Articles, Blog

Enhancing STI Screening in HIV Care with Julie Stoltey MD, MPH

August 13, 2019


(dramatic concert piano music) – [Alice] Good morning, everybody. This is Alice Gandelman, from the California
Prevention Training Center. We’re very happy that
everybody here has joined us for our webinar on improving
STD screening in HIV care. I am going to turn it
over to Majel Arnold, who is going to introduce the webinar at the Office of AIDS Care branch, Majel, are you there? Majel, I’m wondering if your phones are on mute by any chance? I think while we’re waiting for Majel to get sound, I’ll introduce and tell you a little bit
about our speaker today. We are going to be speaking. – Hi Alice. This is Majel, I
think, can you hear me? – Yes.
– Oh, fantastic, okay, great. We had our technical
assistance person here, who helped us out on it. Thank you, Marjorie. Good morning everyone. Should I go ahead and just get started? – Yes, please do, thanks.
– Okay, great! Good morning, everyone. Thank you for joining us on this webinar. I am Majel Arnold and I am the Chief of the Care Branch of
the California Department of Public Health in the Office of AIDS. I oversee the Ryan White
Part B HIV Care Program, the AIDS Medi-Cal Waiver Program, and the Care Housing
Unit, which also includes housing opportunities
for persons with AIDS, we also refer to it as HOPWA. Some of you may be aware
that the Ryan White Part B’s Clinical Quality Management Program and the California
Prevention Training Center are currently working together on a quality improvement project to improve STD screening in two of our Ryan White Part B funded clinics. The main goal of this
project is to increase gonorrhea and chlamydia extragenital or three-point testing, that is screening of urethral, pharyngeal, and rectal sites in men who have sex with men
and who are living with HIV. This project supports the
STD screening objectives that are listed in the California
2017-21 integrated plan and also STD screening
performance measures recommended by HRSA, Health Resources and
Services Administration, for patients who are served
under Ryan White funding. If you haven’t had a chance to see our California’s integrated plan, there’s a PDF copy on the
pod labeled Resources. And it’s located on the
right-hand side of your screen. The Office of AIDS partnered
with CAPTC for this project, because of their extensive
expertise in this area. The CAPTC has done a lot of work to increase the knowledge and skills of healthcare providers in the area of sexual health, including
extragenital screening of chlamydia and gonorrhea. So it’s a great pleasure
to introduce our partner, Alice Gandelman, who you
heard earlier on the call, who is the Director of the
California Prevention Center. And to tell you more about the project and to introduce our webinar presenter. – [Alice] Thank you, Majel. And hello again, everybody. I’m very happy to welcome
you to our webinar on improving STD screening and HIV care. Dr. Stoltey will be
speaking about a number of important STD screening areas, including extragenital screening
and sexual history taking. Julie Stoltey is a physician and a public health medical officer at the California
Department of Public Health in the STD Control Branch. She is also our clinical faculty, at the California
Prevention Training Center. And I’m happy to say that she has also just stepped in as our Medical Director. So we are really excited
to have Julie Stoltey with us in that capacity as well. She’s also assistant clinical professor in the Division of
Infectious Diseases at UCSF. In addition to her primary role, with the STD Control Branch. She also attends on the
Infectious Disease Service at the San Francisco VA Medical Center, so she’s got a lot of
experience to share with us. And just to say a little about
our clinical training center, we are one of eight
national training centers that is a part of the national network of STD/HIV Prevention Training Centers, who work with health
providers who diagnose, treat, and manage patients with STDs and HIV. We do a lot of HIV, STD
interactive work around PrEP, PEP, and a variety of STD issues. So without further ado, I think
I will pass it on to Julie. Julie. – [Julie] Great, thank you very much. We’ll just load up our
slides and get moving. I’m gonna start by covering
epidemiologic trends in chlamydia, gonorrhea, and syphilis, among men who have sex with men. Then review screening recommendations for STDs, including rectal and pharyngeal, gonorrhea, and chlamydia. Discuss methods and best practices for routinely conducting a sexual history. And then close by reviewing
recommended therapy for gonorrhea and chlamydia. And also highlight a couple of examples of complicated STD infections. Let’s take a look at the data. This slide shows trends
in chlamydia, gonorrhea, and early syphilis, which
is infectious syphilis acquired in the last year, in California over the last 25 years. You can see that chlamydia
has been increasing over most of that time period, with more recent increases
in gonorrhea and syphilis. Focusing in on chlamydia, this slide shows chlamydia incidence rates in California, demonstrated
by the blue line and the United States,
demonstrated by the red dotted line from 1990 to 2015. Chlamydia remains the most
common reportable disease in California, and in 2015,
was at its highest level since reporting was mandated in 1990. Here you see chlamydia
incidence rates by gender, with higher rates among
women compared to men. However, the rate increase among males, was 12% between 2014 and 2015, which was twice the rate
increase among females, which was six percent. This slide shows chlamydia incidence rates by gender and age group
for California in 2015. You can see that the highest rates are among adolescent and
young women ages 15 to 24, which may partially reflect the use of reproductive health services, including chlamydia
screenings for females. There are significant disparities with respect to
race/ethnicity for chlamydia, with the highest rates
among African Americans in California. Moving on to gonorrhea,
here you see gonorrhea rates in California, demonstrated
by the blue line, and the United States demonstrated by the dotted red line since 1941. They have largely tracked together with very significant increases
