City and County of Denver Sexually Transmitted Infections Surveillance Report 2005

Transcription

1 City and County of Denver Sexually Transmitted Infections Surveillance Report 2005 Denver Public Health Department Sexually Transmitted Disease Control Program November 2006

2 This report was prepared by: Cornelis A. Rietmeijer, MD, PhD Douglas B. Richardson Christie J. Mettenbrink BS, MSPH, MT (ASCP) With statistical support from: L. Dean McEwen, MBA Denver Public Health Department STI Control Program 605 Bannock Street Denver, CO Tel. (303) Fax. (303)

3 Contents Introduction 4 HIV/AIDS 5 Gonorrhea 6 Chlamydia 6 Syphilis 6 Trends in the Denver Metro Health Clinic 7 STI trends among men who have sex with men 8 Reproductive Health for Young Adults 8 Comment 9 Technical Notes 11 References 12 Figures 13 Tables 19 3

4 Introduction This is the third annual report of reportable sexually transmitted infections (STI) in the City and County of Denver. Since the Denver Metro Health Clinic (DMHC) at Denver Public Health reports more than 50% of all reportable STI in the City and County of Denver, operational changes at this clinic may have considerable impact on STI morbidity reporting in the Denver jurisdiction, impeding the interpretation of trend data. As has been mentioned in previous reports, the institution of a clinic co-pay in December 2002 resulted in a considerable drop in reported STI in , with a modest rebound reported in 2004 due to a number of activities to counteract the negative impact of the copay system. Foremost among these activities was the offering of a no-cost, screeningonly Express Visit for lower-risk clinic clients. Even though the co-pay was largely rescinded in January 2005, the number of visits to the clinic in 2005 stagnated at a level approximately 25% lower than the number of visits in the year prior to the institution of the co-pay. This stagnation is likely compounded by another change in clinic operations: the transition to a fully electronic medical record in March 2005 that resulted in a temporary slowdown in clinic flow. To offset this negative effect, the clinic expanded the Express Visit option, which currently accounts for 25% of all clinic visits. As we have managed and are managing these changes at DMHC, we expect that morbidity reporting will be less affected by operational factors in the clinic and will once again better reflect trends in STI morbidity among the citizens of the City and County of Denver. 4

5 HIV/AIDS In 2005, 265 cases of HIV infection were newly reported for the City and County of Denver, compared to 258 cases in Of cases in 2005, 74 (27.9%) had an AIDS defining condition at the time of HIV diagnosis or had progressed to AIDS within the year. In addition, 152 persons diagnosed with HIV infection prior to 2004 had progressed to AIDS during the year. Thus of 226 persons diagnosed with AIDS in 2004, 32.7% were first diagnosed with HIV infection during the same year. An unduplicated cumulative total of 11,150 persons have been diagnosed with HIV or AIDS in the City and County since Figure 1 shows trend data since After peaking in 1987 at 1,077 cases, a gradual decrease occurred until 1998 when 278 cases were reported. Since then incidence has stabilized. Reported AIDS cases peaked with 563 cases in 1993, declined to 207 cases in 2001 and have since stabilized. Figure 2 shows trends in the relative proportions of diagnosed HIV and AIDS cases. For this analysis, cases were unduplicated within the year, i.e., persons diagnosed with AIDS within the same year as they were diagnosed with HIV were counted as AIDS cases for that year and not as HIV cases. The proportion of AIDS cases increased from 12.8% of all cases in 1985 to 61.8% in 1994 and started to decline again to 53.0% in 2003 and 54.2% in Trends in demographic and risk factors appear in Figures 3-6. Denominators for these analyses comprise all cases of HIV and/or AIDS by first year of report. Women comprised 2.5% of cases in 1985, gradually increasing to 14.7% in 2001 but then decreasing to 12.0% in 2005 (Figure 3). among non-whites increased from 17.6% in 1985 to 50.0% in 2001 and then decreased to 43.4% in In 2005, 15.6% of new cases were diagnosed among blacks and 26.4% among Hispanics (Figure 4). Men who have sex with men (MSM) continue to be the single most important risk group for HIV infection in the Denver area. In 1985, 92.5% of all cases were reported for MSM or MSM who also injected drugs. Over time, this proportion decreased to 66.9% in 2000 and the again increased to 74.0% in Injection drug users comprised 8.7% of cases in 2005, which has been a steady decrease since 1996 when 14.2% of cases were diagnosed in this risk group. Heterosexual contact as an only risk factor was reported for 10.2% of cases in 2005, which has been relatively stable since (Figure 5). Since the beginning of the epidemic, there has been a gradual increase in age at first diagnosis of HIV/AIDS. In 1985, only 27.8% were 35 years or older; in % of cases fell into that age category (Figure 6). The median age at diagnosis increased form 30 in 1985 to 35 in 2005 (Figure 7). 5

