Current STD Testing and Treatment Guidelines Missouri Department of Health and Senior Services Bureau of HIV, STD, and Hepatitis

STD Surveillance 2015 Chlamydia 1,526,638 cases reported 479 cases per 100,000 people (6% increase) Gonorrhea 395,216 cases reported 124 cases per 100,000 people (13% increase) Syphilis (primary and secondary) 23,872 cases reported 8 cases per 100,000 people (19% increase) HIV 44,073 were diagnosed (2014) The number of new HIV diagnoses fell 19% from 2005 to 2014. It is estimated that there are 20 million new STDs in the U.S. each year. These infections can lead to long-term health consequences, such as infertility; they can facilitate HIV transmission; Additionally, the direct cost of treating STDs in the U.S. is $16 billion annually. Chlamydia: Rate of cases among women increased 3.8% and the rate among men increased 10.5% Gonorrhea: 6.8% increase in women and 18% increase in men. Magnitude of increase among males suggest either increased transmission or increased case ascertainment (through increased extra-genital screening) among MSM. https://www.cdc.gov/std/stats15/std-surveillance-2015-print.pdf

National Chlamydia and Gonorrhea Prevalence by Age Group While anyone can become infected with an STD, certain groups, including young people and MSM are at greatest risk. Surveillance data shows both the numbers and rates of reported cases of Ct/GC continue to be among young people aged 15-24. https://www.cdc.gov/std/stats15/std-surveillance-2015-print.pdf

Missouri Chlamydia Prevalence 2014 Source: MDHSS – 2014 Epidemiologic Profile http://health.mo.gov/data/hivstdaids/data.php

National Syphilis Prevalence by Risk Group Rates are increasing at an alarming rate (19%). Syphilis: Men accounted for over 90% of all cases. Among those men whose sex partner was known, 81.7% were MSM. https://www.cdc.gov/std/stats15/std-surveillance-2015-print.pdf

National HIV Prevalence by Risk Group Adolescents and Young Adults Youth aged 13-24 account for 26% of the estimated 47,500 new HIV infections. 57% among blacks/African Americans 20% among Hispanics/Latinos 20% among whites Men who have sex with men (MSM) Although from 2005 to 2014, HIV diagnoses decreased in the U.S. by 19% overall, HIV increased 6% among all gay and bisexual men. 1 in 6 gay and bisexual men will be diagnosed with HIV in their lifetime. 1 in 2 black/African American MSM 1 in 4 Hispanic/Latino MSM 1 in 11 white MSM

Source: MDHSS – 2014 Epidemiologic Profile http://health. mo

CDC Chlamydia and Gonorrhea Screening Recommendations Women Sexually active under 25 years of age Sexually active women aged 25 years and older if at increased risk All pregnant women under 25 years of age and older women at increased risk Pregnant women with chlamydia or gonorrhea infection should have a test-of-cure 3-4 weeks after treatment and be retested within 3 months. Men MSM should be screened at least annually and if at increased risk every 3 to 6 months Screen at sites of contact (urethra, rectum, pharynx) Consider young men in a high prevalence clinical setting *Increased risk: having multiple partners, having a new partner, using condoms inconsistently, having sex while under the influence of alcohol or drugs, having sex in exchange for money or drugs. Both young men and young women are heavily affected by STDs– but young women face the most serious long-term health consequences. It is estimated that undiagnosed STDs cause infertility in more than 20,000 women each year. Chlamydia infections in women are asymptomatic. Untreated infections can result in pelvic inflammatory disease which is a major cause of infertility, ectopic pregnancy and chronic pelvic pain. Pregnant women infected with CT can pass the infection during delivery, potentially resulting in complications leading to blindness and pneumonia. Because of the large burden of disease and risks associated with infection CDC recommends annual CT screening for all sexually active women younger than 25 and older women at an increased risk. (increased risk- new or multiple sex partners).

CDC Syphilis and HIV Screening Recommendations All pregnant women at the first prenatal visit (retest early in the third trimester and at delivery if at high risk) At least annually for sexually active MSM (every 3-6 months if at increased risk) HIV All persons 13-64 years (opt-out) All pregnant women should be screened at first prenatal visit (opt-out) (retest in the third trimester if at high risk) At least annually for sexually active MSM and more often (every 3-6 months) if the patient himself or his sex partner(s) have had more than one partner since the most recent HIV test.