in the 1970s and early ’80s, then tracking down in the 1990s. But over the last several
years, California has seen very sharp increases in gonorrhea. This shows gonorrhea
incidence rates by gender for California from 1990 to 2015. Gonorrhea male cases more than doubled between 2011 and 2015. There were also increases in female cases, but those were of a smaller magnitude. Reasons for these increases
are not yet clear, but may include increased transmission, as well as increased
oral and rectal screening of men who have sex with men. The highest gonorrhea rates for males, were among ages 25 to
29, followed by those in their early 20s, then 30s. For females, the highest rates
were among ages 20 to 24. When California receives
notification of gonorrhea cases, frequently, the Confidential
Morbidity Report of the CMR is not filled out
and we do not get information about gender of sex partners. I’ll just make a quick plug
to remind healthcare providers to fill out your CMRs
when you diagnose a case, so that we can collect this information. We do have the California
Gonococcal Surveillance System, where we conduct enhanced surveillance on a random sample of
gonorrhea cases in California in order to gather information
that we wouldn’t get from routine reporting
by interviewing patients and their providers. On the last, you can see that from standard surveillance information, out of all male gonorrhea
cases in California, the vast majority have unknown
gender of sex partners, and it looks like only nine percent of gonorrhea cases occur in
men who have sex with men. However, from the interviewed cases in the California Gonococcal
Surveillance System, we learned that approximately
54% of gonorrhea cases among men in California were in MSM, and an additional nine percent were in men who have sex with both men and women. Here is additional information from the California Gonococcal
Surveillance System, which shows that almost half
of positive gonorrhea tests from men who have sex with men, were from rectal and pharyngeal sites without a positive urine site. For females and men who
have sex with women, the vast majority of positive
gonorrhea tests reported, are from a genial source. What about HIV status? Again, using data from the California Gonococcal
Surveillance System, we learned that 30% of
men who have sex with men with gonorrhea, were HIV positive and approximately 70% were HIV negative. And this slide shows that
among HIV negative men, who have sex with men with gonorrhea in the California Gonococcal
Surveillance System, 26% reported using PrEP in 2015. And this increased to 35%, who
reported using PrEP in 2016. Racial disparities persist
with rates of gonorrhea among African Americans five times higher than among whites in California. Now taking a look at syphilis. This slide shoes early
syphilis incidence rates in California since 1941,
relative to the U.S. California again with the blue line, the U.S. designated by the red line. Early syphilis cases continue to increase among all regions of California with a 29% increase
just from 2014 to 2015. The majority of syphilis
cases in California are among men who have sex with men. Even national CDC data from 37 states that report on gender of sex partner, and you can see that similarly, the majority of syphilis
infections in the U.S., are among men who have sex with men. Syphilis cases nationally are increasing in every region, but
the steepest increases are in the West. This again demonstrates CDC data for primary and secondary syphilis, with the reported cases
by sex, sexual behavior, and HIV status. You can see that among MSM,
approximately half the cases are HIV positive. However, the percentage of cases that are HIV positive, is
much smaller among women and men who have sex with only women. Either California data, and you can see that 56% of early syphilis cases among men who have sex with men in California are HIV positive, and
44% are HIV negative. What about PrEP use among
syphilis cases in California? This demonstrates the
increasing proportion of PrEP use reported by HIV negative men who have sex with men with
early syphilis in California between 2015 and 2016. And note that this does not include San Francisco or Los Angeles,
the rest of California. The highest rates of early
syphilis in California are among men ages 25 to
29, but high rates occur across multiple age groups. There are persistent disparities
in early syphilis rates by race/ethnicity, with
early syphilis male rates twice as high among
African American males, compared to white males. To summarize, STDs are
increasing in California. In 2015, men who have
sex with men made up 70% of male early syphilis cases and 63% of male gonorrhea cases in California. A high proportion of
the reported STD cases are in MSM who are HIV positive. Increasing percentages of HIV negative MSM with STDs are reporting PrEP use. Therefore, HIV care settings and clinics that prescribe PrEP, provide opportunities to improve STD screening, including rectal and pharyngeal testing among
populations at risk for STDs. Let’s talk about the
screening recommendations, including rectal and pharyngeal STDs. Now we have our poll. The question is, are rectal gonorrhea or chlamydia infections more likely to be symptomatic or asymptomatic in men who have sex with men? A, more likely symptomatic. B, more likely asymptomatic. C, don’t know, that’s why I’m here today. Or hopefully no one will
not vote, please vote. We’ll just wait a few more seconds, ’cause votes are still coming in. Okay, so we’ll close now. So you can see that most people voted that rectal gonorrhea
or chlamydia infections were more likely to be, more likely asymptomatic, which is correct and we’re
gonna talk more about that as we go on. I wanted to start off with
some background information about the interaction of STDs and HIV. STDs can increase the
risk of HIV acquisition and transmission by numerous mechanisms, including reducing
barriers to viral entry, increasing the number and density of HIV-1 receptor-positive
cells via the inflammation induced by STDs. Contributing an imbalance
of protective vaginal flora, and increasing HIV
concentrations in plasma, genital lesions, or secretions. There are also data out of
New York, among other places, that have shown that STDs
predict future HIV risk. Among HIV negative men
