1. California STD/HIV Prevention Training Center
Diseases without Borders: Best Practices for Sexually Transmitted Diseases Care and Prevention
Linda Creegan, MS, FNP
California STD/HIV Prevention Training Center
Border Conference
El Centro, CA June 2014

2. I do not have any financial arrangements or affiliations with commercial sponsors which have direct interest in the subject matter:

3. Sexually Transmitted Diseases
Chlamydia
Chancroid
HPV
Gonorrhea
Trichomonas
Genital herpes
Syphilis
Granuloma inguinale
Lice
HIV / AIDS
Scabies
LGV
Hepatitis B
BV?
M. genitalium
Hepatitis C
Others…..

4. Complications of STDs Infection Chlamydia Gonorrhea HPV Hepatitis B
PID
Infertility
Ectopic pregnancy
Chronic pain
Cancer
Perinatal
Congenital infection
Low birth weight
Stillbirth
HIV
Brain/organ damage
Chlamydia
Gonorrhea
HPV
Hepatitis B
Trichomonas
HSV
Syphilis

5. CA STD Data and Statistics

7. Priority Populations Teens & young people Pregnant women
Gay/Bi men (MSM)
People of color

8. Testing in STD Care Testing applications Types of tests Case finding
Asymptomatic (screening)
Symptomatic (diagnostic)
Follow-up
Guide treatment (HIV resistance testing)
Surveillance
Types of tests
Culture (susceptibility testing)
Serologic tests (antibodies in the blood)
Molecular-based tests (NAAT)
Combo tests
CT/GC
HIV/syphilis
Non-treponemal and treponemal

9. Testing Approaches In clinic Outside the clinic Clinician-collected
Self-collected
Outside the clinic
Collected at lab
Field-based program
Home testing

10. Provide Those Free Sexual Health Services!
Essential Health Benefits related to STD/HIV prevention and care
Must be included in all health plans at no cost-sharing to patient
Annual Wellness visit
STD and HIV screening
STD and HIV care
HPV and Hep B Immunizations
Risk Reduction counseling
Pap smears
Essential health benefits must be included in all insurance packages available in the state insurance exchanges, so these will be benefits that all patients can receive. And of course these are billable services, so when these reproductive health services are provided to patients in your practice, they will be reimbursable.

11. 1. Ask three essential sexual history questions
WHO are your partners?
WHAT are your sexual and drug use practices?
HOW do you try to prevent STDs/HIV?
It all begins with a sexual history or risk assessment. A very brief risk assessment can give you a pretty good idea of the level of this patient’s risk for STIs. With all patients, hit just 3 topics as a screen
Any current protocol/ practice re: sexual risk assessment?  Including self-administered forms that pts fill out? Adolescent and adult history forms both on paper that patients complete and electronic history in EHR.
Risk assessment important since many STDs are asymptomatic

12. 2. Screen for Chlamydia and Gonorrhea
ALL sexually active adolescent and young women ≤ 25 years
Pregnant women
Men who have sex with men (MSM)
Persons living with HIV
Others according to risk
CDC 2010 STD Tx Guidelines.

13. Why screen? Highly prevalent Frequently asymptomatic
Reduces transmission
Prevents complications
HEDIS measure: chlamydia screening in females under 25 years old
Standard of care

14. STD Screening for Women
Sexually Active adolescents & up to age 25 Routine chlamydia and gonorrhea screening Others STDs and HIV based on risk Women over 25 years of age STD/HIV testing based on risk Pregnant women Chlamydia Gonorrhea (<25 years of age or risk) HIV Syphilis serology HepB sAg Hep C (if high risk)
CDC 2010 STD Tx Guidelines

15. Estimated Chlamydia Screening Coverage (HEDIS), Females Age 15–24, USA and California, 1999–2010
National
California
Source: National Committee on Quality Assurance; California DHCS Division of Medi-Cal Managed Care;
Kaiser Permanente Northern CA; California DPH Office of Family Planning
Rev. 4/2012

16. Who is falling through the cracks?
Visits that do not require an exam
Pregnancy test only
Emergency contraception
Contraception method follow-up
Refills
Depo-provera injection
So who are we missing, who is falling thru the cracks? Well, women who come for a clinic visit that does not require an exam. CT screening is pretty much routine at annual exams, but many women come for other types of visits which may be the only time we see them for care. And for these women, we’re much less likely to remember to do a CT test.

