o r i g i n a l c o m m u n i c a t i o n

Predictors of High Chlamydia and

Gonorrhea Positivity Rates Among
Men in the Southern United States
Adelbert B. James, PhD, MPH; William M. Geisler, MD, MPH

Correspondence: Adelbert B. James, PhD, MPH, Department of Pathology

Financial Disclosure: This study was supported by the Region and Laboratory Medicine, Center for Transfusion and Cellular Therapies,
IV Infertility Prevention Project, Health and Human Services/ Emory University School of Medicine, 101 Woodruff Circle, 7300 WMB,
Office of Population Affairs and the Centers for Disease Atlanta, GA 30322 (abjames@emory.edu).

E
Control and Prevention.
pidemiologic and geographic patterns of sexu-
Background: Routine screening for Chlamydia trachomatis ally transmitted infections (STIs) in the southern
and Neisseria gonorrhoeae in men in the United States is not United States suggest high rates of infections in
recommended. However, untreated men remain a poten- nonurban areas and among racial and ethnic minorities.1
tial reservoir for chlamydial and gonococcal infections and The high rates of STIs in the south are poorly under-
reinfection among women. Chlamydia and gonorrhea stood; however, social determinants, including poverty,
positivities and associated epidemiology were evaluated rurality, diverse subpopulations, complex sexual net-
among males in the southern United States. works, access to care, and health insurance coverage,
Methods: Data were analyzed from 603320 males, aged 15 may contribute to higher STI rates.2-4 Few studies have
to 60 years, who were undergoing chlamydia and gonorrhea examined the prevalences and epidemiology of chla-
testing in sexually transmitted disease, family planning, correc- mydial and gonococcal infections in men in the south-
tional, college, and other facilities between 2001 and 2005. ern United States, the region with the highest reported
Results: Males screened were primarily non-Hispanic black
rates of these infections.5
(63%) or non-Hispanic white (37%). Overall, chlamydia and
Routine screening for Chlamydia trachomatis and
gonorrhea positivities were both 13%. From 2001 to 2005,
Neisseria gonorrhoeae in men in the United States is not
the chlamydia positivity increased 32% and the gonorrhea
recommended.6 As untreated men may be potential res-
positivity decreased 28%. With increasing age, chlamydia
ervoirs for chlamydial and gonococcal infection and
positivity decreased, while gonorrhea positivity remained
reinfection in women, early diagnosis and treatment is
relatively stable. However, in men aged less than 30 years,
critical in reducing the high burden of disease. In addi-
both chlamydia and gonorrhea positivities were significantly
tion, treatment may prevent complications in men, such
higher than in men aged 30 years or greater (P < .01). Non-
as acute epididymitis, infertility, and reactive arthritis.7-9
Hispanic blacks had a 5-fold higher risk for gonorrhea and
To date, there have been no recommendations regarding
1.5-fold higher risk for chlamydia than non-Hispanic whites
routine male chlamydia screening, since there is no clear
(P < .001). Men living in metropolitan statistical areas had
evidence that screening men is cost-effective and will
a 1.27-fold higher risk for gonorrhea than men living in non-
have a significant impact in reducing infections and
metropolitan statistical areas (P < .001).
complications in women;9-12 however, selective screen-
ing is recommended for men in settings or venues with
Conclusions: Chlamydia and gonorrhea positivity rates were high chlamydia prevalence.6 Routine chlamydia screen-
high in males in the southern United States relative to the ing has been recommended for sexually active young
rates among men in the United States and were influenced women under the age of 25 years, a population with
by demographic and geographic factors. more sequelae and a higher burden of disease than
men.9,10 There is a large disparity in numbers of reported
Keywords: mens health n sexually transmitted diseases
chlamydia cases between men and women, with men
J Natl Med Assoc. 2012;104:20-27 having 3 times lower cases than women; this suggests
the possibility that men may be underscreened for chla-
Author Affiliations: Emory University School of Medicine, Department mydial infections.13
of Pathology and Laboratory Medicine, Atlanta, Georgia (Dr James); The Infertility Prevention Project (IPP) is funded by a
University of Alabama at Birmingham, Department of Medicine and
grant from the Office of Population Affairs and the
Epidemiology (Dr Geisler).

