Overview of STD Epidemiologic Trends and STD Control Program Initiatives

1. Overview of STD Epidemiologic Trends and STD Control Program Initiatives Gail Bolan MD Chief, STD Control Branch CA Department of Public Health March 31, 2008

2. Overview Why STDs? Re-emergence of syphilis and implications for HIV transmission Chlamydia - the silent epidemic Emergence of drug-resistant gonorrhea

4. How STIs Increase the Risk of HIV Transmission

5. Increased Transmission of HIV in the Presence of other STDs By Increasing Susceptibility Mucosal breakdown due to genital ulcer may facilitate HIV entry Recruitment of WBCs to the site of active infection may act a an area of increased HIV receptors By Increasing Infectiousness Increase of HIV viral load in semen, genital secretions and genital ulcers

6. Increased Transmission of HIV in the Presence of other STDs Being infected with a STD may make it 2 to 23 times easier to transmit HIV, depending on the specific STD Identifying those with both HIV and other STDs and then treating their STDs, may be able to reduce new HIV infections by 23% Detection and treatment of STDs is an important HIV prevention strategy

8. STD Transmission Dynamics R0=ß D c

9. Core Populations Contribute a disproportionate share to the distribution of STDs Contribute to sustaining a changing STD rate in the community Contribute to transmission between individuals

10. 10 Core Public Health Functions and STD Activities

11. 10 Core Public Health Functions and STD Activities

12. STD Prevention and Control Interventions Health Education Behavioral Interventions Screening and Timely Treatment of Asymptomatic Persons Diagnosis and Timely Treatment of Symptomatic Persons Partner Management Vaccination Structural Interventions

13. Empiric STD Treatment Core STD Control strategy syndromes and contacts (“epi treat”) principle is to over treat the individual for the health of the community Independent of test results Prevalence threshold for empiric treatment is unclear Balance public health benefit with: individual costs prudent antimicrobial use

14. Diagnostic Considerations with Empiric Treatment Specific testing is recommended for prevention and public health purposes reporting and surveillance is mandatory additional case findings may occur through partner referral efforts patient referral education and risk reduction counseling may be more effective compliance with treatment regimens may be improved.

15. STD Prevention and Control Program Approaches Population-based Science-based Partnerships Integrate at the client level No one magic bullet Prioritize Evaluate and redirect efforts through available existing funds or new funds

16. Reportable STDs Which diseases? CT,GC, Syphilis, Chancroid, HSV, LGV, GI Syndromes- Non-gonococcal Urethritis (NGU) and Pelvic Inflammatory Disease (PID) By whom? Provider and Laboratory When? Within one working day versus within seven calendar days

17. Limitations of Current STD Surveillance Systems Problems with underreporting and empirical treatment Asymptomatic infections so many cases not detected Cases reflect who is accessing care No co-morbidity data No behavioral risk factor data

18. STD Surveillance in California

19. Gender Asymmetry of STDs:Why Women are at Increased Risk Women are more likely than men to get STDs Power dynamics Prevention technologies Anatomy Women are less likely than men to seek cure Frequency of symptoms Social stigma Women are more difficult to diagnose Women suffer more severe biological and social consequences

20. Normal CervixEffacement of Transitional Zone (SCJ)

21. Factors Contributing to Racial Differences reporting bias poverty and lack of access to health care high prevalence of STD in the community not disease susceptibility not behavior

25. Syphilis Treponema pallidum

26. Syphilis: Overview of Stages This slides gives an overview of the natural history of syphilis, with symptomatic and latent stages.This slides gives an overview of the natural history of syphilis, with symptomatic and latent stages.