17. A pelvic exams is not necessary to obtain a chlamydia test
Nucleic acid amplification tests (NAATs)
Highest sensitivity
Noninvasive samples
Urine
Self-collected vaginal swabs
A pelvic exam isn’t necessary to obtain the sample for a CT test. NAAT tests using urine or vaginal swab samples are in widespread use now. So the urine we get for that pregnancy test can be sent for a CT test as well.

18. Major conclusions
NAATs recommended for detection of genital tract infections in men and
women – with and without symptoms
Optimal specimen types are:
First catch urine for men
Self collected vaginal swabs from women
NAATs recommended for: detection of rectal and oropharyngeal infections

19. CT Test Volume & Prevalence among Females by Age
What about Women over age 25?
CT Test Volume & Prevalence among Females by Age
50% Test Volume
This slide graphically depicts the problem we face in CA – namely the over-screening that is occurring within the low prevalence population of FP women over age 25.
This graph shows 2006 CT test volume and prevalence data by age group for women tested for CT via CA’s F-PACT program (F-PACT, or “Family PACT”, is a CA entitlement program which provides comprehensive reproductive health care to low income female and male residents of the state).
The red line in this graph represents a CT prevalence of 3%, the state’s cost-effective cut-off for universal screening, which was chosen based on research of the 1) literature, 2) statewide surveillance data, and 3) our current level of resources in CA.
.  CT prevalence drops below this line in the groups of women age 25 and older. Yet, the CT test volume remains quite high across these older age groups, with  50% of all Family-PACT chlamydia testing occurring in the population of women over age 25.
This practice of screening older adult women with a CT prevalence lower than the cost-effective level is not an effective use of the limited resources we have in CA.
CA FPACT Data, 2006
*Quest Diagnostics/Unilab: West Hills/Tarzana, Sacramento, San Jose

20. Which women over age 25 should be screened?
Based on risk:
Infection with CT or GC in past 2 years
> 1 sex partner in past 12 months
New partner in past 3 months
Belief that a partner in the past 12 months may have had other sex partners at the same time
Other indications:
Pregnancy
Contact to STD  
New STD diagnosis
CA CT Screening Guidelines Draft;
Howard et al. Over 20. In prep.

21. STI Screening Recommendations: HIV-positive Men & Women
Anatomic Site
Chlamydia
Genital, rectal if exposed
Gonorrhea
Genital, rectal & oral if exposed
Syphilis
Serology
Trichomoniasis
Women only
HSV-2
Hep B sAg
Hep C *
* Screen at least annually; repeat screening every 3-6 months as indicated by risk.
MSM- Consider anal Pap screening
Women-Cervical Pap screening; Consider anal Pap if hx of dysplasia.
Primary Care Guidelines for the Management of Persons Infected with HIV: 2009 Update by the HIVMA of the IDSA. Clin Infect Dis 2009;49,

22. STD Screening for MSM * HIV Syphilis Urethral GC and CT
Rectal GC and CT (if RAI)
Pharyngeal GC (if oral sex)
HSV-2 serology (consider)
Hepatitis B (HBsAg)
Anal Pap (consider for HIV+) *
* At least annually, more frequent (3-6 months) if at high risk (multiple/anonymous partners, drug use, high risk partners)
CDC 2010 STD Tx Guidelines

23. Majority of Rectal Infections in MSM are Asymptomatic
86%
84%
Chlamydia
Gonorrhea
n=316
n=264
Asymptomatic
Urethral Infections
Symptomatic
10%
42%
Chlamydia
Gonorrhea
n=315
n=364
Kent, CK et al, Clin Infect Dis July 2005

