INTRODUCTION: Disease intervention specialists (DIS) are critical for delivering partner services programs that provide partner notification, counseling, referral, and other services for HIV, sexually transmitted infections (STIs), and other infections. This systematic review of partner services and other DIS-delivered interventions for HIV and STIs was conducted to summarize the effectiveness of these programs and identify evidence gaps. METHODS: A systematic literature review was conducted with a narrative synthesis. Articles were located using keyword searches in MEDLINE, Web of Science, CINAHL, and ProQuest through December 2022 and analyzed in 2023-2024. Included studies addressed an intervention of partner services or other DIS-delivered services for HIV or STIs; a United States setting; primary data collection; and an external comparison group or pre-post design. RESULTS: 1,915 unique records were screened for eligibility, with 30 studies included. Overall, DIS-delivered interventions improved clinical outcomes among index patients and population outcomes. Many studies focused on program process measures rather than population-level epidemiologic outcomes. All but one studies were scored as having low or medium strength of evidence. DISCUSSION: The evidence could be strengthened by establishing a streamlined set of core metrics, assessing impact using rigorous causal inference methodologies, linking program and clinical data systems, and supplementing impact evaluations with evidence on implementation strategies.

CONTEXT: Estimating the return on investment for public health services, tailored to the state level, is critical for demonstrating their value and making resource allocation decisions. However, many health departments have limited staff capacity and expertise to conduct economic analyses in-house. PROGRAM: We developed a user-friendly, interactive Excel-based spreadsheet model that health departments can use to estimate the impact of increases or decreases in sexually transmitted infection (STI) prevention funding on the incidence and direct medical costs of chlamydia, gonorrhea, syphilis, and STI-attributable HIV infections. Users tailor results to their jurisdictions by entering the size of their population served; the number of annual STI diagnoses; their prior annual funding amount; and their anticipated new funding amount. The interface was developed using human-centered design principles, including focus groups with 15 model users to collect feedback on an earlier model version and a usability study on the prototype with 6 model users to finalize the interface. IMPLEMENTATION: The STI Prevention Allocation Consequences Estimator ("SPACE Monkey 2.0") model will be publicly available as a free downloadable tool. EVALUATION: In the usability testing of the prototype, participants provided overall positive feedback. They appreciated the clear interpretations, outcomes expressed as direct medical costs, functionalities to interact with the output and copy charts into external applications, visualization designs, and accessible information about the model's assumptions and limitations. Participants provided positive responses to a 10-item usability evaluation survey regarding their experiences with the prototype. DISCUSSION: Modeling tools that synthesize literature-based estimates and are developed with human-centered design principles have the potential to make evidence-based estimates of budget changes widely accessible to health departments.

INTRODUCTION: During the COVID-19 pandemic, the U.S. Centers for Disease Control and Prevention developed a simple spreadsheet-based tool to help state and local public health officials assess the performance and impact of COVID-19 case investigation and contact tracing in their jurisdiction. The applicability and feasibility of building such a tool for sexually transmitted diseases were assessed. METHODS: The key epidemiologic differences between sexually transmitted diseases and respiratory diseases (e.g., mixing patterns, incubation period, duration of infection, and the availability of treatment) were identified, and their implications for modeling case investigation and contact tracing impact with a simple spreadsheet tool were remarked on. Existing features of the COVID-19 tool that are applicable for evaluating the impact of case investigation and contact tracing for sexually transmitted diseases were also identified. RESULTS: Our findings offer recommendations for the future development of a spreadsheet-based modeling tool for evaluating the impact of sexually transmitted disease case investigation and contact tracing efforts. Generally, we advocate for simplifying sexually transmitted disease-specific complexities and performing sensitivity analyses to assess uncertainty. The authors also acknowledge that more complex modeling approaches might be required but note that it is possible that a sexually transmitted disease case investigation and contact tracing tool could incorporate features from more complex models while maintaining a user-friendly interface. CONCLUSIONS: A sexually transmitted disease case investigation and contact tracing tool could benefit from the incorporation of key features of the COVID-19 model, namely its user-friendly interface. The inherent differences between sexually transmitted diseases and respiratory viruses should not be seen as a limitation to the development of such tool.

BACKGROUND: HIV testing is an entry point to access HIV care and prevention services. Building Healthy Online Communities (BHOC) developed a website (TakeMeHome.org) where participants can order HIV home test kits. The purpose of this study was to analyze the costs and impact of the TakeMeHome program. METHODS: We estimated the costs of TakeMeHome across all participating jurisdictions for the first year of the program. We estimated program costs using purchase orders and invoices, contracts, and allocation of staff time, and the costs included website design, participant recruitment, administration and overhead, HIV self-test kits, and shipping and handling. Primary outcomes of the analysis were total program cost, cost per HIV test, and cost per new HIV diagnosis. RESULTS: TakeMeHome distributed 5,323 HIV self-tests to 4,859 participants over a 12-month period. The total program cost over this period was $314,870. The cost per HIV test delivered was estimated at $59, and the cost per person tested was $65. The program identified 18 (0.6% positivity) confirmed new HIV diagnoses that were verified with surveillance data in 7 health jurisdictions at $169,890. The cost per confirmed new HIV diagnosis was estimated at $9,440. CONCLUSIONS: The TakeMeHome program delivered HIV self-testing at a reasonable cost, and the program may be a cost-effective use of HIV prevention resources. The public-private partnership can be an effective mechanism to validate HIV diagnoses identified with self-testing and provide HIV prevention and linkage to care services.

