8/5/2014. STIs in the United States: What s Happening. Overview. Gail Bolan, M.D. 13% 5% 7% 11% 12% 33% 19%

Transcription

1 STIs in the United States: What s Happening Chlamydia Percentage of Reported Cases Among Women by Source of Report, 213 Gail Bolan, M.D. Director, Division of STD Prevention National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention Centers for Disease Control and Prevention August 5, 214 No Conflicts of Interest Nothing to Disclose 13% 5% 7% 11% 12% 19% 33% Private Physician/ HMO Other * Hospital Family Planning Other HD Clinic STD Clinic Missing/Unknown National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Division of STD Prevention *Other includes: Indian Health Service, military, HIV testing, prenatal and other sites NOTE: 213 data are preliminary Overview What s new in STI epidemiology in the United States Changing trends in chlamydia STI clinical preventive services Role of Reproductive Health Providers New Directions in STD Treatment and Management 214 STD Treatment Guidelines Chlamydia Percentage of Reported Cases Among Women by Source of Report, Percent 4% 3% 2% 1% % *Other includes: Indian Health Service, military, HIV testing, prenatal, tuberculosis and other sites NOTE: 213 data are preliminary Rate per 1, 4, 3,5 3, 2,5 2, 1,5 1, 5 Chlamydia Rates of Reported Cases Among Women by Age Group, *percent change during :.3% 15 19: 8.7% 25 29: 3.2% 3+: 4.7% Rate per 1, Gonorrhea Rates of Reported Cases Among Women by Age Group, *percent change during : 4.7% 15 19: 12.9% 25 29: 2.1% 3+: 6.% NOTE: 213 data are preliminary NOTE: 213 data are preliminary 1

2 Complex Prevention Messaging STI CLINICAL PREVENTIVE SERVICES Prevention approach HIV STDs Pregnancy Condoms PrEP HIV Seroadaptation Monogamy Abstinence Long Acting Contraceptives Clinical Pathway of Family Planning Services Screening Women for Chlamydia: Current Recommendations Most clients come to Title X sites for one or more of these services Determine the need for services Assess reason for visit Assess reproductive life plan Assess other sources of primary care Contraceptive Pregnancy Achieving Services testing Pregnancy Basic infertility services Recommendations by CDC, United States Preventive Services Task Force (USPSTF), medical associations Screen all sexually-active females aged <25 years annually Screen women aged 25 years if at increased risk USPSTF: A-rated recommended preventive service Title X clients should also be provided these services, regardless of the reason for clinic visit STD services Preconception health services Clients without another source of primary care should be provided or referred for these services Related preventive health services What STD Clinical Preventive Services should be provided? Sexual Health Assessment to guide management and counseling STI Screening STD Treatment STI vaccination- HPV and Hepatitis A & B Partner Treatment and Management Chlamydia Screening Coverage Trends Among Sexually- Active Women,* by Age and Plan, HEDIS, Percentage Medicaid (21-24 yos) Medicaid (16-2 yos) *Among women enrolled in commercial or Medicaid plans who had a visit where they were determined to be sexually active SOURCE: The State of Healthcare Quality, 212 2

3 Number of Female Family Planning Users Aged <25 years Tested for Chlamydia and Percent Tested, Title X Family Planning, ,6, 1,4, 1,2, 1,, 8, 6, 4, 2, *percent change during # of tests % tested 12.1% 3.5% Screening men No documented substantial secondary prevention Costly What About Men? Highest risk: Partners of chlamydia-infected females SOURCE: Family Planning Annual Report 212, Exhibit A 9a. Provider and Health System Level Issues that Limit Access to Chlamydia Screening Evolving Landscape of EPT: Legal Status Summary Provider knowledge and attitudes Lack of information about disease rates in their community Belief that their patients are not at risk Cannot offer confidential services to adolescents Believe chlamydia is not an urgent medical condition Limited time AK WA MT OR ID WY NV UT CO CA AZ NM HI WA MT ND Other Factors Confidentiality and EOBs Insurance coverage/adequate reimbursement High co-pays and deductibles AK OR ID NV UT CA AZ HI VT ND MN SD WI NY MI IA PA NE OH IL IN WV VA KS MO KY NC TN OK A SC R MS AL GA TX LA FL WY CO NM SD IA NE KS OK TX VT MN WI NY MI OH IL IN WV MO KY TN A R MS AL GA LA FL ME NH MA RI CT NJ DE MD DC 26 EPT is Permissible EPT is Likely Prohibited EPT is Potentially Allowable ME PA VA NC SC NH MA RI CT NJ DE MD 214 (Baltimore only) DC Chlamydia and Gonorrhea Prevalence Monitoring Toolkit Supports STD and FP clinic administrators and managers in monitoring and evaluating CT/GC screening efforts Introduces key indicators for assessing screening efforts Explains how each indicator is useful and how to calculate it Provides examples of each indicator NEW DIRECTIONS IN STD TREATMENT AND MANAGEMENT 3