24. Proportion of CT and GC infections MISSED among 3398 asymptomatic MSM if screening only urine/urethral sites, San Francisco,
Chlamydia
Gonorrhea
Marcus et al, STD Oct 2011; 38: 922-4

25. Chlamydia and Gonorrhea NAA Testing
…not FDA-cleared for rectal or pharyngeal specimens but now the preferred testing method over culture
Validation procedures can be done by labs to allow use of a non-FDA-cleared test or application
Quest & LabCorp currently provide GC/CT NAAT for rectal/pharyngeal specimens

26. NAAT Laboratory Ordering and Billing Codes
For information on specimen collection and transportation, clinicians should contact the local reference laboratory representative.
*CDC does not endorse these laboratories, however, they represent the largest laboratories nationally. There may be other private laboratories that have verified rectal and pharyngeal testing with NAATs. Many PHLs have also verified rectal and pharyngeal testing.
Bolan, CDC webinar March 2011

27. Case Scenario 22 year old female Asymptomatic, no prior STDs
STD Screening done on intake
No known drug allergies
GC positive
CT negative

28. What regimen would you use to treat Gonorrhea?
Ceftriaxone 250 mg IM
Azithromycin 2 gm PO
Ceftriaxone 250 mg IM plus azithromycin 1 gm PO
Ceftriaxone 125 mg IM plus azithromycin 1gm PO

29. Development of GC Resistance
1930s-1970s
1980s
1990s
2000s
2010s
1976: Pen-R NG first identified in US (in CA)
2002: Fluoroquinolones no longer recommended
for TX by CA
1945: Penicillin first used widely for TX
2001: First cephalosporin TX failures in Japan
1986: GISP started by CDC
1991: QRNG
first identified
in US (in HI)
2010: Dual TX
recommended
for TX by CDC
1936: Sulfanilamides introduced as TX
1989: Penicillin no longer recommended for TX by CDC
2007: Fluoroquinolones no longer recommended for TX by CDC

30. Who is most likely to be affected by cephalosporin-resistant GC?
Men who have sex with men
California 30

31. 3. Use Current Treatment for Gonorrhea
[Insert Lecture Name Here]
3. Use Current Treatment for Gonorrhea
Gonorrhea Treatment: Uncomplicated Genital/Rectal/Pharyngeal Infections
Azithromycin 1 g orally **
or Doxycycline 100 mg BID x 7 days
Ceftriaxone 250 mg IM in a single dose
PLUS*
* Regardless of CT test result
**Azithromycin preferred
as 2nd antimicrobial
MMWR Weekly August 10, 2012
MMWR updates CDC 2010 Guidelines
Slide 31

32. Do you have ceftriaxone and azithromycin available onsite?
Yes No

33. Gonorrhea Treatment Alternatives Anogenital Infections
ALTERNATIVE CEPHALOSPORINS:
Cefixime 400 mg orally once
PLUS
Dual treatment with azithromycin 1 g (preferred) or doxycycline 100 mg BID x 7 days, regardless of CT test result
IN CASE OF SEVERE ALLERGY:
Azithromycin 2 g orally once
(Caution: GI intolerance, emerging resistance)
Proposed in case of allergy: gentamicin 240 mg IM + azithromycin 2g orally or gemifloxacin 320 mg orally + azithromycin 2g orally
MMWR / 61(31);

34. Test of Cure
Current TOC recommendation: Test of cure in 1 week for anyone treated w/ alternative regimens
Routine TOC poses implementation challenges
No data on TOC positivity rates in absence of symptoms
Proposed: Limit TOC only to pharyngeal GC treated with alternative regimen, may extend interval to 14 days

35. How to slow the spread of A-R Gonorrhea
New antibiotics
Multiple antibiotics
Surveillance
Rapid response plans
Resistance testing of isolates