6 As of December 31, 2005, a total of 7,065 persons were alive with HIV/AIDS in the City and County of Denver; of these, 3,115 (44.1%) had an AIDS diagnosis. Gonorrhea During the year, 1,331 cases of gonorrhea were reported in the City and County of Denver, a decrease of 44 cases (3.2%) compared with the previous year (Figure 8). However, while cases decreased from 617 to 535 among women (a decrease of 82 or 13.2%), cases increased among males from 758 to 796 (an increase of 38 cases or 5.0%). In the past 5 years, reported gonorrhea cases increased from 1,566 cases in 2001 to 1,738 cases in 2002, declined to 1,292 cases in 2003, and then increased to 1,375 in 2004 (Table 1). The overall case rate fell from 247 cases per 100,000 in 2004 to 239 cases per 100,000 in 2005 (Table 1). As in previous years, case rates in 2005 were higher among males, younger age groups, and African American populations. Among males the case rate (per 100,000) was 281 compared to 195 among females (Table 2). Case rates were highest among year-old males (878; Table 3a) and year-old females (1,219; Table 3b). Rates among blacks (1,012) were 4.3 times higher than among Hispanics (235) and 9.2 times higher than among whites (110). Rates were highest among year-old black men (5,985; Table 5e) and year-old black women (4,306; Table 5f). Chlamydia In 2005, 4,221 cases of chlamydia infection were reported for the City and County of Denver. Compared to the previous year, this represents an increase of 6.2% (248 cases). This follows the 8% increase in 2004 that in turn followed a substantial (16%) decrease noted in 2003 when compared to 2002 (Figure 9). The chlamydia case rate (per 100,000) in 2005 increased to 758 from 713 in The case rate continued to be considerably higher among women (1038) than among men (486; Table 2), but the increases from 2004 were similar for both sexes (6.2% and 6.8% respectively). Age/gender groups with highest rates included year-old females (7,211), year-old females (5,780; Table 3b), and year-old males (2,295; Table 3a). As before, case rates were higher among blacks (2,170) than among Hispanics (1,225), and whites (209; Table 4). Highest chlamydia rates were reported for year-old black women (13,795) followed by year-old black women (12,547), year-old black women (6,381; Table 5f), year-old Hispanic women (9,474) and year-old Hispanic women (8,494; Table 5i). Syphilis In 2005, a total of 28 cases of primary and secondary syphilis were reported, down from 41 cases in 2004, a 31.7% decrease. In addition, there were 11 cases of early latent syphilis for the year, compared to 13 in the previous year. Recent trends in cases and case rates for primary and secondary syphilis are illustrated in Figure 10. Case rates (per 6

7 100,000) were considerably higher among men (9.5) compared to women (0.4), representing a male-to-female ratio of Rates were highest in the year-old male age group (29.8; Table 3a). In 2005, rates were higher among whites (5.7) and blacks (5.4) compared to Hispanics (4.7; Table 4). Of the 39 cases of early (primary, secondary, and early latent) syphilis reported for the City and County in 2005 (for whom race/ethnicity was known), 64.1% were among whites, 28.2% among Hispanics, and 7.6% among blacks, compared to respectively 56.4%, 30.9%, and 10.9% in Trends in the Denver Metro Health Clinic In March, 2005, the Denver Metro Health Clinic (DMHC) switched to an electronic medical record system that necessitated a complete overhaul of the clinic s computer system and associated databases. This also allowed the clinic its first major revision and update of its clinical charting system in almost 20 years. As a result, a number of clinic metrics changed and cannot be easily compared with previous years, specifically those related to number of clinic visits and services delivered. In addition, to offset the negative impact of the clinic co-pay system in 2003, the clinic started to offer a no-cost express visit option that only included chlamydia and gonorrhea urine NAAT testing, and later expanded to include rapid HIV testing as well as RPR screening for syphilis. While the clinic co-pay was largely rescinded in 2005, the express visit option was continued, in part to relieve the impact of the introduction of the electronic medical record on clinic flow. During 2005, the clinic had 18,398 unduplicated patient visits, including 12,966 comprehensive STD evaluations and 2,555 express visits. The total of these two services (15,521) is comparable and roughly equal to the number of clinic visits in 2004 (15,333). In addition, 1,380 clients accessed the independent HIV counseling and testing site in the clinic, 2,261 accessed family planning services and 208 made visits to the DMHC teen clinic. Outreach activities included STD and HIV testing of 669 inmates at the Denver County Jail and of 1,124 patrons of the three Denver bathhouses. For the year, a total of 1,808 cases of chlamydia were diagnosed at DMHC compared to 1,773 in 2004, an increase of 1.9%. This increase was due to a higher number of cases among men (+3.4%), while the number of cases among women decreased slightly (- 0.9%). The number of diagnosed cases of gonorrhea decreased from 837 in 2004 to 798 in 2005 (-4.6%). This decline was specifically due to a decrease among women (-22.0%), while cases among men remained unchanged. The number of cases of primary and secondary syphilis decreased from 25 in 2004 to 18 in 2005, a decrease of 28% (Table 7). Five-year trends in patient volume and diagnosed cases of chlamydia and gonorrhea are presented in Figure 11. Overall case rates (i.e., number of cases/number of visits) were 11.9% and 5.1% for chlamydia and gonorrhea respectively. While cases have increased over the past two year, they have not reached the level of

