1. Sexually Transmitted Infections (STI) The Local (NYC) Perspective
Susan Blank, MD, MPH
Assistant Commissioner STD Control Bureau
New York City Department of Health and Mental Hygiene
Queens, New York

2. Financial Relationships With Commercial Entities
Dr Blank has no relevant financial affiliations to disclose. (Updated 09/05/19)

3. Learning Objectives
After attending this presentation, learners will be able to:
Describe local NYC trends in syphilis, gonorrhea (GC), and chlamydia (CT) in NYC, and in relation to HIV
Identify gaps in screening for CT, GC infections among men who have sex with men (MSM)
Use an incident STI diagnosis as an opportunity to discuss HIV testing and Preexposure prophylaxis (or treatment and Undetectable = Untransmittable (U=U)) with patients

4. Outline
Trends in STI epidemiology in NYC
Current, local NYC issues in syphilis, gonorrhea (GC) & chlamydia
Local Health Department Resources

5. Reported rates CT, GC, P&S syphilis, and HIV (per 100,000) New York City, 2007-2018*
Source: NYC Department of Health & Mental Hygiene (NYC DOHMH)

6. Sexually Transmitted Infections, 2017-2018, NYC & U.S.
Cases of STI reported to NYC Department of Health,
2018 vs. 2017
U.S.
Comparison
STI
2017
2018
% Change
(2017 vs. 2018)
(P&S) Primary and Secondary Syphilis
1,796
2,024
↑ 13%
↑ %
Latent Syphilis
6,192
6,348
↑ 3%
Gonorrhea
23,479
26,068
↑ 11%
Chlamydia
71,660
72,335
↑ 1%
Source: Bureau of STI, NYC DOHMH

7. ↑g bacterial STI & ↓g HIV rates…so what ?
1 in 42 HIV-neg MSM attending NYC STD Clinics were diagnosed with HIV within a year1
1 in 15 HIV-neg MSM (1 in 7 Black MSM) diagnosed w/ anorectal chlamydia/gonorrhea in NYC STD Clinics were diagnosed with HIV within a year2
1 in 20 HIV-neg MSM diagnosed with P&S Syphilis in NYC were diagnosed with HIV within a year3
So………
HIV prevention opportunities exist w/ dx of bacterial STI
1 Pathela P, Jamison K, Braunstein SL, Schillinger JA, Varma JK, Blank S. AIDS Behav May;21(5):
2 Pathela P, Braunstein SL, Blank S, Shepard C, Schillinger JA.  Clin Infect Dis 2015; 61(2)281-7
3. Pathela P, Braunstein SL, Blank S, Schillinger JA. Clin Infect Dis 2013; 57(8)

8. Syphilis Recently released monograph.
Google : “Syphilis Monograph, NYC”

9. Reported P&S syphilis case rates (per 100,000), by sex, New York City, 2000-2018*
*2018 data are preliminary
Source: Bureau of STI, NYC DOHMH

10. Reported male P&S syphilis case rates (/100,000), by race/ethnicity, New York City, 2000-2018
Source: Bureau of STI, NYC DOHMH

11. Reported sex of sex partners,male P&S syphilis cases, by race/ethnicity, New York City, 2018*
Source: Bureau of STI, NYC DOHMH

12. Reported congenital syphilis (CS) cases by vital status, and early syphilis (ES) rate (/100,000 women), NYC,
CS is a devastating outcome of untx’d syphilis in pregnant women (blindness, deafness, MS deformities, liver disease, stillbirth)
there has been a tripling of our small number of cases from 2017 to 2018, and there was one stillbirth among them
the NYC DOHMH has been leaning forward to identify and treat all syphilis in women of child-bearing age, and thus prevent CS altogether.
In nyc we are able to assure treatment to over 90% of early syphilis cases among pregnant people (vs about 772% nationwide).
Nationally, the most common cause is late entry into prenatal care.
In NYC, this is not the case, over half the cases of CS has been due to syphilis acquired during pregnancy….AFTER a negative first prenatal test.
In NYS , the law requires maternal screening for syphilis at first prenatal visit and at delivery
We have responded by proposing to the NYC board of health that a third syphilis screening test be required during the third TM, between 28 and 32 weeks gestation. We expect passage in October and implementation in early 2020.
Source: Bureau of STI, NYC DOHMH

13. Gonorrhea & Chlamydia
Slide 13 of 25

14. Reported gonorrhea case rates (/100,000),
by sex, New York City, *
Reported gonorrhea case rates (per 100,000), by sex, New York City, *
Source: Bureau of STI, NYC DOHMH

15. Reported chlamydia case rates (per 100,000),
by sex, New York City, *
CT screening for sexually active women under 25 yrs has been recommended for decades. (HEDIS, USPSTF), and in NYC screening coverage around 75%
For men, no real equivalent universal recommendations, though screening recs for MSM that include pharyngeal and rectal sites have existed in the last 10 years.
Source: Bureau of STI, NYC DOHMH

