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STI Update

STI Update. HCET Region V Training Project Presenter: J. Dennis Fortenberry, MD, MS. Disclosures.

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STI Update

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  1. STI Update HCET Region V Training Project Presenter: J. Dennis Fortenberry, MD, MS

  2. Disclosures As stated in the No Conflict of Interest policy maintained by Health Care Education and Training, J. Dennis Fortenberry agrees to present the following information fairly and without bias. Funding for this program was provided through the Region V Training Project of Health Care Education and Training. No commercial financial support was used.

  3. Housekeeping • Please remember to complete the Pre-test, Post-test, Sign In form and Evaluation Forms. Fax to HCET at (317) 247-9055. • Save the Date for the EMR Series II Webcast on May 25th from 12:30-2:05 ET.

  4. Need Assistance? • For assistance with registration or presentation materials, call HCET at 317-247-9008. • For technical issues connecting to the Genesys Conferencing System, call the Genesys Help Desk:1-800-305-5208.

  5. J. Dennis Fortenberry Dr. Fortenberry is professor of pediatrics at Indiana University School of Medicine where he specializes in adolescent medicine. He has conducted research related to adolescents, sexual behavior, and sexually transmitted infections for almost 25 years. He also provides sexually transmitted disease (STD) care for patients of all ages at the local STD clinic.

  6. Learning Objectives After this presentation, you will be able to: • Discuss recent research, findings, and implications for Chlamydia screening. • Describe the significance of re-infection and retesting for Chlamydia and gonorrhea. • List strategies for partner notification and treatment for STIs.

  7. Sexually Transmitted Infectionsprevention and screening update J. Dennis Fortenberry MD MS Section of Adolescent Medicine Indiana University School of Medicine School of Medicine • .

  8. Sexually Transmitted InfectionsWhy STI are important in health care (especially for adolescents) • Most people become sexually active during adolescence • About 50% of new STI each year are in 15 – 24 year olds Sutton’s Law, attributed to the famous bank robber, Willie Sutton: - Why do you rob banks? - Because that’s where the money is.

  9. Sexually Transmitted InfectionsU.S. Chlamydia Rates among women and men, by age - per 100,000 Population (2007) 1.1 million cases Centers for Disease Control & Prevention, 2009

  10. Sexually Transmitted InfectionsIndiana Chlamydia Rates among women and men - per 100,000 Population (2007) Centers for Disease Control & Prevention, 2009

  11. Sexually Transmitted Infections Prevention

  12. Sexually Transmitted InfectionsMore successful approaches to STI prevention • Target behavior • Sexual behavior • Partner communication • Condom use • Screening and treatment • Education • Skills building and skills practice • Empowerment Kirby DB et al. Sex and HIV education programs: their impact on sexual behaviors of young people throughout the world. Journal of Adolescent Health. 40(3):206-17, 2007

  13. Sexually Transmitted InfectionsLess successful approaches to STI prevention • Threats and fear • Facts and data • Silence • Stigmatization • Abstinence only Fortenberry et al. Relationships of stigma and shame to gonorrhea and human immunodeficiency virus screening. Am J Public Health, 92:378-381, 2002.

  14. Sexually Transmitted InfectionsAbstinence-only as an inadequate public health STI prevention strategy • Fails to account for method failure • Non-developmental • Withholding of health information • Heterosexual bias Underhill K. Sexual abstinence-only programmes to prevent HIV infection in high income countries: Systematic review. Br J Med. 2007; 335:248-259 Trenholm C, et al. Impact of 4 Title V Section 510 abstinence education programs-Final report. Mathematica Policy Research Inc. 2007 Santelli J, et al. Abstinence-only education policies and programs: a position paper of the Society for Adolescent Medicine. J. Adolesc Health; 38:83-87, 2006

  15. Sexually Transmitted Infections Screening

  16. Sexually Transmitted InfectionsScreening as an STI prevention strategy • Many STI asymptomatic • Chlamydia • Gonorrhea • HSV • HIV • Failure to recognize risk • Stigma Centers for Disease Control & Prevention, 2006

  17. Sexually Transmitted InfectionsUS Preventive Services Task ForceRecommendations for Chlamydia screening • Older non-pregnant women at increased risk • All pregnant women at risk • No recommendations for screening of men • All sexually active women < 25 years US Preventive Services Task Force. Annals of Internal Medicine, 2007; 147:128-134. Rietmeijer K, et al. Chlamydia trachomatis positivity rates among men tested in selected venues in the United States: a review of the recent literature. Sex Trans Dis. 35:S8 – S18, 2008

  18. Sexually Transmitted InfectionsUS Preventive Services Task ForceRecommendations for Chlamydia screening • Older non-pregnant women at increased risk • All pregnant women at risk • No recommendations for screening of men • All sexually active women < 25 years

  19. Racial disparities in Chlamydia testing among women with STI symptoms Wiehe et al. Disparities in Chlamydia testing among young women with STI symptoms. (in press: Sexually Transmitted Diseases)

  20. Sexually Transmitted InfectionsScreening for Sexual Activity in AdolescentsWhen, how and who, what • When • Any health maintenance visit age 10 and older • Any “appropriate” sick visit • After discussion of confidentiality • Parents etc out of room • Following initial positives • How and who • “Do you have a boyfriend or girlfriend right now?” “Have you ever had sex with that person?” “Have you done anything sexual with that person?” • Yes • No • Not really • What • Penile/vaginal • Oral/genital • Penile/anal Ford CA, et al. Anticipatory guidance regarding sex: views of virginal female adolescents. J Adolesc Health 19:179-183, 1996. Reddy DM, et al. Effect of mandatory parental notification on adolescent girls' use of sexual health care services. JAMA. 288:710-714, 2002.

