Sexually Transmitted Infections: Experience in a Multidisciplinary Clinic in a Tertiary Hospital in Spain (2010-2013)

INTRODUCTION:

The number of consultations for sexually transmitted infections (STIs) is increasing in Spain. The aim of this study was to describe and analyze the epidemiological, behavioral, clinical, and microbiological characteristics of patients registered at the STI unit of a tertiary hospital.

METHODS:

This was a retrospective, single-center descriptive study carried out between 2010 and 2013 in a multidisciplinary unit specialized in STIs, situated in a tertiary hospital. Epidemiological, clinical, and behavioral data were gathered using a face-to-face interview and a standardized questionnaire. Samples were collected for microbiology analysis.

RESULTS:

The study included 546 patients: 96% were men, 41% had human immunodeficiency virus (HIV) infection, and 56% were men who have sex with men. The reasons for consultation were the following: urethritis; genital, anal, or perianal ulcers; proctitis; oral ulcers; sexual contact with a person with a known STI; and high-risk sexual contact. The most common microbiological diagnoses were Neisseria gonorrhoeae in urethritis, Treponema pallidum in genital and anal or perianal ulcers, and Chlamydia trachomatis lymphogranuloma venereum serovars in proctitis. The highest prevalences of the main STIs studied occurred in homosexual men with HIV infection.

CONCLUSION:

This study confirms the increase in the incidence of STIs in recent years and the epidemiological characteristics of the HIV/STI epidemic in Spain.

Purchase full article at:   http://goo.gl/gcBfmQ

By:   Moreno-Ribera N¹, Fuertes-de Vega I¹, Blanco-Arévalo JL², Bosch-Mestres J³, González-Cordón A², Estrach-Panella T¹, García-de Olalla P⁴, Alsina-Gibert M⁵.

¹Servicio de Dermatología, Hospital Clínic, Universitat de Barcelona, Barcelona, España.

²Servicio de Enfermedades Infecciosas, Hospital Clínic, Universitat de Barcelona, Barcelona, España.

³Servicio de Microbiología, Hospital Clínic, Universitat de Barcelona, Barcelona, España.

⁴Servicio de Epidemiología, Agencia de Salud Pública de Barcelona, Barcelona, España.

⁵Servicio de Dermatología, Hospital Clínic, Universitat de Barcelona, Barcelona, España. Electronic address: malsina@clinic.ub.es.

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Trichomoniasis: The “Neglected” Sexually Transmitted Disease

KEY POINTS

• Although Trichomonas vaginalis is the most prevalent curable sexually transmitted infection, it has been considered a “neglected” parasitic infection, due to limited knowledge of its sequelae and associated costs.
• Newly available diagnostic methods, including nucleic acid amplification tests, may improve the ability to identify trichomoniasis in the clinical setting.
• Infections usually can be cured with a single oral dose of a nitroimidazole antimicrobial (eg, metronidazole or tinidazole). Allergy and antimicrobial resistance are of concern, given the lack of effective treatment alternatives.
• Prevention approaches include condoms and treatment for all sex partners.

 PREVENTION

Approaches to preventing trichomoniasis include:

• Abstaining from sex
• Using condoms
• Ensuring that all sex partners receive adequate treatment
• Refraining from douching

STDs, including trichomoniasis, can be avoided by abstaining entirely from sex. Among sexually active individuals, however, a more realistic approach may be to use condoms consistently and correctly.⁴⁹

All sex partners of a person diagnosed with T vaginalis infection should be notified promptly and treated appropriately before resuming sexual activity. Patient-delivered partner therapy has been found to be as effective as standard notification, and is an option in states where this strategy is permissible.^50,51

Douching is not effective in reducing trichomoniasis; on the contrary, this practice may be a risk factor for T vaginalis and other sexually transmitted infections.^2,52

Although T vaginalis infection is quite common, and usually curable with a widely available and fairly inexpensive medication, a lack of public awareness makes trichomoniasis a “neglected” STD. Disparities in the prevalence of infection by sex, age, race/ethnicity, and setting should be recognized. The emergence of antimicrobial resistance and lack of alternative treatments is of concern. Additional data regarding the severity and costs of infection, as well as evidence that treatment of T vaginalis can prevent associated conditions, could lead to wider recognition of this infection in the future.