BACKGROUND: Chlamydia remains a significant public health problem that contributes to adverse reproductive health outcomes. In the United States, sexually active women 24 years and younger are recommended to receive annual screening for chlamydia. In this study, we evaluated the impact of estimated current levels of screening and partner notification (PN), and the impact of screening based on guidelines on chlamydia associated sequelae, quality adjusted life years (QALYs) lost and costs. METHODS: We conducted a cost-effectiveness analysis of chlamydia screening, using a published calibrated pair formation transmission model that estimated trends in chlamydia screening coverage in the United States from 2000 to 2015 consistent with epidemiological data. We used probability trees to translate chlamydial infection outcomes into estimated numbers of chlamydia-associated sequelae, QALYs lost, and health care services costs (in 2020 US dollars). We evaluated the costs and population health benefits of screening and PN in the United States for 2000 to 2015, as compared with no screening and no PN. We also estimated the additional benefits that could be achieved by increasing screening coverage to the levels indicated by the policy recommendations for 2016 to 2019, compared with screening coverage achieved by 2015. RESULTS: Screening and PN from 2000 to 2015 were estimated to have averted 1.3 million (95% uncertainty interval [UI] 490,000-2.3 million) cases of pelvic inflammatory disease, 430,000 (95% UI, 160,000-760,000) cases of chronic pelvic pain, 300,000 (95% UI, 104,000-570,000) cases of tubal factor infertility, and 140,000 (95% UI, 47,000-260,000) cases of ectopic pregnancy in women. We estimated that chlamydia screening and PN cost $9700 per QALY gained compared with no screening and no PN. We estimated the full realization of chlamydia screening guidelines for 2016 to 2019 to cost $30,000 per QALY gained, compared with a scenario in which chlamydia screening coverage was maintained at 2015 levels. DISCUSSION: Chlamydia screening and PN as implemented in the United States from 2000 through 2015 has substantially improved population health and provided good value for money when considering associated health care services costs. Further population health gains are attainable by increasing screening further, at reasonable cost per QALY gained.

What do we know about the role of kissing in gonorrhea transmission? Evidence suggests that gonorrheatransmission via kissing is possible, but we do not know if it is a relatively rare event or if it is one of the main drivers of gonorrhea transmission.1-3In this issue, Charlesonand colleagues provide a systematic review of studies of kissing as a risk factor for pharyngeal gonorrhea and chlamydia.4This important systematic review serves to summarize and highlight some of the available evidence of kissing as a possible route of gonorrhea and chlamydia transmission. The authors of the review are at the forefront ofthis field of investigation, and many wereco-authors on four5-8of the six studies included

The annual direct medical cost attributable to human papillomavirus (HPV) in the United States over the period 2004-2007 was estimated at $9.36 billion in 2012 (updated to 2020 dollars). The purpose of this report was to update that estimate to account for the impact of HPV vaccination on HPV-attributable disease, reductions in the frequency of cervical cancer screening, and new data on the cost per case of treating HPV-attributable cancers. Based primarily on data from the literature, we estimated the annual direct medical cost burden as the sum of the costs of cervical cancer screening and follow-up and the cost of treating HPV-attributable cancers, anogenital warts, and recurrent respiratory papillomatosis (RRP). We estimated the total direct medical cost of HPV to be $9.01 billion annually over the period 2014-2018 (2020 U.S. dollars). Of this total cost, 55.0% was for routine cervical cancer screening and follow-up, 43.8% was for treatment of HPV-attributable cancer, and less than 2% was for treating anogenital warts and RRP. Although our updated estimate of the direct medical cost of HPV is slightly lower than the previous estimate, it would have been substantially lower had we not incorporated more recent, higher cancer treatment costs.

OBJECTIVES: We quantified the quality-adjusted life-years (QALYs) lost attributable to chlamydia, gonorrhea, and trichomoniasis in the US, by sex and age group. METHODS: We adapted a previous probability-tree model to estimate the average number of lifetime QALYs lost due to genital chlamydia, gonorrhea, and trichomoniasis, per incident infection and at the population level, by sex and age group. We conducted multivariate sensitivity analyses to address uncertainty around key parameter values. FINDINGS: The estimated total discounted lifetime QALYs lost for men and women, respectively, due to infections acquired in 2018, were 1,541 (95% uncertainty interval: 186, 6,358) and 111,872 (29,777, 267,404) for chlamydia, 989 (127, 3,720) and 12,112 (2,410, 33,895) for gonorrhea, and 386 (30, 1,851) and 4,576 (13, 30,355) for trichomoniasis. Total QALYs lost were highest among women ages 15-24 years with chlamydia. QALYs lost estimates were highly sensitive to disutilities (health losses) of infections and sequelae, and to duration of infections and chronic sequelae for chlamydia and gonorrhea in women. CONCLUSIONS: The three sexually transmitted infections cause substantial health losses in the US, particularly gonorrhea and chlamydia among women. The estimates of lifetime QALYs lost per infection help to prioritize prevention policies and inform cost-effectiveness analyses of STI interventions.

