As you study the slide what patterns do you notice? What surprises you?

Transcription

1 Why do we need statistics? Statistics govern research most certainly, but for us clinicians in the trenches, statistics tell us what is increasing and what is decreasing in the real world. HIV infections were decreasing for a time but the numbers are increasing again. Why? Tuberculosis numbers increased when HIV was increasing. Why? What is the most common bacterial infection? What is the least prevalent/least common bacterial infection at this time? Are women impacted differently from men? Are certain cultural groups impacted more than others? The series of slides that make up this Module contain data collected by the Centers for Disease Control (CDC), which is charged with monitoring infections and epidemics and pandemics. As you study the slide what patterns do you notice? What surprises you? 1

2 STDs STIs = sexually transmitted diseases (AIDS is an STD) = sexually transmitted infections (HIV is an STI) The risk of transmission of an STI/STD is possible with only 1 contact with another person s bodily fluids, or skin-to-skin contact. Vulvovaginal health relates to the health of the human female s vulva and vagina. Candidiasis is a yeast infection that also can lead to thrush. Yeast is present on all persons, and an overgrowth causes a yeast or thrush infection. 75% of all women are likely to have a yeast infection at some point in life time (CDC) 1 in 4 women have an STD/STI at any given time in the United States. (CDC) 2

3 University of Edinburgh (2011, January 18). Link between chlamydia and ectopic pregnancy explained. ScienceDaily. Retrieved January 27, 2011, from /releases/2011/01/ htm: A new study provides evidence for the first time of how chlamydia can increase the risk of an ectopic pregnancy. In an ectopic pregnancy the embryo implants outside the womb, generally in the fallopian tube. University researchers found that women who had sexually transmitted infections were more likely to produce a particular protein in their fallopian tubes. Increased production of this protein -- known as PROKR2 -- makes a pregnancy more likely to implant in the fallopian tube. The study, funded by the Wellbeing of Women and the Medical Research Council, is published in the American Journal of Pathology. It follows on from University research, which showed that production of a similar protein increased the likelihood of smokers having an ectopic pregnancy. Chlamydia is the most common sexually transmitted infection in the UK and the United States. It can be treated but often goes undiagnosed because it can occur without symptoms. The infection is known to cause infertility as it can lead to scarring and blockages in the fallopian tube. This research shows, however, that chlamydial infection linked to ectopic pregnancy causes much more subtle changes in the fallopian tube, without evidence of severe scarring. 3

4 A new study from the Indiana University School of Medicine and the Regenstrief Institute has found that Black and especially Hispanic young women are screened for chlamydia at a significantly higher rate than young white women. This discrepancy in screening rates may contribute to nationwide reporting of higher rates of this sexually transmitted disease among minority young women. The research, which used data from more than 40,000 visits to health care facilities, appears in the February issue of the journal Pediatrics, published online ahead of print on Jan. 24. Despite a recommendation from the U.S. Preventive Services Task Force to annually screen all sexually active young women for this disease, only about half of sexually active women, ages 14 to 25, who receive health care, are screened appropriately. The IU and Regenstrief researchers found that black young women were 2.7 times more likely and Hispanic young women 9.7 times more likely to be screened for chlamydia, compared with white young women. In addition to race or ethnicity, the researchers found screening likelihood varied by insurance status and also by age. Women with public insurance had greater odds of chlamydia testing, compared with women with private insurance. "For some common conditions like breast cancer, white women are more likely to receive a screening test like mammography. For chlamydia infections -- which are highly stigmatized STDs -- white women are less likely, while minority women are more likely, to receive screening. This may mean that providers make judgments about a woman's likelihood of infection based on her race or ethnicity. Yet in an asymptomatic condition like chlamydia, all sexually active young women should be screened," said study first author Sarah E. Wiehe, M.D., M.P.H., assistant professor of pediatrics at the IU School of Medicine and a Regenstrief Institute affiliated scientist. A medical history of STDs was more important than race or ethnicity or insurance status in terms of differences in chlamydia screening. Young women who had a previous STD were more likely to be screened for chlamydia, no matter their race or ethnicity, and differences by race or ethnicity in testing decreased substantially in this subgroup. The same was not true for young women who had been pregnant in the past. After a pregnancy, young minority women were much more likely (24 times for Hispanic women and 4 times for black women) to be screened than young white women. "Even when we accounted for provider-level differences in testing patterns, the bias to screen black and Hispanic young women persisted. We must encourage pediatricians, internists, family medicine physicians and gynecologists to screen all sexually active young women under their care. Chlamydia is a serious and usually asymptomatic disease that may have serious health repercussions," said Dr. Wiehe, a pediatrician and health services researcher. Source: Indiana University School of Medicine (2011, January 24). Young minority women screened at higher rate for chlamydia than young white women. ScienceDaily. Retrieved January 27, 2011, from /releases/2011/01/ htm 4