CONTROVERSIES

Neither trichomoniasis nor T vaginalis infection is a nationally notifiable condition in the United States.⁵³Furthermore, neither the infection nor the disease is currently reportable to the health department of any state. Although the frequency, communicability, and associated health disparities have been clearly identified, consistent data are still lacking regarding severity of infection, preventability of associated adverse events, and costs. Finally, there has been little interest in this infection among members of the general public.⁵³

Below:  Trichomonas vaginalis parasites

Full article at:   http://goo.gl/L5w2rM

By:   Elissa Meites, MD, MPH

Elissa Meites, Division of STD Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, 1600 Clifton Road Northeast, MS E-02, Atlanta, GA 30333, USA;

Elissa Meites: vog.cdc@setieme

  

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Tinea Genitalis: A New Entity of Sexually Transmitted Infection? Case Series & Review of the Literature

Key messages

• Sharply demarcated erythematous scaling plaques or pustules in the genital region should raise suspicion of tinea, especially after sexual intercourse in South East Asia.
• To avoid irreversible scarring alopecia, prompt initiation of antifungal treatment and adequate isolation and identification of the pathogen is essential.
• Marked inflammatory reaction after starting antifungal treatment is frequent and requires systemic prednisone.

Objective

Investigation on recent cases of tinea genitalis after travelling to South East Asia.

Methods

Patients with tinea in the genital region, which emerged after sex in South East Asia, underwent further assessment including microscopy, cultures and DNA analyses.

Results

The case series includes seven patients. In six patients, Trichophyton interdigitale (former Trichophyton mentagrophytes) was detected. Three patients suffered from a severe inflammatory reaction of the soft tissue and two of them needed hospitalisation due to severe pain. In four patients, cicatrising healing was noticed. Five patients were declared incapacitated for work.

Conclusions

Sexual activity should be considered as a potentially important and previously underappreciated means of transmission of T. interdigitale. To avoid irreversible scarring alopecia, prompt initiation of antifungal treatment is essential and adequate isolation and identification of the pathogen is mandatory.

Below:  Erythematous scaling plaques and follicular pustules in an 18-year-old patient

Below:  Pubic area with succulent ulcerated nodules with seropurulent discharge 2 days after beginning of antifungal treatment

Full article at:   http://goo.gl/5kbCMt

By:   Isabelle Luchsinger,1 Philipp Peter Bosshard,2 Romano Silvio Kasper,2 Dominic Reinhardt,1 and Stephan Lautenschlager1

1Outpatient Clinic of Dermatology, Triemli Hospital, Zurich, Switzerland

2Department of Dermatology, University Hospital Zurich, Zurich, Switzerland

Correspondence to Professor Dr Stephan Lautenschlager, Outpatient Clinic of Dermatology, Triemli Hospital, Herman Greulichstrasse 70, Zurich CH-8004, Switzerland; Email: hc.hcireuz.ilmeirt@regalhcsnetual.nahpets

 

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Comparing Databases: Determinants of Sexually Transmitted Infections, HIV Diagnoses & Lack of HIV Testing among Men Who Have Sex with Men

Early detection and treatment of STI/HIV are public health priorities. Our objective was to compare characteristics of men who have sex with men (MSM) in Dutch data available in 2010 from EMIS, an international internet survey, Schorer Monitor, a Dutch internet survey, and data from STI- clinic visits, since these might be subject to different and unknown biases.

Data from Dutch MSM Internet Surveys (EMIS _NLN = 3,787; Schorer Monitor, SMON N = 3,602), and 3,800 STI clinic visits (SOAP) were combined into one dataset. We included factors that were measured in all three databases. The socio-demographics included were age (at the time of the survey), zip code, and ethnicity. Behavioural variables included were the number of sexual partners, condom use with last sexual partner, drug use, being diagnosed with STI, being diagnosed with HIV, and HIV testing. Outcomes we investigated were being diagnosed with STI, HIV, and never been tested for HIV.