who have sex with men, one in 15 with rectal gonorrhea
or chlamydia infection, were diagnosed with HIV within one year. And among MSM with primary
or secondary syphilis, one in 18 were diagnosed
with HIV within one year. The risk was lower, but not low for MSM with no diagnosed rectal
STD or syphilis infection in this analysis. So what are our guidelines? The Centers for Disease
Control and Prevention recommend the following STD screening for men who have sex with men. All MSM should be tested
for HIV, syphilis, urethral gonorrhea and chlamydia, rectal gonorrhea and chlamydia, they’ve had anal sex,
and pharyngeal gonorrhea if they’ve had oral sex. And these tests should be
performed at least annually and more frequently, up
to every three months, if they have high risk, or increased risk, which includes having
multiple sex partners, anonymous sex partners, drug
use in conjunction with sex, having high risk partners. HSV-2 serology of the
considered recommendations from the CDC, all MSM should be tested for Hepatitis B and if they’re not immune, they should be vaccinated. And Hepatitis C testing should be done in HIV positive MSM at least annually, and more frequently, depending on risk. In terms of anal cancer
screening and HIV positive MSM, data are insufficient to
recommend routine screening for the CDC, but some centers do perform anal pap smears and high
resolution endoscopy. This shows STD screening recommendations for HIV positive men and women. And it’s similar to the prior slide, but notes that HIV positive women should be tested for Trichomoniasis and screened for cervical cancer. The United States Preventative
Services Task Force recently came out with updated syphilis screening recommendations for non-pregnant adults and adolescents, in which they recommended screening for symptomatic infection and persons with increased risk for infection. This was given a grade A recommendation, and the strongest
screening recommendations were for men who have sex with men, and HIV infected individuals. Here are some data that demonstrate the high prevalence of
bacterial STDs among MSM. These are data out of the
STD Surveillance Network, which is a national surveillance effort in select STD clinics
throughout the country. It shows the proportion of
men who have sex with men, attending these STD clinics, with primary and secondary
syphilis, gonorrhea, or chlamydia, stratified by HIV status. With HIV positive indicated by red, and HIV negative indicated by blue. And you can see that
there’s high positivity across the board for
syphilis, urethral gonorrhea. Pharyngeal gonorrhea, rectal gonorrhea, urethral chlamydia, and rectal chlamydia. And particularly high positivity, for rectal gonorrhea,
and rectal chlamydia, among HIV positive men
who have sex with men. This slide estimates the
proportion of persons living with HIV in California, that were diagnosed with an STD in 2014. Of over 124,000 persons
living with HIV in California, seven percent were co-infected
with at least one STD, chlamydia, gonorrhea,
or syphilis that year. This seven percent is
likely an underestimate, because this refers only to individuals who were diagnosed with STDs. And we know since so many
STD are asymptomatic, particularly rectal and
pharyngeal infections, many are under tested and under diagnosed. And most of these patients were male, and the majority were men
who have sex with men. And here we see the high incidence of STDs among individuals taking PrEP at Kaiser Permanente San Francisco. In one study, after 12 months of PrEP use, the incidence of any STD was 50%, and the incidence of rectal STD was 33% among this cohort of
individuals taking PrEP. Note that there were zero HIV infections in that time period. So given the CDC guidelines,
recommending screening for STDs among MSM,
including those on PrEP, and among HIV positive individuals, and given this data that
shows high positivity of STDs among HIV positive
MSM in STD clinics and in California, and high STD incidence among the population taking
PrEP in San Francisco, what else do we need to
know regarding screening for these infections? As I’ve mentioned, and as
many of you demonstrated in the poll, we know, the
majority of rectal infections in men who have sex with
men are asymptomatic. So these are data from
San Francisco City Clinic that showed that rectal chlamydia
and gonorrhea infections were approximately 85% asymptomatic compared to urethral chlamydia infections, which were usually, symptomatic, although could be asymptomatic. And urethral gonorrhea infections, which are symptomatic the
majority of the time in men. This shows the high proportion of rectal and pharyngeal
chlamydia and gonorrhea infections associated with a negative urine test. And neither data, again, out of the STD Surveillance Network, looking at men who have
sex with men, over 21,000 who attended STD clinics. And what you could see,
is that if you look at positive pharyngeal
gonorrhea infections, 74% of the time, this was
associated with a concurrent, negative urethral test. So if you’re testing only the urine, you’re missing pharyngeal gonorrhea test. For positive rectal gonorrhea
tests, 72% of the time, this was associated with a
concurrent negative urethral test and looking at all the way on the right, if positive rectal chlamydia test, 88% of the time, this was associated with a concurrent negative urethral test. So we have to screen the sites. Just to show another
study to demonstrate that. If we screen only with a
urine nucleic acid test for gonorrhea or chlamydia, will we identify pharyngeal
and rectal infections? And we’ll miss the majority of cases, and these are the data,
again out of San Francisco that showed if you test only
the urine for chlamydia, you miss 77% of chlamydia infections. And if you test only
the urine for gonorrhea, you miss 95% of gonorrhea infections. So here are the CDC recommendations for an MMWR published in 2014, for the lab-based detection
of chlamydia and gonorrhea. And what they found were
that NAATs were recommended for the detection of
genital tract infections in men and women with
and without symptoms. The optimal specimen types are first catch urine for men and self-collected
vaginal swabs for women. NAATs were also recommended
