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STD and HIV Emerging Issues. Gail Bolan MD Chief, STD Control Branch CA Department of Health Services Assistant Clinical Professor Department of Medicine, UCSF. Overview of Complications of Sexually Transmitted Diseases. Fetal Wastage* Low Birthweight* Congenital Infection*.

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std and hiv emerging issues

STD and HIV Emerging Issues

Gail Bolan MD

Chief, STD Control Branch

CA Department of Health Services

Assistant Clinical Professor

Department of Medicine, UCSF


Overview of Complications ofSexually Transmitted Diseases

Fetal Wastage*

Low Birthweight*

Congenital Infection*

Upper Tract Infection

Systemic Infection


Ectopic Pregnancy*

Chronic Pelvic Pain


Cervical Cancer*

HIV Infection*

* Potentially Fatal

10 core public health functions and std activities

Public Health Functions

STD Prevention Activities

Monitor health status


Diagnosis and investigate health problems

Screening and DIS follow-up

Inform and empower people about health issues

Health Education

Mobilize community partnerships and action

Community mobilization

Develop policies and plans that support efforts

Advocacy, strategic planning and guidelines

10 Core Public Health Functions and STD Activities
10 core public health functions and std activities1

Public Health Functions

STD Prevention Activities

Enforce laws and regulations

Legislation and Regulations

Link people to services and ensure provision of care when unavailable

Access to and provision of quality care

Ensure competent workforce

Staffing and staff development

Evaluate the effectiveness, accessibility, and quality of services


Research new insights and innovative solutions


10 Core Public Health Functions and STD Activities
std prevention and control strategies
STD Prevention and Control Strategies
  • Education and counseling (primary prevention)
    • Project Respect
  • Identification of asymptomatic persons (secondary prevention)
    • Screening
    • HEDIS
  • Identification of symptomatic persons (secondary prevention)
  • Effective diagnosis and treatment (secondary prevention)
    • Test Performance Characteristics
    • Empiric Treatment
  • Partner Management (primary and secondary prevention)
  • Vaccination ( ideally primary prevention)
syphilis overview of stages
Syphilis: Overview of Stages


5-50 years


Early Syphilis

Late Syphilis

epidemiologic vulnerability of syphilis
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
syphilis elimination public health importance
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
primary secondary syphilis cases by gender california 1996 2002
Primary & Secondary Syphilis Cases by Gender, California, 1996–2002

Rate per 100,000


known MSM


5/03 Provisional Data - CA DHS STD Control Branch

risk characteristics of msm p s syphilis cases california 1999 2002
Risk Characteristics of MSM P&S Syphilis Cases, California 1999-2002

1 Percentage excludes unknown

5/03 Provisional Data - CA DHS STD Control Branch

gonorrhea rates by gender california 1993 2002
Gonorrhea Rates by Gender, California, 1993–2002

Rate per 100,000

Source: California Department of Health Services, STD Control Branch

Provisional Data 05/16/2003


Gonococcal Isolate Surveillance Project (GISP), Percent of NeisseriaGonorrhoeae Isolates with Decreased Susceptibility or Resistance to Ciprofloxacin, California Sites, 1991–2002

Note: Resistant isolates have MICs ≥ 1 μg ciprofloxacin/mL. Isolates with decreased susceptibility have MICs of 0.125 – 0.5 μg ciprofloxacin/mL.

STD Clinic Sites: Long Beach, Orange, San Diego, San Francisco

Source: California Department of Health Services, STD Control Branch

Gonococcal Isolate Surveillance Project (GISP) - Location of participating clinics and regional laboratories: United States, 1998
gonorrhea treatment genital rectal infections in adults
Gonorrhea TreatmentGenital & Rectal Infections in Adults

Recommended regimens:

  • Cefixime 400 mg PO x 1 or
  • Ceftriaxone 125 mg IM x 1 or
  • Ciprofloxacin 500 mg PO x 1 or
  • Ofloxacin 400 mg PO x 1 or
  • Levofloxacin 250 mg PO x 1

PLUSif chlamydia is not ruled out:

  • Azithromycin 1 g PO x 1 or
  • Doxycycline 100 mg PO BID x 7 d
why chlamydia why now
Why Chlamydia & Why Now?
  • Most common communicable disease reported disease in California
    • Over 100,000 reported cases in 2001
    • 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
chlamydia action coalition

Chlamydia Action Coalition

A State-Wide Public/Private Partnership

funded by the

California HealthCare Foundation

chlamydia screening hedis measure
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

Numberof sexually active *

* Denominator may exclude plan employees to protect confidentiality


chlamydia hedis data warehouse
Chlamydia HEDIS Data Warehouse
  • Centralized Data Warehouse with Electronic Transmission of Chlamydia Screening Data
    • Collection of HEDIS numerator data
    • Prevalence Monitoring
  • Coordinate with ELR of communicable diseases
hipaa basics
HIPAA Basics
  • What is HIPAA?
    • Health Insurance Portability and Accountability Act
    • Provides the first national standards for protecting the privacy of health information
    • HIPAA Privacy Rule regulates how certain entities, called covered entities, use and disclose certain protected health information (PHI)
who is covered
Who is Covered?
  • Three types of covered entities
    • health plans, (e.g., Medicaid, Medicare, and the Veterans Health Administration)
    • health-care clearinghouses, (billing service, repricing company, or community health information system)
    • health-care providers who transmit health information in electronic form in connection with certain transactions (e.g., physicians, hospitals, and clinics)
impact on public health
Impact on Public Health
  • Public health uses PHI to identify, monitor, and respond to disease, death, and disability among populations
  • Privacy Rule expressly permits PHI to be shared by covered entities for specified public health purposes
  • Public health authority may also be a covered entity in some cases
permitted phi disclosures without authorization
Permitted PHI Disclosures Without Authorization
  • Where required by law
  • PHI can be disclosed to public health authorities and their authorized agents for public health purposes
  • Health research
  • Abuse, neglect, or domestic violence
  • Law enforcement
  • Judicial and administrative proceedings.
  • Cadaveric organ, eye, or tissue donation purposes
  • For oversight activities authorized by law
  • Worker's compensation
included public health activities
Included Public Health Activities
  • reporting of disease or injury
  • reporting vital events (e.g., births or deaths)
  • conducting public health surveillance, investigations, or interventions
  • reporting child abuse and neglect
  • monitoring adverse outcomes related to food (including dietary supplements), drugs, biological products, and medical devices
requirements for covered entities
Requirements for Covered Entities
  • Accounting for Public Health Disclosures
    • Covered entity must be able to provide a patient an accounting of disclosure even for disclosures permitted or required by law
  • Notice of Privacy Practices
    • individuals have the right to adequate notice of the uses and disclosures of PHI that may be made by the covered entity, as well as their rights and the covered entity's legal obligations
  • Minimum Necessary Standard
    • directs covered entities to limit the amount of information disclosed to the minimum necessary to achieve the specified goal
rapid hiv testing

Rapid HIV Testing

A key strategy of the Advancing HIV Prevention Initiative is to use rapid HIV tests to expand HIV testing outside clinical settings.


Reactive Control

Positive HIV-1



Read results

std resources for clinicians

STD Resources for Clinicians

California STD/HIV Prevention Training Center

CDC Treatment Guidelines

California Chlamydia Action Coalition

CA STD Control Branch