36. Suspected GC Treatment Failure What should I do? CDPH Recommendations
CULTURE: if GC culture not available on-site, call CA STD Control Branch for resources
REPEAT TREATMENT: Ceftriaxone 500 mg IM PLUS Azithromycin 2 g orally in a single dose*
REPORT: To your local health department within 24 hours; call STD Control Branch if consult desired
TREAT PARTNERS: All partners in last 60 days should be treated with CTX 500 mg + AZ 2g
TEST OF CURE (TOC): Patient returns in 1 week for TOC with culture (if culture not avail, with NAAT)
* If reinfection suspected instead of treatment failure, OK to repeat treatment with CTX AZ 1g

37. 4. Ensure Partner Management
Patient referral
Ask patient to notify partner and ensure treatment
Suggest patient bring partner to clinic for concurrent treatment (“BYOP”)
Internet-based anonymous notification
Expedited partner treatment (EPT)
Patient-delivered partner treatment (PDPT)
Health department field-delivered treatment
Pharmacy-based
Provider or clinic-based referral
Health department referral

38. Legal Status of EPT in the U.S.
PERMISSIBLE 32 states
UNCERTAIN 11 states
PROHIBITED 7 states
CDC EPT Legal Status Updated August 2012

39. Online Partner Referral
Patients use website to notify partners
- anonymous
- free
- referrals for testing
inspot.org
sotheycanknow.org

40. Nadine 28 y/o non-pregnant female treated for CT
Nadine 28 y/o non-pregnant female treated for CT. When should you schedule her follow-up?
1 week for a TOC
3 weeks for a TOC
3 months for a test for reinfection
1 year for her annual exam
Not sure

41. 5. Retest for CT and GC at three months following treatment
Retesting Recommendations:
Retest all women and men with CT or GC months after treatment*
“Opportunistic” testing
Retest whenever possible, 1-12 mo
*CDC 2010 STD Tx Guidelines,

42. Repeat Chlamydial Infection is Common
Typical
Screening
Prevalence
Retesting
Hosenfeld C, et al. Sex Transm Dis Aug;36(8):478-89

43. Repeat Infection is Dangerous
Repeat CT infection leads to higher risk of complications: PID, ectopic pregnancy, infertility
Most infections are asymptomatic
Relative Risk
Hillis SD, et al. (1997). Am J Obstet Gynecol 176(1 Pt 1):

44. Chlamydia Care Continuum: Family PACT females age ≤25 years (N=686,327)
Total Est Cases
Cases detected
Cases treated
78%
92%
Pt returns 1-6 mo.
retested
60%
Pos at Restest
59%
Source: Family PACT Annual Report FY

45. Getting clients back in for retesting:
Counseling at treatment visit
Written materials
Advance appointments
Traditional reminder systems (telephone and postcards)
Text message and/or reminders
Downer SR et al Aust Health Rev 2006;30:389;
Leong KC et al. Fam Pract 2006; 23:699.

46. Appointment and STI Retest Reminders
For more information:

47. 6. Recommend the HPV Vaccine
Population
ACIP Recommendation
Gender
Age
Females
11-12
(as young as 9)
Routine vaccination with either HPV4 or HPV2
13-26
Routine catch-up vaccination either HPV4 or HPV2*
Males
Routine vaccination w HPV4
13-21
Routine catch-up vaccination HPV4
22-26
Permissive recommendation HPV 4
MSM & HIV+ Males
Routine catch-up vaccination HPV 4
Available now?  At all of our many clinic sites.
b.      What funding sources (VFC, various insurance, private pay) VFC and/or coverage for CHDP-approved and  managed Medi-Cal programs. Utilization of the Merck program for many of our clients in our community clinic setting when not covered and with insufficient income.
c.       Any idea of uptake? When offered and covered, the general acceptance, especially when framed as a cancer-preventative vaccine, is encouragingly high, even among children of relatively conservative parents presenting during CHDP physicals, which was not always the case.
d.      Any problems they have encountered? I am unaware of any problems with stock availability or reported adverse effects other than localized site tenderness
* Irrespective of history of abnormal Pap, HPV, genital warts
MMWR, May ; 59(20): ,
MMWR , December ; 60(50);