  21. Sexually Transmitted InfectionsAge at first coitus – Indianapolis % with no coital experience Tu et al. unpublished data

  22. Sexually Transmitted InfectionsTime from 1st coitus to 1st STI testby age at 1st coitus Median age of 1st test = 15 years Tu et al. Arch Pediatr Adolesc Med. 163:1106-1111, 2009

  23. Sexually Transmitted InfectionsTime from 1st coitus to 1st STI Tu et al. Arch Pediatr Adolesc Med. 163:1106-1111, 2009

  24. Sexually Transmitted InfectionsTime from 1st to Subsequent STI Tu et al. Arch Pediatr Adolesc Med. 163:1106-1111, 2009

  25. Sexually Transmitted InfectionsRepeat Screening for STI in Adolescents • Previous positives • Previous negatives Orr DP, et al. Subsequent sexually transmitted infection in urban adolescents. Archives of Pediatrics and Adolescent Medicine, 155:947-953, 2001.

  26. Chlamydia reinfection Batteiger BE, et al. Repeated Chlamydia trachomatis genital infections in adolescent women. Journal of Infectious Diseases 201:42-51, 2010.

  27. Sexually Transmitted DiseasesNucleic Acid Amplification TestsAdvantages • High sensitivity and specificity • Multiple tests on same sample • Can be used in non-traditional venues • Variety of specimen types • Cervical/urethral • Urine • Vaginal: consider self-obtained Cook RL, et al. Systematic review: noninvasive testing for Chlamydia trachomatis and Neisseria gonorrhoeae. Ann Int Med. 142(11):914-25, 2005

  28. Sexually Transmitted InfectionsSelf-obtained samples • Vaginal • Preferred sample • Better sensitivity than urine; equal or better than cervical • Can be used for wet mount as well • Anal-rectal • Not well tested for women • Oral-pharyngeal Hobbs et al. From the NIH: proceedings of a workshop on the importance of self-obtained vaginal specimens for detection of sexually transmitted infections Sexually Transmitted Diseases 35:8-13, 2008. Dodge et al. Field collection of rectal samples for STI diagnostics among MSM. Int J STD AIDS, 2010

  29. Sexually Transmitted DiseasesOther screening tests to consider • Human immunodeficiency virus • Herpes simplex 2 • Syphilis • Trichomonas Centers for Disease Control and Prevention. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR 55(RR14):1-17, 2006.

  30. Sexually Transmitted DiseasesOther Prevention Strategies • Partner Treatment • Condom use • Immunization

  31. Expedited Partner TherapyCorrelates of Medication Uptake and Use -1 Goldsworth & Fortenberry, Patterns and determinants of patient-delivered partner therapy uptake among healthcare consumers. Sexually Transmitted Diseases, 36:25:32, 2009.

  32. Expedited Partner TherapyCorrelates of Medication Uptake and Use - 2 Goldsworth & Fortenberry, Patterns and determinants of patient-delivered partner therapy uptake among healthcare consumers. Sexually Transmitted Diseases, 36:25:32, 2009.

  33. Expedited Partner TherapyCorrelates of Medication Uptake and Use -3 Goldsworth & Fortenberry, Patterns and determinants of patient-delivered partner therapy uptake among healthcare consumers. Sexually Transmitted Diseases, 36:25:32, 2009.

  34. Sexually Transmitted InfectionsCondom use for STI prevention • Consistent evidence for effectiveness • Chlamydia • Gonorrhea • Genital herpes • Human papillomaviruses • Syphilis • HIV • Efficacy for pregnancy prevention • Decline in use over time within relationships • Condom failure • Breakage • Slippage • Incorrect use Holmes KK et al. Effectiveness of condoms in preventing sexually transmitted infections. Bulletin of the World Health Organization 82:454-461, 2004 Fortenberry JD et al Condom use as a function of time in new and established adolescent sexual relationships. Am J Public Health 92:211-213, 2002

  35. Sexually Transmitted InfectionsInstructions for correct condom use • Open package near top • Check orientation but don’t unroll the condom • Unroll completely over erect penis • Check the tip • Lubricant • Practice

  36. Sexually Transmitted InfectionsImmunization for STI Prevention • Hepatitis B • Human papillomavirus prevention • Two vaccines • Quadrivalent vaccine (types 6, 11, 16, 18) • Bivalent vaccine (types 16, 18) • Women ages 9 – 26 • Men ages 9 – 26

  37. Sexually Transmitted Infections • The conundrum of STI prevention within the concept of sexual health • Prevention is mostly preparation • Diagnosis and treatment is prevention

  38. Sexually Transmitted InfectionsResources • http://www.cdc.gov/std/ • http://www.ashastd.org/ • http://www.iwannaknow.org/ • http://www.scarleteen.com/

  39. Thank you for your participation! • Visit www.hcet.org to view archived presentations and see a list of our upcoming events. • Remember to complete the Pre-test, Post-test, Sign In form, and Evaluation Forms. Fax to HCET at (317)247-9055.

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