Services for GLBTQ Youth

Sexual Health Care Services for GLBTQ Youth Gale R Burstein, MD, MPH, FAAP, FSAHM Erie County Commissioner of Health Buffalo, NY Agenda Introduction Epidemiology Sexual health care services for YMSM Sexual health care services for WSW Discussion 1

Disclosures Dr. Gale Burstein has documented that she has no financial relationships to disclose or Conflicts of Interest to resolve. Unlabeled use: Dr. Gale Burstein s presentations will include discussion of unlabeled use of a product. Dr. Burstein will discuss gonorrhea and chlamydia nucleic acid amplification testing of non-genital specimens that are not FDA-approved. Clinical laboratories my conduct validation studies to obtain CLIA approval to perform these tests EPIDEMIOLOGY Sexual behavior STI outcomes 2

Sexual behavior with same-sex partners among males aged 15 24 years, NSFG 2006-8 Age group Oral sex with Anal sex with 15-19 yo 2% 1% 20-24 yo 6% 3% http://www.cdc.gov/nchs/data/nhsr/nhsr036.pdf Sexual behavior with same-sex partners among females aged 15 24 years, NSFG 2006-8 Age group Any sex with Oral sex with 15-19 yo 11% 7% 20-24 yo 16% 11% http://www.cdc.gov/nchs/data/nhsr/nhsr036.pdf 3

Sexual Identity and Sexual Health-Risk Behaviors Among 9th 12th Grade Students: YRBSS, Selected Sites, US, 2001 2009 Behavior Heterosexual (%) Gay or lesbian (%) Bisexual (%) ever had sexual intercourse 44 67 69 sexual intercourse before age 13 yrs sexual intercourse with >4 persons 5 20 15 11 30 28 currently sexually active 32 53 53 used a condom during last sexual intercourse 66 36 54 www.cdc.gov/mmwr/pdf/ss/ss60e0606.pdf SEXUAL HEALTH CARE SERVICES FOR YOUNG MEN WHO HAVE SEX WITH MEN (YMSM) Epidemiology CDC recommendations 4

Primary and Secondary Syphilis Reported Cases* by Sex, Sexual Behavior, and Race/Ethnicity, US, 2010 Cases 3,000 2,500 2,000 Whites Blacks Hispanics Other 67% of P&S syphilis cases 1,500 1,000 500 0 MSW Women MSM * Of the reported male cases of primary and secondary syphilis, 18.3% were missing sex of sex partner information; 2.0% of reported male cases with sex of sex partner data were missing race/ethnicity data. No imputation was done for race/ethnicity. MSW = men who have sex with women only; MSM = men who have sex with men. STD Surveillance Network (SSuN) Gonorrhea and Chlamydia Proportion of MSM* Testing Positive for Gonorrhea and Chlamydia, by Site, 2010 Percentage 30 Gonorrhea Chlamydia 25 20 15 10 5 0 San Francisco Los Angeles Seattle Denver Chicago New Orleans Birmingham Baltimore Richmond Philadelphia New York City Hartford/ New Haven * MSM = men who have sex with men. 5

STD Surveillance Network (SSuN) Proportion of MSM* Attending STD Clinics with Primary and Secondary Syphilis, Gonorrhea or Chlamydia by HIV Status, 2010 Percentage 20 16 HIV HIV+ 12 8 4 0 P&S syphilis GC urethral GC pharyngeal GC rectal CT urethral CT rectal * MSM = men who have sex with men. HIV negative status includes persons of unknown status for this analysis. GC urethral and CT urethral include results from both urethral and urine specimens. www.cdc.gov/healthyyouth/sexualbehaviors/pdf/hiv_factsheet_ymsm.pdf 6

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63% www.cdc.gov/healthyyouth/sexualbehaviors/pdf/hiv_factsheet_ymsm.pdf Factors associated with STI rates among MSM Loss of fear regarding HIV transmission manageable Dz Internet use to find sex partners use of use of disinhibiting substances with unprotected sex Methamphetamine, ETOH Recreational drugs erectile dysfunction agents Role of oral sex in STI transmission? 8

RECOMMENDATIONS Screening Treatment: emerging gonorrhea resistance Importance of sexual health care for MSM Younger MSM at HIV and STI risk Especially if not discuss sexual orientation with partners, friends, or health care providers Routine screening important for early Dx & Dz transmission interruption Some MSM expect disapproval of lifestyles may avoid seeking healthcare New HIV dx associated w/ syphilis, rectal GC/CT CDC. MMWR 2003; 52:81 6. Scott KC, et al. J Acquir Immune Defic Syndr 2008;48:109 12. Kim AA, et al. Sex Transm Dis 2003;30:813 7. 9

