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Thomas Farley, MD MPH Tulane University Deborah Cohen, MD MPH RAND Corporation

Screening and Treatment for Gonorrhea and Chlamydia as an HIV Prevention Strategy: Rationale and Implementation. Thomas Farley, MD MPH Tulane University Deborah Cohen, MD MPH RAND Corporation. Outline. Study on reasons for non-treatment of STDs

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Thomas Farley, MD MPH Tulane University Deborah Cohen, MD MPH RAND Corporation

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  1. Screening and Treatment for Gonorrhea and Chlamydia as an HIV Prevention Strategy:Rationale and Implementation Thomas Farley, MD MPH Tulane University Deborah Cohen, MD MPH RAND Corporation

  2. Outline • Study on reasons for non-treatment of STDs • Implementation of STD screening in public hospital walk-in clinic • Implementation of STD screening in an HIV clinic

  3. Background • Treatment of non-ulcerative curable STDs reduces HIV transmission • Optimal ways to use STD treatment to prevent HIV infection in the U.S. are not known • Determining primary reasons for non-treatment of STDs can help direct this strategy

  4. Objective To determine the primary reasons why untreated non-ulcerative bacterial STDs in the U.S. are not treated • Lack of symptoms? • Screening programs • Failure to receive medical care for symptoms? • Reducing barriers to medical care • Medical providers did not treat for STDs? • Provider education

  5. Methods (1) Persons age 18-29 who were not seeking care for genitourinary (GU) symptoms at several sites in New Orleans were: • Tested for gonorrhea, chlamydia and HIV using urine-based tests • Surveyed on GU symptoms in the last 12 months • If did not receive medical care for past GU symptoms, surveyed on barriers to care • If received medical care for past GU symptoms, we requested and abstracted medical records

  6. Methods (2) • Estimates made of the total number of persons with STDs in the previous 12 months, the proportion treated, and the reasons for non-treatment in those untreated

  7. Prevalence of Infection By Site * Among persons not seeking care for genitourinary symptoms

  8. Prevalence of STDs by HIV Status

  9. Relationship Between Symptoms and STDs - Females

  10. Relationship Between Symptoms and STDs - Males

  11. Reasons Why Care Not Received for Symptoms

  12. Prior Medical Care Received for Possible STD-related Symptoms N=56 charts with prior visit for genitourinary complaints

  13. Estimates of Natural History of Infection Reconstructed historical cohort of infected persons including: • all found infected at screening • all testing positive at prior medical visits for symptoms • a proportion of persons treated presumptively for STDs at prior medical visits for symptoms.

  14. Gonorrhea Chlamydia n (est.) % of all % of untreated n (est.) % of all % of untreated No recognized symptoms 28.3 45% 86% 148 77% 95% Symptoms 35.2 56% 44.7 23% Did not receive care 4.8 8% 14% 8.4 4% 5% Received care, not treated 0.0 0% 0% 0.0 0% 0% Received care, treated 30.4 48% 36.3 19% Total 63.5 100% 193 100% Estimates of Treatment of STDs in Previous 12 months

  15. Gonorrhea Chlamydia n (est.) % of all % of untreated n (est.) % of all % of untreated No recognized symptoms 7.5 34% 83% 60.9 89% 98% Symptoms 14.7 66% 7.5 11% Did not receive care 1.5 7% 17% 1.1 2% 2% Received care, not treated 0.0 0% 0% 0.0 0% 0% Received care, treated 13.2 59% 6.4 9% Total 22.2 100% 68.4 100% Estimates of Treatment of STDs in Previous 12 monthsMales

  16. Gonorrhea Chlamydia n (est.) % of all % of untreated n (est.) % of all % of untreated No recognized symptoms 20.1 55% 86% 87.7 71% 92% Symptoms 16.7 44% 36.5 30% Did not receive care 3.3 9% 14% 7.2 6% 8% Received care, not treated 0.0 0% 0% 0.0 0% 0% Received care, treated 13.4 36% 29.3 24% Total 36.8 100% 124 100% Estimates of Treatment of STDs in Previous 12 monthsFemales

  17. Summary – Reasons for Non-Treatment Study • Unrecognized infection was frequent for both gonorrhea (2.3%) and chlamydia (10.2%) and did not vary much by gender or site • The most common reason for failure to seek care for symptoms was that symptoms were mild and transient • A large majority of persons with untreated chlamydia or untreated gonorrhea were untreated because they never had symptoms

  18. Conclusions and Recommendations • The primary reason non-ulcerative bacterial STDs are untreated in the U.S. is most infected persons never have symptoms. • The most effective way to use treatment of non-ulcerative STDs to prevent HIV infection in the U.S. is screening for gonorrhea at high-prevalence sites.

  19. Prevalence of Infection By Site * Among persons not seeking care for genitourinary symptoms

  20. STD/HIV Screening in a Public Hospital Walk-In Clinic • Purpose was to determine if STD/HIV screening could be institutionalized by providing testing by no additional resources • ER staff preferred screening in walk-in clinic rather than emergency area • Screening available, offered by signs in waiting area and notification by providers • From December 2000 - November 2001 592 persons tested (<1% of those seen)

  21. Results of STD/HIV ScreeningCharity Hospital Walk-in Clinic, 12/00 – 11/01 • 21 (3.5%) had gonorrhea and 39 (6.6%) had chlamydia • Difficult to locate people to ensure treatment • 6 (1%) of 572 had HIV infection • 3 (0.8%) of 379 females • 3 (1.6%) of 193 males

  22. Prevalence of GonorrheaCharity Hospital Walk-in Clinic, 12/00 – 11/01

  23. Prevalence of ChlamydiaCharity Hospital Walk-in Clinic, 12/00 – 11/01

  24. Summary and ConclusionsSTD/HIV Screening in Public Hospital Walk-in Clinic • STD/HIV screening can be institutionalized in ER, but without external resources number screened will be low • Staff time needed for locating infected persons for treatment

  25. STD Screening in HIV ClinicHIV Outpatient Program, New Orleans, October 1998- June 2001 • 34,837 visits • Includes initial, routine follow-up and problem-focused visits • 2,629 tests - 7.5% of visits • Type for visit not available on lab test slip

  26. Patients* Tested* % Tested Black Females 707 292 41% Black Males 964 297 31% White Females 92 41 45% White Males 708 176 25% Total 2,555 837 33% Percentage of Active Patients TestedHIV Outpatient Program, New Orleans, June 2000-May 2001 * Unduplicated count for 12-month period

  27. Prevalence of STDsHIV Outpatient Program, New Orleans, 1998-2001

  28. Gonorrhea Prevalence vs Convenience Sample of General PopulationNew Orleans

  29. Chlamydia Prevalence vs. Convenience Sample of General PopulationNew Orleans

  30. Summary and ConclusionsSTD Screening in HIV Clinic • STD screening in HIV clinics is feasible and relatively easy to implement • Unless it is routine protocol, providers may not test as often as optimal • STD prevalence is approximately equal that of demographically-matched persons who do not have HIV infection

  31. The Future • Public hospital walk-in clinic will continue screening • Will try to improve compliance at HIV Outpatient Clinic • Plans to expand STD screening to all public HIV clinics in Louisiana

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