Logistic regressions showed that determinants for being diagnosed with STI were having more sexual partners, drug use, and having had an HIV test (aORs 1.3 to 17.1) in EMIS and SMON. Determinants for being diagnosed with HIV in all three databases were older age, living in Amsterdam, and having more partners (aORs 1.8 to 4.4). In EMIS and SMON, drug use, non-condom use, and having STI were additional determinants (aORs 1.6 to 8.9). Finally, determinants associated with never been tested for HIV were being younger (only SOAP), living outside of Amsterdam, having fewer partners, no drug use, and no STI (aORs 0.2 to 0.8).

Risk factors from internet surveys were largely similar, but differed from STI clinics, possibly because it involves self-reports rather than diagnoses or because of differences in timing. The difference between the internet surveys and STI clinic data is much less pronounced for having never been tested, suggesting both are appropriate for this outcome. These findings shed light on conclusions drawn from different data sources, as well as the comparability of recruitment strategies, the robustness of risk factors, consequences of phrasing questions differently, and on (policy) implications based on different data sources.

Full article at:  http://goo.gl/yvXnCE

By:  Chantal den Daas^1*, Maaike Goenee², Bouko H. W. Bakker², Hanneke de Graaf² and Eline L. M. Op de Coul¹

¹Centre for Infectious Disease Control, National Institute for Public Health and the Environment, P.O. Box 1, Bilthoven, The Netherlands

²Rutgers, Utrecht, The Netherlands

 

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Patterns of Sexually Transmitted Infections in Patients Presenting in Special Treatment Clinic in Ibadan South Western Nigeria

Sexually transmitted infections (STIs) are infections that are often transferred from one person to another during sexual activity. In developing countries, an increase in the incidence of STIs is attributed to increasing urbanization, modernization, travel, education and exposure to Western media which has led to increased sexual activity, especially among young people.

This is a retrospective study carried out in the University College Hospital (UCH) Ibadan, Nigeria. The records of a total of 506 patients who attended the clinic between Jan 2010-Dec 2011 were retrieved. The records of the patients’ complaints were taken. Detailed demographic data and history of genital symptoms was taken.

The records of 506 patients were used 43.7% (221) were males and 56.3% (285) were females. The patient's age ranged from one to eighty, the 1-10 age groups and the 71-80 ages were the least represented age group. Age, sex, level of education, presenting complaints, presence of yeast cells, VDRL positivity were variables that were looked at. Of these only sex and occupation were risk factors for transmission of STI.

Good clinical care for patients with STIs should extend beyond therapy and include help to avoid future infections. Control activities should focus on the primary prevention of infection through safer sexual practices. Strategies for improving secondary prevention (health care-seeking behavior and case management) should include identification of people at risk and targeting them for intervention.

Table 4

Relationship between occupation and diagnosis

Occupation	Genital Ulcer Disease	Genital Warts	Gonorrhea	Non Gonococcal urethritis	Bacterial vaginosis	Candidiasis	Pelvic Inflammatory disease	Tinea
Student	11(18%)	27(36%)	7(41.2%)	8(34.8%)	6(33.3%)	29(31.5%)	10(30%)	2(16.7%)
Corpers	3(18%)	5(6.7%)	(0%)	3(13%)	0(0%)	2(2.2%)	0(0%)	0(0%)
Self employed	21(34.4%)	18(24%)	5(29.4%)	7(30.4%)	5(27.8%)	32(34.8%)	11(33.3%)	6(50%)
Commercial sex workers	0(0%)	0(0%)	0(0%)	0(0%)	1(5.6%)	0(0%)	0(0%)	0(0%)
Unemployed	8(13.1%)	13(17.3%)	2(11.8%)	0(0%)	2(11.1%)	7(11.1%)	3(9.1%)	2(8.3%)
Civil servant	15(24.6%)	12(16%)	2(11.8%)	4(17.4%)	4(22.2%)	22(23.9%)	9(27.3%)	1(8.3%)
Drivers	1(1.6%)	0(0%)	0(0%)	1(4.3%)	0(0%)	0(0%)	0(0%)	1(8.3%)

X = 0.017. The above is a frequency table showing the relationship between occupation and diagnosis

Full article at:  http://goo.gl/aXCxQv

By: Victor Ugochukwu Nwadike,1,& Olawale Olusanya,2 Gloria Chinenye Anaedobe,3 Iche Kalu,4 and Kingsley Chiedozie Ojide5

¹Department of Pathology, Federal Medical Centre (FMC) Abeokuta, Ogun State, Nigeria

