Sexual Health in Adolescents Progress in Prevention of STIs: Beyond the Latex Barrier

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1 Sexual Health in Adolescents Progress in Prevention of STIs: Beyond the Latex Barrier Katherine Hsu, MD, MPH* Medical Director, Division of STD Prevention Director, Ratelle STD/HIV Prevention Training Center Massachusetts Department of Public Health August 2012 *No commercial disclosures or conflicts of interest

2 Acknowledgements New England Alliance for Public Health Workforce Development Boston University School of Public Health Massachusetts Association of Public Health Nurses (MAPHN)

3 Accrediting Statements The MAPHN is an approved educational provider by the American Nurses Credentialing Center (ANCC) and the Massachusetts Association of Registered Nurses (MARN). MAPHN will issue 1.0 nursing contact hour for this program which will expire 30 days following the live session.

4 How to Obtain Nursing Continuing Education Credit Please visit: Click on the "Evaluation Forms" link which will take you to the evaluation form in Survey Monkey Fill out your evaluation in Survey Monkey and at the end there will be instructions to click here to get your CE Certificate. Click to open up your certificate first and then submit your evaluation. Thank you! Questions please

5 Continuing Education Disclaimer In compliance with continuing education requirements, all presenters must disclose any financial or other relationships (a) with the manufacturer(s) of commercial product(s) and/or of provider(s) of commercial services discussed in the educational presentation and (b) with any commercial supporters of the activity. The presenter wishes to disclose he/she has no financial interest or other relationship with the manufacturer(s) of commercial products, suppliers of commercial services, or commercial supporters. There is no commercial support.

6 Sexual Health in Adolescents Progress in Prevention of STIs: Beyond the Latex Barrier Katherine Hsu, MD, MPH* Medical Director, Division of STD Prevention Director, Ratelle STD/HIV Prevention Training Center Massachusetts Department of Public Health August 2012 *No commercial disclosures or conflicts of interest

7 Outline Relevance to adolescents Are current methods of prevention working? Discuss STI prevention in context of socialecological model of influences on health Individual level Institutional level Systems level Mention prevention & complexity science Provide resources for STD treatment and prevention

8 Estimated Youth STI Incidence, 2000 ~25% Years Account for: ~48% New Infections 5% Gonorrhea 7% Genital herpes 16% Chlamydia 21% Trichomoniasis ~75% Years Sexually Experienced Population ~52% New Infections Incident STIs* 51% HPV *Also included <1% each HIV, Syphilis, Hepatitis B Weinstock et al., Persp Sex Reprod Health, 2004

9 Chlamydia Rates: United States, Culture Era DFA/EIA Era NAAT Era pre post-1994

10 How many cases of infectious syphilis have you seen in the past 2 years ( )? 30% % 23% 22% >10 BIDMC HIV Update

11 How many cases of infectious syphilis did you see in the 2 years before 2010 ( )? >10 47% 30% 11% 12% BIDMC HIV Update

12 HIV and Syphilis Diagnoses Have Increased in Young MSM Survey of trends in HIV and syphilis diagnoses in 73 large metro areas, 2004/05 and 2007/08 (Torrone et al., JAIDS 2011) 70% of areas had increases in primary+secondary syphilis rates Average increases in young black men HIV: 68% Syphilis: 203% Syphilis/HIV co-infection is common 30-50% of MSM diagnosed with primary and secondary syphilis in urban STD clinics are coinfected with HIV (CDC, STD Surveillance 2010)

13 Influences on Health: The Social Ecological Model Local, state, federal policies Social networks, norms, or Social Structure, Policy, and laws and Systems that regulate or standards (e.g., public support healthy actions agenda, media agenda) Rules, regulations, policies, Community and informal structures (worksites, schools, clinics, religious groups) Interpersonal processes and Institutional/Organizational primary groups (family, peers, social networks, associations) Individual characteristics that that provide social identity and influence behavior such Interpersonal as role definition knowledge, attitudes, beliefs, and personality traits Individual

