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Screening and Treatment for Gonorrhea and Chlamydia as an HIV Prevention Strategy: Rationale and Implementation

Outline. Study on reasons for non-treatment of STDsImplementation of STD screening in public hospital walk-in clinicImplementation of STD screening in an HIV clinic. Background. Treatment of non-ulcerative curable STDs reduces HIV transmissionOptimal ways to use STD treatment to prevent HIV in

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Screening and Treatment for Gonorrhea and Chlamydia as an HIV Prevention Strategy: Rationale and Implementation

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    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

    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

    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

    15. Estimates of Treatment of STDs in Previous 12 months Males

    16. Estimates of Treatment of STDs in Previous 12 months Females

    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

    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

    27. Prevalence of STDs HIV Outpatient Program, New Orleans, 1998-2001

    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

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