16. Reported gonorrhea case rates (per 100,000), by race/ethnicity, New York City, 2000-2018*
Source: Bureau of STI, NYC DOHMH

17. Reported chlamydia case rates (per 100,000), by race/ethnicity, New York City, 2000-2018*
Source: Bureau of STI, NYC DOHMH

18. Extragenital Ct/GC infections associated w/ concurrent negative urethral tests among MSM
Patton ME, Kidd S, Llata E, et al.
Extragenital gonorrhea and chlamydia testing and infection
among men who have sex with men—STD Surveillance Network, United States, 2010–2012. Clinical Infectious Diseases. 2014;58: .
Because these pathogens can affect the orifical sites of exposure and remain asx until there is irreversible damage (PID, epididymitis , arthritic, fistulae)
Need to do extra genital screening to find infections.
Basic urine screening is not enough, as you’ll miss most infections.

19. Reported male rectal gonorrhea and chlamydia cases, New York City, 2011-2018*
We do have evidence of more extragenital screening occurring.
Here you can see that over the last few years, the number of A-R cases reported to the health dept have increased….which is good news. Harkening back to the NYC risk measurements made by Pathela et al,, A-R infection in HIV neg men signals a risk for subsequent hiv among one in 15 (one in 7 among Blacks)……again every A-R infection among MSM is opportunity / obligation to assure HIV status assessed and PrEP (or HIV treatment) addressed.
The inset is of one the provider publications from DOHMHM to guide providers in this area.

20. Sentinel Lymphgranuloma Surveillance, NYC MSM attending NYC Sexual Health Clinics (since 2008)
Rectal Ct/GC NAAT testing for all men reporting receptive anal sex, at NYC PH Lab
Ct-positive male rectal swabs archived, and batch shipped to Wadsworth Lab (NYS PHL)
Multiplex PCR targeting omp1 gene confirms Ct-positive sample as L-2
(9-12% L-2)  2015 (18% L-2)
L-2 infection a/w: HIV status, rectal symptoms (14% asymptomatic)
In NYC SHC, presumptive treatment for LGV:
Patients with rectal symptoms suggestive of proctitis, or
Asymptomatic HIV positive patients with lab-confirmed rectal Ct infection
A quick note on LGV – no good commercial test, but evidence that it happens in NYC.
We know this b/c we archive ct positive A-R specimens and and every few years NYS DOH Labs will do surveillance testing for L1-3 servars of CT that constitute LGV.
Increasing prevalence we’ve found from 2008 through 2015 highlighted here.
Source: Bureau of STI, NYC DOHMH

21. Neisseria gonorrhea isolates with reduced susceptibility to select antibiotics1, NYC DOHMH Sexual Health Clinics, *
While culture is seldom used for gc diagnosis anymore, in NYC we do continue to collect culture specimens from the sexual health clinics and a couple of other sentinel sites.
We routinely collect cultures from pts symptomatic urethritis at one clinic site, and ayone who presents as a contact to GC.
Additionally, culture is done at involved oriface for patients who
-w/symptomatic presentations c/w GC
- presumptive GC treatmentTurning to GC and Abx
- return for treatment of GC+ NAAT
Last year approx cultures were sent, with about 1700 positive for gc. 
What this graphic shows is the # of GC isolates identified by the PHL with increased MICs, since the take home is that while yellow and blue bars for cephalosporins have remained few, in the last few years the number of isolates w/ decrease in MICs, d susceptibility to AZI have really increased….most of those represent very small MIC increases, but some very high mics have been recorded.
Important to note, though, that to date, in NYC we have not (yet) encountered GC superbugs requiring hospitalization or ertepenem-like agents.
Also, we have no evidence of transmission of drug resistant GC to date in NYC.
1 Expanded criteria for collection of specimens for GC culture was implemented al 6 additional Sexual Health Clinics between May-July 2018
*Results received through 8/21/2019
Source: Bureau of STI, NYC DOHMH

22. NYC Health Department Resources
Slide 22 of 25

23. NYC Health Department Resources
STI case reporting, NYC: electronic or phone
NYC Syphilis Registry: Patient results & treatment history
Google: “NYC DOHMH syphilis registry check”
STD Quarterly Reports: Citywide and SHC data
NYC Health Alert Network (HAN): public health notices for providers
Screening & Treatment Guidelines
STD Clinical Consultations,
Case reporting from providers is critical – labs routinely report results to us, but there is information only providers have – pregnancy status, staging/lesion info, race/ethnicity
* Includes unusual manifestations or GC cases with concerns about antibiotic treatment failure or resistance.
Source: Bureau of STI, NYC DOHMH

24. Thank You ! sblank@health.nyc.gov
Slide 24 of 25

25. Question-and-Answer
Slide 25 of 25