5 Anyone who is sexually active can get gonorrhea. If gonorrhea is present, it is caused by Neisseria gonorrhea bacterium. Gonorrhea grows and multiplies in warm, moist places, like the reproductive tract (cervix, uterus, fallopian tubes) and the urethra. The bacterium also grows in the mouth, throat, eyes and anus. The CDC estimates that more than 700,000 persons in the US get new gonorrhea infections every year these are the ones that are reported. A sidekick bacterial STI that occurs frequently with Gonorrhea is Chlamydia. 5

6 Any sexually active person can be infected with gonorrhea. In the US, the highest reporting rates of infection are among sexually active teenagers, young adults and African Americans and Hispanics. In women, gonorrhea is a common cause of pelvic inflammatory diseases (PID). About one million women each year in the United States develop PID. The symptoms may be quite mild or can be very severe and can include abdominal pain and fever. PID can lead to internal abscesses (pus-filled pockets that are hard to cure) and long-lasting, chronic pelvic pain. PID can damage the fallopian tubes enough to cause infertility or increase the risk of ectopic pregnancy. Ectopic pregnancy is a life-threatening condition in which a fertilized egg grows outside the uterus, usually in a fallopian tube. Source: 6

7 CDC: How common is syphilis? In the United States, health officials reported over 36,000 cases of syphilis in 2006, including 9,756 cases of primary and secondary (P&S) syphilis. In 2006, half of all P&S syphilis cases were reported from 20 counties and 2 cities; and most P&S syphilis cases occurred in persons 20 to 39 years of age. The incidence of P&S syphilis was highest in women 20 to 24 years of age and in men 35 to 39 years of age. Reported cases of congenital syphilis in newborns increased from 2005 to 2006, with 339 new cases reported in 2005 compared to 349 cases in Between 2005 and 2006, the number of reported P&S syphilis cases increased 11.8 percent. P&S rates have increased in males each year between 2000 and 2006 from 2.6 to 5.7 and among females between 2004 and In 2006, 64% of the reported P&S syphilis cases were among men who have sex with men (MSM). Syphilis is passed from person to person through direct contact with a syphilis sore. Sores occur mainly on the external genitals, vagina, anus, or in the rectum. Sores also can occur on the lips and in the mouth. Transmission of the organism occurs during vaginal, anal, or oral sex. Pregnant women with the disease can pass it to the babies they are carrying. Syphilis cannot be spread through contact with toilet seats, doorknobs, swimming pools, hot tubs, bathtubs, shared clothing, or eating utensils. 7

8 CDC: How does syphilis affect a pregnant woman and her baby? The syphilis bacterium can infect the baby of a woman during her pregnancy. Depending on how long a pregnant woman has been infected, she may have a high risk of having a stillbirth (a baby born dead) or of giving birth to a baby who dies shortly after birth. An infected baby may be born without signs or symptoms of disease. However, if not treated immediately, the baby may develop serious problems within a few weeks. Untreated babies may become developmentally delayed, have seizures, or die. Source: 8

9 CDC: PID can lead to serious consequences including infertility. PID occurs when certain bacteria, such as chlamydia or gonorrhea, move upward from a woman's vagina or cervix (opening to the uterus) into her reproductive organs. Women can protect themselves from PID by taking action to prevent STDs or by getting early treatment if they have any genital symptoms such as vaginal discharge, burning during urination, abdominal or pelvic pain, pain during sexual intercourse, or bleeding between menstrual cycles. Prompt and appropriate treatment of PID can help prevent complications, including permanent damage to female reproductive organs. Source: 9