for the detection of rectal and oropharyngeal infections. These are more sensitive than culture, they’re not FDA approved for
rectal pharyngeal specimens, but they remain the
preferred and CDC recommended testing method over culture. So although not having been cleared for the rectal and pharyngeal testing with chlamydia and gonorrhea, they can be used by labs that have undergone validation procedures and met all the regulatory requirements for an off-label procedure. And there are multiple
large commercial labs that accept these specimens. There’s also an opportunity
for self-collection, which also requires validation
I’ll talk about in a second. And then, the PTC and the California
Department of Public Health can assist with lab
protocols and billing codes. And here on this slide, we have some of those NAAT ordering and billing codes for your reference, and these slides will be made available. Talking about self-collected rectal and pharyngeal STD testing,
this has been found to be highly acceptable to patients with similar performance compared to clinician-collected specimens. Self-collection can be
performed at the lab along with blood draw/urine collection or in the exam room before or after the provider visit, allowing
for potential streamlining of the collection of the specimens. It potentially can save a
patient an office visit, it can save the provider time. And standing orders and
electronic medical records may facilitate patient-collected testing. I just wanted to show one example that this is available online at the I Want the Kit website. A patient instructions for self-collection of a rectal swab and
there are other examples of these as well. So despite high prevalence
of STDs and guidelines recommending tests, there’s
suboptimal STD screening among men who have sex
with men in HIV care. This reports the percent
of sexually active HIV positive MSM that
were screened for STDs in the Medical Monitoring Project. And you can see, that over
half of the individuals were screened for syphilis,
and only approximately 20% were screened for chlamydia or gonorrhea. In San Francisco in the
Medical Monitoring Project, many sexually active HIV
positive clinic patients, who self-reported being tested for gonorrhea or chlamydia,
did not have evidence of testing when data were extracted from the medical record. And testing was low, 35%
for gonorrhea and chlamydia. We have also seen that recommended annual gonorrhea and chlamydia screening, demonstrated by the darkest
line in this figure, lags behind lipid screening,
which is the light gray line, in seven HIV Care Clinic studies here. So where do we go from here? Well, we need to take a sexual history in order to identify appropriate
clinical intervention. So let’s discuss methods
and best practices for routinely conducting a sexual history. How do we know if our patients are at risk for STDs and HIV? Infections are commonly asymptomatic, so relying on report of
symptoms is not adequate. And discussions about risk
behaviors are necessary. A basic sexual history is important, because it guides our clinical services and prevention efforts
by allowing the provider to individualize STD and HIV related care and prevention efforts with the client. An accurate sexual history helps direct the physical exam and decisions about STD testing and screening, which can lead to the
detection of disease, subsequent treatment, and
prevention of serious sequelae. The sexual history and risk assessment also give the provider
important information to use in counseling the patient regarding risk reduction efforts. When done in a clear and
a non-judgemental way, good rapport is established between the patient and the provider, and the patient can feel comfortable discussing his or her personal situation and asking questions. It also enable referrals
to specialized services, such as substance abuse services. Patients and providers may have concerns related to confidentiality
of the information discussed, and providers may have some discomfort discussing sexual issues. They may not know what
to ask or how to ask it. And then they don’t know what
to do with the information. And they might be concerned
about getting it done in the limited time that they have to do everything else. Barriers to taking a
sexual history may include structural barriers,
including limited time for appointment, in which we have to cover many other pressing items, reimbursement concerns,
issues with de-prioritizing sexual health in general
and STD prevention, in particular, in light
of other medical issues. In dealing with the acute
issues as they arise, rather than taking a
preventative proactive approach. Providers may lack
familiarity with the content of the language, may think
taking a sexual history is harder than it actually is, and may have inadequate
training or practice. And providers may have discomfort
discussing sexual health. There’s a great quote from
the Institute of Medicine from 20 years ago in the Hidden
Epidemic: Confronting STDs. “Ironically, it may
require greater intimacy “to discuss sex than to engage in it.” So how do we begin a sexual history? First, you want to acknowledge
the personal nature of the subject matter. I know this is very personal information. Normalize the conversation,
and emphasize confidentiality. I talk to all of my patients
about their sexual history because it’s an important
part of their health. Before I ask my questions,
I want to let you know that everything we talk
about is confidential. Explain how the information
will help you care for the patient. This information will help me understand if there’s issues with your
health that I can help with. One framework for
approaching a sexual history and asking comprehensive questions, is the five P’s. Partners, practices, past history of STDs, protection from STDs, and pregnancy plans. Partners, have your sex
partners been males, females, or both? Sexual practices. What types of sex did you have? Past STDs. What STDs have you had in the past? What do you do to prevent
getting an STD or HIV? And pregnancy history and plans. Are you and your partner
planning on having a baby or getting pregnant in the next year, or what do you and your girlfriend use to prevent pregnancy? Some general considerations for taking a sexual history are to
make no assumptions. We should ask all
patients about the gender of their sex partners and