Background: Genital herpes (GH), caused by herpes simplex virus type 1 and type 2 (HSV-1, HSV-2), is a common sexually transmitted disease associated with adverse health outcomes. Symptoms associated with GH outbreaks can be reduced by antiviral medications, but the infection is incurable and lifelong. In this study, we estimate the long-term health impacts of GH in the United States using quality-adjusted life years (QALYs) lost. Methods: We used probability trees to model the natural history of GH secondary to infection with HSV-1 and HSV-2 among people aged 18–49 years. We modelled the following outcomes to quantify the major causes of health losses following infection: symptomatic herpes outbreaks, psychosocial impacts associated with diagnosis and recurrences, urinary retention caused by sacral radiculitis, aseptic meningitis, Mollaret's meningitis, and neonatal herpes. The model was parameterized based on published literature on the natural history of GH. We summarized losses of health by computing the lifetime number of QALYs lost per genital HSV-1 and HSV-2 infection, and we combined this information with incidence estimates to compute the total lifetime number of QALYs lost due to infections acquired in 2018 in the United States. Findings: We estimated 0.05 (95% uncertainty interval (UI) 0.02–0.08) lifetime QALYs lost per incident GH infection acquired in 2018, equivalent to losing 0.05 years or about 18 days of life for one person with perfect health. The average number of QALYs lost per GH infection due to genital HSV-1 and HSV-2 was 0.01 (95% UI 0.01–0.02) and 0.05 (95% UI 0.02–0.09), respectively. The burden of genital HSV-1 is higher among women, while the burden of HSV-2 is higher among men. QALYs lost per neonatal herpes infection was estimated to be 7.93 (95% UI 6.63–9.19). At the population level, the total estimated lifetime QALYs lost as a result of GH infections acquired in 2018 was 33,100 (95% UI 12,600–67,900) due to GH in adults and 3,140 (95% UI 2,260–4,140) due to neonatal herpes. Results were most sensitive to assumptions on the magnitude of the disutility associated with post-diagnosis psychosocial distress and symptomatic recurrences. Interpretation: GH is associated with substantial health losses in the United States. Results from this study can be used to compare the burden of GH to other diseases, and it provides inputs that may be used in studies on the health impact and cost-effectiveness of interventions that aim to reduce the burden of GH. Funding: The Center for Disease Control and Prevention © 2023 The Author(s)

Background: Disparities in the health and economic burden of gonorrhoea have not been systematically quantified. We estimated population-level health losses and costs associated with gonococcal infection and sequelae in the United States. Methods: We used probability-tree models to capture gonorrhoea sequelae and to estimate attributable disease burden in terms of the discounted lifetime costs and quality-adjusted life-years (QALYs) lost due to incident infections acquired during 2015 from the healthcare system perspective. Numbers of infections in 2015 were obtained from a published gonorrhoea transmission model. We evaluated population-level disease burden, disaggregated by sex, age, race/ethnicity, and for men who have sex with men (MSM). We conducted a multivariate sensitivity analysis for key parameters. Findings: Discounted lifetime QALYs lost per incident gonococcal infection were estimated as 0.093 (95% uncertainty interval [UI] 0.022-0.22) for women, 0.0020 (0.0015-0.0024) for heterosexual men, and 0.0015 (0.00070-0.0021) for MSM. Discounted lifetime costs per incident infection were USD 261 (109-480), 169 (88-263), and 133 (50-239), respectively. At the population level, total discounted lifetime QALYs lost due to infections acquired during 2015 were 53,293 (12,326-125,366) for women, 621 (430-872) for heterosexual men, and 1,078 (427-1,870) for MSM. Total discounted lifetime costs were USD 150 million (64-277 million), 54 million (25-92 million), and 97 million (34-197 million), respectively. The highest total burden of both QALYs and costs at the population-level was observed in Non-Hispanic Black women, and highest burden per 1,000 person-years was identified in MSM among men and American Indian/Alaska Native among women. Interpretation: Gonorrhoea causes substantial health losses and costs in the United States. These results can inform planning and prioritization of prevention services. Funding: Centers for Disease Control and Prevention, Charles A. King Trust. © 2022 The Author(s)

In the past 2 decades, the demand for information on health economics research to guide health care decision making has substantially increased. Studies have provided evidence that eliminating or reducing tobacco use; eating a healthy diet, including fruit and vegetables; being physically active; reducing alcohol consumption; avoiding ultraviolet radiation; and minimizing exposure to environmental and occupational carcinogenic agents should substantially reduce cancer incidence in the population. The benefits of these primary prevention measures in reducing cancer incidence are not instantaneous. Therefore, health economics research has an important role to play in providing credible information to decision makers on the health and economic benefits of primary prevention. This article provides an overview of health economics research related to primary prevention of cancer. We addressed the following questions: 1) What are the gaps and unmet needs for performing health economics research focused on primary prevention of cancer? 2) What are the challenges and opportunities to conducting health economics research to evaluate primary prevention of cancer? and 3) What are the future directions for enhancing health economics research on primary prevention of cancer? Modeling primary prevention of cancer is often difficult given data limitations, long delays before the policy or intervention is effective, possible unintended effects of the policy or intervention, and the necessity of outside expertise to understand key inputs or outputs to the modeling. Despite these challenges, health economics research has an important role to play in providing credible information to decision makers on the health and economic benefits of primary prevention of cancer.