10 CDC: What is PID? Pelvic inflammatory disease (PID) refers to infection of the uterus (womb), fallopian tubes (tubes that carry eggs from the ovaries to the uterus) and other reproductive organs that causes symptoms such as lower abdominal pain. It is a serious complication of some sexually transmitted diseases (STDs), especially chlamydia and gonorrhea. PID can damage the fallopian tubes and tissues in and near the uterus and ovaries. PID can lead to serious consequences, including infertility, ectopic pregnancy (a pregnancy in the fallopian tube or elsewhere outside of the womb), abscess formation, and chronic pelvic pain. CDC: How common is PID? Each year in the United States, it is estimated that more than 750,000 women experience an episode of acute PID. More than 75,000 women may become infertile each year as a result of PID, and a large proportion of the ectopic pregnancies occurring every year are due to the consequences of PID. Source: 10

11 Ectopic pregnancy presents a major health problem for women of childbearing age. It is the result of a flaw in the human reproductive physiology that allows the egg to implant and mature outside the endometrial cavity, which ultimately ends in death of the fetus. Without timely diagnosis and treatment, ectopic pregnancy can become a life-threatening situation. Ectopic pregnancy currently is the leading cause of pregnancy-related death during the first trimester in the United States, accounting for 9% of all pregnancy-related deaths. In addition to the immediate morbidity caused by ectopic pregnancy, the woman's future ability to reproduce may be adversely affected as well. Ectopic pregnancy was first described in the 11th century, and, until the middle of the 18th century, it was usually fatal. John Bard reported the first successful surgical intervention to treat an ectopic pregnancy in New York City in The survival rate in the early 19th century was dismal. One report demonstrated only 5 patients of 30 surviving the abdominal operation. Interestingly, the survival rate in patients who were left untreated was 1 of 3. Source: 11

12 During the transition from childhood to adulthood, adolescents establish patterns of behavior and make lifestyle choices that affect both their current and future health. Adolescents and young adults are adversely affected by serious health and safety issues such as motor vehicle crashes, violence, substance use, and sexual behavior. They also struggle to adapt behaviors that could decrease their risk of developing chronic diseases in adulthood behaviors such as eating nutritiously, engaging in physical activity, and choosing not to use tobacco. Environmental factors such as family, peer group, school, and community characteristics also contribute to the challenges that adolescents face. Source: Copy this link into your internet browser: This link will take you to the Colorado High School Youth Risk Behavior Survey, The risk behaviors can be identified for several column variables, including sex, race and grade. You change the column variable and then hit go button. 12

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26 Gay and bisexual men and other men who have sex with men (MSM) represent an incredibly diverse community. Gay and bisexual men have both shared and unique experiences and circumstances that affect their physical health and mental health needs as well as their ability to receive high-quality health services. Sexually Transmitted Diseases (STDs) have been increasing among gay and bisexual men. Recent increases in syphilis cases have been documented across the country. In 2008, men who have sex with men (MSM) accounted for 63% of primary and secondary syphilis cases in the United States. MSM often are diagnosed with other bacterial STDs, including chlamydia and gonorrhea infections. Gay and bisexual men can be infected with HPV (Human Papillomavirus), the most common STD in the United States. Some types of HPV cause genital and anal warts and some can lead to the development of anal and oral cancer. Men who have sex with men are 17 times more likely to develop anal cancer than heterosexual men. Men who are HIV-positive are even more likely than those who are uninfected to develop anal cancer. Gonorrhea and chlamydia are sexually transmitted by genital secretions, such as urethral secretions from the penis. Genital herpes and syphilis are transmitted primarily through skin-to-skin contact with sores/ulcers or infected skin that looks normal. HPV is transmitted through contact with infected genital skin or mucosal surfaces/secretions, such as the penis and anus. 26