the number of sex partners. Ask about specific sexual practices, including vaginal, anal, and oral sex. Also, we should be clear
and avoid medical jargon. And clarify when necessary. And also be specific in our questions. I have one colleague who was taking care of his HIV primary care
patient and he asked him if he was sexually active. And the patient said no. And then, he delved further and said, “When was the last time you had sex?” And the patient said, “Three days ago.” Sometimes we need to be extremely clear in our language as well. Other considerations for
sexual history taking, be tactful and respectful,
avoid showing surprise, don’t use a family member as a translator, and be non-judgemental. Recognize patient concerns,
recognize our own biases, and avoid value-laden language, such as you should, why
didn’t you, I think you. So some examples of neutral language, instead of why didn’t you use a condom? Ask, what made it
difficult to use a condom in that situation? Instead of do you tell your
partners you are HIV positive? Ask, what’s your approach to discussing HIV status with partners. Instead of why didn’t
you finish your medicine? Ask, what made it difficult
to finish your medicine? What if time constraints
don’t allow issues to be fully discussed? You can schedule follow-up visits, refer to a counselor if
you have that available in your clinic, offer
patient information sheets, and refer to specialized
care source and/or hotline based on the conversation,
such as support groups, substance abuse treatment, and
domestic violence referrals. Helping clients change
behavior might begin with changing some of our own. If you don’t routinely
take sexual histories, are you sexually active and stop there, give it a try delving into a more comprehensive sexual history. Be willing to practice a new skill and normalize it for yourself, and it will be normalized for the patient. And allow us to tailor
the care that they need. Order appropriate STD
tests, provide appropriate risk reduction counseling. And work on recognizing our biases and keeping them in check. I wanted to mention TaSHA, which is a tablet-based sexual health application that is a self-administered — I’m gonna go outside,
there is an interruption. TaSHA is a tablet-based
sexual health application that the self-administered patient survey. It assists with conducting
routine risk assessment with clinical decision support to help clinicians save time
and improve patient care. Here’s an example of a
question on the tablet. So the patient would be
filling this out themselves. In the past year, have you had sex with men, women, or both? And this is an example
of a provider report that summarizes the patient’s answers. Provides recommendations for STD testing according to national guidelines, and has prompts with suggestions for education and counseling. My colleagues here at the PTC
have additional information about TaSHA if you’re interested in learning more after the webinar. And it’s also attached to the resources. Before I move on to the next section, I’ll just mention that
expert STD clinical services are a key principle in reducing
HIV in the United States. And they’re supported in the
National HIV/AIDS Strategy for the U.S. For the final section we’ll talk about chlamydia and gonorrhea treatments and a couple of examples
of complicated STDs. This slide shows chlamydia
treatment recommendations the CDC STD treatment guidelines for adolescents and adults. The recommended regimens
for non-pregnant individuals with chlamydia are
azithromycin, one gram orally in a single dose, or doxycycline,
100 milligrams orally twice a day for seven days. For pregnant women with chlamydia, the recommended regimen
is only azithromycin, one gram orally in a single dose. And for chlamydia, Test
of Cure is recommended at three or four weeks after
the completion of treatment for pregnant women only. This shows recommendations
for gonorrhea treatment for genital, rectal, and
pharyngeal infections. Two-drug therapy is recommended for all cases of gonorrhea
with ceftriaxone, 250 milligrams IM in a single dose, plus azithromycin one gram orally. And these should both be administered, regardless of chlamydia test results. So, if the patient doesn’t have chlamydia, if they have gonorrhea and no chlamydia, they still get treated with two drugs, ceftriaxone and azithromycin,
one gram orally. And these should be administered, ideally, at the same time and under
directly observed therapy. Some treatment alternatives for gonorrhea for anogenital
infections include, cefixime, 400 milligrams orally once, plus azithromycin, one gram orally, again, regardless of
chlamydia co-infection. So this would be the regimen that’s used for expidited partner therapy
for patients with gonorrhea. But ideally, all patients with gonorrhea get treated with the recommended regimen of IM ceftriaxone plus azithromycin. In case of severe allergy,
the alternative therapies are also two drugs for the
treatment of gonorrhea. Either gentamycin, 240 milligrams IM plus azithromycin, two grams orally, or gemifloxacin, 320 milligrams orally, plus azithromycin, two grams orally. I do want to mention that gemifloxacin is not actually available in
the United States right now, so your alternative regimen,
in case of a severe IG, mediated allergy is the gentamycin plus the azithromycin regimen. Who gets a Test of Cure for gonorrhea? Any patient with pharyngeal gonorrhea that’s treated with an
alternative regimen. So if they have pharyngeal gonorrhea, and they are not treated with ceftriaxone plus azithromycin, they
should have a Test of Cure to ensure clearance. And this should be obtained
14 days after treatment, either using culture or NAAT. In any cases of suspected
treatment failure, there should be a test
conducted with culture and NAAT. And you can consider a
Test of Cure for gonorrhea if a patient is treated with a non-recommended regimen or monotherapy. For the last section of this talk, I wanted to briefly discuss
a couple of examples of complicated STDs that
we may be seeing more of as we encounter increases in STDs. So in 2013, the CDC put out a drug-resistant threat report in which antibiotic resistant gonorrhea was one of three groups oof organisms that was designated with
a threat level of urgent. Meaning that it’s an