20 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 104, NOS. 1 & 2, JANUARY/FEBRUARY 2012
 High Chlamydia and Gonorrhea Positivity Rates

Centers for Disease Control and Prevention. The primary Materials and Methods
goal of the IPP is to screen sexually active young women
aged less than 26 years for chlamydial and gonococcal Study Population and
infections, primarily in family planning and sexually Data Collection
transmitted disease (STD) clinics. Over the last several The study population consisted of males between the
years, IPP has expanded chlamydia screening to men at ages of 15 and 60 years who were tested for C trachoma-
college campuses, the majority of which are historically tis and N gonorrhoeae between 2001 and 2005 in the
black colleges and universities (HBCUs), juvenile deten- southern United States. Participants were tested at sev-
tion centers, adolescent clinics, and other nontraditional eral venues, including STD clinics, family planning
sites. The availability of highly sensitive and specific clinics, adolescent/teen clinics, juvenile detention cen-
nucleic acid amplification tests (NAATs), which can be ters, and college campuses. The majority (60%) of col-
performed on noninvasively collected urine specimens lege campuses were HBCUs. Data were obtained from
rather than invasive genital swabs, has facilitated screen- the region IV and VI IPP monitoring projects. Region
ing men in such venues.14 From 2001 to 2005, the chla- IV consists of the southeastern states of Alabama,
mydia infection rate in men increased by 43.5% from Florida, Georgia, Kentucky, Mississippi, North Carolina,
112.3 to 161.1 cases per 100000 males,15 and this South Carolina, and Tennessee; data from North
increase may be due to the availability of urine screening Carolina were not available for this study. Region VI
and the increased sensitivity afforded by NAATs.7 The consists of the south central states of Arkansas,
purpose of this epidemiologic study was to analyze data Louisiana, New Mexico, Oklahoma, and Texas. Both
of men in the southern United States who were tested for IPP regions used either NAATS or non-NAATS labora-
C trachomatis and N gonorrhoeae through the IPP and tory tests to detect C trachomatis and N gonorrhoeae.
discuss the implications for demographic and geographic Non-NAATs included the Gen-Probe Pace 2C (Gen-
differences and high positivities of STIs in men. Probe Inc, San Diego, California) and culture. The
majority of NAATs performed were the Aptima Combo
2 (Gen-Probe Inc, San Diego, California). These com-
mercial C trachomatis tests are performed by methods

Table 1. Chlamydia and Gonorrhea Positivity by Demographic and Geographical Characteristics,

2001-2005

No. of Males Chlamydia Positivity, % Gonorrhea Positivity, %

All ages 603320 13.3 13.4
Age group, y
15-24 300065 18.3 14.1
25-29 109297 13.1 14.1
30-60 193958 5.8 11.9
Racea
Non-Hispanic black 376102 15.0 18.9
Non-Hispanic white 220074 10.6 4.2
Ethnicitya
Hispanic 61813 13.8 5.4
Non-Hispanic 448782 13.2 14.4
Test typea
Nonnucleic acid amplification tests 410861 10.9 14.4
Nucleic acid amplification tests 169365 19.4 10.5
Region
IV 341680 14.5 13.4
VI 261640 11.8 13.4
Geographyb
Metropolitan statistical areas 181651 12.9 14.7
Nonmetropolitan statistical areas 160029 16.3 12.0
Venue
Teen clinics 1034 28.5 19.1
College 1747 12.0 2.6
Juvenile detention centers 20290 9.2 2.3
Family planning 17462 12.3 10.1
Sexually transmitted disease 547122 13.6 14.1
a
Missing data.
b
Region IV.

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High Chlamydia and Gonorrhea Positivity Rates

