STI Prevention and Screening Molly McHenry Fenway Health May 2016
Presentation Overview CDC Surveillance data Risk Assessment Special Populations and Barriers to Care STI Prevention STI Screening Treatment Resources 2
Surveillance Data
Chlamydia Rates of Reported Cases by Region, United States, 2005 2014 2014-Fig 2. SR, Pg 81
Chlamydia Rates of Reported Cases by Sex, United States, 1994 2014 NOTE: As of January 2000, all 50 states and the District of Columbia have regulations that require the reporting of chlamydia cases. 2014-Fig 1. SR, Pg 8
Chlamydia Rates of Reported Cases by Race/Ethnicity and Sex, United States, 2014 *AI/AN=American Indians/Alaska Natives; NHOPI = Native Hawaiian/Other Pacific Islanders. NOTE: Includes 48 states reporting race/ethnicity data in Office of Management and Budget compliant formats in 2014 2014-Fig M. SR Pg 69
2014-Fig 31. SR, Pg 33 Syphilis Reported Cases by Stage of Infection, United States, 1941 2014
Primary and Secondary Syphilis Reported Cases by Sex and Sexual Behavior, 27 Areas*, 2007 2014 *27 states reported sex of partner data for 70% of reported cases of primary and secondary syphilis for each year during 2007 2014. MSM = men who have sex with men; MSW = men who have sex with women only. 2014-Fig 32. SR, Pg 33
Diagnosis, Rate per 100,000 CDC, 2015 Rate of Diagnosis of HIV Infection among Adults and Adolescents, by Race/Ethnicity 2010 2014 United States 80 70 60 50 40 30 20 10 0 Native Hawaiian/other Pacific Islander Black/African American Multiple Races Hispanic/Latino White American Indian/Alaska Native 2010 2011 2012 2013 2014 Asian 9
I want folks who read the report to walk away knowing that we are not in this epidemic due to our sexual proclivities. This epidemic we are facing is a direct response to systemic issues such as lack of insurance, education, employment, access to friendly and respectful treatment, and the list continues. -Daniel Driffin, co-founder of the Southeast HIV/AIDS Research and Evaluation (SHARE) Project* *Darian, A. Black gay men reject lifetime HIV risk estimate in new CDC report. Georgia Voice February 24, 2016 10
Risk Assessment
Number of partners in last 12 months Barrier use Drug and/or alcohol use with sex Consent How do you decide when to have sex? Identity vs behavior Past history of STDs Screening for violence and coercion 12
Screening for Intimate Partner Violence Intimate partner violence (IPV) is a serious, preventable public health problem that affects millions of Americans. The term "intimate partner violence" describes physical, sexual, or psychological harm by a current or former partner or spouse. This type of violence can occur among heterosexual or same-sex couples and does not require sexual intimacy. * *CDC Violence Prevention http://www.cdc.gov/violenceprevention/intimatepartnerviolence/ 13
Screen shot of our IPV screen from EMR
Sex Work Sexual Coercion and Sex Work Consensual participation in the sex trade, 18 yo Includes porn, stripping, webcam Do you ever trade sex for money? Sex Trafficking* Sex act induced by force, fraud or coercion, 18 yo Commercial sex act, <18 yo Survival Sex** Individuals over the age of 18 who have traded sex acts to meet basic needs of survival without overt force, fraud or coercion. *Victims of Trafficking and Violence Protection Act of 2000: http://www.state.gov/j/tip/laws/61124.htm **Homelessness, Survival Sex and Human Trafficking: As Experienced by the Youth of Covenant House New York https://traffickingresourcecenter.org/resources/homelessness-survival-sex-and-human-trafficking-experienced-youth-covenant-house-new-york 15
Special Populations and Barriers to Care
Mandated reporting Minors Discuss what this means with patients https://www.childwelfare.gov/pubpdfs/manda.pdf#page=2&view=profe ssionals required to report Age of consent vs age of majority https://aspe.hhs.gov/report/statutory-rape-guide-state-laws-andreporting-requirements-summary-current-state-laws Know the laws in your state about providing sexual health care and family planning to minors Prescribing PEP/PrEP to minors 17
Transgender People Individual behaviors alone do not account for the disparate HIV diagnoses among transgender people. Many transgender people face social rejection and marginalization that excludes them from participating and functioning in society. Lack of legal recognition of gender identity can result in the denial of educational, employment, and housing opportunities. Some transgender people who experience poverty rely on sex work to meet their basic survival needs. * However Clinicians should assess STD- and HIV-related risks for their transgender patients based on current anatomy and sexual behaviors. ** *CDC: HIV Among Transgender People http://www.cdc.gov/hiv/group/gender/transgender/ ** CDC: Special Populations http://www.cdc.gov/std/tg2015/specialpops.htm 18
Native American/Indigenous People Forced sterilization of native women by US Government 1973-1976* People of Color *National Library of Medicine: Native Voices https://www.nlm.nih.gov/nativevoices/timeline/543.html 19
Americans of African Decent "Tuskegee Study of Untreated Syphilis in the Negro Male 1932-1972* HeLa Cells 1951-present ** *US Public Health Service Syphilis Study at Tuskegee http://www.cdc.gov/tuskegee/timeline.htm **HeLa Cells: A New Chapter in an Enduring Story https://directorsblog.nih.gov/2013/08/07/helacells-a-new-chapter-in-an-enduring-story/ 20