immediate public health threat that requires urgent
and aggressive action. And I’ll mention that one of the ways to prevent and reduce the
risk of resistant gonorrhea is to screen and treat rectal
and pharyngeal gonorrhea, and also to ensure
appropriate two-drug therapy for gonorrhea with
ceftriaxone and azithromycin. There have been treatment
failures reported, two cephalosporins,
ceftriaxone is a cephalosporin, and there have been
oral treatment failures reported worldwide, in multiple countries, including Japan, Hong
Kong, England and Canada. There have been no
cephalosporin treatment failures reported in the United States to date. So to date, there’s no
documented treatment failure to the recommended regimen for gonorrhea with ceftriaxone plus azithromycin. There have been ceftriaxone
treatment failures reported internationally
and pharyngeal gonorrhea and a few isolates with high-level ceftriaxone resistance reported. These are data from the national Gonococcal Isolates Surveillance project that monitors trends and gonorrhea susceptibility
to antibiotics. This slide demonstrates that
men who have sex with men, are more likely to have gonorrhea with decreased
susceptibility to Ceftriaxone compared to men who have sex with women. So health care providers that care for men who have sex
with men, should be alert for the potential for
them to have gonorrhea that has decreased
susceptibility to antibiotics or alert for potential treatment failure. These are data, from again, that Gonorrhea Surveillance Project, the Gonococcal Isolate
Surveillance Project, and this is just looking in
the California STD clinics that monitor the antimicrobial susceptibility transfer gonorrhea. And what you can see is that
there’s been an increase, particularly in 2016, in
the percent of isolates with decrease susceptibility to azithromycin in California. Antibiotic resistant
gonorrhea, is definitely on — We are alert for it, we’re
paying attention to it, and we want to control
gonorrhea, screen for it, and treat it appropriately to prevent the further development of
antibiotic resistant gonorrhea. I did want to mention one
azithromycin treatment failure in California a couple of years ago, in which a patient presented
with gonococcal urethritis, a male patient with symptomatic gonorrhea and he had this big
history of possible allergy to penicillin when he was a child, and the clinician opted to
treat him with at that time, was the alternative
regimen for the treatment of gonorrhea, which was
azithromycin two grams, which is not recommended only anymore, it’s always a two-drug therapy for the treatment of gonorrhea. And the patient’s symptoms didn’t go away, So he was treated and just
kept on having urethritis. And so he went back in and
the clinician very astutely got a culture and susceptibilities and also delved more deeply
into the patient’s history of the drug allergy and determined that he didn’t actually have
an allergy to penicillin. The patient was treated
then with ceftriaxone and doxycycline and the symptoms resolved. And the gonorrhea that he had was found to be highly resistant to azithromycin. So I think that this is a good example of a case in which the patient should’ve been treated with
the recommended therapy, a two-drug therapy,
ceftriaxone plus azithromycin. But also, the clinician
was also very astute in the sense that they got a culture and a antimicrobial
susceptibility testing, when they realize that the patient might have failed treatment. This has been in the news, just an article about this doctor fearing the spread of super gonorrhea across Britain. There was also a cluster in Hawaii in which a number of gonorrhea isolates were found to have
decreased susceptibility to both ceftriaxone and azithromycin. There were not treatment failures, but it raises alarms
that we need to be alert for the potential of
drug resistant gonorrhea and treatment failures. So if you do have a
suspected gonorrhea failure, you should test with culture and nucleic acid amplification testing and call your local health department if you can’t get gonorrhea culture. You should repeat
treatment with gentamycin, 240 milligrams IM, plus
azithromycin, two grams orally. If you think it’s likely
the patient was re-infected. That this was not a treatment failure, but in fact, the patient was re-infected, then it’s okay to repeat treatment with the recommended
regimen of ceftriaxone plus azithromycin. Any suspected gonorrhea treatment failure should be reported to your
local health department within 24 hours. You should test and treat the partners, all partners in the last 60
days with the same regimen. And a Test of Cure should be obtained with culture and NAAT. Now I’m gonna briefly
talk about ocular syphilis and other complicated STD. Around the end of 2014
and the beginning of 2015, there was a cluster of
ocular syphilis cases that was identified in
Seattle and San Francisco. The majority of the
cases of ocular syphilis were in men who have sex with men, the majority were HIV infected. And several patients had
permanent loss of vision. The California Department of Public Health put out a clinical advisory
about ocular syphilis for clinicians to be alert for it and the CDC had a clinical advisory about ocular syphilis in
the United States as well. Of the ocular syphilis cases described by the CDC and the MMWR last November, 93% were male and 69% of males were men who have sex with men. 51% were HIV infected. I mentioned both antibiotic
resistant gonorrhea and ocular syphilis as two distinct, but concerning STD issues, that
this proportionally affects men who have sex with men and should be on the radar of clinicians. To conclude, bacterial
STDs are highly prevalent among men who have sex with
men and they are increasing. Sexual history taking is a core component of guiding recommended clinical
and preventive services for our patients. STD testing for syphilis
and gonorrhea and chlamydia, including rectal and pharyngeal sites is essential to identify
asymptomatic infections, reduce transmission,
and identify candidates at risk for HIV acquisition
and initiate on PrEP. As STDs increase, we need to be vigilant in our efforts to reduce
associated morbidity, including antibiotic-resistant gonorrhea and ocular syphilis. In HIV care settings and
clinics that prescribe PrEP, provide opportunities