27 Effects on Education and Health Verbal and physical harassment experienced by LGBT youth has negative effects on their education and on their health. In 2009, almost 1 in 3 LGBT middle and high school students responding to an online survey reported that they had missed at least one day of school in the past month because they were concerned about their safety [2]. LGBT youth who experience more frequent harassment perform lower in school by almost half a grade point compared to their non-lgbt peers who experience less frequent or no harassment (gradepoint average of 2.7 for frequently harassed students versus 3.1 for other students) [2]. Such victimization, in turn, is also associated with risky behaviors. One study found that gay males who had been threatened or bullied at school were more likely than those who had not been threatened or bullied to have Been diagnosed with an STD Injected drugs Had more than four sex partners Not used a condom the last time they had sex [4] The stresses experienced by LGBT youth and those who are questioning their sexual orientation, or LGBTQ also put them at greater risk for mental health problems, substance use, suicide, and other health problems [1]. Of particular concern is the increased risk for suicide. A nationally representative study of adolescents in grades 7 through 12 found that lesbian, gay and bisexual youth were more than twice as likely to have attempted suicide than their heterosexual peers [5]. Source: 27

28 Gay, bisexual, and other men who have sex with men (MSM) 1 represent approximately 2% of the US population, yet are the population most severely affected by HIV and are the only risk group in which new HIV infections have been increasing steadily since the early 1990s. In 2006, MSM accounted for more than half (53%) of all new HIV infections in the United States, and MSM with a history of injection drug use (MSM-IDU) accounted for an additional 4% of new infections. At the end of 2006, more than half (53%) of all people living with HIV in the United States were MSM or MSM-IDU. Since the beginning of the US epidemic, MSM have consistently represented the largest percentage of persons diagnosed with AIDS and persons with an AIDS diagnosis who have died. New HIV Infections 2 In 2006, more than 30,000 MSM and MSM-IDU were newly infected with HIV. Among all MSM, whites accounted for nearly half (46%) of new HIV infections in The largest number of new infections among white MSM occurred in those aged years, followed by those aged years. Among all black MSM, there were more new HIV infections (52%) among young black MSM (aged years) than any other racial or ethnic age group of MSM in The number of new infections among young black MSM was nearly twice that of young white MSM and more than twice that of young Hispanic/Latino MSM. Among all Hispanic/Latino MSM in 2006, the largest number of new infections (43%) occurred in the youngest age group (13 29 years), though a substantial number of new HIV infections (35%) were among those aged years. Source: 28

29 HIV and AIDS Diagnoses 3 and Deaths A recent CDC study found that in 2008 one in five (19%) MSM in 21 major US cities were infected with HIV, and nearly half (44%) were unaware of their infection. In this study, 28% of black MSM were HIV-infected, compared to 18% of Hispanic/Latino MSM and 16% of white MSM. Other racial/ethnic groups of MSM also have high numbers of HIV infections, including American Indian/Alaska Native MSM (20%) and Native Hawaiian/Pacific Islander MSM (18%). In 2007, MSM were 44 to 86 times as likely to be diagnosed with HIV compared with other men, and 40 to 77 times as likely as women. From , estimated diagnoses of HIV infection increased approximately 17% among MSM. This increase was likely due to a combination of factors: increases in new infections, increased testing, and diagnosis earlier in the course of infection; it may also have been due to uncertainty in statistical models. In 2008, an estimated 17,940 MSM were diagnosed with AIDS in the 50 states, the District of Columbia, and the US dependent areas an increase of 6% since By the end of 2007, an estimated 282,542 MSM with an AIDS diagnosis had died in the United States and 5 dependent areas. Source: 29

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36 There is a difference between screening and assessment. Screening determines if an individual is a good fit for the treatment agency. Once it is determined that the agency can meet the needs of the client, an in-depth assessment is necessary for treatment planning and coordination of care. As you consider what kind of information is necessary before determining psychoeducation around health and sexual behaviors, the following are important areas to assess: history of drug abuse what, where, for how long, how psychosocial history - family of origin, family of choice sexual history history with system legal, medical, Social Services services previously accessed where, when, etc. integration of services necessary What else do you need to know to be able to assess for risky behaviors? 36

37 1. In the attachments folder, look for a document named the DBH Infectious Diseases Screening Document. I would like you to open that document and study the questions and riskassessment determination. 2. In the same Attachments folder, look for a document named the Biopsychosocial Assessment. I would like you to open that document and study the questions/format. 3. Other things to consider when treatment planning around risky behaviors and drug addiction: How did you learn about sex? Have you ever had protected sex? When? Have you ever been the victim of domestic violence? What relationship boundaries exist? and don t exist? What does client understand about different communication styles? 37

