voluntary high school-based education and screening program to identify and treat chlamydia and gonorrhea (192). The Philadelphia High School STD Screening Program (PHSSSP) was initiated in 2003; a description of the program is presented in Appendix D. Of the ~30,000 students who attended the PHSSSP, ~65% submitted specimens adequate for testing (note that this represents less than 40% of the students enrolled in these grades in the public school system). Five percent of these tested positive for chlamydia, 0.5% for gonorrhea, and 0.3% for both infections.126 Females had higher prevalence of infections than males (prevalence of chlamydia and gonorrhea were 3.3 and 5.1 times higher, respectively). Treatment was administered to 99.9% of students with infection; of those treated, 70.3% received treatment at “in-school” treatment sessions, 22.4% at PDPH STI clinics, with smaller proportions in other venues such as private physicians’ offices. Students treated during

Population and Public Health, Ministry of Health Page 56 Core Public Health Functions for BC: Evidence Review Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections school treatment sessions received significantly faster intervention, as the median time between testing and treatment was 5 days shorter for students who were treated during school treatment sessions than for those treated in other settings (8 days vs. 13 days) (192). The program was felt to be labor-intensive, but was acceptable to students and staff (192). Information on long-term effect on STI prevalence was not available. A concern that has been raised regarding urine-based screening for chlamydia and gonorrhea in non-traditional settings is that screening for other STIs (e.g., HIV and syphilis) may not occur. In this program, all students with an identified infection were counseled to seek follow up for comprehensive STI care (192).

A longitudinal school-based program demonstrated that repeated screening and treatment was associated with a decrease in the prevalence of chlamydia infections, although this was only significant among male students (193). Cohen et al. (193) conducted a study in three urban public high schools in Louisiana (n = >2000). All students in grades 9-12 were given the opportunity to be tested for chlamydia and gonorrhea during three consecutive school years, using urine tests. Students also received education, counseling and treatment (where needed) with oral single-dose antibiotic therapy. Controls were five comparable schools (n = 5063). Between 52%-65% of students participated per year. At the first test, 11.5% of girls and 6.2% of boys were found to be infected with chlamydia, while 2.5% of girls and 1.2% of boys were infected with gonorrhea; more than 90% of infections were asymptomatic. With repeated testing, the chlamydia prevalence among boys decreased to half of what was observed in comparison schools (3.2% vs. 6.4%), while among girls, chlamydia prevalence decreased to a smaller degree (10.3% vs. 11.9%).

A study by Nsuami & Cohen et al (194), conducted an evaluation over a 3-year period in three high schools, and found that the prevalence of chlamydia infection among students who were only tested once was, 6.2% among males and 12.7% among females. Chlamydia infection at first test among students who tested more than once was 1.8% for males and 7.7% for females. Among students tested more than once, no significant difference in chlamydia prevalence was associated with repeat screenings. Incidence rates per 1000 person-months were 4.3 (2.2 among males and 7.1 among females).

In a study by Low et al. (2013), in a school-based screening program, chlamydia positivity was found to increase over time (195). A screening and treatment program began during the 1995-1996 academic year and continued until 2004-2005 in a sample of high schools. Students with positive chlamydia tests received counseling by nurses or physicians, treatment with a single oral dose of azithromycin (1g), were asked to attend the city STI clinic for further examination and testing (including HIV testing), and were asked to refer their sexual partner(s) for assessment. Participation in the screening program ranged between 32.3%-51.4% depending on the year. Over the entire 10-year period, most students were tested at least once. The proportion of students tested decreased with the increased number of years they were registered in their school; 37.7% (females) and 38.6% (males) of students were screened who were registered for only one year, but this declined to 10.6% (females) and 12.7%% (males) for students registered for all four years. Note that females who had a positive chlamydia test in a previous screening were significantly less likely to be tested at subsequent screening opportunities than were those who had a previous negative result (age-adjusted OR 0.77). There was however a higher odds of subsequent participation among students with more recent sexual partners. Chlamydia positivity initially declined slightly in women, and remained stable in men, then in 1998-1999 positivity increased, then was stable again from 1999-2000 onwards for both genders. The authors observe that it is difficult to sustain repeat annual screening.

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Summary: School-based STI screening, coupled with school-based treatment or referral for treatment, has been studied in a number of settings with encouraging although not uniform results. There were high rates of treatment for students with identified infection and those studies that evaluated the impact of school-based screening on STI rates over time produced mixed results. The resource-intensive nature of such screening programs is noted consistently.

5.8.2 Other Studies Barry et al. (196) found that screening in a school in an area with high STI rates had fairly high participation (63% of those in attendance), but relatively low STI yield (no students tested positive for gonorrhea, and 1.3% tested positive for chlamydia although rates varied among students, with higher rates observed among black female students). The authors questioned whether the higher-risk students were in fact in attendance at the schools, and given the resource intensive nature of such a program (each identified case required 63 staff hours), assert that it is important to consider local epidemiology and whether schools have substantial proportions of students likely at high risk for STIs, before establishing a school-based program.

Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence School-based  For  Screening in school-based settings was the subject STI screening facilitating the of a large body of research. Generally, there are and treatment treatment of favourable outcomes related to the treatment of programs cases individuals that are found to have STIs (many of  For which are asymptomatic). Rates of participation in participation in the screening program vary widely. There is also screening inconsistency with respect to the impact of the program program on STI rates over time.

5.8.3 STI Screening in School-based Health Centres (Youth Supplemental Review) School-based health centers (SBHC)a were first established in the United States over 25 years ago to improve access to care for low socioeconomic children and ensure that school-aged children receive quality primary health care (197). Services offered by SBHCs include, but are not limited to, health promotion focusing on reproductive health and STIs. A standard of care in SBHC is to conduct a behavioral risk assessment on each student and discuss risk behaviors. Depending on state laws, some SBHC prescribe or dispense contraceptives and provide confidential STI treatment services. Other SBHC provide only counseling and education and make referrals to local health departments, hospitals, or community agencies. Newly opened SBHC often begin by providing only education and prevention, and some eventually evolve to the provision of contraceptive and reproductive services. The values and preference of the community, school administrators, and parents are key factors. Currently, about 10% to 18% of visits to SBHC are for reproductive services and the National Assembly for School based Health Care survey of SBHC revealed that 60% provided STI diagnosis and treatment and 25% of SBHC dispensed contraception on site. Although most SBHC treat STI among their patient population, several have developed specific programs to address prevention of STI and promote reproductive health. An example of such a program, operating within a Florida SBHC serving a predominantly African American lower socioeconomic neighborhood, is described in Appendix D. a It is unclear whether Health Resource Centers (HRC) and School-Based Health Centers (SBHC) are referring to the same service, or if these are distinct interventions.

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Another term for school-based clinics is Health Resource Centers (HRC). For example, after the School District of Philadelphia adopted Policy 123 (see Appendix D), they partnered with a family planning organization in the community and the Philadelphia Department of Public Health to establish HRCs in nine public high schools. The HRC included a number of services. Students could drop-in for reproductive health information, condoms and general health referrals, and received counseling on the importance of abstinence in preventing STIs and pregnancy. Medical services were not offered within HRCs, but they would refer to nearby health facilities. Each school had slight variations in their HRC logistics, as per the needs of the school (e.g., only opening during lunch, opening during specific hours throughout the day, housed in school health clinics or in classroom or office space, etc.). HRC staff included nurses, psychologists and health educators. The program operates on “passive parental consent”, which means that parents can prevent their child from receiving condoms through the HRC by returning a letter sent home by the school principal; in this model, parental consent is not required for the receipt of counseling or referrals through the centre.

Braun & Provost et al. (198) evaluated an initiative that offered chlamydia screening to a target population of young females accessing reproductive health services within a SBHC. A number of strategies were implemented to support screening initiatives. Health fairs, back-to-school nights and classroom-based health education were implemented to increase awareness and promote students’ utilization of SBHCs. Youth advisory boards were created to allow students to share their perspectives about their SBHC. Other outreach activities were conducted in partnership with existing student groups, such as prom-related promotions, sports tournaments, etc. As well, clinical strategies were implemented to increase screening, such as new screening protocols that required all new sexually active patients to receive a chlamydia test before receiving further services (from which they could opt out if desired); a chart flag system using electronic or paper methods, to remind clinicians to screen for chlamydia irrespective of the reason for their visit, and standing order for chlamydia tests during certain types of visits (e.g., health education visits and pregnancy tests). Eighty-five percent of the 3392 clients that received service reported that the SBHC was their only source of reproductive care in the past 12 months. Among those that received care from the SBHC, 89.1% received a chlamydia test (range 71.9%- 100%). There was 5.6% chlamydia positivity, with highest positivity among African American (12.9%), Pacific Islander (8.6%) and Asian students (7.6%).

Other authors have demonstrated that STI screening offered through SBHC can result in moderate-to- high student participation, and STI detection. For example, in a school-wide chlamydia and gonorrhea screening effort, Salerno et al. (199) found that 69% of students participated in screening and 8.9% tested positive for a STI.

A number of studies demonstrated that when STI screening is offered in health centers, (not simply during reproductive health-focused visits but where screening is offered for students presenting for diverse reasons) moderate to high rates of STI detection can be achieved. Some of these studies were conducted in high STI prevalence communities. For example, Burstein et al. (200) demonstrated that STI screening in middle school health centers can detect fairly high rates of STIs among students. One hundred and seventy female and 43 male students who visited the health center for reasons that were related to various primary health concerns (e.g., reproductive health, illness/injury etc.), were routinely asked to provide urine samples for gonorrhea and chlamydia testing. Among female students, 11.4% tested positive for gonorrhea, and 16.4% tested positive for chlamydia. Among male students, 2.1% tested positive for chlamydia, and the same proportion tested positive for gonorrhea. The incidence of gonorrhea was 34.0 cases/1000 person months (95%CI 19.5-67.5), and incidence of chlamydia was 57.5

Population and Public Health, Ministry of Health Page 59 Core Public Health Functions for BC: Evidence Review Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections cases/1,000 person months (95% CI 35.3-93.8). Joffe et al. (201) supports the utility of SBHC for screening specifically for young men. Among 1434 students in middle schools and highschools in Baltimore and Denver, students were offered screening for chlamydia during various types of health care visits (e.g., athletics physicals, acute care visits, well adolescent visits, etc.). Among asymptomatic adolescent males, 6.8% tested positive for chlamydia.

One study, by Gaydos et al. (202) examined chlamydia reinfection rates among female adolescents presenting for rescreening at SBHCs. As there was not a comparison arm for this study, it is difficult to determine the impact that the presence of the SBHC made on reinfection rates. For the purpose of this study, chlamydia reinfection was defined as a positive chlamydia nucleic acid amplification test (NAAT) occurring between 30-365 days after an initial positive result. Over a seven-year period, more than 10,000 female students were screened for chlamydia (unique females in each year, although females could be screened in more than one year), and the overall prevalence was 18.1% (95% CI 17.4-18.8%), with a variation from year to year (from 15.1% [13.1-17.1] to 19.5% [17.8-21.2%]). Note that chlamydia positivity did not decrease over time, as the lowest prevalence was in 1999 and highest in 2002; the reasons for this are not clear. Among those who tested positive, 46.7% were rescreened. The cumulative incidence of reinfection was 26.3% (95% CI 23.4-29.2%), and of these individuals, 42.8% had one or more negative test results between the initial positive test and subsequent positive test. The age group with the highest risk of reinfection was age 13 years and younger. The authors concluded that their findings support the importance of frequent screening of adolescents for chlamydia, especially if there has been a previous infection.

The literature also suggests that students that have access to a SBHC have a greater likelihood of being screened for a STI than do students without such access. Ethier et al. (203) compared the receipt of health care, including STI screening, among sexually experienced adolescents that did, and did not, have access to a SBHC, in 12 California highschools. Although access to a SBHC did not influence the receipt of reproductive health care or contraceptive use, among females, those who had access to a SBHC did have a significantly greater likelihood of having been screened for a STI (AOR 2.1, 95% CI 1.08-4.22).

In the Netherlands, Wolfers et al. (204) conducted a cluster RCT to evaluate the impact of offering sexual health services to students in senior vocational schools, a group reported to be at high risk for STIs. The intervention, called ROsafe involved educational sessions, an internet-based home assignment and sexual health services offered at school sites including STI testing and sexual health advice (free, anonymous, no appointment required). This full multi-component intervention was delivered to the first experimental group, while the second experimental group received health education only, and the third group received sexual health services only. The control group did not receive any of these intervention components. The intervention arm that received the full ROsafe intervention had 29% of students that had a STI test; this was higher than the other two experimental arms and the control arm (4%). Note that 1.4% of the study sample tested positive for chlamydia.

Summary: Services offered by SBHCs can include health promotion activities focusing on reproductive health and STIs. Studies suggest that SBHCs are an effective way to engage youth in STI screening.

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Intervention Behavioural STI incidence/ Contextual considerations and comments outcomes prevalence School-based   SBHCs are important venues for offering screening to health centers youth in schools, and have demonstrated the ability to detect high rates of STIs in US studies. One study demonstrated that a chlamydia screening initiative engaged a high proportion of SBHC clients, the majority of whom did not have another source for reproductive health care. Another study suggests that this is an important way to engage asymptomatic young men in screening. High rates of reinfection with chlamydia were detected through a SBHC in one study, particularly among younger youth.

The long-term impact of offering STI screening through SBHCs on STI incidence/prevalence is not certain.

5.8.4 Sport-related Settings Sport-related settings may encompass members of a sports team or club, or may involve sports venues, as settings for STI screening. The results from a study by Gold et al. (205) suggest that high recruitment for STI screening may be achieved through sporting clubs. As part of a STI screening initiative among young males in four rural football clubs in Australia, more than 90% of eligible players present at the clubs on the night of the study participated. Among the 80% that had ever had sex, the prevalence of chlamydia was 3.9%. Despite a high percentage having visited their physician in the past year (78.7%), and the fact that most were comfortable with the idea of an annual STI screen, few had ever discussed sex or STIs with their doctor or had a previous STI test.

However, in the United Kingdom (UK), Saunders et al. (206) explored the acceptability of various venues (medical, recreational and sports locales) as places for young men to access self-collected testing kits for STI/HIV testing. Among males aged 18-35 years (n =411), there was a high willingness to access self- collected tests for STIs (85.1%), but there was low acceptability of sporting venues as test pick-up points (11.7%); although there was greater acceptance among those who actually participated in sports (53.9%). In this study, the most acceptable pick-up points were healthcare facilities, specifically general practice (79.9%), genitourinary medicine (GUM) clinics (66.8%) and pharmacies (65.4%).

Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence Screening in  For  A limited research base was identified on screening sports/sports promoting among sports teams/in sports venues. One study in team-related screening Australia demonstrated a very high screening settings uptake participation, while another study suggests that there is potentially a greater acceptance of screening in these venues among those who actually participate in sports.

Evidence is needed to assess how this impacts on STI rates over time.

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5.8.5 Occupational Groups Screening based on occupational group involves offering screening to workers of a particular job classification. Kourbatova et al. (207) discuss that the national STI control program in the Russian Federation involves routine, compulsory STI screening based on occupation. Seven percent of the population are screened through these programs, which focus on syphilis and gonorrhea, and may also include Trichomoniasis, chlamydia and HIV. Among study participants (n = 1000), the prevalence of syphilis based on the results of Rapid Plasma Regain (RPR) and Treponema Pallidum Particle agglutination Assay (TPPA) tests was 1.2%. Market salespeople had a significantly higher prevalence of syphilis compared with the other three occupational groups studied (food handlers and other food industry workers, education and health care providers, and hotel and other public utility workers) combined (4.4% vs. 0.1%). The prevalence of gonorrhea was 0.3%. The authors also examined cost- effectiveness, and the incremental cost per case of STI treated was 8409 rubles ($252USD) for syphilis screening (compared with no screening) with higher incremental costs associated with expanding the program to include gonorrhea screening.

Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence Occupational   A single study was found that offered screening group screening based on occupational groups. Varying rates of STIs was observed among different groups.

Evidence is needed to assess the impact on STI rates over time.

5.8.6 Family Court System Johnson et al.(191) examined the feasibility of using the Family Court System in Philadelphia (which involves Juvenile Court and Domestic Relations) (208) as a venue for screening adolescents, especially males, for chlamydia and gonorrhea. The study sample was comprised of adolescents on probation under the jurisdiction of the Family Court System of Philadelphia. The Family Court STD Screening Program, which is described in detail in Appendix D, offered education and voluntary non-invasive screening for chlamydia and gonorrhea. The program was incorporated into the routine probation intake protocol, and therefore ideally 100% of adolescents would have been offered testing and counseling, however less than half of these adolescents were offered testing at intake. Over a 2.5 year period, 2270 adolescents were counseled about STIs, and over 79.6% of these voluntarily submitted a urine sample for STI testing. Overall, 8.4% were positive for chlamydia and/or gonorrhea (13.9% of females and 7.0% of females). High rates of treatment were confirmed (93.3% of males and 100% of females with positive tests).

Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence Screening in For reaching  A single study on screening within the family family court the target court system revealed that less than half of the system population target population was offered testing at intake,  For facilitating however there were very high treatment rates. access to treatment Evidence is needed to assess the impact on STI rates over time.

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5.8.7 Prisons Arriola et al. (209) examined STI screening in five jails in the US. Screening was offered during medical intake and, in some settings, during HIV prevention education sessions delivered by a community organization. Over 2000 inmates were tested for chlamydia, 1300 for gonorrhea and 930 for syphilis. Six percent had chlamydia, 3% had gonorrhea and 2% had syphilis. Among those who tested positive for any of these STIs, 78% were treated (79% of those testing positive for chlamydia, 66% for gonorrhea and 100% for syphilis); the remainder either declined treatment or were released before being notified of their results or receiving treatment.

Kahn et al. (210) (2002) examined syphilis screening among arrestees in a jail in Louisiana. Between 1994-1998, 76% of 50,000 arrestees were screened. Screening occurred during the mandatory routine health assessment of arrestees, completed within 24-hours of arrival. Among those screened, 1.3% were diagnosed with untreated syphilis and 61% of these received treatment before release, while 4.7% had previously been treated for syphilis. During this period a decline in syphilis rates was observed among both arrestees as well as in the wider community making it difficult to draw an association with activities that were unique to the prison.

Intervention Behavioural outcomes STI incidence/ Contextual considerations and comments prevalence Screening in For reaching the target  Fair screening rates were reported, while the prisons population treatment rates varied. One of the key factors in  For facilitating access treating cases in this setting is that individuals may to treatment be discharged prior to completing STI investigation and treatment.

This literature is not clear on the impact of screening on STI incidence/prevalence over time, although there is some suggestion of moderate levels of treatment for those who screen positive. Note that Ariola et al. (2001) outline key considerations for screening activities in this setting, and these are presented for information in Appendix D, without assuming that there is strong evidence for this screening based on the included studies.

5.8.8 Shelter Residents Grimley et al. (211) examined STI testing among adults at three shelters in two US cities (see the program description in Appendix D). The recruitment rate was very high (96% in one city shelter and 98% in the other). Note that at the time of screening, all study participants reported having no signs or symptoms of infection. The rate of chlamydia was 15.0% in city B and 6.4% in city A; gonorrhea was 5.0% and 3.2%; and syphilis was 0.08% and 1.4%, respectively. Treatment rates were high: 89.0% in city A and 94.0% in city B.

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Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence Screening in  For promoting  In a single study among adults in US shelters, shelters screening uptake high screening program participation, as well as  For facilitating high treatment rates, were reported. access to treatment Evidence is needed to assess the impact on STI rates over time.

5.8.9 STI Testing of Commercial Sex Workers in Outreach Settings In a study by Chen et al. (212), female sex workers in China were specifically offered free rapid syphilis testing as part of an outreach program. Over 2800 female sex workers were offered testing and 95% participated. A positive result was identified in 6.8% of participants, and 75% were willing to attend a STI clinic for confirmatory diagnostic testing and treatment. Numerous other identified studies examined screening among sex trade workers, however in these contexts screening was combined with other interventions and these have been captured in other respective sections within this report.

Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence Screening for For  A single study suggests that outreach supports commercial sex supporting screening uptake, and access to diagnostic testing workers screening and treatment. Note that numerous other studies uptake have included outreach screening for sex trade  For workers, as part of a wider program with other facilitating interventions (see report). access to treatment Evidence is needed to assess the impact on STI rates over time.

5.8.10 MSM Sex on Premises Establishments, Saunas, Bathhouses Lister et al. (213) studied an outreach STI/HIV screening program in men-only saunas in Australia. This involved a nurse who set up within the sauna and administered screening. One hundred percent of the men that tested positive obtained their results, whether by telephone, returning to the sauna to speak with the nurse, receiving results from the health unit, or by email, and all received treatment. The authors compared this STI/HIV screening program to an anonymous program that had been in operation previously in Australia in 2001-2002, and had in fact been modified to create the “comprehensive STI testing clinic” that was evaluated in the study. No explicit rationale was provided for the selection of this comparison anonymous intervention, although presumably it provided a natural experiment as well as the opportunity to assess two different approaches so that jurisdictions could decide which approach they preferred. It was found that the anonymous program contacted more clients per hour (14 vs. 3), but the STI/HIV program had a significantly higher proportion of men that tested positive for chlamydia and/or gonorrhea (17% vs. 10.7%), and a higher proportion of those who tested positive obtained their test results (100% vs. 70%).

Bathhouses may contain nurses that provide traditional in-person STI testing services, however these initiatives have limitations as they are not accessible for men who visit bathhouses at times when testing is not occurring, and some men find the procedure to be embarrassing which represents a barrier (214). Therefore, in a Canadian study, O’Byrne et al. (214) placed chlamydia/gonorrhea urine testing kits in two

Population and Public Health, Ministry of Health Page 64 Core Public Health Functions for BC: Evidence Review Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections bathhouses in an urban centre. Drop-boxes were used to house the testing kits and also served as a drop-off point for the completed kits. The study duration was six months and had a relatively small sample (n = 50). No one tested positive for chlamydia or gonorrhea, however among those who underwent testing, some did so for the first time, and eight of these individuals underwent further testing, and these eight were diagnosed with syphilis. It is noteworthy that 60% of the sample that had accessed the testing kit had not previously accessed STI testing services from a sexual health clinic. As well, a number of testing kits were taken but not returned.

Ciesielski et al. (215) found that the yield of syphilis detection with a targeted syphilis screening program among MSM in a variety of non-medical settings (including bathhouses and MSM-oriented bars, as well as mobile vans) was 0.9% (over 14,000 syphilis tests were performed). This was found despite the fact that this targeted outreach screening campaign was implemented in seven US cities where there was a recent outbreak of syphilis among MSM, and despite the fact that many individuals with syphilis had met their sexual partners in similar venues to where the screening took place (e.g., bathhouses, bars, etc.). The yield in bathhouses in particular was 1.2%.

Intervention Behavioural STI Contextual considerations and outcomes incidence/prevalence comments MSM sex on premises  For facilitating  A few studies in this area suggest that establishments, treatment for screening uptake might be supported bathhouses, saunas cases through outreach, as might treatment screening  For for individuals that test positive. supporting obtaining results Evidence is needed to assess the impact on STI detection, as well as rates over time.

5.8.11 Street Screening conducted in ‘street’ settings is located outside of a fixed venue (e.g., on street corners, in parks, etc.). Götz et al. (216) conducted a study in the Netherlands involving chlamydia and gonorrhea testing offered through an outreach STI prevention program, to males and females aged 15-29 years. Youths, particularly of non-Dutch ethnicity, were approached by outreach workers in three separate settings: group settings (e.g., projects for Surinamese/Antillean immigrants, Surinamese/Antillean and African women, teenage school dropouts of all ethnicities); street settings (e.g., street corners, parks and underground stations); and sessions at vocational training schools. The street setting yielded the lowest participation (17%), with much higher participation in the other settings (80% in the group settings, and 73% in the schools).

Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence Street-based  For screening  In one study in the Netherlands, screening screening uptake was offered in various settings outside of fixed venues. Screening uptake varied widely, with the lowest proportion screened in street corners, parks and underground stations, etc.

Evidence is needed to assess the impact on STI rates over time.

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5.8.12 Other Studies Rusch et al. (217) conducted a study in the downtown eastside in Vancouver, BC, assessing a community health clinic that offered a weekly program for women. One of the appeals of this program was that it offered a broader range of services (e.g., food and social activities) as well as a place to access health care, thereby attracting a wider range of individuals from the community. Among the sample of 126 women, 70% had ever traded sex, 80% had used non-injection drugs and 40% used injection drugs. Seventy-three percent of participants submitted a urine sample for STI testing; there were no positive gonorrhea results and 2.2% positive chlamydia results (this includes among 2.6% of those who did not report any sexual activity in the past). This prevalence rate may be reflective of the fact that most women in the sample were over the age of 35 years, although the authors note that this age is still lower than might be expected for those involved in sex work.

Bergman et al. (218) evaluated the use of point-of-care (POC) syphilis and HIV tests in Edmonton, Alberta (AB), a province affected by a syphilis outbreak. Potential benefits of POC tests include the rapid availability of test results (usually in less than 30 minutes); reducing loss to follow-up as prolonged waiting periods are not involved; and facilitating immediate treatment. In this study, POC tests were administered through outreach in various settings (correctional facilities, inpatient addiction facilities, health centres, inner city drop-in centres, agencies working with sex trade workers, and bathhouses and bars). These locations were selected in part because they facilitated access to populations that had been represented in the AB syphilis outbreak (e.g., MSM, sex trade workers, injection drug users (IDUs) and Aboriginal individuals). These were also settings that already offered routine STI testing. Among 1183 individuals offered POC testing, 81.5% underwent testing for syphilis and/or HIV. Among those tested for syphilis, 2.8% were positive; and the majority (86%) had been previously treated for syphilis without evidence of new infection. The remainder, who were new infections, were treated. Acceptance of testing was fairly high across settings (from 69.6% in community organizations to 91.3% in settings serving MSM, with >80% of individuals in correctional, inpatient addictions, and health facilities accepting testing).

Compared to standard laboratory serological testing, the POC tests had a sensitivity of 85.3% (95% CI 68.9 – 95.0) and specificity of 100% (95% CI 99.6-100.0). Note that the authors discuss the need for caution when using treponemal POC tests among a previously syphilis seropositive population, as this test cannot distinguish between old and new syphilis infections, and there is a need for some way to confirm that cases have not been previously treated. In this study, retreatment was avoided because the testing nurse was able to access the provincial STI database to verify previous syphilis diagnosis and treatment.

As previously mentioned, Hengel et al. (190) reviewed numerous other outreach screening studies, including among youth who have left school/at risk of dropping out of school, males attending a drug treatment facility, and parenting centre and leisure centre attendees. Other target populations included travelers staying in backpacker accommodation, and settlement dwellers in South Africa. Studies vary in the proportion of population tested, and the treatment rate.

These outreach screening studies have many unique elements, however some common principles emerge (see Box 4).

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Box 4: Key elements to consider in STI outreach programs Know the population being screened; identify key sites and methods for outreach that are appropriate for the unique context.

An existing venue, or existing group structure (e.g., sports teams), may have advantages for accessing certain populations. However, studies have also demonstrated important and successful street-based outreach where appropriate.

For individuals that test positive for selected STI(s) (e.g., chlamydia and gonorrhea), ensure that a process is in place for subsequent screening for other STIs (i.e., a complete STI screen).

Ensure that there is a protocol for follow-up with individuals who had positive test results but did not access their results or present for treatment.

5.9 Home-based STI Testing Home-based testing refers to STI testing that can be conducted within the home, rather than requiring individuals to present to a health care facility. A selection of studies explored different ways to make home-based STI testing accessible to target populations. Utilizing the home as a testing venue may avoid the stigma of attending a STI clinic, and reduce direct interaction with health care providers, thus encouraging testing among those who would be least likely to seek medical care otherwise (219). Studies in the United Kingdom (UK) and Denmark demonstrated that mailing samples for testing is acceptable and cost-effective (219–221). A study in the US demonstrated that mailing vaginal swab specimens was feasible, and that the validity of diagnostic testing was not affected (221).

Home-based testing may have elements of both micro- and meso-level interventions. While testing is targeted to the individual, and requires individuals to independently collect and submit their samples for testing, home-based testing is often implemented through a wider program targeting specific population(s). For this reason, this topic is addressed in both the micro- and meso-level sections of this report.

Bloomfield et al. (219) sought to reach a population that was felt to have sub-optimal STI screening rates. The target population was individuals living in a particular neighbourhood in San Francisco that had the highest rates of gonorrhea and syphilis in 1999; this neighbourhood is described as being the “cultural centre” for MSM. Free STI testing kits and surveys were made available at pharmacies and gyms because the former is an established site for health interventions, and the latter is a known meeting place for health-focused individuals. Two hundred and nine kits were picked up from these locations, and 38% were returned by mail, with half arriving within two days. Participants were given a telephone number to call for results. Individuals with positive results were notified and several treatment options were offered (within an STI clinic, delivered to them, or picked up at the pharmacy). Five percent of samples were found to be positive for chlamydia or gonorrhea (approximately 4% chlamydia and 1% gonorrhea). All individuals chose to have the prescription for treatment telephoned to the pharmacy where they could pick it up. Some participants expressed concerns about confidentiality, privacy and safety (56%, 54% and 34% were very concerned about these areas, respectively). The cost per received sample was about $30, including the cost per kit ($3.86) as well as testing, advertising and mailing costs (219).

A free home-testing program for chlamydia and gonorrhea called “I Know” was implemented by the Los

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Angeles County Department of Public Health, targeting African American and Latina women (222). A social marketing campaign was undertaken to encourage women to order home collection kits via telephone or online. Within the first year of the program, over 2927 kits were ordered and 1619 specimens were returned (1543 that were testable). The online method was much preferred over the telephone with 96% of testing kit orders placed via a website and 88% of results obtained via the program website. Note that this testing volume was four times the average volume seen among females age 12-25 years at the Los Angeles County Public Health STI clinics during the same period. Testing revealed that 8.5% were positive: 7.9% chlamydia and 1.0% gonorrhea. Eighty-eight percent of those who tested positive were treated by STI program nurses, 3.8% were referred to other jurisdictions, while 8.4% could not be contacted (222).

Supporting the potential advantage of home-based screening versus screening in traditional health care facility settings, Graseck, et al. (223) compared home-based screening with clinic-based screening. They found that home-based users were more likely to complete screening compared to clinic-based users (56.3% versus 25.0%; RR 2.2, 95% CI 1.7-2.7).

In terms of impact on STI outcomes, some of the data presented in the micro-level interventions section on chlamydia screening and PID and other morbidity will be revisited here, because these studies involve home-based STI testing. In the study by Ostergaard, et al. (89) a home sampling (intervention) group was compared a screening program based on conventional swab sampling performed at a physician’s office (control) group, in Denmark. At one year, a significantly higher proportion of women in the control group (4.2%) required treatment for PID compared to 2.1% in the intervention group (p = 0.045).

However, in the study by Andersen, et al. (90) involving a large sample of women and men in Denmark, an intervention group was offered an opportunity to be tested for chlamydia via a home sample that they could mail directly to the laboratory, while the control group was the rest of the population living in the county. After a nine year follow-up period, there were no significant differences between the intervention group and control group in terms of PID, ectopic pregnancy, infertility, IVF treatment, or births in women, and in men, there was no significant difference in epididymitis.

Summary: Studies in the United Kingdom (UK) and Denmark demonstrated that mailing samples for testing is acceptable and cost-effective while a study in the US demonstrated that mailing vaginal swab specimens was feasible, and that the validity of diagnostic testing was not affected.

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Intervention Behavioural STI incidence/ Contextual considerations and comments outcomes prevalence Home-based STI  To support  Generally favourable in terms of feasibility and testing screening uptake appears to support the uptake of STI testing. One study found that ordering a testing kit online, and obtaining results online, were much preferred over telephone methods. Some studies observed a higher screening volume with home-based testing, although it is not clear why and whether this finding (observed in settings outside of Canada) would be similar in a Canadian context. There were concerns expressed by participants in some studies about privacy, confidentiality and safety, and these would need to be addressed in any similar intervention.

5.10 Internet-based Campaigns and Services for MSM (MSM Supplemental Review) As the internet has evolved over the past two decades, MSM have increasingly used the internet to meet sexual partners. There is an association between use of the internet to meet sexual partners and an increased number of partners, an increased number of partners known to have HIV, and an increased in reported anal sex when compared with partners met via other modes (224). McFarlane, et al.(225) conducted a qualitative study looking at internet-based health promotion and disease control in eight US cities (Chicago, New York, Miami, Fort Lauderdale, San Francisco, Los Angeles, Houston and Atlanta). They found that online efforts were generally divided into several categories:  Partner notification on the internet—the authors noted that the use of e-mail was preferable to the use of live chat because of the differences in time required for partner finding (one does not have to stay in a chat room for long periods waiting for partners to log on; other problems identified include people using multiple, anonymous online personas). Overall, four of the eight cities reported having some sort of online partner notification system via e-mail in 2004, with limited evaluation. Some concerns have been reported with issues of privacy.  Chat room outreach—four of the eight cities in 2004 conducted chat room outreach. This was usually accomplished by having staff members logging into chat rooms with a user name like “letstalkaboutsex” or “askmeabouthealth”. “Profiles” were often created explaining their purpose for visiting chat rooms, the types of questions they could answer, and referral information for testing and treatment. Chat room staff was generally passive and waited for questions.  Online testing—this was piloted in San Francisco (see below).

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 Online banner advertisements—online banner advertisements have been used in advertising since the early 1990s. These advertisements take up a small proportion of the screen, can be clicked on, and the user will be transferred to another website. Banner advertisements are sold by “impressions” or the number of times an advertisement appears on a webpage. When a user clicks the ad, the buyer of these advertisements usually pay a fee of 5 cents to 10 dollars to the hosting website. The San Francisco Department of Public Health (SFDPH) conducted an online banner advertisement campaign that is reviewed below.  Interactive, targeted interventions—these interviews are more interactive than a typical didactic educational website. Usually, the intervention begins with the participant answering questions about risk behaviours. The computer program then provides tailored, targeted feedback to the visitor. One intervention that was developed and tested in the US was the SmartSexQuest (226), which aimed to increase STI and HIV testing among MSM and increase condom use. Despite men logging on and reading through the materials, only 15% returned follow-up questionnaires after 3 months.

Klausner, et al. (227) published a descriptive evaluation of the online efforts of the SFDPH. A website was created; there was individual online outreach, banner advertisements, chats, an educational site, message boards, warnings and an online syphilis testing program. During two months in 2002, staff conducted 57 hours of outreach on three internet sites (AOL, Craigslist and M4M4Sex) resulting in 212 interactions. Thirty-five or 16% redeemed incentive coupons at the municipal STI clinic. There were nine banner ad campaigns shown over 33 million times on gay.com and AOL, resulting in a 0.1% click-through rate. There were seven, one-hour chats on gay.com with 10-50 people in the chat room at any one time, and 15 questions answered per hour. About 840 people participated in seven sessions. The “Ask Dr. K” site received 100 questions a week.

The SFDPH also piloted an online syphilis testing website (228). Persons could log onto stdtest.org to obtain a physician-ordered laboratory requisition and a unique identification number. This requisition could then be taken to any number of local, private laboratories for specimen collection and analysis. Results were sent to the SFDPH, who then posted the results on the website, along with the unique identification number. From June 2003-January 2004, there were thousands of visitors to STDTest.org (described above), but only 140 completed syphilis testing. Of these, six (4.3%) tested positive.

One other study done in the Netherlands also looked at online syphilis testing (229). The authors developed a website that presented information on syphilis and allowed users to download a referral letter which they could bring to a laboratory to test for syphilis. Results were available one week after the blood test. They compared the percentage of syphilis infected men detected online with those at a local STI clinic during the same time frame. During 15 months, 898 visitors to the website downloaded a referral letter. Of these, 93 (10%) men tested and 96% of these obtained their test results online. Through the website, the authors found a significantly higher percentage of men who needed treatment for syphilis compared with the STI clinic (50% online versus 24% STI clinic, p < 0.01). Of the online users who tested positive 3 of 10 had never visited the STI clinic before.

InSPOT is a web-based partner notification service, originally developed for MSM with the goal of helping them notify partners of possible STI exposure (230).The website design was based on extensive input from key community advisors and on-site testing in San Francisco with samples drawn from the general population.

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Two sections of inSpot exist:  Tell Them, in which users choose one of six e-cards, and they type in up to six e-mail addresses of recipients. They then select an STI from a pull-down menu and can type in a personal message. They can add their own e-mail address or send the e-card anonymously. When the recipient clicks on the e-card, they are sent to a page with disease-specific information.  Get Checked, which is divided into STI information, a map of local testing sites, and links to online resources.

To ensure privacy, e-mail addresses are not stored. An initial evaluation by Levine, et al. (230) showed that an average of 750 people visited inSpot.org daily. Fewer than 10 people reported receiving e-cards in error. Since its launch in 2004, inSPOT has since expanded in three countries, ten cities, and nine US states. Online, provider and street intercept surveys performed on MSM between March and December 2005 found that 13-26% knew what inSPOT was, with 65-74% saying they would send or would recommend sending an e-card, if appropriate. Pattern of diseases reported by Levine, et al. (230) found that 15.4% of e-cards were for gonorrhea, 14.9% were for syphilis, 9.3% were for HIV, 11.6% were for chlamydia, and 48.8% were for “other” including cervicitis, “crabs”, scabies, hepatitis A, B, and C, LGV, Molluscum contagiosum, nongonococcal urethritis, Shigella, Trichomoniasis, and “unspecified.”

Kerani, et al. (155) conducted a RCT of inSPOT. They offered enrollment in the trial to 393 MSM who were diagnosed with chlamydia and/or gonorrhea in a RCT in four arms: inSPOT, patient-delivered partner therapy (PDPT), combined inSPOT and PDPT, and standard partner management. However, only 75 (19%) enrolled and the rest declined enrollment. Among the 75 enrollees, only 53 completed baseline and follow-up interviews. The study was halted early due to low enrollment. Among the 27 men assigned to an inSPOT arm, only one used inSPOT to notify more than one partner. There were no significant differences between partners notified, treated, or tested for syphilis in adjusted analysis between those assigned to inSPOT and no inSPOT.