27. Risk Factors for Syphilis socioeconomic class exchange of sexual services for drugs crack cocaine IDU multiple sex partners residence in high prevalence disease areas lack of access to health care

28. Risk Factors for Congenital Syphilis Lack of prenatal care (56%) Lack of screening during pregnancy (14%) Infection acquired late in pregnancy (14%) Treatment failure (8%) Physician delay (6%) Lab error (2%)

30. Epidemiologic Vulnerability of Syphilis No animal reservoir Long incubation period Limited infectiousness Low cost and widely available diagnostic tests Single dose therapy No antimicrobial resistance

31. Syphilis Elimination:Public Health Importance Important, measurable health outcomes Substantial cost savings Annual cost savings of ~1 billion Supports multiple public health goals Reduction of racial disparities Infectious disease control, including HIV prevention Bio-terrorism preparedness Reproductive health and infant health Identifies opportunities to improve public health infrastructure Focus for critical collaboration between communities & health departments Addresses unfinished history & broken trust

32. Key Steps Necessary to Eliminate Syphilis Improve surveillance capacity and use CD models Develop regional and local rapid outbreak response teams Design health care infrastructure for testing, treatment and prevention of at-risk persons, especially sexual and social networks Create partnerships and linkages with organizations serving at-risk populations

33. Syphilis EliminationNational Goals by 2005 Reduce P & S syphilis to <1,000 cases (0.4 cases per 100,000 population) California <150 cases Increase percentage of syphilis-free counties to at least 90%

35. Congenital Syphilis Cases in Infants < 1 Year of Age versus Female Primary & Secondary Syphilis Rates, California, 1990–2005

40. Why is syphilis increasing among MSMs? Improved HIV therapy, well-being, and survival “Prevention fatigue” Increased use of erectile dysfunction drugs, methamphetamine, poppers Old & new ways to meet partners Baths, parks Internet Anonymous partners False reassurance afforded by HIV serosorting? Lack of prevention emphasis in HIV primary care settings?

41. Sexual Risk Behavior Among MSM, San Francisco (1998-2003) In parallel with the increasing rates for syphilis and gonorrhea, there has been an increasing rate of high-risk sexual behavior among MSM. This slide represents trends in sexual risk behavior from 1998 to 2003 as measured by The Stop Aids project. The top yellow line represents report of unprotected sex with two or more partners in the last six months. The lower red line represents report of unprotected anal sex with two or more partners of unknown HIV serostatus in the past six months. Each line shows an upward trend since 1998. In parallel with the increasing rates for syphilis and gonorrhea, there has been an increasing rate of high-risk sexual behavior among MSM. This slide represents trends in sexual risk behavior from 1998 to 2003 as measured by The Stop Aids project. The top yellow line represents report of unprotected sex with two or more partners in the last six months. The lower red line represents report of unprotected anal sex with two or more partners of unknown HIV serostatus in the past six months. Each line shows an upward trend since 1998.

42. Selected Characteristics of MSM Syphilis Cases, California 2000-2005

44. Syphilis Prevention and Control Interventions Health Education Behavioral Interventions Screening and Timely Treatment of Asymptomatic Persons Diagnosis and Timely Treatment of Symptomatic Persons Partner Management (Vaccination) Structural Interventions

45. The Three “R”s of Syphilis Recognize Rx Report

46. Diagnostic Tests for Syphilis Darkfield / DFA-TP PCR VDRL/RPR FTA-abs / TP-PA (MHA-TP) EIA

47. Syphilis EIA Tests Treponemal test but test performance characteristics may be inferior to TP-PA (Captia) Can be used for screening but if positive then need quantitative RPR/VDRL Advantages if comparable sensitivity and specificity Not miss prozones Low cost Both IgM and IgG tests available No clinical value of IgM in adult syphilis diagnosis

48. Syphilis EIA Trep- Chek Testing Algorithm: Southern Kaiser

49. Syphilis Resistant to Azithromycin! I want to begin by discussing several important points of connection between STDs and HIV. I’m leaving out the maternal/child transmission issues today; and concentrating on issues related to sexual transmission. Most basically, we know that similar sexual and drug-use behaviors can transmit both STDs and HIV. But in addition to the actual behaviors, other biological factors come into play and can make transmission of HIV more likely or less likely. The potential interactions between HIV and STDs are in fact multiple and complex.I want to begin by discussing several important points of connection between STDs and HIV. I’m leaving out the maternal/child transmission issues today; and concentrating on issues related to sexual transmission. Most basically, we know that similar sexual and drug-use behaviors can transmit both STDs and HIV. But in addition to the actual behaviors, other biological factors come into play and can make transmission of HIV more likely or less likely. The potential interactions between HIV and STDs are in fact multiple and complex.