in the manufacturers protocol. logistic regression was used to assess for associations of
Large metropolitan statistical areas in region IV were chlamydia and/or gonorrhea positivity with the follow-
identified based upon population estimates and defined ing predictors: age, race, laboratory test type, geogra-
by the Office of Management and Budget as areas with phy, and venues. The study was reviewed by the Emory
a total population16 of at least 250000. Areas with total University institutional review board and determined to
populations of less than 250000 were classified as non- have exempt status.
metropolitan statistical areas. Data from 27 out of a total
of 34 metropolitan statistical areas in region IV were Results
obtained using both patient and clinic zip codes. A total of 603320 tests were evaluated for C tracho-
Metropolitan statistical areas in region VI were not matis and N gonorrhoeae between 2001 and 2005. The
available for this study. median age of participants was 25 years. The race distri-
Geographic information systems and spatial analysis bution consisted primarily of non-Hispanic black (63%)
tools were utilized to describe patterns and distribution and non-Hispanic white (37%) men. Among non-His-
of chlamydia and gonorrhea positivities in each state. panic blacks evaluated, 62% resided in region IV, mainly
Geographic information system maps were generated by in Tennessee and Georgia. Among non-Hispanic whites
Arc Map version 9.2 (ESRI, Redlands, California.) The evaluated, the majority (52%) lived in region VI, primar-
chlamydia and gonorrhea positivity rates were calcu- ily in Texas and Oklahoma.
lated by dividing the number of cases over the total num- Of the total number of men tested, 57% were tested
ber of tests conducted within each state. in region IV. Approximately 71% of the testing was con-
ducted using the non-NAAT Gen Probe Pace 2 assay.
Data Analysis However, most states switched during the study period
The racial and ethnic composition of the study sam- to NAATs, and from 2001 to 2005, the number of chla-
ple was non-Hispanic black, non-Hispanic white, and mydia and gonorrhea tests increased by 53.4%. A total
Hispanic. Other races were not included in our analyses of 181651 males were tested in metropolitan statistical
due to the small number of men. Age was categorized areas in region IV, and more than half of all tests (52.9%)
into 7 age groups: 15 to 24, 25 to 29, 30 to 34, 35 to 39, were conducted in Atlanta, Georgia; Birmingham,
40 to 44, 45 to 49 and 50 to 60 years. The positivities of Alabama; Nashville, Tennessee; and Louisville,
both C trachomatis and N gonorrhoeae were calculated Kentucky. Non-Hispanic blacks accounted for 76% of
by age groups, race, test types, clinics, venues, metro- subjects tested in metropolitan statistical areas.
politan statistical areas, states, and regions. Odds ratios, The overall positivity of chlamydia and gonorrhea
P values, and 95% confidence intervals were calculated was 13% each. A total of 12975 men (2.2%) had both
to estimate statistical significance. Bivariate analyses chlamydia and gonorrhea. The relationship of chlamydia
were performed using the statistical software SPSS ver- and gonorrhea positivities to demographic and geo-
sion 15 (SPSS Inc, Chicago, Illinois). Multivariate graphic characteristics is illustrated in Table 1. Chlamydia

Figure 1. Chlamydia and Gonorrhea Positivity Among Men in the Southern United States by Year

22 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 104, NOS. 1 & 2, JANUARY/FEBRUARY 2012
 High Chlamydia and Gonorrhea Positivity Rates

