1. INFERTILITY PREVENTION PROJECT (IPP) Roxanne Ereth, MPH STD Control Program Manager September 2, 2009

2. Infertility Prevention Project The IPP was established by the CDC and the Office of Population Affairs to reduce the incidence of sexually transmitted diseases that can lead to infertility. –Reduce infertility, ectopic pregnancy and chronic pelvic pain –Reduce STD-related neonatal infections –Reduce further infection

3. Infertility Prevention Project Funded through a portion of the CDC Comprehensive STD Systems Grant –Arizona Family Planning Council: Title X (Federal) family planning clinics 40 clinics, 3 juvenile detention centers and mobile vans –Title V (HRSA:State) funded family planning clinics 16 sites –11 Juvenile detention, 3 prisons

4. Infertility Prevention Project Title X Family Planning Program –Only federal grant program dedicated solely to providing individuals with comprehensive family planning and related preventive health services –Designed to provide access to contraceptive services, supplies and information to all who want and need them –By law, priority to persons from low-income families

5. Infertility Prevention Project Title V Family Planning Program –Federal-State Title V Block Grant Partnership Budget includes Federal funds, State matching funds, local maternal and child health funds, other funds, and program income. –For every $4 of Federal funds, at least $3 must be matched with State and local funds.

6. Infertility Prevention Project Goal Assess and reduce the prevalence of chlamydial infection and associated complications through: –Increased education and training –Targeted screening –Timely and effective treatment –Effective partner referral and treatment –Disseminate information to providers and policy makers.

7. Infertility Prevention Project Chlamydial infections cost the U.S. health care system $3 to $4 billion annually. –Management of women with PID and its complications –Management of infants hospitalized with chlamydial pneumonia

8. Infertility Prevention Project Chlamydia trachomatis: –Can cause cervicitis, acute pelvic inflammatory disease (PID), and pre- and postpartum maternal and infant infections. Accounts for 25 – 50% of the 1 million recognized cases of PID in the US each year. ~ 20% of women treated for PID will be infertile Another 18% will experience chronic pelvic pain from the infection ~ 6% will have an ectopic pregnancy Each year, more than 155,000 infants are born to chlamydia- infected mothers. Almost two-thirds of the infants born vaginally to chlamydia-infected mothers become infected during delivery and are at high risk for developing inclusion conjunctivitis and pneumonia. Most common cause of neonatal eye infections and of afebrile interstitial pneumonia in infants less than six months of age

9. Infertility Prevention Project Chlamydial infections are associated with increased susceptibility to and infectiousness of HIV infections. –Women and men infected with chlamydia or other STDs are three to five times more likely than non- infected individuals to acquire sexually transmitted HIV. –An HIV-infected person who also is infected with an STD may be three to five times more likely to transmit HIV to another through unprotected sexual contact

10. Infertility Prevention Project 70-90% of Chlamydia infections in women are asymptomatic and at least 50% are asymptomatic in men –Screen Cost-effective if prevalence is at least 3% in a given population Prevalence monitoring surveillance has indicated that women, less than 25 years of age, screened for chlamydia in family planning settings have a prevalence greater than 3%

11. Infertility Prevention Project Chlamydia trachomatis –The cervix of teenage girls and young women is not fully matured: probably more susceptible to infection

12. Infertility Prevention Project

13. Gonorrhea-related activities are being encouraged. –If gonorrhea is seven percent of the sum of gonorrhea and chlamydia among women <26 years of age, then a minimum of seven percent of total IPP testing funds should be devoted to targeted gonorrhea screening

14. Infertility Prevention Project Targeted screening –All sexually active females who are ≤ 25 years annually: most risk for PID –Sex partners of individuals who test positive –Due to funding: higher risk populations that include women presenting at STD clinics, in correctional settings and some family planning settings