BACKGROUND: Syphilis rates have increased substantially over the past decade. Women are an important population due to negative sequalae and adverse maternal outcomes including congenital syphilis. We assessed whether racial and ethnic disparities in primary and secondary (P&S) syphilis among heterosexually active women differ by region and age group. METHODS: We synthesized four national surveys to estimate numbers of heterosexually active women in the United States from 2014 through 2018 by region, race and ethnicity, and age group (18-24, 25-29, 30-44, and ≥ 45 years). We calculated annual P&S syphilis diagnosis rates, assessing disparities with rate differences and rate ratios comparing White, Hispanic, and Black heterosexually active women. RESULTS: Nationally, annual rates were 6.42 and 2.20 times as high among Black and Hispanic than among White heterosexually active women (10.99, 3.77, and 1.71 per 100,000, respectively). Younger women experienced a disproportionate burden of P&S syphilis and the highest disparities. Regionally, the Northeast had the highest Black-White and Hispanic-White disparities using a relative disparity measure (relative rate) and the West had the highest disparities using an absolute disparity measure (rate difference). CONCLUSIONS: To meet the racial and ethnic disparities goals of the Sexually Transmitted Infections National Strategic Plan, tailored local interventions that address the social and structural factors associated with disparities are needed for different age groups.

BACKGROUND: Men who have sex with men (MSM) experience high rates of gonococcal infection at extragenital (rectal and pharyngeal) anatomic sites, which often are missed without asymptomatic screening and may be important for onward transmission. Implementing an express pathway for asymptomatic MSM seeking routine screening at their clinic may be a cost-effective way to improve extragenital screening by allowing patients to be screened at more anatomic sites through a streamlined, less costly process. METHODS: We modified an agent-based model of anatomic site-specific gonococcal infection in U.S. MSM to assess the cost-effectiveness of an express screening pathway in which all asymptomatic MSM presenting at their clinic were screened at the urogenital, rectal, and pharyngeal sites but forewent a provider consultation and physical exam and self-collected their own samples. We calculated the cumulative health effects expressed as gonococcal infections and cases averted over five years, labor and material costs, and incremental cost effectiveness ratios (ICER) for express versus traditional scenarios. RESULTS: The express scenario averted more infections and cases in each intervention year. The increased diagnostic costs of triple-site screening were largely offset by the lowered visit costs of the express pathway and, from the end of year 3 onward, this pathway generated small cost savings. However, in a sensitivity analysis of assumed overhead costs, cost savings under the express scenario disappeared in the majority of simulations once overhead costs exceeded 7% of total annual costs. CONCLUSIONS: Express screening may be a cost-effective option for improving multi-site anatomic screening among U.S. MSM.

BACKGROUND: The purpose of this study was to provide updated estimates of the average lifetime medical cost per infection for chlamydia, gonorrhea, and trichomoniasis. METHODS: We adapted a published decision tree model that allowed for 7 possible outcomes of infection: (1) symptomatic infection, treated, no sequelae; (2) symptomatic infection, not treated, sequelae; (3) symptomatic infection, not treated, no sequelae; (4) asymptomatic infection, treated, sequelae; (5) asymptomatic infection, treated, no sequelae; (6) asymptomatic infection, not treated, sequelae; and (7) asymptomatic infection, not treated, no sequelae. The base case values and ranges we applied for the model inputs (i.e., the probability and cost assumptions) were based on published studies. RESULTS: The estimated lifetime medical costs per infection for men and women, respectively, were $46 (95% credibility interval, $32-$62) and $262 ($127-$483) for chlamydia, $78 ($36-$145) and $254 ($96-$518) for gonorrhea, and $5 ($1-$14) and $36 ($17-$58) for trichomoniasis. Cost estimates for men were most sensitive to assumptions regarding the probability that the infection is symptomatic, the probability of treatment if asymptomatic, and the cost of treatment of infection. Cost estimates for chlamydia and gonorrhea in women were most sensitive to assumptions regarding the probability and cost of subsequent pelvic inflammatory disease. CONCLUSIONS: These estimates of the lifetime medical cost per infection can inform updated estimates of the total annual cost of sexually transmitted infections in the United States, as well as analyses of the value and cost-effectiveness of sexually transmitted infection prevention interventions.