Hightow-Weidman, et al. (231) compared a formalized internet partner notification (IPN) and text messaging service for partner notification (txtPN) in North Carolina with outcomes for the previous year. They compared the number of IPN and txtPN contacts initiated and their outcomes from July 1, 2011 to June 30, 2012, with outcomes from January 1, 2010 to December 31, 2010, the year before the collaboration. They found that 362 IPN contacts were initiated compared with 133 in 2010. Seven new cases of HIV infection, 11 new cases of syphilis, and 19 known previous HIV-positive persons were identified. Text messaging for partner notification was used for 29 contacts who did not initially respond to traditional notification or IPN. Forty-eight percent responded to txtPN in a median time of 57.5 minutes.

An example of an instant messaging/chat room intervention is that of PowerON (232). PowerON is an organization that provides counselling to MSM online in real time through instant messaging. Moskowitz, et al. (232) analyzed a sample of 279 transcripts of exchanges between PowerON counselors and gay.com users. They found that 43% of the instant message sessions discussed information about HIV/STIs. Risk taking behaviours were addressed in 39% of the sessions. Information about HIV/STIs and general counselling were given in 23 and 18% of the counselling sessions, respectively. The authors conclude that the internet can be a medium through which sexual health information to MSM can be dispersed.

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Muessig, et al. (233) recruited a sample of 22 black MSM and conducted focus groups to inform the development of phone-based HIV/STI apps. Despite the fact that half the sample group earned less than $11,000 annually, all participants owned a smart phone, had unlimited texting and many had unlimited data plans. Themes that emerged were that the phones were integral to their lives and were the primary means of accessing the internet. Communication was usually done through text messaging and messaging through social networking sites. Half used their phones to find sex partners, and over half used their phones to find health information. For an HIV-related app, participants stated they were looking for user-friendly content about test site locations, information about STIs, information about symptoms, the risks of drug and alcohol use, safe sex, sexuality and relationships, gay-friendly health providers and connection to other gay and HIV-positive men.

Blas, et al. (234) conducted an observational, cross sectional study looking at whether online banner advertisements offering free HIV and syphilis testing in a South American setting would result in more testing when compared to an online banner advertisement that did not offer free HIV and syphilis testing. The inclusion of the health incentive increased the frequency of completion of surveys (5.8 versus 3.4%, p < 0.001). Eleven percent of participants who said they had completed the survey offering free testing visited the STI clinic. Of those who attended the clinic, 6% had already been diagnosed as having HIV, while 5% tested positive for HIV and 8% tested positive for syphilis. Although in this South American setting, free incentives advertised online increased STI clinic attendance, it is unclear whether offering free HIV and syphilis testing in the Canadian setting, where universal health care exists, would increase STI clinic attendance. However, offering other incentives (free condoms, for example) should be further investigated.

Summary: While there have been published studies on internet-based campaigns for MSM, most studies have been observational or provide only descriptive statistics. More rigorous, controlled studies are needed to determine if the many types of internet campaigns are indeed effective in decreasing STI rates and improving outcomes.

Intervention Behavioural STI incidence/ Contextual considerations and comments outcomes prevalence Internet-based   While there have been published studies on internet-based campaigns for campaigns for MSM, most studies have been observational or MSM provide only descriptive statistics. More rigorous, controlled studies are needed to determine if the many types of internet campaigns are indeed effective in decreasing STI rates and improving outcomes.

5.11 Online Initiatives to Promote STI Testing for Youth (Youth Supplemental Review) In a recent publication, Mann et al. (11) describe the Get Tested Why Not campaign, an initiative of Ottawa Public Health, that aims to increase access to testing for chlamydia and gonorrhea infection and access to sexual health information, specifically targeted to youth (age 15-29 years). The campaign involves a website and text messaging service. A number of key stakeholders and experts were involved in program development, including a Youth Advisory Committee, College of Physicians and Surgeons of Ontario, information technology and communication professionals, as well as the development of new partnerships with private laboratories to ensure participants had an option of testing locales. A number of unique features that were included in the program are described in Appendix D.

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The campaign was advertised through social media sites such as Twitter and Facebook, as well as through transit advertising, posters, business cards and condom wallets. The program website allows users to assess their risk of chlamydia and gonorrhea and recommendations are given related to whether they should be tested. If a participant is symptomatic, they are advised to see their regular health care provider or present to Ottawa Public Health’s Sexual Health Centre. A lab requisition form can be downloaded and printed and samples can be dropped off at any of 26 partner labs in the city. In an evaluation of this campaign, over a 12-month period there were over 13,000 website hits (82% unique visitors), and 104 requisitions were submitted for chlamydia and gonorrhea testing. Of the submitted requisitions, 57% of these were by individuals age 15-29 years, with individuals age 15-19 years comprising 30% of requisitions, and individuals age 20-24 years comprising 45% of requisitions. Fifty-three percent were male and 47% female. Four asymptomatic chlamydia cases were detected (3.8% of requisitions), while no gonorrhea cases were detected. Further, among those who completed a website survey, 53% indicated that they would change their behaviour due to visiting the website (e.g., encourage their partner to get tested, increase the frequency of STI testing, use condoms more frequently).

Woodhall et al. (235) evaluated the use of websites to increase access to free chlamydia tests through the National Chlamydia Screening Program (NCSP) in England, among 15-24 year old individuals. The NCSP offers free chlamydia testing and treatment to sexually active individuals under age 25 years. Tests can be accessed through multiple channels (e.g., general practitioner [GP] offices, pharmacies in the community, community health and reproductive services, as well as online). For the online option, tests are ordered through a website and then sent to the requestor via postal mail; the individual then takes a sample, delivers it to the laboratory, and accesses their results via text message. Multiple websites offer free testing through the NCSP, and 58 of these sites were evaluated for 2006-2010. Five percent of the chlamydia tests conducted in the study areas were accessed online, and the number of tests accessed online increased from <1% of all tests to 6% of all tests during the study period. Despite the fact that individuals utilizing online testing services were similar to those presenting to general practice or community sexual and reproductive health services for testing, the proportion of tests that were positive from the internet sample was higher than tests from general practice and slightly lower than community sexual and reproductive health services (7.6%, 5.6% and 8.2%, respectively). It appeared that young males were reached through this service at a higher rate than females, which is important as this group is described as being difficult to engage with for chlamydia testing. Further, individuals that accessed the websites came from a wider range of socio-economic backgrounds, whereas the in-person testing services had a higher proportion of tests among individuals of lower socio-economic status; this might reflect lower access to private internet services. As well, women that accessed online testing were more likely to have had more than one sexual partner in the past year and a new sexual partner in the past three months. Note that the provision of additional health promotion information and recommendations for accessing other services/follow-up with a health care professional, varied between sites. This inconsistency was identified as a limitation, as was the geographically based model of service delivery.

Summary: Online interventions to promote STI testing using websites and text messaging services as well as advertising using social media have shown promising outcomes related to changes in self- reported sexual behaviour of youth who accessed the information.

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Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence Online   In the UK, an intervention that used websites to initiatives to promote access to free STI screening through the promote STI national program, found that although the proportion testing for youth of tests accessed online increased, it was still far below more traditional methods of access. It was found that young men were reached at a higher rate than women, which may be important for engaging this group. A study from Ontario indicated that participants in an intervention involving website and text messages indicated that just over half they would change their behaviour as a result of visiting the website.

5.12 Contact Tracing and Social Networks Ogilvie et al. (2005) describe the use of a social networking approach during a syphilis epidemic in Vancouver, BC (236). This epidemic was mainly among heterosexuals, with concentration in the Downtown East Side, among sex trade workers and their clients, as well as people who use illegal drugs (236). Traditional methods of contact tracing were difficult to implement (e.g., sex trade workers were either unable or unwilling [e.g., due to fear] to identify their contacts, as well as other factors). For this reason, a social networking approach was utilized (see Box 5). Contract tracing was undertaken using non-traditional methods and a broad group of individuals were identified, which enabled the construction of a social network. Street nurses with the BC Centre for Disease Control, conducted health interviews on the street and information was gained over time through multiple interactions. Social network interviewing cues were used (i.e., location, event, partner lists). A key question used was ‘‘Who do you think should be tested for syphilis?’’ and the identification of contacts included but was not limited to sexual partners (236). Observation of the environment at points of social aggregation for sex trade workers was also conducted in order to identify contacts. Further, peer workers identified individuals that were particularly hard to reach. Social network maps were used to identify contacts of cases. Street nurses recommended testing for syphilis and conducted these tests on the street as the opportunity arose. This study found that using a social network approach facilitated the identification of a significantly higher proportion of syphilis cases linked to a case, and a significantly higher percentage of syphilis cases than were identified by the Street Nurse program (14.9% vs. 23.1%) (236).

Box 5: Social networking approach in STI control (236–238) At the heart of a social network approach is the understanding of how people are connected with each other in a social framework (238). A social networking-informed approach would involve the documentation of all close associations of STI-infected individuals (sexual and other types of associations) and calculate the degree. When social networking is used, contacts are conceptualized broadly, and include close friends, roommates, previous sexual partners, individuals that the index case might be involved in risky activities with (e.g., drug use), acquaintances thought to be involved sexually with others in the interviewee's social group, etc. As Rothenberg et al.(238) describe, all such contacts would be offered testing and follow-up care. Through interviewing the contacts, and the contacts of the contacts (i.e., “snowball” approach to network sampling), this can reveal the risk for syphilis within this broad group and determine what subsequent actions to take (e.g., treatment, further elicitation of contacts, etc.). Interventions are delivered to this network (e.g., education, screening and diagnostic testing, treatment), and the intent is that STI transmission will eventually be impacted within the community.

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The use of a social network approach during a syphilis epidemic is also reported by Engelgau et al (237). However, it is not clear from this article whether the same broad approach was used as described in Ogilvie et al (236). The authors describe the social network approach as utilizing an intensive campaign of partner notification and cluster investigation among other interventions; however it is not clear whether multiple interviews over time were utilized. During a 5-6 month campaign, 373 case-patients had partner notification/cluster investigations, and 11% of their sex partners and 3% of high-risk associates were found to have syphilis. The cost per case detected was more than double the costs that were incurred pre-campaign. While more individuals were identified using this intensive partner notification/cluster investigation approach compared to the pre-campaign period, other interventions had a greater yield as well. Note that syphilis incidence in the area within which the study was conducted decreased during the study period, and it is difficult to determine the impact of this as well as the relative contribution of different aspect(s) of the campaign (237).

Another Canadian example of network analysis is found in a publication by De et al. (239) in Edmonton, Alberta (AB), where an outbreak of gonorrhea was investigated among neighbouring aboriginal reservations and industrial towns using a sexual network analysis. The authors state that “sex partners” were identified, and therefore it is unclear whether the contacts were defined as broadly as they were by Ogilvie et al. (i.e. including but not limited to sexual partners). In this analysis, 182 network members were identified, including 107 index cases of gonorrhea and 75 named sexual contacts. A motel bar in a particular town in the region was confirmed to be the key venue in this outbreak, and examining social interaction through the bar led to the construction of a network of individuals that allowed for the linkage of seemingly isolated outbreaks. This study concluded that individuals with the highest information centrality scores (i.e., central role in their social network) should be the targets of intervention.

Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence Contact tracing using  For detection  Using a social networking approach for a social network of STI cases contact tracing has been shown to have approach advantages over the traditional ‘one-time interview’ approach. Evidence from a syphilis outbreak in Vancouver, BC demonstrated a comparatively higher proportion of cases detected through this method. Another study suggests that increased costs may be a consideration.

Evidence is needed to assess how this impacts on STI rates.

5.13 Presumptive Treatment Presumptive treatment of STIs is defined as treatment for a presumed infection in a person, or a group of people, at high risk of infection (240). Presumptive treatment for STIs may be given once, or at repeated intervals in which case it is termed periodic presumptive treatment (PPT) (241–244). Presumptive treatment/PPT tries to bypass the need to seek treatment, which has particular importance where STIs are asymptomatic, and among populations where treatment seeking is low. The aim of presumptive treatment/PPT is to reduce the pool of individuals infected with STIs, and thereby reduce STI incidence (241–244). Although treatment is provided to individuals, this is discussed as a meso-level

Population and Public Health, Ministry of Health Page 75 Core Public Health Functions for BC: Evidence Review Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections intervention because the studies described herein involve the delivery of treatment to an entire group that is defined based on a common factor (e.g., involvement in sex trade work, or incarcerated MSM), irrespective of individual STI-status.

In the literature, sex trade workers were a key population studied. Presumptive treatment of STIs among sex workers involves the treatment of curable STIs based on sex workers’ high risk and prevalence of infection, rather than on signs and symptoms or the results of laboratory tests (241). Control of STI transmission in commercial sex networks reduces secondary transmission, and has been shown to have impact at broader population levels (244). Another population studied was incarcerated MSM.

5.13.1 One-time Presumptive Treatment Wi et al. (245) conducted a study in the Philippines among sex trade workers reached during a one- month period of increased outreach (n = 1938 out of the estimated 2000-2500 sex workers in the study area). This study involved the administration of a single round of presumptive treatment (azithromycin 1-g), along with improved outreach to female sex workers (through which presumptive treatment was administered and condoms were promoted and distributed) and STI screening services. The explicit aim of the multi-pronged intervention was to quickly reduce the prevalence of chlamydia and gonorrhea among female sex workers through the provision of presumptive treatment, and to maintain this reduced prevalence through enhancing preventive and treatment services. STI screening services were established for two groups of unregistered sex workers: in brothels (BSWs) and on the street (SSWs). No changes were made to existing screening methods for registered sex workers (RSWs) or guest relations officers (GROs). The proportion of women in each group that received presumptive treatment at the two and 10 month follow periods were as follows: 79% and 70% (BSW), 63% and 32% (SSW), 50% and 17% (RSW), and 75%, and 33% (GRO), respectively. STI screening improved considerably for BSW and SSW (who previously were without access), and therefore they were more likely to receive STI treatment in the period after receiving presumptive treatment. This study found that among BSWs, the baseline prevalence of chlamydia and/or gonorrhea declined from 52% to 27% at one month, and 23% after seven months. Among SSWs, prevalence declined from 41% to 25% at one month and then was 28% at seven months. Among RSWs baseline, one month and seven month prevalence was 36%, 26% and 34%, respectively; while among GROs the prevalence was 20%, 6%, 24%, respectively. Therefore, all four groups demonstrated significant chlamydia/gonorrhea decreases at one month, however at six months the BSWs and SSWs had sustained decreased prevalence, but prevalence had returned to baseline levels for RSWs and GROs. Considering community-level impact, the prevalence of chlamydia/gonorrhea among clients of BSWs significantly decreased from 28% to 15% at six months.

Chen et al. (246) describe the mass syphilis screening and treatment of MSM inmates in the Los Angeles County Men’s Central Jail that are voluntarily segregated from the general population of inmates. During a syphilis outbreak among MSM, a syphilis control program in this unit was implemented, consisting of screening, mass prophylactic treatment, high-risk behavior detection, and education. Chlamydia and gonorrhea screening were also added for new inmates. All inmates were offered a single dose of azithromycin (1g), irrespective of whether they had participated in screening. Between March-August, 2000, over 800 inmates were screened for syphilis and 5% (n = 38) tested positive; 9 of these cases were new diagnoses. A high proportion accepted azithromycin (94%). Further, 2% tested positive for chlamydia and 1% for gonorrhea. The authors note that it was difficult to evaluate the effectiveness of azithromycin therapy due to the turnover of the inmate population.

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Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence Periodic presumptive   One-time presumptive treatment was treatment evaluated in one study among sex trade workers, and in another study among incarcerated MSM. The former study found an initial decreased STI prevalence over time in all groups offered presumptive treatment, however this decline was only sustained among groups that had expanded STI screening and treatment services. There was also a reduction in the STI prevalence of the clients of one group that had expanded STI services in addition to presumptive treatment. This suggests that while presumptive treatment can be effective over the short-term, other control measures must be implemented in order to maintain STI reductions over the long-term. The study in a prison setting, documented a high acceptance rate of prophylactic treatment, but was not able to assess long-term impact due to turnover within the prison population.

5.13.2 Periodic Presumptive Treatment (PPT) A study in South African mining communities involved the administration of PPT (directly observed 1-g dose of azithromycin) along with prevention education, to female sex workers (n = 407 over 9-months) (244). A mobile monthly clinic was utilized for the delivery of PPT, examination and counseling. The baseline prevalence of chlamydia and/or gonorrhea was almost 25%, however at the first monthly follow-up visit, the prevalence declined to 12.3% (with 69% follow-up). Similarly, at baseline 12.3% of the women had genital ulcer disease, and this declined to 4.4%. Local miners were also assessed. The baseline prevalence of chlamydia and/or gonorrhea was 10.9%, which significantly decreased to 6.2% at the 9-month follow-up assessment; while the prevalence of genital ulcer disease significantly decreased from 5.8% to 1.3%. Note that the decrease observed in miners in this study was greater than that seen among miners living distant from the study site.

A systematic review of PPT among sex trade workers concluded that this intervention can reduce the prevalence of chlamydia, gonorrhea and ulcerative STIs among this population (241). The authors further note that additional benefits may include an impact on STI and HIV transmission at a population level. As presumptive treatment strategies are temporary interventions, other control measures are required in order to maintain reduced prevalence (e.g., condom promotion, ongoing screening and treatment programs).

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Intervention Behavioural STI incidence/prevalence Contextual considerations and comments outcomes Periodic  For long-term impact on A study among female sex workers in South presumptive STI rates Africa found that PPT along with prevention treatment education resulted in declining STI prevalence among FSW as well as local miners in the surrounding community. A systematic review also found a positive impact on STI prevalence among sex trade workers, with emphasis that longer-term strategies are needed to support this short- term measure.

Contextual considerations include that studies were conducted among female sex workers in South Africa and the Philippines, and incarcerated MSM in the US.

5.14 Targeted Mass Treatment In the Downtown Eastside in Vancouver, a targeted syphilis mass treatment intervention was implemented in January-February, 2000, in response to a sexually-transmitted syphilis outbreak primarily among heterosexual individuals (247,248). This involved the administration of one dose of oral azithromycin to over 3000 at-risk individuals, as well as utilizing “secondary carry” involving more than 800 individuals taking over 2000 doses to peers and sexual contacts that did not present for treatment. Although syphilis rates significantly decreased initially up to the six month point, in the aftermath, rates increased in 2001 to a higher level than expected. Rekart et al. (247) therefore caution against the routine targeted mass treatment for syphilis.

Rekart et al. (248) also examine the additional interventions offered to those who participated in mass treatment: education about syphilis, STIs and risk reduction delivered via handouts, poster and oral communication; condoms (male and female), lubricant, clean needles and syringes; and referral to social services and health agencies. Outcomes were assessed among mass treatment participants (defined as having been approached to participate in mass treatment, irrespective of whether they did or not; n = 212) after one-year, with comparison made to eligible non-participants (i.e., living in the DTES during the period of mass treatment but had not been approached to participate; n = 211). Laboratory results revealed that there were no significant differences between the diagnosis of syphilis, chlamydia or gonorrhea between participants and non-participants (syphilis 7% vs. 4%; chlamydia 8% vs. 6%; and gonorrhea 2% vs. 2%). Further, 47.9% of participants vs. 38.0% of non-participants reported an increased awareness of syphilis, but this difference was not significant. Compared to the previous year, mass treatment participants reported significantly decreased intercourse without a condom, decreased oral sex without a condom and increased condom use by sex workers.

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Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence Targeted mass   The literature related to syphilis prophylaxis, with treatment studies conducted in Vancouver, BC, has urged caution in the administration of mass prophylaxis. One study provided evidence of positive behavioural impacts.

5.15 Patient-delivered Partner Therapy (PDPT) A discussion of PDPT was included in the micro-level interventions section of this report and, as such, the evidence related to this intervention will not be discussed here nor will an evidence rating be assigned. Rather, in order to complement the previous discussion of PDPT, Appendix E presents a discussion of the policy and legal issues related to this intervention.

5.16 Conditional Cash Transfers Conditional cash transfers operate on the principle of conditionality (i.e., making payments for contingent, such as engaging in preventive care or attending school). While studies have evaluated the impact of this intervention on HIV as well as herpes simplex virus 2 (HSV-2) infection, in keeping with the focus of this review, only literature that focused on bacterial STIs is summarized here.

A RCT was conducted in rural Tanzania with a sample of males and females age 18-30 years (n = 2399) (249). This study had three arms: low-value cash transfer arm (eligible for up to $30 over the study = 10,000 Tanzanian shillings); high-value cash transfer arm (eligible for up to $60 over the study = 20,000 Tanzanian shillings); and a control arm (no conditional case transfer but otherwise experienced same study procedures as intervention participants, including counseling and free STI treatment for the individual and partners who tested positive). Intervention arm participants could receive conditional cash transfer incentive payments if they tested negative for chlamydia, gonorrhea and trichomonas, during the testing periods at 4-, 8- and 12-months (if there was a positive test for any one of these STIs, they were not eligible for the cash transfer). Individuals were able to receive curative treatment and continue in subsequent rounds. As well, individuals that converted from a baseline negative syphilis (or HSV-2) test to a positive test at 12-months, were not eligible for the 12-month cash transfer. The cash transfers were clearly a self-reported motivator for behaviour change, and a gradient was observed. In the high-value conditional cash transfer group, 59% reported that the money motivated them ‘very much’ to change their behaviour, and 12.5% reported that it motivated them ‘somewhat’; while these values were 37.4% and 20.6% in the low-value conditional cash transfer group, respectively. The combined prevalence of chlamydia, gonorrhea and trichomonas is also combined with Mycoplasma genitalium, although the presence of the latter infection alone did not preclude the cash transfers, because the authors stated that there is uncertainty regarding transmission pathways. After adjusting for a number of variables (e.g., gender, education, age, marital status, socioeconomic status, village and baseline STI status), at 4- and 8-months, at the 12-month point there was a significantly decreased combined prevalence for the high cash transfer group compared to the control group, (although there were not significant differences in the combined prevalence of the four bacterial STIs) (RR 0.73, 95% CI 0.47-0.99), but not for the low cash transfer group (RR 1.06, 95% CI 0.75-1.38).

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Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence Conditional cash   While there are other studies examining non- transfers bacterial STI outcomes, the one study that was reviewed that had bacterial STI outcomes, demonstrated promising results. After one year, conditional cash transfers were associated with lower prevalence of four STIs. Note that this outcome was not observed during earlier study periods, and a gradient effect was noted. More research specifically on bacterial STIs would be helpful to confirm this finding that was observed in a rural low-income country setting.

With respect to behavioural change, participants report motivation to change behaviour.

5.17 Community Mobilization Community mobilization is defined as “a capacity-building process through which community individuals, groups, or organizations plan, carry out, and evaluate activities on a participatory and sustained basis to improve their health and other needs, either on their own initiative or stimulated by others” (250). There are a number of studies that explicitly involve community mobilization efforts among sex trade workers in low- and middle-income countries. These studies generally document a positive association between these interventions and lower STI rates. Often community mobilization occurs in conjunction with other program components, such as improved access to STI services and education in the wider environment to support adoption of recommended behaviour changes. In most cases, community mobilization is also tied in with policy changes, and these are described in the “macro- level” section of this report. It is therefore difficult to tease out the relative contribution of each program element to the observed outcomes; however it is reasonable to assume that mobilization and empowerment are important elements of efforts to promote and sustain behaviour change within a community. As health promotion tells us, education/instruction about behaviour change must be accompanied by empowerment and environmental changes that gives people the tools and support to make healthier choices.

A study was conducted in 2008 in India that evaluated the impact of a program among female sex workers involving the following components: community mobilization and peer-mediated outreach (a participatory mapping and numeration exercise was conducted, then peer-mediated outreach began which identified the difficulties that sex workers experienced and tried to promote “camaraderie and kinship” among this community); increased access to and promotion of utilization of sexual health services, expansion of condom accessibility through social marketing, and increased condom availability in non-traditional outlets; and creating an enabling environment to support the program (251). Over a 30-month period, STI prevalence significantly decreased: syphilis 25% vs. 12%; chlamydia 11% vs. 5%; gonorrhea 5% vs. 2%; and Trichomoniasis 33% vs. 14%. Changes were also seen with respect to condom use: condom use at last sex with occasional clients significantly increased from 65% to 90%, and with regular partners increased from 7% to 30%.

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The Avahan program was implemented among female sex workers in India (252). This program is the India AIDS initiative; the objective is to halt and reverse the spread of HIV. This program delivered preventive services to female sex workers aiming to address determinants of HIV risk (proximal and distal) and included: peer outreach education; clinical services for managing STIs, condom promotion and distribution; community mobilization and building an enabling environment. Assessments in round one (2006) and round two (2009) revealed that significant declines in syphilis, chlamydia and gonorrhea occurred: syphilis 15.8% vs. 10.8%; chlamydia 8% vs. 6.2%; gonorrhea 7.4% vs. 3.9%. Further, there were significant increases in the proportion of female sex workers reporting zero unprotected sex acts (76.2% vs. 94.6%). Condom use with occasional and regular clients were significantly higher among sex workers exposed to Avahan compared to those that were not.

Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence Community   Studies of initiatives in which community mobilization mobilization was a key element, revealed significant decreases in STIs and risk behaviours among sex trade workers.

5.17.1 Other Multi-component Interventions An intervention in Peru called PREVEN combined four components: promotion of condom use for sex trade workers and the general population; strengthened STI syndromic management by pharmacy workers; mobile-team outreach for sex trade workers for STI screening and treatment; and periodic presumptive treatment of female sex workers for Trichomoniasis (253). This multi-component intervention was evaluated in a RCT, randomized at the level of the community/city, among a large sample (n = 12,930) of urban male and females age 18-29 years in the general population, and female sex workers. The outcome of interest was community-level prevalence of chlamydia, gonorrhea, syphilis and trichomonas. Data was collected at baseline and during the following up period three to four years later (both surveys and biological samples for STI testing were collected). The change in STI prevalence among young adults was 1.1% lower among intervention cities compared to control cities, but this change was not significant (p = 0.096). However, when the data was disaggregated, among young women there was a significant absolute risk reduction of 2.6% (8.2% vs. 11.0%, p = 0.024) in intervention cities, and among female sex workers 14.5% had any STI in intervention cities compared to 22.1% in control cities (7.4% lower, p = 0.023). This significant difference was not reflected among men (4.4% vs. 5.1%), nor was the prevalence of chlamydia among men who had sex with female sex workers in the past year (7.2% vs. 3.5% in intervention and control cities, respectively, with a RR of 0.68, 95% CI 0.28- 1.68).

Intervention Behavioural STI incidence/ Contextual considerations and comments outcomes prevalence Other multi-   Based on a single study in Peru, a multi-component component intervention (without a formal policy element) produced interventions encouraging reductions in STIs among some populations (young women and FSWs) but not other populations. This division of evidence is somewhat arbitrary because a number of other interventions reviewed in this evidence review have multiple components, and are classified in other sections.

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5.18 MSM-focused Community Partnerships and Events (MSM Supplemental Review) In 2003-04, the New York City Department of Health and Mental Hygiene (NYC DOHMH) developed Hot Shot!, a community-based program held throughout New York City. The program addressed general MSM health, including STI and HIV screening, vaccinations, cardiovascular health screenings, mental health, tobacco, and other drug use (254). Among 1634 attendees, 445 persons accessed one or more service, with four newly diagnosed with syphilis and seven with HIV. The NYC DOHMH developed this program after extensive consultations with community-based organizations and a local, health department-initiated coalition known as the Syphilis Advisory Group. Through this project, the NYC DOHMH was able to reach out to the MSM population, strengthen community partnerships and address pressing health issues within the MSM community.

The Frontiers Prevention Project (FPP) (255) aimed to empower key populations in India most affected by HIV. The FPP set out to improve advocacy within these groups, changing policies that affect these groups, and increasing community awareness. The provision of a complete set of prevention interventions, aimed at reducing risk behaviours and STI incidence, resulted in a lower HIV incidence among the key populations. The goal of the project was to ensure an environment in which adequate services and commodities were available for key populations. For MSM, there was a significant decrease between baseline and follow-up for syphilis seropositivity (40% to 32% in FPP group versus 34% to 29% in non-FPP group, p < 0.05).

Summary: There is some evidence to support community-based partnerships and events in case finding for syphilis.

Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence MSM focused   There is some evidence to support community partnerships community-based partnerships and events and events in case finding for syphilis.

5.19 Conclusion The evidence base on the meso-level of interventions is diverse and fairly extensive. Some interventions are the subject of multiple studies and have a strong body of corroborating evidence, while others are only the subject of one of two identified studies. This review has revealed that there are multiple preventive interventions to consider at the levels of groups, communities and institutions.

The STI-related outcomes in the literature were related to sexual behaviours that may have implications for STI risk (e.g., condom use), other variables such as screening uptake and partner elicitation, and incidence and prevalence of STIs. While it is of interest to determine morbidity and mortality outcomes, this data was extremely limited (with no literature discussing mortality, and note that mortality from bacterial STIs is extremely rare with the exception of congenital syphilis).

An important consideration related to meso-level and macro-level interventions (discussed below), is the scope of application (e.g., scale and duration). Not all interventions are created equal; for example, the same intervention implemented over a six month versus a six year period, may have very different impacts on group or community-level STI-related outcomes. The same can be said for an intervention

Population and Public Health, Ministry of Health Page 82 Core Public Health Functions for BC: Evidence Review Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections that is implemented among a small versus a large proportion of the target population. A key determinant of the effectiveness and impact of an intervention on STI incidence/prevalence relates to the burden of STIs in the wider community. Reducing the incidence/prevalence of STIs at a population level affects individual risks of acquisition, and interventions that cover only a small group of people may not result in the same level of impact if STI rates in the wider community are unaffected. Nevertheless, STIs are a major population health issue, and it is essential that preventive interventions go beyond the level of individuals and include groups, communities, institutions and policies.

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6.0 MACRO-LEVEL INTERVENTIONS

The aim of this section is to consider the role that policy interventions play in the prevention and control of sexually transmitted infections (STIs) (256,257). A wide variety of terms are used to describe policy instruments, including legislation, regulations, acts, resolutions, guidelines, etc. (256).

In the context of STI prevention and control, "STI-specific" policy instruments refer to policies that impact, almost exclusively, issues relating to STIs, such as technical guidelines for STI screening, diagnosis and treatment (256). Other policies aim to address broader social, economic or organizational issues that have an impact on STIs. In fact, such "non-STI-specific" policy interventions may have important STI-related impact (256). As Casson et al. (258) assert, “laws act as pathways for social determinants that impact [STI] risk or resilience in multiple ways”.

As with the meso-level interventions, the STI-related outcomes in the macro-level literature were related to sexual behaviours that may have implications for STI risk, and incidence and prevalence of STIs. Morbidity and mortality data was not identified.

Application of the rating scale The evidence rating scale was applied per the criteria identified in the text portion of Figure 2. As discussed in the meso-level interventions section, the limitation of this approach in this directed, non- systematic review, is that there were often very few studies (sometimes only one study) of a particular macro-level intervention, therefore there was not a corroboration of findings. This is particularly important when the study is as a result of a natural experiment, which will rarely be repeated (as occurred for a selection of macro-level interventions). This means that corroboration, theoretical rationale, study features, etc. have to be carefully weighed to arrive at a rating.

6.1 STI-specific Policy with an Evaluation of Impact on STIs 6.1.1 Condom Use Policy The 100% Condom Use Program (100% CUP) is a policy that has been implemented in multiple low- and middle-income countries, representing a partnership between public health, law enforcement and government. It aims to ensure that a condom is used in all commercial sex encounters, and aims to make this a standard in all facilities so that there is no opportunity to select one commercial sex establishment over another based on use or non-use of condoms. The 100% CUP is described in Appendix D. This policy was found to be one of the most discussed in the global health context and has been studied in multiple jurisdictions. In this review, articles are included that specifically discuss the 100% CUP, and others that discuss this program in combination with other interventions (i.e. community mobilization).

In Thailand, a government program began in 1989 that had the following components: government purchase and distribution of enough condoms to protect most of those engaged in commercial sex in the country (condoms were distributed to sex trade workers at their periodic during periodic STI examinations); sanctions against commercial sex establishments where condoms were not used consistently; and a media campaign that “bluntly advised men to use condoms with prostitutes” (259). Data was reported on five STIs: syphilis, gonorrhea, non-gonococcal urethritis, LGV, and chancroid. Hanenberg et al. (259) found that the use of condoms in commercial sex increased from 14% to 94% between 1989-1993 and that cases of these five STIs decreased by 79% in men (259). Note that in men,

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STIs began to slowly decline in 1986 (three years prior to introduction of the 100% CUP), then there was a steep decline beginning in 1989. This pre-100% CUP decline may be because gonorrhea and chancroid were slowly decreasing, as these were susceptible to quinolone antibiotics that were introduced in Thailand in 1986; the other STIs hardly saw minor decreases before 1989. In 1989, there was a decline in all STIs, with gonorrhea and chancroid declining more than before, and the other three STIs declining rapidly. Among female sex trade workers, the number of incident STI cases declined by 54%. It is also noteworthy that a number of new STI clinics opened during this period, thus potentially increasing the rate of STI detection; this may mean that the decline in STI rates was greater than that observed.

Zhongdan et al. (260) evaluated a 100% CUP demonstration over a 15-month period in a particular area of China, with the intent to ensure that condoms be used in all commercial sex encounters. The managers and staff within so-called ‘sex entertainment establishments’ (e.g., karaoke clubs, bars, hairdressing facilities, restaurants and massage parlors) were informed about the new policy by public health workers and the police. They were told that if they did not comply with policy, they were at risk of temporary or permanent closure; other consequences included warnings or fines for non-compliance with the policy. Condoms were made available and affordable for sex workers in commercial sex establishments as well as within stores and clinics. Other STI services that were offered included counseling, education and mobile clinic services. Condom use was monitored by questioning every male patient seeking STI services at project STI clinics about which sex establishments they visited and whether they used a condom; this helped to identify non-compliant establishments that then received a warning. Surveys were also conducted that examined sex worker condom use and sex establishment owner’s enforcement of the policy.

At baseline, only 60% of sex trade workers had used a condom during their last sexual encounter. Twenty-eight percent of study participants were diagnosed with at least one STI based on laboratory testing and clinical examination; 21.8% with chlamydia; 2.9% with gonorrhea; 6.9% with syphilis and 4.9% with genital warts. Post-intervention, condom use increased to 88.5% at 12-months and 94.5% at 15-months. The impact on STI rates post-intervention varied. Chlamydia prevalence initially increased to 30.4% at six months, then declined to 14.5% at 15-months, then increased to 24% at 21-months. Gonorrhea was not reported, and syphilis counts were 6.5% at baseline, 0% at 12 months and 2.9% at 21 months (there may be questions about accurate measurement). At the six month follow-up, 95% of commercial sex establishments were in compliance with the policy. The authors conclude that the available evidence does not clearly reveal program effectiveness. They also note that the SARS crisis, which occurred at the same time as this study, may have resulted in decreased monitoring of project activities due to a shift in the workload of public health staff.

Sopheab et al. (261) conducted a survey among female trade sex workers in Cambodia, where a 100% CUP was implemented in 2001 (requiring brothel-based female sex workers to use condoms with all clients). Consistent condom use with clients was reported by 80% of sex trade workers, but only 38% always used condoms with “sweethearts” or casual partners. Being new to sex work was the only factor significantly associated with "any STI" (OR = 2.1). Prevalence of syphilis was 2.3%; chlamydia 14.4%; gonorrhea 13.0%; and any STI, 24.4%. Prevalence of each STI in 2005 was significantly lower than in 1996, but essentially the same as the prevalence observed in 2001 (the year of the policy implementation). New sex trade workers were found to have substantially higher prevalence than those who had worked in the sex trade for longer. The percent of sex trade workers who used condoms consistently was high with clients but remained low with non-paying sex partners. Because of the high turnover of sex trade workers, the prevention needs of new sex trade workers should be determined.

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Summary: The 100% CUP has demonstrated a positive impact in increasing condom uptake among sex trade workers and client in Thailand, China and Cambodia. Generalization of these findings to a North American context is inconclusive based on the studies reviewed.

Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence 100% CUP  For increasing  The 100% CUP was discussed widely in the Program condom usage literature, particularly in low- and middle- income countries. Studies have varied in the demonstration of impact on STI rates and therefore more research is warranted.

However, this intervention demonstrated a positive impact in increasing condom uptake among sex trade workers/clients.

Evidence about the 100% CUP was found in Thailand, China and Cambodia, with no studies from North America. As well, the 100% CUP is specifically targeted to sex trade workers/clients. Application in other settings is therefore uncertain.

6.1.2 Integrated Policy and Community Mobilization Interventions Two articles were found that assessed interventions that combined community mobilization and government policy initiatives. Kerrigan et al. (262) implemented a community solidarity combined with government policy intervention among female sex workers in one region of the Dominican Republic, and a community solidarity intervention only in another region, over a one year period. Elements of the Thailand 100% condom program model were adapted to the Dominican Republic context. Implementation occurred in commercial sex establishments, and managers at all sites (n = 68 sites) agreed to participate. There was a significant decrease in the proportion of individuals with one or more STIs (chlamydia, gonorrhea, Trichomoniasis) in the combined intervention site only (28.8% to 16.3%; OR 0.50, 95%CI 0.32, 0.78). The change in STI prevalence in the site with the community mobilization intervention only was from 25% to 15.9%, but this change was not significant. Further, there were significant increases in condom use with regular partners; verbal rejections of encounters that were not safer sex encounters; and participating sex establishments’ ability to achieve the goal of no STIs in routine monthly screenings of sex workers. In the site with community mobilization only, there were significant increases in condom use with new clients.

Kang et al. (263) also examined an integrated intervention (systematic 100% condom promotion combined with activities in community solidarity, activities to reduce stigma and discrimination, outreach education to promote risk-related behaviour change and promote health care seeking, etc.) on HIV/STIs among female sex workers in China. Between 2004 and 2009, the intervention was implemented in six intervention counties (n = 1157 female sex worker) and compared with 10 control counties (n = 2169). It is reported that the prevalence of syphilis was 0.17% among the intervention group and 1.89% among controls (OR 11.1, 95% CI 2.7, 46.1). Further, intervention sites had significantly higher condom use at last sex with clients and regular partners.

