STD Prevention & Control in a Time of Changing Resources The Need for Stronger Partnerships

1. STD Prevention & Control in a Time of Changing ResourcesThe Need for Stronger Partnerships George Walton, MPH, CPH, MLS(ASCP)CM STD Program Manager Bureau of HIV, STD, and Hepatitis

2. Objectives • Discuss the epidemiology of chlamydia, gonorrhea, syphilis, and HIV in Iowa. • Explain current STD prevention activities conducted by IDPH, including partner services. • Describe recent changes in Iowa’s STD morbidity & resources and how they relate to changing priorities and prevention strategies. • Explore options for increased collaboration among the various health professionals in Iowa whose work includes sexual health, emphasizing STDs with high incidence like chlamydia. • Discuss Iowa’s ongoing syphilis epidemic and the impact of various prevention and control strategies.

3. STDs – A diverse group • Numerous STDs have been identified • 25+ • All STDs are treatable, many are curable • Certain STDs are reportable to state or local public health agencies • Follow up is performed • Varying degrees • Goal – reduce incidence and mitigate deleterious effects upon the population’s health

4. Reportable STDs

5. Epidemiology and Surveillance Data

6. Chlamydia • 2013 surveillance data: • Greatest number of cases of any reportable disease (STD or otherwise) in Iowa and U.S. • 11,006 cases reported in Iowa • 70% of cases <25 years of age • 72% of cases among women • Greater number screened • Certain racial and ethnic groups disproportionately impacted • 18% of cases among black, non-Hispanic populations • 7% among Hispanic populations • 1,422,976 reported nationally (2012 data)

7. Gonorrhea • 2013 surveillance data: • Second most commonly reported infection in Iowa and U.S. • 1,471 cases reported • 55% of cases <25 years of age • 76% under 30 years of age • 55% of cases among women • Black, non-Hispanic persons highly disproportionately impacted, 31% of reported cases • Hispanic populations account for 6% of reported cases • 334,826 cases reported nationally (2012 data)

8. Chlamydia and Gonorrhea in Iowa, 2000-2013

9. Gonorrhea – top 10 counties by rate per 100,000 population

10. Syphilis • 2013 surveillance data (early syphilis only): • 171 cases of early syphilis reported in Iowa • More evenly distributed among age groups • Men accounted for 91% of cases • Men who have sex with men (MSM) disproportionately impacted • Of males diagnosed in 2013, more than 80% were MSM • 30,170 reported nationally (2012 data)

11. Early Syphilis in Iowa, 2000-2013

12. HIV Infection • 2013 surveillance data: • 122 new diagnoses in Iowa • 72% of cases were men • MSM are highly impacted • 84% of the male cases (60% overall) • Disparities among racial and ethnic minorities • Black, non-Hispanic persons, 23% of cases • Hispanic persons, 7% of cases • 46% of new diagnoses among 25-44 year olds • Foreign born: 27 (22% of total) in 2013 • 49,273 new HIV cases nationally (2011 data)

14. STD Prevention Activities

15. Examples of IDPH Activities • Surveillance and Epidemiology • Ultimate goal – inform other prevention activities and raise awareness among medical providers, other health professionals, and the public. • Partner Services • Includes interviewing patient for risk reduction counseling and contact tracing/confidential partner notification to interrupt the chain of infection. • Screening for certain STDs • Many are asymptomatic. Screening the most affected populations is a key prevention strategy. • Assuring adequate treatment • Increasing condom availability

16. Partner Services • Conducted by Disease Prevention Specialists (DPS) • A broad array of services offered to: • Persons with HIV, syphilis, gonorrhea, or chlamydia. • Examples: prevention counseling, assuring adequate treatment and linkage to medical care, referral to other services. • Identified partners of persons with these infections. • Confidential partner notification is a core component. • Data show that notification by DPS is more effective than by patients themselves at reducing infection rates. • Others who are at increased risk and may benefit from screening or other prevention services. • All conducted while adhering to strict confidentiality standards. • Participation strongly encouraged but is voluntary.

