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

Rationale and ImplementationThomas Farley, MD MPH

Tulane University

Deborah Cohen, MD MPH

RAND Corporation

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

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

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

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

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

Prevalence of Infection By Site

Site Screened n % n %Public hospital walk-in clinic* 286 9 3.1% 32 11.2%Public hospital emergency rooms (2)* 263 4 1.5% 25 9.5%Private hospital emergency room* 234 6 2.6% 30 12.8%Public dental clinic 327 6 1.8% 31 9.5%

Facility for homeless youth 100 2 2.0% 14 14.0%Vocational/technical school 95 3 3.2% 9 9.5%Community college 76 2 2.6% 10 13.2%Colleges (2) 229 5 2.2% 13 5.7%

Total 1,610 37 2.3% 164 10.2%

Gonorrhea Chlamydia

* Among persons not seeking care for genitourinary symptoms

Prevalence of STDs by HIV Status

Total Pos. % RR p-value Pos. % RR p-value

HIV-positive 16 2 12.5% 5.6 0.05 1 6.3% 0.61 NS

HIV-negative 1,567 35 2.2% 161 10.3%

Total 1,583 37 2.3% 162 10.2%

Gonorrhea Chlamydia

Relationship Between Symptoms and STDs - Females

Symptom Total Pos. % RR p-value Pos. % RR p-valueGenital discharge

Present 223 8 3.6% 1.6 0.28 22 9.9% 0.92 NSAbsent 747 17 2.3% 80 10.7%

DysuriaPresent 78 1 1.3% 0.5 NS 5 6.4% 0.59 0.22Absent 892 24 2.7% 97 10.9%

Any genitourinary symptomsPresent 260 8 3.1% 1.3 NS 26 10.0% 0.93 NSAbsent 706 17 2.4% 76 10.8%

Total 972 26 2.2% 102 10.5%

*Present at any time in the previous 12 months, including at the time of screening

Gonorrhea Chlamydia

Relationship Between Symptoms and STDs - Males

Symptom Total Pos. % RR p-value Pos. % RR p-valueGenital discharge

Present 42 6 14.3% 14.1 <.0001 7 16.7% 1.79 0.17Absent 592 6 1.0% 55 9.3%

DysuriaPresent 40 6 15.0% 14.7 <.0001 6 15.0% 1.58 0.26Absent 589 6 1.0% 56 9.5%

Any genitourinary symptomsPresent 76 7 9.2% 10.2 0.0001 10 13.2% 1.39 0.31Absent 551 5 0.9% 52 9.4%

Total 638 12 2.2% 62 9.7%

*Present at any time in the previous 12 months, including at the time of screening

Gonorrhea Chlamydia

Reasons Why Care Not Received for SymptomsOther Reasons

Reason n % n %

Symptoms not severe 13 30.2% 11 25.6%

Symptoms went away quickly without treatment 5 11.6% 9 20.9%

Medical care costs too much 4 9.3% 3 7.0%

Did not think it was serious 3 7.0% 0 0.0%

Thought it was normal 2 4.7% 0 0.0%

No symptoms 1 2.3% 0 0.0%

Did not know where to get medical care 1 2.3% 2 4.7%

Would have to wait too long to be seen 1 2.3% 2 4.7%

Did not have enough time to get medical care 1 2.3% 3 7.0%

Afraid people might find out I had an STD 0 0.0% 1 2.3%

Staff at clinic would not treat me with respect 0 0.0% 0 0.0%

Other/don't know 5 11.6% 6 14.0%

No reason listed 7 16%

Total 43 43 *

Primary Reason

Prior Medical Care Received for Possible STD-related Symptoms

n %P rovider type

P ublic STD clinic 17 30%P ublic hospital ER/walk-in 12 21%Other public provider 5 9%P rivate 15 27%Other 7 13%

ExaminationFemales - pelvic examination 24 59%Males - examination of genitalia 9 60%

Laboratory testsGonorrhea 66 68%Chlamydia 66 70%Syphilis serology 25 29%HIV test 18 20%

TreatmentCovers gonorrhea 26 64%Covers chlamydia 39 61%

N=56 charts with prior visit for genitourinary complaints

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.