14 Influences on Health: The Social Ecological Model Social Structure, Policy, and Systems Community Institutional/Organizational Condoms Interpersonal Individual

15 Condom Effectiveness Back in 2001 Consistent condom use results in REDUCTION in HIV transmission from men to women and vice versa in heterosexual couples where one is infected with HIV ( 87%, range 60-96%) REDUCTION in gonorrhea transmission from women to men ( %, range %) Insufficient evidence to determine condom efficacy for Prevention of gonorrhea and chlamydia infection in women Prevention of syphilis, chancroid, trichomonas, genital herpes, genital HPV in men and women Hitchcock P. NIH Consensus Panel Report, 2001

16 Holmes KK et al. Bull World Health Organ 82(6):454-61, 2004

17 Why Are Estimates of Condom Efficacy Disappointing? Difficulties assessing partner infection status If not exposed to an STD carrier, no way to prove risk reduction with condom use! Difficulties assessing condom use Over-reporting of condom use (social desirability bias) Improper use (breakage or bad timing) May be better to use number of unprotected sex acts versus the percentage of times a condom is used, since the latter doesn t account for frequency of intercourse Until they invent the full-body condom Holmes KK et al. Bull World Health Organ 82(6):454-61, 2004

18 Figure 1 No randomised trials have shown a survival advantage for the use of parachutes when leaving airplanes at altitude. Smith GCS, Pell JP. BMJ 2003; 327:

19 Condoms: They work, but can we convince patients to use them?

20 Influences on Health: The Social Ecological Model Social Structure, Policy, and Systems Community STD Screening Guidelines Institutional/Organizational Interpersonal Individual

21 Screening Guideline Sources American Cancer Society (ACS) American College of Obstetrics and Gynecology (ACOG) American Society for Colposcopy and Cervical Pathology (ASCCP) Centers for Disease Control and Prevention (CDC) United States Preventive Services Task Force (USPSTF) American College of Physicians (ACP) HIV Medicine Association (HIVMA) American Academy of Pediatrics (AAP)

22 Why Bother Screening? Percent of Persons with STI Who Are Asymptomatic Men Women Urethra Rectum Pharynx Cervix Rectum Urethra Any Gonorrhea Chlamydia Genital herpes

23 Chlamydial and Gonococcal Infections Identified From Urine/urethral Screening Only: Gay/bisexual men, San Francisco % 53% 54% 56% 47% 44% Chlamydia n = 655 Gonorrhea n = 892 Identified Not Identified (Kent et al. CID 2005 updated)

24 Tests Recommended for Chlamydia & Gonorrhea Screening STD WHO WHAT TEST HOW OFTEN Chlamydia Gonorrhea All women <25 years old Women >=25 years old at increased risk (prior STI, new or multiple sex partners, inconsistent condom use, sex for money or drugs) MSM All women at increased risk of infection (females <25 at greatest risk; prior STI, new or multiple sex partners, inconsistent condom use, sex for money or drugs OR residence in communities with high prevalence) MSM NAAT on cervical or vaginal swab or firstcatch urine NAAT on urethral swab or first-catch urine NAAT on rectal swab if lab will do it, culture if not NAAT on cervical or urethral swab or firstcatch urine NAAT on rectal or pharyngeal swab if lab will do it, culture if not Annually Test of reinfection 3 mos postinfection Annually CDC or USPSTF Recommendations

25 Adolescent Screening: What about the boys?! Insufficient evidence to recommend routine chlamydia screening in young men feasibility efficacy cost Consider screening adolescent/young adult males in clinical settings associated with high chlamydia prevalence adolescent clinics, correctional facilities, STD clinics, MSM defined by the CDC those known to have a 1% or greater prevalence of infection among patient population served