to improve STD screening and sexual health
promotion among populations at risk for STDs. I wanted to point out
some clinical guidelines and resources for you so that
CDC STD treatment guidelines are available online, they
were most recently updated in 2015 and they have a
vast amount of information about screening recommendations and treatments and resources. The STD Clinical Consultation
Network is available at stdccn.org. If you have a question about
the treatment of your patient, any STD related treatment question, or other question or
request for resources, you can enter that in online here, and someone will get back to you. You can also call 510-620-3400 with STD questions. And there’s also a free STD
treatment guidelines app that the CDC created. You can search in your
app store for STD TX and you can find this. It’s a rally handy resource as well and make sure that it’s
free, don’t pay for anything. Because then it’s not the right one. I just wanted to briefly
acknowledge some of my colleagues who helped with the
preparation of these slides. And that concludes this
portion and I thank you, and please let me know if
you have any questions. I think we’re taking
questions into the chat box. – [Alice] Yes, thank
you so much, Dr. Stoltey for the very comprehensive
and excellent presentation. And I just wanted to remind folks, because we’ve been gathering questions during the webinar, and several of you have asked if slides will be available and they absolutely will. At the beginning of
the webinar we included some poll questions
and I think we’re going to include them again and
one of the important ones is for you to provide your email address. Because we did not
require pre-registration for this webinar. That’s one thing that would be important for us to have so we can send you those slides when we’re done. We’re also going to provide them and make them available as resources and you might have remembered
that Majel Arnold at the beginning of the
webinar, alerted you to some other resources
that we have available here at the resource pod. One is the Office of AIDS Integrated Prevention and Care Plan. I know that we have a lot of prevention and care participants, so
many of you may be involved in clinical care, many of you are involved in prevention for HIV
and STD, so that will be a very valuable resource. When Dr. Stoltey alluded to the TaSHA, which is the Tablet Assisted
Sexual Health Assessment. We have a demonstration
video that’s also available in the resources. I think what we’re going
to do, is we’re going to get started with a few questions and we again, for those
of you who didn’t type your questions and if you have any, please do that, but we’re gonna go ahead and get started with the
ones that we have so far. So Julie’s gonna
go ahead and answer one of the questions regarding NAAT. I think one of the questions was just what is NAAT. I’m sorry for not specifying that. So NAAT stand for Nucleic
Acid Amplification Test. It’s basically a molecular test for gonorrhea and chlamydia. And for instance, if
you give a urine sample, that is being tested by NAAT. So a urine sample that is being tested for gonorrhea and chlamydia
is tested with NAAT, it’s the technology and
it’s a type of test. And it’s the vast majority of
gonorrhea and chlamydia test in California and in
this country currently are conducted via that
type of test, a NAAT test. A Test of Cure was another question. So just to clarify what that is. Test of Cure is a test
that would be conducted for chlamydia three or
four weeks after treatment. For gonorrhea would be probably about two weeks after treatment. And this is a test to
ensure that the patient cleared the infection. And that is recommended in just the specific scenarios that I mentioned. So if the patient has ongoing symptoms, you would get a Test of Cure. If they’re pregnant and have chlamydia, they get a Test of Cure. If for gonorrhea, if they
have pharyngeal gonorrhea, they’re treated with
an alternative regimen and you want to document
clearance with a Test of Cure. If you think they have a
suspected treatment failure. You should get a Test of Cure. So there’s specific times where you would get a Test of Cure. I do want to mention and I
didn’t put this in this talk, that all patients with
gonorrhea or chlamydia should have repeat
testings three months or so after they’re treated. Because they’re likely
reinfection is so high that we really want to identify those repeat infections and make sure patients get the appropriate treatment if they are in fact, infected. – [Alice] Thanks, Julie. So another question you might be able to answer that came across, one is an easy one and I think
it might have been covered in another, another
responded may have responded, but one person wanted to know
what the last P stood for. – [Julie] The last P was family planning, pregnancy planning, pregnancy prevention if you’re talking to
a heterosexual couple. But I think more broadly
to ask all of our patients about what they’re
planning for their families and are they planning for children. The other five P’s are partners, asking about sex partners. Practices, asking about sexual practices. Past STDs and prevention of STD and HIV. And the last one, pregnancy
history and plans. – [Alice] Thanks, Julie. Somebody noted that they
were finding it difficult to assess recent syphilis
versus late infection when assessing. Maybe you can talk a little bit about resources or —
– Yeah, that’s a good question I didn’t get into the staging of syphilis just because it would be
beyond the scope of this talk. I will just mention before
I very briefly describe it, that we do have a
syphilis clinical webinar on the PTC website that
can be accessed for free that Dr. Sharon Adler did just last year, so it’s really up-to-date
that goes through all of the clinical
presentations of syphilis, the staging of syphilis, treatment recommendations for syphilis. So that is available on
the California PTC website. Basically, in terms of staging syphilis, we stage into either early syphilis, which is syphilis
acquired in the last year, or late syphilis, which
would be syphilis acquired over a year ago. And if the patient has latent syphilis, meaning they have no signs or symptoms and we’re trying — And I think that’s what this