Estimates of Treatment of STDs in Previous 12 months

    Gonorrhea Chlamydia

   n

(est.)% of all

% of untreated

n (est.)

% of all

% of untreated

           

No recognized symptoms 28.3 45% 86% 148 77% 95%

Symptoms 35.2 56%   44.7 23%  

  Did not receive care 4.8 8% 14% 8.4 4% 5%

 Received care, not treated 0.0 0% 0% 0.0 0% 0%

 Received care, treated 30.4 48%   36.3 19%  

Total 63.5 100%   193 100%  

Estimates of Treatment of STDs in Previous 12 monthsMales

    Gonorrhea Chlamydia

   n

(est.)% of all

% of untreated

n (est.)

% of all

% of untreated

No recognized symptoms 7.5 34% 83% 60.9 89% 98%

Symptoms 14.7 66%   7.5 11%  

  Did not receive care 1.5 7% 17% 1.1 2% 2%

 Received care, not treated 0.0 0% 0% 0.0 0% 0%

 Received care, treated 13.2 59%   6.4 9%  

Total 22.2 100%   68.4 100%  

Estimates of Treatment of STDs in Previous 12 monthsFemales

    Gonorrhea Chlamydia

   n

(est.)% of all

% of untreated

n (est.)

% of all

% of untreated

No recognized symptoms 20.1 55% 86% 87.7 71% 92%

Symptoms 16.7 44%   36.5 30%  

  Did not receive care 3.3 9% 14% 7.2 6% 8%

 Received care, not treated 0.0 0% 0% 0.0 0% 0%

 Received care, treated 13.4 36%   29.3 24%  

Total 36.8 100%   124 100%  

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

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.

Prevalence of Infection By Site

Site Screened n % n %Public hospital walk-in clinic* 286 9 3.1% 32 11.2%Public hospital emergency rooms (2)* 263 4 1.5% 25 9.5%Private hospital emergency room* 234 6 2.6% 30 12.8%Public dental clinic 327 6 1.8% 31 9.5%

Facililty for homeless youth 100 2 2.0% 14 14.0%Vocational/technical school 95 3 3.2% 9 9.5%Community college 76 2 2.6% 10 13.2%Colleges (2) 229 5 2.2% 13 5.7%

Total 1,610 37 2.3% 164 10.2%

Gonorrhea Chlamydia

* Among persons not seeking care for genitourinary symptoms

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)

Results of STD/HIV ScreeningCharity 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

Prevalence of GonorrheaCharity Hospital Walk-in Clinic, 12/00 – 11/01

0%

2%

4%

6%

8%

10%

12%

14%

16%

18-24 25-35 Over 35

Age

Per

cent

pos

itiv

e

MaleFemaleTotal

Prevalence of ChlamydiaCharity Hospital Walk-in Clinic, 12/00 – 11/01

0%

5%

10%

15%

20%

25%

18-24 25-35 Over 35

Age

Per

cent

pos

itiv

e

MaleFemaleTotal

Summary and ConclusionsSTD/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

STD Screening in HIV ClinicHIV 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

Percentage of Active Patients TestedHIV Outpatient Program, New Orleans, June 2000-May 2001

25%176708White Males

33%8372,555Total

92

964

707

Patients*

White Females

Black Males

Black Females

45%41

31%297

41%292

% TestedTested*

* Unduplicated count for 12-month period

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

Tested Positive % Positive

Gonorrhea 2,629 46 1.7%

Chlamydia 2,629 56 2.1%

Gonorrhea Prevalence vs Convenience Sample of General Population

New Orleans

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

15-19 20-24 25-29 30-34 35-39 40-44 45-49 > 50

Age Group

Gon

orrh

ea P

reva

lenc

e (%

)

HOP Population

Chlamydia Prevalence vs. Convenience Sample of General Population

New Orleans

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

15-19 20-24 25-29 30-34 35-39 40-44 45-49 > 50

Age Group

Chl

amyd

ia P

reva

lenc

e (%

)

HOP Population

Summary and ConclusionsSTD 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

The Future

• Public hospital walk-in clinic will continue screening

• Will try to improve compliance at HIV Outpatient Clinic

• Plans to expand STD screening to all public HIV clinics in Louisiana