1. STD Screening in HIV Clinics: Value and Implications Thomas Farley, MD MPH Tulane University Deborah Cohen, MD MPH RAND Corporation

2. Background (1) Sexual Activity in HIV+ Persons ) Much emphasis in U.S. response to the AIDS epidemic is on identification, referral, and treatment of HIV-infected persons; however... …many HIV-infected persons continue to be sexually active after diagnosis and during treatment ) HIV prevention strategies should include intensive counseling to HIV-infected persons who continue to practice unprotected sex ) Identification of these persons needed

3. Background (2) STDs in HIV+ Persons ) Curable STDs facilitate the spread of HIV infection ) Diagnosis and treatment of curable STDs in HIV- infected persons helps prevent HIV infection in partners, even when infected persons continue unprotected sex ) STD screening and treatment in HIV clinics is essential part of overall strategy for HIV prevention ) Still, routine STD screening does not occur in most HIV clinics

4. CDC Guidelines: “HIV Prevention Through Early Detection and Treatment of Other Sexually Transmitted Diseases”* ) “Persons already infected with HIV should be screened routinely for STDs…including gonorrhea, chlamydial infection, syphilis, and -- among women -- trichomoniasis… Screening frequency should be at least yearly if any potential risk exists for STD acquisition. It should be performed more frequently if any incident STDs are detected by symptoms or screening. These services should be provided as part of and at the site of routine, quality HIV care. “ *MMWR 1998;47(RR12):1-24.

5. Background (3) STD Screening in HIV+ Clinic in New Orleans ) In October 1998, HIV/STD Programs in Louisiana began offering routine gonorrhea and chlamydia screening to HIV Outpatient Program (HOP) in New Orleans ) Screening by urine-based Ligase Chain Reaction (LCR) test ) Clinic: 2,500 active patients, 12,000 visits per year; 22% CD4 count < 200 ) Protocol routine urine screening at initial and biannual visits; but up to provider to order tests

6. Objectives )To determine the prevalence of gonorrhea and chlamydia and secular trends in prevalence among HIV-infected persons in care )To assess relationship between STD prevalence in HIV-infected persons and STD rates in general population )To assess value of continued routine STD screening in HIV clinics

7. Methods ) Analyzed data from gonorrhea/chlamydia laboratory slips from October 1998 - June 2001 ) Obtained data on number of visits and number of active patients from HOP clinic billing database ) Compared HOP clinic results to screening of convenience samples of persons 18-29 in New Orleans as part of unrelated study ) Compared HOP results to city-wide trends in gonorrhea and chlamydia obtained from Louisiana Office of Public Health

8. Relationship Between Visits and Tests HIV Outpatient Program, New Orleans, October 1998- June 2001 34,837 visits –Includes initial, routine follow-up and problem- focused visits 2,629 tests - 7.5% of visits Type for visit not available on lab test slip

9. Percentage of Active Patients Tested HIV Outpatient Program, New Orleans, June 2000-May 2001 25%176708White Males 33%8372,555Total 92 964 707 Patients* White Females Black Males Black Females 45%41 31%297 41%292 % TestedTested* * Unduplicated count for 12-month period

10. Prevalence of STDs HIV Outpatient Program, New Orleans, 1998-2001 TestedPositive % Positive Gonorrhea 2,629461.7% Chlamydia 2,629562.1%

11. Prevention Benefit of STD Screening Based on mathematical model* of the effect of STD treatment on HIV transmission: –Treatment of 46 HIV-infected persons with gonorrhea prevents 7 cases of infection in partners –Treatment of 56 HIV-infected persons with chlamydia prevents 12 cases of infection in partners –Total: prevention of HIV/AIDS in 19 persons * Adapted from Chesson and Pinkerton. JAIDS 2000;24:48-56

12. Prevalence of STDs by Race and Sex HIV Outpatient Program, New Orleans, 1998-2001

13. Prevalence of STDs by Age Group HIV Outpatient Program, New Orleans, 1998-2001

14. Convenience Sample to Estimate Population Prevalence of STDs Persons offered urine-based screening for gonorrhea, chlamydia, and HIV May 1999 – July 2000 Sampled from 10 sites in New Orleans, including: –Hospital emergency rooms and walk-in clinics –Dental clinic –Colleges –Facility for homeless youth –Vo-tech school Excluded persons seeking care for genitourinary symptoms Age 18-29 only; 82% Black, 14% White N=1,610

15. Gonorrhea Prevalence vs Convenience Sample of General Population New Orleans

16. Chlamydia Prevalence vs. Convenience Sample of General Population New Orleans

17. Secular Trends in Prevalence HIV Outpatient Program, New Orleans, 1998-2001

18. Trends in Prevalence Among Persons < 30 HIV Outpatient Program, New Orleans, 1998-2001

19. Trends in Prevalence Among Persons > 30 HIV Outpatient Program, New Orleans, 1998-2001

20. Comparison of Trends in Gonorrhea HOP Prevalence vs. Surveillance Data New Orleans, 1998-2001

21. Comparison of Trends in Chlamydia HOP Prevalence vs. Surveillance Data New Orleans, 1998-2001

22. Summary Among HIV-infected persons in care, 1.7% had gonorrhea and 2.1% had chlamydia Treatment of these infections prevented an estimated 19 cases of HIV/AIDS in partners STD prevalence did not vary substantially by race or sex, but was higher in persons under age 30 STD prevalence was similar to that of general population STD prevalence varied over time in parallel with population STD rates

23. Conclusions Routine STD screening in HIV clinics is feasible Screening and treatment for gonorrhea and chlamydia in HIV clinics prevents substantial number of HIV infections, even when prevalence is ~2%. HIV-infected persons in care continue to practice high risk sexual behavior, probably at about the same level and in the same sexual networks as the general population STD screening in HIV clinics identifies persons with curable STDs who can be treated and intensively counseled to prevent transmission of HIV to others

24. Recommendations Routine STD screening should be established in all HIV clinics, following CDC guidelines Intensive counseling and partner notification should be implemented for HIV-positive persons in care who have STDs Prevention of STDs in the general population should be considered an HIV prevention strategy, as it should lead to lower STD rates in HIV- infected persons and thus less HIV transmission