1. Infertility Prevention Project Region I November 15, 2010 Boston, Massachusetts Infertility Prevention Project Region I November 15, 2010 Boston, Massachusetts Steven J. Shapiro Infertility Prevention Project Coordinator CDC/NCHHSTP/DSTDP/PTB Disclaimer: The findings and conclusions in this presentation are those of the author and do not necessarily represent the views of the Centers for Disease Control and Prevention.

2. Topics National Infertility Prevention Project:  CSPS 2011  DSTDP Update  Health Care Reform  Gonorrhea  STD Treatment Guidelines  “What is IPP”

3. CSPS 2011 Technical Reviews Technical Reviews Additional Funds Additional Funds –1.546 million dollars in FY 2010 »$118K- National Chlamydia Coalition »$190K- Infrastructure Shortfall »$500K- “The Future of IPP” »$730K- Additional Project Area Funds Expansion of CT/GC screening and treatment services Expansion of CT/GC screening and treatment services Supplement to CSPS 2011 Supplement to CSPS 2011

4. DSTDP Update Personnel Changes Personnel Changes Agency Winnable Battles Agency Winnable Battles Consultations Consultations Guidelines Guidelines »Laboratory and Treatment 2009 STD Surveillance Report 2009 STD Surveillance Report »Online November 22

5. Health Care Reform What does this mean for CDC, in general, and STD Prevention specifically?

6. Health Care Reform Key Issues Key Issues –Performance Improvement –Affordable Care Act –National HIV/AIDS Strategy “The Future of IPP” “The Future of IPP” –Infrastructure-driven evaluation »IPP in the project areas »Environmental Scan »Recommendations for the Future

7. DRIP, DRIP, DRIP

8. Headlines you will never see………….

9. Bono Responds to Gonorrhea Outbreak

10. George Clooney accepts the Bob Hope Humanitarian Award For raising Awareness of Gonococcal Antimicrobial Resistance

11. President Obama signs Gonorrhea Elimination Bill

12. Gonorrhea Case Rates by Sex, 1999-2009* Women Men Rate per 100,000 *2009 data are preliminary

13. Gonorrhea Case Rates by Sex, 2004-2009 Women Men Rate per 100,000 *2009 data are preliminary

14. Gonorrhea Case Rates by Race/Ethnicity, 2004- 2009 Black American Indian Asian White Hispanic Rate per 100,000 *2009 data are preliminary

15. Gonorrhea Case Rates by Age Group, 2004-2009 15-19 30-34 20-24 25-29 Rate per 100,000 *2009 data are preliminary

16. Gonorrhea Case Rates Among Black Men and Women by Age, 2004-2009 Women15-19 Men 25-29 Women 20-24 Men 20-24 Rate per 100,000 *2009 data are preliminary

17. Gonorrhea is Not Increasing… In Fact, Gonorrhea May Be Decreasing  National Job Training Program  Decreases 2004-2009  NHANES  Numbers too small  Testing discontinued in 2009 (last cycle gonorrhea included: 2007-2008)  Despite…  More people being tested for gonorrhea?  Targeted screening efforts?

18. BUT….. New England New England –Maine 18% –Mass 20% –NH 47% –VT 24% –CT 3% –RI 11% Others –NJ 12% –NYC 12% –PA 23% –MD 9% –AK 26% –CA 14% –HI 8.5% –Guam 58% –PR 24%

19. 2010 STD TREATMENT GUIDELINES Up and coming (preliminary language only—final language pending):

20. Gonorrhea Treatment: Uncomplicated Infections of the Cervix, Urethra, and Rectum Cefixime (400mg PO) OR Ceftriaxone (250mg IM) PLUS Azithromycin (1g PO) OR Doxycycline (100mg PO, 2x/day, 7 days) (Regardless of whether or not chlamydia is ruled out)

21. Screening Among Pregnant Women: Chlamydia  2010: All pregnant women should be routinely screened for chlamydia during the first prenatal visit.  Retest during 3 rd trimester: Women aged ≤25 years and those at increased risk  If diagnosed with chlamydia in 1 st trimester, retest within 3-6 months (preferably 3 rd trimester)  Changes from 2006: Strengthened and clarified retesting language

22. Screening Among Pregnant Women: Gonorrhea  2010: All pregnant women at risk for gonorrhea or living in a high-prevalence area should be screened for gonorrhea during the first prenatal visit.  Retest during 3 rd trimester: Women at continued risk  If diagnosed with chlamydia in 1 st trimester, retest within 3-6 months (preferably 3 rd trimester)  Changes from 2006: Strengthened and clarified retesting language

23. Chlamydia Screening Among Young Women: 2010  Annual screening of all sexually active women aged ≤25 years is recommended, as is screening of older women with risk factors (e.g., those who have a new sex partner or multiple sex partners)...USPSTF updated their chlamydia screening guidance and found that the epidemiology of chlamydial infection in the U.S. has not changed since the last review. In issuing recommendations, USPSTF made the decision to alter the age groups used to demonstrate disease incidence (i.e., from persons ≤25 years of age to those aged ≤24 years). CDC has not changed its age cutoff, and thus continues to recommend annual chlamydia screening of sexually active women aged ≤25 years.

