Screening and Treatment for Gonorrhea and Chlamydia as

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 • Implementation of STD screening in public hospital walk-in clinic • Implementation of STD screening in an HIV clinic

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 nontreatment of STDs can help direct this strategy

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

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

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

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

Prevalence of STDs by HIV Status

Relationship Between Symptoms and STDs - Females

Relationship Between Symptoms and STDs - Males

Reasons Why Care Not Received for Symptoms

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

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.

Estimates of Treatment of STDs in Previous 12 months Gonorrhea n (est. ) % of all Chlamydia % 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% 4. 8 8% 14% 8. 4 4% 5% 0. 0 0% 0% 30. 4 48% 36. 3 19% 63. 5 100% 193 100% Total Did not receive care Received care, not treated Received care, treated

Estimates of Treatment of STDs in Previous 12 months Males Gonorrhea No recognized symptoms Symptoms n (est. ) % of all 7. 5 Chlamydia % of untreated n (est. ) % of all % of untreated 34% 83% 60. 9 89% 98% 14. 7 66% 7. 5 11% Did not receive care 1. 5 7% 1. 1 2% 2% Received care, not treated 0. 0 0% 0% Received care, treated 13. 2 59% 6. 4 9% 22. 2 100% 68. 4 100% Total

Estimates of Treatment of STDs in Previous 12 months Females Chlamydia Gonorrhea 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% Received care, treated 13. 4 36% 29. 3 24% 36. 8 100% 124 100% Total

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

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.

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

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)

Results of STD/HIV Screening Charity 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

Prevalence of Gonorrhea Charity Hospital Walk-in Clinic, 12/00 – 11/01

Prevalence of Chlamydia Charity Hospital Walk-in Clinic, 12/00 – 11/01

Summary and Conclusions STD/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

STD Screening in HIV Clinic HIV Outpatient Program, New Orleans, October 1998 - June 2001 • 34, 837 visits – Includes initial, routine follow-up and problemfocused visits • 2, 629 tests - 7. 5% of visits • Type for visit not available on lab test slip

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

Prevalence of STDs HIV Outpatient Program, New Orleans, 1998 -2001 Tested Positive % Positive Gonorrhea 2, 629 46 1. 7% Chlamydia 2, 629 56 2. 1%

Gonorrhea Prevalence vs Convenience Sample of General Population New Orleans

Chlamydia Prevalence vs. Convenience Sample of General Population New Orleans

Summary and Conclusions STD 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

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