CT and GC Screening: What about the guys?! Gale R Burstein, MD, MPH, FAAP, FSAHM Erie County Department of Health SUNY at Buffalo School of Medicine Buffalo, NY

Questions 1) What are published federal agency and medical professional organizations’ guidelines for GC/CT screening sexually active adolescent males 1) What is evidence for published federal agencies and medical professional organizations’ recommendations for ♂ GC/CT screening?

Methods Evidence-based federal and national professional medical organization ♂ GC/CT screening recommendations collected and reviewed  Organizations: AAP, AAFP, ACOG, CDC, USPSTF Background papers reviewed

RESULTS Chlamydia

♀ Routine annual chlamydia screening AAPall sexually active ≤25 yrs ACOGall sexually active adolescents AAFP all sexually active <24 yrs CDC all sexually active ≤25 yrs USPSTF all sexually active <24 yrs

♂ Routine annual chlamydia screening AAP (draft) MSM (Q 3-6 mo if ↑ risk); Screen based on individual and population-based risk factors (CT-exposed in past 60 days); Consider screening if multiple partners and in clinic settings with ↑ prevalence, e.g., jails or juvenile detention, Job Corp, STD clinics, SBHCs, adolescent clinics AAFP Insufficient evidence to recommend routine screening CDC MSM (Q 3-6 mo if ↑ risk); CT-exposed in past 60 days Consider screening ♂<30 yrs in clinical settings with ↑ prevalence (e.g., adolescent clinics, jails or juvenile detention, STD clinics, SBHCs, EDs, Job Corp, military recruits); Insufficient evidence to recommend general population screening USPSTF* Insufficient evidence to recommend routine screening *Update in progress

EVIDENCE

CT Prevalence of Among Men Screened in 4 U.S. Cities* Objective: ♂ CT Prevalence in 4 U.S. Cities Methods: Urine CT testing offered to ♂ during in Baltimore, Denver, San Francisco, and Seattle in:  juvenile/adult detention  adolescent 1º care clinics  adult 1º care clinics  high school clinics  college clinics  health fairs,  street outreach programs,  CBOs  drug rehabilitation program *Schillinger JA, et al. Sex Transm Dis 2005;2:

Results 23,507 men tested at >50 venues in 4 cities  median age = 21 yrs  44% NH black; 25% Hisp; 19% NH white; 7%API; 10% other  96% asymptomatic overall ♂ CT prevalence = 7%  Location Baltimore=12% Denver=10% San Francisco=5% Seattle=1%  Age yo=8% yo=9% Schillinger JA, et al. Sex Transm Dis 2005;2:

Results cont’d Adolescent 1º care: 16% CBO: 12% High school clinic: 9% Adult 1º care: 8% Adult detention: 7% Juvenile detention: 6% Drug rehab: 5% Street outreach 3% College clinics: 3% School health fair: 1% Prevalence by venue Schillinger JA, et al. Sex Transm Dis 2005;2:

Program Cost and Cost-Effectiveness (CE) of Screening Men for Chlamydia to Prevent PID* Objective: determine if screening ♂ to prevent PID is CE Methods:  ♂ CT screening study data applied to estimate CE of CT screening strategies: ♂ screening expanded ♀ screening combining Disease Intervention Specialists (DIS) – provided partner notification (PN) with screening  Cases of PID and quality-adjusted life years (QALYs) lost were primary outcome measures *Gift TL, et al. Sex Transm Dis 2008; 35 suppl; S66-S75.

Results: Targeting high-risk ♂ (↑ # partners in past year and ↑ CT prevalence) for screening was cost saving vs. expanded screening of low-risk ♀  More cost savings if ♂ already receiving health screenings  Screening ♂ in general population not cost saving Combining PN with ♂ screening was more effective than screening ♂ alone Gift TL, et al. Sex Transm Dis 2008; 35 suppl; S66-S75.

RESULTS Gonorrhea

♀ Routine gonorrhea screening AAP (draft) all sexually active ♀ <25 yrs ACOGall sexually active ♀ adolescents AAFP all sexually active ♀ if ↑risk for infection (all young [<25 yrs] sexually active or persons with other individual or population risk factors) CDC all sexually active ♀ <25 yrs USPSTF* all sexually active ♀ if ↑risk for infection (all young [<25 yrs] sexually active or persons with other individual or population risk factors) *Update in Progress

USPSTF GC Risk Factors ♀ & ♂ < 25 yrs are highest risk for GC GC risk factors include: H/O GC, other STIs, new or multiple sexual partners, inconsistent condom use, sex work, and drug use. GC prevalence varies widely among communities and patient populations.  African Americans and MSM have higher prevalence of infection than general population in many communities and settings. Individual risk depends on the local epidemiology of disease.  Local public health provide guidance to clinicians to help identify populations at ↑ risk in their communities. In communities w/ ↑ GC prevalence, broader screening of sexually active young people may be warranted, especially in settings serving individuals who are ↑ risk. Clinicians may consider other population-based risk factors, i.e., residence in urban communities and communities with ↑ poverty rates Low community GC prevalence may justify more targeted screening

♂ Routine gonorrhea screening AAP (draft) MSM (Q 3-6 mo if ↑ risk); Contact in past 60 days; Consider screening on basis of individual and population based risk factors (persons of color, ↑ community prevalence) AAFP Insufficient evidence to recommend for or against routine GC screening for in ♂ at ↑increased risk for infection CDC MSM, contact in past 60 days USPSTF* Insufficient evidence to recommend for or against routine GC screening for in ♂ at ↑increased risk for infection *Update in Progress

USPSTF Justification for ♂ GC Morbidity from undiagnosed and untreated genital GC is lower in ♂ than in ♀ Clinical Sx more likely to lead to Dx and Rx in ♂;  prevalence of Asx GC in ♂ men is lower USPSTF judges small magnitude of potential harms of screening ♂ for GC Given low prevalence of Asx ♂ GC, USPSTF could not determine the balance of benefits and harms of GC screening in ♂ at ↑ risk for infection

QUESTIONS DISCUSSION