50. Syphilis TreatmentPrimary, Secondary & Early Latent Recommended regimen for adults: Benzathine penicillin G 2.4 million units IM in a single dose Alternatives (non-pregnant penicillin-allergic adults): Doxycycline 100 mg po bid x 2 weeks Tetracycline 500 mg po qid x 2 weeks Ceftriaxone 1 g IV or IM qd x 8-10 d Azithromycin 2 g po in a single dose

52. Bicillin® L-A for SyphilisError in Los Angeles County In March 2004, the Los Angeles Gay & Lesbian Center notified county health officials that it has given the wrong medication to about 300 syphilis patients seeking treatment since 1999 Clients were administered the penicillin formula Bicillin® C-R instead of the long acting penicillin formula Bicillin® L-A (benzathine penicillin G) The formula given to center clients contains only half the dose of benzathine penicillin G that CDC recommends for treatment of syphilis I want to begin by discussing several important points of connection between STDs and HIV. I’m leaving out the maternal/child transmission issues today; and concentrating on issues related to sexual transmission. Most basically, we know that similar sexual and drug-use behaviors can transmit both STDs and HIV. But in addition to the actual behaviors, other biological factors come into play and can make transmission of HIV more likely or less likely. The potential interactions between HIV and STDs are in fact multiple and complex.I want to begin by discussing several important points of connection between STDs and HIV. I’m leaving out the maternal/child transmission issues today; and concentrating on issues related to sexual transmission. Most basically, we know that similar sexual and drug-use behaviors can transmit both STDs and HIV. But in addition to the actual behaviors, other biological factors come into play and can make transmission of HIV more likely or less likely. The potential interactions between HIV and STDs are in fact multiple and complex.

54. Recent Examples of Missed Opportunities in California Case #1 9/26/03 30 year yo HIV-infected gay male presented to HIV care provider with a painful, erythematous rash on his groin. Rx with ketoconazole 10/2/03 returned to the clinic with a rash over 50% of his body and a serologic test was ordered. 10/9/03 returned again and a serologic test was ordered. 10/13/03 local health department received a lab report of RPR 1:8 and reactive TP-PA obtained on 10/2/03. 10/13/03 was Rx with Benzathine PCN 2.4 mu

55. Issue # 1: Missed or mistaken clinical features of symptomatic syphilis

56. Issue # 2: No presumptive treatment provided

57. Issue 3: Titer not collected near treatment date

58. Issue 4: Delays in Reportingby Labs and Providers

59. Public Health Management of Early Syphilis Cases, California 2003 Despite presentation of clinical manifestations of syphilis, diagnosis and treatment of this STD often are delayed Presumptive treatment of syphilis appears to be infrequent; more often, diagnostic testing guides treatment decisions Titers not obtained near date or treatment may make follow-up serologies difficult to interpret and assessment of treatment adequacy incorrect Reporting of syphilis is frequently delayed by both providers and labs, potentiating missed opportunities for prevention

61. Partner Referral Regulations California State Law Requirements Providers role- Instruction to the patient. It shall be the duty of the physician in attendance on a person having a venereal disease or suspect of having a venereal disease, to instruct such patient in a precautionary measures for preventing the spread of the disease, the seriousness of the disease and the necessity of treatment and prolonged medical supervision. The attending physician in every case of venereal disease coming to him for treatment, shall endeavor to discover the source of infection as well as any sexual or any other intimate contacts while the patient was in communicable stage of the disease. The physician shall make an effort through the cooperation of the patient to bring those cases in for examination and if necessary, treatment.

