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

Early Syphilis Los Angeles County

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

Types of Clinics

• Public

• Private

• HMO

• Hospital/University

• Community Based Organization

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

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