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Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence Combined community   Studies of combined community mobilization and policy mobilization and policy initiatives revealed initiatives significant decreases in STIs and risk behaviours.

Studies are in low- and middle-income countries.

6.1.3 Performance Measures and Private Health Insurance Burstein et al. (264) examined the new chlamydia screening Health Plan Employer Data and Information Set (HEDIS) performance measure: a measure to determine the proportion of sexually active female youth and young adult members of Medicaid and commercial health plans that are tested annually for chlamydia. Although HEDIS is only a measure to estimate performance, many health plans attempt to change practices to improve their performance ratings and to improve treatment. The authors therefore examined the new performance measure’s association with changes in clinical practice, and sought to evaluate chlamydia screening policies and testing practices and results in response to the HEDIS chlamydia-screening performance measure.

The authors examined the electronic medical records of female members age 15-26 years enrolled in the Kaiser Permanente Mid-Atlantic States (KPMAS) health plan, a managed care organization, to estimate chlamydia testing and positive tests two years before and after introduction of the HEDIS measures (37,000+ female patients from 1998-1999 and 37,000+ female patients from 2000-2001). They also interviewed the chiefs of KPMAS departments of obstetrics and gynecology, pediatrics, internal medicine and family practice, about any departmental practice and policy changes that were implemented related to the screening of sexually active females age 15-26 years for chlamydia.

All of the specialty departments that provided primary care to youth/young adult female patients reported developing a specific strategy for increasing chlamydia screening. For example, in the Obstetrics & Gynecology department, a policy was instituted to routinely collect a chlamydia test when a pap test was performed, and this was operationalized by placing a chlamydia collection swab next to the pap test collection materials. The family medicine and internal medicine departments advised health care providers to perform chlamydia tests at the time of pap tests, and this was delivered at departmental meetings. In the pediatrics department, in addition to advising providers at departmental meetings to conduct chlamydia tests at the time of pap tests, this was also communicated through written memoranda, and provider training was offered as well as operation of a sub-specialty adolescent health care clinic. However, none of these departments made systems-level changes in clinical encounter protocols.

While the proportion of females age 15-26 years that were sexually active remained constant over the four years of analysis (52%), there was a significant increase in the proportion of females tested for chlamydia (55% to 72%). Testing increased most among the Obstetrics & Gynecology department, suggesting that their simple clinical practice change made a difference. There was a 10% increase in the number of female patients identified with chlamydia.

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Although this data is from the US and specifically concerns a private health insurance plan, the issue of performance measures, and operationalizing performance measures generally, has relevance for the Canadian context. Performance measures initiatives are active in Canada; one example are the performance indicators for organized cervical cancer screening programs (related to Papanicolaou [Pap] test coverage, cytology, system capacity, follow-up and cancer-related outcomes) (265). Performance indicators provide a means to monitor performance in a particular area, and also facilitate comparisons between jurisdictions (265). As such, there is the potential for practices to be changed in light of the establishment of such measures.

Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence Performance  To support  Evidence from the United States suggests that measures screening a change in performance measures can have an impact on STI screening, as participating institutions seek to implement measures to improve their performance.

The impact on STI rates however is unclear.

6.1.4 Private Health Plan Reimbursement Law In the 1990s, the US states of Maryland (MD), Georgia (GA) and Tennessee (TN) enacted laws that required health plans to reimburse for chlamydia screening for the populations at risk. The impact of these laws of chlamydia screening rates was assessed for GA and TN (MD was excluded due to non- specificity of the law and insufficient data) (266). The authors extracted monthly chlamydia screening rates on women within employer-sponsored private insurance plans and compared changes in screening rates in these two states to 10 southern states. There were increases in screening rates in both GA and TN after the enactment of the laws, but the data from the other ten states showed similar increases over the same period; therefore, there was no significant difference.

The application of this finding to the BC context is difficult to assess, given health care system differences, as well as the finding of no significant difference in screening rates.

Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence Health plan  For impact on  Significant differences in chlamydia screening reimbursement law STI screening rates among states that did and did not for STI screening rates implement a health plan reimbursement law, were not identified in a single US study.

6.1.5 Sex Worker Registration The municipal government of Tijuana, Mexico has a system whereby registration cards are issued to sex workers through the municipal health department (267). The cost of this registration is $360 per person per year. There is mandated quarterly STI screening and monthly HIV testing that occurs at the municipal health department. Sirotin et al. (267) conducted a study among registered female sex workers (n = 410) to see if registration was associated with health benefits. Forty-four percent of participants in this study were registered with the municipal health department. The authors found that registered sex workers were significantly less likely than unregistered sex workers to test positive for

Population and Public Health, Ministry of Health Page 88 Core Public Health Functions for BC: Evidence Review Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections gonorrhea (4% vs. 12%), syphilis (18% vs. 40%), or any STI (33% vs. 53%), and the prevalence of active syphilis and chlamydia were similar. But after adjusting for other confounders associated with registration, registration was not found to be associated with the lower risk for a positive STI test. However, registered sex workers were found to have significantly fewer sex partners in the past month (median 70 vs. 145, p<0.001), as well as being significantly less likely to have had a sex partner who had ever injected drugs (7% vs. 25%, p<0.001).

Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence Registration of sex   In one study of registration of sex workers trade workers with the in Mexico, registration was not found to be municipal health associated with lower risk of testing department positive for STIs, in an adjusted model.

6.2 STI-specific Policy without an Evaluation of Impact on STIs 6.2.1 Screening Legislation Casson et al. (2002) describe the passage of legislation that guided STI screening efforts within a jurisdiction (258). While this article provides an interesting perspective on this process, and outlines the scope of such legislation, an evaluation of impact was not identified through the course of this review. See Box 6 for the description of Georgia’s Chlamydia Screening Bill (268).

Box 6: Georgia’s Chlamydia screening bill (268) The challenge: 80% of women infected with chlamydia are asymptomatic.

The process: Georgia’s state epidemiologist obtained federal funding to conduct pilot chlamydia screenings, and it was found that teenage girls had an incidence of chlamydia as high as 15% in some locations, and concerning rates of chlamydia were detected in all geographic areas across the state (urban and rural).

The Georgia Legislative Women’s Caucus, along with the American Social Health Association and other women’s advocacy groups, formed a Georgia STD Coalition. A Study Committee on Infectious Diseases, created as a result of a Georgia legislature resolution, determined that the cost of chlamydia complications was $51 million per year, and $59 million for hospitalizations due to chlamydia. This committee recommended that there was a need for the screening of at-risk populations.

The legislation: In 1998, legislation was filed that required all Georgia insurers to include an annual chlamydia screening as basic coverage for women under age 30 years. Despite some objections, the Georgia Chlamydia Screening Insurance legislation became law in July 1998. As well, the state budget included funds for public health to provide screening in public health clinics for at-risk women who were uninsured.

Evaluation: No evaluation of this legislation was identified in the course of this search.

Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence STI screening 0 0 Legislation from the US is described but no legislation evaluation is found

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6.3 Non-STI-specific Policy with an Evaluation of Impact on STIs 6.3.1 Alcohol Policy A number of publications have been identified that explore the relationship between various alcohol- related policies and STI rates, with a negative relationship proposed between interventions that increase alcohol control/decrease access and STI rates (269–274). A suggested mechanism for this relationship is that risky sexual practices that increase the risk of STI transmission (e.g., unprotected sex, unplanned sex, sexual assault and sex with multiple partners) are co-related with alcohol use. As such, policies that reduce population alcohol consumption and drinking above the Canadian Low-Risk Alcohol Drinking Guidelines (275) will likely reduce STIs. Alcohol policies include: increased alcohol taxes and alcohol prices; increased minimum legal drinking age; and “zero-tolerance” laws for drunk driving. Studies also evaluate density of alcohol outlets. These studies are generally ecological and therefore have limitations in establishing exposure-outcome relationships at the level of the individual, and in ensuring that other factors are not responsible for observed changes in STI rates (see Table 4 below).

For example, a study by Cohen et al. (269) involved a longitudinal analysis of alcohol outlets and gonorrhea in Los Angeles. As a result of the 1992 Civil Unrest, 270 alcohol outlets surrendered their licenses due to vandalism and arson. This provided a natural experiment to evaluate the impact of changes in alcohol outlet density on rates of gonorrhea in this region. The authors also note that if it is in fact the presence of boarded up buildings that signal social disorder and a change in community norms and tolerance of high-risk behaviour that is related to elevated STI rates, then the STI rates should in fact increase following the civil unrest. The analysis was at the level of the census tract; individuals that had been diagnosed with gonorrhea were identified and their addresses were geo-coded and aggregated by census tract. Age adjustment was performed. The authors found that after the civil unrest, a one-unit decrease in alcohol outlets per mile of roadway was associated with 21 fewer cases of gonorrhea per 100,000 in affected tracts vs. unaffected tracts (this finding was significant). A general decline in gonorrhea rates occurred during this time period in Los Angeles, however the decline in the study area where alcohol outlets were closed was higher. It is acknowledged however that there are many limitations, as multiple factors operating at the same time may have been responsible for decreased STI rates (e.g., an enhanced police presence in these neighbourhoods that discouraged high-risk behaviours).

The major findings of these studies are summarized in Table 4 below, many of which are published in economic journals and use an economics research methodology that is unfamiliar and therefore difficult to critically appraise with respect to the quality of research methods.

Table 4: Summary of Key Findings in Studies Exploring the Relationship between Alcohol Policy and STI Rates Reference Alcohol policy element Relationship with STI rates Chesson & Alcohol taxes A $1 increase in the per-gallon liquor tax is associated with a decline in Harrison gonorrhea rates by 2.1%. (2000) A $0.20 per six-pack increase in the beer tax is associated with a decline in gonorrhea rates by 8.9% Carpenter Zero Tolerance drunk Adoption of a Zero Tolerance Law is associated with a significant (2005) driving laws for reduction in gonorrhea rates among 15-19 year old white males in underage individuals particular (with no effect for older males, or black individuals, and mixed effects for white females). Sen & Luong Higher beer prices in Higher beer prices are correlated with a reduction in chlamydia and (2008) Canadian provinces gonorrhea rates.

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Reference Alcohol policy element Relationship with STI rates Scribner et al. Alcohol outlet density in A 10% increase in off-sale alcohol outlet density accounts for a .8% (1998) New Orleans increase in gonorrhea rates.

In response to the request for an expansion of the literature review on alcohol policy, an expert at the BC Ministry of Health provided a list of published and unpublished documents. These have been identified separately from the primary search, and are discussed below.

Booth et al. (276) conducted a review of the effects of alcohol pricing and promotion on alcohol consumption and a variety of other outcomes, including impact on STIs, in the UK. This unpublished document reviewed systematic reviews and meta-analyses. The authors reiterate the rationale for a postulated relationship in that while alcohol consumption does not itself cause STIs, it may increase the risk of exposure to a STI through risky sexual behaviour, as well as that alcohol may compromise the ability of the immune system to fight infections. The authors cite a single systematic review by Cook & Clark (277). Eight of 11 studies found that “hazardous” alcohol consumption (see below) is associated with an increased risk of STIs, and the other three studies found no significant association. Of these three studies that did not find a significant association, the authors reported a number of limitations including a small sample size in one study and the use of an insensitive measure of STIs in a second study. However, it is important to note that there were many different measurements of alcohol consumption, therefore it is difficult to determine which pattern of alcohol consumption is associated with the highest risk (276). The conclusion is that, based on these eight studies within the systematic review, alcohol consumption is associated with an increased incidence of STIs. The authors note however that it is challenging to establish a “consistent mechanism for direct causal effects”, due to the fact that there may be other explanations for the engagement in risk behaviours other than alcohol consumption.

Examining the Cook & Clark (277) paper in more detail, the stated objective was to examine the association between problematic alcohol consumption and STDs. Problem drinking involved “any specific drinking pattern that has been shown to be associated with harmful clinical or social problems”; specifically defined as “binge drinking (5+ drinks for men, 4+ drinks for women), high quantity/frequency (>7 drinks/week for women, >14 drinks/week for men), being drunk or intoxicated, or having alcohol- related problems or disorders.” Forty-two articles were felt to be eligible for detailed review based on specified criteria, while 11 of these included specific measures of problem drinking. These 11 articles are summarized in Table 5 below (note that one of the articles, Cook et al. (278), is not included here because the only STI reported was herpes simplex virus type 2 [HSV-2] infections).

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Table 5: Articles Examining the Association between Problematic Alcohol Consumption and STIs, identified by Cook & Clark (2005) Reference Population and Details of alcohol and Key Findings Comments Setting STI measures Shafer et al. Male youth in a youth STI Compared with youth Limitation: Self- (1993) (279) detention All participants asked who did not drink: reported STD center (n = 414). whether they ever had Youth reporting daily data was 65% African American a STD, and 65% tested drinking (13% of the combined with for chlamydia and sample) significantly lab and clinical Cross-sectional study gonorrhea (urethral more likely to have a data. culture), syphilis current or past STD (OR (serology), hepatitis B 3.53; 95% CI, 1.61–7.2). (serology), or genital Youth reporting heavy warts (clinical drinking (>20 examination). drinks/week) had Alcohol increased risk of STD (OR Quantity and 2.23; 95% CI, frequency of standard 1.08–4.62) – this when drinks consumed in controlling for lifetime past 3 months. number of sexual partners and low condom use. Ericksen & Data from the 1990 STI Binge drinking was Self-reported Trocki (1994) National Alcohol Survey question: associated with STD data (280) Survey (probability “have you ever had a increased risk of STD in sample of adults in 48 sexually transmitted men, which did not Cannot States, men n = 882, (venereal) disease (for remain significant during determine women n = 979). example, syphilis, multivariate analysis, temporal gonorrhea, genital and no increased STI risk relationship herpes, genital warts, in women. between alcohol chlamydia)?” Having >3 symptoms of consumption Alcohol drinking and STD Alcohol assessment associated with an questions included increased risk of STD in binge drinking (Five or both men and women more and this remained drinks in one sitting on during multivariate at least a weekly basis analysis. over the past year) and problem drinking (having three or more of eight major symptoms associated with alcohol abuse or dependence).

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Reference Population and Details of alcohol and Key Findings Comments Setting STI measures Ellen et al. Heterosexual men and STI Men who reported Limitations: The (1996) (281) women (n = 1442) Laboratory and clinical being drunk before sex alcohol variable attending assessments for were more likely to be (being drunk public STD clinics in gonorrhea and diagnosed with before sex in the three cities in the US. syphilis. gonorrhea (OR, 1.14; previous three -61% male Alcohol 95% CI, 1.02–1.29), but months) may -70% African American Self-report: how often this result did not lack validity. -More than 25% they were drunk from remain significant during Questions about current users of crack alcohol during sex in remain significant in whether the cocaine. the prior 3 months. multivariate analysis. No sample size was relationship between large enough to Cross-sectional study. being drunk during sex detect a and syphilis among men, difference in or for gonorrhea or syphilis rates, syphilis among women. given that 5% of the sample had syphilis.

Zhang et al. Women >25 years STI Compared with women Limitations: (1996) (282) who attended cervical Trichomonas who did not drink at Potentially large cancer screening identified by pap baseline, the RR of time difference program in China smears and baseline incident trichomonas between between 1974-1985 (n and every 2 years infection was baseline = 16,797). (average 3.5 significantly higher assessment of screenings per among women who alcohol Cohort study woman). drank 1-9 drinks per consumption Alcohol week [1.7 (95% CI, 1.30– and incident Number of drinks per 2.23)] but not among trichomonas week (0, 1–9, 10 or those who drank >10 infection more) and the number drinks per week [0.69 (detected up to of years of drinking (0, (95% CI, 0.22–2.15)]. 9 years later). 1–9, 10 or more). Uncertain why trichomonas was higher among women who drank 1-9 drinks/week but not 10 drinks/week.

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Reference Population and Details of alcohol and Key Findings Comments Setting STI measures Chokephaibulkit Pregnant youth in STI No significant difference Limitations: et al. (1997) Tennessee. Cases had chlamydia infection in the prevalence of Unclear what is (283) been diagnosed with diagnosed by culture. alcohol abuse between meant by chlamydia infection cases (33%) and controls ‘alcohol abuse’. (culture) at first Alcohol (39%). Sample size may prenatal visit (n = 67); Questionnaire also have been controls of similar age assessed for ‘alcohol small. and socio-economic abuse’, but details not status had first provided. prenatal visit on same day, but were not infected (n = 53).

Case control study Wilson et al. Women from clinical STI When assessing whether (1998) (284) and community-based Tested for chlamydial there was an increased settings in Brooklyn and gonococcal risk of a new STD with (1990-1994), n = 677, infections using consecutive levels of 232 had HIV. cervical culture, and alcohol consumption, 86% African American. trichomonas infection the result was not using vaginal culture statistically significant Cohort study at baseline and every (RR, 1.09; 95% CI, 0.97– 6 months. 1.22).

Alcohol Self-reported: number of times drank alcohol per week in a 1-year period (measured on a 7-point scale ranging from “never” to “more than 4 times a day”). Miranda et al. Women in prison in STI “Ever abusing alcohol” Limitation: (2000) (285) Brazil (n = 121) Gonorrhea (cervical was significantly definition of culture), chlamydia associated with syphilis alcohol abuse. Ross-sectional study (enzyme-linked infections only (OR, 2.0; immunosorbent 95% CI, 1.1–5.5), but not assay), syphilis with the other STIs. (Venereal Disease Research Laboratory [VDRL] screening with confirmation), and trichomonas (vaginal wet mount). Alcohol Survey that assessed whether the woman had “ever abused alcohol.”

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Reference Population and Details of alcohol and Key Findings Comments Setting STI measures Mehta et al. Male and female STI There were two alcohol Limitations: (2001) (286) emergency Urine sample used to questions that were Questions ask department patients test for gonorrhea and associated with an about “ever” in Baltimore; chlamydia using ligase increased risk of STD in having alcohol presenting for medical chain reaction. men: “ever been problems, but treatment of any type. Alcohol annoyed by others this is related to Note that the analysis Four CAGE questions criticizing your drinking” “current” STIs. was limited to (a screening test for and “ever had a drink participants aged 18- alcohol abuse and first thing in the 31 years. dependence). morning,” but only the latter question remained significant in multivariate analysis. None of the alcohol questions were associated with STDs in women. Miller et al. Aboriginal males and STI Persons with alcohol Limitations: (2001) (287) females aged 12 to 40 Laboratory testing for abuse were significantly Validity of years who were seen chlamydial and more likely to have an alcohol abuse at least twice between gonococcal infections incident gonococcal measure. 1996-1998 for STD (using a infection (RR, 1.46; P = testing at any of nine urine-based 0.007), but there was no public clinics in polymerase chain significant association Australia (n = 1034). reaction assay) and with chlamydial syphilis (serology). infections Alcohol (RR, 1.18; P = 0.28) or Alcohol abuse was syphilis (RR, 0.63; P = defined as “binge 0.42). drinking or regular heavy use” according to Aboriginal health workers. Thomas et al. Men and women STI The prevalence of (2001) (288) enlisted in the US chlamydia testing by a chlamydia among Navy in California (n = urine-based LCR assay. women who engaged in 299). problem drinking, Alcohol compared to those who Cross-sectional Problem drinking was did not, was 21.4% vs. defined as “consuming 4.6% (OR 6.6, 95% CI, alcohol until you 1.6–27.8) after adjusting passed out or for current pregnancy. vomited” within the previous 30 days.

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A working paper by Markowitz et al. (289) examined whether alcohol is a causal factor that affects sexual activity and risky sexual behavior among youth and young adults. Data was derived from the National Longitudinal Survey of Youth 1997 cohort (NLSY97) (n = 7900) and the biennial Youth Risk Behavior Surveys (YRBS) (n = 58,000). There was found to be a negative and statistically significant relationship between beer tax and male gonorrhea rates for both 15-19 and 20-24 year old males. Other conclusions were that alcohol use appears to have no causal influence in determining whether an individual has sex, and that alcohol use lowers contraception use (condoms and birth control specifically) among sexually active individuals.

Grossman et al. (271) examined the relationship between alcohol policies (e.g., beer taxes and statutes pertaining to alcohol sales and drunk driving) and rates of gonorrhea and AIDS among youth and young adults. They concluded that higher beer taxes are associated with lower rates of gonorrhea for males. Blood Alcohol Concentration (BAC) laws (i.e. laws that make it illegal to drive with a BAC higher than a certain level), and dry counties were found to have no effect. Zero tolerance laws with respect to drunk driving may also lower the gonorrhea rate among males under the legal drinking age.

Summary: While not demonstrated in all studies, literature on alcohol policies that look at various consumption and access measures found that alcohol reduction rates are associated with lower STI rates.

Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence Alcohol policy (e.g.,   The literature on alcohol policy includes the taxes, zero tolerance examination of multiple measures of reduced drunk driving laws, alcohol access or consumption and finds that minimum drinking measures that involve alcohol reduction are age, alcohol outlet associated with lower STI rates. This result is not density) mirrored in all studies, and the challenges in establishing causality are recognized, however there is a well-supported mechanism of association that has itself received support in the literature (i.e. the association between alcohol consumption and risky behaviour), and corroboration of evidence in a number of studies.

6.3.2 Other Policy Other ecological studies explore different policy-related variables and STI-rates, such as welfare policy (290,291). As this review is directed, there may yet be other policy initiatives that affect bacterial STIs that were not identified using the given search strategy.

6.4 Funding and Fees 6.4.1 STI Clinic Fees A study by Rietmeijer et al. (292) explored the impact of charging service fees for STI clinic attendance, on clinic attendance and gonorrhea and chlamydia detection. Although STI clinics often offer services at no or minimal cost, due to budget challenges a clinic in Denver introduced a clinic fee of $15 for Denver residents and up to $65 for non-residents. One month after the co-payment introduction, visits fell by 30%. This decline was greatest among women and younger individuals, with a particularly high decline

Population and Public Health, Ministry of Health Page 96 Core Public Health Functions for BC: Evidence Review Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections among residents from a neighbouring county that had to pay the higher $65 fee. Compared to the previous year, during the first three quarters of the year following the fee change there were 28.5% fewer visits (over 3000 fewer visits) to the clinic. Chlamydia diagnosis decreased by 28.1%; women and individuals under the age of 20 years were disproportionately affected (40% and 42%, respectively). There were also 38.1% fewer gonorrhea diagnoses. Among MSM, the number of visits decreased by 21%; gonorrhea diagnoses decreased by 40%; while early syphilis diagnoses increased by 8.8% (from 34 to 37 cases). Among individuals of lower socio-economic status (incomes below 100% of the federal poverty guidelines), the proportion decreased from 60% in the six weeks prior to the co-payment to 29% in the six weeks after, to 41% (which is still below the level prior to the co-payment). Further, although there was also a decline in gonorrhea and chlamydia cases by health care providers outside of the clinic during this same period, it was much smaller than the decline seen at the clinic, and the ratio of cases reported by the clinic and those reported by other sites, also declined. This suggests that even if there was a general decline in gonorrhea and chlamydia cases, the introduction of the co-payments at the Denver clinic had an effect on STI diagnoses.

Intervention Behavioural STI incidence/ Contextual considerations and comments outcomes prevalence Clinic co-  For impact on  For impact on STI Based on a single, well done natural experiment payments clinic visits diagnosis with strong theoretical rationale, the introduction of even a modest fee for STI clinic care has been shown to result in a considerable decline in clinic visits and impact the diagnosis of STIs.

6.4.2 Federal Funding Chesson & Owusu-Edusei, Jr (293) sought to examine the relationship between federal funding for syphilis elimination and syphilis. In 1999, the CDC instituted a national syphilis elimination plan. The authors examined syphilis incidence data, at the state level, between 1997-2005 and studied the association between amount of state-level funding and subsequent syphilis rates. They found that greater amounts of state-level funding for syphilis elimination in a given year were associated with lower state-level syphilis rates in subsequent years. Note that to test their results, tuberculosis was substituted for syphilis, and they did not find an impact of syphilis prevention funding on the tuberculosis rates. This suggests that the association observed between syphilis elimination funding and reduced syphilis incidence rates was not driven by a correlation between syphilis elimination funding and other state-level factor(s) that influence communicable disease incidence generally. Therefore the authors suggest that federally-funded syphilis elimination activities are having an inverse impact on syphilis rates.

Intervention Behavioural STI incidence/ Contextual considerations and comments outcomes prevalence Federal funding N/A  An inverse association was found between the amount for STI elimination of federal funding for syphilis elimination activities and the subsequent syphilis rate in later years, at the state level in a US study. Although this study design is ecological, it is appropriate for an examination of data at this level, and well-designed. While this topic would benefit from additional research to corroborate this finding, a sound theoretical rationale and study features, are key factors that influenced this rating.

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6.5 Clinic-based Systems Interventions Focused on Youth (Youth Supplemental Review) 6.5.1 Clinical Practice Improvement Focused on Youth (Youth Supplemental Review) Shafer et al. (294) describe a clinical practice improvement intervention that was designed to increase chlamydia screening among sexually active adolescent females (aged 14-18 years), seen during routine check-ups in pediatrics clinics, in a particular large Health Maintenance Organization (HMO) in the US. A RCT was conducted involving the random assignment of 10 pediatric clinics to the clinical practice improvement intervention (n = 1017 sexually experienced adolescent females) or to a control intervention (n = 1194). Staff at all sites received a one-hour session that included information about the epidemiology of chlamydia in adolescents, and the current chlamydia screening and treatment recommendations. The clinical practice improvement intervention was additionally implemented in the intervention sites and included engagement, team-building, redesign of clinical practice, and sustaining the gain (see Appendix D). Over the entire 18-month period, 47% of females in the intervention sites were screened compared to 17% at control sites; at 16-18 months, the screening rate among intervention clinics was 0.65 (95% CI 0.53-0.77) compared to 0.21 (95% CI 0.09-0.33) in the control clinics. Further, the chlamydia infection rate for the intervention clinics was 5.8% compared to 7.6% in the control sites (test of significance not reported).

6.5.2 Primary Care Systems Intervention Focused on Youth (Youth Supplemental Review) Ozer et al. (178) evaluated a systems-level intervention involving health provider training and the integration and utilization of modified screening and charting tools, aimed at increasing primary care clinicians’ screening and brief counseling of adolescents in a number of areas, including sexual behaviour. Component one involved training workshops to increase health care providers knowledge, self-efficacy and skills to conduct preventive services, and was delivered through didactic presentations, discussion, demonstration and role plays. Component two included the addition of follow-up questions to a screening questionnaire as well as prompts and cues relevant to the target areas in order to remind health care providers to screen and deliver brief counseling messages. Two pediatric clinics within a HMO in California were intervention sites (n = 37 providers), and two clinics served as control sites where usual care was delivered (n = 39 providers). The screening and counseling behaviours of health care providers were based on adolescents’ (age 13-17 years) reports collected after well-care visits (presumed to refer to visits for regular preventive care). Rates of screening and counseling increased significantly across all areas, including related to sexual behaviour, while significant increases were not seen in comparison sites. The training component appears to be responsible for most of this increase, with the addition of the tools not accounting for much additional change. Little detail is provided on the specific content of the sexual behaviour intervention so as to limit interpretation of these findings for this review.

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Intervention Behavioural STI incidence/ Contextual considerations and comments outcomes prevalence Clinic-based  To support  Data from HMOs in the US indicate that systematic changes systems screening in clinical practice can positively impact STI screening interventions uptake uptake among target populations on female youth.

A favourable impact on chlamydia infection is suggested in one study, however without the reporting of a test of significance it is difficult to know the implications of this result.

Implications for the Canadian context vs. the HMO context, is uncertain.

6.6 Mass Media Targeting Youth (Youth Supplemental Review) A selection of studies examined the relationship between various forms of mass media (television, music, movies, magazines, etc.) (295) as well as STI incidence/prevalence and sexual risk behaviours. The postulated mechanism for an association is the portrayal of sexual images while rarely portraying the consequences of sexual risk behavior (295,296). However, what is lacking is literature that evaluates an intervention limiting mass media consumption on behavioural or biological outcomes.

Wingood et al. (296) conducted a 12 month prospective study to examine the impact of the exposure to rap music videos on the incidence of STIs (chlamydia, gonorrhea and Trichomoniasis) and health risk behaviours (multiple sex partners, condom use, and other behaviour such as fighting, arrests, alcohol and drug use) among African American adolescent females (n = 522). Participants were between 14 and 18 years of age, had been sexually active in the past six months, and lived in lower socio-economic status neighbourhoods in Alabama. Adolescents were asked to estimate the volume and type of rap music videos they viewed, and the viewing circumstances (whom they viewed videos with, and where videos were viewed). Adolescents were tested for the three STIs under study. Over the 12-month period, 37.6% acquired a new STI, and adolescents that had greater exposure to rap music videos were significantly more likely to have acquired a new STI compared to those that had less exposure to rap music videos (AOR – adjusted by parental monitoring and adolescents’ employment status – 1.6 (95% CI 1.1-2.3, p=0.04). As well, 14.8% had sexual intercourse with someone other than their steady partner, and adolescents with greater music video exposure were significantly more likely to have had multiple sexual partners (AOR 2.0 (95% CI 1.1-3.4, p = 0.02). Condom use was not found to be significantly associated with rap music video viewings. As there are different types of rap music videos, data was collected on the type of rap music videos viewed; 70% of participants viewed a type of video that the authors report is explicit about sex and violence, however associations between each type of rap music video and STI incidence was not reported.

Wingood et al. (297) examined the association between exposure to sexually explicit (i.e., X-rated) movies and African American adolescent females’ sexual health-related attitudes and behaviours, in a cross-sectional study. Participants were age 14-18 years and sexually active within the past six months. Media exposures and sexual health attitudes were assessed by survey; interview assessed sexual behaviours (administered by African American female interviewers in private rooms); and self-collected vaginal swabs were used to assess STIs (chlamydia, gonorrhea and Trichomoniasis). Almost 30% of adolescents reported exposure to X-rated movies. Twenty eight percent of the sample had one or more STIs, with 5% diagnosed with mixed STI infections (chlamydia, gonorrhea and Trichomoniasis prevalence was 17.5%, 5.2% and 12.9%, respectively). Exposure to X-rated movies was associated with being

Population and Public Health, Ministry of Health Page 99 Core Public Health Functions for BC: Evidence Review Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections significantly more likely to test positive for chlamydia (AOR – for single-parent family and being monitored by someone other than one’s mother – 1.7, 95% CI 1.04-2.80, p = 0.03). A number of other attitudes and sexual risk behaviours were significantly associated with exposure to X-rated movies, including an increased likelihood of having had multiple sex partners (AOR 2.0 [95% CI 1.09-3.67, p = 0.03], and increased likelihood of not having used contraception in the past six months (AOR 1.5 [95% CI 1.03-2.30]).

Other authors such as L’Engle et al. (295), focused on attitudes (e.g., intentions to be sexually active) and sexual behaviours rather than STI incidence or prevalence outcomes. Significant associations are consistently observed between exposure to sexual content in the media and sexual intentions and sexual activity. For example, among a sample of 1011 Caucasian and African American male and female adolescents in the US, L’Engle et al. found that media influences accounted for 13% of the variance in intentions to have sexual intercourse in the near future; 10% of the variance in light sexual activity (having a crush, dating, being in a private place and kissing); and 8% of the variance in heavy sexual activity (breast touching, genitalia touching, oral sex and sexual intercourse), after controlling for age, sex, race and socio-economic status. Note that demographic factors predicted more variance in intentions to have sexual intercourse than media, parental, school or religion factors. However, media variables predicted more variance in sexual intentions and activities than did religion and school factors; more variance in light sexual activity than parent factors and peer factors; while media variables predicted less variance in sexual intentions than parental and peer factors, and less variance in heavy sexual activity than peer factors.

Interestingly, the American Academy of Pediatrics has proposed that adolescents’ access to sexually explicit media should be limited, and offered suggestions for how this might be accomplished. This includes enforcing the age limit for attending, renting or purchasing X-rated movies, and educating parents about the effects of viewing sexually explicit media on adolescent sexual health and behaviours. A media history form that has been developed by the American Academy of Pediatrics can be used to document and understand media use habits; pediatric visits can be used to provide education about media use in the home; and health concerns can be co-related with media use (298). It is uncertain however whether these suggestions have been implemented and evaluated.

Sznitman et al. (299) conducted a study that evaluated the impact of mass media messages on sexual risk behaviour change among African American adolescent males age 14-17 years (n = 1383). At baseline, 8.3% of participants tested positive for at least one STI (chlamydia, gonorrhea, Trichomoniasis), 19% reported multiple recent vaginal sex partners and 32% reported unprotected sex (vaginal, oral and/or anal) in the past 3 months. Two cities in each of two regions were selected; within each region, one city served as an intervention site and the other as a control site. All adolescents that tested positive for STI(s) were treated and received risk reduction counseling, however in intervention cities, adolescents were also exposed to a mass media HIV prevention program. This involved messages on mass media channels that were popular with African American youth (TV and radio), and took the form of “mini-dramas” involving African American adolescents resolving situations regarding sexual risk behaviour and modeling appropriate responses to challenges. High exposure to these advertisements were confirmed among the target population. This study found that among adolescents that tested positive for STI(s), those in the control arm reduced their number of vaginal sex partners and unprotected sex over the first six months, however after six months they returned to their previously high levels of risk behaviour. Whereas those in the intervention sites that received the mass media program demonstrated more stable reductions in unprotected sex. This suggests that mass media

Population and Public Health, Ministry of Health Page 100 Core Public Health Functions for BC: Evidence Review Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections interventions, coupled with other traditional care, may support long-term reductions in sexual risk behaviour.

Summary: A selection of studies demonstrated an association between exposure to different types of mass media (e.g., with sexually explicit content) and STI rates and sexual risk behaviours. However, what is lacking is literature that evaluates an intervention limiting mass media consumption on behavioural or biological outcomes.

Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence Mass media   An association between exposure to targeting youth different types of mass media (e.g., with sexually explicit content) and STI rates have been reported in prospective cohort and cross-sectional studies. There is a plausible mechanism and corroboration of evidence of this association.

What is lacking is research evaluating the impact of interventions that limit adolescents’ access to sexually explicit media, and how this impacts STI burden and sexual risk behaviour.

6.7 Social Marketing and Public Awareness Campaigns for MSM (MSM Supplemental Review) In the 1990s and early 2000s, a syphilis epidemic emerged in San Francisco. Data indicated at that time that the majority affected were MSM (300). As a result, the San Francisco Department of Public Health conducted a social marketing campaign to increase syphilis testing and awareness among MSM (300). Social marketing is a research-driven approach to behaviour change and consists of five components: branding, segmentation, price, placement, and promotion (301). The SFDPH conducted a social marketing campaign, the Healthy Penis campaign, in collaboration with a San Francisco-based social marketing firm in response to the syphilis epidemic. The primary campaign message was to deliver the “get tested” message to MSM. Secondary objectives were to increase awareness about the syphilis epidemic in MSM and to increase knowledge about syphilis. The campaign was conducted in MSM- concentrated neighborhoods. Humorous cartoon strips using characters like “Healthy Penis” and “Phil the Sore” were used to promote syphilis testing, to publicize the rise in syphilis rates among MSM, to provide information on syphilis transmission, symptoms and prevention, and to delineate the connection between syphilis and HIV. Cartoon strips were initially published in a popular gay Bay Area publication. Other posters were posted on streets, in bars and commercial sex venues, on bus shelters and on buses, on palm cards and on banner advertisements on popular internet sites for meeting sex partners for MSM. Figure 1 in Appendix F depicts an example of the cartoon strip.

To evaluate the campaign, the authors conducted two sets of surveys, one at six months after the campaign began, and the second 2.5 years after the campaign began. An increasing proportion of respondents reported syphilis testing in the previous six months by campaign awareness level (Cochran- Armitage trend test z = -3.303, p = 0.001) for the first evaluation; and z = -2.304, p = 0.02 for the second evaluation. After controlling for confounders, each increase in campaign awareness level during the first

Population and Public Health, Ministry of Health Page 101 Core Public Health Functions for BC: Evidence Review Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections evaluation was associated with a 90% increase in likelihood for having tested for syphilis in the past six months (OR 1.9, 95% CI 1.3-2.9). In the second evaluation, each increase in campaign awareness level was associated with a 76% increase in syphilis testing (OR 1.76, 95% CI 1.01-3.1). In 2005, after the campaign, the incidence of early syphilis was lower than in the previous three years, with decreases in cases among MSM accounting for the drop (data not provided). Although ecological, the authors surmise that this campaign, along with other San Francisco Public Health Department syphilis elimination efforts may have contributed to this decrease.

In Seattle and surrounding King County, in response to an increase in syphilis, chlamydia, and gonorrhea rates among MSM, Seattle Public Health established the “STD/HIV Prevention Task Force” (Task Force) to examine the health needs of MSM in Seattle and King County (302). The Task Force created a document entitled, “A Community Manifesto: A New Response to HIV and STDs”. This document had several objectives:  To identify and address key sexual behavioural issues  To promote an ethical framework for consideration and discussion by MSM  To promote practices to enhance personal and community sexual health for HIV-positive and HIV-negative MSM  To incite action so that future generations of gay and bisexual men do not inherit HIV as their problem.

The manifesto was first placed in both half and whole page formats in two Seattle weekly newspapers in October 2003. The manifesto was then reprinted weekly in these two publications for three months and then less frequently until a final publication in March 2004. Two local press conferences were also held to distribute the manifesto. The King County Executive and Director of Public Health publicly signed the manifesto to indicate their concern about the increasing risk behaviours and STIs among MSM. The manifesto was also posted on a website. A total of 136 persons endorsed and signed on to the manifesto. Seventy responses were submitted via the website. Sixty-seven percent indicated support for the manifesto, 18% did not support the manifesto and 16% gave no indication of their support. Themes of the focus group and comments on the website included:  Responsibility  Tone—some felt that there was a blaming and shaming tone of the manifesto toward HIV positive individuals  Timing—some felt that “the time is well past for this type of message”  Authorship—some wondered who wrote the manifesto

For those who completed the survey (web-based, mail-in or street-intercept), 84% had heard about the manifesto. About half of all respondents reported that the manifesto made them think about their sexual choices and behaviours. Twenty-seven percent indicated they had made changes to their behaviours. Sixty-one percent strongly agreed or agreed with the manifesto; 19% disagreed or strongly disagreed with it; 18% was neutral.