26 Chlamydia and Gonorrhea Nucleic Acid Amplification Testing not FDA-cleared for rectal or pharyngeal specimens but now the preferred testing method over culture

27 CDC GC/CT Screening Highlights Urine in men and vaginal swab in women are the best NAAT specimens to collect for screening Self-collected vaginal swab versus clinician-collected vaginal swab?! Increased emphasis on repeat screening of all infected with chlamydia and gonorrhea -- recommended at 3 months after treatment test of re-infection, not test of cure

28 Effective Practice Changes to Increase Uptake of Re-Screening Implementation of pop-up reminders at six large family planning clinics in California retesting rates for chlamydia and gonorrhea among those patients who returned to the clinic increased by 23% (from 70 to 86%) Western New York, University at Buffalo student health clinic implemented a three-step Treatment- Letter-Reminder ( , phone calls) in those with chlamydia infection re-testing rates went from 16 to 89% Howard et al., Burstein et al., 2012 National STD Prevention Conference Abstracts

29 Tests Recommended for Syphilis, Trichomonas, & Herpes Screening STD WHO WHAT TEST HOW OFTEN Syphilis Persons at increased risk (MSM, sex for money or drugs, correctional settings) Pregnant women Serum nontreponemal test (RPR or VDRL) or treponemal EIA Confirm positive result with serum treponemal test (FTA- ABS, TPPA) Trichomonas HIV-infected women Saline microscopy of vaginal fluid, culture, antigen detection test, NAAT Optimal frequency unknown Genital Herpes Not recommended for everyone Type-specific serology USPSTF Recommendations

30 What have you seen used most as a 1. RPR screening test for syphilis? 2. Syphilis EIA (or other specific treponemal test ) 3. Not sure

31 Marrazzo, CDC-NNPTC Webinar: Sexual Health in MSM, June 7, 2012

32 Low tech vs high tech 180 tests per hour, no manual pipetting

33 Marrazzo, CDC-NNPTC Webinar: Sexual Health in MSM, June 7, 2012

34 CDC-Recommended Algorithm for Reverse Sequence Syphilis Screening 3% Radolf JD et al. MMWR, 2011 Probable false positive EIA If high risk: repeat RPR in several weeks 57% Assess for hx of treated syphilis, sx/signs If treated, no further action If untreated, consider tx for latent syphilis 32%

35 Uses of Herpes Serology Definite Indications: Diagnosis of genital ulcers or lesions, especially when lesions cannot be sampled or are unlikely to yield virus Management of sex partners of persons w/ herpes Implications for counseling, antiviral therapy in infected partner Consider screening persons at risk for HIV transmission (HIV+) Other Uses: Pregnant women and partners (select vs. all) Patient request? Not clear whether all sexually active persons should be screened (cost vs. benefit) Guerry et al. CID 2005, Strick CID 2006

36 Screening asymptomatic populations for STIs: Assuming 1% prevalence of gonorrhea GC test + GC test - GC Infected Not GC Infected ,307 1,000 99,000 Sensitivity = 97.6% = Positivity in Disease 97.6% x 1,000 = 976 Specificity = 99.3% = Negativity in Health 99.3% x 99,000 = 95,832 PPV = 976 / ( ) = 58.5% False Alarm Rate = 41.5% NPV = 98,307 / ( ,307) = 100.0% False Reassurance Rate = 0.0%

37 Screening: A form of secondary prevention

38 CDC Definition of Sexual Health Sexual health is a state of wellbeing in relation to sexuality across the lifespan that involves physical, emotional, mental, social, and spiritual dimensions. Sexual health is an inextricable element of human health and is based upon a positive, equitable, and respectful approach to sexuality, relationships, and reproduction, that is free of coercion, fear, discrimination, stigma, shame, and violence. It includes the ability to understand the benefits, risks, and responsibility of sexual behavior; the prevention of disease and other adverse outcomes, and the possibility of fulfilling sexual relationships. Sexual health is impacted by socioeconomic and cultural contexts including policies, practices, and services that support healthy outcomes for individuals and their communities. Developed by the Sexual Health Workgroup of the CDC-HRSA Advisory Committee, 2011