48. The HPV Family Mucosal HPVs (~40 types) Dermal HPVs Common skin warts
I’ll start by providing an overview of human papillomavirus family.
Currently, there are over 100 types of HPV. These HPVs can be separated into those that infected skin, also called dermal types, that cause common skin warts, and those that infect mucosal tissue, including genital and oral areas. Mucosal HPVs are transmitted through intimate and sexual contact. The genital HPV types can be further subdivided into high-risk types and low-risk types depending on their ability to cause cancer.
“Low-risk”
Wart types
“High-risk”
Cancer types

49. Incidence of Cervical HPV Detection in Women from the Time of Sexual Debut0%
10%
20%
30%
40%
50%
60%
70% 6 12 18 24 30 36 42 48
Cervical HPV Detection
Cohort study of 242 women with <= 1 lifetime partner followed for 48 months to assess incident HPV infection (PCR)
Cervical HPV infection was assessed using highly sensitive PCR tests.
By 4 years post sexual debut, over 60% of women were infected with HPV, demonstrating just how common HPV is.
The median time from the first sexual experience to HPV detection was only 3 months.
Time since first intercourse (months)
Collins et al. Br J Obstet Gynecol 2002;109:96

50. Clearance of HPV Infections Over 2 Years
Percent HPV Infected
On this graph you can see how quickly HPV infection goes away on its own without treatment. The line follows the clearance of HPV infections over 2 years.
These data are from a study of young women infected with HPV who were tested multiple times for about 24 months. As you can see, by 2 years, 90% of women infected with HPV, completely cleared their infection. The median persistence of any specific HPV type was only about 6 months.
HPV infection clears as a result of a healthy immune response which then provides type-specific protection from reinfection for at least 10 years.
Time from HPV infection (months)
Adapted from Brown et al. JID 2005:191;182

51. Low Risk Mucosal HPVs TYPES Most common: 6, 11
Others: 40, 42, 43, 44, 54, etc
DISEASES
Genital and oral warts
Respiratory papillomatosis
Low grade cervical Pap abnormalities
The most common low risk mucosal HPV types are 6 and 11, which account for about 90% of genital warts. These HPVs can cause genital and oral warts, respiratory papillomatosis, an infection of the vocal cords in infants exposed at birth, and low grade cervical abnormalities on Pap tests.
I’ll let you know here that the next 2 slides contain graphic pictures of the some of the diseases caused by low risk HPV types.

52. Anogenital Warts
Source: DOIA Website, 2000

53. HPV Vaccine Efficacy in Preventing Precancer and Warts
HPV Disease
HPV 4
HPV 2
FEMALES
CIN 2+
98%
Genital Warts
100%
---
VIN/VaIN 2+
MALES
Genital warts
90%
AIN
78%
CIN = Cervical Intraepithelial Neoplasia AIN = Anal Intraepithelial Neoplasia
VIN = Vulvar Intraepithelial Neoplasia VaIN = Vaginal Intraepithelial Neoplasia
Future II Study Group. N Engl J Med 2007;356(19):
Garland SM et al. NEJM 2007;356(19):
Paavonen et al. Lancet. 2009;374(9686):301-14
Giuliano et al. NEJM 2011; 364:401-11
Palefsky et al. NEJM 2011; 365:

54. ACIP Recommendations: Administration, Precautions and Contraindications
Synchronized dosing: 3-dose schedule, second dose at 1-2 months after first dose, third dose 6 months after first dose
Minimum intervals:
Minimum time b/w 1st & 2nd = 4 wks
Minimum time b/w 2nd & 3rd = 12 wks
Minimum time b/w 1st & 3rd = 24 wks
If schedule is interrupted, the series does not need to be restarted
HPV vaccines can be given simultaneously/before/after other vaccines
If possible, the same product should be used for all doses in the series
No change in cervical cancer screening recommendations
MMWR, May 28, 2010; 59(20): ,