Non-judgemental history Important for clinicians to be culturally competent Routinize asking behavioral screening questions without assumptions or judgments For example, asking, Do you have sex with men, women or both? Want patients to feel comfortable disclosing previously unreported behavior Routinely ask sexually active MSM about STD Sx urethral discharge dysuria genital and perianal ulcers regional lymphadenopathy skin rash anorectal symptoms c/w proctitis discharge and pain on defecation or during anal intercourse 10

Recommended HIV/STI screening (At least) annual serology HIV serology if HIV- syphilis serology confirmatory test if reactive; www.cdc.gov/std/treatment/2010/specialpops.htm#msm Recommended HIV/STI screening: NAATs Urethral N. gonorrhoeae and C. trachomatis in men who have insertive intercourse; urine NAAT is preferred; Rectal N. gonorrhoeae and C. trachomatis in men who have receptive anal intercourse NAAT of rectal swab is preferred Pharyngeal N. gonorrhoeae in men who have receptive oral intercourse NAAT of oral swab is preferred pharyngeal C. trachomatis asymptomatic screening not recommended www.cdc.gov/std/treatment/2010/specialpops.htm#msm 11

Nongenital GC/CT NAAT vs Culture Performance Schachter J,et al. Sex Transm Dis. 2008;35:637-42. Performance of NAATs for Diagnosis of Rectal Infection Rectal Infection C. trachomatis N. Gonorrhoeae % Sensitivity/Specificity % Sensitivity/Specificity ProbeTec (SDA) 100/90 100/96 Amplicor (PCR) 96/92 96/96 Aptima Combo2 100/89 100/96 (TMA) Culture 46/99 72/100 Bachmann, L et al. J. Clin Microbiol. 2010;48(5);1827-1832. 12

Performance of NAATs for Diagnosis of Pharyngeal N. Gonorrhoeae Infection Pharyngeal Gonococcal Infections (N=961) % Sensitivity % Specificity ProbeTec (SDA) 97% 94% Amplicor (PCR) 91% 72% Aptima Combo2 (TMA) 100% 96% Culture 65% 99% Bachmann, et al. J Clin Micro. 2009;47:902-907. How to order screen Non-genital GC/CT NAATs can be done by clinical laboratory with CLIA approval Gen-Probe APTIMA testing QUEST diagnostics test codes LabCorp diagnostics test codes Pharyngeal 70051X 188698 Rectal 16506X 188672 Urine/Urethral 13363X 183194 26 Relevant CPT Billing Codes: CT detection by NAAT: 87491 GC detection by NAAT: 87591 13

Consider HCV testing HIV+ MSM Initial HIV evaluation Evaluation for new, unexplained ALT Screen when high-risk sexual behaviors or concomitant ulcerative STIs Consider. HSV-2 evaluation with type-specific serologic tests if infection status is unknown; HSV-2 serostatus knowledge may be helpful in identifying persons with previously undiagnosed genital tract infection Anal cytologic abnormalities screening anal cancer incidence in HIV+ MSM evidence is limited concerning natural hx of anal intraepithelial neoplasias, screening methods reliability, safety and response to Tx, and programmatic support needed for screening activity 14

Consider. More frequent STI screening (i.e., at 3 6- month intervals) MSM with multiple or anonymous partners MSM who have sex with illicit drug use or whose sex partners use illicit drugs methamphetamine Vaccination Hepatitis A and B HPV for MSM thru age 26 years 15

High intensity behavioral counseling (HIBC) to prevent STIs/HIV Recommended for all adolescents and young adults at risk for HIV/STIs ACA allows twice yearly (modifier code 33) Client-centered STD/HIV prevention counseling involves tailoring risk reduction discussion of to patient's individual situation based on CDC s Project RESPECT 20-30 min motivational interviewing sessions www.cdc.gov/hiv/topics/research/respect/ Who will pay for MSM preventive services in ACA? Fessler, DA, et al. Sex Transm Dis 2012;39:449 452. 16

Resources http://www.ncsddc.org/resources/occs GONORRHEA Emerging resistance 17

CDC. Cephalosporin Susceptibility Among Neisseria gonorrhoeae Isolates --- United States, 2000 2010. MMWR. 2011; 60(26);873-877. Percent of gonorrhea isolates with cefixime MICs >0.25 ug/ml and ceftriaxone MICs >0.125 ug/ml, by sex of sex partner, GISP, U.S., 200-2010 www.cdc.gov/mmwr/preview/mmwrhtml/mm6026a2.htm?s_cid=mm6026a2_w Treatment for Uncomplicated Gonococcal Infections of the Cervix, Urethra, and Rectum Recommended Ceftriaxone 250 mg IM Once PLUS Azithromycin 1 g Orally Once OR Doxycycline 100 mg Orally Twice a day for 7 days Quinolones are no longer recommended in the United States for the treatment of gonorrhea and associated conditions, such as PID www.cdc.gov/mmwr/preview/mmwrhtml/mm6131a3.htm?s_cid=mm6131a3_w 18