39 Sexual Exploration We don't teach infants to crawl or walk by moving their limbs for them although they are inefficient at first, this is something they have to do for themselves Of course, we want to minimize risk "if crawling is unsafe because the floor is dirty or littered with broken glass, the appropriate response is not to confine and restrict the child Bay-Cheng L et al., "Not from Always a crawling, Clear Path": Making Space but for Peers, to Adults, clean and Complexity up the in Adolescent mess." Girls' Sexual Development, from Sexualization of Girls and Girlhood, Zurbriggen EL and Roberts T-A, eds. in press, Oxford University Press.

40 Adolescent Brain Development Work-in-progress being replaced by adaptive-adolescence theories» Love of novelty leads directly to useful experience; hunt for sensation provides the inspiration needed to "get you out of the house" and into new terrain» Risk-taking occurs because more weight is given to payoff, particularly new social rewards and relationships, not because less weight is given to risk (risk-taking is necessary to move out of the home into less secure situations)» "They didn't take more chances because they suddenly downgraded the risk," says Steinberg. "They did so because they gave more weight to the payoff."

41 Influences on Health: The Social Ecological Model Expedited Partner Therapy Social Structure, Policy, and Systems Community Institutional/Organizational Interpersonal Individual

42 What is Expedited Partner Therapy (EPT)? A partner management strategy to tx sex partners of patients diagnosed w/ Ct Clinician provides medication or prescription to patient, who brings it to his/her partner(s) Partner tx given without the health care provider first examining the sex partner

43 Percent Infection During Follow-up Among Patients Completing The EPT Trial Standard care Expedited care P= P= P= Gonorrhea Chlamydia Gonorrhea or Chlamydia N=358 N=1595 Golden MR, NEJM 2005 N=1860

44 Chlamydia Infection and EPT EPT is supported by the CDC and permissible in at least 30 states Standard treatment for chlamydia infection is one oral dose of 1g of the antibiotic azithromycin EPT has been shown to be safe and effective in the treatment of sex partners Most states with long-standing EPT programs also have had no reports of adverse events

45 CDC EPT guidelines PDPT can prevent reinfection of index case and has been associated with a higher likelihood of partner notification

46 What state are you from? 1. Massachusetts 2. New York 3. Other

47 Clinical Provider Notification CLINICAL ADVISORY: UTILIZING EXPEDITED PARTNER THERAPY (EPT) FOR CHLAMYDIA INFECTION IN MASSACHUSETTS August 2011 Advisory is posted on MDPH website Advisory will be distributed through licensing Boards and Division of STD Prevention provider network Will collaborate to provide link on MMS website as well as other professional organizations

48 Partner/Patient Information A Message for Partners about Chlamydia Infection Expedited Partner Therapy (EPT) August 2011 Information sheet provided by the Massachusetts DPH (or comparable to that provided by the DPH) will be given out whenever possible with each dose of azithromycin and be available online Question/Answer format easy-to-read language, translated into 4 additional languages Encouragement to follow-up with clinical provider

49 Pharmacy Information Utilizing Expedited Partner Therapy (EPT) for Chlamydia Infection September 2011 Information sheet provided by the Massachusetts Board of Registration in Pharmacy Although every prescription in the Commonwealth is normally required to contain name and address of patient, EPT (or E.P.T. or Expedited Partner Therapy") may be used in place of the name, and the address may be left blank

