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Diseases without Borders: Best Practices for Sexually Transmitted Diseases Care and Prevention

Diseases without Borders: Best Practices for Sexually Transmitted Diseases Care and Prevention. Linda Creegan, MS, FNP California STD/HIV Prevention Training Center linda.creegan@ucsf.edu Border Conference El Centro, CA June 2014.

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Diseases without Borders: Best Practices for Sexually Transmitted Diseases Care and Prevention

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  1. Diseases without Borders:Best Practices for Sexually Transmitted Diseases Care and Prevention Linda Creegan, MS, FNP California STD/HIV Prevention Training Center linda.creegan@ucsf.edu Border Conference El Centro, CA June 2014

  2. I do not have any financial arrangements or affiliations with commercial sponsors which have direct interest in the subject matter:

  3. Chlamydia Gonorrhea Syphilis HIV / AIDS Hepatitis B Hepatitis C Chancroid Trichomonas Granuloma inguinale LGV M. genitalium HPV Genital herpes Lice Scabies BV? Others….. Sexually Transmitted Diseases

  4. Complications of STDs • Chlamydia • Gonorrhea • HPV • Hepatitis B • Trichomonas • HSV • Syphilis

  5. CA STD Data and Statistics

  6. Priority Populations • Teens & young people • Pregnant women • Gay/Bi men (MSM) • People of color

  7. Testing in STD Care Testing applications • Case finding • Asymptomatic (screening) • Symptomatic (diagnostic) • Follow-up • Guide treatment (HIV resistance testing) • Surveillance Types of tests • Culture (susceptibility testing) • Serologic tests (antibodies in the blood) • Molecular-based tests (NAAT) • Combo tests • CT/GC • HIV/syphilis • Non-treponemal and treponemal

  8. Testing Approaches • In clinic • Clinician-collected • Self-collected • Outside the clinic • Collected at lab • Field-based program • Home testing

  9. Provide Those Free Sexual Health Services! • Essential Health Benefits related to STD/HIV prevention and care • Must be included in all health plans at no cost-sharing to patient • Annual Wellness visit • STD and HIV screening • STD and HIV care • HPV and Hep B Immunizations • Risk Reduction counseling • Pap smears

  10. 1. Ask three essential sexual history questions WHO are your partners? WHATare yoursexual and drug use practices? HOW do you try to prevent STDs/HIV? Risk assessment important since many STDs are asymptomatic

  11. 2. Screen for Chlamydia and Gonorrhea ALL sexually active adolescent and young women ≤ 25 years Pregnant women Men who have sex with men (MSM) Persons living with HIV Others according to risk CDC 2010 STD Tx Guidelines. www.cdc.gov/std/treatment

  12. Why screen? • Highly prevalent • Frequently asymptomatic • Reduces transmission • Prevents complications • HEDIS measure: chlamydia screening in females under 25 years old • Standard of care

  13. STD Screening for Women Sexually Active adolescents & up to age 25 Routine chlamydia and gonorrhea screening Others STDs and HIV based on risk Women over 25 years of age STD/HIV testing based on risk Pregnant women Chlamydia Gonorrhea (<25 years of age or risk) HIV Syphilis serology HepBsAg Hep C (if high risk) • CDC 2010 STD Tx Guidelines www.cdc.gov/std/treatment

  14. Estimated Chlamydia Screening Coverage (HEDIS), Females Age 15–24, USA and California, 1999–2010 National California • Source: National Committee on Quality Assurance; California DHCS Division of Medi-Cal Managed Care; • Kaiser Permanente Northern CA; California DPH Office of Family Planning Rev. 4/2012

  15. Who is falling through the cracks? • Visits that do not require an exam • Pregnancy test only • Emergency contraception • Contraception method follow-up • Refills • Depo-provera injection

  16. A pelvic exams is not necessary to obtain a chlamydia test • Nucleic acid amplification tests (NAATs) • Highest sensitivity • Noninvasive samples • Urine • Self-collected vaginal swabs

  17. Major conclusions NAATs recommended for detection of genital tract infections in men and women – with and without symptoms Optimal specimen types are: First catch urine for men Self collected vaginal swabs from women NAATs recommended for: detection of rectal and oropharyngeal infections

  18. What about Women over age 25? CT Test Volume & Prevalence among Females by Age • 50% Test Volume CA FPACT Data, 2006 • *Quest Diagnostics/Unilab: West Hills/Tarzana, Sacramento, San Jose

  19. Which women over age 25 should be screened? Based on risk: • Infection with CT or GC in past 2 years • > 1 sex partner in past 12 months • New partner in past 3 months • Belief that a partner in the past 12 months may have had other sex partners at the same time Other indications: • Pregnancy • Contact to STD   • New STD diagnosis CA CT Screening Guidelines Draft; Howard et al. Over 20. In prep.