²Medical Microbiology, Pathcare Nigeria, Lagos, Lagos State, Nigeria

³Special Treatment Clinic, Department of Medical Microbiology, University College Hospital Ibadan, Oyo State, Nigeria

⁴Department of Medical Microbiology, Federal Medical Centre, Umuahia, Abia State

⁵Department of Medical Microbiology, Federal Teaching Hospital Abakaliki, Ebonyi State

^&Corresponding author: Victor Ugochukwu Nwadike, Department of Pathology, Federal Medical Centre (FMC) Abeokuta, Ogun State, Nigeria

  

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Risk Behavior and Sexually Transmitted Infections among Transgender Women and Men Undergoing Community-Based Screening for Acute and Early HIV Infection in San Diego

The transgender community represents an understudied population in the literature. The objective of this study was to compare risk behavior, and HIV and sexually transmitted infection (STI) rates between transgender women and transgender men undergoing community-based HIV testing.With this retrospective analysis of a cohort study, we characterize HIV infection rates as well as reported risk behaviors and reported STI in 151 individual transgender women and 30 individual transgender men undergoing community based, voluntary screening for acute and early HIV infection (AEH) in San Diego, California between April 2008 and July 2014.

HIV positivity rate was low for both, transgender women and transgender men undergoing AEH screening (2% and 3%, respectively), and the self-reported STI rate for the prior 12 months was 13% for both. Although transgender women appeared to engage in higher rates of risk behavior overall, with 69% engaged in condomless receptive anal intercourse (CRAI) and 11% engaged in sex work, it is important to note that 91% of transgender women reported recent sexual intercourse, 73% had more than 1 sexual partner, 63% reported intercourse with males, 37% intercourse with males and females, and 30% had CRAI.

Our results indicate that in some settings rates of HIV infection, as well as rates of reported STIs and sexual risk behavior in transgender men may resemble those found in transgender women. Our findings support the need for comprehensive HIV prevention in both, transgender women and men.

Full article at: http://goo.gl/q0ZtT3

By: Green N1, Hoenigl M, Morris S, Little SJ.

• 1From the Division of Infectious Diseases, Department of Medicine, University of California San Diego (UCSD) (NG, MH, SM, SJL); Division of Family Medicine, University of California San Diego (UCSD), San Diego, CA (SM); Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine (MH); and Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria (MH).  

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Gonorrhoea & Chlamydia Prevalence amongst Trans Women, 2009–2012

Via: http://ht.ly/Tw3kq @UNDP

Estimation of Prevalence & Incidence of Sexually Transmitted Infections in Iran; A Model-Based Approach

Routine reporting of sexually transmitted infections (STIs) in Iran is one of the main information sources on STIs, endures some diminution under influence of several factors. We aimed to adjust registered STI data with a model-based approach and estimate the incidence and prevalence of STIs in Iran.

In this cross-sectional study, we developed a stochastic compartmental model considering effects of influential factors on STI reporting process to adjust registered STI data. We reviewed literature and used Delphi method to collect data and estimate model parameters. We calibrated the model using Monte Carol simulation with 95% confidence interval (CI). Finally, we validated the models by comparing their output with investigational data.

• The estimated prevalence of male urethral discharge was 0.40%; 
• the prevalence of genital ulcers was 3.68% in women and 0.16% in men. 
• The estimated incidence for Neisseria gonorrhoeae, Chlamydia trachoma and syphilis per 1000 women was 2.44, 5.02 and 0.04 respectively; 
• the corresponding figures per 1000 men were 0.43, 0.82 and 0.005.

Various factors are responsible for the obvious underestimation in the number of STIs registered in Iran. Notwithstanding this underestimation, our models offer an indirect method of estimating the prevalence of STIs in the country. 

Providing policymakers and STI experts with more realistic estimates might prompt policymakers and STI experts to recognize the importance of STIs in Iran and help them to develop appropriate prevention and control programs.

Via: http://ht.ly/SRXqq Full PDF article at: http://goo.gl/NXWvfc

By: Nasirian M1, Baneshi MR2, Kamali K3, Haghdoost AA4.

