Control Efforts for Trichomoniasis in STD Clinics

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1 Control Efforts for Trichomoniasis in STD Clinics Christina Muzny, MD, MSPH Associate Professor of Medicine, Division of Infectious Diseases University of Alabama at Birmingham Last Updated: 3/22/18 uwptc.org

2 Disclosures K23AI (NIH/NIAID) BV pathogenesis study R01AI (NIH/NIAID) Trichomonas vaginalis treatment trial in HIV-negative women

3 Epidemiology of T. vaginalis in U.S. Women and Men, NHANES Prevalence among U.S. women (1.8%) and men (0.5%) ages (urine specimens were testing using the Gen-Probe Aptima T. vaginalis NAAT [Hologic]) T. vaginalis prevalence was associated with female sex, black race, older age, having less than a high school education, being below the poverty level, and having 2 sexual partners in the past year T. vaginalis prevalence in this study exceeds estimates of T. vaginalis burden in other highincome countries 2 1 Clin Infect Dis 2018 Mar 15. E-pub ahead of print; 2 Sex Transm Infect 2016, doi: /sextrans

4 Complications Associated with T. vaginalis Infection Associated with HSV-2 acquisition 1 and increased risk of cervical neoplasia 2 Increased risk of post-hysterectomy infection 3 Associated with pelvic inflammatory disease 4 Associated with preterm birth 5 Associated with increased risk of HIV 6 1 J Infect Dis 2007;196:1692-7; 2 Int J Epidemiol 1994;23:682-90; 3 Am J Obst Gynecol 1990;163: ; 4 Am J Obstet Gynecol 2011;205:324,e1-7; 5 Sex Transm Dis 1997;24: ; 6 J Infect Dis 2007;195:

5 T. vaginalis is a Neglected STI There are no established T. vaginalis screening, surveillance, or control programs for women or men in the U.S. Routine screening is only recommended in HIV-infected women, at entry to care and then annually Screening might be considered for persons in high prevalence settings (STI clinics, correctional facilities) and among asymptomatic persons at high risk (multiple sex partners, exchange of sex for money or drugs, illicit drug use, STI history) 2015 CDC STD Treatment Guidelines

6 Poll #4: Does your STD clinic systematically screen all patients for T. vaginalis? A) Yes B) No

7 Poll #5: Does your STD clinic use a NAAT to diagnose T. vaginalis? A) Yes B) No

8 Epidemiology of T. vaginalis at the Jefferson County Health Department STD Clinic In 2012, all patients presenting to the JCDH STD clinic started to be screened for T. vaginalis using the Gen-Probe T. vaginalis NAAT (Hologic) We reviewed the clinical and laboratory data of men (n=2,514) and women (n=3,821) receiving a T. vaginalis NAATat this clinic between Overall T. vaginalis prevalence: 20.2%; 27.0% in women and 9.8% in men Correlates of T. vaginalis in women: age >40, African American race, leukorrhea on wet mount, elevated vaginal ph, positive whiff test, co-infection with gonorrhea Correlates of T. vaginalis in men: age >40, African American race, 5 PMNs/HPF on urethral Gram stain T. vaginlais NAAT detected 1/3 more infections in women than wet mount alone Clin Infect Dis 2014;59:834 41

9 Lack of National Surveillance for T. vaginalis T. vaginalis said to meet only 3* out of 7 criteria: - Frequency * - Associated disparities or inequities * - Communicability * - Severity adverse outcomes said to be uncommon among mainly asymptomatic patients, although this has not been studied in detail - Associated costs minimal data available - Preventability it is unclear whether a national control program would reduce T. vaginalis prevalence, given ongoing challenges in chlamydia screening programs - Public Interest a lack of public interest may reflect a lack of public knowledge? Sex Transm Dis 2013;40:113 6

10 There are no national control programs beyond clinical management of T. vaginalis-infected patients and their partners Both patient and partner must be treated to prevent re-infection Female cure rates increase 20% when male partners are treated 1 CDC recommends partner referral for T. vaginalis treatment 2 Expedited partner therapy (EPT) might have a role in partner management of T. vaginalis 2 - A RCT by Kissinger failed to find lower repeat T. vaginalis infection rates for the EPT arm compared to 2 partner-referral arms, however EPT might be cost-saving 3 - A second RCT by Schwebke found lower repeat T. vaginalis infection rates among women in the EPT arm compared to partner referral and contact tracing arms 4 1 Acta Obstet Gynecol Scand 1981;60: ; CDC STD Treatment Guidelines; 3 Sex Transm Dis 2006; 33:445 50; 4 Sex Transm Dis 2010;37:392 6

11 Successful STI Control Measures Use of sensitive screening tests - T. vaginalis NAATs are available Availability of effective, affordable, single-dose medications MTZ treatment of T. vaginalis is the most affordable treatment for any STI Accurate reporting of cases not available for T. vaginalis Initiation of mandatory reporting to the CDC not done for T. vaginalis Treatment of infected partners EPT permissible in many but not all states and has mainly been used for treatment of male partners of women with chlamydia or gonorrhea J Infect Dis 2005;192:2036 8

12 Poll #6: Should EPT for T. vaginalis-infected patients be recommended at STD clinics? A) Yes B) No

13 Poll #7: Does your STD clinic offer EPT for women infected with T. vaginalis? A) Yes B) No

14 Legal Status of Expedited Partner Therapy (EPT)

15 Next Steps What can we, as STD clinic providers, do to improve control efforts for T. vaginalis?

16 THANK YOU! Questions/Comments?