55. ACIP Recommendations: Administration, Precautions and Contraindications
Pregnancy: HPV vaccines are not recommended for use in pregnant women; however pregnancy testing is not needed before vaccination. Any exposure to vaccine during pregnancy should be reported to the appropriate vaccine pregnancy registry: Pregnancy Registry: (Merck) or (GSK vaccine)
Contraindications: allergy to vaccine component, severe illness
Quadrivalent HPV vaccine contains yeast antigens
Bivalent HPV vaccine in prefilled syringes contraindicated for persons with anaphylactic latex allergy
 Adverse reactions should be reported to VAERS: or
MMWR, May 28, 2010; 59(20): ,

56. Vaccine Funding Programs
Vaccines for Children Program
Up to age 18, Medicaid eligible, uninsured or underinsured
Receiving immunizations through a Federally Qualified Health Center or Rural Health Clinic, or
Native American or Alaska Native
Merck Vaccine Assistance Program
Age ≥ 19, low income, and no health insurance coverage
Phone number (8a-8p EST)
Merck Dose Replacement Program
Vaccine doses provided but not reimbursed
GSK Vaccines Access Program
Age 19-25, income eligible, and no heath insurance

57. HPV Vaccine Uptake, Girls Ages 13-17
National Immunization Survey,
49%
44%
37%
25%
MMWR 2008 / 57(40):1100-3; MMWR 2009 / 58(36): ;
MMWR 2010 / 59(32): ; MMWR 2011 / 60(33):

58. 7. Offer Management for Recurrent/Persistent Vaginitis
Challenges in Managing Vaginitis
Patient factors
Self-treatment may preclude diagnosis
Clients seek help from multiple providers
Provider factors
Under-utilization of available tests
Insensitive clinic-based tests
Dependent on provider skills

59. Bacterial Vaginosis Decrease in lactobacilli
Polymicrobial overgrowth
Enzymes degrade the protective effects of cervical mucus and immune factors
Most common cause of vaginitis
Sequelae
SAb, PROM, PTL, PTD
Increases susceptibility to HIV, HSV, trich
Pathogenesis is unclear; Recurrence is common
Is BV an infection?
What is the microbial cause?
What is the association with sexual activity?
Photo: Seattle PTC

62. Bev….. “I have BV again!”
Recurrence rates as high as 30% at 3 months and 80% at 9 months
Etiology unclear
Resistance?
Re-infection?
Unrecognized trigger?
Failure of lactobacilli to recolonize?
Management
Confirm diagnosis
Condoms
No douching
Intermittent metronidazole gel (twice a week intravaginally)

63. Recurrent BV: Success with Suppressive Treatment
Recurrence
MTNZ
Placebo
P value
Prophylactic phase (4 mo)
Clinical
13/51 (26%)
26/44 (59%)
<.001
Gram Stain
8/45 (18%)
14/35 (40%)
.03
Observation phase (3 mo)
Clinical
26/51 (51%)
33/44 (75%)
.02
Gram Stain
17/45 (38%)
17/35 (49%)
.33
Sobel JD et al, Am J ObGyn. May 2006

64. Candice…….
Majority of women have no predisposing or underlying conditions
Non-albicans more common
Pathogenesis is unclear
Deficient host response?
Overactive host response?
Relapse/reinfection?
Photos; Mosby STD Atlas 1997 and Seattle STD/HIV PTC
Initial Treatment
Longer regimen of topical therapy (7-10 d)
Fluconazole (100 mg, 150 mg, or 200 mg) p.o. every 3rd d x 3
Maintenance Regimens
Fluconazole (100 mg, 150 mg, 200 mg) qw x 6 m
OR if not feasible
Topical antifungals used intermittently