question was getting at. And we’re trying to determine
if they’re early or late. If we can’t confirm
that they were infected sometime in the last year. Ways that we would do that would be a clear physical exam
sometime in the last year that documented signs of
primary and secondary syphilis. An RPR that had a four-fold
increase in the prior year. If the patient was a
contact to another patient with early syphilis, or
if this was the only time that that patient could
have acquired syphilis. So if they had their sexual debut and they never had sex
before in the last year. So then we would know
it was early syphilis. If we can’t determine that,
then we stage the patient as essentially latency
of unknown duration. The reason we make these determinations of early versus late,
is that this determines what the patient is treated with. So if it’s early syphilis, they’re treated with bisillin Q4, which is
benzathine penicillin G, 2.4 million units IM in a single dose. But if it’s late syphilis, then it’s benzathine penicillin
G, 2.4 million units IM once a week for three weeks. And so, determining if
they acquired syphilis in the last year, or if it’s unknown, or they acquired it a long time ago, that determines what they’re treated with. – [Alice] Great, thank you, Julie. And this question I know that is maybe a little bit variable in terms of your perspective on this,
but one of the questions came in regarding certain
clinics or programs covering cefixim costs. I don’t know if you have
anything to say about that. – [Julie] I don’t have really
information about that, but if you want to send
us a specific email, we can try to get more information and get back to you about
your specific question. – [Alice] I know that the
coverage will often vary based on, you know, the type of coverage that the patient has or the providers. And this one question noted it, sounded like that was
a Family PACT question that we can try to work with you on that. And then there are other
questions around the cost and others as well. I do see a question about
how to get a DIS on-board. It’s a little bit of a broad question, but I will tell folks that there are very specific training courses for disease intervention specialists that are also part of our National Network
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of Prevention Training Centers and we have one of those centers here as part of the Prevention Training Center. I’m not quite sure what
the specific nature of that question was,
but if somebody wants to type in a more specific question, we can certainly attempt to answer that. I know that we have
clinical and non-clinical folks on the line, which is great. – [Julie] There is another question about Hepatitis C testing for all MSM versus for just HIV positive MSM. It’s a very good question. So there are standard recommendations for testing HIV positive
MSM for Hepatitis C on entry and to care
and at least annually, more frequently dependent on risk. In terms of Hep C testing
for HIV negative MSM, I would say there’s not
standardized CDC guidelines on that yet, but there are
definitely clinical practices that are doing that, given all of the innovations and
treatment for Hepatitis C that have happened in the last few years. And also, there have
been at least a couple of documented cases of sexually transmitted Hepatitis C in HIV negative MSM who are on PrEP, and so, I think that there
are clinical practices that are screening for Hep
C among HIV negative MSM, but there’s not standard
CDC guidelines on that yet. We’re looking for other
questions right now. – [Alice] We just have another
minute or two for questions and I thought I would
also kind of open it up to our OA partners to
see if there’s anything that you’d like to either
comment on or any question. We know that Dr. Stoltey
covered a variety of issues regarding STD screening,
including extra genital testing, sexual history taking, which we know are both extremely important. Majel, if you or any of your colleagues have any last questions or comments, I want to make sure to
offer that opportunity for you all as well. – [Majel] Thanks,
Alice, this is Majel. So at this time, we
don’t have any questions. We do want to thank again, Dr Stoltey for a very informative and educational presentation. Just looking at all of
the different comments from folks, it definitely stirred up a lot of questions so we’re happy that the
slides will be available, as well as the recording of this webinar. So thank you again for
putting this all together. This is a really good
webinar, training webinar. – [Alice] Great, and we do notice that there have been a few other questions that have come in. And what we are going to
do, is we will address them and because I believe we have just about everybody’s email address. We will make them
available so when we make the archives webinar available, we will also include a copy
of some of the questions that we weren’t able to get to. I’m just trying to be
sensitive of our time, unless you feel you can answer something in about 30 seconds, Julie. I know there was a question that — – [Julie] There was a quick question about pharyngeal chlamydia screening and there’s not a
recommendation for testing for pharyngeal chlamydia
because some prior data had not shown that
there’s a high prevalence of chlamydia in the pharynx. It’s not considered really a hospitable environment for chlamydia. That said, most tests in
the pharynx are bundled. If you’re screening for
gonorrhea in the throat, you’re also getting chlamydia. And if you identify it,
you should treat it. And so, those are the
screening guidelines, but often we end up testing
for pharyngeal gonorrhea and chlamydia and then if
you have a positive test, it should be treated. – [Alice] Thank you, Julie. And again, just to
reiterate, there’s a lot of resources and information
around many of the areas that Julie covered on our website, at Californiaptc.com. We also again, we’ll make
these slides available. So I just wanted to thank everybody for your participation in this webinar. So if you have any questions
regarding STD screening or extra genital screening,
sexual history taking, et cetera, please feel
free to send us a question and we’ll do our best to get back to you. Thank you all for participating.

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