24. Chlamydia Screening Among Young Women: Changes from 2006  Age cut-off remains the same  Addresses USPSTF age change  No change to risk factors  Added language: Among women, the primary focus of chlamydia screening efforts should be to detect chlamydia and prevent complications, whereas targeted chlamydia screening in men should only be considered when resources permit and do not hinder chlamydia screening efforts in women.

25. Chlamydia Screening Among Men  2010: Although evidence is insufficient to recommend routine chlamydia screening in sexually active young men because of several factors (feasibility, efficacy, cost), the screening of sexually active young men should be considered in clinical settings with a high prevalence of chlamydia (e.g., adolescent clinics, correctional facilities, STD clinics).  Changes from 2006: Expansion to allow for venue- based male screening

26. Chlamydia Retesting: Women and Men  2010: Chlamydia-infected women and men should be retested approximately 3 months after treatment…If retesting at 3 months is not possible, clinicians should retest whenever persons next present for medical care in the 12 months following initial treatment.  Changed from 2006: Strengthened language

27. Gonorrhea Screening Among Young Women  2010: The prevalence of gonorrhea varies widely among communities and populations; providers should consider local gonorrhea epidemiology when making screening decisions. Widespread screening is not recommended. However, because infections among women are frequently asymptomatic, targeted screening of young women (i.e., those aged <25 years) at increased risk for infection is a primary component of gonorrhea control in the U.S.  Changes from 2006: Emphasis on targeted screening and use of local data, no change in risk factors

28. Gonorrhea Retesting: Women and Men  2010: Clinicians should retest patients 3 months after treatment…If patients do not seek medical care for retesting in 3 months, providers are encouraged to test these patients whenever they next seek medical care within the following 12 months.  Changed from 2006: Strengthened language

29. What is IPP Public Health Services Act Section 318A Public Health Services Act Section 318A CSPS Project Areas (64)- approx. 28 million annually CSPS Project Areas (64)- approx. 28 million annually –Based on historical formula »Initial distribution (early 90’s): Need and quality »Current distribution: Demonstrated and estimated need –Within CSPS structure (through 2013) DSTDP POC- Program Consultants DSTDP POC- Program Consultants Infrastructure (10)- approx. 2.2 million annually Infrastructure (10)- approx. 2.2 million annually –Funds awarded through OPA’s regional Family Planning Training Centers (3 year grant cycle, ending 6/30/2011). DSTDP POCs- ESB, PTB, SDMB, LRRB and HSREB DSTDP POCs- ESB, PTB, SDMB, LRRB and HSREB

30. Division Priorities IPP IPP –Prevention of STD-related infertility –Prevention of STD-related adverse outcomes of pregnancy –Strengthen STD prevention capacity and infrastructure –Address health disparities

31. Project Areas Goal: Goal: –Provide CT/GC screening and treatment services for at-risk women and their sex partners »Use of funds varies depending on project area

32. Project Areas Accomplishments: Accomplishments: –09-0902 CSPS »“Use your data” »3% CT positivity threshold established »Flexibility regarding “50% rule” »Continued expansion of screening and treatment services into non-FP/STD facilities »Increasing number of tests reported »Regional gonorrhea meetings: Target gonorrhea screening

33. IPP Funding Levels and Number of CT/GC Tests Reported, 2001-2009 Tests reported Funding

34. Project Areas Strengths Strengths –Well-established partnership between STD, FP, labs »Available forum to address program issues –Programmatic evaluations conducted at low cost –Leadership can look beyond categorical funding Weaknesses Weaknesses –Epi support varies from non-existent to extensive –Lack of publication/dissemination of special projects –Leadership is bound by categorical funding and history –Disease burden is larger than available resources

35. Infrastructure Goal: Goal: –Support and improve the ability of public health departments to implement IPP activities and promote interventions that prevent STD-related infertility Activities Activities –Administration –Coordination –Communication –Prevalence monitoring and data management –Education and program promotion –Enhanced activities –Independent laboratory consultant

36. Infrastructure - Accomplishments Establishment of infrastructure performance measures Establishment of infrastructure performance measures »Screening coverage estimates »Test utilization by age Establishment of pan-regional grant objectives Establishment of pan-regional grant objectives »Native American and Alaskan Native health care delivery systems »Development of pregnancy-test only epi profiles Data standardization Data standardization De-emphasis of regional screening criteria De-emphasis of regional screening criteria Epi-methods workgroup and process Epi-methods workgroup and process Enhancement of IHS Partnership Enhancement of IHS Partnership Support for regional GC meetings Support for regional GC meetings Increased submission and acceptance of conference abstracts Increased submission and acceptance of conference abstracts

37. Infrastructure Small Projects (examples) Small Projects (examples) »Pacific Island assessments »Collaboration with HMOs: Chlamydia trends and PID surveillance [ESB] »Provider adherence to screening criteria assessment »Adolescent confidentiality »EPT support »Cross-regional data analysis »Rescreening assessment »Concurrency study »Laboratory studies »Jail screenings [HSREB]

38. Infrastructure Strengths Strengths –Regions provide recognized leadership on a variety of issues –Partner with branches other than PTB –Extensive representation on National Chlamydia Coalition (NCC) –Independence fosters flexibility and critical thinking –Available funding mechanism –Partnership recognized as a successful model Weaknesses Weaknesses –Unable or unwilling to publish work –Ten distinct regional partners with varying levels of capacity

39. Questions?