NASTAD Annual Meeting 5 May, 2008 John M. Douglas, Jr., MD Director Division of STD Prevention

1. Division of STD Prevention: Program Priorities and Opportunities for Collaboration and Integration NASTAD Annual Meeting 5 May, 2008 John M. Douglas, Jr., MD Director Division of STD Prevention

2. DSTDP Priorities: Addressing The Hidden Epidemic “STDs are hidden epidemics of tremendous health and economic consequences in the U.S. They are hidden from public view because many Americans are reluctant to address sexual health issues in an open way and because of the biological ands social factors associated with these diseases. In addition, the scope, impact, and consequences of STDs are underrecongnized by the public and health care professionals. ”

3. Prevalence of STIs Among 14 – 19 Year-Old U.S. Females, NHANES 2003 – 2004 (Forhan et al, 2008 Natl STD Prevention Conference)

4. COALITION OF SENATORS INTRODUCES LEGISLATION RECOGNIZING NATIONAL STD AWARENESS MONTH(Senate Press Release, April 30, 2008) • Today, Senators Hillary Rodham Clinton (D-NY), Russ Feingold (D-WI), Robert Menendez (D-NJ), and Frank Lautenberg (D-NJ) introduced a resolution designating April as National Sexually Transmitted Disease (STD) Awareness Month. Representative Stephanie Tubbs Jones (D-OH) introduced the companion resolution in the House of Representatives. • “The Centers for Disease Control and Prevention (CDC) recently found that one in four young women between the ages of 14 and 19—about 3.2 million teens—is infected with a sexually transmitted disease. These numbers are far too high, and we must be doing more to protect teens against these infections and prevent their spread,” Senator Clinton said.

5. Division of STD Prevention Goals • Prevention of STI-related • Infertility • Adverse outcomes of pregnancy • Cancers • HIV transmission • Strengthen STD prevention capacity and infrastructure • Reduce STD-related health disparities • Address effects of social/economic determinants and costs of STD

6. Priorities for Infertility Prevention: CT & GC Control • Chlamydia • Expand screening of sexually active women < 26 • public sector screening into potentially higher prevalence populations (e.g., schools, detention) • private sector screening (enhanced promotion of guidelines, partnerships with health plans and professional organizations) • Reduce re-infection (improved partner management—EPT, re-screening) • Male screening (selected high-prevalence venues) • Gonorrhea • Maintain effective therapy • Monitoring GC resistance • Access to effective antibiotics—a growing problem • Develop approaches to deal with racial disparities in GC • Partner with communities to examine implications of focusing on reducing GC in African-Americans • Target traditional efforts (screening, RX, partner RX) to areas of need

7. Primary and secondary syphilis, by year and sex: reported rates and male-to-female rate ratios, United States,1981-2007* (Weinstock, Nat STD Conf, 2008) *Preliminary 2007 data

8. Priorities for SEE • Address MSM epidemic • Enhanced public and provider awareness, especially HIV care providers • Use new internet-based prevention approaches • Use integrated guidance to enhance efficiency of STD/HIV partner services • Ongoing use of local data to tailor program efforts • Address potential for re-emerging syphilis in heterosexual populations

9. Priorities for Vaccine Preventable STI • Partnerships are key • HBV • 317 funds provides tremendous opportunity for enhanced immunization in STD clinics, corrections, other venues • HPV • Implementation of monitoring systems • Ongoing need for awareness • Opportunity to frame STD prevention as “everyone’s business”

10. HPV Vaccine: Issues for 2008 • Vaccine licensure for use in women older than age 26 likely later in 2008 • Efficacy likely to be high, but lower CE with lower HPV incidence • What recommendations should be made? • Licensure of a 2nd HPV vaccine expected in 2008 • Issues regarding recommendations for bivalent vaccine (16, 18) vs. current vaccine (types 16, 18, 6, 11) • Should a preference be stated for one vaccine? • Are there differences related to protection against HPV 16/18 (duration, immunogenicity, cross protection)? • Are differences related to protection against HPV 6/11 (warts, RRP) sufficient to express a preference? • Can the vaccines be used interchangeably (for protection against HPV 16/18)? • Licensure of vaccine for use in males possible in 2009 • What recommendations should be made? • How will vaccine be marketed (eg, STD vaccine)?

11. STD Disparities: Framing the Problem Multiple factors contribute to STD disparities in African-Americans, including social determinants outside of the traditional public health paradigm • High incarceration rates • Low educational attainment • High levels of uninsured • Racial inequality • To address STD disparities, involvement of affected communities at all steps in the process is required • Messages must be framed and communicated appropriately to minimize stigma • Approaches must be acceptable to the affected communities • Integration of strategies with HIV essential to maximize impact • “people should look into what can be done to break down the silos of overlapping epidemics…”

12. STD Disparities: Next Steps • Consultation documents • Meeting Report posted on DSTDP website http://www.cdc.gov/std/general/STDHealthDisparitiesConsultationJune2007.pdf • Meeting background papers to be collated and published • CDC structures • DSTDP STD Disparities Workgroup • National STD Disparities Coordinator • Draft DSTDP STD Disparities action plan under review by external partners • Ongoing sub-committees of meeting consultants and other stakeholders • Opportunities for responding to Health Disparities with PCSI • Collaborative efforts with DHAP’s Heightened Response to HIV/AIDS in African Americans • Broader platform and framing through NCHHSTP Disparities effort and report http://www.cdc.gov/nchhstp/healthdisparities/ • Formative research on development and impact of combined STD/HIV prevention messages in African-American communities