38 Reporting Requirements: In Colorado Clients have the right to refuse to be tested for infectious diseases and should not be denied treatment services based solely on that refusal, except where there is a potential public health threat to other clients or treatment staff. Treatment providers must evaluate the potential exposure risk for other clients & treatment staff, particularly for potential exposure to infectious tuberculosis. In all instances, clients should be educated about the benefits to themselves & others from proper & early diagnosis & treatment of infectious diseases. Primary physicians and other medical personnel who diagnose are the mandated reporters to the Colorado Department of Public Health and Environment, and to the county health department for all infectious diseases. Counselors are not mandated reporters for infectious diseases. Counselors do not determine the initial medical diagnosis, using blood work, etc. in most States 38

39 Clinicians need to be alert for the following as they are doing their initial intakes, assessments, treatment planning and case management: injection drug use if they have injected even 1 time, they need to be tested for HIV and Hepatitis C sexual partners of injection drug users runs a greater risk for contracting Hepatitis B or C, HIV, gonorrhea, syphilis unprotected sexual contacts raises the risk for all STIs, STDs, HIV multiple sex partners runs the risk of multiple asymptomatic STIs poor urban dwellers substandard housing: people in poverty are often neglected regarding medical services and education crowded living arrangements greater risk for tuberculosis homelessness immune system is compromised, nutrition is poor history incarceration and/or institutionalization risk for tuberculosis lower socioeconomic status lack of services, education, insurance history recurrent STDs, reactive tuberculosis more susceptible to STIs, STDs in future also looking for dermatomal Herpes infection for HIV 39

40 The mental health clinician has several roles that he or she must navigate when working with clients. This training in Infectious Diseases fall under the biology (health) component of our bio-psycho-social-spiritual-emotional delivery of services. Our treatment services differ with each client and often include the following: assessing for immediate as well as long term client risk factors providing pre- and post-test counseling support providing and following-up on client referrals conducting and supporting harm reduction education and treatment retention interventions facilitating contact tracing and partner notifications participating in staff development activities participating in and supports community-based interventions SAMHSA: TIP 6: Screening for Infectious Diseases Among Substance Abusers 40

41 Thoughts regarding risk reduction strategies: The longer the client remains in treatment, the better the client outcomes not only for substance issues but also for infectious disease containment and harm reduction. Working to prevent client s return to drug use is an important strategy for reducing the incidence of infectious diseases. Our agencies need to focus on maintenance efforts and not just on treatment. A client should be in a continuum of care that lasts a minimum of 12 months, preferably 18 months. This can include inpatient, residential, IOP, OP and groups or meetings. One area clients would like assistance with is learning how to develop competent, proactive health care system utilization skills. Clients need psycho-education from clinicians about the relationship between drug use and the transmission of infectious diseases. They need information presented in a neutral, caring, informative manner. Clients should be encouraged to consider sobriety testing versus abstinence (if they are not on paper) as an initial step towards harm reduction. 41

42 Additional thoughts regarding risk reduction strategies: Provide clients with pictures and information about various routes of transmission and possible symptoms of infection or disease. DO not use scare tactics they usually work against us instead of for us. Review with clients ways they can avoid or minimize exposure. Talk about condoms and alternatives. Demonstrate how to put on condoms. Give them resources in your area for free condoms, dental dams and female condoms. Encourage participation in a HIV/AIDS support group for HIV-positive clients. HIV is no longer considered a fatal illness and is classified as a chronic illness. Support and education are necessary to ensure a higher quality of life and to decrease HIVs progression towards AIDs. Abstinence is the only way to prevent disease transmission and is a viable option to consider. 42

43 Forum Questions: Please post your answers to the following questions and respond to the answers from two of your training-mates. 1. What statistics on the slides or the Colorado website surprised you the most? 2. What additional areas requirement assessment, in order to have an informed and realistic treatment plan? Point to ponder: You have just completed Module 1 of the Infectious Diseases training congratulations. Module 2 will be very graphic as I present slides with pictures of all of the infectious diseases we are studying, that are sexually or contact transmitted. A picture is worth a thousand words is the reason for showing you these slides and why our clients should see the slides. Do the client have sex in the dark, or when they are high? If so, this spells danger! 43