17. A closer look at chlamydia prevention activities

18. How do we respond to chlamydia cases? • IDPH now performs partner services for very few cases. • Only when specifically requested. • Obtain verification of adequate treatment from clinician. • If patient was adequately treated, that’s it! • Interview criteria have been cut back over the years due to growing numbers of cases of other STDs. • Syphilis, gonorrhea, and HIV are deemed “higher priority” than chlamydia cases. • Numbers of cases increases every year, number of staff stays the same.

19. Waving the white flag or calling for backup?

20. Maybe it is a good time to rethink chlamydia prevention activities… • Partner Services is a tried and true method. • It’s been used successfully for many decades – “gold standard” intervention for syphilis. • But…syphilis has different characteristics than chlamydia. • Syphilis has a very predictable symptomatology pattern. • Relatively easy to determine when someone was infected. • Effective investigation/partner services will reveal whether you’ve found the “source”. • More likely to follow distinctive disease patterns – it has a lower incidence so increases in cases more easily noticed. • Thus you can more readily associate clusters of cases with one another.

21. Maybe it is a good time to rethink chlamydia prevention activities… • On the other hand, chlamydia… • Is much more prevalent. It has the highest incidence of any reportable condition! • It is often asymptomatic, making it difficult to determine when the infection was acquired. • Thus, it can be nearly impossible to identify the “source.” • Are partner services really the most efficient use of our limited resources? • If not partner services, then what?

22. Screening! • Chlamydia is highly concentrated in a specific population (adolescents and young adults). • If we were to select 100 sexually active teens at random vs those selected via partner services referral… • Where would we find more positives per time spent? • Public Health is calling for backup! • We need our partners in medicine and other health professionals to help. • “Free” clinics are constantly closing or cutting back hours. • Public Health does not have the capacity to screen everyone who should be. • Tests with high sensitivity and specificity are now much more widely available.

23. Screening! • A lot of support already in place for chlamydia screening • Grade A recommended service from the United States Preventive Services Task Force (USPSTF) for sexually active females 24 years of age and younger. • Covered at no cost sharing as a result of Affordable Care Act. • It’s a measure for Healthcare Effectiveness Data and Information Set (HEDIS). • Many plans offer incentives to patients and providers for this service. • We still have safety net providers • Community-Based Screening Services (CBSS).

24. Additional options • Expedited Partner Therapy (EPT) • Clinical practice of treating the sex partners of patients diagnosed with chlamydia and/or gonorrhea by providing prescriptions or medications to the patient to take to his or her partner(s) without the health care provider first examining the partner(s). • Data show this practice reduces re-infection rates. • Approx. 20% reduction for CT; 50% for GC (compared to patient referral) • Supported by several national organizations – CDC, AAFP, ACOG • It is legal in Iowa!

25. Expedited Partner Therapy 139A.41 CHLAMYDIA AND GONORRHEA TREATMENT. Notwithstanding any other provision of law to the contrary, a physician, physician assistant, or advanced registered nurse practitioner who diagnoses a sexually transmitted chlamydia or gonorrhea infection in an individual patient may prescribe, dispense, furnish, or otherwise provide prescription oral antibiotic drugs to that patient's sexual partner or partners without examination of that patient's partner or partners. If the infected individual patient is unwilling or unable to deliver such prescription drugs to a sexual partner or partners, a physician, physician assistant, or advanced registered nurse practitioner may dispense, furnish, or otherwise provide the prescription drugs to the department or local disease prevention investigation staff for delivery to the partner or partners.