62. Traditional Partner Treatment Options for Syphilis Patient referral Provider or clinic referral Health department referral

64. Innovation in Partner Notificationvia Internet Individuals use Web siteto notify partners - anonymous - free - referrals for testing provided http://www.inspot.org

68. Phil and the Penis on the Go

69. ChlamydiaThe Silent Epidemic

75. Risk Factors for CT Infections unmarried status lower socio-economic conditions multiple sexual partners history of STD young age ectopy use of oral contraceptives concurrent gonorrhea

76. Chlamydia Prevention and Control Interventions Health Education Behavioral Interventions Screening and Treatment of Asymptomatic Persons Diagnosis and Treatment of Symptomatic Persons Partner Management Vaccination Structural Interventions

77. Why Chlamydia & Why Now? Most common communicable disease reported disease in California Over 100,000 reported cases Over 75% of cases are seen in the private sector Significant health consequences Most common cause of preventable infertility Facilitates sexual transmission of HIV New technology = new opportunity Urine tests & single dose treatment = easier to reach, treat & cure at-risk populations HEDIS increases private sector interest Potential public/private partnership

78. Action Agenda for Chlamydia Prevention and Control in California:  A Five Year Plan

79. California Chlamydia Action Coalition A State-Wide Public-Private Partnership funded by the California HealthCare Foundation State and local health departments Managed Care Organizations Community Based Organizations Private providers and professional societies Family Planning, school-based, and correctional programs Women’s Health Organizations Laboratories and University researchers Diagnostic and pharmaceutical companies Policymakers and the public California Health Care Foundation State and local health departments Managed Care Organizations Community Based Organizations Private providers and professional societies Family Planning, school-based, and correctional programs Women’s Health Organizations Laboratories and University researchers Diagnostic and pharmaceutical companies Policymakers and the public California Health Care Foundation

81. Clinic-based Chlamydia Screening Recommendations US Preventive Services Task Force, 2001 Sexually active women age 25 and younger should be screened annually Endorsed by the CDC, ACOG & other medical associations As of 2000, NCQA HEDIS measure In their 1993 STD Treatment Guidelines, the Centers for Disease Control and Prevention recommended routine screening for chlamydia in at risk populations. The CDC currently recommends annual screening for adolescents under age 20. Women ages 20-24 should be screened if they have new or multiple sex partners and inconsistent condom use. These or similar guidelines have been developed by the U.S. Preventive Services Task Force and many prominent medical societies: American Medical Association, American College of Obstetrics and Gynecology, American Academy of Family Practice, and American Academy of Pediatrics.In their 1993 STD Treatment Guidelines, the Centers for Disease Control and Prevention recommended routine screening for chlamydia in at risk populations. The CDC currently recommends annual screening for adolescents under age 20. Women ages 20-24 should be screened if they have new or multiple sex partners and inconsistent condom use. These or similar guidelines have been developed by the U.S. Preventive Services Task Force and many prominent medical societies: American Medical Association, American College of Obstetrics and Gynecology, American Academy of Family Practice, and American Academy of Pediatrics.

82. Chlamydia Screening HEDIS Measure The Measure: the percentage of Medicaid and commercially enrolled women 15 through 25 who were identified as sexually active, who were continuously enrolled during the reporting year, and who have at least one test for chlamydia during the reporting year. Number tested

83. Chlamydia Care Quality Improvement Toolbox A collection of resources that can be utilized by health plans, medical groups and provider organizations to: Educate physicians, providers, members and patients about chlamydia screening, diagnosis, treatment and public health laws Promote compliance with guidelines

84. Selection of Screening Tests Test sensitivity Test specificity, PPV and need for additional testing Ease of specimen collection Cost Other Need to test nongenital specimens (rectum, pharynx) Need for antimicrobial susceptibility testing

86. Tests to Detect Chlamydia EIA DNA probe DFA Culture NAATs * Sensitivity 50-65% 60-70% 65-70% 70-80% 85-90%

87. Recommend Nucleic Acid Amplification Tests for Detecting Chlamydia Noninvasive Urine and self-collected vaginal swabs Non-clinical settings Pelvic and genital exams not necessary Clinic intake areas Community based organizations Home testing