Introduction: Sexual behavior information can provide context for understanding rates of sexually transmitted infections (STI) and inform potential impact of interventions. Methods: We used 20132016 National Health and Nutrition Examination Survey (n=4930) and 20112015 National Survey of Family Growth (n=16,643) data from sexually experienced 2044-year old US females and males to estimate the number of lifetime and past year partners and percent with a new past year partner overall and by marital status, in 5-year age groups. Group differences were qualitatively assessed. Results: Estimates from both surveys were comparable. The median number of lifetime sex partners ranged from 4.2 to 5.2 across age groups among females and was higher among older (9.1) than younger (4.6) males, persons with a new past year partner than those without, and persons widowed/divorced/separated/never married than those married/living with partner. Percents with 2 past year partners and a new past year partner were highest in the youngest age group and lower with age. Percent with a new past year partner was 1946 percentage points higher in persons widowed/divorced/separated/never married (range 21.756.4%) compared to persons married/living with partner (range 2.712.4%). Conclusions: In the USA, there are differences in sexual behaviors by gender, age, and marital status. The percent of adults with a new sex partner is lower with increasing age; however, a portion of all subgroups reported having had a new sex partner in the past year indicating some adults remain at risk of acquiring an STI. Policy Implications: These data can help inform policies for STI screening and other interventions. 2021, This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply.

The field of sexually transmitted infection (STI) prevention depends heavily on having current estimates of the health and economic burden of STIs. These estimates guide priorities in research, public health decisions, and governmental policies. Recent estimates have been cited in crucial public health and policy documents, such as STI treatment guidelines,1 STI surveillance reports,2 public health recommendations,3,4 and government budget justifications and priorities.5 Publishing these estimates is one of the most important contributions of the journal, Sexually Transmitted Diseases (STD), to the field.

INTRODUCTION: We estimated the lifetime medical costs of diagnosed cases of diseases attributable to human papillomavirus (HPV) infections acquired in 2018. METHODS: We adapted an existing mathematical model of HPV transmission and associated diseases to estimate the lifetime number of diagnosed cases of disease (genital warts; cervical intraepithelial neoplasia; and cervical, vaginal, vulvar, penile, anal, and oropharyngeal cancers) attributable to HPV infections that were acquired in 2018. For each of these outcomes, we multiplied the estimated number of cases by the estimated lifetime medical cost per case obtained from previous studies. We estimated the costs of recurrent respiratory papillomatosis in a separate calculation. Future costs were discounted at 3% annually. RESULTS: The estimated discounted lifetime medical cost of diseases attributable to HPV infections acquired in 2018 among people aged 15-59 years was $774 million (in 2019 U.S. dollars), of which about half was accounted for by infections in those aged 15-24 years. HPV infections in women accounted for about 90% of the lifetime number of diagnosed cases of disease and 70% of the lifetime cost attributable to HPV infections acquired in 2018 among ages 15-59 years. CONCLUSIONS: We estimated the lifetime medical costs of diseases attributable to HPV infections acquired in 2018 to be $774 million. This estimate is lower than previous estimates and likely represents the impact of HPV vaccination. The lifetime cost of disease attributable to incident HPV infections is expected to decrease further over time as HPV vaccination coverage increases.

BACKGROUND: The purpose of this study was to estimate the cost of syphilis in the United States, in terms of the average lifetime direct medical cost per infection. METHODS: We used a decision tree model of the natural history of syphilis. The model allowed for numerous possible outcomes of infection, including treatment for syphilis at various stages, inadvertent treatment, and late syphilis outcomes in those who are alive and still infected 30 years after acquisition. Future costs were discounted at 3% annually. Model inputs such as the cost and probability of each outcome were based on published sources. The probabilities we applied yielded outcomes consistent with reported cases of syphilis by stage from national surveillance data and number of deaths due to late syphilis from national mortality data. RESULTS: The estimated, discounted lifetime cost per infection was $1,190 under base case assumptions (2019 dollars). Treatment costs associated with late syphilis outcomes such as cardiovascular syphilis accounted for only $26 of the average lifetime cost per infection. Results were most sensitive to assumptions regarding the treatment cost per case of unknown duration or late syphilis. In the probabilistic sensitivity analyses, the 2.5th and 97.5th percentiles of the 10,000 simulations of the lifetime cost per infection were $729 and $1,884, respectively. CONCLUSIONS: Our estimate of the lifetime cost per infection is about 50% higher than in a previous study, a difference due in large part to our higher cost assumptions for benzathine penicillin G.s.

BACKGROUND: We estimated the lifetime medical costs attributable to STIs acquired in 2018, including sexually acquired HIV. METHODS: We estimated the lifetime medical costs of infections acquired in 2018 in the United States for eight STIs: chlamydia, gonorrhea, trichomoniasis, syphilis, genital herpes, human papillomavirus (HPV), hepatitis B, and HIV. We limited our analysis to lifetime medical costs incurred for treatment of STIs and for treatment of related sequelae; we did not include other costs such as STI prevention. For each STI except HPV, we calculated the lifetime medical cost by multiplying the estimated number of incident infections in 2018 by the estimated lifetime cost per infection. For HPV, we calculated the lifetime cost based on the projected lifetime incidence of health outcomes attributed to HPV infections acquired in 2018. Future costs were discounted at 3% annually. RESULTS: Incident STIs in 2018 imposed an estimated $15.9 billion (25th-75th percentile: $14.9-16.9 billion) in discounted, lifetime direct medical costs (2019 U.S. dollars). Most of this cost was due to sexually acquired HIV ($13.7 billion) and HPV ($0.8 billion). STIs in women accounted for about one-fourth of the cost of incident STIs when including HIV, but about three-fourths when excluding HIV. STIs among 15-24-year-olds accounted for $4.2 billion (26%) of the cost of incident STIs. CONCLUSIONS: Incident STIs continue to impose a considerable lifetime medical cost burden in the United States. These results can inform health economic analyses to promote the use of cost-effective STI prevention interventions to reduce this burden.