4 STD Treatment Guidelines Evidence-based Approach STD Prevention Opportunities with EHR and MU Enlistment of Subject Matter Expert Key Questions Systematic Review of Evidence Guidelines 3 day Meeting April 213 Answer the Key Questions Rate the quality of the evidence Identify critical gaps in knowledge (research agenda) Electronic case-base reporting Monitoring adverse outcomes (eg PID, ectopic pregnancy, infertility, neurosyphilis) Prevention through point-of-care STD clinical decision support Electronic adoption (computable) of STD clinical guidelines Background papers; Tables of evidence 214 Guidelines CDC STD Treatment Guidelines Authoritative, evidence-based source for STD clinical management Recommended regimens preferred over alternative regimens Alphabetized unless there is a priority of choice Available at Wall charts, pocket guides, ebook Webinars, podcasts STD Treatment Mobile App for Apple devices (iphone & ipads) and Droid devices (phones & tablets). Currently under revision for release in 214 Chlamydia Treatment: Areas of Clinical Uncertainty Effectiveness of azithromycin < doxycycline in anorectal infection (Hathorn, Steedman) Doxycycline delayed-release 2mg tablet daily of 7 days Equally efficacious to generic doxycycline 1mg BID x 7 days Less GI side effect Consider as an alternative regimen but costly Concerns over amoxicillin use in pregnancy due to chlamydia persistence in vitro Use only as an alternative regimen STD Treatment Mobile app Chlamydia Reminders Main Menu Condition Quick Pick Treatment Information Screen young females Self collected vaginal swabs for NAATs EPT as permissible by law Retest 3 months after treatment 4

5 GC Treatment: Areas of Clinical Uncertainty Higher ceftriaxone and/or azithromycin doses recommended outside U.S. (UK, Japan, etc.) although no data to support increasing doses Ceftriaxone in vitro susceptibility and clinical efficacy data in U.S. stable Ceftriaxone and cefixime Rx failures rare, all outside U.S. Azithromycin 1g effectiveness meets lower CI >95% threshold Azithromycin resistance remains low, but can develop quickly Pelvic Inflammatory Disease Both inpatient and outpatient approaches showed similar short and long-term outcomes Regimens should be effective against GC and Ct quinolones not recommended Using metronidazole to treat anaerobes and BV should be individualized Consider client acceptance, availability, cost, antimicrobial susceptibility Can treat with IUD in place CDC Treatment Recommendations for Gonococcal Infections (proposed) Ceftriaxone 25 mg IM x 1 PLUS Azithromycin 1 g po x 1 Doxycycline 1 mg po BID x 7 days Alternatives If ceftriaxone not available or for expedited partner therapy (EPT): Cefixime 4 mg po x 1 PLUS Azithromycin 1 g po x 1 If cephalosporin allergy: Gentamicin (24mg IM or 5 mg/kg IM) /azithro 2 g po or Gemifloxacin 32 mg po /azithro 2 g po Azithromycin 2 g po x 1 TOC if alternative regimen used for pharyngeal GC at ~14 days with NAAT Syphilis: Areas of Clinical Uncertainty Serologic response after treatment 17-21% with early syphilis with not achieve a fourfold decline in nontrep titer at 6 months Role of reverse screening algorithm Neurosyphilis definition 29 Cervicitis Algorithm for reverse sequence syphilis screening EIA or CIA Evaluation Ct/GC NAAT, Tv, BV Persistent cervicitis Mycoplasma genitalium EIA/CIA+ EIA/CIA- If incubating or primary syphilis is suspected, treat with benzathine penicillin G 2.4 million units IM x 1 and/or repeat in 1-2 weeks If <25 yr, empiric therapy for Ct/GC Quantitative RPR If >25 yr, risk assessment and patient availability determine empiric tx Evaluate clinically, determine if treated for syphilis in the past, assess risk of infection, and administer therapy according to CDC s STD Treatment Guidelines if not previously treated RPR+ Syphilis (past or present) TP-PA+ Syphilis (past or present) TP-PA RPR- TP-PA- Syphilis unlikely If at risk for syphilis, repeat RPR in 2 to 4 weeks MMWR / February 11, 211 / Vol. 6 / No. 5 5