Martinez-Donate, et al. (303) conducted a social marketing campaign, “Hombres Sanos” (Healthy Men), targeted toward Latino heterosexual-identified MSM in a major US city. They developed materials to change social norms related to condom use and to promote HIV/STI testing. In their materials, they focused on promoting condom use during sexual encounters with men and featured condom use as a way to keep same sex practices secret. For example, they developed a poster that showed the shadow of two men having sex projected against the wall of a public bathroom. Most people not familiar with

Population and Public Health, Ministry of Health Page 102 Core Public Health Functions for BC: Evidence Review Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections male-to-male sexual encounters in public settings would not notice this poster as the shadow’s shape was ambiguous enough (Figure 2 in Appendix F). The text included Spanish-language captions, “No one knows… and with a condom, no one will.” Services offered include a male health exam that screened for diabetes, hypercholesterolemia and hypertension, in addition to HIV and STI testing.

To evaluate the campaign, the authors conducted cross-sectional surveys every month with samples of Latino men. Two hundred and sixty men were recruited per survey wave. Men were recruited from seven “low-risk” venues (workplaces, shopping centres), and five “high-risk” venues (an adult bookstore and bars and clubs). They found that there were no changes in the prevalence rates of unprotected sexual practices with females over the previous 60 days. There was a significant increase in the percentage who reported and demonstrated condom carrying during the campaign (AOR 2.28, 95% CI 1.59-3.27) and post-campaign (AOR 1.62, 95% CI 1.06-2.49), compared with baseline. HIV testing during the previous six months increased significantly from baseline to post campaign (AOR 3.13, 95% CI 2.06- 4.75). The percentage of heterosexual respondents who knew where to get tested for HIV increased during the campaign (AOR 1.60, 95% CI 1.26-2.02) and post campaign phases (AOR 1.57, 95% CI 1.18- 2.08). Respondents’ average level of perceived risk for HIV was higher during the campaign (B=0.013; 95% CI 0.04-0.13) and post campaign (B=0.27, 95% CI 0.17-0.37) than during baseline.

Pedrana, et al. (304) conducted a social marketing campaign among Australian MSM to address the rise in HIV and STI rates. In February 2008, the Victorian AIDS Council/Gay Men’s Health Centre launched the “Drama Downunder” social marketing campaign. The campaign used mainstream advertising, as well as gay media and included multiple advertising channels. Other innovative methods for dissemination include fridge magnets, drink holders and underwear. Campaign-specific events were held. The campaign used humour extensively and a website was created. Figure 3 in Appendix F depicts a sample of a campaign poster.

Surveying a convenience sample of 295 MSM, the authors found that campaign awareness was high (86%). In multivariable logistic regression, awareness of the campaign was independently associated with having had any STI test within the past 6 months (prevalence ratio 1.5, 95% CI 1.0-2.4). Compared with the 13 months before the campaign, their data showed significant increasing testing rates for HIV (RR 1.17 initial period, RR 1.27 continued campaign period), syphilis (RR 1.19 initial period, RR 1.29 continued campaign period) and chlamydia (RR 1.15 initial period, RR 1.28 continued campaign period) among HIV-negative MSM (all p < 0.01) as compared to baseline.

Finally, Wei, et al. (305) conducted a Cochrane Review looking at RCTs using an interrupted time series and pretest-posttest design studies (uncontrolled or controlled) that compared social marketing interventions with no intervention. They found three studies and included it in their final analysis. Their meta-analysis showed that the campaigns were effective on HIV testing uptake (OR 1.58, 95% CI 1.40- 1.77) but were not effective in increasing STI testing uptake (OR 0.94, 95% CI 0.68-1.28). They also noted a high risk of bias and a low quality of evidence for the three studies.

Darrow and Biersteker (306) and Guy, et al. (307) were serial cross-sectional pretest-posttest design studies without a control while Darrow and Biersteker implemented a social marketing campaign in South Florida. About 800 posters and 173,000 palm cards were distributed in bars, clubs and elsewhere; 119 advertisements were placed in local publications and six billboards were erected. Syphilis alert banners appeared on three websites and three different public service announcements were created and scheduled to be broadcast 1770 times on radio or television. Figure 4 in Appendix F depicts some of

Population and Public Health, Ministry of Health Page 103 Core Public Health Functions for BC: Evidence Review Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections the posters and palm cards used. Risky sexual practices and patterns of recreational drug use did not change. There were no significant increases in knowledge, clinic visits or testing or treatment for syphilis.

Guy, et al. (307) conducted the “Check-It-Out” social marketing campaign targeting a broad range of MSM in Australia. Posters and takeaway cards (Figure 5 in Appendix F) were developed and displayed in six hotels, four nightclubs, two gyms, five cafes, and 13 sex on premises venues frequented by the MSM community. Annual behavioural surveys were conducted following the social marketing campaign found that there was no significant increase in this overall proportion of MSM reporting having an HIV or STI test in the past 12 months.

Summary: Although various social marketing campaigns have shown promise in uncontrolled studies, with some studies demonstrating an increase in uptake of STI testing and a reduction of risk behaviours, the evidence from controlled studies for the use of social marketing campaigns in controlling for bacterial STIs is not conclusive.

Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence Social marketing   Although various social marketing campaigns campaigns for MSM have shown promise in uncontrolled studies, the evidence from controlled studies for the use of social marketing campaigns in controlling for bacterial STIs is poor. Some studies have shown an increase in uptake of STI testing and a reduction of risk behaviours. No studies were found evaluating the impact of social marketing campaigns on STI incidence/prevalence.

6.8 CDC and PHAC Guidelines: Special Populations As previously discussed in the micro-level interventions section, the following is a review of key guidelines in Canada and the US regarding a variety of special populations. No evaluation was found of these guidelines in their entirety (i.e. incidence/prevalence of bacterial STIs before and after a jurisdiction adopts these guidelines). However, many of the interventions discussed in this review, for which evidence is available, comprise these guidelines.

Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence PHAC and CDC 0 0 No evaluation was found of the impact of guidelines these guidelines on STI rates at the population level, however there is literature examining use among health care providers (discussed below), and these guidelines consist of interventions that are discussed throughout this report.

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6.8.1 Pregnant Women US CDC guidelines suggest women be screened as early as the first prenatal visit for HIV (308), syphilis (309) hepatitis B surface antigen (HBsAg) (310), and chlamydia (311). In addition, pregnant women who live in an area with a high prevalence or at risk for gonorrhea should be screened (312). These risk factors include women under the age of 25 years, a previous gonorrhea infection, other STIs, new or multiple sex partners, inconsistent condom use, sex trade work, and drug use. If they are found to have gonococcal infection during the first trimester, they should be retested within 3-6 months, preferably in the third trimester. Women deemed to be at high risk should also be retested in the third trimester for the above. US guidelines do not recommend routine testing in asymptomatic pregnant women for bacterial vaginosis (BV), trichomonas vaginalis, or HSV-2 in asymptomatic pregnant women (113).

Canadian guidelines recommend all pregnant women be screened for HIV, HBsAg, chlamydia and gonorrhea and syphilis (13). Although Trichomoniasis and BV have been shown to adversely affect pregnancy outcomes, owing to the increased risk of pre-term birth with treatment, routine screening is not recommended. Canadian guidelines recommend counselling on the signs and symptoms of HSV infection, as well as risk reduction behaviours. Routine screening with HSV serology is not routinely recommended. If a known or serosusceptible pregnant woman is known to have a partner with oral or genital herpes, it is important to advise abstinence from oral and/or genital sexual contact. For a pregnant woman with genital warts, Cesarean section is not recommended for reduction of transmission of HPV to the newborn. This is similar with US CDC recommendations. If a pregnant woman is acutely infected with HBV or are chronic carriers, they can transmit the virus to the infant. Use of hepatitis B immunoglobulin (HBIg) and HBV vaccine in the neonate can prevent 95% of cases. The first dose of HBV vaccine should be administered within 12 hours of birth and HBIg immediately after birth. The infant should also receive two additional doses at 1 and 6 months. If a pregnant woman has HCV, they should be referred to specialists who have expertise in the treatment of HCV. Current treatments are contraindicated in pregnancy for HCV. For women not pregnant, it is recommended that if they have received ribavirin as part of a combination treatment for HCV infection, they and their partner should use an effective form of birth control to prevent pregnancy.

6.8.2 Adolescents US CDC guidelines recommend routine screening for chlamydia and gonorrhea for all sexually active females aged 25 years and younger is recommended (311,312). Evidence is insufficient to recommend routine screening for chlamydia in sexually active young men. HIV screening should be discussed with all adolescents and encouraged for those who are sexually active and/or use injection drugs (313). The routine screening of adolescents for syphilis, Trichomoniasis, BV, HSV, HPV, hepatitis A (HAV), and HBV is not recommended (113).

Canadian guidelines do not include a separate chapter on adolescents, but the specific infection chapters recommend screening for gonorrhea and chlamydia in males and females aged 25 years and younger (13).

6.8.3 Children In children (other than neonatally acquired) with STIs, close collaboration between clinicians, and child protection authorities is essential. Official investigations should be initiated promptly. Gonorrhea, syphilis, and chlamydia are virtually indicative of sexual contact, and for a young child, of sexual abuse. In Canada, the law recognizes some minors as having the ability to consent in some situations (13).

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Persons over the age of 14 are recognized as being able to give consent to participate in sexual activities, unless the activities are taking place in a relationship where one participant has some authority over or is in a position of trust in relation to the other person, where there is dependence, or where there is exploitation. A 12 or 13 year old can also consent to engage in sexual activity with someone who is less than two years older and with whom there is no relationship of trust, authority, dependency, or exploitation. Children under 12 do not have the legal capacity to consent to any form of sexual activity. Canadian guidelines recommend children being screened throughout childhood, during routine visits to health care providers’ offices, for evidence of sexual abuse.

As with US CDC guidelines, Canadian guidelines recommend the direct involvement of experienced teams or services. The role of the health care provider is not to determine guilt or innocence of the suspected parties but to: 1. Take a pertinent medical history. 2. Ensure the physical and emotional well-being of the patient. 3. Treat or prevent illness or injury. 4. Accurately record spontaneous disclosure or volunteered information. 5. Obtain and document physical findings consistent with abuse or suspicions of abuse. 6. Inform the child and caregivers about the medical outcome of the investigation. 7. Assist child protection and law enforcement agencies in their investigation.

Forensic specimens should be obtained by professionals trained in these procedures. Chemoprophylaxis is recommended if:  The patient presents within 48 hours after an assault.  It is requested by the parent or guardian (or patient).  The patient is at high risk for an STI.

Follow-up tests are recommended. All persons named as suspects in child sexual abuse cases should be evaluated for STI. Chemoprophylaxis may or may not be offered and treatment decision is based on history, clinical findings, and test results.

6.8.4 Inmates and Persons in Correctional Facilities US CDC guidelines recommend universal screening of adolescent females for chlamydia and gonorrhea at intake in juvenile detention facilities (113). CDC guidelines also suggest universal screening of adult females at intake for chlamydia and gonorrhea up to 35 years of age. This is largely based on the fact that females in juvenile detention facilities and young women under the age of 35 years have high rates of chlamydia (314) and gonorrhea (315). For syphilis, they recommend universal screening on the basis of local area and institutional prevalence of early infectious syphilis. No other comprehensive US guidelines have been developed.

Canadian guidelines suggest components of STI prevention programs for the general population are also applicable to the prison population (13). This includes education, voluntary testing and counselling, distribution of clean needles or bleach, distribution of condoms and drug-dependence treatment. Partner notification and testing and treatment of recent sexual contacts are important as well. Correctional Services Canada (CSC), along with the PHAC, has implemented initiatives aimed at preventing and controlling the transmission of STIs within federal correctional facilities. These include confidential, voluntary testing for inmates on admission and throughout incarceration, and pre- and post-test counselling. Serologic testing and also HAV and HBV immunization are offered. Educational

Population and Public Health, Ministry of Health Page 106 Core Public Health Functions for BC: Evidence Review Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections materials are also provided. CSC also has provided condoms, bleach kits, and a pilot project of tattoo parlours in six federal prisons. CSC, however, does not provide needle distribution or exchange services owing to its zero-tolerance policy on drug use in prisons.

Health care providers should take a complete sexual history (PHAC, 2009), including asking about high risk sexual practices such as receptive and insertive anogenital intercourse, or-anal intercourse, unprotected sex, sharing of sex toys, receptive manual-anal intercourse, substance use during sex, tattooing and IDU and other drug use. Canadian guidelines recommend greater use of routine testing for inmates at risk, including screening for chlamydia, gonorrhea, syphilis, HIV, and HBV. If symptoms are present, inmates should be tested for HSV. HCV serology should be obtained for those who use injection drugs, have tattoos or engage in high risk sexual practices. HAV serology should also be obtained for those at high risk.

6.8.5 Men Who Have Sex with Men US CDC guidelines recommend that clinicians should assess the STI-related risks for all male patients, including asking about the sex of sex partners (113). Risk assessment for MSM should be nonjudgmental. Counselling on high-risk activities should be done. Health care providers should also be familiar with the local community resources available to assist MSM at high risk. Symptoms associated with common STIs, such as urethral discharge, dysuria, genital and perianal ulcers, lymphadenopathy, skin rash, and other anorectal symptoms. Routine laboratory testing should include HIV serology, and syphilis serology. For those who have had insertive intercourse during the preceding year, testing of the urine using nucleic acid amplification testing (NAAT) for chlamydia and gonorrhea is suggested. For those who have had receptive anal intercourse during the preceding year, a NAAT test for rectal infection for chlamydia and gonorrhea is suggested. A NAAT test for pharyngeal infection for gonorrhea is suggested for those who have had receptive oral intercourse during the preceding year. Testing for chlamydia pharyngeal infection is not recommended by the US CDC. Screening for HSV-2 with type- specific serology can be considered if infection status is not known. Screening for anal cancer and pre- cancerous lesions in the anus can be considered but the evidence on this practice is limited. STI screening at frequent intervals of every three to six months can be considered for MSM who have multiple or anonymous partners, or those who have sex associated with illicit drugs. Testing for HBsAg should also be considered, and if not infected and not immunized, be immunized for both HBV. If not immune to HAV, vaccination is also recommended. Routine serologic testing of HCV should also be considered.

Canadian guidelines also suggest taking an appropriate history and discussing the risks of specific sex practices (13), including receptive and insertive anogenital intercourse, oral-anal intercourse, unprotected sex, sharing of sex toys, rectal douching in association with receptive anogenital intercourse, receptive manual-anal intercourse, anonymous partnering and use of anonymous partnering venues, substance use accompanying sex, and IDU and substance use. Canadian guidelines suggest that based on the risk assessment, routine STI screening at all potential sites of infection for chlamydia, gonorrhea, and syphilis, HIV serology, and HBV and HAV serology (if not previously immunized, known to be immune, or known to be positive). Asymptomatic screening for HSV and HPV is not currently recommended.

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6.8.6 Women Who Have Sex with Women US CDC guidelines state that women who have sex with women (WSW) should not be presumed to be at low or no risk for STIs based on the gender of their sexual partners (113). CDC guidelines note that there is paucity of evidence regarding STI risk transmitted by sex between women, but that sexual practices such as digital-vaginal or digital-anal contact, especially with shared penetrative sex items are a possible means of transmission of infected cervico-vaginal secretions. While the rate of chlamydia transmission between women remains unknown, infection can be acquired from past or current male partners. There have been reports of syphilis transmitted between female partners as well (113). Thus US CDC guidelines recommend screening for STIs in WSW. Screening for BV, although common among WSW, is not advised for asymptomatic women, and neither is treatment.

Canadian guidelines suggest that STI-screening for WSW should be based on a detailed risk assessment, not on assumptions of low risk behaviours (13).

6.8.7 Sex Trade Workers Sex trade workers may be female, male, or transgender who exchange sexual services for money, food, or shelter (13). Canadian guidelines focus on the promotion of safer sexual behaviour through female and male condom availability and education on correct usage, improved negotiating skills and supportive policies and laws (13). Education, outreach work, accessible services, advocacy, community development, program coordination and sex worker involvement are all cited by the Canadian guidelines as best practices. HBV vaccination should be available to all sex trade workers, and HAV vaccination should be available to those at high risk (male sex trade workers).

Evaluation of sex trade workers includes a routine STI history and physical examination. Women should undergo a speculum exam and throat and rectal exam, if warranted. History and counselling should focus on asking about current and past drug use, regular partners, and condom usage with clients and partners.

6.8.8 Neonates Vertical transmission of chlamydia and syphilis can occur to the neonate born to mothers infected with chlamydia or syphilis. Screening of pregnant women for STIs has been discussed above. Hollier and Workowski (316) conducted a review of the treatment of STIs in pregnancy and the recommendations presented below are based on their findings.

Syphilis—US CDC guidelines suggest nontreponemal screening during pregnancy at the first prenatal visit and a repeat test in the third trimester (113). Penicillin G, in benzathine, aqueous procaine, or aqueous crystalline form, is the drug of choice in all stages of syphilis (316). It is also the only effective treatment for the prevention of congenital syphilis. Other antibiotics have not been shown to be effective or have had adverse fetal effects. For penicillin-allergic patients, desensitization therapy should be considered.

Gonorrhea—Cefixime and ceftriaxone are recommended as treatment for pregnant women diagnosed with gonorrhea. Untreated infection is associated with septic spontaneous abortion and infection after induced abortion, preterm delivery, premature rupture of membranes, chorioamnionitis, and postpartum infection (316). Neonatal infections include ophthalmia neonatorum, scalp abscess or disseminated disease.

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Chlamydia—Untreated chlamydia infection increases the risk of preterm delivery, premature rupture of membranes and perinatal mortality (316). Conjunctivitis and pneumonia can also occur to infants born to mothers with genital chlamydia infection. Treatment for pregnant women consists of azithromycin 1 g in a single dose or amoxicillin 500 mg three times a day for 7 days. Treatment for the neonate diagnosed with chlamydial conjunctivitis or pneumonia is with oral erythromycin (113).Topical erythromycin is not effective.

Trichomonas —Trichomonas infection in pregnancy has been associated with preterm premature rupture of membranes, preterm delivery, and low birth weight infants (316). However, because of an increased rate of adverse outcomes among those treated for trichomonas in two RCTs (317,318), screening of asymptomatic women and subsequent treatment is not recommended.

Bacterial vaginosis (BV)—BV during pregnancy may be associated with premature rupture of membranes, preterm labour, preterm birth, chorioamnionitis, post-abortion endometritis and postpartum endometritis. Although US guidelines do not recommend universal screening for BV, Hollier and Workowski (316) note that all symptomatic pregnant women should be tested and treated with oral metronidazole.

6.8.9 Aboriginal People Neither the US nor Canadian guidelines address Native American or Aboriginal groups with regard to STI prevention and control. One article was found by Steenbeek looking at a holistic approach in preventing STI among First Nations and Inuit adolescents in Canada (319). Steenbeek outlines several strategies to assist nurses, particularly practitioners of holistic nursing, in delivering health education to Aboriginal youth on the prevention of STIs. These strategies include participatory action research (PAR), the use of peer leaders, and the development of self-advocacy skills. PAR is a form of research that involves collaboration between the researchers and the population being researched, a process by which both parties educate one another; and a focus on knowledge production that benefits the local community. PAR therefore, involves the participants in a way that other research might not; the participants “own” their own data and use it to better their lives. Steenbeek argues for adolescent peer educators in the area of STI prevention programs. Peer educators can distribute STI-related information, collect accurate data, program planning, and modify relevant norms and behaviours for youth no longer in school and street youth. Steenbeek states that studies have shown that health promotion programs need to include messages delivered by people who share similar life experiences in order for them to be effective. However, Steenbeek acknowledges that, as of 2004 at least, there is little evidence to support the use of peer educators among the Aboriginal population. Finally, developing self-advocacy skills among Aboriginal adolescents is another strategy that may be employed to prevent STIs. Steenbeck defines self-advocacy as “the ability to seek, evaluate, and use information to promote one’s own health.” Steenbeck suggests that holistic health nurses can help Aboriginal adolescents become appropriately assertive by teaching them to ask for information and to make their own decisions about their care. Role-playing, teaching negotiation skills, and making health education materials accessible can help adolescents understand their own health problems and to share them with others whom they trust. The main goal is to allow Aboriginal adolescents take control of their own health. Steenbeck notes that some other aspects of self-advocacy health promotion programs may include presenting pre-adolescents with a healthy picture of adulthood, maintaining sexual abstinence, and the physiology of puberty in pubertal developmental transition. Nurses involved in monitoring their physical development should be aware of signs of high stress, poor coping, and devaluation of self, especially during periods of transition.

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6.9 CDC and PHAC Guidelines: Interventions In addition to the reviews and primary research presented in the micro-level interventions section of this report, the interventions discussed in the CDC and PHAC guidelines are reviewed here. No jurisdiction-wide evaluation of these guidelines was found during the course of this search.

6.9.1 Counselling The US CDC guidelines states the US Preventive Services Task Force (USPSTF) recommends high-intensity behavioural counselling for all sexually active adolescents and for adults at increased risk for STIs and HIV. This includes, for providers, taking an appropriate sexual history and educating clients and patients on abstinence, condom use, limiting the number of sexual partners, and modifying sexual practices. This should be done in a nonjudgmental manner that respects the client’s or patient’s culture, minority status, language, age, and sexual orientation. Interactive counselling can be effectively used by health care providers. Extensive training is not required to perform effective risk reduction counselling, but the quality of counselling is improved when providers are trained. The US CDC has training resources located on their website (http://www.cdc.gov/std/training/onlinetraining.htm). Other effective behavioural interventions are also summarized on their website (http://www.effectiveinterventions.org).

Canadian guidelines suggest an 11-step process in preventing, diagnosing, and managing STIs in the primary care setting (13): 1. Assessing the reason for a consultation 2. Knowing about STI risk factors and epidemiology 3. Performing a brief patient history and STI risk assessment 4. Providing patient-centered education and counselling 5. Performing a physical examination 6. Selecting appropriate screening/testing 7. Diagnosing by syndrome or by organism and post-test counselling 8. Treating 9. Reporting to public health and partner notification 10. Managing co-morbidity and associated risks 11. Following up

In assessing the reason for a consultation, the Canadian guidelines present an algorithm whereby providers can assess the risk for STIs (Figure 3).

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Figure 3: STI Risk Assessment in a Primary Care Setting

Adapted from the Canadian Guidelines on Sexually Transmitted Infections – January 2010 (Government of Canada, 2010).

The Canadian Guidelines list risk factors that are associated with an increased risk of STIs. They suggest that the following should be asked, in addition to asking about symptoms of STIs:  Sexual contact with person(s) known to have an STI  Sexually active youth under age 25 years  A new sexual partner or more than two sexual partners in the past year  Serially monogamous individuals who have one partner at present but who have had a series of one-partner relationships over time  No contraception or sole use of non-barrier methods of contraception  Injection drug use  Other substance use, especially during sex  Any individual who is engaging in unsafe sexual practices (sharing sex toys; oral or anal sex; sex with blood exchange)  Sex trade workers and their clients  Exchanging sex for money, drugs, shelter, or food  Homelessness  Anonymous sex (internet, bathhouse)  Victims of sexual abuse  Previous STI

Common counselling topics that are recommended include advice on serial monogamy, contraceptive advice, discussion of safer sex for youth contemplating initiation of sexual activity, acceptance of sexuality, planning prevention (such as buying condoms, seeking testing, limiting alcohol and drug use

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6.9.2 Abstinence The US CDC recommends abstinence (from oral, vaginal, and anal sex) and the reduction of the number of sex partners as a way to avoid or reduce the transmission of STIs (12).

Canadian guidelines also recommend discussion of abstinence and mutual monogamy as a component of safer-sex counselling.

6.9.3 Male Condoms Male latex condoms, when used consistently and correctly, are highly effective in preventing the transmission of bacterial STIs, including chlamydia, gonorrhea, syphilis, chancroid, and Trichomoniasis (12). In Canada, condoms are also regulated by Health Canada and are considered medical devices (320).

6.9.4 Female Condoms Canadian guidelines note that the female condom, in the form of a polyurethane vaginal pouch is commercially available and can be used as an alternative barrier form of STI prevention (13). Although the manufacturer does not recommend it, some have used it for anal intercourse. US CDC guidelines state that the efficacy for this use is unknown; Canadian guidelines suggest modifications, training, and research are needed to address possible safety concerns, as there appears to be a higher incidence of rectal bleeding and slippage in comparison to the male condom.

6.9.5 Topical Microbicides and Spermicides The US CDC guidelines state that studies looking at non-specific topical microbicides for the prevention of HIV and STIs have generally shown them to be ineffective (12). Spermicides containing N-9 should not be used due to the increased risk of acquiring HIV and STIs. Both US and Canadian guidelines also caution against the use of N-9 lubricated condoms due to the increased risk of HIV and STI acquisition (12,13). Moreover, both guidelines recommend against the use of N-9 rectally.

6.9.6 Male Circumcision Although the World Health Organization and the Joint United Nations Programme on HIV/AIDS (UNAIDS) have recommended that male circumcision be scaled up as an effective intervention for the prevention of HIV in countries with high HIV prevalence, predominantly heterosexual transmission and low male circumcision prevalence (321), the US CDC guidelines have not made similar recommendations for the US. Canadian guidelines have not recommended for or against male circumcision for HIV or STI prevention in their latest guidelines.

6.9.7 Patient-delivered Partner Therapy (PDPT) US CDC guidelines recommend that when the index patients indicate that their partner is not likely to seek evaluation and treatment, PDPT, which is a form of expedited partner therapy (EPT) (12) may be effective, where legal. EPT is giving treatment without partners seeing a health care provider.

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Canadian guidelines suggest that partner notification may be done by the patient, health care providers, or public health authorities (13):  Self- or patient referral: the infected person accepts full responsibility for informing partners of the possibility of exposure to an STI and for referring them for treatment and management.  Health care providers/public health referral: with the consent of the infected person, the health care provider takes responsibility for confidentially notifying partners of the possibility of their exposure to an STI (no names are ever given, even though in some relationship it may be obvious as to who the index case is).  Contract referral: the health care provider negotiates a time frame with the infected person (usually 24-48 hours) to inform his or her partners of their exposure and to refer them to appropriate services.

Canadian guidelines also discuss some barriers to partner notification including fear of physical or emotional abuse from partner notification; fear of losing a partner; feared legal procedures; fear of re- victimization on the part of sex crime victims; and anonymous partnering. Public health or health care provider referral may be the best option for some of these perceived barriers. Canadian guidelines also discuss in brief EPT and PDPT, but state that these novel methods are still controversial.

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6.10 Evaluation of STI Control Strategies 6.10.1 Evaluation of STI Control Strategies at the Level of Populations Using the above described directed GoogleTM search, and within the published literature, no studies were found that evaluated the impact of jurisdiction-wide STI control strategies (e.g., CDC, PHAC, and provincial STI Control Strategies) and their impact on STI rates. This is not surprising, as such as a study has a number of epidemiological and methodological challenges. A study of this nature would need to measure STI rates before and after implementation of an entire region-wide control strategy, finding some way to control for the almost certain reality that certain components of the strategy will already be in operation within the region prior to the time of official strategy implementation. Further, to ensure that another control strategy had not been adopted by the jurisdiction during the same time period (or if it had, to find some way to control for the effect of this strategy which almost certainly will have similar interventions). For example, Canada may be signatory to both a Public Health Agency of Canada strategy and the World Health Organization strategy; further, provinces and territories within Canada may also have their own strategies. These three strategies will likely have many common elements and some differences, therefore it would be extremely complex to tease apart the relative contribution of each strategy to the STI burden within the population.

However, an unpublished document was provided by an expert reviewer that presented an evaluation of a specific Alberta syphilis prevention campaign (322). This campaign was undertaken in response to a syphilis outbreak declared in 2007. The Syphilis Prevention Campaign targeted youth and young adults age 16-24 years, and had two streams: 1) Don’t You Get It (DYGI) and 2) Plenty of Syph (POS). The aim of both steams was to make individuals more cautious about their sexual behaviours and to encourage testing if at risk, and included raising doubts that sexual partners may be affected by syphilis. Messages were disseminated via multiple mediums, including television, radio and online advertisements (CTV, ComedyNetwork, MTV, MSN, Facebook, etc.); video boards in restaurant/bar bathrooms; and posters in restaurants/bars. Evaluation data was collected through a 10-item public survey in eight communities across the province, primarily in bars as well as on the street (n = 996), and STI clinic nurse/manager interviews.

Eighty-nine percent of respondents recalled seeing or hearing at least one of the advertising components used in the campaign. There were some differences in the particular component(s) that respondents remembered hearing or seeing when disaggregated by age, gender and geographic location. Seventy-six percent of participants reported receiving the messages that a person could have syphilis and not know it, and 75% knew that syphilis may not have visible symptoms. Approximately half shared the information that they had learned from the information they learned through the campaign (with individuals age 25-39 years being most likely to share information, and individuals over age 50 years being least likely). Among respondents that had seen/heard/visited campaign resources, the majority did not feel that the information in the advertisements/websites made them wonder whether they might be at risk of having syphilis (“not at all” [59%]), while 29% reported “a little” and 12% reported “a lot”. The youngest ages (age 16-17 years) were the most likely to indicate that the information made them wonder either “a little” (40%) or “a lot” (30%) whether they might be at risk of having syphilis. Sixty-seven percent stated that they would be very likely to get tested if they felt they were at risk of having syphilis, while 17% reported “somewhat likely” and 17% reported being “somewhat likely”. Seventy-seven percent reported that they would know where to get tested if they felt at risk of having syphilis, with a general increase with age (excepting the oldest category age 60 and older). One-third reported still needing information about syphilis.

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Interestingly, the STI clinic nurses observed that, beginning from the launch of the campaign, there was an increased volume in the number of people visiting STI clinics, increased numbers requesting STI testing, and increased number of individuals requesting syphilis testing and/or confirming that STI testing included syphilis testing. The information from the provincial laboratories also reported increased STI testing during the campaign. Information from provincial lab labs also indicated increased testing of STIs during the campaign.

6.10.2 Evaluation of STI Control Strategies or Guidelines at the Institutional Level Three studies from the US were identified that explored health provider adherence to CDC treatment guidelines, and factors associated with adherence. These studies do not evaluate the relative impact on the presence of guidelines on STI rates however.

Swails et al. (2014) conducted a case-control study that examined adherence to the CDC treatment guidelines among health care providers in Massachusetts (323). Data was collected by the Massachusetts Department of Public Health Division of STD Prevention, who called providers that ordered gonococcal tests that tested positive. These providers were asked to complete a case report form that included identification of the treatment given. It was found that 96% were treated according to the CDC guidelines (at that time), while 4% were not. A number of factors were found to be significantly associated with non-adherence, although the confidence intervals were very wide: patient penicillin or cephalosporin allergy (AOR], 8.7; 95% CI 2.6–29); private offices and health maintenance organization (HMO) practices (AOR 16; 95% CI, 1.6–155) compared with family planning/STD clinics; and non–high-incidence rate cities (AOR 4.3; 95% CI, 1.8–11).

In a study in Philadelphia, the Department of Public Health sent notice (via Health Alert) to local health care providers that emphasized the preferred treatment for gonorrhea (stimulated by increasing resistance to cephalosporins that, in 2012, led to the CDC no longer recommending cefixime and instead recommending dual treatment with ceftriaxone plus either azithromycin or doxycycline, as first-line treatment) (324). After this, the Department of Public Health’s STD Control Program began active treatment surveillance for all reported gonorrhea cases, and was able to determine treatment in 92% of the cases. It was found that 92% were given the recommended treatment, while 8% were not. Health care providers that diagnosed two or less gonorrhea cases were more likely to treat with therapy that was not recommended.

Hogben, Wimberly & Moore (2007) evaluated the disseminated of the CDC Control and Prevention Sexually Transmitted Disease Treatment Guidelines, however the impact of the use of these guidelines on STI rates is uncertain (325). Among a sample of physicians in the Atlanta area that treated patients with STIs, 56% had a copy of the guidelines and 26% knew how to access them (among physicians who did not treat STIs, these proportions were 25% and 30%, respectively). Half of those who had copies of the guidelines had accessed them from the internet.

Two studies in Australia, and one study in London, evaluated the impact of introducing STI screening guidelines/strategies. In an Australian sexual health centre, an audit was performed to examine STI testing rates before and after the introduction of guidelines that recommended regular STI screening of MSM (326). It was found that there was a significant increase in testing rates for most STI tests after the guidelines, and in 2002 61% of MSM had all recommended tests within the past year.

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One study that did evaluate the impact of introducing a guideline on STI screening specifically, was authored by Lister et al. and introduced in the section examining electronic technologies in a clinic setting (183). Therefore, this intervention encompasses both the guideline itself, and the electronic reminder to implement the guideline in practice. As discussed, there was a significant increase in rectal chlamydia testing, and a significant reduction in pharyngeal chlamydia and gonorrhea testing. There was no change about the proportion of tests that were positive. In another study in London, a HIV unit introduced a strategy of regular serological screening for syphilis during routine follow up care. This strategy was evaluated in the second year after it was introduced, and it was found that 90% of individuals with a surrogate marker of having had routine follow-up blood work, done also had syphilis serology done. There was a higher syphilis rate in those treated after the strategy was introduced compared to those treated in the year prior (7.3 per 1000 patient years [95% CI 5.2-9.9] vs. 2.8 per 1000 patient years [95% CI 1.8-4.9).

Intervention Behavioural STI Contextual considerations and comments outcomes incidence/prevalence STI Control Strategies  0 There is evidence of a positive impact of and Guidelines guidelines on the uptake of STI screening in studies from Australia and the UK, and some positive impacts on knowledge from a syphilis prevention campaign in Alberta.

Data from the US does reveal that adherence to CDC STI treatment guidelines seems quite high.

No evaluation of jurisdiction wide control strategies or treatment guidelines for impact on subsequent STI rates was found.

6.11 Conclusion The literature on macro-level interventions, although comparatively smaller than the micro- and meso- level literature base, contained a wide variety of policy-related interventions. It is important to note that these interventions involved both STI-specific and non-STI specific policy, demonstrating that STIs can be influenced by a range of factors within the environments of individuals, families and communities (including policies related to condom use, alcohol, health care performance measures, national-level funding, financial factors at the level of local institutions, etc.). As such, STI Control Strategies for jurisdictions must take into account this broad milieu.

As with meso-level interventions, scale and duration are key factors to consider when evaluating macro- level interventions. In addition, the availability of appropriate population-level measurement data (or lack thereof) can determine what can be learned about the true impact of both meso- and macro-level interventions. In this respect, the existence of a population-based survey that collects both behavioural and biological outcome data is a tremendous asset.

There has been no evidence of the evaluation of STI control strategies at a population heath and or institution level. An evaluation of these types of strategies would likely be very complex given the various components of each strategy and how these impact the STI burden within the population.

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Although this review has identified a number of promising interventions at the meso- and macro-levels, there is limited evaluative data that assesses both sexual behaviour and STI incidence/prevalence or morbidity, and specifically, limited evaluative data from BC. As such, a rating of “warrants further research” (particularly regarding biological outcomes) is associated with a number of these interventions, and may continue to be even if they are well-designed and implemented and potentially effective. There is the concern that effectiveness may not be able to be adequately measured in the absence of appropriate data. What is needed in order to evaluate many meso- and macro-level interventions, is a population-based survey that can validate changes in behaviour as well as biological outcomes (e.g., STI incidence/prevalence, morbidity. As such, the existence of such a survey in the BC- context, that includes self-reported behavioural and STI data, which is ideally linked to objective biological data, would be highly advantageous to the future evaluation of programs and interventions delivered to populations within the province.

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7.0 STI CONTROL STRATEGIES

7.1 World Health Organization The aim of the WHO strategy is to provide an overview of STI prevention and control interventions from a global perspective; however, many of the described activities are relevant to developed countries as well.

Organization: World Health Organization (327)

Title: Global strategy for the prevention and control of sexually transmitted diseases: 2006-2015- Breaking the chain of transmission.

Date of publication: 2007

Purpose/objectives: Provides a global framework for the prevention and control of sexually transmitted infections, outlining essential elements of an effective response to the burden of infection and provides information on key issues.

Target audience: National managers for managers for sexual and reproductive health programs; public- and private-sector health-care providers; health ministers, policy-makers; international agencies and NGO partners; donors.

Transmission dynamics Understanding transmission dynamics helps in the design of STI intervention and control strategies. According to transmission dynamics, the distribution and transmission characteristics of an STI change over time and within/between subpopulations. Figure 4 shows a simplified description of the relationship between subpopulations.

Figure 4: Transmission Dynamics of Sexually Transmitted Infections at the Population Level

Source: WHO. 2007. Global strategy for the prevention and control of sexually transmitted infections 2006-2015 (327)

Prevention and control interventions STI prevention and control interventions and programs need to take into account transmission dynamics described above. Other considerations when planning STI prevention and control programs include:  vulnerable populations;  behaviours or circumstances which place these populations at risk;

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 best methods to disrupt or break chains of transmission; and  how to prioritize, scale up, and sustain interventions.

Vulnerable populations STI control and prevention strategies need to target individuals belonging to high-risk populations:  Sex workers and their clients who have sex with regular partners;  mobile populations;  men who have sex with men;  men who have sex with men and who also have sex with women;  substance users, especially those engaged in trade of sex for drugs;  incarcerated persons, especially juveniles;  refugees (internal and external) and displaced persons;  members of uniformed services, including military and police;  tourists and recreational sex tourists; and  victims of sexual and gender-based violence.

Adolescents need special consideration as they are at higher risk of acquiring STIs. Contributing factors to higher risk include lack of information, skills, health-care and support during the years of sexual development.

Promoting healthy sexual behaviour The WHO strategy recommends providing individuals with accurate and explicit information on safer sex, such as proper use of condoms; the importance of abstinence and the delay in onset of sexual activity; keeping one sexual partner; and reducing multiple sexual partners.