positivity was higher with NAATs testing vs non-NAATs years significantly more likely to test positive for C tracho-
(19.4% vs 10.9%). From 2001 to 2005, the chlamydia matis than men aged 30 years or more (adjusted odds ratio
positivity increased by 32% and the gonorrhea positivity [AOR], 3.2; 95% confidence interval [CI], 3.19-3.38; P <
decreased by 28% (Figure 1). Chlamydia positivity was .05). Other predictors of chlamydia positivity were non-
higher in subjects aged 15 to 24 years vs 25 to 29 and 30 Hispanic black race and residence in nonmetropolitan sta-
to 60 years (18.3% vs 13.1% and 5.8%), non-Hispanic tistical areas. Race was the strongest predictor of gonor-
blacks vs non-Hispanic whites (15% vs 10.6%), region rhea positivity, with non-Hispanic blacks more likely to
IV vs region VI (14.5% vs 11.8%), and nonmetropolitan test positive for gonorrhea than non-Hispanic whites
statistical areas vs metropolitan statistical areas (16.3% (AOR, 6.0; 95% CI, 5.82-6.26; P < .05). Younger age also
vs 12.9%). Chlamydia-infected men had a lower median predicted gonorrhea positivity. The use of non-NAATs
age than men with gonorrhea (22 vs 24 years). With was associated with a lower chlamydial positivity (AOR,
increasing age, the chlamydia positivity decreased to 0.41; 95% CI, 0.41-0.42; P < .05); however, use of non-
5.8%; however, the gonorrhea positivity remained rela- NAATs was associated with a higher gonorrhea positivity
tively stable (Figure 2). Chlamydia positivity varied by (AOR, 1.15; 95% CI, 1.13-1.18; P < .05); these findings
state and ranged from 10.9% to 21.2% (Figure 3A). are likely reflective of the time period in which non-
States implemented NAATs at different times, however a NAATs or NAATs were performed. Young men attending
significant increase in testing occurred in 2005 (Table 2). teen clinics were at increased risk for both chlamydial and
The gonorrhea positivity was higher in non-Hispanic gonococcal infections.
blacks vs non-Hispanic whites (18.9% vs 4.2%) and in
metropolitan statistical areas vs nonmetropolitan statis- Discussion
tical areas (14.7% vs 12.0%). In New Orleans, Louisiana; Our findings suggest that chlamydia and gonorrhea
Atlanta; Memphis, Tennessee; and Jacksonville, Florida, positivity in selected venues in the southern United
the gonorrhea positivity was greater than 19%. In States was high (13%) among males. The majority of
Arkansas, Georgia, and Louisiana, the gonorrhea posi- men were tested at STD clinics, which may account for
tivity was at least 17% (Figure 3B). The gonorrhea posi- the high positivity. Between 2001 and 2005, the reported
tivity also varied by clinic type, with the highest positiv- number of cases of chlamydial infection among men in
ity in teen clinics. the south increased from 52024 to 72268 (the reported
Predictors of chlamydia and gonorrhea positivity are rate of chlamydial infection in 2005 was 136.7 cases per
illustrated in Table 3. Younger age was the strongest pre- 100000 population). During the same period, the reported
dictor of chlamydia positivity, with men aged less than 30 number of gonorrhea cases in men decreased from 88498

Figure 2. Age-Specific Chlamydia and Gonorrhea Positivity Among Men in the Southern United States,
2001-2005

JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 104, NOS. 1 & 2, JANUARY/FEBRUARY 2012 23
High Chlamydia and Gonorrhea Positivity Rates

Figure 3. Positivity Among Men in Selected Venues in the Southern United States, 2001-2005
A. Chlamydia

B. Gonorrhea

Data source: Infertility Prevention Monitoring Project.

24 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 104, NOS. 1 & 2, JANUARY/FEBRUARY 2012
 High Chlamydia and Gonorrhea Positivity Rates

to 73444 (the reported rate of gonorrhea cases in 2005 proportion of the population than in any other US
was 138.9 cases per 100000 population).15 region.1 Approximately 78% of the most impoverished
In a 2002 prospective cohort study, Miller et al counties in the United States are located in the south,
reported that the overall chlamydial and gonococcal and 92% of rural non-Hispanic blacks reside in the
prevalences among men in the United States were 3.67% south.2 However, the disproportionate number of
and 0.44%, respectively;17 the overall chlamydial and infected non-Hispanic black men is a major concern.
gonococcal prevalences among non-Hispanic black men Data on individual risk factors were not available for this
were 11.12% and 2.36%, respectively.17 Other studies study to further investigate this disparity; however sev-
have estimated that chlamydial and gonococcal preva- eral risk factors have been reported for the apparent high
lences in men range between 3.2% and 8.2%, and 1% rates of gonorrhea among non-Hispanic blacks. Sexual
and 4.3%, respectively.11,12 Based on the higher positivity networks, particularly among non-Hispanic blacks, may
in our study vs lower prevalences in other studies in the play an important role as core transmitters of gonor-
general population, there is clearly a need for increased rhea.21 In addition, sex partner selection (eg, potential
male testing in clinic venues in high-risk areas. for choosing higher STD risk partners), assortative mat-
Younger age (<30 years) was the strongest predictor ing (ie, more often choosing sexual partners of the same
of chlamydia in men, as has been demonstrated in other race/ethnicity), and spatial bridges (ie, mixing of sexual
studies.12,18,19 In contrast, gonorrhea positivity did not dif- partner between more distant geographic areas) may
fer as greatly by age. The reasons for the differences account for racial disparities;2,21-24 other studies have sug-
between chlamydia and gonorrhea positivities with gested poverty, deteriorated physical conditions of local
increasing age are not fully understood. However, there neighborhoods, alcohol availability, and incarceration
are at least 2 possible explanations: (1) differences in may contribute to the high rates of gonorrhea, particu-
biological properties of the bacteria that cause these larly in the south.1,25,26 Local STD programs need to
infections as well as differences in risk factors and clini- address barriers to male testing in non-Hispanic black
cal characteristics of the infections and (2) the higher men and divert resources to high-positivity areas in non-
transmissibility of gonorrhea.20 To date, there are no Hispanic black communities.
published guidelines with male age screening criteria The high chlamydia positivity in our study may be
for chlamydia and gonorrhea. More research is needed attributed to the increased testing. The availability of the
to ascertain an age and positivity cutoff for screening more sensitive NAATs that can be performed on noninva-
males for these infections. sively collected specimens has facilitated the detection of
Our study illustrates significant racial disparities in more cases particularly among asymptomatic men.12 From
chlamydia and gonorrhea positivities between non-His- 2001 to 2005, the reported chlamydia rate among men in
panic blacks and non-Hispanic whites. Non-Hispanic the United States increased; however, during the same
black race was the strongest predictor of gonorrhea and period, the reported gonorrhea rate in the southern United
this has been demonstrated in other studies.1,17 Non- States decreased27 by 17.6%. A second explanation for
Hispanic blacks living in the south constitute a higher high positivity among men in this study may be due to the

