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Melanie M. Taylor MD, MPH Los Angeles County STD Program

STD Testing Protocols, STD Testing, and Discussion of Sexual Behaviors in HIV Clinics in Los Angeles County. Melanie M. Taylor MD, MPH Los Angeles County STD Program. Acknowledgements. Tracie McClain MD, MPH Bessie Brown Getahun Aynalem MD, MPH Lisa Smith DrPH Peter Kerndt MD, MPH

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Melanie M. Taylor MD, MPH Los Angeles County STD Program

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  1. STD Testing Protocols, STD Testing, and Discussion of Sexual Behaviors in HIV Clinics in Los Angeles County Melanie M. Taylor MD, MPH Los Angeles County STD Program

  2. Acknowledgements • Tracie McClain MD, MPH • Bessie Brown • Getahun Aynalem MD, MPH • Lisa Smith DrPH • Peter Kerndt MD, MPH • Tom Peterman MD, MSc

  3. Early Syphilis Los Angeles County

  4. HIV Seropositivity Among Early Syphilis Cases, 2001-2003

  5. HIV In Los Angeles • 45,000 persons living with AIDS or HIV aware of status* • An estimated additional 9,000 persons with AIDS or HIV that are unaware of status* *Office of AIDS Programs and Policy. Los Angeles County Department of Health Services. HIV Prevention Plan Addendum. 2003

  6. Objectives • To evaluate knowledge of syphilis epidemic among HIV care providers • To determine STD screening practices in HIV care clinics • To quantify use of STD screening/testing protocols in HIV care clinics • To evaluate the frequency and nature of discussion of sexual behaviors in HIV clinics

  7. Study Design/Methods In-person or phone interview performed by one interviewer 17 Question Survey Results analyzed using SPSS Clinics received: Patient information cards for 6 STDs, CA STD treatment guidelines, MMWR: Prevention for Positives, Posters of primary and secondary syphilis symptoms, STD reporting forms

  8. Sample Summary • Survey Respondents: N = 36* • Represented Clinics: N = 48 • Represented HIV Care Providers: N = 184 • Represented Patients: N = 28,119 • *Medical Directors allowed to complete surveys for multiple sites under their direction

  9. Survey of Clinical Care Representatives from 48 Clinics Enrolling >50 HIV Patients Clinician Type % of Sample Medical Directors 31 Clinic Directors 3 HIV/AIDS Program Coordinators 11 Physicians 33 Nurse Practitioners 17 Physician’s Assistants 3 Medical Assistant 3

  10. Types of Clinics • Public • Private • HMO • Hospital/University • Community Based Organization

  11. Clinic Types Public 20% Community Based Organization 31% Hospital/ University 10% Private/HMO 38% Source: LAC DHS STD Program; N=44,205

  12. Knowledge of Syphilis Epidemic When asked about LA syphilis rates, 100% spontaneously reported they were higher. 97% thought they were higher than the national average.

  13. Clinics Performing STD Testing at the First Visit STD Test Number (%) Syphilis 48 (100) Chlamydia 32 (67) Gonorrhea 32 (67) Herpes 0 (0) HPV (Pap Smears) 7 (15) Trichomoniasis 3 (6) Hepatitis screen (A, B, C) 48 (100)

  14. Use of a Written STD Protocol Clinical Practice Number (%) Use of STD testing protocol 24 (50) Protocol Based on: CDC Guidelines 3 (13) LAC STD Program Screening Recommendations 4 (17) Standardized Electronic Sexual Risk Assessment 9 (38) Other 3 (13) Unknown 5 (21)

  15. Activities of Clinics Reporting Use of Written Protocols (WP) for STD Testing Activity WP Use WP Non-Use OR(95%CI) P Value Asymptomatic Testing Every 3-6 months: Syphilis 20 (83) 14 (58) 3.6 (0.9-13.7) 0.055 GC/CT 7 (79) 6 (25) 1.2 (0.3-4.4) 0.5 Patients asked about unsafe sex behavior at each visit 24 (100) 0 (0) 2.2 (1.4-3.4) <0.001

  16. Written Protocol Use by Clinic Type Clinic Type WP Use WP Non-Use OR (95% CI) P Value Early Intervention Program** 22 (92) 11 (46) 13.0 (2.5-68.1) 0.001 CBO 15 (63) 0 (0) 2.7 (1.6-4.5) <0.001 HMO 0 (0) 7 (29) 0.7 (0.5-0.9) 0.009 Hosp/Univ 2 (8) 3 (13) 0.6 (0.1-4.2) 1.0 Private 2 (8) 9 (38) 0.2 (0.03-0.8) 0.04 Public 5 (21) 5 (21) 1.0 (0.2-4.0) 0.6

  17. Questions Frequently Included in Sexual Risk Assessments -Have you practiced unsafe/unprotected (without a condom) sex since your last visit? -Have you have unprotected oral, anal, or vaginal sex since your last visit? -Do/did you use a condom when you have/had sex? -If unsafe sex, what was the HIV status of your partner(s)?

  18. Questions Frequently Included in Sexual Risk Assessments -If unsafe sex, was your partner(s) aware of your HIV status? -Have you used any recreational drugs that were linked to your sexual activity? -Was your sexual interaction with an anonymous partner(s)? If anonymous, where did the sexual interaction take place? (bathhouse, sex club, via internet contact, other) -What type of sex practices do/did you engage in? -Have you had sex with men, women or both?

  19. Conclusions • Written protocols for STD testing may promote sexual risk assessment questioning among HIV providers • These written protocols may insure STD testing per CDC/IDSA guidelines for HIV positive persons at sexual risk

  20. Limitations • Actual experience of the patients was not evaluated • Sample size limited some analyses • Unable to determine the values of sexual risk questions in predicting disease • 9/48 (19%) clinics operated by one organization and may have skewed the results.

  21. LA County Recommendations for STD Screening among HIV Positive Persons

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