6 High EIA/CIA Index Values May Predict TP- PA Positivity (n=255) N=79 individuals with CIA index value >12.; 1% were TP-PA positive T. vaginalis Infection Management (proposed) Highly sensitive tests (e.g., NAATs) are encouraged for diagnostic testing of individuals with symptoms of trichomoniasis Retesting 3 months after TV treatment is recommended for women NAATS may be done 2 weeks after treatment T. vaginalis infection areas of clinical uncertainty Asymptomatic screening of non HIV-infected pregnant women, individuals receiving care at high-prevalence settings (e.g., correctional facilities, STD clinics), or individuals at high risk for infection Management of nitroimidazole-resistant TV Park IU et al. JID 211 Herpes Anogenital HSV 1 is increasing but serologic tests do not distinguish anogenital from orolabial Serologic screening in general population not recommended Recurrent/atypical genital sx with negative HSV cultures T vaginalis and HIV infection in Women TV is an independent risk factor for HIV acquisition TV increases probability of acquiring HIV OR 2.6 (CI: ) Hughes, 212 TV-infected women more likely to test positive for HIV HR 2.1 (CI:1.1 4.) Mavedzenge, 21 TV infection associated with incident HIV in women OR 2.7 (CI:1.3 6.) Van der Pol, 28 Partner with genital herpes Client requests test for genital herpes Maternal TV is a risk factor for HIV vertical transmission Maternal TV increases HIV vertical transmission risk RR 1.7 (CI:1. 2.9) Gumbo, 21 Famciclovir out of alphabetical order Individualize use of episodic or suppressive antiviral therapy Treating TV reduces genital HIV shedding Women treated for TV less likely to shed HIV vaginally RR.3 (CI:.1.9) Kissinger, 29 Genital viral load decreases.5 (log 1) after TV treatment P<.1 Anderson, 212 HPV Infection Management (proposed) HPV Vaccine recommendations updated ACIP recommendation for routine vaccination of males at age with quadrivalent vaccine and catch up to 21 years ACIP recommendation for vaccination through age 26 years for MSM and HIV-infected with quadrivalent vaccine Podophyllin resin 1-25% moved to alternative therapy for genital warts Case reports of adverse effects with misuse Case reports of inflammatory responses to imiquimod In a small number of case reports, might have been associated with worsened inflammatory or autoimmune skin disease such as psoriasis, vitiligo, and lichenoid dermatoses Additional formulation of imiquimod 3.75 % cream applied daily Management of TV with HIV co-infection (proposed) HIV-infected women should receive periodic screening for TV including at entry to care and annually HIV-infected, pregnant women should be screened for TV,? at mid-gestation HIV-infected women diagnosed with TV should receive metronidazole 5mg BID for 7 days to improve cure rates HIV-infected women with TV randomized to 7 days of metronidazole 5mg BID (vs. 2g once) had less TV at TOC and at 3 months RR.46, CI: (Kissinger, 21) 6

7 Bacterial Vaginosis STD Treatment Key Issues Not recommended Single dose metronidazole 2g due to lower efficacy Recurrent BV twice weekly metronidazole gel reduced the frequency BV in pregnancy treat if symptoms, insufficient evidence to screen Prophylaxis before surgery screen and treat Gonorrhea: Chlamydia: Trichomonas: HPV: Two drugs Screen/retest in 3 months if positive Azithromycin in pregnancy Expanded diagnosis options Screen women with HIV Encourage HPV vaccine Proposed New Sections Transgender men and women Emerging Issues Role of Mycoplasma genitalium Good evidence for role in urethritis; may play role in PID; No commercially-available test for M. genitalium Treatment concerns- resistance to doxycycline > azithromycin Sexual transmission of HCV HIV-infected infected individuals especially MSM HIV infected individuals should be tested at initial evaluation and at least annually and more frequently depending on local circumstances What to Say to Clients Get tested to know your infection status Talk to your partner and know your partner s infection status If infected, treat curable infections If unknown or incurable, use condoms consistently and correctly 213 STD Treatment Guidelines Consultants Meeting Participants Track I Ward Cates/KKH - Moderator Jeanne Marrazzo-Rapporteur Susan Cu-Uvin Eileen Dunne Carolyn Gardella Linda Gorgos Lisa Hollier Patty Kissinger Elissa Mietes Paul Nyirjesy Ina Park Susan Phillip Mona Sariaya Jane Schwebke Jack Sobel David Soper Rick Sweet Harold Weisenfeld Track II Ned Hook- Moderator Anne Rompalo- Rapporteur D Jana Akinyemi John Brooks Virginia Caine Stephanie Cohen Khalil Ghanem Scott Holmberg Peter Leone Henry Makadon Ken Mayer Leandro Mena Pablo Sanchez Brad Stoner Anna Wald George Wendel Track III David Martin - Moderator Will Geisler Rapporteur Laura Bachmann Gale Burstein Jordan Dimitrakoff Dennis Fortenberry Matt Golden Sarah Guerry Maggie Hammerschlag Hunter Handsfield Kathy Hsu Sara Kidd Lisa Manhart Kees Reitmeyer Arlene Sena Stephanie Taylor Jon Zenilman 39 For more information please contact Centers for Disease Control and Prevention 16 Clifton Road NE, Atlanta, GA 3333 Telephone, 1-8-CDC-INFO ( )/TTY: cdcinfo@cdc.gov Web: Thank you Questions? gyb2@cdc.gov The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. National Center for HIV/AIDS, Viral Hepatitis, STD & TB Prevention Division of STD Prevention Looking Forward 7