Treatment for Uncomplicated Gonococcal Infections of the Cervix, Urethra, and Rectum Alternative 1: If Ceftriaxone is not available Cefixime 400 mg Orally Once PLUS Azithromycin 1 g Orally Once OR Doxycycline 100 mg Orally Test of cure in 1 week PLUS Twice a day for 7 days www.cdc.gov/mmwr/preview/mmwrhtml/mm6131a3.htm?s_cid=mm6131a3_w Treatment for Uncomplicated Gonococcal Infections of the Pharynx Ceftriaxone 250 mg IM Once PLUS Azithromycin 1g Orally Once OR Doxycycline 100 mg Orally Twice a day for 7 days www.cdc.gov/mmwr/preview/mmwrhtml/mm6131a3.htm?s_cid=mm6131a3_w 19

Treatment for Uncomplicated Gonococcal Infections of Cervix, Urethra, Rectum, and Pharynx Alternative 2: If patient is cephalosporin-allergic Azithromycin 2 g Orally Once Test of cure in 1 week PLUS www.cdc.gov/mmwr/preview/mmwrhtml/mm6131a3.htm?s_cid=mm6131a3_w GC Follow up testing Test of cure is not recommended if recommended regimen is administered Test of cure is recommended if alternative regimen is administered Sx persist after Tx and not from reinfection (Rx failure) Test of cure by N. gonorrhoeae culture Test isolated GC for antimicrobial susceptibility If no Cx access, use NAAT most GC NAATs negative within a week of GC Rx Repeat testing in 3 months regardless of Rx www.cdc.gov/mmwr/preview/mmwrhtml/mm6131a3.htm?s_cid=mm6131a3_w 20

SEXUAL HEALTH CARE SERVICES FOR YOUNG WOMEN WHO HAVE SEX WITH WOMEN (WSW) Epidemiology CDC recommendations Risk and Protective Factors Related to STIs Among WSW WSW are diverse group with variations in sexual identity, sexual behaviors, sexual practices, and risk behaviors. Sexual identity is not necessarily = sexual behaviors and sexual partners gender Many y (up to 87%) who report same-sex behavior have partners Cannot assume that who self-identify as lesbian never had partners Koh AS, et al. Sex Transm Dis 2005; 32:563 9. Tao G. Am J Public Health 2008;98:1007 9. Goodenow C, et al. Am J Public Health 2008; 98:1051 8. 21

Sexual identity and behavioral risks among adolescents and young adults Massachusetts Youth Risk Behavior Survey from 1995 to 2001 Among who reported only sexual partners 82% identified as heterosexual 14% identified as lesbian or bisexual 4% identified as not sure Goodenow C, et al. Am J Public Health 2008; 98:1051 8. Sexual identity and behavioral risks among adolescents and young adults who identified as NOT heterosexual and reported same-sex partners more likely than heterosexual participants to report multiple lifetime and recent sexual partners illegal drug use prior pregnancy prior STD H/O coerced into sexual contact Goodenow C, et al. Am J Public Health 2008; 98:1051 8. 22

BV among WSW BV common among with partners can share strain-specific specific genital bacteria with their partners Specific bacterial species associated with BV Tx failure Gorgos LM, et al. Clin Infect Dis 2011;53(S3):S84 91. C trachomatis positivity rate among WSW and WSMW was 7% versus 5% among WSM Singh D, et al. Am J Public Health 2011;101:1284 1290. 23

HPV among WSW HPV infections common among WSW Sexual HPV transmission likely occurs between Marrazzo JM, et al. Am J Public Health 2001; 91:947 52. STI care for WSW Report of same-sex behavior should not deter providers from STI screening chlamydia and syphilis as recommended Routine cervical CA screening should be offered to all as per guidelines, regardless of sexual preference or sexual practices All should be offered HPV vaccine as per ACIP guidelines 24

BV among WSW Routine screening is not recommended Tx of partners of with BV not recommended Encouraging awareness of signs and symptoms of BV Encouraging healthy sexual practices may be helpful e.g., cleaning shared sex toys between uses BV Rx http://www.cdc.gov/std/treatment/2010/vaginal-discharge.htm#a1 25

Recurrent BV Metronidazole gel 2x/week x 4-6 months Oral nitroimidazole followed by intravaginal boric acid and suppressive metronidazole gel metronidazole orally PLUS fluconazole Qmonth Resources The National LGBT Health Education Center at the Fenway Institute www.lgbthealtheducation.org/ Gay Lesbian Medical Association www.glma.org/ 26

QUESTIONS.. THANK YOU!!!!!!!!!!!!! 27