50 Massachusetts: How to Provide EPT for Chlamydia Provision of EPT by clinicians is voluntary, not required MDPH recommends three options for clinicians implementing EPT for chlamydia: 1. Written prescription for named sex partner(s) of infected patient 2. Written prescription using, in place of the partner s name and address, Expedited Partner Therapy, E.P.T. or EPT, which partner can have filled at any Massachusetts pharmacy 3. Direct dispensation of medication, one dose to be taken immediately by patient, additional dose or doses to be delivered by patient to the sex partner(s) (separate, properly labeled container(s) should be used for dose(s) for each sex partner) If an EMR or e-prescribing system does not permit prescription for Expedited Partner Therapy, E.P.T. or EPT, an information sheet listing fields required is available online to assist prescribers with generating a written prescription Providers may also wish to consider contacting a prescription form vendor to obtain blank prescription forms

51 Summary of NYS EPT Law* Permissible for Chlamydia (Ct) only Ct may be lab-confirmed or presumptive/clinical dx HCP may dispense medication, or prescription HCP protected from liability Regulations specify how to practice EPT * NB Repealed January 1, 2014

52 Summary of NYS EPT Regulations Do not use EPT if index co-infected w/ GC or syphilis Requires EPT informational materials be provided for patient to give partner HCP must counsel patient to tell partner that it is important to read said materials before taking medication Specifies content of informational materials Specifies prescription format Specifies Ct reporting requirements

53 NY EPT Resources NYC DOHMH EPT Webpage: Key materials available: Law Regulations Dear colleague letter from Commissioners of Health Provider guidelines Pharmacist FAQ Patient information Partner information EPT brochure for HCP Links to other sites, including CDC, White paper

54 NYS EPT Regulations: Reporting requirements (1) EPT law and regulations do not affect obligation to report Ct to local DOH (requirement remains) (2) Reports of cases of Ct provided with EPT shall include the designation EPT plus the no. of sex partners for whom a prescription or medication provided

55 Expedited Partner Therapy: It works, but can we convince providers to use it?

56 Thinking Beyond the Latex Barrier Expedited Partner Therapy Social Structure, Policy, and Systems Community STD Screening Guidelines Institutional/Organizational Condoms Interpersonal Individual

57 Bolan, National STD Prevention Conference 2012

58 RCT evidence for preventing sexual HIV transmission Study Effect size (CI) Treatment for prevention (HPTN 052) 96% (73; 99) PrEP for discordant couples (Partners PrEP with FTC/TDF) 73% (49; 85) PrEP for heterosexuals (Botswana TDF2 with FTC/TDF) Medical male circumcision* (Orange Farm, Rakai, Kisumu) STD treatment* (Mwanza) Microbicide* (CAPRISA 004 tenofovir gel) HIV Vaccine (Thai RV144) 0% % 63% (21; 48) 54% (38; 66) PrEP for MSMs (iprex with FTC/TDF) 44% (15; 63) 42% (21; 58) 39% (6; 60) 31% (1; 51) Abdool Karim SS & Q. Antiretroviral Efficacy prophylaxis...lancet 2011;378:e23-5 Slide courtesy of Ken Mayer, 2012

59 Bolan, National STD Prevention Conference 2012

60 Bolan, National STD Prevention Conference 2012

61 Misnomer! Prevention Screening Counseling Management AND Treatment Guidelines

62 California PTC Seattle PTC Denver PTC St. Louis PTC AL-NC STD/HIV PTC Region II (New York) PTC STD/HIV PTC at Johns Hopkins Sylvie Ratelle (Boston) PTC of New England Part I - Clinical and Laboratory Training

63 How to Obtain Nursing Continuing Education Credit Please visit: Click on the "Evaluation Forms" link which will take you to the evaluation form in Survey Monkey Fill out your evaluation in Survey Monkey and at the end there will be instructions to click here to get your CE Certificate. Click to open up your certificate first and then submit your evaluation. Thank you! Questions please

64 Links to PHN Webinar Archives The link to the archives and the PP slides are available at To view the archive select the session you wish to view, click on the right facing arrow below the large black viewing box and the video will play. You can also access the archive link and the PP slides on the MAPHN website at 64

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