1. Stepping into the Future: Four Decades of Public Health STD Services in Seattle H. Hunter Handsfield, MD Professor Emeritus of Medicine University of Washington Former Director, STD Control Program Public Health-Seattle & King County (1978-2005)

2. Syphilis — Reported Cases by Stage of Infection, United States, 1941–2014 2014-Fig 31. SR, Pg 33

3. Gonorrhea — Rates of Reported Cases by Year, United States, 1941–2014 2014-Fig 12. SR, Pg 19

4. Public Health STD Clinics ~1910-1950 Designed primarily to manage syphilis and secondarily gonorrhea and other STIs Some programs had strong academic alliances and became centers of research (e.g. Johns Hopkins/Baltimore) Although designed to serve indigent patients, as centers of expertise many probably had fairly broad patient spectrum Secondary and tertiary care; not designed with prevention in mind or with a population orientation –“Public” health primarily meant that many people were affected “Contact tracing” functions start in the 1930s US Public Health Service “Venereal Disease Research Laboratory”

5. Public Health STD Clinics ~1910-1950 Modern public health concepts evolved starting in the 1930s –Thomas Parran “Shadow on the Land” –Federal (USPHS) “contract tracing” employees (“Field epidemiology”  “Epidemiologists”) (“Sex cops”) –US Public Health Service “Venereal Disease Research Laboratory”  Centers for Disease Control [and Prevention] Penicillin mid-1940s –Single dose or short course treatment –Wholesale shift to general care –Entire academic departments were disbanded

6. Public Health STD Clinics ~1950-1970 Municipal and state public health departments sharply curtailed STD services and/or shifted support to other programs (TB, vaccine preventable diseases, non-STD sexual health, etc) Federal (USPHS) support and personnel continued and expanded with nearly exclusive emphasis on contact tracing External research funding virtually disappeared However, in the 1960s… –Resurgent gonorrhea –Emergence of chlamydial infections, NGU, genital herpes and warts, and much of the currently recognized spectrum of STI syndromes –Compartmentalization of sexual health –Clinical demand rapidly exceeded resources

7. Seattle-King County Public Health STD Clinic 1970-78 Antiquated clinic on the 11 th floor of the Public Safety Building (Police Department) 90-120 patients/day, first come first served, wait times 1-8 hr, new patients after ~1 pm typically advised to return the next day Service providers –Physician/director (Alf H. B. Pedersen, MD, MPH) –Nurses (all female) “examined” women: speculum examination, GC Gram stains and cultures, saline and KOH microscopy; no bimanual exam –Male “clinicians” examined male patients; federal “epidemiologists” were often recruited to examine males –“Assembly line” approach: Clerical/demographic intake  Screener, medical history  Nurse/clinician  Lab (microscopy)  Nurse/clinician  [Physician]  Nurse/clinician for treatment (e.g. APPG/probenecid)  Contact tracing, sexual history

8. Seattle-King County Public Health STD Clinic 1970-1978 Dawn of modern STD research and intellectual ferment in the United States, also in its early stages in UK; microbiology/ID orientation –King Holmes (joining Andre Nahmias, Fred Sparling, Julie Schachter) –Integration with University of Washington based research and training NIH and CDC funding: Low competition for burgeoning resources Early trainees: Paul Wiesner, Jim Harnisch, Walt Carney, Walter Stamm, Dave Martin, Tom Quinn, Larry Corey, many more Service provision in the STD clinic Emerging pathogens and syndromes: C. trachomatis, HSV, HPV (warts), NGU, MPC, BV and other vaginal discharge syndromes Second clinic Harborview Medical Center, Feb 14 (Valentine’s Day) 1972 –Noon to 8:00 pm –Single clinician model –Academic orientation: Teaching, research –Rapid acceptance: Patients “voted with their feet” (PSB 18K  12K, HMC 15K by 1975)

9. Seattle-King County Public Health STD Clinic 1978-1990 PSB Clinic closes, all services moved to HMC –8:00 am – 8:00 PM –18K visits/year Expanding clinician responsibilities and roles Clinician-based model: Clerical intake  Midlevel practitioner: clinical history, exam, specimen collection, rapid lab tests, treatment, counseling  Contact tracing for selected patients –Midlevel practitioners (Nurse Practitioners, Physician Assistants) –Continued academic integration; formal affiliation and Community based services and screening: MSM (Seattle Gay Clinic, bath house screening and counseling, C. trachomatis screening) STD Prevention Training Centers

10. Seattle-King County Public Health STD Clinic 1978-1990 Public Health/UW Integration Joint recruitment for director with full time academic appointment –Soon replicated for other Public Health “Control Officers”: TB (Charlie Nolan), Communicable Diseases (Russ Alexander, Jeff Duchin), HIV/AIDS (Bob Wood) –One serious recruitment failure (the course of history doesn’t necessarily run smoothly) All funding and personnel converted to UW responsibility –Soon followed by assumption by UW of all responsibility for HMC –Priority patients dictated to UW by King County contract, including STDs –PHSKC rents STD program space from the University in a building owned by King County –The central importance of marital integration: Patricia McInturff Expanded clinical and sexual history data base, computerization

11. Seattle-King County Public Health STD Clinic 1978-1990 Public Health/UW Integration CDC: STD Prevention Training Centers Acceleration of federally funded (NIH) clinical and epidemiologic research Leadership: STD Program leadership and STD clinic medical director, typically post-ID fellowship –Ned Hook, Ann Collier, Jane Schwebke, Margot Schwartz, Beverly Leite, Connie Celum, Matt Golden Replication of the model: Denver (Frank Judson), San Francisco, Baltimore, etc, etc HIV/AIDS Prevention Program

12. Seattle-King County Public Health STD/HIV Control Program: Today Integrated STD/HIV Prevention Program Leadership: Director Matt Golden; Associate Directors Lindley Barbee, Julie Dombrowski Technological and operational advances –Triage model for expedited care –Sexual/STI history by CASI –Electronic medical record –Biomedical model of HIV prevention Integration and collaboration with UW/HMC HIV/AIDS Clinic (Madison Clinic) Local clinical management guidelines –Modeled on but distinct from CDC recommendations Expansion of PrEP

13. Components of Improving Primary Care for MSM in the UW System 1)Systematically identify MSM patients 2)Define specialty network of providers -All UW primary care clinics have a provider interested in MSM care -Center for transgender health 3)Train specialty providers 4)Make patients aware of specialty care 5)Alter EMR to promote standards of care

14. Implications for HIV/STD Program Organization Program integration Is it time to overtly promote HIV & STD program integration? Teams within these programs need greater integration Surveillance, field services, clinical Leadership Most programs have very limited physician or scientific leadership Need greater interaction with healthcare system, schools, policy-related capacity Can program expand new policy and collaborative work with the existing leadership structures?