INTRODUCTION: The objective of this study was to assess incremental costs and benefits of a human papillomavirus (HPV) vaccination program expanded to include "mid-adults" (adults aged 27 through 45 years) in the United States. METHODS: We adapted a previously published, dynamic mathematical model of HPV transmission and HPV-associated disease to estimate the incremental costs and benefits of a 9-valent HPV vaccine (9vHPV) program for people aged 12 through 45 years compared to a 9vHPV program for females aged 12 through 26 years and males aged 12 through 21 years. RESULTS: A 9vHPV program for females aged 12 through 26 years and males aged 12 through 21 years was estimated to cost < $10,000 quality-adjusted life year (QALY) gained, compared to no vaccination. Expanding the 9vHPV program to include mid-adults was estimated to cost $587,600 per additional QALY gained when including adults through age 30 years, and $653,300 per additional QALY gained when including adults through age 45 years. Results were most sensitive to assumptions about HPV incidence among mid-adults, current and historical vaccination coverage, vaccine price, and the impact of HPV diseases on quality of life. CONCLUSIONS: Mid-adult vaccination is much less cost-effective than the comparison strategy of routine vaccination for all adolescents at ages 11 to 12 years and catch-up vaccination for women through age 26 years and men through age 21 years.

BACKGROUND: Diagnoses of HIV infection among male adults and adolescents >13 years with infection attributed to heterosexual contact decreased 2014 through 2018. Racial disparities exist; HIV diagnoses are higher among Black/African American men compared to men of other races/ethnicities. In 2018, Black/African American males accounted for 61% of diagnosed HIV infections attributed to heterosexual contact among males. SETTING: We used national HIV surveillance data from Atlas Plus to obtain the annual case counts of new HIV diagnoses in males with infection attributed to heterosexual contact and population size for years 2014 through 2018 for males (United States excluding territories) by racial/ethnic group. METHODS: We used an adjusted population denominator to calculate rates of diagnoses of HIV infection acquired through heterosexual contact per 100,000 males and twelve absolute and relative measures of disparity to calculate racial/ethnic disparity changes from 2014 to 2018. RESULTS: Results from all disparity measures indicate that disparities decreased in 2018, compared to 2014. The decreases ranged from 18.8% to 34.6% among the four absolute disparity measures and from 5.3% to 22.7% among the eight relative disparity measures. CONCLUSION: Despite the decrease, disparities remain. Tailored, effective strategies and interventions are needed to address the social and structural factors associated with HIV risk among heterosexual Black men and to promote continued progress towards reducing disparities.

Examination of complex public health policy issues can benefit from a mixed methods approach led by multidisciplinary teams.1,2 Evolving problems confronted by law and public health inherently demand dynamic perspectives from diverse fields. However, in practice, professionals often succumb to established ways of approaching an issue within their own disciplines and areas of expertise.3 The mixed methods approach uses quantitative and qualitative research methods to provide a more comprehensive understanding of a research question than any single method could provide. A key advantage of using a mixed methods approach is that the concurrent, coordinated design can offset the weaknesses of either individual approach. Although quantitative research may be inadequate to understand the context in which a phenomenon occurs, qualitative research alone may invoke subjectivity and may not yield generalizable findings. Therefore, the scientific study of the effects of public health law necessitates a multidisciplinary approach.4 A multidisciplinary approach draws on the diverse subject matter expertise, training, and skills of partners from various fields.

BACKGROUND: Point-of-care testing (POCT) assays for chlamydia are being developed. Their potential impact on the burden of chlamydial infection in the United States, in light of suboptimal screening coverage, remains unclear. METHODS: Using a transmission model calibrated to data in the United States, we estimated the impact of POCT on chlamydia prevalence, incidence, and chlamydia-attributable pelvic inflammatory disease (PID) incidence, assuming status quo (Analysis 1) and improved (Analysis 2) screening frequencies. We tested the robustness of results to changes in POCT sensitivity, the proportion of patients getting treated immediately, the baseline proportion lost to follow-up (LTFU), and the average treatment delay. RESULTS: In Analysis 1, high POCT sensitivity was needed to reduce the chlamydia-associated burden. With a POCT sensitivity of 90%, reductions from the baseline burden only occurred in scenarios in which over 60% of the screened individuals would get immediate treatment and the baseline LTFU proportion was 20%. With a POCT sensitivity of 99% (baseline LTFU 10%, 2-week treatment delay), if everyone were treated immediately, the prevalence reduction was estimated at 5.7% (95% credible interval [CrI] 3.9-8.2%). If only 30% of tested persons would wait for results, the prevalence reduction was only 1.6% (95% CrI 1.1-2.3). POCT with 99% sensitivity could avert up to 12 700 (95% CrI 5000-22 200) PID cases per year, if 100% were treated immediately (baseline LTFU 20% and 3-week treatment delay). In Analysis 2, when POCT was coupled with increasing screening coverage, reductions in the chlamydia burden could be realized with a POCT sensitivity of 90%. CONCLUSIONS: POCT could improve chlamydia prevention efforts if test performance characteristics are significantly improved over currently available options.

