1. Creating a Screening Algorithm for Sexually Transmitted Infections: Baiye N. Orock, MPH, U of S School of Public Health Dr. Mark Vooght, MHO, FHHR April 2015

5. Issue: Develop an Evidence-based STI Screening Decision Tool The development of an STI screening decision tool to be used by healthcare providers Screening to be risk-based ? This to be informed by conducting a literature review

6. RESEARCH QUESTIONS: 1. What are the evidence-based algorithms for identifying sexually transmitted infection risk factors and testing requirements in adult patients presenting to primary care? 2. What are the evidence-based guidelines regarding optimal risk grouping, age cohorts, risk categories, and timing of screening for sexually transmitted infections in adult patients?

8. Asymptomatic Patients:

9. Symptomatic Patients

10. Utilizing the Evidence: We predominantly used 6 STI Guidelines, to create a screening algorithm Risk-based

11. Offer routine screening (Chlamydia, Gonorrhea, HIV & Syphilis) to ALL sexually active clients. Yes No Syndromic management 1. Routine screening plus 2 HBV, HCV. As part of investigation, consider routine screening plus risk based screening below Are there any STI-related Signs & Symptoms? FemaleMale Is client pregnant? YesNo ALL < 25 &/or at high risk * ? < 30 & sexually active? Yes No Routine screening plus 3 HBV Routine screening plus 4 HBV, HCV. Routine screening Risk - based screening Yes Important: Go through ALL questions as client may be in more than one risk category SEXUALLY TRANSMITTED INFECTION/BLOOD BORNE PARTHOGEN (STI/BBP) SCREENING ALGORITHM Is this visit related to a sexual health concern?

12. Routine screening & Other 2 Add HAV 5, HBV 5, HCV. Add HBV 5. Add HBV 5 ; consider Chancroid #, LGV #, Granuloma inguinale # Add HBV 5, HCV. consider Parasitic 7 STI Using IV drugs or other addictive substances? Same-sex partner( MSM 6 /WSW) or bisexual? Sex trade workers and/or their clients? Recently in an STI endemic area 8 ? Are there any other risk factors 9 ? Client requests STI screening Risk-Based Screening: Important: Go through ALL questions as the client may be in more than one risk category:

13. SUPERSCRIPT: 1 - Focused primary and secondary prevention counselling; treatment as necessary and partner follow up. 2 – Offer routine screening and/or screening based on institutional or local prevalence of STI. 3 – For all pregnant women, Chlamydia and Gonorrhea screening recommended for first prenatal visit. If positive, re-test within 3 – 6 months. 4 – For all pregnant women at high risk, Chlamydia and Gonorrhea screening recommended for first and third trimesters. Also repeat HIV serology during labour for those at high-risk. 5 - Offer serological screening and immunize accordingly following Hepatitis A and B immunization recommendations as per the Saskatchewan Immunization Manual, available at: http://www.health.gov.sk.ca/sim-chapter10http://www.health.gov.sk.ca/sim-chapter10 6 – Sample collection for MSM should be at site of receptive/penetrative oral or anal sex (Pharyngeal, urethral and/or rectal). 7 – Examples of a parasitic STI include trichomoniasis, pubic lice and scabies. Screening may be necessary only for trichomoniasis. 8 – For a list/map of STI endemic regions/countries, refer to: http://www.who.int/gho/hiv/hiv_013.jpghttp://www.who.int/gho/hiv/hiv_013.jpg --- HIV -endemic regions http://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/sexually-transmitted-diseases.htmlhttp://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/sexually-transmitted-diseases.html -- Syphilis- endemic regions (see Table 3). NB: “The largest number of new infections occurs in the region of South and Southeast Asia, followed by sub-Saharan Africa, Latin America, and the Caribbean” CDC, 2011. SEXUALLY TRANSMITTED INFECTION/BLOOD BORNE PARTHOGEN (STI/BBP) SCREENING ALGORITHM STI /BBP Screening Algorithm

14. 9 - OTHER RISK FACTORS: -Sexual contact with person(s) with a known STI. -A new sexual partner or more than two sexual partners in the past year. -Serially monogamous individuals. -No contraception or the use of only non-barrier methods of contraception (i.e. no condoms). -Any individual engaging in unsafe (i.e. Unprotected) sexual practices -“Survival sex”: exchanging sex for money, drugs, shelter or food. -Anonymous or internet sexual partnering. -Victims of sexual abuse. -Previous history of STI -Living in an area with high prevalence of STI. HAV = Hepatitis A Virus. HBV = Hepatitis B Virus. HCV = Hepatitis C Virus. HIV = Human Immunodeficiency Virus. LGV = Lymphogranuloma venerum. #- Use professional discretion (i.e. screen based on prevalence of STIs in the countries recently visited). *- presence of one or more risk factors for STI/BBP. To maximise its benefit, this algorithm is to be used together with the “STI Risk Assessment in Primary Care Settings” tool. For further details please refer to the Canadian guidelines on Sexually Transmitted Infections and the Saskatchewan Communicable Disease control Manual available at: http://www.phac-aspc.gc.ca/std-mts/sti-its/cgsti-ldcits/index-eng.php http://www.health.gov.sk.ca/cdc-section5#page=2 ABBREVIATIONS Updated 2013-08-01

15. Utility of the Screening Tool: Used in concert with the STI Syndromic-based risk-assessment tool

16. Sexual health-related visit Presence of No symptoms signs/symptoms but concerns Non-Sexual health-related visit Brief risk assessment ( See back of page) Risk identified No risk identified *Routine Asymptomatic screening Minimal prevention counseling Maintenance of safer practices Discussion of future risk avoidance Focused risk assessment Focused prevention counseling Syndromic management Testing/screening Treatment and partner follow-up STI Risk Assessment in Primary Care Settings

17. Testing Code Key

18. Survey Conclusion & Recommendations: Recommendations  Development of an accompanying STI risk-based client questionnaire  Creation of a partnership with eHealth to develop a province wide format for the Electronic Medical Records (EMR) system.  Have strategically located patient-specific posters or monitor displays, with appropriate STI prevention and control messages (especially risk factors), at waiting areas in physician offices and health clinics  Of the Physicians, NPs and PHNs who participated in an implementation survey of the developed tools, (screening algorithm and clinical assessment tool): - 92% found them easy to use, - 46% found the algorithm cluttered - 100% rated the content as good to excellent, and