Health education Health education about STIs should include:  promoting voluntary testing and counseling of both infected and uninfected people;  encouraging individuals to openly discuss STIs and sexual behaviour with their sexual partners.

Providing condoms and other barrier methods The WHO Strategy recommends the use of the male latex condom, and recognizes it as the single, most effective technology available to reduce STIs.

Delivering prevention and care According to the WHO strategy, the goal of delivering care for people with STIs is to prevent long-term complications in those already infected and to prevent the spread of infection to their uninfected partners, fetus, or neonate. STI prevention and control programs should promote accessible, acceptable, and effective interventions. Treatment should be prompt when an STI is diagnosed or suspected.

Strategies for prevention and care of STIs Components of an effective STI prevention and control strategy prevention and control program should include:  Correct diagnosis by syndrome or laboratory diagnosis. Laboratory testing may not always be convenient; waiting for results may delay treatment. Syndromic diagnosis/management is recommended for patients presenting with consistently recognizable signs and symptoms.

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 Case finding. As STIs are often asymptomatic, WHO recommends case-finding for patients who seek care for non STI-related reasons.  Notification and treatment of sexual partners. The WHO strategy recommends treating the sexual partners of index patients in whom STIs have been diagnosed and treated;  Age-appropriate education and counseling to reduce or prevent further risk-taking behavior;  Providing effective treatment; and  Promoting and providing condoms with clear instructions.

Scaling up The WHO strategy recommends scaling up small-scale prevention or pilot programs, effective in small or limited geographical areas or populations, in order to have impact on a wider scale.

Improving information for policy and program development  Surveillance Recommended surveillance strategies include disaggregated case-reporting by age and sex; assessing and monitoring STI prevalence in defined populations; monitoring anti-microbial resistance; assessment of etiology of infections. Data should be collected for patient care, program design and monitoring, and advocacy/resource allocation.  Monitoring and evaluation Progress of STI intervention and prevention programs needs to be monitored and evaluated in order to make sure that program activities are effective. Monitoring of programs ensure that programs are performed as planned; are on time and within budgeted resources; and determine whether the activities are producing the expected outcome or impact  Integration with other programs and partners STI prevention and control activities should be integrated into other relevant public health programs, thereby widening the coverage of interventions of the respective programs.  Laboratory support Effective STI control strategies require adequate laboratory support, such as defining clear laboratory guidelines; strengthening of laboratories at national and regional levels; and where feasible, at local levels. Figure 5 describes roles and responsibilities of laboratories at these different levels of service.

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Figure 5: Roles and Responsibilities of Laboratories at National, Regional, and Local Levels

Source: WHO. 2007. Global strategy for the prevention and control of sexually transmitted infections 2006-2015 (327)

Priority components for immediate action The WHO strategy recommends that strategies be implemented for which there is sufficient evidence for impact and feasibility. The WHO strategy identifies two levels of priorities. Priority 1 activities (Table 6a) are those which have already been implemented with only modest additional human and financial resources, but may need “scaling up” for maximum usefulness at the national level. Priority 2 activities (Table 6b) require significantly more resources, and should be implemented when these resources become available.

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Table 6a: Summary of Priority 1 Activities for Immediate Implementation Priority 1 Activities Indicators National-level Targets 1. Build on success. Scale 1(a). Proportion of primary point-of-care 1(a). 90% of primary point-of-care up of services for sites providing comprehensive case sites provide comprehensive care diagnosis and treatment management for symptomatic infections. for people with sexually- of sexually-transmitted 1(b). Proportion of pregnant women with transmitted infections by 2015. infections (use sexually-transmitted infections at selected 1(b). By 2015, 90% of women and syndromic management healthy facilities who are appropriately men with sexually-transmitted where diagnostic diagnosed, treated, and counselled infections at health-care facilities resources are limited). according to national guidelines. are appropriately diagnosed, treated, and counselled. 2. Control congenital 2. Proportion of pregnant women aged 2(a). More than 90% of first-time syphilis as a step 15-24 years attending antenatal clinics antenatal clinic attendees aged 15- towards elimination. with a positive serology for syphilis. 24 years screened for syphilis.

2(b). More than 90% of women seropositive for syphilis treated adequately by 2015. 3. Scale-up sexually- 3. Proportion of HIV-positive patients with 3(a). Strategies and guidelines on transmitted infection sexually-transmitted infections who are interventions for HIV-positive prevention strategies given comprehensive care including advice patients with sexually-transmitted and programmes for on condom use and partner notification. infections in place by 2010. HIV-positive persons. 3(b). 90% of primary point-of-care sites provide effective care to HIV- infected patients with sexually- transmitted infections. 4. Upgrade surveillance of 4(a). Number of prevalence studies 4(a). At least two rounds of sexually-transmitted regularly conducted (at sentinel sites or in prevalence surveys conducted by infections within the sentinel populations) every three to five 2015. context of second- years. 4(b). Routine reporting of sexually- generation HIV 4(b). Annual incidence of reported transmitted infections established surveillance. sexually-transmitted infections (syndromic and sustained over five consecutive or etiological reporting). years by 2015. 5. Control bacterial genital 5(a). Proportion of confirmed cases of 5(a). Zero cases of chancroid ulcer disease. bacterial genital ulcer disease among identified in patients with genital patients with genital ulcerative diseases. ulcer disease by 2015. 5(b). Percentage of pregnant women aged 5(b). Less than 2% of positive 15-24 years attending antenatal clinics syphilis serology among antenatal with a positive serology for syphilis. clinic attendees aged 15-24 years. 6. Build on success. 6(a). Health needs identified and national 6(a). By 2010, health needs, Implement targeted plans for control of sexually-transmitted policies, legislation, and regulation interventions in high- infections, including HIV, for key high-risk reviewed; plans in place and risk and vulnerable and vulnerable populations developed and appropriately selected country- populations. implemented. specific targeted interventions 6(b). Proportion of young people (aged implemented. 15-24 years) with infections that were 6(b). At least two rounds of detected during diagnostic testing for prevalence surveys conducted sexually-transmitted infections. among groups with high-risk behavior and among young people by 2015. Source: WHO. 2007. Global strategy for the prevention & control of sexually transmitted infections 2006-2015 (327)

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Table 6b: Summary of Priority 2 Activities to be Implemented when Resources are Available Priority 2 Activities Indicators National-level Targets 1. Implement age- 7. Percentage of schools with at least one 7(a). Review of policies and appropriate teacher who can provide life-skills-based development of age-appropriate comprehensive sexual education about prevention of HIV and training and information materials health education and other sexually-transmitted infections. for schools completed by 2007. services. 7(b). Increased number of teachers trained in participatory life-skills-based HIV education that includes other sexually- transmitted infections by 2015. 2. Promote partner 8(a). Proportion of patients with sexually- 8(a). Plans and support materials treatment and prevention transmitted infections whose partners(s) for partner notification developed, of reinfection. are referred for treatment. and health-care provider training in place by 2010. 8(b). The proportion of patients who bring in, or provide treatment to, their partners doubled by 2010. 3. Support roll-out of 9(a). Policy and plans for universal 9(a). Plans in place regarding effective vaccines (against vaccination against hepatitis B. vaccination against hepatitis B and hepatitis B and human human papillomavirus infection by papillomavirus and, 9(b). Plans and policy reviews and 2008. potentially, herpes simplex strategies for use of human 9(b). Pilot vaccination programs type 2 infections). papillomavirus and potential herpes initiated and scaling up in progress simplex virus type 2 vaccines. by 2010. 4. Facilitate development and 10. Proportion of patients assessed for 10(a). HIV testing and counselling implementation of sexually-transmitted infections who are available in all setting providing universal opt-out voluntary routinely counselled and offered care for people with sexually- counselling and testing for confidential testing for HIV. transmitted infections by 2015. HIV among patients with 10(b). The proportion of patients sexually-transmitted with sexually-transmitted infections. infections who receive voluntary counselling and testing for HIV doubled. Source: WHO. 2007. Global strategy for the prevention and control of sexually transmitted infections 2006-2015 (327)

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7.2 England Department of Health The framework recommends that STI intervention programs target populations at highest risk of infection, and recommends providing people with accurate, non-biased sexual health education and information, so that they will make informed and responsible choices.

Organization: England Department of Health (328)

Title: A framework for sexual health improvement in England

Date of publication: March 2013

Purpose/objectives: The purpose of the document is to provide an evidence base that helps improve the sexual health of the whole population.

Target audience: Health Services Chief Executives, Medical Directors, Directors of Public Health, Directors of Nursing.

Prevention across the life course Individuals require age-appropriate education, information and support to promote life-long sexual health, including STI prevention and control.

Key principles for best practices in sexual health The framework identifies the following key principles as best practice for wider sexual health, including STI prevention and control.

 Prevention Behaviour change. Health education must be combined with prevention interventions based on behaviour-change theory.  Leadership Elected health officials, health directors, etc., play a strong role in developing local sexual health policy. Leaders should work together with community organizations and private businesses to improve local sexual health.  Wider determinants of sexual health Sexual health is linked to other key factors contributing to health and wellbeing, such as alcohol and substance misuse; smoking; obesity; mental health; and violence (especially gender-based violence). The framework recommends that efforts should be combined in addressing these wider factors, rather than individually addressing each one.  Needs of vulnerable groups The framework recommends that services and interventions be targeted at vulnerable groups who are at high risk of poor sexual health.  STI prevention The framework recommends condoms as the best way for sexually active people of any age to avoid an STI. Other STI prevention services include providing open access services offering efficient and confidential testing, treatment, and partner notification.  Surveillance Accurate STI surveillance is essential for identifying and treating members of high-risk groups, service planning, and for monitoring the effects of interventions.

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7.3 European Centre for Disease Prevention and Control Chlamydia control in Europe, despite having a primary focus on chlamydia prevention and control strategies, was included in this review since chlamydia is the most common bacterial STI. The prevention and control strategies for chlamydia are applicable to other STIs.

Organization: European Centre for Disease Prevention and Control (329)

Title: Chlamydia control in Europe

Date of publication: 2009

Purpose/objectives: Guidance to about national strategies for chlamydia control in Europe; provides a framework for developing, implementing or improving national chlamydia control in Europe.

Target audience: Developers of health policy in Europe

Essential control activities The guidelines identify the following range of activities required for chlamydia control:  primary prevention which includes sexual health and relationship education, focusing on young adults;  promotion of safer sex and condom use;  effective diagnosis and treatment of infection;  effective identification and treatment of partners of infected individuals; and  active case-finding to treat and identify asymptomatic cases.

Developing chlamydia control strategies  A step-by-step strategy for chlamydia control Chlamydia Control in Europe, suggests using a step-based approach when planning a chlamydia control program (Table 7). The goal is to make sure that patient management infrastructure and quality controls are in place prior to introducing community-based intervention such as screening. Each step is graded with a letter, (A to D), according to levels of evidence associated with each intervention.

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Table 7: Suggested Step-based Approach to Developing a Chlamydia Control Program

Source: Chlamydia control in Europe, 2009 (329)

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7.4 Department of Health and Ageing, Commonwealth of Australia Organization: Department of health and ageing, Commonwealth of Australia (330)

Title: Second National Sexually Transmissible Infections Strategy 2010-2013

Date of publication: 2010

Purpose/objectives: To reduce the transmission of and morbidity and mortality caused by bacterial STIs and to minimize the personal and social impact of the infections.

Target audience: Health directors/professionals responsible for health policy development, clinicians, professional and community organizations

Guiding principles The guiding principles behind Second National Sexually Transmissible Infections Strategy are:  STIs can be prevented by adopting and maintaining protective behaviours. Before healthy behaviours can be applied, education and prevention programs need to be in place.  The framework for effective STI prevention and control activities is provided by the Ottawa Charter for Health Promotion, which respects the human rights of vulnerable, marginalized populations.  Harm reduction is an important measure in preventing transmission.  Cooperative consultation needs to underpin effective partnerships between governments, communities, researchers, and health professionals.

Priority action areas The strategy identifies chlamydia, gonorrhea, syphilis, and trichomonas infection as the highest priority STI infections.

Variables affecting spread of STIs:  risk of transmission;  number of at-risk sexual partners of an individual; and  period of infectiousness of a specific STI.

Elements of a comprehensive approach to STI control:  health promotion and prevention;  early intervention and partner notification;  access to clinical care and support;  surveillance and research.

Health promotion and prevention STI prevention and control requires engaging the broader community and educating people about STIs and their consequences.

Young people The strategy recommends school-based sex education, focusing on risk-taking behaviours among young people. Peer education and social marketing are also identified as effective tools in the prevention of STIs.

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Aboriginal populations STI prevention and control activities need to be delivered in the cultural context of Aboriginal people when addressing this population’s health needs.

Men who have sex with men The strategy recommends peer-based prevention and control activities.

Sex workers The strategy recommends peer-based prevention and control activities, as well as understanding the importance of workplace safety and marginalization among this group.

Tools for prevention The strategy recommends water-based lubricants and condoms as the primary tool for the prevention of STI transmission.

Partner notification The strategy recommends urgent notification of an infected person’s partners in order to stop the chain of transmission.

Clinical management The use of other qualified and trained health care professionals, such as nurses, is recommended for diagnosing and treatment of STIs. Individuals should be offered diagnostic services during their health visits as part of preexisting programs, such as prenatal or well-person visits.

7.5 Manitoba Health/Public Health, Communicable Disease Control Unit Organization: Manitoba Health/Public Health, Communicable Disease Control Unit (331)

Title: Provincial sexual transmitted diseases control strategy

Date of publication: 2001

Purpose/objectives: To provide provincial leadership in the prevention of the spread of sexually transmitted diseases; to reduce burden of STD morbidity in Manitoba by focusing on the needs of vulnerable populations.

Target audience: Government, regional health authorities, community groups

Sexually transmitted diseases prevention goals  Condom use Proper use of latex condoms generally blocks the transmission of most STIs during penetrative sexual intercourse and/or oral sexual activity. Despite condom use having increased, and being perceived as socially responsible, there are still sub-populations inconsistently using condoms, especially young people aged 15-24 years.  Screening and testing Since a timely diagnosis of STIs, especially chlamydial infections, is essential for early treatment and partner notification, the strategy recommends urine-based chlamydia testing for youth aged 15-24 years.

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 Sexually transmitted diseases among adolescents Serial monogamy, the usual pattern for sexual relationships among 15-24 year olds, has been identified as a barrier to condom use, since young individuals claim that knowing their partners’ sexual history precludes them from using condoms. The strategy encourages young people to either abstain from sex or use a latex condom.  Core groups The guidelines identify “core groups” as being transient individuals living in urban areas; individuals with high rates of sex partner change; and drug use. Research on STI prevention and control must focus on identifying these core groups, and their social and sexual dynamics. Group-specific screening may be more effective than aggressive contact tracing if a core group can be identified geographically.

Prevention efforts  Primary prevention The strategy’s focus is on harm reduction, versus abstinence from high-risk behaviors, since abstinence may not be a realistic goal for some individuals and communities. It is recommended that parents, teachers, youth care workers, medical professionals, outreach personnel and peers be involved in helping individuals choose lower-risk behaviours.

Sexual activity Primary prevention strategies identified by the strategy include:  targeting high-risk risk groups with culture and age appropriate education;  individual and group behavioural interventions;  peer education;  community-based outreach;  sexual health promotion materials in remote and or small communities;  provincial sexual health phone lines/Websites.

Injection Drug Users (IDU) The strategy recommends prevention interventions for IDU because of the STI risks associated with injecting cocaine:  needle distribution and exchange, and safe injection sites;  safe disposal sites for used injection equipment;  non-prosecution of personal users;  involvement of pharmacies with needle exchange and sales; and  public media campaigns.

School-based prevention The strategy recommends that school-based STI prevention activities be implemented since sexual norms are set during adolescence. Recommended interventions include:  using peer counselors and educators;  information that is age-appropriate and clear;  ensuring that the audience understands risk associated with sexual behaviours;  addressing social and media influences  teaching interpersonal skills that focus on harm reduction; and  allowing sufficient classroom time per school year.

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Prison-based interventions The strategy recognizes that providing STI prevention and control activities in prisons can be a challenge, since these interventions must occur in the context a security environment.

Research The strategy recommends that the medical community be involved in research activities that support STI control.

 Secondary Prevention Screening programs The strategy recommends:  the screening of core groups for STIs;  standardization of education for health care professionals providing pre- and post-test counseling;  increased accessibility to testing;  allowing qualified non-physician health care professionals, such as public health nurses to order the appropriate tests; and  testing for gonorrhea and chlamydial using nucleic amplification testing. Urine testing could decrease psychological and physical barriers and increase access to testing.

Contact tracing The strategy recommends contact tracing as an important means of identifying and treating new cases of STIs. Contact tracing can prevent reinfection of the treated partner, control antimicrobial resistance, and encourage timely treatment. The strategy views contact tracing as an important method of identifying members of core groups of infected individuals, allowing the identification of sexual networks.

Surveillance The strategy support strong STI surveillance activities, supported by dedicated resources and mandatory reporting.

 Tertiary Prevention Access to treatment The strategy identifies both barriers to accessing timely and effective treatment of STIs as well as supportive factors. Barriers include:  concerns regarding treatment competence by physicians;  concerns about stigmatization;  lack of coordination and sharing of information between service providers and the community;  lack of treatment support programs;  lack of adequately funded programs;  lack of appropriate time to implement programs.

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Supportive factors which have potential to enhance effective and timely treatment of STIs include:  consultation with infected and affected people regarding service delivery;  consulting First Nations communities regarding prevention, detection, and intervention services;  integration of community-based services;  changing stigma of needle exchange/condom distribution;  “one-stop shopping” for harm reduction services;  addressing conflicting policies, e.g., prisons and needle distribution;  working with, not against, community groups and/or leaders.

Adherence to treatment The strategy considers adherence to a particular treatment regimen to be dependent on several behaviours. Some of the factors that the strategy states have a positive effect on adherence to treatment regimens include:  high self-efficacy;  patient's belief in the medications;  supportive social and community environments;  fewer medications to take per day; and  ability to take medication at home.

Prevention strategies and disease phase The strategy suggests a phase-specific approach to STI prevention and control, which is population specific and differentiates between the general population (maintenance networks) and core groups (spread networks). The approach is summarized in Figure 6.

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Figure 6: Two-pronged Phase-appropriate STI Prevention and Control Strategy

Source: Manitoba’s Provincial Sexually Transmitted Diseases Control Strategy (August 2001) (331)

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APPENDIX A: SUMMARY OF DATABASE SEARCH RESULTS

Youth Database(s): Ovid MEDLINE® In-Process & Other Non-Indexed Citations and Ovid MEDLINE® 1945- Present Search Strategy: # Searches Results 1 youth.mp. or Adolescent/ 1572736 2 Chlamydia Infections/ or Chlamydia/ 13986 3 Gonorrhea/ 11625 4 Syphilis/ 15858 5 Lymphogranuloma Venereum/ 1215 6 Sexually Transmitted Diseases, Bacterial/ or sexually transmitted 3171 infection.mp. 7 Primary Prevention/ 13637 8 Secondary Prevention/ 1739 9 Tertiary Prevention 80 10 Health Promotion/ 50756 11 Harm Reduction 1480 12 2 or 3 or 4 or 5 or 6 41231 13 7 or 8 or 9 or 10 or 11 65612 14 1 and 12 and 13 107

Database: EMBASE Search Strategy: # Searches Results 1 youth.mp. or Adolescent/ 1312448 2 Chlamydia Infections/ or Chlamydia/ 16939 3 Gonorrhea/ 13692 4 Syphilis/ 23381 5 Lymphogranuloma Venereum/ 1404 6 Sexually Transmitted Diseases, Bacterial/ or sexually transmitted 36802 infection.mp. 7 Primary Prevention/ 25810 8 Secondary Prevention/ 15040 9 Tertiary Prevention 43526 10 Health Promotion/ 70090 11 Harm Reduction 2603 12 2 or 3 or 4 or 5 or 6 76914 13 7 or 8 or 9 or 10 or 11 148657 14 1 and 12 and 13 483

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Database: All EBM Reviews Search Strategy: # Searches Results 1 youth.mp. or Adolescent/ 75443 2 Chlamydia Infections/ or Chlamydia/ 452 3 Gonorrhea/ 390 4 Syphilis/ 77 5 Lymphogranuloma Venereum/ 8 6 Sexually Transmitted Diseases, Bacterial/ or sexually transmitted 200 infection.mp. 7 Primary Prevention/ 571 8 Secondary Prevention/ 156 9 Tertiary Prevention 1 10 Health Promotion/ 2887 11 Harm Reduction 63 12 2 or 3 or 4 or 5 or 6 965 13 7 or 8 or 9 or 10 or 11 3613 14 1 and 12 and 13 10

Database: Health and Psychosocial Instruments No results were found

MSM Search results using Ovid Medline. 1 Chlamydia Infections/ or Chlamydia/ or Chlamydia trachomatis 18328 2 Gonorrhea/ 12178 3 Syphilis/ 16644 4 Lymphogranuloma venereum/ 1299 5 Sexually Transmitted Diseases, Bacterial/ 899 6 Sexually transmitted infections.mp 5977 7 1 or 2 or 3 or 4 or 5 or 6 49340 8 Tertiary Prevention/ or Secondary Prevention/ or Primary Prevention/ or 403362 prevention.mp 9 Health Promotion/ 54805 10 Harm Reduction/ 1644 11 8 or 9 or 10 449416 12 Control.mp? or Communicable Disease Control/ 2078158 13 11 or 12 2425817 14 Homosexuality, Male/ or men who have sex with men.mp 11763 15 7 and 11 and 13 and 14 368 16 Limit 15 to English language 358

Search results using Ovid EMBASE 1 Chlamydia Infections/ or Chlamydia/ or Chlamydia trachomatis 25951 2 Gonorrhea/ 15129 3 Syphilis/ 25050

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4 Lymphogranuloma Venereum/ 1491 5 Sexually Transmitted Diseases, Bacterial/ 36381 6 Sexually transmitted infections.mp 6817 7 1 or 2 or 3 or 4 or 5 or 6 87555 8 Tertiary Prevention/ or Secondary Prevention/ or Primary Prevention/ or 716949 prevention.mp 9 Health Promotion/ 69346 10 Harm Reduction/ 2547 11 8 or 9 or 10 774503 12 Control.mp or Communicable Disease Control/ 2553605 13 11 or 12 3176766 14 Homosexuality, Male/ or men who have sex with men.mp 5835 15 7 and 11 and 13 and 14 727 16 Limit 15 to English language 709

Search results using Ovid EBM Reviews. 1 Chlamydia Infections/ or Chlamydia/ or Chlamydia trachomatis 524 2 Gonorrhea/ 390 3 Syphilis/ 77 4 Lymphogranuloma Venereum/ 8 5 Sexually Transmitted Diseases, Bacterial/ 22 6 Sexually transmitted infections.mp 316 7 1 or 2 or 3 or 4 or 5 or 6 1149 8 Tertiary Prevention/ or Secondary Prevention/ or Primary Prevention/ or 46633 prevention.mp 9 Health Promotion/ 2887 10 Harm Reduction/ 63 11 8 or 9 or 10 48938 12 Control.mp or Communicable Disease Control/ 145193 13 11 or 12 172559 14 Homosexuality, Male/ or men who have sex with men.mp 309 15 7 and 11 and 13 and 14 32 16 Limit 15 to English language 32

Search using Ovid Health and Psychosocial Instruments 1 Chlamydia Infections/ or Chlamydia/ or Chlamydia trachomatis 0 2 Gonorrhea/ 0 3 Syphilis/ 0 4 Lymphogranuloma Venereum/ 0 5 Sexually Transmitted Diseases, Bacterial/ 0 6 Sexually transmitted infections.mp 22 7 1 or 2 or 3 or 4 or 5 or 6 22 8 Tertiary Prevention/ or Secondary Prevention/ or Primary Prevention/ or 0 prevention.mp 9 Health Promotion/ 0 10 Harm Reduction/ 0

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11 8 or 9 or 10 1830 12 Control.mp or Communicable Disease Control/ 4859 13 11 or 12 6547 14 Homosexuality, Male/ or men who have sex with men.mp 65 15 7 and 11 and 13 and 14 0 16 Limit 15 to English language 0

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APPENDIX B: SUMMARY OF REVIEWED STUDIES

MICRO-LEVEL INTERVENTIONS ACROSS POPULATIONS – Randomized Controlled Trials Paper Country Intervention Population Follow-up rate Decreased risk- Effect on STI risk Notes taking behaviour during study Behavioural Interventions Boyer, et al. US Cognitive-behavioural Female marine At first follow- NR A higher proportion (2005) intervention on recruits up, 80.8%. At of the control group preventing STIs and second follow- had a post- unintended up, 64%. intervention STI or pregnancies. unintended pregnancy (OR 1.41, 95% CI 1.01-1.98). Among participants with no history of STIs or pregnancy but who engaged in risky sexual behaviours, the control group was more likely to acquire an STI (OR 3.24, 95% CI 1.74- 6.03).

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Paper Country Intervention Population Follow-up rate Decreased risk- Effect on STI risk Notes taking behaviour during study Chacko, et US Client-centered Young women For intervention No significant No effect on al. (2010) motivational group: 70% at 6 differences number of behavioural months, 61% at between groups on chlamydia and intervention to 12 months. client-initiated gonorrhea episodes. promote seeking of For standard clinic visits in STI check-ups. care group: 82% response to 7 high- at 6 months, risk behaviours, 68% at 12 consistent condom months use or movement along the stages of change obtained at baseline. Champion US Cognitive behavioural Abused ethnic 93% at 6 months NR Intervention group The intervention is and Collins intervention versus minority and 94% at 12 had fewer infections grounded in (2011) enhanced adolescent months at 0-6 months (0 knowledge of the counselling. women versus 6.6%), 6-12 target months (3.6 versus populations’ 7.8%) and 0-12 behaviours and months (4.8 versus culture. The great 13.2%), all p < 0.01 cost of saying “no” to unsafe sex—the loss of a partner— may be greater than the risk of acquiring STIs, even HIV.

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Paper Country Intervention Population Follow-up rate Decreased risk- Effect on STI risk Notes taking behaviour during study Crosby, et US Brief, clinic-based Young African At 3 months, Those receiving the Those receiving the al. (2009) safer sex program American men 74.1%. intervention were intervention were administered by a lay newly more likely to less likely to acquire health adviser. diagnosed with report using subsequent STIs an STI condoms during (50.4% versus last sexual 31.9%, p = 0.002). intercourse (72.4% versus 53.9%, p = 0.008). They also reported fewer sexual partners (2.06 versus 4.15, p > 0.001) and fewer acts of unprotected sex (12.3 versus 29.4, p = 0.045).

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Paper Country Intervention Population Follow-up rate Decreased risk- Effect on STI risk Notes taking behaviour during study DiClemente, US Behavioural African At 6 months, Participants in the Chlamydia et al. (2004) intervention to American girls 90%. At 12 intervention arm infections were reduce risk aged 14-18 months, 87.3%. reported using reduced OR 0.17, behaviours, HIV, STIs, years. condoms more 95% CI 0.03-0.92 and pregnancy. Four, consistently in the over 12 months. 4 hour group sessions 30 days preceding There were no were given the six month significant emphasizing ethnic assessment (75.3% differences in and gender pride, HIV in intervention gonorrhea or knowledge, versus 58.2% in trichomonas communication, control) and the 12 infections, although condom use skills and month assessment there was a trend healthy relationships. (73.3% versus toward lower rates 56.5%). Over the in the intervention 12 month period, group. adjusted OR was 2.01, 95% CI (1.28- 3.17). They also reported more consistent condom use in the 6 months preceding the 6 month (61.3 versus 42.6%) and 12 month assessments (58.1% versus 45.3%) and over the entire period (AOR 2.30, 95% CI 1.51-3.50).

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Paper Country Intervention Population Follow-up rate Decreased risk- Effect on STI risk Notes taking behaviour during study Feldblum, et Madagascar Peer education Female sex At 6 months, OR for reported OR for chlamydia, al. (2005) supplemented by workers 89% in peer only. condom use was gonorrhea, individual risk At 6 months, 1.4 (95% CI 1.1 to Trichomoniasis and reduction counselling 92% in peer + 1.8). aggregate STI were by a clinician versus clinic. 0.7 (0.4-1.0), 0.7 condom promotion (0.5-1.0), 0.8 (0.6- by peer educators 1.2) and 0.7 (0.5- only. 0.9), respectively. Grimley, et US Brief face-to-face Mostly African At 6 months, In the intervention The combined al. (2009) behavioural American 75% and 58% of group, 32% gonorrhea and intervention. the intervention, reported consistent chlamydia incidence and comparison condom use versus declined to 6% in group returned, 23% in the the intervention respectively. comparison group group versus 13% in (p = 0.03). the comparison group (p = 0.04).

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Paper Country Intervention Population Follow-up rate Decreased risk- Effect on STI risk Notes taking behaviour during study Guilamo- US Parent-based Latino and 94.6% at nine They found NR Ramos, et intervention African months. statistically al. (2010) delivered to mothers American youth. significant reduced in a pediatric clinic as rates of they waited for their transitioning to child to complete a sexual activity and physical examination. frequency of sexual intercourse at nine- month follow-up in the control versus intervention group (22.2 versus 6.8%, p < 0.05). Sexual activity increased from 6 to 22% for young adults in the “standard of care” control group, but remained at 6% among young adults in the intervention condition at nine month follow-up.

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Paper Country Intervention Population Follow-up rate Decreased risk- Effect on STI risk Notes taking behaviour during study Harvey, et US Health behaviour Heterosexual At three months, No significant NR Participants in the al. (2009) change model couples 83% for women, intervention effect intervention 79% of men. At 6 found among condition months, 77.7% couples at three participated in of women (men months or among three weekly were not women at six sessions, each followed-up at months. lasting 2.5 hours. six months). At each session, facilitators provided information and involved participants in discussions to address key individual and relationship factors that influence increased use of condoms. There were other activities on skill- based activities.

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Paper Country Intervention Population Follow-up rate Decreased risk- Effect on STI risk Notes taking behaviour during study James, et al. UK Individually focused Patients at a At 4 months, Intervention NR (1998) counselling and skills genitourinary 51% subjects were training intervention, clinic. significantly more including written likely than controls materials, to receive to report carrying written materials condoms when only, or control. anticipating sexual intercourse with new partner (p < 0.05). There were no significant effects on levels of knowledge about correct condom use, attitudes to condoms, self- reported condom use or incidence of STI. Jemmott, et US Skill-based HIV/STI African At 12 months, Skills-intervention Skills-intervention al. (2005) risk-reduction American and 88.6%. participants participants were intervention Latino reported less less likely to test adolescent girls unprotected sex at positive for STI 12 months (mean (10.5% versus 18.2% [SE], 2.27 versus [2.9 versus 2.8%], p 4.04 [0.81 versus = 0.05). 0.80], p = 0.03), fewer sexual partners (0.91 versus 1.04 [0.05 versus 0.05], p = 0.04).

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Paper Country Intervention Population Follow-up rate Decreased risk- Effect on STI risk Notes taking behaviour during study Jemmott, et US Brief HIV/STI risk African Return rates Those in the skill- Intervention al. (2007) reduction American were 91.8%, building participants were intervention women 90.2%, and interventions less likely to test 86.9% at three, reported less positive for an STI six and 12-month unprotected sexual than control follow-ups, intercourse participants (d = respectively. (Cohen’s d[d] = 0.20, p = 0.03). 0.23, p = 0.02), reported a greater proportion of protected sex (d = 0.21, p = 0.05). Kalichman, US A three hour African At one month, Those who NR et al (1999) behavioural skills American 93%. At three received the building intervention women months, 90%. intervention used that educated the female condom women about the to a greater extent female condom, than did the motivating female control group. condom use, and building behavioural skills relevant to the female condom.

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Paper Country Intervention Population Follow-up rate Decreased risk- Effect on STI risk Notes taking behaviour during study Kamali, et Uganda Behavioural and STI Rural Uganda Median follow- NR Incidence of active al. (2003) interventions up 3.6 years per syphilis and person (cluster prevalence of randomized trial) gonorrhea were lower in the behavioural and STI intervention group than in the control group (incidence RR for syphilis 0.52, 95% CI 0.27 – 0.98; prevalence ratio for gonorrhea, 0.25, 95% CI 0.10-0.64) Kamb, et al. US There were 2 Heterosexual, At three months, At three and six At 12-month follow- (1998) interactive HIV/STD HIV-negative 71%, at six month follow-up up, 20% fewer counselling patients aged 14 months, 70%, at visits, self-reported participants in each interventions with years or older 9 months, 64%, condom use was counselling didactic prevention and at 12 100% higher in intervention had messages typical of months, 66%. both the enhanced new STIs compared current practice counselling and with those in the brief counselling didactic messages arms compared arm (p = 0.008). with those in the didactic messages arm.

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Paper Country Intervention Population Follow-up rate Decreased risk- Effect on STI risk Notes taking behaviour during study Krauss, et US Brief one session Female partners At 7 week A higher NR al. (2000) intervention of male follow-up, proportion of injection drug 81.1%. women who took users pre-test assessment reported consistent safer sex (66.7%) versus those who did not (55.6%). The adjusted odds ratio was 0.22 (95% CI 0.06-0.78). Among women who did not take pre-tests, 76.9% reported consistent safer sex versus 33.3% in the pamphlet group. Marion, et US A nurse practitioner African For intervention, NR At 15 months, the al. (2009) directed, culturally American at visit 2: 63%, at probability of an specific, intensive women having visit 3: 53%, at intervention intervention past STIs visit 4: 48%. For participant having control, at visit 2: an STI was 20% less 76%, at visit 3: than a control 69%, at visit 4, participant. 58%. Metcalfe, et US HIV testing and 15-39 year old 99% of the rapid- Behaviours were STI was acquired by al. (2005) counselling in 1 visit STI clinic test group and similar between 19.1% of the rapid with standard HIV patients in 3 US 69.4% of the groups. group and 17.1% of testing and cities. standard-test the standard group counselling in 2 visits. group. (RR1.11, 95% CI 0.96-1.29).

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Paper Country Intervention Population Follow-up rate Decreased risk- Effect on STI risk Notes taking behaviour during study Morrison- US Sexual risk-reduction Low-income, For intervention: Those receiving the NR The intervention Beedy, et al. intervention, urban, teenage 84% at three sexual risk- provided HIV (2013) supplemented with girls months, 86% at reduction information, post-intervention 6 months, 76% intervention increased booster sessions at 12 months. showed decreases readiness to For control: 84% in total episodes of reduce risk at three months, vaginal sex and all behaviours, and 82% at 6 follow-ups, the instructed, months, and 76% number of modeled, and at 12 months. unprotected allowed girls to vaginal sex acts at practice three and 12 interpersonal and months, and total self-management number of sex skills facilitating partners at six sexual risk months. reduction and condom use. The intervention addressed the concerns of girls. The control group consisted of general health promotion topics. Patterson, Mexico Brief behavioural Female sex At 6 months, There were Cumulative STI et al. (2008) intervention to workers 81.6% increases in the incidence in the promote condom use number and intervention versus percentage of control groups was protected sex acts 13.8 versus 24.92 and decreases in per 100 person- the number of years (p = 0.034), a unprotected sex 40% decline. acts with clients (p < 0.05).

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Paper Country Intervention Population Follow-up rate Decreased risk- Effect on STI risk Notes taking behaviour during study Peipert, et US Transtheoretical General At 24 months, Intervention group No difference in al. (2008) model-tailored expert population 61% in participants were rates of STI. system intervention intervention more likely to arm, 67% in report use of dual control arm. contraceptive methods during follow-up (adjusted hazard ratio, 1.7, 95% CI 1.09-2.66). Proude and Australia Brief intervention Young adults 68% returned Self-reported NR D’Este aged 18-25 follow-up behaviour did not (2004)115 years questionnaires. change significantly. Scholes, et US Theory-based Women aged For the control Intervention group NR al. (2003) tailored minimal self- 18-24 years group, at 3 reported help intervention months: 87%, significantly more and at six condom use overall months: 85%. (AOR 1.86, 95% CI For the self-help 1.32-2.65) and with group, at three recent primary months: 91% partners (OR 1.97, and at six 95% CI 1.37-2.86). months: 88%. They also reported using condoms for a higher proportion of intercourse episodes, carried condoms, discussed condoms with partners, and had higher self- efficacy to use condoms with primary partners.

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Paper Country Intervention Population Follow-up rate Decreased risk- Effect on STI risk Notes taking behaviour during study Senn, et al. Switzerland The two different Travelers aged BI + condom There was no NR (2011) intervention arms 18-44 years who distribution significant were: motivational traveled group: 66% at difference among brief intervention (BI) without their two years. the groups in terms and provision of regular sexual Condom of condom use. condoms. partner distribution group: 67% at two years. Standard consultation: 66% at two years. Shain, et al. US Three small-group Mexican At six months, NR During first six (1999) sessions of 3-4 hours American and 82%. At 12 months, rates of each designed to help African months, 89%. subsequent women recognize American infection versus personal females with control group was susceptibility, commit non-viral STIs. 11.3 versus 17.2% (p to changing their = 0.05). During the behaviour and second 6 months, acquire necessary rates of infection skills. were 9.1 versus 17.7%, p = 0.008. Over the entire 12 months, rates of infection were 16.8 versus 26.9%, p = 0.004.

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Paper Country Intervention Population Follow-up rate Decreased risk- Effect on STI risk Notes taking behaviour during study Shain, et al. US Standard and Hispanic Retention rate NR Adjusted infection (2004) enhanced (addition American and was 91%. rates were higher in of optional support African controls than in the groups) gender- and American enhanced in year 1, culture-specific small women year 2, and group behavioural cumulatively (26.8 interventions versus 15.4% (p = 0.004, 23.1 versus 14.8% p < 0.03, 39.8 versus 23.7%, p < 0.001 respectively) and in the standard arm (26.8 versus 15.7%, p = 0.006; 23.1 versus 14.7%, p = 0.03, 39.8 versus 26.2% p < 0.008, respectively).