90. Are we screening the wrong women? The majority of women in the target age range (25 and younger) are NOT being screened Meanwhile A large proportion of current testing is being done for women over age 25

91. Chlamydia Test Volume and Prevalence by Age among Female Patients in Public and Private Clinics

92. Factors to Consider when Designing a Cost-effective Screening Program Prevalence of disease in population Sensitivity and specificity of screening criteria Test performance characteristics of diagnostic test Cost of test Cost of treatment and complications

93. Uses and Abuses of Screening Tests Screening tests are ubiquitous in practice Principles of screening are widely misunderstood Goal of screening is to test apparently well people to find those at increased risk of a disease or disorder Inappropriate screening is harmful Injurious to one’s health Stigmatizing Costly

94. When Earlier Diagnosis is Worth the Cost ? If improves survival or quality of life If the clinician has the time to manage the Dx before Sx develop If the patient with an earlier Dx will comply with intervention If the screening program effectiveness has been established If the test cost, accuracy and acceptability are acceptable to the patient and society (Sackett, Clinical Epidemiology: a basic science for clinical medicine)

95. Current Chlamydia TreatmentAdolescents and Adults Recommended regimens: Azithromycin 1 g PO x 1 Doxycycline 100 mg PO BID x 7 d Alternative regimens: Erythromycin base 500 mg PO QID x 7 d Erythro ethylsuccinate 800 mg PO QID x 7 d Ofloxacin 300 mg PO BID x 7 d Levofloxacin 500 mg PO QD x 7 d

96. Partner Treatment Options for Chlamydia Patient referral Provider or clinic referral Health department referral

97. Patient-Delivered Partner Therapy for Chlamydia Infection Untreated infection in male partner is a risk factor for repeat infection in women Repeat infections place women at increased risk of upper tract complications Single dose therapy is very safe and easy to administer PDPT reduces the rate of re-infection compared to patient referral PDPT legislation enacted January 1, 2001 Amendment to the Business and Professions and Health and Safety Codes Sets forth exceptions to the Medical Practice Act and is does not constitute unprofessional conduct “Notwithstanding any other provision of law, a physician, nurse practitioner, certified nurse-midwife, and physician assistant who diagnoses a sexually transmitted chlamydia infection may prescribe to that patient’s sexual partner or partners without examination of that patient’s partner or partners” Amendment to the Business and Professions and Health and Safety Codes Sets forth exceptions to the Medical Practice Act and is does not constitute unprofessional conduct “Notwithstanding any other provision of law, a physician, nurse practitioner, certified nurse-midwife, and physician assistant who diagnoses a sexually transmitted chlamydia infection may prescribe to that patient’s sexual partner or partners without examination of that patient’s partner or partners”

98. PDPT Clinical Trial: Reinfection Rates by Study Arm Diagnosis: Uncomplicated genital chlamydia infection First-line: Attempt to bring partners in for evaluation and treatment Priority patients: Females with male partners Partners: Males who are uninsured or unlikely to seek medical services Medication: Azithromycin 1.0 g orally once Number of doses: Limited to the number of sex partners in past 60 days Education materials must accompany medication Patient counseling: Abstinence until 7 days after treatment and until 7 days after partners have been treated Evaluation: Recommend re-test patients for chlamydia 3-4 months after treatment Adverse reactions: Report to 1-866-556-3730Diagnosis: Uncomplicated genital chlamydia infection First-line: Attempt to bring partners in for evaluation and treatment Priority patients: Females with male partners Partners: Males who are uninsured or unlikely to seek medical services Medication: Azithromycin 1.0 g orally once Number of doses: Limited to the number of sex partners in past 60 days Education materials must accompany medication Patient counseling: Abstinence until 7 days after treatment and until 7 days after partners have been treated Evaluation: Recommend re-test patients for chlamydia 3-4 months after treatment Adverse reactions: Report to 1-866-556-3730