Table 2. Chlamydia Positivity Among Men Using Nucleic Acid Amplification Tests by State and Year of
Testing
Year 2001 2002 2003 2004 2005
CT CT CT CT CT
Positivity, Total No. Positivity, Total No. Positivity, Total No. Positivity, Total No. Positivity, Total No.
States % of Tests % of Tests % of Tests % of Tests % of Tests
AL - - - - - - - - 22.5 1590
AK - - - - - - - - - -
FL 26.1 472 28.8 853 9.4 32 10.0 10 29.4 109
GA 12.2 1224 19.9 2566 16.6 3498 18.5 5727 19.6 3742
KY - - - - - - - - 16.6 11443
LA - - 6.4 667 9.8 1220 7.1 1214 8.6 1122
MS 1.0 383 4.0 833 - - 27.9 8407 26.3 12413
NM - - - - 0 1 18.5 3886 18.0 5349
OK - - 16.3 295 8.9 608 9.6 645 8.1 795
SC 0 8 20.3 1891 23.0 474 18.9 10493 16.2 12467
TN - - - - 22.1 17613 20.5 22941 19.6 24835
TX - - - - - - 13.7 1342 14.3 8196
Total 13.2 2087 16.7 7105 20.3 23447 20.4 54665 18.9 82061
Abbreviation: CT, chlamydia.

JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 104, NOS. 1 & 2, JANUARY/FEBRUARY 2012 25
High Chlamydia and Gonorrhea Positivity Rates

large number of men who were diagnosed at STD clinics. not be generalizable to lower-risk male populations
Based upon the high gonorrhea positivity of greater than since most participants in our study were tested at high-
10%, the majority of these men may have been symptom- risk venues, including STD clinics. Second, clinical data
atic. Other factors which may account for increase chla- (eg, symptoms) and behavioral data (eg, condom use,
mydia positivity have been published elsewhere.28 sexual practices, etc) were not available for this study,
Our findings illustrate geographic differences in both which would have been helpful in providing a clearer
chlamydia and gonorrhea positivities. The positivities understanding of the epidemiology of chlamydia and
varied by regions, states, metropolitan statistical areas, gonorrhea in the southern United States. Third, the lack
and venues. Gonorrhea positivity was higher in metro- of clinical data did not allow us to compare positivity
politan statistical areas than nonmetropolitan statistical between symptomatic and asymptomatic men. Fourth,
areas vs the opposite for chlamydia positivity. Chlamydia some states did not collect unique identifiers, and there
and gonorrhea positivities were highest in teen and STD could have been some men that had repeat testing per-
clinics and lowest in juvenile detention centers. These formed, which could possibly have contributed to the
differences in positivity may be attributed to the geo- positivity rates.
graphic differences in disease burden of both men and In summary, our study suggests that age, race, geo-
women and the type of venue where testing was con- graphic location, and venues are significant predictors
ducted. However, due to the high positivities among of high chlamydia and gonorrhea positivities among
young men attending teen clinics, increased resources men residing in the south. The high positivity of these
and testing are necessary to help reduce STIs among this STIs in men is a potential reservoir for infection and
high-risk group. recurrent infections in women. Therefore, early identifi-
The strengths of this study include the large number cation through increased screening of asymptomatic
of men who were evaluated. To date, our study is one of men may provide the opportunity to reduce the high bur-
largest studies of chlamydia and gonorrhea ever con- den of disease in communities in the southern United
ducted among men. In addition, the opportunity to com- States. Moreover, more research on racial and geo-
pare the positivities of both the southeastern and south graphic differences in chlamydia and gonorrhea in the
central states provides further information on STI epide- south could help guide screening strategies.
miology in the southern United States. However, there
are several limitations to our study. First, our results may