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Paper Country Intervention Population Follow-up rate Decreased risk- Effect on STI risk Notes taking behaviour during study Strathdee, Mexico Brief combination Female sex 97% had at least NR aRR for group B 0.88 Group A: Didactic et al. (2013) interventions workers who one follow-up (95% CI 0.40-1.94), injection risk inject drugs visit over 12 group C 0.38 (95% intervention and months. CI 0.16-0.89), group didactic sexual risk D 0.37 (95% CI 0.16- intervention 0.89), relative to Group B: group A. HIV/STI Interactive incidence decreased injection risk by over 50% in the intervention and interactive sex didactic sexual risk intervention intervention compared to Group C: didactic. Interactive sexual risk intervention and didactic injection risk intervention Group D: interactive injection risk intervention and interactive sexual risk intervention. Thurman, et US Sexual Awareness For Adolescents and Intervention Adults and teens Teens in SAFE al. (2008) Everyone (SAFE) adults who were participation randomized to intervention had behavioural African- or rates were 92% SAFE intervention lower incidence of intervention Mexican- for at least one had significant gonorrhea and American who session, 82% for decreases in high- chlamydia at 0 to 6 had been at least two risk sexual months and diagnosed with sessions, and behaviours. cumulatively (52%, an STI 79% for all p = 0.04; 39%, p = sessions. 0.04).

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Paper Country Intervention Population Follow-up rate Decreased risk- Effect on STI risk Notes taking behaviour during study Trent, et al. US Brief behavioural Adolescents Intervention The intervention NR (2010) intervention provided aged 15 to 21 group at 2 groups had higher at the time of years with mild weeks: 59%. rates of 72-hour diagnosis of pelvic to moderate Control group at follow-up (32 inflammatory disease PID. 2 weeks: 63%. versus 16%) and (PID) partner treatment (71 versus 53%), p = 0.1. There were no differences in medication completion, sexual abstinence or partner notification. Warner, et US Brief STI prevention Attendees of a 96% of patients NR Patients assigned to al. (2008) messages in a video publicly funded analyzed. intervention had shown in a high STI clinic. significantly fewer volume clinical STIs compared with setting control (hazard ratio, 0.91, 95% CI 0.84-0.99) Wingood, et US Behavioural Women with At six months, Women in the Women in the al. (2004) intervention HIV in Alabama 92.6%. At 12 intervention intervention group emphasizing gender and Georgia. months, 85.2% reported fewer had a lower pride, maintaining episodes of incidence of current and unprotected chlamydia and identifying new vaginal intercourse gonorrhea (OR = network members, (1.8 versus 2.5, p = 0.19, p = 0.006). HIV transmission 0.022), were less knowledge, likely to report communication and never using condom use skills, condoms (OR = and healthy 0.27, p = 0.008). relationships.

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Paper Country Intervention Population Follow-up rate Decreased risk- Effect on STI risk Notes taking behaviour during study Wingood, et US Two 4-hour HIV African 72.9% at six Participants in the Participants in the al. (2013) intervention sessions American months and HIV intervention, HIV intervention, based on Social women 74.7% at 12 relative to the relative to the Cognitive Theory and months health promotion health promotion the Theory of Gender intervention had intervention had and Power were lower risk of lower risk of non- given. concurrent male viral incident STI sex partners (OR (OR 0.62, 95% CI 0.55, 95% CI 0.37- 0.40-0.96). 0.83). Witte, et al. Mongolia Enhanced Female sex For HIV-SSR There were NR (2011) behavioural workers in group: 71.4% at decreases among intervention. Three Mongolia two weeks, all groups in groups: a 67.4% at three unprotected sex relationship-based months, 67.4% and number of sex HIV sexual risk at six months. acts with clients, reduction For +MI group: but the between- intervention (HIV- 81.0% at 2 group differences SSR); the same weeks, 79.3% at were not intervention plus three months; significant. motivational 81.0% at six interviewing(+MI); a months. control condition For WC group: focused on wellness 72.9% at two promotion (WC). weeks, 72.9% at three months, 84.8% at six months.

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Paper Country Intervention Population Follow-up rate Decreased risk- Effect on STI risk Notes taking behaviour during study Screening to prevent PID Andersen, Denmark Home sampling for General 100% N/A No significant et al. (2011) chlamydia population (population- differences between trachomatis (men and based health the intervention and women) registers) control group for PID, ectopic pregnancy, infertility, IVF treatment, births or, for men, epididymitis. Graseck, et US Home-based Women using For home-based Home-based users NR al. (2010) screening versus long-acting screening, 56% were more likely to clinic-based screening reversible completed complete screening contraceptive screening. For compared to clinic- methods clinic-based based (56.3% (previously screening 33% versus 25.0%). enrolled in the completed CHOICE screening. project).

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Paper Country Intervention Population Follow-up rate Decreased risk- Effect on STI risk Notes taking behaviour during study Oakeshott, UK Chlamydia screening Female college 94% at 12 NR Incidence of PID in There is evidence et al. (2010) and treating students months screened women to suggest that was 1.3% compared screening for with 1.9% in chlamydia at controls (RR 0.65, baseline reduces 95% CI 0.34-1.22). risk of PID, but Seven of 74 control may be women who tested overstated. positive for chlamydia. Most episodes of PID occurred in women who tested negative for chlamydia at baseline. Ostergaard, Denmark Home versus Females in At 12 months, N/A 2.1% of women in et al. (2000) conventional Denmark 51.1% of the intervention sampling for intervention group, and 4.2% in chlamydia group, and the control group trachomatis 58.5% in control had been treated group. for PID (p = 0.045). Scholes, et US Screening for Women in a At 12 months, N/A RR 0.44 (95% CI al. (1996) chlamydia large health 76% 0.20-0.90) trachomatis to maintenance prevent PID. organization Scholes, et US Chart prompts to Women aged N/A (clinics were No significant NR al. (2006) screen for chlamydia. 14-25 randomized) effect on testing

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Paper Country Intervention Population Follow-up rate Decreased risk- Effect on STI risk Notes taking behaviour during study Walker, et Australia Computer reminders General Cluster Testing increased NR al. (2010) for chlamydia population randomized trial; from 8.3% to 12.2% screening in general 100% of control in the intervention practice clinics and 94% group and from of intervention 8.8% to 10.6% in clinics. the control group, both p < 0.01. Overall the intervention group had a 27% (OR 1.3, 95% CI 1.1-1.4) greater increase in testing. Male condoms – No RCTs Reviewed

Female condoms Fontanet, et Thailand Female condoms Female sex 100% (cluster There was a 17%, There was a 24%, al. (1998) when clients refuse workers randomized trial) non-significant non-significant male condoms. reduction in reduction in the Establishments unprotected sex weighted geometric randomized to two acts in the mean incidence of groups-one where male/female STIs in the sex only male condoms condom group. establishments of were available and the male/female another where male condom group. and female condoms were available. Feldblum, et Kenya Cluster randomized Rural Kenya 100% (cluster Consistent female There was no al. (2001) trial; six intervention randomized trial) condom use was significant sites received male reported by 11 and difference in STI and female condoms; 7% of intervention prevalence between the other sites only site women at six the two sites. male condoms. and 12 months.

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Paper Country Intervention Population Follow-up rate Decreased risk- Effect on STI risk Notes taking behaviour during study Steiner, et Jamaica Standard clinic Men with Choice group, No significant No significant al. (2006) condom, or a choice urethral 62% at difference in difference in first of 4 different discharge completion. condom usage incidence of condoms Control group, chlamydia, 59% at gonorrhea, or completion. Trichomoniasis Cervical diaphragms Ramjee, et Southern Cervical diaphragm Women Over 93% No significant al. (2008) Africa with lubricant gel difference in the with condoms versus rate of acquisition condoms alone of chlamydia or gonorrhea. Topical microbicides Cutler, et al. ? Use of conceptrol Women ? NR There was a Article not (1977) “marked degree of available. protection against reinfection with gonorrhea in women who used it for 6 months after presenting with infection”.

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Paper Country Intervention Population Follow-up rate Decreased risk- Effect on STI risk Notes taking behaviour during study Kreiss, et al. Kenya N-9 Women At completion, NR There was a (1992) 84% reduced risk of gonococcal cervicitis (RR 0.4, p < 0.0001) but an increased risk of genital ulcers (RR 3.3, p < 0.0001) and vulvitis (RR 3.3, p < 0.0001). There was also a trend toward increased in HIV seroconversion that was not significant (RR 1.7, 95% CI 0.9-3.0). Louv, et al. US N-9 Women using At 6 months, NR Women assigned to (1988) reliable forms of 78%. the N-9 group were birth control less likely to become infected with gonorrhea (RR 0.75, 90% CI, 0.58- 0.96) and chlamydia (RR 0.79, 90% CI 0.64-0.97).

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Paper Country Intervention Population Follow-up rate Decreased risk- Effect on STI risk Notes taking behaviour during study Niruthisard, Thailand N-9 High-risk 76% in the N-9 NR For all cervical et al. (1992) women group, and 75% infection, RR 0.75 in the placebo (95% CI, 0.5-1.1). In group women who used N- 9 for more than 75% of their coital acts, the infection rate was reduced by 40% (95% CI, 0.3-1.0). However the rate of symptomatic irritation was increased by 70% among N-9 users (95% CI, 1.1-2.6). Rendon, et ? Suppository forms of Women 56% NR Gonorrhea was Article not al. (1980)119 phenylmercuric diagnosed in 2 of 24 available acetate, N-9, and women using placebo phenylmercuric acetate, 4 of 24 using N-9, and 8 of 29 using placebo. These results were significant.

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Paper Country Intervention Population Follow-up rate Decreased risk- Effect on STI risk Notes taking behaviour during study Richardson, Kenya N-9 Female sex At 12 months, NR There was a et al. (2001) workers 69% in the N-9 significantly higher group, and 61% incidence of in the placebo gonorrhea in the N- group. 9 group than in the placebo group (RR 1.8, 95% CI 1.0-3.1). No significant differences were observed for the other STIs. Roddy, et al. Cameroon N-9 Female sex At completion, NR There were no (1998) workers 90% significant differences in the rate of new HIV, gonorrhea or chlamydia infection. Roddy, et al. Cameroon N-9 versus condoms Female sex For the control NR The RR for (2002) workers (condoms) gonococcal infection group, 99%. For in the gel group the gel and versus the condom condoms group, group was 1.5 (95% 99%. CI, 1.0-2.3) and 1.0 for chlamydia (95% CI 0.7-1.4).

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Paper Country Intervention Population Follow-up rate Decreased risk- Effect on STI risk Notes taking behaviour during study Rosenberg, Thailand Contraceptive sponge High-risk Thai 36% in the NR There were lower et al. (1987) women sponge group, risks of infection 34% in the non- with chlamydia and user group gonorrhea (RR 0.67, 95% CI 0.42-1.07; RR 0.31, 95% CI 0.16- 0.60), but higher rates of Candida (RR 2.76, 95% CI, 0.96- 7.98). Van Three Cellulose sulfate Women In cellulose NR No significant Trial stopped early Damme, et African and sulfate group, effects were found al. (2008) two Indian 98%. In the on the rates of sites placebo group, gonorrhea and 98%. chlamydia.

Male circumcision Mehta, et Kenya Male circumcision Men aged 18-24 95.4% tested for NR The incidence of al. (2009) years the 3 infections STIs did not differ by during follow-up. circumcision status.

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Paper Country Intervention Population Follow-up rate Decreased risk- Effect on STI risk Notes taking behaviour during study Sobngwi- South Africa Male circumcision Men aged 18-24 33% in both NR There were no Tambekou, years groups significant et al. (2009) differences in the two groups on the prevalence of gonorrhea or chlamydia or trichomonas. But there was a trend toward reduced risk of acquisition of these STIs. The ORs for gonorrhea, chlamydia, and trichomonas are 0.97 (p = 0.84), 0.58, (p = 0.065) and 0.54 (p = 0.062), respectively. Tobias, et Uganda Male circumcision HIV negative For the NR No significant al. (2009) uncircumcised intervention differences in the males aged 15- group: at 12 incidence of syphilis 49 years months, 97.6%; (HR 1.10, 95% CI at 24 months, 0.75-1.65). 88.7%. For the control group: at 12 months, 91.9%; at 24 months, 88.7%.

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Paper Country Intervention Population Follow-up rate Decreased risk- Effect on STI risk Notes taking behaviour during study Patient-delivered partner therapy and other forms of expedited partner therapy Cameron, et UK PDPT versus PTK Women testing 45% at 12 NR There was no al. (2009) (partners send in positive for months significant urine for testing) chlamydia at a difference in versus standard genitourinary reinfection of patient referral medicine, family chlamydia between planning, and PDPT versus patient termination of referral, PTK versus pregnancy patient referral or clinics. PDPT versus PTK. Golden, et US Expedited partner General For intervention, NR EPT was more al. (2005) therapy (EPT)- population 68% completed effective than participants in the study. For standard referral of EPT group had the control group, partners in reducing option to give 68% completed persistent or medications to their study. recurrent infection sex partners or if they among patients with preferred, have study gonorrhea (3 versus staff members 11%, p = 0.01) and contact partners and chlamydia (11 provide them with versus 13%, p = medication without 0.17). an exam.

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Paper Country Intervention Population Follow-up rate Decreased risk- Effect on STI risk Notes taking behaviour during study Kerani, et al. US PDPT and inSPOT, a Men who have Of the 75 The number of NR (2011) web-based partner sex with men enrollees, 71% partners treated notification service. with chlamydia completed per original patient Four arms: inSPOT, and/or baseline and was 2.33 in the PDPT, combined gonorrhea. follow-up PDPT arm and 1.52 inSPOT and PDPT and interviews. in the non-PDPT standard partner arms. PDPT management. assignment increased the mean number of partners treated per original patient by 54% (ratio of means 1.54, 95% CI, 1.01- 2.34).

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Paper Country Intervention Population Follow-up rate Decreased risk- Effect on STI risk Notes taking behaviour during study Kissinger, et US Three arms: PDPT, Men with a 37.5% agreed for Men in the PDPT Among those Those tested were al. (2005) booklet-enhanced diagnosis of follow-up arm were more tested, men in the similar to those partner referral, or urethritis at a testing. likely than men in PDPT and BEPR not tested with standard partner public STI clinic. the BEPR and PR arms were less likely regard to the referral Most (95%) arms to report than those in the PR study variables were African having seen their arm to test positive measured. American. partners, having for chlamydia talked to their and/or gonorrhea partners about the (23.0%, 14.3%, and infection, having 42.7%, respectively; given the p < 0.001). intervention to their partners, and having been told by their partners that the antibiotic treatment had been taken (55.8%, 45.6%, 35.0%, respectively; p < 0.001). Kissinger, et US PDPT. Those with Women 89% returned for The percentage of NR al. (2006) trichomonas were attending a one follow-up women reporting given treatment to family planning visit. that their partners give to their partner. clinic who were were treated was culture positive similar for PDPT and treated for but significantly trichomonas. lower for booklet enhanced partner referral compared to standard partner referral.

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Paper Country Intervention Population Follow-up rate Decreased risk- Effect on STI risk Notes taking behaviour during study Low, et al. UK Partner notification General Intervention A total of 65.3% of NR Conclusion is that (2006) at the general population group: 73.6% participants practice based practice immediately Control group: receiving practice partner after diagnosis by 75% nurse led partner notification by trained practice notification had at trained nurses is nurses with least one partner at least as telephone follow-up treated compared effective as by a health advisor or with 52.9% of referral to referral to a specialist those referred to a specialist health health advisor at a genitourinary advisor at genitourinary medicine clinic genitourinary medicine clinic. (Risk difference medicine clinic. 12.4%, 95% CI - 1.8% to 26.5%). Lyng and NR Single dose tinidazole NR 89% NR Relapse rate with Christensen to sexual partner or tinadazole-treated (1981) placebo to sexual partner was 5.1% partner for patients and with placebo- with positive treated partner was trichomonal cultures. 23.7% (p = 0.01). Thus there is a 78% reduction in the relapse rate.

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Paper Country Intervention Population Follow-up rate Decreased risk- Effect on STI risk Notes taking behaviour during study Nuwaha, et Uganda Patient-based partner Patients NR For women, in the NR al. (2001) referral (PBPR) attending an STI PDPM group, 86 of compared with clinic in 103 partners were patient-delivered Kampala, treated, compared partner medication Uganda with 23 of 104 (PDPM) partners in the PBPR group (RR 4.55, 95% CI 2.92- 7.08, p < 0.001). For casual partners, 18 of 51 were reported treated in the PDPM group, compared with only 3/45 partners in the PBPR group (RR 1.43, 95% CI 1.40-2.65; p < 0.01). Schillinger, US PDPT with General A total of 81% NR Risk of reinfection et al. (2003) azithromycin by population returned for at was 20% lower females with least one follow- among women in chlamydia to male up visit. the PDPT arm (12%) sex partners than among those in the self-referral arm (15%). This was not statistically significant (OR 0.80, 95% CI 0.62-1.05).

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Paper Country Intervention Population Follow-up rate Decreased risk- Effect on STI risk Notes taking behaviour during study Schwebke US Self-referral of Females and 40% at 3 months NR No significant and partners (PR), partners difference in Desmond patient-delivered diagnosed with repeated infection (2010) partner therapy Trichomoniasis rates when PDPT or therapy (PDPT) or DIS were compared public health disease to the reference of intervention (DIS) PR. However, when locating partners and PDPT was compared delivering to DIS or PR/DIS medications in the combined at one field. month, the PDPT group had lower repeat infection rate (5.8 versus 15% and 5.8 versus 12.5%, respectively).

MICRO-LEVEL INTERVENTIONS ACROSS POPULATIONS – Non-RCTs Paper Country Intervention Population Study type Decreased risk- Effect on STI risk Notes taking behaviour during study Behavioural interventions In-iw, et al. US Health Adolescents Retrospective NR Those having health education (2012) education cohort study counselling were less likely to counselling having recurrent STI (adjusted OR 2.24, p = 0.041). Laughon, et US Brief nursing Battered Pre-post Number of safer N/A The authors note a al. (2011) intervention women intervention sex behaviours small sample, lack of increased from a control group and baseline to no randomization in follow-up, this study, although although not the intervention statistically shows promise. significant.

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Paper Country Intervention Population Study type Decreased risk- Effect on STI risk Notes taking behaviour during study Ulibarri, et Mexico Brief Female sex Pre-post The intervention NR al. (2012) behavioural workers intervention decreased the intervention mean number of promoting sex acts with condom use clients, and the mean number of sex acts with clients in the following month (86.6 to 77.4, and 32.3 to 14.5, respectively).

Male condom Ahmed, et Uganda Male condom General Cohort N/A Consistent condom use al. (2001) Ugandan reduced syphilis (OR 0.71, 95% CI 0.53-0.94), gonorrhea/chlamydia (OR 0.50, 95% CI 0.25-0.97). Crosby, et US Male condoms African Cohort/Survey N/A The RR for non-consistent al. (2003) American condom use, compared with females consistent condom use for aged 14-18 acquiring chlamydia, years gonorrhea, or Trichomoniasis was 1.69 (95% CI, 1.16-2.46). Ness, et al. US Male condom African Cohort study NR RR of 0.5 (95% CI 0.3-0.9) for (2004) use American consistent condom users. females

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Paper Country Intervention Population Study type Decreased risk- Effect on STI risk Notes taking behaviour during study Sanchez, et Peru Male condoms Female sex Cohort/survey NR Reported consistent condom al. (2004) workers use is associated with a statistically significant 62% reduction in risk of acquiring gonorrhea and 26% reduction in risk of acquiring chlamydia.

New Technologies Dokkum, et Netherlands Text messaging General Pre-post N/A Proportion of invitees al. (2012) (SMS) population intervention returning a sample increased reminders for aged 16 to significantly from 10 to 14% chlamydia 29 years after email/SMS reminders. screening Gold, et al. Australia Text messaging General Pre-post N/A Increase in knowledge (p < Eighteen percent (2011) for sexual population intervention 0.01) and STI testing (p < 0.05) withdrew from health aged 16-29 over time in both males and receiving the text promotion years females. messages and only 40% completed the follow-up survey.

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Paper Country Intervention Population Study type Decreased risk- Effect on STI risk Notes taking behaviour during study Ehlman, et US Internet-based General Cross- N/A From 361 early syphilis The authors used the al. (2010) Partner population sectional patients, a total of 888 sex US CDC Disease Notification who met sex partners were investigated, of Investigation (IPN) program partners which 381 (43%) were via IPN. Specialist disposition for early online IPN led to an 8% increase in codes. If patient with syphilis the overall number of syphilis syphilis only provided infections patients with at least one internet-locating treated sex partner, 26% more information for sex partners being medically partner, the partner examined, and treated if was sent an email. necessary, and 83% more sex (Email was also used partners notified of their STI if partner could not exposure. be notified using traditional means.) Jones, et al. US Facebook site Young adults Descriptive There was a 23% There was a 54% reduction in (2012) that addresses aged 15 to pilot study self-reported positive chlamydia cases the signs, 24 years. increase in among 15-17 year olds. symptoms, condom treatment, utilization. screening and prevention of chlamydia infection

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Paper Country Intervention Population Study type Decreased risk- Effect on STI risk Notes taking behaviour during study Screening Gottlieb, et US Screening and Young Systematic N/A N/A Authors conclude that al. (2013) treating women review data from RCTs offer chlamydia evidence that trachomatis chlamydia screening genital and treatment is an infection to important and useful prevent PID intervention to reduce the risk of PID among young women. However, the magnitude of the benefit may have been overestimated. Hollier and US Treatment of Pregnant Review N/A N/A This is a review Workowski STI in women looking at the (2005) pregnancy diagnosis and treatment of various STIs in pregnancy to prevent vertical transmission.

Topical microbicides Obiero, et Multinational Topical General Systematic NR There was no evidence of an al. (2012) microbicides population review effect of any microbicide on the acquisition of gonorrhea, syphilis, condyloma cuminatum, trichomonisasis or HPV.

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Paper Country Intervention Population Study type Decreased risk- Effect on STI risk Notes taking behaviour during study Partner notification and patient-delivered partner therapy Stephens, US Patient- General Program NR Adjusted RR was 0.99 (95% CI, et al. delivered population evaluation 0.86-1.14) for chlamydia (2009) partner reinfection and 0.90 (95% CI, therapy 0.72-1.11) for gonococcal reinfection.

Aboriginal Steenbeck Canada Health Aboriginal Review NR NR This paper outlines (2004) promotion youth three strategies in STI prevention that holistic health nurses can use.

MESO- LEVEL INTERVENTIONS ACROSS POPULATIONS Paper Population Intervention Results Social diffusion NIMH Collaborative High-risk populations Community Popular Opinion No significant differences in chlamydia incidence were found between HIV/STD prevention in China, India, Peru, Leader (C-POL) intervention intervention and control venues in any of the four countries, nor for Trial Group (2010) Russia and Zimbabwe trichomonas incidence in women in any of the three countries. Significantly decreased rates of HSV-2 among the intervention venues in China (average difference -1.26, p=0.012 across venues) and Russia (-1.50, p = 0.016) but this was not observed in the other three countries (note however that there were a low number of incident cases of HSV-2 in most countries). Comparison of gonorrhea and syphilis between intervention and control venues were not performed due to low incidence rates in all countries. Note that there were high response rates (84.4% at 12-months and 82.0% at 24-months for interviews, and 74% for HIV/STD testing at baseline, 12- and 24-months). Chin et al. (2012) Adolescents Group education: Meta-analysis demonstrated that comprehensive risk-reduction. -risk reduction interventions resulted in 31% of STI prevalence (risk ratio [RR] = 0.69) -abstinence Conclusions could not be drawn re: abstinence education. Jemmott et al. African American “Sister-to-Sister: The Black Individual and group skill-building arms in RCT had lower likelihood of (2007) Women Women’s Health Project” testing positive for a STD than control participants at 12 months.

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Paper Population Intervention Results Outreach – screening Cohen et al. (1999) High school students School-based screening With repeated testing, the chlamydia prevalence among boys significantly decreased to half of what was observed in comparison schools (3.2% vs. 6.4%), while among girls, chlamydia prevalence decreased to a smaller degree and was not significant (10.3% vs. 11.9%). Nsuami & Cohen High school students School-based screening Chlamydia infection at first test among students who tested more than once (2000) was 1.8% for males and 7.7% for females. Among students tested more than once, no significant difference in chlamydia prevalence was associated with repeat screenings. Incidence rates per 1000 person-months were 4.3 (2.2, males; 7.1, females). Low et al. (2013) High school students School-based screening Chlamydia positivity initially declines slightly in women, and remained stable in men, then in 1998-1999 positivity increased, then was stable again from 1999-2000 onwards for both genders. Presumptive treatment Steen et al. (2000) Female sex workers Presumptive treatment Baseline prevalence of chlamydia and/or gonorrhea was ~25%. At the first and miners in South monthly follow-up visit, prevalence declined to 12.3% (69% follow-up). African mining At baseline 12.3% of the women had genital ulcer disease, and this declined community to 4.4%. Among miners, baseline prevalence of chlamydia and/or gonorrhea was 10.9%, which significantly decreased to 6.2% at the 9-month follow-up assessment; while the prevalence of genital ulcer disease significantly decreased from 5.8% to 1.3%. Ramos et al. (2006) Sex workers in the Presumptive treatment PT for BSW (brothel-based sex workers) and SSW (street): BSW baseline Philippines prevalence of chlamydia and/or gonorrhea 52%, which decreased to 27% at one month post-presumptive treatment, and 23% after seven months. Among SSWs, the baseline prevalence was 41% and this decreased to 25% at one month and then was 28% at seven months. No PT for RSW (registered) and guest relations officers (GRO): RSWs baseline, one month and seven month prevalence was 36%, 26% and 34%, respectively; while among GROs the proportions were 20%, 6%, 24%, respectively.

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Paper Population Intervention Results Rekart et al. (2003) Primarily heterosexual Mass targeted syphilis Syphilis rates significantly decreased up to the six month point, rates outbreak in DTES, treatment increased in 2001 to a higher level than expected. Vancouver At one year, no significant differences between the diagnosis of syphilis, Rekart et al. (2005) gonorrhea or chlamydia between participants (approached to participate in mass treatment, irrespective of whether they did or not) and non- participants (syphilis 7% vs. 4%; chlamydia 8% vs. 6%; and gonorrhea 2% vs. 2%). Conditional cash transfers De Walque et al. Males and females Intervention arm 1: High After controlling for numerous demographic variables as well as baseline STI (2012)225 age 18-30 years in conditional cash transfers status, compared to the control group, although there were not significant largely rural villages in Intervention arm 2: Low differences in the combined prevalence of the four bacterial STIs at 4- and 8- Tanzania. conditional cash transfers months, at the 12-month point there was a significantly decreased Control: no cash transfers combined prevalence for the high cash transfer group (RR 0.73, 95% CI 0.47- 0.99), but not for the low cash transfer group (1.06 (95% CI 0.75-1.38). Outcome: combined prevalence of chlamydia, gonorrhea, trichomonas and Mycoplasma genitalium, by objective testing.

MACRO-LEVEL INTERVENTIONS ACROSS POPULATIONS Paper Population Intervention Results 100% Condom Use Program Hanenberg et al. Sex trade workers and male clients in 100% CUP Cases of the five major STIs decreased by 79% in men. (1994) Thailand Zhongdan et al. Sex trade workers in China 100% CUP Chlamydia prevalence initially increased to 30.4% at 6- (2008) months, then declined to 14.5% at 15-months, then increased to 24 % at 21-months. Gonorrhea was not reported, and syphilis counts were very low [11/170 (6.5%) at baseline; 0/85 at 12 months and 3/102 (2.9%) at 21 months). Sopheah et al. Sex trade workers in Cambodia 100% CUP Prevalence of each STI in 2005 was significantly lower (2008) than in 1996, but essentially the same as prevalence observed in 2001 (year of the policy implementation).

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Paper Population Intervention Results Community mobilization Reza-Paul et al. Female sex workers in India Community mobilization and peer- STI prevalence significantly decreased: syphilis 25% vs. (2008) mediated outreach, increased 12%; chlamydia 11% vs. 5%; gonorrhea 5% vs. 2%; and access to and promotion of trichomonas 33% vs. 14%. utilization of sexual health services, and creating enabling environment to support the program. Mainkar et al. Female sex workers in India Avahan program Significant declines in syphilis, chlamydia and gonorrhea (2000) occurred: syphilis 15.8% to 10.8%; chlamydia 8% to 6.2%; gonorrhea7.4% to 3.9%.

Community mobilization and policy integrated interventions Kerrigan et al. Female sex workers in Dominican Community solidarity combined Significant decrease in the proportion of individuals with (2006) Republic with elements of the Thailand 100% one or more STIs (gonorrhea, Trichomoniasis, chlamydia) CUP adapted to Dominican in the combined intervention site only (28.8% to 16.3%; Republic context OR 0.50, 95%CI 0.32,0.78). Change in STI prevalence in the site with the community mobilization intervention only was from 25.% to 15.9%, but this change was non- significant. Kang et al. (2013) Female sex workers in China 100% condom promotion, Prevalence of syphilis 0.17% among the intervention community solidarity, activities to group vs. 1.89% among control group (OR 11.1, 95% CI reduce stigma and discrimination, 2.7, 46.1). outreach education to promote risk-related behaviour change and promote health care seeking, etc.

Sex trade workers registration Sirotin et al. Sex trade workers Registration Registered sex workers were significantly less likely than (2010) unregistered sex workers to test positive for gonorrhea (4% vs. 12%), syphilis (18% vs. 40%), or any STI (33% vs. 53%); but the prevalence of active syphilis and chlamydia were similar. But after adjusting for other cofounders associated with registration, registration was not found to be associated with the lower risk for a positive STI test.

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Paper Population Intervention Results Alcohol policy Chesson & Alcohol taxes $1 increase in the per-gallon liquor tax is associated with Harrison (2000) a decline in gonorrhea rates by 2.1%. A $0.20 per six-pack increase in the beer tax is associated with a decline in gonorrhea rates by 8.9%. Carpenter (2005) Youth and young adults Zero Tolerance drunk driving laws Adoption of a Zero Tolerance Law is associated with a for underage individuals significant reduction in gonorrhea rates among 15-19 year old white males in particular (with no effect for older males, or black individuals, and mixed effects for white females). Sen & Luong Higher beer prices in Canadian Higher beer prices are correlated with a reduction in (2008) provinces chlamydia and gonorrhea rates. Scribner et al. Alcohol outlet density in New A 10% increase in off-sale alcohol outlet density accounts (1998) Orleans for a .8% increase in gonorrhea rates. Cohen et al. Residents of LA neighbourhood post- Alcohol units closure post-civil After the 1992 civil unrest in LA, one unit decrease in (2006) civil unrest unrest alcohol outlets per mile of roadway was associated with 21 fewer cases of gonorrhea per 100,000 in affected tracts vs. unaffected tracts. Shafer et al. Male youth in a youth detention STI Compared with youth who did not drink: (1993) center (n = 414). All participants asked whether they Youth reporting daily drinking (13% of the sample) 65% African American ever had a STD, and 65% tested for significantly more likely to have a current or past STD (OR chlamydia and gonorrhea (urethral 3.53; 95% CI, 1.61–7.2). Cross-sectional study culture), syphilis (serology), Youth reporting heavy drinking (>20 drinks/week) had hepatitis B (serology), or genital increased risk of STD (OR 2.23; 95% CI, 1.08–4.62) – this warts (clinical examination). when controlling for lifetime number of sexual partners Alcohol and low condom use. Quantity and frequency of standard drinks consumed in past 3 months.

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Paper Population Intervention Results Erickson & Trocki Data from the 1990 National Alcohol STI Binge drinking was associated with increased risk of STD (1994) Survey (probability sample of adults in Survey question: “have you ever in men, which did not remain significant during 48 States, men n = 882, women n = had a sexually transmitted multivariate analysis, and no increased STI risk in women. 979). (venereal) disease (for example, Having >3 symptoms of drinking associated with an syphilis, gonorrhea, genital herpes, increased risk of STD in both men and women and this genital warts, chlamydia)?” remained during multivariate analysis. Alcohol Alcohol assessment questions included binge drinking (5 or more drinks in 1 sitting on at least a weekly basis over the past year) and problem drinking (having 3 or more of 8 major symptoms associated with alcohol abuse or dependence). Ellen et al. (1996) Heterosexual men and women (n = STI Men who reported being drunk before sex were more 1442) attending Laboratory and clinical assessments likely to be diagnosed with gonorrhea (OR, 1.14; 95% CI, public STD clinics in three cities in the for gonorrhea and syphilis. 1.02–1.29), but this result did not remain significant US. Alcohol during remain significant in multivariate analysis. No -61% male Self-report: how often they were relationship between being drunk during sex and syphilis -70% African American drunk from alcohol during sex in among men, or for gonorrhea or syphilis among women. -More than 25% current users of crack the prior 3 months. cocaine.

Cross-sectional study. Zhang et al. Women >25 years who attended STI Compared with women who did not drink at baseline, the (1996) cervical cancer screening program in Trichomonas identified by Pap RR of incident trichomonas infection was significantly China between 1974-1985 (n = smears and baseline and every 2 higher among women who drank 1-9 drinks per week 16,797). years (average 3.5 screenings per [1.7 (95% CI, 1.30–2.23)] but not among those who drank woman). >10 drinks per week [0.69 (95% CI, 0.22–2.15)]. Cohort study Alcohol Number of drinks per week (0, 1–9, 10 or more) and the number of years of drinking (0, 1–9, 10 or more).

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Paper Population Intervention Results Chokephaibulkit Pregnant youth in Tennessee. Cases STI No significant difference in the prevalence of alcohol et al. (1997) had been diagnosed with chlamydia Chlamydia infection diagnosed by abuse between cases (33%) and controls (39%). infection (culture) at first prenatal visit culture. (n = 67); controls of similar age and socio-economic status had first Alcohol prenatal visit on same day, but were Questionnaire assessed for ‘alcohol not infected (n = 53). abuse’, but details not provided.

Case control study Wilson et al. Women from clinical and community- STI When assessing whether there was an increased risk of a (1998) based settings in Brooklyn (1990- Tested for chlamydial and new STD with consecutive levels of alcohol consumption, 1994), n = 677. gonococcal infections using cervical the result was not statistically significant 232 had HIV. culture, and trichomonas infection (RR, 1.09; 95% CI, 0.97–1.22). 86% African American. using vaginal culture at baseline and every 6 months. Cohort study Alcohol Self-reported: number of times drank alcohol per week in a 1-year period (measured on a 7-point scale ranging from “never” to “more than 4 times a day”). Miranda et al. Women in prison in Brazil (n = 121) STI “Ever abusing alcohol” was significantly associated with (2000) Gonorrhea (cervical culture), syphilis infections only (OR, 2.0; 95% CI, 1.1–5.5), but not Ross-sectional study chlamydia (enzyme-linked with the other STIs. immunosorbent assay), syphilis (Venereal Disease Research Laboratory [VDRL] screening with confirmation), and trichomonas (vaginal wet mount). Alcohol Survey that assessed whether the woman had “ever abused alcohol.”

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Paper Population Intervention Results Mehta et al. Male and female emergency STI There were two alcohol questions that were associated (2001) department patients in Baltimore; Urine sample used to test for with an increased risk of STD in men: “ever been annoyed presenting for medical treatment of gonorrhea and chlamydia using by others criticizing your drinking” and “ever had a drink any type. Note that the analysis was ligase chain reaction first thing in the morning,” but only the latter question limited to participants aged 18-31 (LCR). remained significant in multivariate analysis. None of the years. Alcohol alcohol questions were associated with STDs in women. 4 CAGE questions (a screening test for alcohol abuse and dependence). Miller et al. Aboriginal males and females aged 12 STI Persons with alcohol abuse were significantly more likely (2001) to 40 years who were seen at least Laboratory testing for chlamydial to have an incident gonococcal twice between 1996-1998 for STD and gonococcal infections (using a infection (RR, 1.46; P = 0.007), but there was no testing at any of 9 urine-based polymerase chain significant association with chlamydial infections public clinics in Australia (n = 1034). reaction assay) and syphilis (RR, 1.18; P = 0.28) or syphilis (RR, 0.63; P = 0.42). (serology). Alcohol Alcohol abuse was defined as “binge drinking or regular heavy use” according to Aboriginal health workers. Thomas et al. Men and women enlisted in the US STI The prevalence of chlamydia among women who (2001) Navy in California (n = 299). Chlamydia testing by a urine-based engaged in problem drinking, compared to those who did LCR assay. not, was 21.4% vs. 4.6% (OR 6.6, 95% CI, 1.6–27.8) after Cross-sectional adjusting for current pregnancy. Alcohol Problem drinking was defined as “consuming alcohol until you passed out or vomited” within the previous 30 days. Fees and funding Reitmeijer et al. Denver neighbourhood residents and Co-payments (clinic fee $15 for In addition to decreased clinic visits, chlamydia diagnosis (2005) non-residents residents and up to $65 for non- decreased by 28.1% (women and individuals under the residents). age of 20 years were disproportionately affected [40% and 42%, respectively]). 38.1% fewer gonorrhea diagnosis. Among MSM, gonorrhea diagnosis decreased by 40%, while early syphilis diagnoses increased by 8.8% (from 34 to 37 cases).

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Paper Population Intervention Results Chesson & Residents of US states Federal funding for STI elimination Greater amounts of state-level funding for syphilis Owusu-Edusei, Jr elimination in a given year were associated with lower (2008) state-level syphilis rates in subsequent years.

INTERVENTIONS FOR YOUTH Paper Population Methods Results Parental monitoring Crosby et al. Sexually active African American female Prospective cohort study – 18-month Youth that perceived that parental monitoring was (2003)31 youth age 14-18 years (n = 217) from low- period. STIs (gonorrhea, chlamydia and infrequent at baseline were significantly more likely income neighbourhoods. Youth that tested trichomonas) identified through self- to acquire chlamydia (AOR 1.8 [95% CI, 1.01-3.21]) positive at baseline for a STI were treated. collected vaginal swab specimens. or Trichomoniasis (AOR 2.4 [95% CI 1.22-4.87]) STIs tested at baseline, and three compared to youth that perceived greater levels of subsequent points during the study monitoring. During 18-month follow-up, youth that period: 6-, 12- and 18-months. perceived that parental monitoring was infrequent Parental monitoring assessment through were significantly more likely to test positive for a questionnaire with Likert scale, asking: STI (AOR 2.1 [95% CI 1.16-3.74]). how often parents/parental figures knew were they were when they were not at Association only, no intervention. home or at school; and how often parents knew whom they were with when not at home or school. Adjustment for baseline STI prevalence.