Percentage 100 People With Disabilities PAP TEST RATES 2010 90 80 70 60 50 No Disability Movement Difficulty Iezzoni L.I. MD (2016) Make No Assumptions. Used with permission. Sensory Emotional Difficulty Difficulty Disabilities Cognitive Difficulty Self-care Limitation 21
Other Populations LGBQ People Undocumented people Fears of deportation People who are uninsured or underinsured Currently or formerly incarcerated people Kink community Consensual play and safety 22
Prevention
Condoms Protective Barriers Greater protection against fluid based transmission vs skin-to-skin Correct use Condom use demonstrations in the clinical setting Discussing barriers to use Lube How do you decide when to use a condom? Other barriers Female condom Dental dam Gloves 24
Other Prevention Measures 9vHPV vaccinations* PEP/PREP (ECHO training in fall) HIV Treatment as Prevention** Expedited Partner Therapy Cleaning and sterilizing toys Behavioral health referral Contraception Abstinence and monogamy *Use of 9-Valent Human Papillomavirus (HPV) Vaccine: Updated HPV Vaccination Recommendations of the Advisory Committee on Immunization Practices http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6411a3.htm **CDC: HIV Treatment as Prevention http://www.cdc.gov/hiv/risk/art/ 25
Community and Local Resources Anonymous and/or free screening Local DPH STD clinics National Network of STD Clinical Prevention Training Centers http://nnptc.org/training-centers/ 26
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Screening
When to screen CDC recommendations very depending on* age sex (assigned at birth) HIV status Pregnancy Specific to MSM I offer STI screening With every new patient intake With every physical With every contraceptive counseling visit *CDC Screening Recommendations http://www.cdc.gov/std/tg2015/screening-recommendations.htm 29
HIV Screening Opt-Out as of 2006* Testing should be routine unless patient refuses Pre and post counseling no longer required 4th Generation Ag/Ab Testing Rapid vs Serum Communication of results In person vs phone or email CDC recommends screening:** At least once for all people 13-64 years old All pregnant people At least annually for sexually active MSM *AIDS.gov Opt-Out Testing https://www.aids.gov/hiv-aidsbasics/prevention/hiv-testing/opt-out-testing/ **CDC 2015 STD Treatment Guidelines http://www.cdc.gov/std/tg2015/screeningrecommendations.htm 30
Gonorrhea and Chlamydia Location dictated by type of sex reported Oral First Catch Urine (FCU) Vaginal/cervical Rectal Self Swab option for vaginal and rectal NAAT testing preferred Vaginal swab > FCU?* CDC recommends screening:** Sexually active women under 25 MSM at least annually At least annually for people who are HIV+ Increased screening with increased risk *Falk L. Sampling for Chlamydia trachomatis infection - a comparison of vaginal, first-catch urine, combined vaginal and first-catch urine and endocervical sampling. Int J STD AIDS. 2010 Apr;21(4):283-7. doi: 10.1258/ijsa.2009.009440. **CDC 2015 STD Treatment Guidelines http://www.cdc.gov/std/tg2015/screening-recommendations.htm 31
Two step serum blood test* Cannot be cultured in vitro Syphilis Nontreponemal test with reflex to treponemal test DPH as a resource for reactive screens CDC Recommends Screening:** All pregnant people At least annually for sexually active MSM At lest annually for people who are HIV+ *CDC 2015 STD Treatment Guidelines http://www.cdc.gov/std/tg2015/syphilis.htm **CDC 2015 STD Treatment Guidelines http://www.cdc.gov/std/tg2015/screening-recommendations.htm 32
Wet Prep vs BD Affirm CDC Recommendations:* Trichomoniasis Consider for women receiving care in high-prevalence settings (e.g., STD clinics and correctional facilities) and for women at high risk for infection (e.g., women with multiple sex partners, exchanging sex for payment, illicit drug use, and a history of STD) At least annually for sexually active women who are HIV+ *CDC 2015 STD Treatment Guidelines http://www.cdc.gov/std/tg2015/screening-recommendations.htm 33
Hepatitis Hep C Not efficiently transmitted sexually CDC recommends screening:* All people born between 1945-1965 Other people at increased risk Annually if HIV+ Hep B CDC recommends screening:* All pregnant people Women at increased risk All MSM for HBsAg If HIV+ check HBsAg and anti- HBc and/or anti-hbs *CDC 2015 STD Treatment Guidelines http://www.cdc.gov/std/tg2015/screening-recommendations.htm 34
Culture vs Ab screening Presentation varies WIDELY Rash/sores Rectal pain Dysuria Asymptomatic HSV infection Viral shedding on 10% of days* The Herpes Handbook http://www.herpeshandbook.org/ HSV CDC recommends that serum HSV screening should be considered in various populations. I do not routinely screen in asymptomatic patients *Genital Herpes CDC Fact Sheet: http://www.cdc.gov/std/herpes/stdfact-herpes-detailed.htm 35
Genital Herpes Initial Visits to Physicians Offices, United States, 1966 2013 NOTE: The relative standard errors for genital herpes estimates of more than 100,000 range from 19% to 23%. SOURCE: National Disease and Therapeutic Index, IMS Health, Integrated Promotional Services. IMS Health Report, 1966 2013. The 2014 data were not obtained in time to include them in this report. 2014-Fig 53. SR Pg 48
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