8 STI Trends among Men Who Have Sex with Men In 2005 there were 944 visits to DMHC by men who reported a male sex partner in the previous year, comprising 6.2% of all clinic visits. This is down 14.9% from 1,110 visits in 2002, but up 27.2% from 746 visits in 2003 and 9.9% form 944 visits in Gonorrhea was diagnosed at 144 visits (15.8%) in 2005, compared to 92 visits (13.2%) in 2003 and 86 visits (10.7%) in Overall, gonorrhea among MSM accounted for 24.1% of all male cases in the clinic in 2005, compared to 14.3% in Chlamydia was diagnosed at 73 visits (8.2%) in 2005, compared to 52 visits (7.0%) in 2003, and 59 visits (7.4%) in Primary and secondary syphilis were diagnosed at 13 visits (1.4%) in 2005, compared to 6 visits (0.8%) in 2003, and 13 visits (1.5%) in In 2005, among 113 MSM with HIV infection (self-reported or by test at the day of visit), 27% (n=31) had gonorrhea, 8% (n=9) had chlamydia and 7% (n=8) had primary or secondary syphilis, compared to respectively 11%, 7%, and 0.7% among un-infected MSM. Of all gonorrhea, chlamydia and primary and secondary syphilis infections diagnosed among MSM in 2005, respectively 22%, 12%, and, 62% were among HIV-infected MSM. Reproductive Health for Young Adults (ReHYA) With the introduction of nucleic acid amplification testing (NAAT) for gonorrhea and chlamydia in the mid-1990s, Denver Public Health was among the first public health departments in the country to use this non-invasive, urine-based technique to screen for these pathogens among asymptomatic, high-risk individuals in non-clinical settings, including juvenile detention centers, school-based clinics, community-based organizations, and street outreach. In 2005, 2,787 urine samples were tested through the ReHYA program, up 31% from the previous year. Of these samples, 384 (13.8%) tested positive for chlamydia and 67 (2.4%) for gonorrhea. Five-year testing and positivity trends are shown in Figure 12. Data on testing volume and positivity rate by venue are summarized in Table 9a. The largest positivity rates were seen among women in juvenile detention centers (chlamydia 20.5%; gonorrhea 8.1%, Table 9c), followed by males in school-based clinics (chlamydia 14.8%, gonorrhea 3.4%, Table 9b). 8