Table 3. Predictors of Chlamydia and Gonorrhea Prevalence, 2001-2005

Chlamydia Gonorrhea

OR 95% CI P Valueb OR 95 % CI P Valueb

Age group, y
15-29 3.29 3.23-3.36 < .001 1.22 1.20-1.24 < .001
30-60 1.0 1.0
Race
Non-Hispanic black 1.48 1.45-1.51 < .001 5.3 5.17-5.40 < .001
Non-Hispanic white 1.0 1.0
Ethnicity
Hispanic 1.05 1.03-1.08 < .001 0.34 0.33-0.35 < .001
Non-Hispanic 1.0 1.0
Test type
Nonnucleic acid amplification tests 0.51 0.51-0.52 <.001 1.44 1.41-1.46 <.001
Nucleic acid amplification 1.0 1.0
Geographya
Metropolitan statistical areas 0.74 0.75-0.78 <.001 1.27 1.24-1.29 <.001
Nonmetropolitan statistical areas 1.0 1.0
Venues
Teen clinics 2.54 2.21-2.90 < .001 1.44 1.24-1.69 < .001
Colleges 0.87 0.75-1.00 .054 0.17 0.12-0.22 < .001
Juvenile detention centers 0.64 0.61-0.67 < .001 0.14 0.13-0.16 <.001
Family planning 0.89 0.85-0.93 <.001 0.68 0.65-0.72 < .001
Sexually transmitted disease 1.0 1.0
Abbreviations: OR, odds ratio (unadjusted); CI, confidence interval.
a
Region IV.
b
P < .05.

26 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 104, NOS. 1 & 2, JANUARY/FEBRUARY 2012
 High Chlamydia and Gonorrhea Positivity Rates

ics in three US citiesIndianapolis, New Orleans, Seattle. Int J STD AIDS.