99. Patient Delivered Partner Therapy Legislation in CA (Ortiz bill SB 648) Enacted January 1, 2001 Amendment to the Business and Professions and Health and Safety Codes Sets forth exceptions to the Medical Practice Act and is does not constitute unprofessional conduct “Notwithstanding any other provision of law, a physician, nurse practitioner, certified nurse-midwife, and physician assistant who diagnoses a sexually transmitted chlamydia infection may prescribe to that patient’s sexual partner or partners without examination of that patient’s partner or partners”

101. Infection During Follow-up Among Patients Completing the EPT Trial

102. Chlamydia and Gonorrhea Expedited Partner Treatment Expedited Partner Treatment (EPT) or Patient-Delivered Partner Treatment (PDPT) Add as option for partner management for heterosexual men and women First line management is clinical evaluation Concern regarding co-morbidities (e.g., PID in women, HIV in MSM) CDC will develop separate guidance on EPT/PDPT

103. The 3 most common barriers for both NPs and MDs were concern that PDPT results in incomplete care for the partner, concern that PDPT is dangerous without knowing the partner’s medical or allergy history, and concern that the practice will not be reimbursed About 35% of MDs and 25% of NPs were concerned about being sued, just over 20% thought that PDPT should only be given if the partner’s name is given, and fewer than 10% agreed that PDPT is only for male partners of female cases. Next looked at barriers as predictors of routine use of PDPT For both MDs and NPs, reporting one of 3 barriers was significantly associated with not routinely using PDPT in practice: concern about Incomplete care, not knowing medical/allergy history, and concern about being sued. Although concern that the practice of PDPT would not be paid for was common, it was not significantly associated with reported PDPT use. The 3 most common barriers for both NPs and MDs were concern that PDPT results in incomplete care for the partner, concern that PDPT is dangerous without knowing the partner’s medical or allergy history, and concern that the practice will not be reimbursed About 35% of MDs and 25% of NPs were concerned about being sued, just over 20% thought that PDPT should only be given if the partner’s name is given, and fewer than 10% agreed that PDPT is only for male partners of female cases. Next looked at barriers as predictors of routine use of PDPT For both MDs and NPs, reporting one of 3 barriers was significantly associated with not routinely using PDPT in practice: concern about Incomplete care, not knowing medical/allergy history, and concern about being sued. Although concern that the practice of PDPT would not be paid for was common, it was not significantly associated with reported PDPT use.

104. Chlamydia and Gonorrhea Repeat Infection1-6 months after infectionby Data Source, 2004 This is the epi curve for years 2001-2003 of gonorrhea cases by month in Butte County. These are all the cases. The aqua green represents Oroville cases, the light blue is Chico and the top grey is Other area. Oroville cases, represented in green, represent the majority of gonorrhea cases. For this reason we focused our investigation on Oroville case-patients.This is the epi curve for years 2001-2003 of gonorrhea cases by month in Butte County. These are all the cases. The aqua green represents Oroville cases, the light blue is Chico and the top grey is Other area. Oroville cases, represented in green, represent the majority of gonorrhea cases. For this reason we focused our investigation on Oroville case-patients.

105. Recommendations for Chlamydia Re-Testing after Treatment Prefer “re-testing” to “re-screening” High rates of re-infection after treatment Consider re-testing of females; some experts suggest re-testing of males Time frame: 3 months after treatment

106. Chlamydia Screening in Heterosexual Males Screening in males not routinely recommended Need evidence of reduction of infection in women to be cost effective However, selective screening in high prevalence populations may be beneficial Modeling suggests Chlamydia prevalence among males should be at least 6% CDC will develop separate guidance in this area

107.