15. Chlamydia tests performed in prevalence monitoring sites, among women ≤25 years of age Arizona, 2008 Facility Name Site Type#Tested#PositivePositivity Cochise Juvenile Detention Juvenile Detention Center19315.70% Coconino Juvenile DetentionJuvenile Detention Center5240% Durango Juvenile DetentionJuvenile Detention Center4044117.50% East Mesa Juvenile DetentionJuvenile Detention Center2653814.30% Mohave Juvenile DetentionJuvenile Detention Center971010.3% Pinal Juvenile DetentionJuvenile Detention Center1401611.4% Black Canyon SchoolJuvenile Detention Center16395.5% Pima Juvenile DetentionJuvenile Detention Center4348018.4% ASU FPTitle X FP467326.9% Care FPTitle X FP352174.8% Coconino FPTitle X FP724557.6% Mohave FPTitle X FP717415.7% Mt Graham TeenTitle X FP3184413.8% Pima FPTitle X FP27602318.4% Pinal FPTitle X FP128615712.2% Planned Parenthood of AZTitle X FP81996828.3% Yavapai FPTitle X FP1056615.8% Graham County FPTitle X FP711115.5% Gila County Health Dept.Title X FP661218.2% Maricopa FPTitle X FP229125.2% Estrella Jailnon-Title X FP3737921.2% Apache FPnon-Title X FP56610.7% Cochise FPnon-Title X FP2062411.7%

16. Chlamydia Tests Performed in Prevalence Monitoring Sites Among Women >25 years of Age Arizona, 2008 Facility Name Site Type#Tested#PositivePositivity ASU FPTitle X FP358143.9% Care FPTitle X FP8278.5% Coconino FPTitle X FP267134.9% Mohave FPTitle X FP10311.0% Pima FPTitle X FP1139403.5% Pinal FPTitle X FP685273.9% Planned Parenthood of AZTitle X FP823151.8% Yavapai FPTitle X FP539132.4% Graham County FPTitle X FP15213.3% Gila County Health Dept.Title X FP2600.0% Maricopa FPTitle X FP23762.5% Estrella Jailnon-Title X FP6147211.7% Apache FPnon-Title X FP2500.0% Cochise FPnon-Title X FP7711.3% Greenlee FPnon-Title X FP600.0% Graham County FPnon-Title X FP4824.2% La Paz FPnon-Title X FP3400.0% Navajo FPnon-Title X FP17642.3% Yuma FPnon-Title X FP1000.0% NAU FronskeOther3500.0% Coconino County JailJail10110.0%

17. Infertility Prevention Project Screening for women or men –Nucleic acid amplification tests are the most sensitive tests for detecting Chlamydia in women. –CT urogenital infection can be diagnosed by NAAT using urine or swab specimens collected from the endocervix or vagina. –NAAT for C. trachomatis performed on an intraurethral swab or urine specimen is the preferred test for men. Currently use GenProbe’s APTIMA dual test –Urine specimen

18. Infertility Prevention Project Recommended Regimens: –Azithromycin 1 g orally in a single dose OR –Doxycycline 100 mg orally twice a day for 7 days.

19. Infertility Prevention Project No person with Chlamydia trachomatis infection can be considered adequately treated until all of his or her sex partner(s) have also been treated.

20. Infertility Prevention Project http://www.azdhs.gov/phs/oids/std/index.htm EPT is a cost-saving and cost-effective partner management strategy. In April of 2008, Senate Bill 1078 was passed which amends ARS 32-1401.27 and 32-1854 to allow allopathic, naturopathic, and osteopathic physicians, or physician assistants to dispense or prescribe antimicrobial medications to contacts of patients with communicable diseases without an intervening health assessment of the partner.

21. Infertility Prevention Project Patient-delivered partner therapy (PDPT): patients take medication/prescription to their partner(s). Pharmacy access programs: partners obtain medication at a participating pharmacy. Field-delivered therapy: health department personnel deliver medication to partners.

22. Infertility Prevention Project Test of Cure –Non-pregnant patients do not need to be retested for chlamydia after completing treatment with a recommended or alternative regimen unless compliance is in question, symptoms persist or re-infection is suspected.

23. Infertility Prevention Project Re-Testing –3 months following treatment for detecting re- infection: occurs in 10-25% of persons –NAATs identify nuclear material from chlamydia organisms Positive tests may occur up to 4 weeks following adequate treatment. Retesting should not be performed prior to 4 weeks post-treatment.

24. Approximately 26,000 tests run at ASLS –No longer has the capacity –Can only run APTIMA (NAAT) More sensitive More expensive Infertility Prevention Project

25. Future plans/options –RFP for private laboratory posted –Proposals have been received and being evaluated Sites not under AZ Family Planning Council (Title V, Corrections) must have MOU –Ensure specimens submitted meet criteria –Discontinue sites with low prevalence or who don’t abide by criteria –Review single test option rather than CT and GC –Review restrictions for males

26. Infertility Prevention Project Region IX Guidelines http://www.centerforhealthtraining.org/proj ects/documents/2009%20Region%20IX% 20Chlamydia%20Clinical%20Guidelines.p df