• 1Regional Knowledge Hub, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran. Department of Biostatistics and Epidemiology, Isfahan University of Medical Sciences, Isfahan, Iran.
• 2Research Center for Modeling in Health, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran.
• 3Center for Disease Control (CDC), Ministry of Health and Medical Education, Tehran, Iran.
• 4Professor of Epidemiology and Biostatistics in Kerman University of Medical Sciences, Research Center for Modeling in Health, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran. 

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Emergence and Evolution of Internationally Disseminated Cephalosporin-Resistant Neisseria gonorrhoeae Clones from 1995 to 2005 in Japan

Neisseria gonorrhoeae strains with resistance to extended-spectrum cephalosporins (ESCs), last options for first-line monotherapy of gonorrhoea, likely emerged and initially disseminated in Japan, followed by international transmission. In recent years, multi-locus sequence typing (MLST) ST1901 and N. gonorrhoeae multiantigen sequence typing (NG-MAST) ST1407 isolates with the mosaic penicillin-binding protein (PBP) 2 XXXIV have accounted for most ESC resistance globally. Our aim was to elucidate the initial emergence and transmission of ESC-resistant strains by detailed examination of N. gonorrhoeae isolates from 1995 to 2005 in Kanagawa, Japan.

Already in 1995, one cefixime-resistant (CFM-R) isolate was found, which is the first CFM-R isolate described globally. After 1996, the prevalence of CFM-R and CFM-decreased susceptibility (CFM-DS) isolates significantly increased, with the peak resistance level in 2002 (57.1 % CFM-R). In 1997–2002, the CFM-R MLST ST7363 strain type with the mosaic PBP 2 X was predominant among CFM-R/DS isolates. The first CFM-R/DS MLST ST1901 clone(s), which became the predominant CFM-R/DS strain type(s) already in 2003–2005, possessed the mosaic PBP 2 X, which was possibly originally transferred from the MLST ST7363 strains, and subsequently acquired the mosaic PBP 2 XXXIV. The first MLST ST1901 and NG-MAST ST1407 isolate was identified in Kanagawa already in 2003.

The two main internationally spread cefixime-resistant gonococcal clones, MLST ST7363 and ST1901 (NG-MAST ST1407 most frequent internationally) that also have shown their capacity to develop high-level ceftriaxone resistance (superbugs H041 and F89), likely emerged, evolved and started to disseminate in the metropolitan area, including Kanagawa, in Japan, which was followed by global transmission.

Below:  Molecular epidemiological relatedness of Neisseria gonorrhoeae isolates from 1998 to 2005 in the Kanagawa area, Japan. Minimal spanning tree of 48 MLST STs shows genetic distance of STs derived from 370 isolates. Circle sizes denote the number of isolates sharing the same ST. Black indicates N. gonorrhoeae isolates with resistance or decreased susceptibility to cefixime

Read more at:  http://ht.ly/SmGvU 

By:

Ken Shimuta¹, Yuko Watanabe², Shu-ichi Nakayama¹, Tomoko Morita-Ishihara¹, Toshiro Kuroki², Magnus Unemo³ and Makoto Ohnishi^14*

Prevalence and Sociodemographic Risk Factors of Chlamydia, Gonorrhoea & Syphilis: A National Multicentre STI Survey in New Caledonia, 2012

To estimate prevalence and identify sociodemographic risk factors for Neisseria gonorrhoeae (NG), Chlamydia trachomatis (CT) and Treponema pallidum infections in New Caledonia.

• CT was the most common sexually transmitted infection, with a prevalence of 9%, 
• followed by NG 3.5%, 
• previous or latent syphilis 3%, 
• NG and CT co-infection 2.1% 
• and active syphilis 0.4%

Being from a young age group (18-25 years), being single, having a low level of education and province of residence were all associated with higher prevalence of all three STIs. Being of Melanesian origin was associated with higher prevalence of both CT and NG. There was a significant interaction between ethnic group and province of residence for prevalence of CT. Female gender was associated with higher prevalence of CT.

The prevalence of CT was similar to estimates from other healthcare-based surveys from the Pacific, but higher for NG and lower for active syphilis infection. All sexually transmitted infections estimates were much higher than those found in population-based surveys from Europe and the USA. The sociodemographic risk factors identified in this study will help guide targeted prevention and control strategies in New Caledonia.