109. Gonorrhea

114. Gonorrhea Increases in California, 1999 versus 2005

115. Gonorrhea Increases in California, 1999 versus 2005

116. Outbreak Response Alert providers Proper treatment Screen at risk asymptomatic patients Treat partners Investigate cases Risk patterns Refine prevention/intervention strategies

117. California Enhanced Syphilis / Enhanced Gonorrhea DataClinical Setting of Diagnosis by Gender - 2004

118. California Enhanced Syphilis / Enhanced Gonorrhea DataSelected Risk Data by Gender of Sex Partners - 2004

119. Emerging Antimicrobial Resistance Neisseria gonorrhoeae Treponema pallidum Herpes simplex virus Trichomonas Chlamydia trachomatis

120. Gonococcal Isolate Surveillance Project (GISP) : United States, 2003

122. Gonorrhea Treatment in California Recommended regimens: Ceftriaxone 125 mg IM x 1 Cefixime 400 mg PO x 1 Alternative oral regimen: Cefpodoxime 400 mg po x 1 Alternatives for PCN allergic: Spectinomycin 2 g IM x 1 Azithromycin 2 gm Co-treat for chlamydia unless ruled out by NAAT

123. for patients with gonorrhea in California…

124. California Enhanced Gonorrhea DataAny Fluroquinolone Use by Health Jurisdiction - 2004

125. HSV Issues Role of type-specific HSV serologic tests Role of suppresssive therapy to reduce transmission

126. Genital Herpes – Testing Issues Type-specific HSV-2 serology tests may be useful: Recurrent/atypical symptoms with negative culture Clinical diagnosis without lab confirmation Patients with a partner with genital HSV Some experts recommend serology tests: Patients who request testing or as part of “comprehensive STD evaluation” Multiple partners, HIV-infected, MSM with high HIV risk, (pregnancy) Universal screening NOT recommended

127. HSV Shedding and Transmission Asymptomatic shedding more common in first 2 years (5-10% of days), less common later (2% of days) Research with discordant couples finds sexual transmission ~12% per year 17% male to female 4% female to male Most sexual transmission occurs during symptomatic shedding Suppression therapy reduces both shedding and transmission

128. Rates of Transmission of HSV-2 to Susceptible Partners is Reduced with Once-Daily Suppressive Therapy NOTE: Shedding study was a substudy (N=89) of this one… source partners swabbed the genital region daily for 2 months for testing by PCR. If the source partner had recurrences, they were treated with episodic therapy of 500mg twice daily valacyclovir for 5 days, and then returned to randomly assigned medication. Corey L, Wald A, Patel R, Sacks SL, Tyring SK, Warren T, Douglas JM Jr, Paavonen J, Morrow RA, Beutner KR, Stratchounsky LS, Mertz G, Keene ON, Watson HA, Tait D, Vargas-Cortes M; Valacyclovir HSV Transmission Study Group. Once-daily valacyclovir to reduce the risk of transmission of genital herpes. N Engl J Med. 2004 Jan 1;350(1):11-20. NOTE: Shedding study was a substudy (N=89) of this one… source partners swabbed the genital region daily for 2 months for testing by PCR. If the source partner had recurrences, they were treated with episodic therapy of 500mg twice daily valacyclovir for 5 days, and then returned to randomly assigned medication. Corey L, Wald A, Patel R, Sacks SL, Tyring SK, Warren T, Douglas JM Jr, Paavonen J, Morrow RA, Beutner KR, Stratchounsky LS, Mertz G, Keene ON, Watson HA, Tait D, Vargas-Cortes M; Valacyclovir HSV Transmission Study Group. Once-daily valacyclovir to reduce the risk of transmission of genital herpes. N Engl J Med. 2004 Jan 1;350(1):11-20.

129. Genital Herpes – Treatment Issues Prevention of sexual transmission: Antiviral treatment at suppression dose Indications may include: discordant couples, persons with multiple partners, MSM Reassess discordant partner annually for seroconversion Counsel regarding condoms, disclosure, abstinence

130. Whew! Where to from here?

131. Data for Each County: www.dhs.ca.gov/ps/dcdc/STD/stddatasummaries.htm

132. STD Resources California STD/HIV Prevention Training Center www.stdhivtraining.org California STD Control Branch www.dhs.ca.gov/ps/dcdc/STD/stdindex.htm CDC STD Program www.cdc.gov/std California Chlamydia Action Coalition www.ucsf.edu/castd