9 Comment MSM continue to account for a disproportionate number of STIs, particularly HIV, gonorrhea, and syphilis. While the proportion of first-diagnosed HIV/AIDS accounted for by MSM and MSM who also inject drugs had decreased to an all-time low of 66.9% in 2000, this proportion has since steadily increased to 74.0% in At the same time, the number of MSM who make visits to DMHC also continues to increase as is the proportion of MSM diagnosed with gonorrhea at the clinic. While the absolute numbers of new HIV/AIDS cases among MSM has remained relatively stable since 2000, the non- HIV STI trends are worrisome and should prompt a renewed prevention effort among this vulnerable population. In this context, enhancements in the DPH HIV testing programs that include a more routine offering of HIV testing at DMHC, the use of rapid tests to increase the likelihood that infected individuals will learn their positive results, and an extensive linkage to care and prevention program for those infected, are steps in the right direction. Since more than 50% of chlamydia and gonorrhea cases in the City and County of Denver are reported from one of the Denver Public Health STI programs (including clinic and outreach programs), variations in the operations of these programs may have significant impact on STI morbidity reporting. For example, as we have reported on previously, the institution of a co-pay system at DMHC resulted in dramatic decreases of reported chlamydia and gonorrhea cases in 2003 and, even though the co-pay was largely rescinded in 2005, our 2005 report shows that we have yet to fully recover from that impact. The introduction of a new electronic medical record system at DMHC in March of 2005 compounded the problem as the transition into the new system was accompanied by a slowing of patient flow for a number of months and an associated decrease in the number of patients that could be given a full exam during the day. This negative effect was largely offset by the expansion of the express visit which had been introduced in 2004 as a no-cost, screening-only option to compensate for the fall in patient volume due to the co-pay. While the numbers of reported chlamydia and gonorrhea cases are once again approaching normal levels, there remains a serious concern that clinic-based programs will continue to seriously underestimate the real morbidity in the community. Over 80% of chlamydial infections in women and over 50% of infections among males are asymptomatic and, while gonococcal infections are more likely to be symptomatic among males, many such infections, especially among women, are asymptomatic as well. Since clinics rely for a large part on patients who self-refer because they have symptoms, large numbers of cases will remain undetected, thus fuelling endemic levels of these infections that appear to have been stable for many years. Clearly, innovative, sustainable programs focusing on high-risk, asymptomatic individuals are necessary to make a substantial impact on the spread of chlamydia and gonorrhea in the community. The ReHYA program, in existence for over 10 years, has attempted to do this by offering non-invasive, urine-based screening in venues with concentrations of high-risk individuals. As shown in this report, chlamydia positivity 9

10 rates in a number of these venues exceed the overall positivity rate at DMHC which is all the more concerning as the clinic population is self-selected for symptoms whereas the venue-based population is not. Our data stress the importance of conducting outreach testing in these and other high-risk venues and offer a strong rationale to expand these programs. 10

11 Technical Notes Data for reportable STIs, including HIV/AIDS, syphilis, gonorrhea, and chlamydia are sent electronically from the Colorado Department of Public Health and Environment (CDPHE) to the Denver Public Health Department (DPH) on a monthly basis. HIV/AIDS cases are downloaded from the CDC HIV/AIDS Reporting System (HARS), while other STIs are downloaded from the STD Management System (SMS). Both HARS and SMS are CDC-supported databases maintained at CDPHE. Downloads include reportable cases with a City and County of Denver domicile or cases that have been diagnosed at Denver Health (including the Denver Metro Health Clinic and HIV Counseling and Testing Site) but have a domicile outside the City and County of Denver. Individual persons may be included more than once if they have multiple diagnoses, or if they have the same diagnosis at different times. However, persons with manifestations of a single STI at multiple anatomical sites (e.g., simultaneous urethral and pharyngeal gonorrhea) on the same date are counted as a single case. HIV-infected patients who move into the Denver jurisdiction in a given year are included in the HARS database by the year that they were first diagnosed with HIV and/or AIDS. By contrast, patients who move out of the jurisdiction will stay in the database. Therefore, year-to-year statistics will show slight upward variations even for the earlier years of the HIV epidemic. Case reporting for notifiable STI is incomplete and completeness of reporting may vary from year to year. Moreover, many case reports have missing data. Most importantly, information on race/ethnicity is often missing. For the City and County of Denver in 2005, race/ethnicity data were not available for 25.7% of gonorrhea case reports, 39.3% of chlamydia reports, and 12.1% of syphilis reports. We used the method used by the Centers for Disease Control and Prevention to prorate cases according to the distribution of cases for which these variables were specified. 2 Rates of infection were calculated using population estimates for the years from the U.S. Census Bureau. 3 11

12 References 1. Rietmeijer CA, Alfonsi GA, Douglas JM, Lloyd LV, Richardson DB, Judson FN. Trends in clinic visits and diagnosed Chlamydia trachomatis and Neisseria gonorrhoeae infections after the introduction of a copayment in a sexually transmitted infection clinic. Sex Transm Dis. Apr 2005;32(4): CDC. Sexually Transmitted Disease Surveillance, 2003.Atlanta, GA: U.S. Department of Health and Human Services, September U.S. Census Bureau. alldata.html. Accessed October 26,

