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STD Testing Protocols, STD Testing, and
Discussion of Sexual Behaviors in HIV Clinics in
Los Angeles County
Melanie M. Taylor MD, MPH
Los Angeles County STD Program
Acknowledgements
• Tracie McClain MD, MPH
• Bessie Brown
• Getahun Aynalem MD, MPH
• Lisa Smith DrPH
• Peter Kerndt MD, MPH
• Tom Peterman MD, MSc
HIV Seropositivity Among Early Syphilis Cases, 2001-2003
0%10%20%30%40%50%60%70%80%90%
100%
MSM MSW All Female
UnknownNegativePositive
HIV In Los Angeles
• 45,000 persons living with AIDS or HIV aware of status*
• An estimated additional 9,000 persons with AIDS or HIV that are unaware of status*
*Office of AIDS Programs and Policy. Los Angeles County Department
of Health Services. HIV Prevention Plan Addendum. 2003
Objectives
• To evaluate knowledge of syphilis epidemic among HIV care providers
• To determine STD screening practices in HIV care clinics
• To quantify use of STD screening/testing protocols in HIV care clinics
• To evaluate the frequency and nature of discussion of sexual behaviors in HIV clinics
Study Design/Methods
In-person or phone interview performed by one interviewer
17 Question SurveyResults analyzed using SPSSClinics received: Patient information cards for 6 STDs, CA STD treatment guidelines, MMWR: Prevention for Positives, Posters of primary and secondary syphilis symptoms, STD reporting forms
Sample Summary
• Survey Respondents: N = 36*
• Represented Clinics: N = 48
• Represented HIV Care Providers: N = 184
• Represented Patients: N = 28,119
• *Medical Directors allowed to complete surveys for multiple sites under their
direction
Survey of Clinical Care Representatives from 48 Clinics Enrolling >50 HIV Patients
Clinician Type % of SampleMedical Directors 31Clinic Directors 3HIV/AIDS Program Coordinators 11Physicians 33Nurse Practitioners 17Physician’s Assistants 3Medical Assistant 3
Community Based
Organization31%
Hospital/University
10%
Public 20%
Clinic Types
Private/HMO38%
Source: LAC DHS STD Program; N=44,205
Knowledge of Syphilis Epidemic
When asked about LA syphilis rates,
100% spontaneously reported they were higher.
97% thought they were higher than the national average.
Clinics Performing STD Testing at the First Visit
STD Test Number (%)
Syphilis 48 (100)
Chlamydia 32 (67)
Gonorrhea 32 (67)
Herpes 0 (0)
HPV (Pap Smears) 7 (15)
Trichomoniasis 3 (6)
Hepatitis screen (A, B, C) 48 (100)
Use of a Written STD ProtocolClinical Practice Number
(%)Use of STD testing protocol 24 (50)Protocol Based on:
CDC Guidelines 3 (13)LAC STD Program Screening Recommendations 4 (17)Standardized Electronic Sexual Risk Assessment 9 (38)Other 3 (13)Unknown 5 (21)
Activities of Clinics Reporting Use of
Written Protocols (WP) for STD Testing Activity WP Use WP Non-Use OR(95%CI) P Value
Asymptomatic Testing
Every 3-6 months:
Syphilis 20 (83) 14 (58) 3.6 (0.9-13.7) 0.055
GC/CT 7 (79) 6 (25) 1.2 (0.3-4.4) 0.5
Patients asked about unsafe sex behavior at each visit
24 (100) 0 (0) 2.2 (1.4-3.4)<0.001
Written Protocol Use by Clinic TypeClinic Type WP Use WP Non-Use OR (95% CI) P Value
Early Intervention Program** 22 (92) 11 (46) 13.0 (2.5-68.1) 0.001 CBO 15 (63) 0 (0) 2.7 (1.6-4.5) <0.001 HMO 0 (0) 7 (29) 0.7 (0.5-0.9) 0.009 Hosp/Univ 2 (8) 3 (13) 0.6 (0.1-4.2) 1.0 Private 2 (8) 9 (38) 0.2 (0.03-0.8) 0.04 Public 5 (21) 5 (21) 1.0 (0.2-4.0) 0.6
Use of Written Protocol for STD Testing by Clinic Type
0
20
40
60
80
100
120
Private/HMO Public Hosp/Univ CBO
Clinic Type
Questions Frequently Included in Sexual Risk Assessments
-Have you practiced unsafe/unprotected (without a condom) sex since your last visit?
-Have you have unprotected oral, anal, or vaginal sex since your last visit?
-Do/did you use a condom when you have/had sex?
-If unsafe sex, what was the HIV status of your partner(s)?
Questions Frequently Included in Sexual Risk Assessments
-If unsafe sex, was your partner(s) aware of your HIV status?
-Have you used any recreational drugs that were linked to your sexual activity?
-Was your sexual interaction with an anonymous partner(s)? If anonymous, where did the sexual interaction take place? (bathhouse, sex club, via internet contact, other)
-What type of sex practices do/did you engage in?
-Have you had sex with men, women or both?
Conclusions
• Written protocols for STD testing may promote sexual risk assessment questioning among HIV providers
• These written protocols may insure STD testing per CDC/IDSA guidelines for HIV positive persons at sexual risk
Limitations
• Actual experience of the patients was not evaluated
• Sample size limited some analyses• Unable to determine the values of sexual
risk questions in predicting disease• 9/48 (19%) clinics operated by one
organization and may have skewed the results.
LA County Recommendations for STD Screening among HIV Positive Persons
E a r l y S y p h i l i s S u r v e i l l a n c e S u m m a r y C a s e s r e p o r t e d a s o f D e c e m b e r 3 1 , 2 0 0 3 I s s u e d J a n u a r y 1 5 , 2 0 0 4
S e x u a l l y T r a n s m i t t e d D i s e a s e P r o g r a m
2 6 1 5 S o u t h G r a n d A v e n u e , R o o m 5 0 0 L o s A n g e l e s , C A 9 0 0 0 7 T E L ( 2 1 3 ) 7 4 4 - 3 0 7 0 F A X ( 2 1 3 ) 7 4 9 - 9 6 0 6
w w w . l a p u b l i c h e a l t h . o r g / s t d