13. Program Collaboration & Service Integration: Opportunities for STD Prevention Programs • Core public health activities • Partner services • Training and guidance • Monitoring and evaluation • Surveillance & data systems • HIV prevention • Expanded testing • Viral hepatitis prevention • Expanded venue-based HBV immunization • Cervical cancer prevention • Initiation and monitoring of immunization programs • Reproductive health • STD testing in FP clinics, EC and other OC in STD clinics

14. Program Integration and DSTDP’s ’09 CSPS Program Announcement • Encourage DSTDP’s grantees to: • Provide opt-out HIV testing in STD clinics. • Offer adult hepatitis B vaccination, HIV and STD screening in high prevalence areas or settings where high risk individuals seek care. • Offer comprehensive STD/HIV PS to co-infected • Integrate HIV, hepatitis and STD prevention into health education messages.

15. PCSI: Recommendations for HIV/STD Partners Services • Principles for STD partner notification and HIV PCRS similar, but have evolved differently, creating tension for combined programs and assessment of co-infected persons co-infected. • Integration efforts underway • Harmonized interview record • Contains standardized behavioral variables (e.g., partner gender, drug use) • Integrated program guidance • Expected release August 2008 • Implementation plan under development • New HIV testing FOA encourages partner services as a “required activity” • May enhance collaborations & efficiencies of HIV and STD prevention programs

16. Enhanced STD/HIV Interview Record Form • Developed collaboratively with DHAP to better capture behavioral (gender of partners, places met or had sex with partners) and co-infection data • 2006--gender of partner data began to be submitted, now reported from majority of project areas • Roll-out • New versions of STD*MIS (version 4.1 12/07, version 5.0 3/08) to accept new data • Webinars to provide staff training on use of new form • PTCs to modify DIS training for new staff • 2008—CDC is requesting partner gender & HIV status from all project areas for syphilis, optional for GC/CT • STD*MIS upgrades • Will support selected content from PEMS, may be useful for some PEMS reporting requirements • Have been supported by DHAP surveillance funds

17. Use of STD Information Systems for Partner Services Data • New interview record (linked to but distinct from “field record”) • Better morbidity data on index cases (eg, partner gender, drugs, venues, co-infection), but not partner services data • Reported through STD data systems (eg, STD*MIS) • Sources of partner services data from STD prevention programs • Performance Measures (aggregate data on syphilis) • STD data systems (eg, STD*MIS) • Aggregate data used for annual progress reports • Individual data collected but not reported to CDC • Linkage of STD information systems to PEMS • Varies by system (eg, PRISM in FL) • For STD*MIS, process to add extra PEMS-required variables to STD*MIS 5.0 and to allow export to PEMS underway

18. Internet-related STD/HIV prevention activities: a work in progress • NCSD guidance on internet-based prevention activities • Modules in Partner Services and Outreach now available • Module on Health Communication: draft available • Real-world implementation: examples • Activities with Manhunt.com • Outreach: 157 organizations in 37 states • Partner Services: 14 states, 4 cities • InSpot partner services • 8 cities (SF, Chicago, LA, NY, Philadelphia, Portland, Seattle, DC) • 8 states (CA, CO, FL, ID, IN, MA, MN, WI) • Assessment of results: Internet PN for MSM with syphilis • Chicago: IPN accounted for 40% of SP evaluated/RXd (Gratzer, C9b) • D.C.: Over 6 m, 41/60 (68%) of SP with no other locating information informed through IPN (Ehlman, C9d) • Curriculum development underway • Incorporate internet into current DIS efforts • Find locating information on-line • Conduct internet-based PN through on-line venues • Use internet to local sex events, sex venues, cruising sites

19. National Network of Prevention Training Centers: A Symphony in 3 Parts • Part 1: Clinical training on STD/HIV prevention, diagnosis, and treatment • Historical core has been STD diagnosis and RX • Increasing emphasis on HIV prevention, care • Additional focus on viral hepatitis • Active collaboration with local TB training efforts • Part 2: Behavioral training on STD/HIV prevention interventions (DEBI) and necessary foundational skills • Many interventions relevant to STD clinics (RESPECT, Voices/Voces) or to STD outcomes (Many Men, Many Voices) • Part 3: Clinical and behavioral training related to partner counseling and referral services www.stdhivpreventiontraining.org

20. Integration of STD and Viral Hepatitis Prevention: Training • PTCs conducted hepatitis training needs assessment leading to development of several hepatitis training courses • PTC curriculum modules • “Hepatitis” 1 of 12 core curriculum modules taught in clinical training • Included in pre-requisite self-study training for newly hired DIS • Hepatitis Web Study Project • Interactive, case-based training for prevention diagnosis, and management of viral hepatitis • Developed by Seattle PTC & Northwest AETC with funding from CDC/DVH • 16 online case studies with more planned • Offers free CME & CNE • 879 CME credits & 814 CNE credits issued to date

21. Acknowlegements Kevin O’Connor Rheta Barnes Sara Forhan The findings and conclusions in this presentation are those of the author and do not necessarily represent the views of the CDC/ATSDR