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Paper Population Methods Results Crosby et al. Pregnant African American females age 14- Sexual risk behaviours were assessed At baseline, 51.2% of participants reported a past (2002)44 20 years that were sexually active in the past through interview. STI; 45% of these participants reported being 2 months, in an urban area in the southern Perceived family support was assessed treated for a STI within the past 6 months. Only less US by survey, and included questions about frequent mother-daughter communication about the receipt of emotional support, family the prevention of AIDS was associated with self- efforts to help, and being able to talk reported STIs, as was not residing with a family about problems. member/relative. Low perceived family support Mother-daughter communication was was not found to be significant, nor was less assessed by survey, and included frequent communication about STI prevention or questions about having discussions less frequent discussion about sex. about sex, prevention of HIV/AIDS, and prevention of STIs. STI history was assessed by survey. Urine samples were collected for STI testing.

Electronic technologies Downs et al. Adolescent girls in an urban setting (n = 300) RCT Adolescents in the intervention arm were (2004)72 Intervention: Interactive video significantly less likely to report having been Control condition 1: The same content in diagnosed with a STI. Chlamydia diagnostic tests book form (PCR assay of chlamydia trachomatis) Control condition 2: Brochures demonstrated a non-significant trend in this These 3 initiatives delivered at baseline, direction. plus booster sessions at 1, 3 and 6 months.

Home-based testing Østergaard Highschool students; intervention group (n = Intervention group: tested for chlamydia At one year, 2.9% of the intervention group had et al. (2000) 867), control group (n = 833). by home sampling. new chlamydial infection, compared to 6.6% of the 64 Control group: tested in a physician’s control group (p = 0.026). Significantly fewer office. women in the intervention group reported being treated for PID compared to the control group (2.1% vs. 4.2%, p = 0.045).

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Paper Population Methods Results Cook et al. Females age 15-24 years who had a recent RCT (the Detection Acceptability 71% of the intervention group returned at least one (2007)63 STI (chlamydia, gonorrhea or Trichomoniasis) Intervention for STDs in Youth [DAISY] home test, and 10% of tests were positive for or had certain risk factors including age <20 study). chlamydia and/or gonorrhea. Although significantly years, African American, monthly douching, Intervention group: home testing kit for more chlamydia and gonorrhea tests overall were >1 sexual partner in the past year or living in testing at 6, 12 and 18 months. Samples completed per year by the home testing group a neighbourhood with higher chlamydia were mailed directly to the laboratory. (1.94 vs. 1.41 test per women-year, p <0.001), and rates (n = 403); 70% of the sample was Comparison group: postcard invitation to more specifically asymptomatic tests (1.18 vs. 0.7 African American. attend a medical clinic for testing during tests per woman-year, p<0.001), there was no the same intervals. significant difference in the incidence rate of STIs detected overall (20.4 vs. 24.1 infections per 100 woman-years, p = 0.28) as well as when disaggregated for chlamydia or gonorrhea. Østergaard 17 highschools in Denmark RCT Intervention arm had significantly higher testing et al. (1998) Intervention arm: home sampling rates: females - 93.4% tested vs. 7.6% in the control 67 Control arm: usual testing (i.e., students arm (p < 0.001); males - 97.3% vs.1.6% (p < 0.001). were offered testing at their doctors or Among females, 4.6% chlamydia positivity vs. 0.6% at the local clinic) in control group (p <0.001). Among males, chlamydia positivity was 2.5% vs. 0.4% (p < 0.05). A significantly higher proportion of participants in the control arm reported symptoms. Multi-component interventions – children, parents and teachers Lonczak et Elementary school students, teachers and Intervention: Seattle Social Development A significant difference in STI diagnosis was not al. (2002)24 parents Project implemented during elementary found overall, but after controlling for poverty, school. there was a significant difference among African Evaluation at age 21 years. Americans in the intervention versus control arms: 7% vs. 34% reported being diagnosed with a STI in their lifetime (OR 0.11, p < 0.01) or a difference of 27%. For non-African Americans, this difference was 3%.

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Paper Population Methods Results School-based health centers Gaydos et Female adolescents presenting for Chlamydia testing offered within SBHCs Overall chlamydia prevalence was 18.1% (95% CI al. (2008)46 rescreening at SBHCs (10,000+ over 7-years) (middle and highschools). 17.4-18.8%), with a variation from year to year (from 15.1% [13.1-17.1] to 19.5% [17.8-21.2%]). Chlamydia positivity did not decrease over time. Among those who tested positive, 46.7% were rescreened. The cumulative incidence of reinfection was 26.3% (95% CI 23.4-29.2%), and of these individuals, 42.8% had one or more negative tests results in between the initial positive test and subsequent positive test. The age group with the highest risk of reinfection was age 13 years and younger. Shafer et al. Sexually active adolescent females (age 14- RCT - random assignment of 10 pediatric Over an 18-month period, 47% of females in the (2002)30 18 years), seen during routine check-ups in clinics to the clinical practice intervention sites were screened compared to 17% pediatrics clinics, in a HMO in the US improvement intervention (n = 1017 at control sites; at 16-18 months, the screening rate sexually experienced adolescent females) among intervention clinics was 0.65 (95% CI 0.53- or to a control intervention (n = 1194). 0.77) compared to 0.21 (95% CI 0.09-0.33) in the Control arm: one-hour session that control clinics. Chlamydia infection rate for the included information about the intervention clinics was 5.8% compared to 7.6% in epidemiology of chlamydia in the control sites (test of significance not reported). adolescents, and the current chlamydia screening and treatment recommendations. Intervention arm: same, but additionally the clinical practice improvement intervention was implemented that included engagement, team-building, redesign of clinical practice, and sustaining the gain.

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Paper Population Methods Results Mass media Wingood et African American adolescent females (n = 12-month prospective study to examine 37.6% acquired a new STI, and adolescents that had al. (2003)53 522) between 14 and 18 years of age, had the impact of the exposure to rap music greater exposure to rap music videos were been sexually active in the past six months, videos on the incidence of STIs significantly more likely to have acquired a new STI and lived in lower socio-economic status (chlamydia, gonorrhea and compared to those that had less exposure to rap neighbourhoods in Alabama. Trichomoniasis) and health risk music videos (AOR 1.6 (95% CI 1.1-2.3, p=0.04). behaviours. Association only. No intervention. Wingood et African American females age 14-18 years Cross-sectional study examining the ~30% reported exposure to X-rated movies, and al. (2001)54 and sexually active within the past six association between exposure to 28% had >1 STI with 5% diagnosed with mixed STI months. sexually explicit (i.e., X-rated) movies and infections. Chlamydia, gonorrhea and STIs, sexual health-related attitudes and Trichomoniasis prevalence was 17.5%, 5.2% and behaviours. 12.9%, respectively. Exposure to X-rated movies was associated with being significantly more likely to test positive for chlamydia (AOR 1.7 (95% CI 1.04-2.80, p = 0.03).

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INTERVENTIONS FOR MSM Paper Country Population Methods Results Behavioural Interventions European Europe Behavioural interventions Systematic The authors found four studies that looked at Centre for review unprotected anal intercourse (UAI) as an Disease outcome. For behavioural outcomes, two studies Prevention and found no significant differences. The other four Control (ECDC), found RR of 0.47-0.86. 2009 One study found a RR of 1.66 (95% CI 1.00-2.74). Herbst, et al. Multinational Behavioural interventions Systematic Overall interventions were associated with a (2005) review significant decrease in unprotected anal intercourse (OR 0.77, 95% CI 0.65-0.92), reduction in number of sexual partners (OR = 0.85, 95% CI 0.61-0.94), and a significant increase in condom use during anal intercourse (OR 1.61, 95% CI 1.16- 2.22). Interventions that were successful were based on theoretical models, including interpersonal skills training, and incorporated several delivery methods and were delivered over multiple sessions. Johnson, et al. Multinational Behavioural interventions Systematic They found 44 studies evaluating 58 interventions (2008) review with a total of 18,585 participants. Forty interventions that compared to minimal or no HIV prevention intervention reduced occasions for UAI by 27% (95% CI 15-37%). The other 18 interventions reduced UAI by 17% when compared with other standard therapies (95% CI 5-27%).

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Paper Country Population Methods Results Chemoprophylaxis for syphilis Wilson, et al. Australia Chemoprophylaxis for syphilis Mixed-methods They surveyed 2095 gay men; 52.7% of them (2011) (95% CI 50.6-54.8%) indicated that they would be very likely or slightly likely to use chemoprophylaxis to reduce their chances of acquiring syphilis. When told it would help reduce infections in the gay community, that number rose to 75.8% (95% CI 74.0-77.6%). Their mathematical model showed that this could reduce the number of syphilis cases by 50% after 12 months of use and 85% after 10 years. Community Partnerships and Events Blank, et al. US The New York City Department of Health and Descriptive Of 1634 attendees, 445 persons accessed one or (2005) Mental Hygiene developed Hot Shot! to address more service; 4 were newly diagnosed with general MSM health issues, including STI. syphilis and seven with HIV. Gutierrez, et al. India The Frontiers Prevention Project (FPP) aimed to Two cross- For MSM, there was a significant decrease (2010) empower the key populations in India most sectional surveys between baseline and follow-up for syphilis affected by HIV. The FPP set out to improve seropositivity (40% to 32% in FPP group versus advocacy within these groups, changing policies 34% to 29% in non-FPP group, p < 0.05). that affect these groups, and increasing community awareness. The provision of a complete set of prevention interventions, aiming to reduce risk behaviours and STI incidence, resulted in a lower HIV incidence among the key populations. The goal of the project was to ensure an environment in which adequate services and commodities were available for key populations.

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Paper Country Population Methods Results Male circumcision Templeton, et Multinational Male circumcision Systematic For bacterial STIs, they found six studies looking al. (2010) review at the association between circumcision and STIs in MSM. For gonorrhea and chlamydia, two studies found no significant association between circumcision status and urethral gonorrhea or chlamydia. Wiysonge, et al. Multinational Male circumcision Systematic For syphilis outcomes, 8 pooled studies showed (2011) review no significant association between male circumcision and syphilis.

Internet-based marketing campaigns Blas, et al. Peru Online banner advertisements offering free HIV Observational, The inclusion of the health incentive increased (2007) and syphilis testing cross sectional the frequency of completion of surveys (5.8 versus 3.4%, p < 0.001). Eleven percent of participants who said they had completed the survey offering free testing visited the STI clinic. Of those who attended the clinic, 6% had already been diagnosed as having HIV, while 5% tested positive for HIV. Eight percent tested positive for syphilis.

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Paper Country Population Methods Results Klausner, et al. US Internet-based prevention intervention-website Descriptive During two months in 2002, staff conducted 57 (2004) was created, there was individual online outreach, hours of outreach on three internet sites; banner advertisements, chats, an educational site, resulting in 212 interactions: AOL, Craigslist and message boards, warnings and an online syphilis M4M4Sex. Thirty-five or 16% redeemed incentive testing program. coupons at the municipal STI clinic. There were 9 banner ad campaigns shown over 33 million times on gay.com and AOL, resulting in a 0.1% click- through rate. There were 7 one-hour chats on gay.com with 10-50 people in the chat room at any one time, and 15 questions answered per hour. About 840 people participated in 7 sessions. The “Ask Dr. K” site receives 100 questions a week. From June 2003-January 2004, there were thousands of visitors to STDTest.org, but only 140 completed syphilis testing. Of these, six (4.3%) tested positive. Koekenbier, et Netherlands Online-mediated syphilis testing Cohort study During 15 months, 898 visitors to the website al. (2008) downloaded a referral letter. Of these, 93 (10%) men tested and 96% of these obtained their test results online. Through the website, the authors found a significantly higher percentage of men who needed treatment for syphilis compared with the STI clinic (50% online vs. 24% STI clinic, p < 0.01). Of the online users who tested positive 3 of 10 had never visited the STI clinic before. Levine, et al. US Online syphilis testing Descriptive During the first year 218 tests were performed (2005) and 13 had reactive serology. Six were diagnosed with a new syphilis infection. McFarlane, et US Internet-based health promotion and disease Review of Authors looked at eight cities in the US (Chicago, al. (2005) control programs in New York, Miami, Fort Lauderdale, San Francisco, eight cities; Los Angeles, Houston and Atlanta). Public health qualitative officials were contacted for interviews regarding local, online efforts to implement disease control and health promotion strategies.

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Paper Country Population Methods Results Moskowitz, et US Use of instant messaging counselling Descriptive About 43% of the instant message sessions al. (2008) discussed information about HIV/STIs. Risk taking behaviours were addressed in 39% of the sessions. Information about HIV/STIs and general counselling were given in 23 and 18% of the counselling sessions, respectively. Muessig, et al. US Mobile phone apps Qualitative Authors recruited a sample of 22 black MSM. (2013) Despite the fact that half the sample earned less than $11,000 annually, all participants owned smart phones and had unlimited texting and many had unlimited data plans. Themes that emerged were that the phones were integral to their lives and were the primary means of accessing the internet. Communication was usually done through text messaging and messaging through social networking sites. Half used their phones to find sex partners, and over half used their phones to find health information. For an HIV-related app, participants stated they were looking for user-friendly content about test site locations, information about STIs, information about symptoms, the risks of drug and alcohol use, safe sex, sexuality and relationships, gay- friendly health providers and connection to other gay and HIV-positive men.

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Paper Country Population Methods Results STI Screening Chesson, et al. US Rectal screening for chlamydia and gonorrhea Mathematical The authors looked at two different models—a (2013) model base case, in which only benefits to those screened were included; and a dynamic version, in which the population impacts were also looked at. The cost per quality-adjusted life year gained through screening MSM for rectal chlamydia and gonorrhea was $16,300 in the static version of the model and the cost per quality adjusted life year gained was less than $0, meaning the measure was cost-saving. Sexton, et al. US Self-screening RCT Self-administered testing was significantly better (2013) at identifying pharyngeal gonorrhea (discordant 3%) and rectal gonorrhea (discordant 2.9%) (p < 0.01) and had results similar to provider administered testing for pharyngeal chlamydia (discordant 0.5%) and rectal chlamydia (discordant 1.1%). Tuli, et al. US Screening among MSM inmates Mathematical Modeling suggests that a screening, treatment (2009) modeling and condom provision intervention for inmates can be cost saving for incarcerated MSM who have sex before incarceration and no condom use, and for incarcerated MSM who have sex before incarceration and condom use by 20% of screened inmates. For inmates who have no sex, the net cost would be almost $180,000. Vriend, et al. Netherlands Anorectal chlamydia screening in care at HIV Mathematical There will be cost savings by routine once yearly (2013) treatment centers model chlamydia screening of MSM in care at HIV treatment centres if these patients do not seek care elsewhere.

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Paper Country Population Methods Results Social Marketing Campaigns Ahrens, et al. US Healthy penis campaign Cross-sectional An increasing proportion of respondents reported (2006) survey syphilis testing in the previous six months by campaign awareness level (Cochran-Armitage trend test z = -3.303, p = 0.001) for the first evaluation; and z = -2.304, p = 0.02 for the second evaluation. After controlling for confounders, each increase in campaign awareness level during the first evaluation was associated with a 90% increase in likelihood for having tested for syphilis in the past six months (OR 1.9, 95% CI 1.3-2.9). In the second evaluation, each increase in campaign awareness level was associated with a 76% increase in syphilis testing (OR 1.76, 95% CI 1.01- 3.1). Ecologically, the incidence of early syphilis was lower than in the previous three years (data not provided). Katzman, et al. US A “Community Manifesto” to appeal to control Cross sectional For those who completed the survey (web-based, (2007) HIV/STIs among the MSM community survey mail-in or street-intercept), 84% had heard about the manifesto. About half of all respondents reported that the manifesto made them think about their sexual choices and behaviours. Twenty-seven percent indicated they had made changes to their behaviours. Sixty-one percent strongly agreed or agreed with the manifesto; 19% disagreed or strongly disagreed with it; 18% was neutral.

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Paper Country Population Methods Results Martinez- US Hombres Sanos; social marketing campaign for Before-after There were no changes in the prevalence rates of Donate, et al. heterosexually identified Latino MSM unprotected sexual practices with females over (2010) the previous 60 days. There was a significant increase in the percentage who reported and demonstrated condom carrying during the campaign (AOR 2.28, 95% CI 1.59-3.27) and post- campaign (AOR 1.62, 95% CI 1.06-2.49), compared with baseline. HIV testing during the previous six months increased significantly from baseline to post-campaign (AOR 3.13, 95% CI 2.06-4.75). The percentage of heterosexual respondent who knew where to get tested for HIV increased at the campaign (AOR 1.60, 95% CI 1.26-2.02) and post- campaign phases (AOR 1.57, 95% CI 1.18-2.08). Respondents’ average level of perceived risk for HIV was higher during the campaign (B=0.013; 95% CI 0.04-0.13) and post-campaign (B=0.27, 95% CI 0.17-0.37) than during baseline. Pedrana, et al. Australia Social marketing campaign Before-after Surveying a convenience sample of 295 MSM, the (2012) authors found that campaign awareness was high (86%). In multivariable logistic regression, awareness of the campaign was independently associated with having had any STI test within the past 6 months (prevalence ratio 1.5, 95% CI 1.0- 2.4). Compared with the 13 months before the campaign, their data showed significant increasing testing rates for HIV (RR 1.17 initial period, RR 1.27 continued campaign period), syphilis (RR 1.19 initial period, RR 1.29 continued campaign period) and chlamydia (RR 1.15 initial period, RR 1.28 continued campaign period) among HIV-negative MSM (all p < 0.01).

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Paper Country Population Methods Results Wei, et al. Multinational Social marketing Systematic They found three studies and included it in their (2013) review final analysis (Darrow and Biersteker, 2008; Guy, 2009; McOwan 2002). Their meta-analysis showed that the campaigns were effective on HIV testing uptake (OR 1.58, 95% CI 1.40-1.77) but were not effective in increasing STI testing uptake (OR 0.94, 95% CI 0.68-1.28). They also noted a high risk of bias and a low quality of evidence for the three studies.

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APPENDIX C: SUMMARY OF EVIDENCE RATINGS

MICRO-LEVEL INTERVENTIONS – ACROSS POPULATIONS Intervention Behavioural STI incidence/ Contextual considerations and comments outcomes prevalence General behavioural   Results of trials looking at general behavioural interventions have been mixed. There is some interventions and risk evidence to support implementation of this strategy in limited settings but further studies should reduction counselling be done evaluating the impact of this intervention on a wider scale. Behavioural   Behavioural interventions stressing ethnic pride and skill-building have been shown to be interventions stressing effective in African- and Latino-American populations. ethnic pride and skill- building Small group sessions   Small group support sessions have shown to positively affect risk behaviours and reduce the risk of STIs in African- and Latino-American women. Peer education   Peer education sessions have been shown to be effective in reducing STI rates and increasing condom usage among female sex workers in developing nations. Cognitive-behavioural   There is some evidence that cognitive-behavioural interventions can help reduce the risk of STIs interventions and improve health behaviours. Brief behavioural   There is evidence that cognitive-behavioural interventions can help reduce the risk of STIs and interventions improve health behaviours. Many of these studies were done in African- and Latino-American populations and young adults. Screening and treating N/A  RCTs have shown a decreased risk of PID in those screened for chlamydia in studies in developed for STI to prevent PID nations, but the benefits of screening may be overstated. Male condoms N/A  Male condoms have been shown to be highly effective in preventing the transmission of STIs. Studies have been done in a variety of settings in North America and in developing nations. Female condoms N/A  Although the female condom, as a technology, is effective as a mechanical barrier to viruses and semen, poor uptake of the female condom and cost limit its recommendation for wide dissemination. However, it should be noted that there is a lack of safety data on usage during anal intercourse. Cervical diaphragms N/A  The use of diaphragms for STI prevention is as effective as male condoms, as a technology. However, poor uptake may limit its recommendation for wide dissemination. Topical spermicides N/A  Topical spermicides have not been shown to be effective in reducing the transmission of STI, and in fact may facilitate the transmission of STI, especially in the case of N-9.

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Intervention Behavioural STI incidence/ Contextual considerations and comments outcomes prevalence Topical microbicides N/A  Topical tenofovir has shown promise in preventing the transmission of HIV only. More research is needed into whether other microbicides is effective in preventing STI acquisition. Male circumcision N/A  There is evidence to suggest that male circumcision is effective in preventing transmission of STI but most studies were done in developing nations with high HIV prevalence. Limited evidence exists for a wide policy of recommending male circumcision in developed nations. Accordingly, the US CDC and Canadian guidelines have not recommended for or against this strategy in developed nations. Patient referral N/A  Patient referral is generally less effective than provider referral and PDPT.

Contact slips N/A  More research is warranted into whether contact slips can be used as a partner notification technique. Provider referral N/A  Although provider referral has shown some promise, more research is needed before this strategy can be recommended. PDPT N/A  PDPT has been shown in multiple studies, including randomized controlled trials, particularly in chlamydia and gonorrhea, to reduce reinfection rates. Some caution, however, should be exercised given that gonorrhea is becoming a multi-drug resistant organism and may require parenteral treatment. PDPT should only be implemented for chlamydia in the heterosexual population. For MSM, because there is a higher risk for HIV infection, PDPT may only be cautiously offered, if at all, to ensure appropriate testing and counselling.

MESO-LEVEL INTERVENTIONS – ACROSS POPULATIONS Intervention Behavioural STI incidence/ Contextual considerations and comments outcomes prevalence Group education – risk   Group education involving risk reduction has been shown to be effective in impacting STI rates in reduction some, but not all, studies.

This intervention has also been shown to impact sexual risk behaviour outcomes in some, but not all, studies.

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Intervention Behavioural STI incidence/ Contextual considerations and comments outcomes prevalence Group education -   Group education with an abstinence message has revealed a positive impact on sexual initiation abstinence in a recent study. However a meta-analysis suggests that conclusions cannot be drawn and some other studies have not found an impact.

Impact on STI rates is uncertain based on the reviewed literature. Skill building in group   As a general principle, in group education, beyond just providing information, skill-building is an education important element. Both individual-and group-level skill building interventions have contributed to decreased STI rates and risky sexual behaviour. Community opinion   Community opinion leaders, based on diffusion of innovation theory, are postulated to influence leaders community norms. A large, randomized, multi-site study did not demonstrate reduced STI incidence, yet a comprehensive comparison intervention may have made it difficult to detect a difference.

Evidence related to sexual risk behaviour was also not conclusive.

A small study suggests a beneficial effect on reducing HIV/STI-related stigma. Peer mentors within a   The single identified study (RCT) on the topic of a peer mentor operating within their social social network network, revealed encouraging reductions of risky sexual behaviour.

However impact on STI rates is uncertain. Contact tracing using a  For  Using a social networking approach for contact tracing has been shown to have advantages over social network approach detection of the traditional ‘one-time interview’ approach. Evidence from a syphilis outbreak in Vancouver STI cases demonstrated a comparatively higher proportion of cases detected through this method. Another study suggests that increased costs may be a consideration.

Evidence is needed to assess how this impacts on STI rates. Electronic technologies  To support  The evidence is supportive of electronic technologies, sometimes in conjunction with another in STI clinic settings testing STI intervention (such as the introduction of guidelines, or intensive DIS follow-up) being effective in screening, improving various outcomes related to STI diagnosis and follow-up care (e.g., STI screening, diagnosis, re- timely follow-up post-diagnosis, rescreening). testing Impact on STI rates over time is uncertain.

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Intervention Behavioural STI incidence/ Contextual considerations and comments outcomes prevalence Disease Intervention  To support  Limited study suggests a positive impact on partner elicitation. Specialists (DIS) within a partner clinic setting elicitation Research on the impact of DIS on STI rates is needed. (Note that there is also a study of a combined DIS and electronic technologies intervention that demonstrates promising results). Syphilis testing during  To support  Including routine syphilis testing with every blood test that is collected as part of HIV monitoring routine HIV monitoring syphilis resulted in a significant increase in early syphilis detection, among HIV-positive MSM in an detection Australian study.

Impact on STI rates is uncertain. Male clinics   Male health clinics are suggested as an important way to promote male access to STI care. The limited study identified on this topic reported positive impact on STI knowledge and suggests positive impacts on sexual risk behaviour, however impact on STI detection and STI rates is not reported. Mobile clinics  To support  A single study revealed mobile clinics as a feasible and acceptable way to reach community screening members and test for STIs. Note that general health services were also offered in order to uptake decrease stigma.

Impact on STI rates over time is not examined. School-based STI  For  Screening in school-based settings was the subject of a large body of research. Generally, there is screening and treatment facilitating favourable outcomes related to the treatment of individuals that are found to have STIs (many of programs the which are asymptomatic). Rates of participation in the screening program vary widely. There is treatment of also inconsistency with respect to the impact of the program on STI rates over time. cases  For participation in screening program

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Intervention Behavioural STI incidence/ Contextual considerations and comments outcomes prevalence Screening in  For  A limited research base was identified on screening among sports teams/in sports venues. One sports/sports team- promoting study in Australia demonstrated a very high screening participation, while another study related settings screening suggests that there is potentially a greater acceptance of screening in these venues among those uptake who actually participate in sports.

Evidence is needed to assess how this impacts on STI rates over time. Occupational group   A single study was found that offered screening based on occupational groups. Varying rates of screening STIs was observed among different groups.

Evidence is needed to assess the impact on STI rates over time. Screening in family For  A single study on screening within the family court system revealed that less than half of the court system reaching the target population was offered testing at intake, however there were very high treatment rates. target population Evidence is needed to assess the impact on STI rates over time.  For facilitating access to treatment Screening in prisons For  Fair screening rates were reported, while the treatment rates varied. One of the key factors in reaching the treating cases in this setting is that individuals may be discharged prior to completing STI target investigation and treatment. population  For This literature is not clear on the impact of screening on STI incidence/prevalence over time. facilitating access to treatment

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Intervention Behavioural STI incidence/ Contextual considerations and comments outcomes prevalence Screening in shelters  For  In a single study among adults in US shelters, high screening program participation, as well as promoting high treatment rates, were reported. screening uptake Evidence is needed to assess the impact on STI rates over time.  For facilitating access to treatment Screening for For  A single study suggests that outreach supports screening uptake, and access to diagnostic testing commercial sex workers supporting and treatment. Note that numerous other studies have included outreach screening for sex screening trade workers, as part of a wider program with other interventions (see report). uptake  For Evidence is needed to assess the impact on STI rates over time. facilitating access to treatment MSM sex on premises  For  A few studies in this area suggest that screening uptake might be supported through outreach, establishments, facilitating as might treatment for individuals that test positive. bathhouses, saunas treatment for screening cases Evidence is needed to assess the impact on STI detection, as well as rates over time.  For supporting obtaining results Street-based screening  For  In one study in the Netherlands, screening was offered in various settings outside of fixed screening venues. Screening uptake varied widely, with the lowest proportion screened in street corners, uptake parks and underground stations, etc.

Evidence is needed to assess the impact on STI rates over time.

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Intervention Behavioural STI incidence/ Contextual considerations and comments outcomes prevalence Home-based STI testing  To support  Generally favourable in terms of feasibility and appears to support the uptake of STI testing. One screening study found that ordering a testing kit online, and obtaining results online, were much preferred uptake over telephone methods. Some studies observed a higher screening volume with home-based testing, although it is not clear why and whether this finding (observed in settings outside of Canada) would be similar in a Canadian context. There were concerns expressed by participants in some studies about privacy, confidentiality and safety, and these would need to be addressed in any similar intervention.

There is uncertainty regarding the potential impact of home-based STI testing on STI morbidity over time, as two studies revealed contradictory findings, with a large study with a long follow- up period revealing no differences between home-based screening and a control condition. Presumptive treatment   One-time presumptive treatment was evaluated in one study among sex trade workers, and in another study among incarcerated MSM. The former study found an initial decreased STI prevalence over time in all groups offered presumptive treatment, however this decline was only sustained among groups that had expanded STI screening and treatment services. There was also a reduction in the STI prevalence of the clients of one group that had expanded STI services in addition to presumptive treatment. This suggests that while presumptive treatment can be effective over the short-term, other control measures must be implemented in order to maintain STI reductions over the long-term. The study in a prison setting, documented a high acceptance rate of prophylactic treatment, but was not able to assess long-term impact due to turnover within the prison population.

Periodic presumptive  For long- A study among female sex workers in South Africa found that PPT along with prevention treatment term impact education resulted in declining STI prevalence among FSW as well as local miners in the on STI rates surrounding community. A systematic review also found a positive impact on STI prevalence among sex trade workers, with emphasis that longer-term strategies are needed to support this short-term measure. Targeted mass   The literature related to syphilis prophylaxis in BC, has urged caution in the administration of treatment mass prophylaxis. Community mobilization   Studies of initiatives in which community mobilization was a key element, revealed significant decreases in STIs and risk behaviours among sex trade workers.

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Intervention Behavioural STI incidence/ Contextual considerations and comments outcomes prevalence Other multi-component   Based on a single study in Peru, a multi-component intervention (without a formal policy interventions element) produced encouraging reductions in STIs among some populations (young women and FSWs) but not other populations. This division of evidence is somewhat arbitrary because a number of other interventions reviewed in this evidence review have multiple components, and are classified in other sections. Conditional cash   While there are other studies examining non-bacterial STI outcomes, the one study that was transfers reviewed that had bacterial STI outcomes, demonstrated promising results. After 1-year, conditional cash transfers were associated with lower prevalence of four STIs. Note that this outcome was not observed during earlier study periods, and a gradient effect was noted. More research specifically on bacterial STIs would be helpful to confirm this finding that was observed in a rural low-income country setting.

With respect to behavioural change, participants report motivation to change behaviour.

MACRO-LEVEL INTERVENTIONS – ACROSS POPULATIONS Intervention Behavioural STI incidence/ Contextual considerations and comments outcomes prevalence Performance measures  To support  Evidence from the United States suggests that a change in performance measures can have an screening impact on STI screening, as participating institutions seek to implement measures to improve their performance.

The impact on STI rates however is unclear. 100% CUP Program  For  The 100% CUP was discussed widely in the literature, particularly in low- and middle-income increasing countries. Studies have varied in the demonstration of impact on STI rates and therefore more condom research is warranted. usage However, this intervention has demonstrated a positive impact in increasing condom uptake among sex trade workers/clients. Combined community   Studies of combined community mobilization and policy initiatives revealed significant decreases mobilization and policy in STIs and risk behaviours. initiatives

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Intervention Behavioural STI incidence/ Contextual considerations and comments outcomes prevalence Health plan  For impact  Significant differences in chlamydia screening rates among states that did and did not implement reimbursement law for on STI a health plan reimbursement law, were not identified in a single US study. STI screening screening rates STI screening legislation 0 0 Legislation is described but no evaluation is found. Alcohol policy (e.g.,   The literature on alcohol policy includes the examination of multiple measures of reduced taxes, zero tolerance alcohol access or consumption and finds that measures that involve alcohol reduction are drunk driving laws, associated with lower STI rates. This result is not mirrored in all studies, and the challenges in minimum drinking age, establishing causality are recognized, however there is a well-supported mechanism of alcohol outlet density) association that has itself received support in the literature (i.e., the association between alcohol consumption and risky behaviour), and corroboration of evidence in a number of studies. Registration of sex trade   In one study of registration of sex workers in Mexico, registration was not found to be associated workers with the with lower risk of testing positive for STIs, in an adjusted model. municipal health department Clinic co-payments For impact For impact Based on a single well done natural experiment with strong theoretical rationale, the on clinic visits on STI introduction of even a modest fee for STI clinic care has been shown to result in a considerable diagnosis decline in clinic visits and impact the diagnosis of STIs. Federal funding for STI N/A  An inverse association was found between the amount of federal funding for syphilis elimination elimination activities and the subsequent syphilis rate in later years, at the state level in a US study. Although this study design is ecological, it is appropriate for an examination of data at this level, and well- designed. While this topic would benefit from additional research to corroborate this finding, a sound theoretical rationale and study features, are key factors that influenced this rating. PHAC and CDC 0 0 No evaluation was found of the impact of these guidelines on STI rates at the population level, Guidelines however there is literature examining use among health care providers (discussed below), and these guidelines consist of interventions that are discussed throughout this report.

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Intervention Behavioural STI incidence/ Contextual considerations and comments outcomes prevalence STI Control Strategies  0 There is evidence of a positive impact of guidelines on the uptake of STI screening in studies from and Guidelines Australia and the UK, and some positive impacts on knowledge from a syphilis prevention campaign in Alberta.

Data from the US does reveal that adherence to CDC STI treatment guidelines seems quite high.

No evaluation of jurisdiction wide control strategies or treatment guidelines for impact on subsequent STI rates was found.

MICRO-LEVEL INTERVENTIONS – YOUTH Intervention Behavioural STI incidence/ Contextual considerations and comments outcomes prevalence Computer-based   Note that the review of this study is intended to complement the previous discussion of education and skill individual-level behavioural interventions, and not stand on its own. This particular computer- building behavioural based program that combined education and skill-building, had some positive behavioural intervention for youth outcomes (while others did not differ from traditional print-based materials) as well as lower rates of self-reported STIs. However, objective STI data is uncertain. Online interventions   Systematic review/meta-analysis data suggests that “new digital media/interactive computer- (general or multiple based” interventions, can have a positive impact on behavioural outcomes. interventions) Determining impact on STI rates would benefit from further research.

Acceptance is high among youth. Home-based STI testing For  Although not all studies have found a differential impact on STI detection, the bulk of the promoting evidence suggests that home-based STI testing has advantages over traditional face-to- testing and face/clinic testing in promoting testing uptake among youth, as well as detecting STIs. STI detection

MESO-LEVEL INTERVENTIONS – YOUTH Intervention Behavioural STI incidence/ Contextual considerations and comments outcomes prevalence

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Intervention Behavioural STI incidence/ Contextual considerations and comments outcomes prevalence Parental monitoring   An association between parental monitoring and sexual risk behaviours has been consistently identified, and in one prospective cohort study, an association between parental monitoring and STI incidence was identified. What is lacking is literature evaluating a parental monitoring intervention. Worksite based   A single identified study examining a workplace-based program for parents of adolescent programming for children, and demonstrated positive impact on parent-child communication about sexual parents behaviour, but it is uncertain how this impacts subsequent adolescent sexual behaviour and STI rates. Multi-component   Interventions delivered to target populations of children/young youth, varied in their approaches targeting components and scope (e.g., involvement of parents and teachers, community service children/younger youth elements). However, the studies in this area all suggest that the period of children/early adolescence is an important time for STI prevention interventions can reduce sexual risk behaviour over the long-term. These studies also highlight the importance of the social and community context for youth.

Impact on STI incidence/prevalence was only assessed in one study, and a significant difference was only found among African American individuals. Further study is warranted. Multi-component   Similarly to the multi-component school-based interventions delivered to younger students, approach targeting along with their teachers and parents, a multi-component intervention among highschool youth in highschool students had numerous positive impacts on sexual risk behaviour. In this single study however, the intervention did not seem to impact sexual initiation, but did decrease sexual risk behaviours.

Impact on STI incidence/prevalence is uncertain. Peer education alone   Peer education alone demonstrated improvements in STI-related knowledge and undergoing STI and combined with testing. This was expanded to include outreach screening, in partnership with a faith-based outreach screening in organization, which demonstrated further positive impact in engaging youth in STI screening. partnership with a faith- based organization Impact on STI incidence/prevalence warrants further research.

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Intervention Behavioural STI incidence/ Contextual considerations and comments outcomes prevalence School-based health   SBHCs are important venues for offering screening to youth in schools, and have demonstrated centers the ability to detect high rates of STIs in US studies. One study demonstrated that a chlamydia screening initiative engaged a high proportion of SBHC clients, the majority of whom did not have another source for reproductive health care. Another study suggests that this is an important way to engage asymptomatic young men in screening. Further, high rates of reinfection with chlamydia were detected through a SBHC in one study, particularly among younger youth.

The long-term impact of offering STI screening through SBHCs on STI incidence/prevalence is not certain. Online initiatives to   In the UK, an intervention that used websites to promote access to free STI screening through promote STI testing the national program, found that although the proportion of tests accessed online increased, it was still far below more traditional methods of access. It was found that young men were reached at a higher rate than women, which may be important for engaging this group. A study from Ontario indicated that participants in an intervention involving website and text messages, indicated that just over half they would change their behaviour as a result of visiting the website.

MACRO-LEVEL INTERVENTIONS – YOUTH Intervention Behavioural STI incidence/ Contextual considerations and comments outcomes prevalence Clinic-based  To support  Data from HMOs in the US indicate that systematic changes in clinical practice can positively systems screening uptake impact STI screening uptake among target populations on female youth. interventions A favourable impact on chlamydia infection is suggested in one study, however without the reporting of a test of significance it is difficult to know the implications of this result.

Implications for the Canadian context vs. the HMO context, is uncertain.

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Intervention Behavioural STI incidence/ Contextual considerations and comments outcomes prevalence Mass media   An association between exposure to different types of mass media (e.g., with sexually explicit content) and STI rates have been reported in prospective cohort and cross-sectional studies. There is a plausible mechanism and corroboration of evidence of this association.

What is lacking is research evaluating the impact of interventions that limit adolescents’ access to sexually explicit media, and how this impacts STI burden and sexual risk behaviour.

MICRO-LEVEL INTERVENTIONS – MSM Intervention Behavioural STI incidence/ Contextual considerations and comments outcomes prevalence Behavioural   There is evidence to suggest that behavioural interventions are effective in reducing sexual risk interventions for behaviours among MSM. MSM However, there is a paucity of data for effectiveness in reducing STI and HIV transmission risk. Interventions that were found to be most effective are those based on theoretical models, interpersonal skills training, with multiple delivery methods, and a focus on the adverse effects of risky sexual behaviour and HIV/STI infections. Chemoprophylaxis   One mixed-methods study has shown acceptability among gay men to use chemoprophylaxis to for syphilis reduce the transmission of syphilis. Running this through a model shows the potential to reduce syphilis transmission rates by 85% over 10 years. More research is needed to demonstrate that this would be an effective intervention, especially balanced against the risks of antibiotic treatment. Male circumcision   There is very limited evidence to support male circumcision in the prevention of bacterial STIs. The quality of evidence is low; hence randomized trials of MSM in the prevention of both HIV and STIs are warranted. Self-screening N/A  While one study showed some promise in self-screening, limitations in the control group mean that this strategy cannot yet be recommended. More research is needed.