BACKGROUND: During 2008-2015, the estimated annual HIV incidence rate in the United States decreased for each transmission risk category, except for men who have sex with men (MSM). Racial/ethnic disparities exist, with higher incidence rates for Black and Hispanic/Latino MSM. SETTING: This analysis examines changes, 2010-2015, in disparities of HIV incidence among Black, Hispanic/Latino and White MSM. METHODS: We compared results from the rate ratio, rate difference, weighted and unweighted index of disparity, and population attributable proportion. We calculated incidence rates for MSM using HIV surveillance data and published estimates of the MSM population in the United States. We generated 95% confidence intervals for each measure and used the Z statistic and associated P values to assess statistical significance. FINDINGS: Results from all but one measure, Black-to-White rate difference, indicate that racial/ethnic disparities increased during 2010-2015; not all results were statistically significant. There were statistically significant increases in the Hispanic/Latino-to-White MSM incidence rate ratio (29%, P < 0.05), weighted index of disparity with the rate for White MSM as the referent group (9%, P < 0.05), and the population attributable proportion index (10%, P < 0.05). If racial/ethnic disparities among MSM had been eliminated, a range of 55%-61% decrease in overall MSM HIV incidence would have been achieved during 2010-2015. CONCLUSIONS: A large reduction in overall annual HIV incidence among MSM can be achieved by eliminating racial/ethnic disparities among MSM. Removing social and structural causes of racial/ethnic disparities among MSM can be effective in reducing overall annual HIV incidence among MSM.

Background: In the United States, the routine age for human papillomavirus (HPV) vaccination is 11 to 12 years, with catch-up vaccination through age 26 years for women and 21 years for men. U.S. vaccination policy on use of the 9-valent HPV vaccine in adult women and men is being reviewed. Objective: To evaluate the added population-level effectiveness and cost-effectiveness of extending the current U.S. HPV vaccination program to women aged 27 to 45 years and men aged 22 to 45 years. Design: The analysis used HPV-ADVISE (Agent-based Dynamic model for VaccInation and Screening Evaluation), an individual-based transmission dynamic model of HPV infection and associated diseases, calibrated to age-specific U.S. data. Data Sources: Published data. Target Population: Women aged 27 to 45 years and men aged 22 to 45 years in the United States. Time Horizon: 100 years. Perspective: Health care sector. Intervention: 9-valent HPV vaccination. Outcome Measures: HPV-associated outcomes prevented and cost-effectiveness ratios. Results of Base-Case Analysis: The model predicts that the current U.S. HPV vaccination program will reduce the number of diagnoses of anogenital warts and cervical intraepithelial neoplasia of grade 2 or 3 and cases of cervical cancer and noncervical HPV-associated cancer by 82%, 80%, 59%, and 39%, respectively, over 100 years and is cost saving (vs. no vaccination). In contrast, extending vaccination to women and men aged 45 years is predicted to reduce these outcomes by an additional 0.4, 0.4, 0.2, and 0.2 percentage points, respectively. Vaccinating women and men up to age 30, 40, and 45 years is predicted to cost $830 000, $1 843 000, and $1 471 000, respectively, per quality-adjusted life-year gained (vs. current vaccination). Results of Sensitivity Analysis: Results were most sensitive to assumptions about natural immunity and progression rates after infection, historical vaccination coverage, and vaccine efficacy. Limitation: Uncertainty about the proportion of HPV-associated disease due to infections after age 26 years and about the level of herd effects from the current HPV vaccination program. Conclusion: The current HPV vaccination program is predicted to be cost saving. Extending vaccination to older ages is predicted to produce small additional health benefits and result in substantially higher incremental cost-effectiveness ratios than the current recommendation. Primary Funding Source: Centers for Disease Control and Prevention.

BACKGROUND: Baltimore and San Francisco represent high burden areas for gonorrhea in the United States. We explored different gonorrhea screening strategies and their comparative impact in the two cities. METHODS: We used a compartmental transmission model of gonorrhea stratified by sex, sexual orientation, age, and race/ethnicity, calibrated to city-level surveillance data for 2010-2017. We analyzed the benefits of 5-year interventions which improved retention in care cascade or increased screening from current levels. We also examined a 1-year outreach screening intervention of high-activity populations. RESULTS: In Baltimore, annual screening of population aged 15-24 was the most efficient of the five-year interventions with 17.9 additional screening tests (95% Credible Interval [CrI] 11.8-31.4) needed per infection averted while twice annual screening of the same population averted the most infections (5.4%, 95%CrI 3.1-8.2%) overall with 25.3 (95%CrI 19.4-33.4) tests per infection averted. In San Francisco, quarter-annual screening of all men who have sex with men was the most efficient with 16.2 additional (95%CrI 12.5-44.5) tests needed per infection averted and it also averted the most infections (10.8%, 95%CrI 1.2-17.8%). Interventions that reduce loss to follow-up after diagnosis improved outcomes. Depending on the ability to of a short-term outreach screening to screen populations at higher acquisition risk, such interventions can offer efficient ways to expand screening coverage. CONCLUSIONS: Data on gonorrhea prevalence distribution and time trends locally would improve the analyses. More focused intervention strategies could increase the impact and efficiency of screening interventions.