  20. STI Screening Recommendations: HIV-positive Men & Women * * Screen at least annually; repeat screening every 3-6 months as indicated by risk. MSM- Consider anal Pap screening Women-Cervical Pap screening; Consider anal Pap if hx of dysplasia. Primary Care Guidelines for the Management of Persons Infected with HIV: 2009 Update by the HIVMA of the IDSA. Clin Infect Dis 2009;49, 651-681.

  21. STD Screening for MSM • HIV • Syphilis • Urethral GC and CT • Rectal GC and CT (if RAI) • Pharyngeal GC (if oral sex) • HSV-2 serology (consider) • Hepatitis B (HBsAg) • Anal Pap (consider for HIV+) * • * At least annually, more frequent (3-6 months) if at high risk (multiple/anonymous partners, drug use, high risk partners) • CDC 2010 STD Tx Guidelines www.cdc.gov/std/treatment

  22. Majority of Rectal Infections in MSM are Asymptomatic Rectal Infections 84% 86% Gonorrhea Chlamydia n=316 n=264 Asymptomatic Urethral Infections Symptomatic 10% 42% Gonorrhea Chlamydia n=364 n=315 Kent, CK et al, Clin Infect Dis July 2005

  23. Proportion of CT and GC infections MISSED among 3398 asymptomatic MSM if screening only urine/urethral sites, San Francisco, 2008-2009 Chlamydia Gonorrhea Marcus et al, STD Oct 2011; 38: 922-4

  24. Chlamydia and Gonorrhea NAA Testing …not FDA-cleared for rectal or pharyngeal specimens but now the preferred testing method over culture Validation procedures can be done by labs to allow use of a non-FDA-cleared test or application Quest & LabCorp currently provide GC/CT NAAT for rectal/pharyngeal specimens

  25. NAAT Laboratory Ordering and Billing Codes For information on specimen collection and transportation, clinicians should contact the local reference laboratory representative. *CDC does not endorse these laboratories, however, they represent the largest laboratories nationally. There may be other private laboratories that have verified rectal and pharyngeal testing with NAATs. Many PHLs have also verified rectal and pharyngeal testing. Bolan, CDC webinar March 2011

  26. Case Scenario • 22 year old female • Asymptomatic, no prior STDs • STD Screening done on intake • No known drug allergies • GC positive • CT negative

  27. What regimen would you use to treat Gonorrhea? • Ceftriaxone 250 mg IM • Azithromycin 2 gm PO • Ceftriaxone 250 mg IM plus azithromycin 1 gm PO • Ceftriaxone 125 mg IM plus azithromycin 1gm PO

  28. Development of GC Resistance 1976: Pen-R NG first identified in US (in CA) 2002: Fluoroquinolones no longer recommended for TX by CA 1945: Penicillin first used widely for TX 2001: First cephalosporin TX failures in Japan 1986: GISP started by CDC 1991: QRNG first identified in US (in HI) 2010: Dual TX recommended for TX by CDC 1936: Sulfanilamides introduced as TX 1989: Penicillin no longer recommended for TX by CDC 2007: Fluoroquinolones no longer recommended for TX by CDC

  29. Who is most likely to be affected by cephalosporin-resistant GC? Men who have sex with men California 30

  30. 3. Use Current Treatment for Gonorrhea Gonorrhea Treatment: Uncomplicated Genital/Rectal/Pharyngeal Infections Ceftriaxone 250 mg IM in a single dose Azithromycin 1 g orally ** or Doxycycline 100 mg BID x 7 days • PLUS* • * Regardless of CT test result **Azithromycin preferred as 2nd antimicrobial MMWR Weekly August 10, 2012 MMWR updates CDC 2010 Guidelines