13 Figure HIV and AIDS By Year of first Report HIV/AIDS Surveillance City and County of Denver, HIV AIDS Figure 2 HIV (no AIDS in same year ) and AIDS By Year of Report HIV/AIDS Surveillance City and County of Denver, % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% AIDS HIV

14 Figure 3 HIV/AIDS by Gender Year of First HIV Report HIV/AIDS Surveillance City and County of Denver, % 80% 60% 40% Female Male 20% 0% Figure 4 HIV/AIDS by Race/Ethnicity Year of First HIV Report HIV/AIDS Surveillance City and County of Denver, % 80% 60% 40% 20% Other Native Hispanic Black White 0%

15 Figure 5 HIV/AIDS by Mode of Exposure Year of First HIV Report HIV/AIDS Surveillance City and County of Denver, % 80% 60% 40% 20% OTHER HETERO IDU MSM/IDU MSM 0% Figure 6 HIV/AIDS by Age Year of First HIV Report HIV/AIDS Surveillance City and County of Denver, % 80% 60% 40% > % 0% <15 15

16 Figure 7 Median Age at HIV/AIDS Diagnosis Year of First HIV Report HIV/AIDS Surveillance City and County of Denver, Age Figure 8 Gonorrhea Reported and Case Rate per 100,000 City and County of Denver Rate / 100, Rate

17 Figure Chlamydia Reported and Case Rate per 100,000 City and County of Denver Rate / 100, Rate Figure 10 Primary and Secondary Syphilis Reported and Case Rates per 100,000 City and County of Denver Rate / 100, Rate

18 Figure 11 Gonorrhea and Chlamydia Diagnoses Denver Metro Health Clinic Gonorrhea Chlamydia Figure 12 Reproductive Health for Young Adults Numbers of Tests Chlamydia (CT) and Gonorrhea (GC) Positivity Rates 3500 % Positive Tests CT GC

19 TABLE 1. Reportable STD cases and rates, Denver, Rate per 100,000 population Diagnosis Race Gender A ge Gonorrhea A ll A ll A ll Chlamydia Syphilis, all Syphilis, P&S Syphilis, Early TABLE 2. Reportable STD cases and rates by gender, Denver, Rate per 100,000 population Diagnosis Race Gender A ge Gonorrhea A ll Male A ll Female Chlamydia Male Female Syphilis, all Male Female Syphilis, P&S Male Female Syphilis, Early Male Female

20 TABLE 3a. Estimated reportable STD cases and rates, males by age, Denver, Rate per 100,000 population Diagnosis Race Gender A ge Gonorrhea A ll Male years years years years years years years years years Chlamydia years years years years years years years years years Syphilis, all years years years years years years years years years Syphilis, P&S years years years years years years years years years Syphilis, Early years years years years years years years years years

21 TABLE 3b. Estimated reportable STD cases and rates, females by age, Denver, Rate per 100,000 population Diagnosis Race Gender A ge Gonorrhea A ll Female years years years years years years years years years Chlamydia years years years years years years years years years Syphilis, all years years years years years years years years years Syphilis, P&S years years years years years years years years years Syphilis, Early years years years years years years years years years

22 TABLE 4. Estimated reportable STD cases and rates by race, Denver, Rate per 100,000 population Diagnosis Race Gender A ge Gonorrhea A sian/pi A ll A ll Black Hispanic Native A mer White Chlamydia A sian/pi Black Hispanic Native A mer White Syphilis, all A sian/pi Black Hispanic Native A mer White Syphilis, P&S A sian/pi Black Hispanic Native A mer White Syphilis, Early A sian/pi Black Hispanic Native A mer White

23 TABLE 5a. Estimated reportable STD cases and rates, Asians & Pacific Islanders, by age, Denver, Rate per 100,000 population Diagnosis Race Gender A ge Gonorrhea A sian/pi A ll years years years years years years years years years Chlamydia years years years years years years years years years

24 TABLE 5b. Estimated reportable STD cases and rates, Asian & Pacific Islander males, by age, Denver, Rate per 100,000 population Diagnosis Race Gender A ge Gonorrhea A sian/pi Male years years years years years years years years years Chlamydia years years years years years years years years years

25 TABLE 5c. Estimated reportable STD cases and rates, Asian & Pacific Islander females, by age, Denver, Rate per 100,000 population Diagnosis Race Gender A ge Gonorrhea A sian/pi Female years years years years years years years years years Chlamydia years years years years years years years years years