Background: Criminal justice system involvement has been associated with health issues, including sexually transmitted disease. Both incarceration and sexually transmitted disease share associations with various social conditions, including poverty, stigma, and drug use. Methods: United States state laws (including Washington, D.C.) regarding drug possession and consequences of drug-related criminal convictions were collected and coded. Drug possession policies focused on mandatory sentences for possession of marijuana, crack cocaine and methamphetamines. Consequences of drug-related convictions included ineligibility for public programmes, ineligibility for occupational licences and whether employers may ask prospective employees about criminal history. We analysed correlations between state sexually transmitted disease rates and percentage of a state's population convicted of a felony. Results: First-time possession of marijuana results in mandatory incarceration in one state; first-time possession of crack cocaine or methamphetamines results in mandatory incarceration in 12 (23.5%) states. Many states provide enhanced punishment upon a third possession conviction. A felony drug conviction results in mandatory ineligibility for the Supplemental Nutrition Assistance Program and/or Temporary Assistance for Needy Families in 17 (33.3%) states. Nine (17.6%) states prohibit criminal history questions on job applications. Criminal convictions limit eligibility for various professional licences in all states. State chlamydia, gonorrhoea and syphilis rates were positively associated with the percentage of the state population convicted of a felony (p < 0.05). Conclusion: While associations between crime, poverty, stigma and health have been investigated, our findings could be used to investigate the relationship between the likelihood of criminal justice system interactions, their consequences and public health outcomes including sexually transmitted disease risk.

Vaccination against human papillomavirus (HPV) is recommended to prevent new HPV infections and HPV-associated diseases, including some cancers. The Advisory Committee on Immunization Practices (ACIP)* routinely recommends HPV vaccination at age 11 or 12 years; vaccination can be given starting at age 9 years. Catch-up vaccination has been recommended since 2006 for females through age 26 years, and since 2011 for males through age 21 years and certain special populations through age 26 years. This report updates ACIP catch-up HPV vaccination recommendations and guidance published in 2014, 2015, and 2016 (1-3). Routine recommendations for vaccination of adolescents have not changed. In June 2019, ACIP recommended catch-up HPV vaccination for all persons through age 26 years. ACIP did not recommend catch-up vaccination for all adults aged 27 through 45 years, but recognized that some persons who are not adequately vaccinated might be at risk for new HPV infection and might benefit from vaccination in this age range; therefore, ACIP recommended shared clinical decision-making regarding potential HPV vaccination for these persons.

Estimates of medical care costs for cervical and other cancers associated with human papillomavirus (HPV) are higher in studies published in recent years than in studies published before 2012. The purpose of this report is (1) to review and summarize the recent cancer cost estimates and (2) to illustrate how the estimated cost-effectiveness of HPV vaccination might change when these recent cost estimates are applied. Our literature search yielded 6 studies that provided updated medical care cost estimates for 5 HPV-associated cancers. We found that applying the current cancer cost estimates had a notable impact on the estimated medical costs averted by HPV vaccination over an extended time frame (100 years), and a moderate impact on the estimated cost per quality-adjusted life year (QALY) gained by HPV vaccination. For example, for catch-up vaccination of teenagers and young adults, applying the more recent cancer costs reduced the estimated cost per QALY gained by about $12,400. The cost studies we identified in our literature review are up-to-date and based on reliable data sources from United States settings, and can inform future studies of HPV vaccination cost-effectiveness in the United States. However, careful consideration is warranted to determine the most appropriate cost values to apply.

Concern has been expressed that human papillomavirus (HPV) vaccination programs might promote risky sexual behavior through mechanisms such as risk compensation, behavioral disinhibition, or perceived endorsement of sexual activity. This study assesses whether HPV vaccination status is associated with any differences in selected sexual behaviors among young sexually-active women in the US. Our dataset includes young, adult female respondents from questionnaire data collected in the National Center for Health Statistics' National Health and Nutrition Examination Survey from 2007 to 2014. The empirical approach implements a doubly robust estimation procedure, based on inverse probability of treatment weighting. For robustness, we implement several specifications for the propensity model and the outcomes model. We find no consistent association between HPV vaccination and condom usage or frequency of sex. Specifically, we find no evidence that HPV vaccination is associated with condom usage or with whether a person had sex more than 52 or more than 104 times per year. We find inconsistent evidence that HPV vaccination is associated with a person having sex more than 12 times per year. As in previous research, HPV vaccination does not appear to have a substantive effect on sexual behavior among young sexually-active women in the US.