1. Revision of Region II IPP Screening Criteria May 16, 2007 Region II IPP Advisory Committee Meeting Cicatelli Associates Inc. New York City

2. Region II IPP Strategic Plan 2005-2009  PRIORITY 1: Target/Expand Chlamydia Screening to Young Sexually Active Women and Men at Risk for Infection in Public and Private Settings. GOAL: All at risk men and women under the age of 25 will be screened at least annually. GOAL: All at risk men and women under the age of 25 will be screened at least annually. OBJECTIVE 1A: Revise regional screening criteria for females so that screening is targeted to the most at-risk populations by October 2007.OBJECTIVE 1A: Revise regional screening criteria for females so that screening is targeted to the most at-risk populations by October 2007.

3. Screening Workgroup Members  Eileen Crayne (NJ DHSS STD)  Debbie Polacek (NJFPL)  Jennifer Howard (PPGNNJ)  Steve Rubin, Preeti Pathela, and Julie Schillinger (NYC DOHMH STD)  Alison Muse (NYS DOH STD)  Gale Burstein (Erie County DOH) Facilitator  Kelly Opdyke (CAI - Infrastructure)

4. Region II Minimum Selective Screening Criteria* Title X Clinics  All women ≤ 24 years of age attending the clinic for an initial or annual visit will be screened for chlamydia STD Clinics  All women ≤ 29 years of age attending the STD clinic will be screened for chlamydia *Region II IPP, 2003 Protocols & Guidelines

5. Current Limitations of Screening Criteria & Proposed Revisions Areas of Consideration:  Client Age  Clinic Site Type  Pelvic Exam  Re-Screening  Males  Local Prevalence  Test Technology  Females ≥26 years

6. Criteria: Client Age Current Limitation  Criteria do not address screening among females age 25 years age bracket does not correspond with USPSTF or CDC criteria (<26 yrs); clients age 25 omitted age bracket does not correspond with USPSTF or CDC criteria (<26 yrs); clients age 25 omitted Proposed Revision  Criteria based on national standards all sexually active females age ≤25 yrs (i.e. <26 yrs) Includes expanding screening to females age 25 in Family Planning

7. Criteria: Clinic Site Type Current Limitation  Criteria do not address screening in sites other than STD or FP Proposed Revision  Criteria no longer specific to site type, but should consider local prevalence data

8. Criteria: Pelvic Exam Current Limitation  Screening contingent on pelvic exam Proposed Revision  Expanded to include limited service clients (no pelvic exam) using urine-based NAAT

9. Criteria: Re-Screening Current Limitation  Criteria do not address re-screening of positives (as per national guidelines) Proposed Revision  Expanded to include recommendation for re-screening positive females within 3-12 months as per CDC guidelines

10. Criteria: Males Current Limitation  Criteria do not address screening of males Proposed Revision  Provision for screening sexually active young males in high-prevalence settings

11. Criteria: Local Prevalence Current Limitation  Criteria do not address targeted screening based on local prevalence Proposed Revision  Recommendation for sites to adjust age criteria based on local age-specific prevalence (≥2%)

12. Criteria: Test Technology Current Limitation  No mention of preferred diagnostic test methodology Proposed Revision  Recommendation to use NAAT, as per CDC lab guidelines

13. Criteria: Females ≥26 Yrs Current Limitation  No guidance on testing in females outside of age criteria Proposed Revision  Recommendation for clinical considerations for testing females age 26 and over

14. Region II Minimum Selective Screening Criteria - Proposed  The Region II Infertility Prevention Project Chlamydia Screening Workgroup has developed selective screening criteria for chlamydia based on national recommendations provided by the CDC in the 2006 STD Treatment Guidelines (http://www.cdc.gov/std/treatment/2006/urethritis -and-cervicitis.htm#uc4). http://www.cdc.gov/std/treatment/2006/urethritis -and-cervicitis.htm#uc4http://www.cdc.gov/std/treatment/2006/urethritis -and-cervicitis.htm#uc4  Providers should follow CDC guidelines for screening and treating pregnant women.

15. Region II Minimum Selective Screening Criteria - Proposed FEMALESScreening  Annually screen all sexually active females ≤ 25 years of age for chlamydia. Re-Screening  All females, regardless of age, should be retested for chlamydia 3 months after being treated for a positive chlamydia test, or when they next present for care within the following 3-12 months.

16. Region II Minimum Selective Screening Criteria - Proposed MALES  Screening of sexually active young males should be considered in clinical settings with a high prevalence of chlamydia (e.g., adolescent clinics, job corps, correctional facilities, and STD clinics).

17. Recommendations for Implementation: Use of Limited Resources  Programs must consider implementation of these recommendations in relation to program resources, including fiscal, personnel, and technological.  The program’s aim should be to achieve the highest level of disease identification within this context.

18. Recommendations for Implementation: Test Technology  Use of highly sensitive and specific NAAT (nucleic acid amplification tests) is strongly recommended (http://www.cdc.gov/std/labguidelines). http://www.cdc.gov/std/labguidelines  Use of urine-based NAAT can facilitate non- invasive screening of females who do not require a pelvic exam, as well as males.

19. Recommendations for Implementation: Local Age-Specific Prevalence  Sites with an age-specific chlamydia prevalence rate of less than 2% * should consider further targeting screening criteria based on local prevalence data.  Conversely, sites with an age-specific chlamydia prevalence rate of greater than 2% * may consider expanding criteria.  *Adjusted for laboratory test type.

20. Recommendations for Implementation: Clinical Considerations Risk History  Multiple sex partners in last 90 days  New sex partner in last 90 days  STD infection in past year  Contact to STD  Possible non- monogamous partner Clinical Findings  Friable Cervix  Mucopurulent Cervicitis  Cervical motion/Tenderness  Pelvic Inflammatory Disease (PID)  Urethritis  New STD diagnosis  Bacterial Vaginosis Testing of females ≥26 years of age with one or more of the following documented risk factors or clinical findings may be clinically indicated:

21. Recommendations for Implementation: Test of Cure  Except in pregnancy, test-of-cure (repeat testing 3–4 weeks after completing therapy) is not recommended for persons treated with the recommended or alterative regimens, unless therapeutic compliance is in question, symptoms persist, or re-infection is suspected.

22. Rationale  CDC STD Tx and Lab Guidelines  USPSTF Ct screening recommendations  NCQA HEDIS measure for Ct screening  ACOG Pap guidelines for females <21 yrs  California Over 20 Study preliminary findings  Regional IPP data on high Ct prevalence among walk-in pregnancy test clients  CDC Males Screening Consultation outcomes

23. Breakout Groups Pro’s – Con’s  Science  Promotes Targeted Use of Limited Resources  Ease of Implementation

24. Next Steps  Which of the proposed revisions should be adopted?  What are the pros and cons to consider?  What other information do we need to move forward?  Region II IPP Screening Workgroup.