26 TABLE 5d. Estimated reportable STD cases and rates, Blacks, by age, Denver, Rate per 100,000 population Diagnosis Race Gender A ge Gonorrhea Black A ll years years years years years years years years years Chlamydia years years years years years years years years years

27 TABLE 5e. Estimated reportable STD cases and rates, Black males, by age, Denver, Rate per 100,000 population Diagnosis Race Gender A ge Gonorrhea Black Male years years years years years years years years years Chlamydia years years years years years years years years years

28 TABLE 5f. Estimated reportable STD cases and rates, Black females, by age, Denver, Rate per 100,000 population Diagnosis Race Gender A ge Gonorrhea Black Female years years years years years years years years years Chlamydia years years years years years years years years years

29 TABLE 5g. Estimated reportable STD cases and rates, Hispanics, by age, Denver, Rate per 100,000 population Diagnosis Race Gender A ge Gonorrhea Hispanic A ll years years years years years years years years years Chlamydia years years years years years years years years years

30 TABLE 5h. Estimated reportable STD cases and rates, Hispanic males, by age, Denver, Rate per 100,000 population Diagnosis Race Gender A ge Gonorrhea Hispanic Male years years years years years years years years years Chlamydia years years years years years years years years years

31 TABLE 5i. Estimated reportable STD cases and rates, Hispanic females, by age, Denver, Rate per 100,000 population Diagnosis Race Gender A ge Gonorrhea Hispanic Female years years years years years years years years years Chlamydia years years years years years years years years years

32 TABLE 5j. Estimated reportable STD cases and rates, Whites, by age, Denver, Rate per 100,000 population Diagnosis Race Gender A ge Gonorrhea White A ll years years years years years years years years years Chlamydia years years years years years years years years years

33 TABLE 5k. Estimated reportable STD cases and rate, White males, by age, Denver, Rate per 100,000 population Diagnosis Race Gender A ge Gonorrhea White Male years years years years years years years years years Chlamydia years years years years years years years years years

34 TABLE 5l. Estimated reportable STD cases and rates, White females, by age, Denver, Rate per 100,000 population Diagnosis Race Gender A ge Gonorrhea White Female years years years years years years years years years Chlamydia years years years years years years years years years

35 TABLE 5m. Estimated reportable STD cases and rate, Native Americans, by age, Denver, Rate per 100,000 population Diagnosis Race Gender A ge Gonorrhea NatA m A ll years years years years years years years years years Chlamydia years years years years years years years years years

36 TABLE 5n. Estimated reportable STD cases and rates, Native American males, by age, Denver, Rate per 100,000 population Diagnosis Race Gender A ge Gonorrhea NatA m Male years years years years years years years years years Chlamydia years years years years years years years years years

37 TABLE 5o. Estimated reportable STD cases and rates, Native American females, by age, Denver, Rate per 100,000 population Diagnosis Race Gender A ge Gonorrhea NatA m Female years years years years years years years years years Chlamydia years years years years years years years years years

38 TABLE 6. Number and percentage of patient visits by gender, age, race/ethnicity and county of residence, Denver Metro Health Clinic, No. % No. % No. % No. % No. % Total 17, , , , Gender Male 11, , , , , Female 6, , , , , Age (yrs.) , , , , , , , , , , , , , , , , , , , , , , , , , ! Race/ethnicity White, non-hispanic 6, , , , , Black 4, , , , , Hispanic 5, , , , , Other, non-hispanic , County Denver 12, , , , , Jefferson 1, , Tricounty* 3, , , , , Other Comprehensive + Express visits (see text, page 7). *Includes Adams, Arapahoe and Douglas counties

39 TABLE 7. Number and percentage of gonorrhea and chlamydia case by gender, Denver Metro Health Clinic, Gonorrhea No. % No. % No. % No. % No. % Total , Male Female Chlamydia Total 1, , , , , Male 1, , , , , Female

40 TABLE 8. Number and percentage* of gonorrhea, chlamydia, syphilis, and HIV cases among MSM Visiting the Denver Metro Health Clinic, No. % No. % No. % No. % No. % Visits , Gonorrhea CT Syphilis All Primary Secondary Early Latent Unknow n/late Latent HIV All HIV by history HIV by test *Percentages for gonorrhea, chlamydia and HIV by test are of number tested. Percentages for syphilis, HIV All and HIV by test are of visits