  31. Do you have ceftriaxone and azithromycin available onsite? • Yes • No

  32. ALTERNATIVE CEPHALOSPORINS: Cefixime 400 mg orally once PLUS Dual treatment with azithromycin 1 g (preferred) or doxycycline 100 mg BID x 7 days, regardless of CT test result IN CASE OF SEVERE ALLERGY: Azithromycin 2 g orally once (Caution: GI intolerance, emerging resistance) Gonorrhea Treatment AlternativesAnogenital Infections Proposed in case of allergy: gentamicin 240 mg IM + azithromycin 2g orally or gemifloxacin 320 mg orally + azithromycin 2g orally • MMWR 2012 / 61(31);590-594

  33. Test of Cure • Current TOC recommendation: Test of cure in 1 week for anyone treated w/ alternative regimens • Routine TOC poses implementation challenges • No data on TOC positivity rates in absence of symptoms • Proposed: Limit TOC only to pharyngeal GC treated with alternative regimen, may extend interval to 14 days

  34. How to slow the spread of A-R Gonorrhea • New antibiotics • Multiple antibiotics • Surveillance • Rapid response plans • Resistance testing of isolates

  35. Suspected GC Treatment Failure What should I do? CDPH Recommendations * If reinfection suspected instead of treatment failure, OK to repeat treatment with CTX 250 + AZ 1g

  36. 4. Ensure Partner Management Patient referral • Ask patient to notify partner and ensure treatment • Suggest patient bring partner to clinic for concurrent treatment (“BYOP”) • Internet-based anonymous notification Expedited partner treatment (EPT) • Patient-delivered partner treatment (PDPT) • Health department field-delivered treatment • Pharmacy-based Provider or clinic-based referral Health department referral

  37. Legal Status of EPT in the U.S. PERMISSIBLE 32 states UNCERTAIN 11 states PROHIBITED 7 states CDC EPT Legal Status Updated August 2012 www.cdc.gov/std/ept

  38. Online Partner Referral Patients use websiteto notify partners - anonymous - free - referrals for testing inspot.org sotheycanknow.org

  39. Nadine28 y/o non-pregnant female treated for CT.When should you schedule her follow-up? • 1 week for a TOC • 3 weeks for a TOC • 3 months for a test for reinfection • 1 year for her annual exam • Not sure

  40. Retesting Recommendations: Retest all women and men with CT or GC 3 months after treatment* “Opportunistic” testing Retest whenever possible, 1-12 mo 5. Retest for CT and GC at three months following treatment *CDC 2010 STD Tx Guidelines, www.cdc.gov/std/treatment

  41. Retesting Prevalence Typical Screening Prevalence Repeat Chlamydial Infection is Common Hosenfeld C, et al. Sex Transm Dis. 2009 Aug;36(8):478-89

  42. Repeat Infection is Dangerous Repeat CT infection leads to higher risk of complications: PID, ectopic pregnancy, infertility Most infections are asymptomatic Relative Risk Hillis SD, et al. (1997). Am J Obstet Gynecol 176(1 Pt 1): 103-7.

  43. Chlamydia Care Continuum: Family PACT females age ≤25 years (N=686,327) Total Est Cases Cases detected Cases treated 78% 92% Pt returns 1-6 mo. retested 60% Pos at Restest 59% Source: Family PACT Annual Report FY 11-12 http://www.familypact.org/Research/reports/FamPactAnnualReport2011-12_ADA.pdf

  44. Getting clients back in for retesting: • Counseling at treatment visit • Written materials • Advance appointments • Traditional reminder systems (telephone and postcards) • Text message and/or email reminders Downer SR et al Aust Health Rev 2006;30:389; Leong KC et al. Fam Pract 2006; 23:699.

  45. Appointment and STI Retest Reminders For more information: providers@bedsider.org

  46. 6. Recommend the HPV Vaccine * Irrespective of history of abnormal Pap, HPV, genital warts MMWR, May 28 2010; 59(20):626-629 , 630-632 MMWR , December 23 2011; 60(50);1705-1708

  47. The HPV Family Mucosal HPVs (~40 types) Dermal HPVs Common skin warts (~60 types) “Low-risk” Wart types “High-risk” Cancer types

  48. 70% 60% Cervical HPV Detection 50% 40% 30% 20% 10% 0% 0 6 12 18 24 30 36 42 48 Incidence of Cervical HPV Detection in Women from the Time of Sexual Debut • Time since first intercourse (months) • Collins et al. Br J Obstet Gynecol 2002;109:96

  49. Clearance of HPV Infections Over 2 Years • Percent HPV Infected • Time from HPV infection (months) • Adapted from Brown et al. JID 2005:191;182

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