26. Iowa’s syphilis epidemic continues

27. Syphilis Overview – Stages of the Infection • Primary • Characterized by painless chancres (sores) at the site of infection. • Highly infectious. • Resolves with or without treatment (approx. 3 weeks). • Secondary • Characterized by diffuse rash and lymphadenopathy. • Resolves with or without treatment (approx. 4 weeks). • Early Latent • Resolution of signs but infection acquired <1 year ago. • Late Latent • Infection >1 year ago • Not infectious

28. Early/Infectious Syphilis • First three stages of syphilis (primary, secondary, and early latent) are collectively referred to as “early syphilis” or “infectious syphilis”. • Greatest interest in terms of public health. • Late syphilis important medically • Severe, life-threatening complications can develop 15-30 years after untreated infection • Tertiary syphilis • Neurosyphilis – not a stage; can occur at any stage

29. Syphilis in Iowa • In 2013, 171 cases of early syphilis • Compared to the 31 cases in 2011, this is over a 450% increase • What’s different now than in 2011? • Surge in our MSM populations • 55% of cases in 2011; nearly 85% in 2012 & 2013 • More who are comorbid with HIV • 15% of cases in 2011 • 27.2% in 2012 • 31% in 2013 • Case numbers remain high in 2014

30. Syphilis Prevention and Control Strategies • Partner Services • Contact tracing and partner notification are key. • Find the “source” of the infection. • Prevent spread and re-infection. • Is the “gold” in the gold standard fading? Challenges… • Increasing number of “anonymous” partners. Often meet online or via apps like “Grindr”. Very little identifying or locating information available. • Resistance to partner services. Clients refusing to participate. • We will expand to do “clustering” with our early syphilis cases. • Others in the index patient’s social circles that may benefit from testing besides sex partners.

31. Syphilis Prevention and Control Strategies • Calling for more backup! • Medical providers may have longer relationships and better rapport with patients – encourage them to work with Public Health and participate in Partner Services. • It’s worked well for others. Reduces risk of re-infection. Done confidentially. • If partner services doesn’t yield results, what else can be done?

32. Syphilis Prevention and Control Strategies • Syphilis is concentrated in a particular population. Need to find the infected and undiagnosed/untreated. Increased screening!

33. Syphilis Prevention and Control Strategies • Treatment • Easily treated and cured • Primary, secondary or early latent syphilis: • 2.4 million units of long-acting benzathine penicillin G (Bicillin L-A), intramuscular injection. • Late latent syphilis: • Three injections, spaced 1 week apart, needed for late syphilis. • Other penicillin derivatives used for neurosyphilis (most administered intravenously).

34. Syphilis Prevention and Control Strategies • Presumptive treatment • Persons presenting with symptoms should be tested and treated the same day. • All sex partners to early syphilis should be presumptively. • Sex partners within last 90 days should be treated even if tests are negative. • Sex partners greater than 90 days should be treated presumptively if there is any uncertainty about follow up. • If sex partners are treated very early, their infectious period can be virtually eliminated, reducing the spread of the infection. Presumptive treatment is aprevention strategy!

35. Syphilis – addressing the epidemic • Multifaceted response is required. • Continued partner services, including clustering. • Increased awareness among providers • Be vigilant for signs/symptoms and test and treat accordingly • Screen populations at greatest risk (e.g. MSM) • Treat patients and their sex partners appropriately (including presumptive treatment, when appropriate) • Encourage participation in partner services • Increased awareness in the community • Education • Risk reduction • Seek screening more frequently

36. Future of STD Prevention & Control • Governmental public health agencies to return focus to assessment, assurance, and policy development. • Too pervasive for any one group to address on its own. • Public Health, Medicine, Health Insurers, Community-Based Organizations, Health Educators, Schools, other non-profits, etc. must collaborate, pool resources, and take advantage of each other’s expertise.

37. Thank you for all that you do! • Let’s continue to find ways to work together to meet our common goals of reducing the incidence of STDs and improving the sexual health of Iowans! • Contact information: George Walton, MPH, CPH, MLS(ASCP)CM STD Program Manager Bureau of HIV, STD, and Hepatitis Iowa Department of Public Health 321 E. 12th St | Des Moines, IA 50319-0075 Office: 515-281-4936 | Fax: 515-281-0466 George.Walton@idph.iowa.gov