1. Screening and Treatment for Gonorrhea and Chlamydia as an HIV Prevention Strategy: Rationale and Implementation Thomas Farley, MD MPH Tulane University Deborah Cohen, MD MPH RAND Corporation

2. Outline Study on reasons for non-treatment of STDs Implementation of STD screening in public hospital walk-in clinic Implementation of STD screening in an HIV clinic

3. Background Treatment of non-ulcerative curable STDs reduces HIV transmission Optimal ways to use STD treatment to prevent HIV infection in the U.S. are not known Determining primary reasons for non- treatment of STDs can help direct this strategy

4. Objective To determine the primary reasons why untreated non-ulcerative bacterial STDs in the U.S. are not treated Lack of symptoms?  Screening programs Failure to receive medical care for symptoms?  Reducing barriers to medical care Medical providers did not treat for STDs?  Provider education

5. Methods (1) Persons age 18-29 who were not seeking care for genitourinary (GU) symptoms at several sites in New Orleans were: Tested for gonorrhea, chlamydia and HIV using urine-based tests Surveyed on GU symptoms in the last 12 months If did not receive medical care for past GU symptoms, surveyed on barriers to care If received medical care for past GU symptoms, we requested and abstracted medical records

6. Methods (2) Estimates made of the total number of persons with STDs in the previous 12 months, the proportion treated, and the reasons for non-treatment in those untreated

7. Prevalence of Infection By Site * Among persons not seeking care for genitourinary symptoms

8. Prevalence of STDs by HIV Status

9. Relationship Between Symptoms and STDs - Females

10. Relationship Between Symptoms and STDs - Males

11. Reasons Why Care Not Received for Symptoms

12. Prior Medical Care Received for Possible STD-related Symptoms N=56 charts with prior visit for genitourinary complaints

13. Estimates of Natural History of Infection Reconstructed historical cohort of infected persons including: all found infected at screening all testing positive at prior medical visits for symptoms a proportion of persons treated presumptively for STDs at prior medical visits for symptoms.

14. Estimates of Treatment of STDs in Previous 12 months GonorrheaChlamydia n (est.) % of all % of untreated n (est.) % of all % of untreated No recognized symptoms28.345%86%14877%95% Symptoms35.256% 44.723% Did not receive care4.88%14%8.44%5% Received care, not treated0.00% 0.00% Received care, treated30.448% 36.319% Total63.5100% 193100%

15. Estimates of Treatment of STDs in Previous 12 months Males GonorrheaChlamydia n (est.) % of all % of untreated n (est.) % of all % of untreated No recognized symptoms7.534%83%60.989%98% Symptoms14.766% 7.511% Did not receive care1.57%17%1.12% Received care, not treated0.00% 0.00% Received care, treated13.259% 6.49% Total22.2100% 68.4100%

16. Estimates of Treatment of STDs in Previous 12 months Females Gonorrhea Chlamydia n (est.) % of all % of untreated n (est.) % of all % of untreated No recognized symptoms20.155%86%87.771%92% Symptoms16.744% 36.530% Did not receive care3.39%14%7.26%8% Received care, not treated0.00% 0.00% Received care, treated13.436% 29.324% Total36.8100% 124100%

17. Summary – Reasons for Non-Treatment Study Unrecognized infection was frequent for both gonorrhea (2.3%) and chlamydia (10.2%) and did not vary much by gender or site The most common reason for failure to seek care for symptoms was that symptoms were mild and transient A large majority of persons with untreated chlamydia or untreated gonorrhea were untreated because they never had symptoms

18. Conclusions and Recommendations The primary reason non-ulcerative bacterial STDs are untreated in the U.S. is most infected persons never have symptoms. The most effective way to use treatment of non-ulcerative STDs to prevent HIV infection in the U.S. is screening for gonorrhea at high-prevalence sites.

19. Prevalence of Infection By Site * Among persons not seeking care for genitourinary symptoms

20. STD/HIV Screening in a Public Hospital Walk-In Clinic Purpose was to determine if STD/HIV screening could be institutionalized by providing testing by no additional resources ER staff preferred screening in walk-in clinic rather than emergency area Screening available, offered by signs in waiting area and notification by providers From December 2000 - November 2001 592 persons tested (<1% of those seen)

21. Results of STD/HIV Screening Charity Hospital Walk-in Clinic, 12/00 – 11/01 21 (3.5%) had gonorrhea and 39 (6.6%) had chlamydia Difficult to locate people to ensure treatment 6 (1%) of 572 had HIV infection –3 (0.8%) of 379 females –3 (1.6%) of 193 males

22. Prevalence of Gonorrhea Charity Hospital Walk-in Clinic, 12/00 – 11/01

23. Prevalence of Chlamydia Charity Hospital Walk-in Clinic, 12/00 – 11/01

24. Summary and Conclusions STD/HIV Screening in Public Hospital Walk-in Clinic STD/HIV screening can be institutionalized in ER, but without external resources number screened will be low Staff time needed for locating infected persons for treatment

25. STD Screening in HIV Clinic 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

26. 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

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

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

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

30. Summary and Conclusions STD Screening in HIV Clinic STD screening in HIV clinics is feasible and relatively easy to implement Unless it is routine protocol, providers may not test as often as optimal STD prevalence is approximately equal that of demographically-matched persons who do not have HIV infection

31. The Future Public hospital walk-in clinic will continue screening Will try to improve compliance at HIV Outpatient Clinic Plans to expand STD screening to all public HIV clinics in Louisiana