Universal anorectal N/A  There is evidence for once yearly universal anorectal screening for chlamydia and gonorrhea screening for among MSM. This recommendation rests on the fact that three studies have shown this to be chlamydia and cost-savings and the fact that selective screening based on history may miss many infections. gonorrhea

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MESO-LEVEL INTERVENTIONS – MSM Intervention Behavioural STI incidence/ Contextual considerations and comments outcomes prevalence Community   There is some evidence to support community-based partnerships and events in case finding for partnerships and syphilis. events Internet-based   While there have been published studies on internet-based campaigns for MSM, most studies campaigns have been observational or provide only descriptive statistics. More rigorous, controlled studies are needed to determine if the many types of internet campaigns are indeed effective in decreasing STI rates and improving outcomes.

MACRO-LEVEL INTERVENTIONS – MSM Intervention Behavioural STI incidence/ Contextual considerations and comments outcomes prevalence Social marketing   Although various social marketing campaigns have shown promise in uncontrolled studies, the campaigns evidence from controlled studies for the use of social marketing campaigns in controlling for bacterial STIs is poor. Some studies have shown an increase in uptake of STI testing and a reduction of risk behaviours. No studies were found evaluating the impact of social marketing campaigns on STI incidence/prevalence.

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APPENDIX D: DESCRIPTIONS OF SELECTED INTERVENTIONS

Box 1: Philadelphia High School STD Screening Program (PHSSSP)

Letters were sent to parents and guardians of students in advance of the PHSSSP implementation, describing the risks of chlamydia and gonorrhea infections, high rates of infection in Philadelphia, and nature of the voluntary screening program. The letter encouraged parents to discuss the problem of STDs with their children, but parental consent was not required in accordance with regulations in Pennsylvania.

The Philadelphia Public Health Department (PDPH) staff worked with school administrators to set up the program in each high school. Groups of approximately 60 students attended an educational and screening session, led by specially trained disease intervention specialists and STD educators. The 25-minute interactive educational portion included an overview of common STDs and risk factors for STDs with an emphasis on chlamydia and gonorrhea. During the sessions, it was emphasized that screening was voluntary and confidential, and that free and confidential treatment would be made available for those who tested positive. Screening was available for all students who attended the educational sessions, however the importance of screening for those who had ever engaged in sexual intercourse was emphasized.

Each high school's sessions were planned to ensure that each student was scheduled to attend a session for one period during the school day; some students were missed because of absence or truancy. Sessions were held at each school over five months.

Every student was given a testing kit, consisting of a brown paper bag with: 1) a form to be completed by the students (name, date of birth, address, phone number, ethnicity, preferred method for contact by PDPH staff, and a self-selected secret code); 2) a urine collection cup; and 3) a card with a PDPH telephone number to call for test results. Students were asked to provide urine specimens if they wanted to be tested. Small groups of students (equal to the number of stalls in the bathrooms), were accompanied to the bathrooms by PDPH staff who collected kits as students exited (irrespective of whether a urine specimen was provided). Specimens were tested for chlamydia and gonorrhea using NAAT at the PDPH Public Health Laboratory.

Students who phoned PDPH were given their test results after confirmation of their secret code. Students with positive test results were informed when PDPH staff would be at their school to provide treatment, were instructed to abstain from sex until completing treatment, and were encouraged to ensure that their partners received treatment. Those with partners in the same school were told that partners could come to ‘in-school’ treatment sessions. The staff at each school established ways to ensure that attendance at treatment sessions would be confidential. When students with positive test results attended ‘in-school’ treatment sessions, a PDPH clinician provided a single-dose observed therapy (1 g azithromycin orally for the treatment of chlamydia and/or 400 mg cefixime orally for the treatment of gonorrhea). Students with allergy or other contraindications were referred to a public health center or to their physician for treatment. Students who received treatment within the school or at PDPH clinics received STD risk avoidance counselling, were referred for complete STD and HIV testing, and given referral cards listing PDPH clinics for their sexual partners. Students with symptoms of PID or epididymitis were treated and referred for immediate evaluation.

For students with positive tests that did not call for their results, PDPH staff tried to confidentially inform them about the treatment session at their school. Students that did not attend the school treatment sessions were actively followed by PDPH and offered assistance (including with transportation) to attend a PDPH clinic or other healthcare provider of their choice. Staff then followed up with the healthcare providers to ensure that appropriate treatment had been given.

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Box 2: Family Court STD Screening Program

The Family Court is responsible for adjudicating all cases of delinquency among juveniles in Philadelphia. The Screening Program began in April 2004 through a collaborative effort between the Philadelphia Department of Public Health, Sexually Transmitted Disease (STD) Control Program, and the Family Court of Philadelphia. It was designed to offer all youth under Court-ordered supervision, who had been adjudicated delinquent and placed on probation, an opportunity to receive a confidential screening for chlamydia and gonorrhea using urine samples. It seems appropriate for STD screening of youth because most of the youth already provide urine for drug testing; as well, probation officers can provide current addresses to help assure treatment when necessary. Note that adolescents adjudicated delinquent in Family Court are released and return to their communities; therefore, if they have a STI infection and do not receive treatment, there is a risk of continuing infection spread.

Before the program started, input was sought from the Offices of the Public Defender and the District Attorney. Potential barriers to program implementation were addressed. These included concerns about confidentiality of testing and test results, self-incrimination by adolescents, and possible bias by the court if positive results are known.

Directly after the Family Court hearing and intake into the probation system, youth were directed by probation officers to the STD screening office (staffed by one full time public health employee) in the Family Court building where they were offered confidential STD screening. Participation was voluntary. In Pennsylvania, parental consent is not required for STD testing, diagnosis, or treatment of minors. If recent testing could not be documented through public health records, the adolescent was given a brief educational/motivational presentation and then asked to permit a portion of the urine specimen collected for required drug testing to also be tested for chlamydia and gonorrhea. Adolescents were asked to select a secret code that would allow them to access their results by telephone 1 week from the testing date by calling an identified public health number. Participants who telephoned public health were given their test results after confirmation of their secret code, and, if necessary, directed to a medical facility for treatment. Treatment was provided through the public health STD clinics and included antibiotic therapy, risk reduction counselling, testing for other STDs as appropriate (including HIV), referral for other services as needed, and partner referral counselling. All adolescents who tested positive were followed-up by Disease Intervention Specialist staff to confirm that treatment had been received or arrange for treatment.

Box 3: Shelter-based screening program Adult shelter clients were taken to a private room within the shelter for an interview, and asked to provide urine, blood and oral fluid samples for STI/HIV testing (chlamydia, gonorrhea, syphilis and HIV). Testing was free and confidential, however participants were informed that positive results would be reported to the State Department of Health. Pre- and post-test counselling was provided. Participants were asked to access their test results by returning to the shelter where they were screened after one week. Participants who tested positive for chlamydia or gonorrhea were treated on-site at the shelter in a private location by a project nurse (1 g azithromycin single oral dose for CT, 400 mg ofloxacin single oral dose for gonorrhea). Individuals with infection were instructed to inform their partners and abstain from sexual intercourse until their sexual partners had completed treatment. Those who tested positive for either syphilis or HIV were taken to the local health department by project staff for treatment, partner notification, and follow-up care.

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Box 4: Description of the 100 % Condom Use Program (100% CUP) The 100% Condom Use Program began in Thailand in 1989 and has been implemented in Cambodia, Philippines, Vietnam, China, Myanmar, Mongolia and Laos PDR, with variations in program components between countries. It is a collaborative program between local authorities (health services, police, public security, local governor or government office) and all sex entertainment establishments (owners, managers and sex trade workers) that aims to reduce the sexual transmission of HIV and STIs by ensuring that condoms are used during commercial sex. The program aims to promote the use of condoms 100% of the time in 100% of risky sexual relations in 100% of the sex entertainment establishments in a large geographic area, whether a town, district, province or whole country. The main characteristic of the program is the empowerment of sex trade workers to be able to assert “No condom – No sex” in sex work. The intent is that there is no choice but to use condoms because all sex establishments will have the same rule “No condom – No sex”.

Box 5: Description of the CHAT intervention The CHAT intervention curriculum defines a Peer Mentor as someone who has meaningful conversations with partners, friends, and other people in their social network. The intervention emphasized that the main difference between this program and their usual conversations was that as Peer Mentors in the CHAT program, they used a specific set of communication skills to engage in meaningful conversations about HIV and STI risk reduction. The four communication skills, which also represent the intervention’s acronym, (CHAT) are: 1) Choose the right time and place; 2) Hear what the person is saying; 3) Ask Questions; and 4) Talk with respect.

Box 6: The ImPACT intervention

The ImPACT intervention includes a 22-minute video containing footage about the importance of parental monitoring and adolescent risk and protective behaviours through interviews, parent-youth conversations, youth- to-youth discussions, as well as demonstrations and communication/negotiation. The key messages in the video included the importance of monitoring youth (i.e., know where they are, whom they are with, and what they are doing); talking with youth about sex before they begin to have sex or engage in other risky behaviours; being aware that parents and youth should know how to use a condom; emphasizing self-protection including abstinence and the use of both condoms and other forms of contraceptives; and emphasizing that drug and alcohol use has risks and can lead to risky sexual behaviours.

After the video was played for the parent-youth dyad in their home by project staff, the parent and youth were asked to role-play a vignette, with prompts; demonstrate the proper use of a condom on a plastic model; and then review the key points in the video and repeat the role play to try and incorporate the messages from the video. Finally, parents were given a copy of the video along with written material that reviewed the key messages.

Box 7: Draw the Line/Respect the Line program

The Draw the Line/Respect the Line Program is a 20-session curriculum, intended to help students to develop their personal sexual limits and practice skills needed to keep those limits, even when challenged.

The program was implemented in grades 6, 7 and 8 classrooms, and was intended to be delivered over a three- year period and have a cumulative effect (i.e., later lessons built on principles learned in earlier lessons). The 6th grade curriculum featured limit setting and refusal skills in situations that were not related to sex (e.g., pressure to use drugs, lie or steal). The 7th grade curriculum addressed personal limits related to sexual intercourse, and using skills to maintain person limits and respect the limits of others (e.g., identifying risky situations and refusal skills). The 7th grade curriculum also discussed the consequences of unplanned sexual intercourse, including STIs and pregnancy. The 8th grade curriculum included presentations from a speaker that was living with HIV, demonstration of condom use, and practice of refusal skills in a dating situation.

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The program was interactive and used different ways of delivering information (e.g., small group discussions, large- group discussions, skill practice in pairs or small groups, stories, etc.).

The curriculum was designed to be appropriate for diverse ethnic groups. Further, as the sample was comprised of 60% Latino participants, the curriculum included key concepts that were important in the Latino culture. As well, all program materials were provided in English and Spanish.

The program curriculum was delivered by trained health educators, and taught during a specific period at each school.

Box 8: Safer Choices program

Safer Choices, a program implemented among students in grades nine and 10, has five components: 1) School organization: A School Health Promotion Council involves representation from teachers, students, parents, administrators and community representatives. 2) Curriculum and staff development: Teachers are trained to deliver the classroom curriculum, involving 10 sessions at each of the grade nine and 10 levels (20 total sessions). 3) Peer resources and school environment: A Safer Choices club or team hosts activities that are implemented throughout the school. 4) Parent education: Includes parent newsletters, student-parent homework activities, tips on talking to youth about STIs, and other activities for parents. 5) School-community linkages: To increase students’ familiarity with the support services in the community, and to increase their access to these services (e.g., homework assignments to learn about local services, resource guides, presentations by individuals who are living with HIV, etc.).

Box 9: Clinical Practice Improvement Intervention

The clinical practice improvement intervention involved four steps: 1) Engage: Enlist the involvement of HMO leadership by presenting evidence showing that there is a gap between the current situation and chlamydia screening best practice. 2) Team Building: Individuals that were particularly interested in adolescent health were identified by the research time and chiefs of staff in the pediatric departments, and these individuals would comprise the adolescent care team that would champion the project (i.e., nurses, administrators, medical assistants and medical practitioners). They completed a workshop focused on skill building in group processes, implementation of a change model (plan- do-study-act) and developed a practice toolkit consisting of customized clinic flowcharts, exit polls and the Why to Pee! (Y2P) campaign materials. The Y2P targets adolescent girls and attempts to raise awareness and interest in screening. 3) Redesign clinical practice: The adolescent care team met monthly to review data on chlamydia screening rates and notes from charts to discuss barriers to screening and strategies to overcome these, and to assess improvements in screening rates. Note that all of the sites felt that the most effective way to accomplish screening was to implement a universal urine specimen collection from all adolescents at the time of registration. Practitioners subsequently determined which adolescents were sexually active, and these specimens were sent for testing. Adolescents with positive results were contacted and received treatment. Attempts were also made to treat partners. 4) Sustain the gain: Monitoring progress was achieved through the development of performance indicators (i.e., number of visits and chlamydia screening rates).

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Box 10: Example of a Florida SBHC program

Funding and Staff This SBHC is funded by the county hospital through a half-penny sales tax. The staff includes a nurse practitioner (NP), registered nurse (RN), social worker, and a receptionist and medical records clerk.

Parental consent Enrolment requires notarized parental consent. The SBHC has a notary on site and parents often come in to sign the consent form.

Scope of services (including but not limited to STI-related services) A range of health services are offered, including: treatment of minor illness and injury; health promotion; laboratory services; family planning; STI-HIV testing; and mental health counselling.

Every student that presents to the SBHC is asked to complete a behavioural risk assessment tool; this tool was modeled after the Guidelines for Adolescent Preventive Services, developed by the American Medical Association.

In addition, the SBHC uses a unique “group” physical model. This is conducted on specific days by medical students from the local medical school along with SBHC primary care providers. Students begin the program by attending seminars, which may include topics on diet, exercise, STI, healthy lifestyles, and self-esteem. One station highlights the various programs offered by the SBHC and health education materials are available on health-related topics. Students process through various stations including height and weight, vital signs, vision, blood work, individual physical examinations, and risk assessments.

STI-specific services Two broad components: 1) Primary health care, including testing and treatment of STI/HIV, and mental health counselling. 2) Engaging students in prevention programs through a peer mentoring program, STI/HIV website, classroom teaching and community involvement.

The SBHC promotes abstinence first and supports safer sex for adolescents that do not choose abstinence.

Risk assessments conducted through the group assessment process described previously, identifies students at risk for STI/HIV. These students are asked to make appointments with the SBHC for follow-up services. It appears that students can also attend the SBHC on their own initiative and receive services.

Peer-educators: The SBHC staff directs and supervises the peer educators in conjunction with adolescent volunteers. Approximately 50 candidates each year are recruited to be peer educators. They learn about the program by word of mouth, referrals, and classroom presentations and from other peer educators. Students are required to participate in 8 hours of training and testing to prepare them to become peer educators. These trained peer educators lead school activities, which include classroom sessions on STI-HIV, community health resources, communication and negotiation skills to say “no,” and safer sex strategies. At these sessions, participants are given a pretest and posttest questionnaire on the subject matter discussed to provide feedback to peer educators on the effectiveness of their teaching. Data from the questionnaires are then used to improve strategies and methods. Peer educators meet regularly to develop new programs and activities, which may include health fairs, speaking at school assemblies, and participating in walk-a-thons in the community. These activities are ways the peer educators get their messages out about abstinence, safer sex, and prevention of STI beyond the classroom setting.

Website: The website is interactive and student friendly and contains information on the SBHC; basic information on gonorrhea, chlamydia, syphilis, herpes, hepatitis, venereal warts, and HIV-AIDS; statistics on the incidence and prevalence of STI-HIV-AIDS; and links students to different websites to get additional information on STI, safe sex, condom use, and other important health topics. The website also has an HIV-AIDS quiz, with true and false

Population and Public Health, Ministry of Health Page 214 Core Public Health Functions for BC: Evidence Review Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections questions, such as “The first system that HIV-AIDS attacks to weaken the body is your nervous system,” or “On September 3, 2002, the first cure was found for HIV.” Teachers are involved with the website and encourage its use. To encourage widespread use of the website, contests are held throughout the year. Those students who answer the most questions correctly about STI-HIV treatment and prevention receive prizes. Another component of the website is a section on “Ask the Expert,” where students are linked to answers to questions on such teenage issues as: What is acne? What causes bad breath? What is ringworm? In 2004, approximately 2000 high school teenagers accessed the website. Each year, new students are enrolled in the program for continual updating and maintenance of the website. This program runs parallel to the peer education program and compliments the program.

Classroom education: Workshops include self-esteem workshops to improve students' self-concept. The social worker goes into classrooms on a regular basis to provide education on various topics, such as STI-HIV prevention, self-esteem, stress management, and other mental health subjects.

Box 11: Policy 123

Policy 123, which was adopted in 1991 by the Board of Education for the School District of Philadelphia, is a package of interventions designed to reduce rates of STIs, HIV and pregnancy among youth. The three strategies of this policy are: 1) “To direct schools to develop instruction that promotes ‘healthy habits and moral values regarding human sexuality’ and to convey that ‘abstinence is the most effective way of preventing pregnancy, STIs and HIV’”. 2) To authorize education for staff, outreach directed at parents and the development of partnerships with health care providers in the community. 3) To recommend that the school district be involved in initiatives that maximize condom access and create a pilot program (phased-in) of condom availability in schools that have grades 9-12.

Box 12: Features of the Get Tested Why Not program, Ottawa Public Health

Website features: -Mapping function, allowing for ready identification of the nearest laboratory using Google maps. -A floating “hide” button that users can select to quickly leave the website if there are concerns about privacy. -A scrolling text marquee that contains information about sexual health.

Text/SMS service: Users can text an automatic system that will provide information about sexual health and local resources. Available 24 hours per day.

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Box 13: Challenges related to STI screening in prison and suggested solutions Challenge Suggestion Inmates may initially decline testing but then want to be Offer screening at various points during an inmate’s tested at a later time. time in prison. Inmates may be released prior to testing results being Contract with laboratories that can return results available, thereby missing the opportunity for treatment. quickly.

Establish a process for community follow-up for inmates that are released before being notified of positive test result(s). Establish a process for notifying inmates and offering this community follow-up. Safety and security are the priority, therefore where there Careful tracking and ensuring that data is correct and are lockdowns, shift changes, and processing of certain comprehensive. inmates, the daily screening and treatment activities may be affected. This may make it difficult to identify the total number of inmates that can be offered screening.

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APPENDIX E: PATIENT-DELIVERED PARTNER THERAPY (PDPT)– THE POLICY AND LEGAL ENVIRONMENT

Hodge et al. (332) discuss expedited partner therapy (EPT), the delivery of medications or prescriptions by persons living with a STI to their sexual partners without prior clinical assessment of those partners. Clinicians provide patients with sufficient medication directly or via prescription, for them and their partners and encourage patients to have their partners seek clinical assessment (332). The CDC evaluated EPT studies and concluded that EPT is a “useful option” to promote partner treatment, particularly for male partners of women with chlamydia infection or gonorrhea; and in 2006, the CDC recommended EPT as an option for certain populations with specific conditions (333) (334).

The benefits and concerns related to PDPT/EPT include (332) (335): Benefits:  Treatment of hard-to-reach partners who may not otherwise receive treatment.  Treatment of partners as the same time as the patient, which can avoid reinfection; there is evidence that not treating both partners when one presents with gonorrhea and chlamydia is associated with an increased risk of PID in females, and risk of reinfection of the index case.

Concerns:  Potential for missed morbidity in partners who are treated without being assessed clinically (e.g., partners may have concurrent STIs or PID or other sequelae that is missed because they are not examined).  Lost opportunity to counsel sexual partners about risk reduction, and to in turn refer their other partners for assessment and treatment.  Legal questions about providing medications or prescriptions to individuals that the clinician has not personally assessed or established a physician-patient relationship (this consideration potentially applies to other health care professionals as well, such as Nurse Practitioners or Advanced Practice Outpost Nurses).

In a survey of state boards of medicine and pharmacy in the US, Golden et al. (2005) found that 88% of boards felt that EPT was illegal or of “uncertain” legality. This was partly due to the fact that the legal issues had not been addressed (336).

Health care providers do not usually provide prescription medications to non-patients; this helps to ensure that individuals do not gain access to medications they do not need or that could be dangerous to them. However, there are exceptions to this that are done in an attempt to ensuring that safe and effective medications are made available to people who need them (332):  Physicians providing prescription medications to children or elderly patients through parents or caregivers.  Spouses given medications.  Medications for people with mental disabilities may be distributed through court-appointed guardians.  Public health practitioners provide flu vaccines without an extensive clinical evaluation.  In response to outbreaks of meningococcal meningitis in hospitals, hospital staff and their family members may be provided antibiotics without being personally assessed. This may apply to other settings as well.

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Hodge et al. (2008) determined that, at the time of their review, 3/4 of states or territories in the U.S. either expressly permit EPT or do not expressly prohibit EPT (see Figure 1) (332).

Figure 1: Map Depicting the Legal Status of EPT across the U.S.

Reference: Hodge et al. (2008) (332)

EPT is legally permissible in 12 jurisdictions because their laws or governing authorities expressly allow the practice of EPT. Examples of excerpts from these jurisdictions are presented in the table below.

Examples of different EPT regulations in different jurisdictions (332) Jurisdiction Source Excerpt California Statutory law A physician in California may “provide prescription antibiotic drugs to [a] patient’s sexual partner[s]. . . without examination of that patient’s partner[s]” for treating chlamydia, gonorrhea, or other STDs (337). Tennessee Board of medical Promulgated administrative rules allowing EPT for the ““effective and safe examiners treatment to partners of patients infected with [chlamydia infection] who for various reasons may not otherwise receive appropriate treatment.” (338) Colorado Board of medical Board of medical examiners recommended EPT in response to the examiners compelling need for partners to receive treatment (339). Nevada Administrative Adopted the CDC’s STD treatment guidelines which include EPT (240). code

In 28 jurisdictions, EPT is legally potentially allowable; this conclusion was reached because the laws within these jurisdictions may allow EPT, subject to specific interpretations or inconsistent or ambiguous provisions, or there are policy statements supporting EPT, or regulations adopting current STD treatment guidelines that support EPT (332). In 13 jurisdictions, EPT is probably precluded (332).

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The Canadian context In Ontario, the College of Physicians and Surgeons of Ontario (CPSO) medication prescribing policy, under the heading “Physician Patient Relationship”, states:

“Exceptions The circumstances in which physicians are permitted to prescribe without a prior assessment of the patient can include: Prescribing for the sexual partner of a patient with a sexually transmitted infection (STI) who, in the physician’s determination, would not otherwise receive treatment and where there is a risk of further transmission of the STI…” (340)

In Ontario, the Provincial Infectious Diseases Advisory Committee (PIDAC), a multidisciplinary scientific advisory body who provide advice to the Chief Medical Officer of Health, offered the following recommendations regarding PDPT (335):

“12.1 Patient-Delivered Partner Therapy (PDPT) should be considered as an option for difficult to reach contacts of chlamydia or gonorrhea when usual contact tracing methods are unsuccessful [IA] Evidence is available only from studies of heterosexual men and women.  PDPT must be used with caution in populations at high risk for HIV and syphilis  Patient information sheets must be included in PDPT…”

The official position on PDPT in the BC environment was not identified through the online search used for this evidence review. An additional search, beyond that specified in the methodology, was conducted to search for relevant documents, including:

 Search terms in GoogleTM: o “College of Registered Nurses of British Columbia Patient-Delivered Partner Therapy for STI” o “College of Physicians and Surgeons of British Columbia Patient-Delivered Partner Therapy for STI”  The websites of both organizations were searched using the terms “patient-delivered partner therapy”.  Title-based search of CPSBC “guidelines” and “laws” sections, with full review of any documents that seemed likely to contain this information (e.g., “Prescribing Practices, Countersigning Prescriptions and Internet Prescribing”).

This search did not identify any results; however, this information may be contained in codes or policies that were not available through the aforementioned search. A dedicated search of the policies of these Colleges would likely be more fruitful.

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APPENDIX F: EXAMPLES OF SOCIAL MARKETING CAMPAIGNS

Figure 1: A cartoon strip from the Healthy Penis campaign.

Adapted from Ahrens, et al. (2006). Permission to reproduce not required.

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Figure 2: Sample of a poster in the Hombres Sanos campaign.

Adapted from Martinez-Donate, et al. (2010). Permission to reproduce granted by The Sheridan Press.

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Figure 3: An example of a Drama Downunder campaign poster.

Adapted from Pedrana, et al. (2012). Permission to reproduce granted by Wolters Kluwer Health.

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Figure 4: A sample of social marketing campaign materials from Darrow and Biersteker (2008).

Permission to reproduce granted by The Sheridan Press.

Figure 5: An example of a poster from the “Check-It-Out” campaign.

Adapted from Guy, et al. (2009). Permission to reproduce by BMJ Publishing Group Ltd.

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APPENDIX G: RECOMMENDED KNOWLEDGE MOBILIZATION PARTNERS

This appendix was created by the BC Ministry of Health after the bacterial STI prevention interventions were identified and rated. It lists all interventions that had a two star rating in biological and/or behavioural outcomes. In the absence of a population-based sexual health survey, some promising and effective interventions did not achieve two star or higher ratings. Such STI prevention interventions were added following consultation with BCCDC subject matter experts who ranked the interventions as important to consider for programming based on provincial epidemiology, current context and/or currently emerging trends.

To effectively tackle bacterial STI in the province, action is required across the social determinants of health and needs to involve all levels of government as well as the not-for-profit and private sectors (341). Maximizing effective approaches to preventing and addressing STIs among British Columbians, but particularly young adults and MSM, must engage the public systems they use – this includes the health system, the education system (through the Ministry of Education), the social development system (such as through the Ministry for Children and Family Development, or the Ministry of Social Development/Social Innovation), the criminal justice system (through the Ministry of Justice), and partners in civil society. Accordingly, this table lays out the highly rated or promising interventions, and identifies the potential public systems and partners (termed knowledge mobilization partners) that have a role to play in implementing strategies aligned with the evidence. Leadership in multiple sectors will be crucial to achieving meaningful and sustainable outcomes.

The knowledge mobilization partners suggested are not exhaustive, but highlight the opportunities for leadership and types of collaboration required within the health system and beyond to effectively prevent STIs. Three distinct categorizations are provided. Some are mostly within the scope of BC’s health-authorities, including both regional and the Provincial Health Services Authority (PHSA). Regional health authorities would include organizations such as Providence HealthCare. These would also include BC Centres for Excellence in HIV/AIDs, and BC Centre for Excellence in Women’s Health. In some cases, implementation may best be undertaken in partnership with the First Nations Health Authority (343).b Additionally, there are interventions that require partnership among multiple health sector partners, and interventions that require health sector collaboration with other sectors comprising civil society.

The role and work of the Ministry of Health, regional health authorities, the Provincial Health Services Authority and the First Nations Health Authority, are articulated in the Ministry of Health 2014/15 - 2016/17 Service Plan (342).

b The First Nations Health Authority (FNHA) in BC assumed the programs, services, and responsibilities formerly handled by Health Canada's First Nations Inuit Health Branch – Pacific Region in 2013. Their vision is to “transform the health and well-being of BC's First Nations and Aboriginal people by dramatically changing healthcare for the better”.

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The term 'health sector’ encompasses all organizations (that perform services) whose primary function is to prevent illness, promote well-being, and treat disease. This extends from public health programs, contracted agencies, and community organizations to the more familiar “bricks- and-mortar” hospitals and specialist services.

Notes: For micro-level interventions, regional health authorities, PHSA and BCCDC programs would offer these mostly through clinical programs such as the Oak Tree Clinic, or BCCDC STI clinic locations/outreach, regional STI or primary care clinics, etc.

Community based organizations for this purpose are those that are often contracted by health authorities or other agencies to better reach and engage people into care and other social services.

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Micro-Level Interventions Intervention Implementation Primary knowledge mobilization partners STI/HIV Prevention Counselling and Behavioural Interventions, including: 1) General behavioural interventions and Falls within health authority scope and  Regional health authorities and risk reduction counselling mandate in collaboration with health system PHSA/BCCDC and community partners.  Independent health care providers  Community-based organizations

2) Behavioural interventions stressing Falls within health authority scope and  Regional health authorities and ethnic pride and skill-building mandate in collaboration with health system PHSA/BCCDC (for example, the Chee and community partners who support ethno- Mamuk program) cultural populations.  Independent health care providers  Community-based organizations supporting ethno-cultural populations

 Regional health authorities and 3) Behavioural interventions for MSM Falls within health authority scope and PHSA/BCCDC mandate in collaboration with health system  Independent health care provider and community partners who support MSM  Community-based organizations populations. supporting MSM

 Regional health authorities and 4) Cognitive-behavioural interventions Falls within scope and mandate of health PHSA/BCCDC authorities in collaboration with health  Independent health care providers system and community partners.  Community-based organizations

 Regional health authorities and 5) Brief behavioural interventions Falls within scope and mandate of health PHSA/BCCDC authorities in collaboration with health  system and community partners. Independent health care providers  Community-based organizations

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Intervention Implementation Primary knowledge mobilization partners Small group sessions Requires collaboration among the health  Regional health authorities and system, community partners, and partners PHSA/BCCDC outside the health system.  Independent health care providers  Community-based organizations  Workplace health/labour sector  Ministry of Education  Ministry of Children and Family Development Peer education Requires collaboration among the health  Regional health authorities and system, community partners, and partners PHSA/BCCDC outside the health system.  Community-based organizations  Workplace health/labour sector  Ministry of Education  Ministry of Children and Family Development Online interventions targeting youth (general Falls within scope and mandate of health  Regional health authorities and or multiple interventions) authorities, but requires collaboration with PHSA/BCCDC health system, community partners and  Community-based organizations partners outside the health system.  Workplace health/labour sector  Ministry of Education  Ministry of Children and Family Development

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Intervention Implementation Primary knowledge mobilization partners Innovative STI Screening programs, including: 1. Home-based STI screening for youth Falls within scope and mandate of health  Public Health Microbiology and authorities and individual care providers, but Reference Laboratory/BCCDC requires collaboration with health system and  Independent health care providers community partners.  Community-based organizations Requires home testing kits to be approved for  Health system and industry partners sale in Canada.

2. Self-screening for MSM Falls within scope and mandate of health  Public Health Microbiology and authorities, but requires collaboration with Reference Laboratory/BCCDC health system and community partners. Community-based organizations Requires home testing kits to be approved for  Health system and industry partners sale in Canada Use of male condoms Falls within scope and mandate of health  Regional health authorities and authorities, but requires collaboration with PHSA/BCCDC health system and community partners, and  Independent health care providers partners outside the health system.  Community-based organizations  Workplace health/labour sector  Ministry of Education  Ministry of Children and Family Development Patient-Delivered Partner Therapy Falls within scope and mandate of health  Regional health authorities and authorities in collaboration with relevant PHSA/BCCDC independent health care providers and  Independent health care providers professional colleges.  Community-based organizations

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Meso-Level Interventions Intervention Implementation Primary Knowledge Mobilization Partner(s) Social Diffusion, including: 1) Community opinion leadersc Requires collaboration among the health system,  Community-based organizations community partners.  Regional health authorities and PHSA/BCCDC (for example, through outreach with immigrant populations)

2) Peer mentors within a social Requires collaboration among the health system,  Regional health authorities and network community partners, and partners outside the PHSA/BCCDC health system.  Independent health care providers  Community-based organizations  Workplace health/labour sector  Ministry of Education  Ministry of Children and Family Development

c Listed as a stand-alone intervention, but meant to be an integral component of any community-based work.

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Intervention Implementation Primary Knowledge Mobilization Partner(s) Group Education, including: 1) Risk reduction Requires collaboration among the health system,  Regional health authorities and including community partners, and partners PHSA/BCCDC outside the health system.  Independent health care providers  Community-based organizations  Ministry of Justice  Ministry of Education  Ministry of Children and Family Development

2) Skill building in group education Requires collaboration among the health system,  Regional health authorities and including community partners, and partners PHSA/BCCDC outside the health system.  Independent health care providers  Community-based organizations  Ministry of Justice  Ministry of Education  Ministry of Children and Family Development

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Intervention Implementation Primary Knowledge Mobilization Partner(s) Clinic-based Interventions, including: 1) Disease Intervention Specialists Falls within scope and mandate of health  Regional health authorities and (DIS) authorities in collaboration with relevant PHSA/BCCDC independent health care providers and others in  Independent health care providers the health system.

 Regional health authorities and 2) Electronic technologies in STI clinics, Falls within scope and mandate of health PHSA/BCCDC including active use of electronic authorities in collaboration with relevant  Independent health care providers medical records, reminders, and independent health care providers. other software to promote care

3) Syphilis testing during routine HIV Falls within scope and mandate of health  Regional health authorities and monitoring authorities, including laboratories, in collaboration PHSA/BCCDC with community partners who may provide HIV  Independent health care providers testing, and with relevant independent health care  Community-based partners providers.

Falls within scope and mandate of health  Regional health authorities and 4) Male clinics authorities in collaboration with community PHSA/BCCDC partners who support men, and relevant  Independent health care providers independent health care providers.  Community-based partners

5) Mobile clinics Falls within scope and mandate of health  Regional health authorities and authorities in collaboration with community PHSA/BCCDC partners who provide mobile services, and relevant  Independent health care providers independent health care providers.  Community-based partners

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Intervention Implementation Primary Knowledge Mobilization Partner(s) Venue or Group-based Screening Outreach: 1) School-based STI screening and Falls within scope and mandate of health  Regional health authorities and treatment programs authorities, but requires collaboration with health PHSA/BCCDC system and community partners, and partners  Independent health care providers outside the health system.  Community-based organizations  Ministry of Education

2) School-based health centers Falls within scope and mandate of health  Regional health authorities and authorities, but requires collaboration with health PHSA/BCCDC system and community partners, and partners  Independent health care providers outside the health system.  Community-based organizations  Ministry of Education

 Regional health authorities and

3) Screening in prisons Requires collaboration with health system and PHSA/BCCDC community partners, and partners outside the  Independent health care providers health system  Community-based organizations

 Ministry of Justice

 Regional health authorities and 4) Screening in shelters Falls within scope and mandate of health PHSA/BCCDC authorities, but requires collaboration with  community partners. Community-based organizations

5) Screening for commercial sex workers Falls within scope and mandate of health  Regional health authorities and authorities, but requires collaboration community PHSA/BCCDC partners.  Community-based organizations

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Intervention Implementation Primary Knowledge Mobilization Partner(s) 6) Screening at MSM sex-on-premises Falls within scope and mandate of health  Regional health authorities and establishments, bathhouses, saunas authorities, but requires collaboration with PHSA/BCCDC community partners.  Community-based organizations

7) Home-based STI testing Falls within scope and mandate of health  Regional health authorities and authorities, but requires collaboration. PHSA/BCCDC Requires kits to be approved for sale in Canada.  Community-based organizations  Health system and industry partners

Internet-based promotional campaigns and services to increase STI testing: 1) for MSM Requires collaboration with health system and  Regional health authorities and community partners. PHSA/BCCDC  Community-based organizations who support MSM

2) For youth Requires collaboration among the health system,  Regional health authorities and including community partners, and partners PHSA/BCCDC outside the health system.  Community-based organizations who support youth  Ministry of Education Contact tracing using a social network Falls within scope and mandate of health  Regional health authorities and approach authorities in collaboration with relevant PHSA/BCCDC independent health care providers and community  Community-based organizations partners.  Independent health care providers Periodic presumptive treatment Falls within scope and mandate of health  Regional health authorities and authorities in collaboration with relevant PHSA/BCCDC independent health care providers.  Independent health care providers

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Intervention Implementation Primary Knowledge Mobilization Partner(s) Community mobilization Requires collaboration among the health system,  Regional health authorities and including community partners. PHSA/BCCDC  Community-based organizations

Macro-Level Interventions

Intervention Implementation Primary Knowledge Mobilization Partner(s) STI-specific policy with an evaluation of impact, including: 1) 100% CUP Program Requires collaboration among the health system,  Regional health authorities and and partners outside the health system. PHSA/BCCDC  Independent health care providers  Community-based organizations  Ministry of Justice

2) Combined community mobilization Requires collaboration among the health system,  Regional health authorities and and policy initiatives including community partners. PHSA/BCCDC  Community-based organizations  Ministry of Health

3) Performance measures  Regional health authorities and Falls within the scope and mandate of the Ministry PHSA/BCCDC of Health as well as health authorities, but requires  Community-based organizations collaboration among multiple health system Ministry of Health partners. Ministry of Justice Ministry of Education Ministry of Children and Family Development

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Intervention Implementation Primary Knowledge Mobilization Partner(s) Clinic-based systems interventions Falls within scope and mandate of health  Regional health authorities and authorities in collaboration with relevant PHSA/BCCDC independent health care providers.  Community-based organizations Mass media Campaigns: 1) targeting youth Requires collaboration among the health system  Regional health authorities and and community partners, and partners outside the PHSA/BCCDC health sector.  Independent health care providers  Community-based organizations that support youth  Ministry of Education

 Regional health authorities and 2) Social marketing campaigns for Requires collaboration among the health system, PHSA/BCCDC MSM including community partners who support MSM.  Independent health care providers  Community-based organizations that support MSM

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ABBREVIATIONS AND ACRONYMS

CDC: United States Centers for Disease Control and Prevention DIS: Disease intervention specialist EPT: Expedited Partner Therapy GUM: Genitourinary medicine clinic FSW: Female sex trade worker MSM: Men who have sex with men NAAT: Nucleic acid amplification test PCR: Polymerase chain reaction PDPT: Patient-delivered partner therapy PHAC: Public Health Agency of Canada PID: Pelvic inflammatory disease PN: Partner notification PPT: Presumptive periodic treatment RCT: Randomized controlled trial SBHC: School-based health centers SMS: Short messaging service STD: Sexually transmitted disease STI: Sexually transmitted infection WHO: World Health Organization

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