Read more at: http://ht.ly/SmCLj

By: Corsenac P1, Noël M2, Rouchon B1, Hoy D3, Roth A3.

• 1Department of Epidemiology, Agence Sanitaire et Sociale de la Nouvelle-Calédonie (ASSNC), Noumea, New Caledonia.
• 2New Caledonia Health and Social Affairs Service, Noumea, New Caledonia.
• 3Research Evidence and Information Programme, Public Health Division, Secretariat of the Pacific Community, Noumea, New Caledonia. 
  
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Prevalence of Genital Chlamydia Trachomatis in Iran: A Systematic Review & Meta-Analysis

To determine the overall prevalence of Chlamydia trachomatis in Iranian males and females and to find out the effect of this bacterium on fertility potential and its association with urogenital symptoms.

C. trachomatis prevalence for women and men was high and ranged from 0 to 32.7% and 0 to 23.3%, respectively (95% CI). The pooled prevalence of the bacterium in the female population was 12.3% (95% CI: 10.6-14.2%) and in men was 10.9% (95% CI: 7.6-15.4%). A high level of heterogeneity was seen for both men (I² = 77.4%; P < 0.001) and women (I² = 77.5%; P < 0.001); but in men and not in women, some evidence for publication bias was observed [Egger's test (two-tailed P = 0.013); Begg's test (two-tailed P = 0.025)]. Analysis of symptomatic/infertile group with asymptomatic/fertile group in females, the overall OR was above 1 and the overall P-value was below zero.

This bacterium may play a role in female infertility or be associated with clinical manifestations; thus, planning national programmes for adequate diagnosis of genital infections caused by this pathogen is necessary. Furthermore, screening strategies, particularly for asymptomatic individuals, and treatment of infected people can reduce consequent complications.

Via: http://ht.ly/S9BGr

By: Ahmadi MH, Mirsalehian A, Bahador A.

Department of Microbiology, School of Medicine, Tehran University of Medical Sciences, Iran

Elevated Sexual Risk Behaviors among Post-Incarcerated Young African American Males in the South

The dramatic racial disparities in the rates of HIV/STIs among African Americans make understanding broader structural factors that increase the risk for HIV/STIs crucial. The current study of young 564 African American men attending sexually transmitted infection (STI) clinics investigated whether those who had ever been incarcerated reported recent sexual behaviors relatively more risky than their counterparts who had never been incarcerated. 

Participants were recruited from clinics treating STIs in three southern U.S. cities. Males 15–23 years of age who identified as Black/African American and reported recent (past two months) sexual activity were eligible. Linear mixed-effects models and Generalized Estimating Equation (GEE) models were used to assess associations between baseline incarceration history and sexual risk behavior over a 6-month follow-up period. Mean age was 19.6 years (SD=1.87). 

At baseline, 240 (42.6%) men reported history of incarceration. Incarceration history predicted several risk behaviors over a 6-month follow-up period. Compared to those with no incarceration history, men previously incarcerated reported a desire to conceive a pregnancy, were less likely to have used a condom at last sex act and were more likely to have used drugs and alcohol before sex in the past two months. 

A history of incarceration may influence the sexual risk behavior of young African American males. Prevention programs and interventions should intensify support for post-incarceration African American males to help mitigate this behavior.

Read more at:  http://ht.ly/S6DN5

Via: JaNelle M. Ricks, DrPH,1 Richard A. Crosby, PhD,2,3 and Ivy Terrell, MPH4

1Department of Behavioral Sciences and Health Education, Emory University Rollins School of Public Health, 1518 Clifton Rd. NE, Atlanta, GA 30322, USA

2Department of Health Behavior, College of Public Health at the University of Kentucky, 111 Washington Ave, Lexington, KY 40506, USA

3The Kinsey Institute for Research in Sex, Gender, and Reproduction, Morrison Hall 302, 1165 E Third Street, Bloomington, IN 47405, USA

4Department of Pediatrics at Louisiana State University Health Sciences Center-New Orleans, 433 Bolivar Street, New Orleans, LA 70112, USA

Correspondence: JaNelle M. Ricks, DrPH, Department of Behavioral Sciences and Health Education, Emory University Rollins School of Public Health, 1518 Clifton Road, Room 426, Atlanta, GA 30322