65. Trixie….. CDC Consult & T. vaginalis susceptibility (404-718-4141)
First treatment failure, re-treat with:
Metronidazole 500 mg PO BID x 7 days
If repeat failure, treat with:
Metronidazole 2 g PO x 5 days
Tinidazole 2 g PO x 5 days
Susceptibility testing: send isolate to CDC
CDC Consult & T. vaginalis susceptibility
( )

66. Diagnostic tests for Trichomonas
BioMed Diagnostics
Needs incubator
Read at 3 and 5 days
Sekisui Diagnostics
CLIA-waived
Results in 10 minutes
83% sensitive compared
to culture
Gen-Probe APTIMA
Trichomonas vaginalis Assay
Same specimen types as for
other APTIMA tests
Close to 100% sensitive;
Slightly less sensitive using urine
Over 99% specific

67. Trich in HIV + Women Screen on entry to care
Retest at 3 months after treatment
Consider metronidazole 500 mg p.o. bid x 7d instead of stat dose

68. OH, NO!! She’s allergic to metronidazole!

69. Treatment Options with “Azole” Allergy
Consult with specialist
Metronidazole desensitization
Helms et al, Am J Obstet Gynecol 2008
Perlman et al, Am J Obstet Gynecol, 1996
Kurohara et al, j Allergy Clin Immunol, 1991
Paramomycin vaginal inserts
not as effective

70. 8. Encourage Good Old Condoms!
And last but certainly not least, good old condoms!!

71. Openers for a Conversation about Condoms
Tell me about your experience with condoms.
Some men take condoms almost for granted, and other men really dislike them. What about you?
How willing have you found guys to be about using condoms?

72. Making the Change
Goal: to improve patient care by improving medical practice What can you do on your own? What can you realistically influence? What can you advocate for?

73. THANK YOU!!!!
Questions?

74. A bit more info…..

75. Online STD Resources CDC Treatment Guidelines
California STD/HIV Prevention Training Center
California Department of Public Health STD Control Branch

76. California Laws and Regulations

77. STD Reporting to Public Health
Which diseases?
Syphilis  within 1 day
HIV/AIDS
Chlamydia, including LGV
Gonorrhea
Chancroid
Pelvic Inflammatory Disease (PID)
By whom?
Provider and Laboratory
To whom? The jurisdiction where patient resides
How? CMR to be completed by the provider
Within
7 days

78. Partner Management Provider Responsibility
The clinician should:
Attempt to determine the source of infection
Determine the intimate and sexual contacts of the infected patient
Make an effort with patient to bring in those contacts for exam and treatment
Persons determined as source of infection but not under treatment within 10 days of infection should be reported to the health officer
EPT is allowable for CT, GC, and trichomoniasis
CCR Title 17 §2636

79. Minor’s Rights to STD Care in California
Minors age 12 and above are able to consent to STD and reproductive health care without parental permission
As of January 1, 2012, minors may also consent to medical care related to prevention of STD (e.g., HPV vaccine)
Minors have a right to confidentiality
Parents are not liable for costs of STD care
Reporting requirements for non-consensual (and “unlawful”) sexual activity
CA Family Code §6926

80. Valacyclovir Group (N=743)
Transmission of HSV-2 to Susceptible Partners is Reduced with Once-Daily Suppression
1484 heterosexual couples randomized to 500 mg of valacyclovir vs placebo once daily for 8 months
Monthly serum samples collected from susceptible partners
Valacyclovir group showed
decreased transmission
lower frequency of shedding
fewer copies of HSV-2 DNA when shedding occurred
Valacyclovir Group (N=743)
Control Group (N=741)
Corey et al, NEJM 2004; 350(1):11-20.

81. Gardasil or Cervarix: Which is better?
BOTH HPV Vaccines:
Effective in preventing 16/18-related cervical dysplasia
Good safety profile
High cost
Gardasil advantages:
Protects against 6/11-related genital warts
Licensed for males
Indications vulvar/vaginal dysplasia
Cervarix advantages:
Higher titer levels
May give greater cross-protection against other oncogenic HPV types
Effectiveness data for preventing persistent re-infection