Acknowledgments 2004;15(12):822-828.
We would like to acknowledge the assistance of 13. Centers for Disease Control and Prevention. Sexually Transmitted Dis-
LaZetta Grier from the Centers for Disease Control and ease Surveillance 2006. Atlanta, GA: Centers for Disease Control and Pre-
Prevention in providing the data from the region VI vention, US Dept of Health and Human Services; 2007.
Infertility Prevention Project (IPP), Tony Lombardi for 14. Johnson RE, Green TA, Schachter J, et al. Evaluation of nucleic acid
amplification tests as reference tests for Chlamydia trachomatis infections
data support, and assistance from William Chamberlain in asymptomatic men. J Clin Microbiol. 2000;38(12):4382-4386.
from the Emory University Regional Training Center. We 15. Centers for Disease Control and Prevention. Sexually Transmitted Dis-
also would like to recognize the region IV and VI IPP data ease Surveillance 2005. Atlanta, GA: Centers for Disease Control and Pre-
subcommittees, which oversee the collection of IPP data. vention, US Dept of Health and Human Services; 2006.
16. US Census Bureau. Annual estimates of the population of metropolitan
References and micropolitan statistical areas: April 1, 2000 to July 1, 2006. Washington,
1. Farley TA. Sexually transmitted diseases in the Southeastern United States: DC: US Census Bureau; 2007.
location, race, and social context. Sex Transm Dis. 2006;33(suppl 7):58S-64S. 17. Miller WC, Ford CA, Morris M, et al. Prevalence of chlamydial and
2. Aral SO, OLeary A, Baker C. Sexually transmitted infections and HIV in gonococcal infections among young adults in the United States. JAMA.
the Southern United States: an overview. Sex Transm Dis. 2006;33(suppl 2004;291(18):2229-2236.
7):1S-5S. 18. Todd CS, Haase C, Stoner BP. Emergency department screening
3. Aral SO. Patterns of sexual mixing: mechanisms for or limits to the spread for asymptomatic sexually transmitted infections. Am J Public Health.
of STIs? Sex Transm Infect. 2000;76(6):415-416. 2001;91(3):461-464.
4. Geisler WM, Chyu L, Kusunoki Y, Upchurch DM, Hook EW III. Health insur- 19. Mehta SD, Rothman RE, Kelen GD, Quinn TC, Zenilman JM. Unsuspect-
ance coverage, health care-seeking behaviors, and genital chlamyd- ed gonorrhea and chlamydia in patients of an urban adult emergency
ial infection prevalence in sexually active young adults. Sex Transm Dis. department: a critical population for STD control intervention. Sex Transm
2006;33(6):389-396. Dis. 2001;28(1):33-39.
5. Centers for Disease Control and Prevention. Sexually Transmitted Diseas- 20. Centers for Disease Control and Prevention. Increases in gonor-
es Surveillance 2008. Atlanta, GA: Centers for Disease Control and Preven- rheaeight western states, 2000-2005. MMWR Morb Mortal Wkly Rep.
tion, US Dept of Health and Human Services; 2009. 2007;56(10):222-225.
6. Centers for Disease Control and Prevention. Male chlamydia screening 21. Jennings JM, Curriero FC, Celentano D, Ellen JM. Geographic identifi-
recommendations. Atlanta, GA: Centers for Disease Control and Preven- cation of high gonorrhea transmission areas in Baltimore, Maryland. Am J
tion, US Dept of Health and Human Services; 2007. Epidemiol. 2005;161(1):73-80.
7. Fung M, Scott KC, Kent CK, Klausner JD. Chlamydial and gonococcal 22. Kerani RP, Handcock MS, Handsfield HH, Holmes KK. Comparative geo-
reinfection among men: a systematic review of data to evaluate the need graphic concentrations of 4 sexually transmitted infections. Am J Public
for retesting. Sex Transm Infect. 2007;83(4):304-309. Health. 2005;95(2):324-330.
8. Arcari CM, Gaydos JC, Howell MR, McKee KT, Gaydos CA. Feasibility 23. Kerani RP, Golden MR, Whittington WL, Handsfield HH, Hogben M, Hol-
and short-term impact of linked education and urine screening interven- mes KK. Spatial bridges for the importation of gonorrhea and chlamydial
tions for chlamydia and gonorrhea in male army recruits. Sex Transm Dis. infection. Sex Transm Dis. 2003;30(10):742-749.
2004;31(7):443-447. 24. Ford K, Sohn W, Lepkowski J. American adolescents: sexual mixing pat-
9. Berg AO, Allan JD, Frame PS, et al. Screening for chlamydia infection: terns, bridge partners, and concurrency. Sex Transm Dis. 2002;29(1):13-19.
recommendations and rationale. US Preventive Services Task Force. Am J 25. Cohen D, Spear S, Scribner R, Kissinger P, Mason K, Wildgen J. Broken
Nurs. 2002;102(10):87-92 windows and the risk of gonorrhea. Am J Public Health. 2000;90(2):230-
10. US Preventive Services Task Force. Screening for chlamydial infection: 236.
US Preventive Services Task Force Recommended Statement. Ann Intern 26. Scribner RA, Cohen DA, Farley TA. A geographic relation between alco-
Med. 2007;147:128-134. hol availability and gonorrhea rates. Sex Transm Dis. 1998;25(10):544-548.
11. Schillinger JA, Dunne EF, Chapin JB, et al. Prevalence of Chlamydia 27. Aral SO, Fenton KA, Holmes KK. Sexually transmitted diseases in the USA:
trachomatis infection among men screened in 4 US cities. Sex Transm Dis. temporal trends. Sex Transm Infect. 2007;83(4):257-266.
2005;32(2):74-77. 28. Fine D, Dicker L, Mosure D, Berman S. Increasing chlamydia positivity in
12. Kohl KS, Sternberg MR, Markowitz LE, et al. Screening of males for women screened in family planning clinics: do we know why? Sex Transm
Chlamydia trachomatis and Neisseria gonorrhoeae infections at STD clin- Dis. 2008;35(1):47-52. n

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