CDC 2015 STD Treatment Guidelines www.cdc.gov/std/tg2015/

Uncomplicated CT Treatment CDC Recommended Regimen: Azithromycin 1 g orally in a single dose OR Doxycycline 100 mg orally twice a day for 7 days A test of cure (repeat testing after treatment) is not permissible unless therapeutic compliance is in question, symptoms persist, or re-infection is suspected. Positive clients who have been adequately treated should be retested, no sooner than three months after treatment, to identify re-infection, regardless of whether or not sex partners were treated CDC’s Sexually Transmitted Diseases Treatment Guidelines, 2015. http://www.cdc.gov/std/tg2015/tg-2015-print.pdf

Uncomplicated CT Treatment CDC Recommended ALTERNATIVE Regimen: Erythromycin base 500 mg orally 4x/day for 7 days OR Erythromycin ethylsuccinate 800 mg orally 4x/day for 7 days Levofloxacin 500 mg orally 1x/day for 7 days Ofloxacin 300 mg orally 2x/day for 7 days CDC’s Sexually Transmitted Diseases Treatment Guidelines, 2015. http://www.cdc.gov/std/tg2015/tg-2015-print.pdf

Uncomplicated GC Treatment urogenital, anorectal, and pharyngeal CDC Recommended Regimen: Ceftriaxone 250 mg IM in a single dose PLUS Azithromycin 1 g orally in a single dose ** CDC’s Sexually Transmitted Diseases Treatment Guidelines, 2015. http://www.cdc.gov/std/tg2015/tg-2015-print.pdf

Uncomplicated GC Treatment urogenital, anorectal, and pharyngeal CDC Recommended ALTERNATIVE Regimen: If ceftriaxone is not available: Cefixime 400 mg orally in a single dose PLUS Azithromycin 1 g orally in a single dose CDC recommends a test of cure in 14 days if client is treated with alternate regimens other than the recommended therapy for uncomplicated pharyngeal infection *Alternate regimens are not effective for pharyngeal infection CDC’s Sexually Transmitted Diseases Treatment Guidelines, 2015. http://www.cdc.gov/std/tg2015/tg-2015-print.pdf

Uncomplicated GC Treatment urogenital, anorectal, and pharyngeal CDC Recommended ALTERNATIVE Regimen: If cephalosporin allergy: Gemifloxacin 320 mg orally in a single dose PLUS Azithromycin 2 g orally in a single dose OR Gentamicin 240 mg IM single dose CDC recommends a test of cure in 14 days if client is treated with alternate regimens other than the recommended therapy for uncomplicated pharyngeal infection *Alternate regimens are not effective for pharyngeal infection CDC’s Sexually Transmitted Diseases Treatment Guidelines, 2015. http://www.cdc.gov/std/tg2015/tg-2015-print.pdf

Positive CT/GC Client Follow-up Positive clients should be instructed to abstain from sexual intercourse until they and their sex partners have been adequately treated 7 days after a single-dose regimen 7 days after completion of a 7-day regimen Positive clients should be retested approximately 3 months after treatment, regardless of whether they believe that their sex partners were treated. All sexual partners during the 60 days preceding onset of symptoms or diagnosis of CT/GC should be referred for evaluation, testing and presumptive treatment.

GISP Gonococcal Isolate Surveillance Project Monitors trends in N. gonorrhoeae bacteria in the United States. 26 selected STD clinics collect specimens from the first 25 men who attend their clinic and have been diagnosed with urethral gonorrhea. A total of 5,093 isolates were collected in 2014. Azithromycin increased from 0.6% in 2013 to 2.5% in 2014. Gonorrhea has progressively developed resistance to each of the antimicrobials used to treat GC, resulted in a change to CDC treatment guidelines to a dual therapy of Ceftriaxone and Azithromycin.

Missouri STD Testing Program CDC Grant: STD AAPPS- Improving Sexually Transmitted Disease Programs through Assessment, Assurance, Policy Development and Prevention Strategies. Program enrollment is offered to health care agencies, such as LPHAs and CBOs in Missouri, dependent upon: Chlamydia/Gonorrhea prevalence. Percentage of underinsured or uninsured clientele. Population’s access to STD prevention services. Available funding. Provides Chlamydia, Gonorrhea, Syphilis and HIV testing to 165 sites in Missouri through the state public health lab. Provides select medication for Chlamydia and Gonorrhea.

Contacts Dustin Hampton, Prevention Programs Manager Missouri Dept of Health & Senior Services Bureau of HIV, STD & Hepatitis 573-526-2610 Dustin.Hampton@health.mo.gov Yelena Friedberg, HIV/STD Testing Program Supervisor 573-526-7304 Yelena.Friedberg@health.mo.gov Kelsey Owsley, HIV/STD Testing Program Coordinator 573-526-3607 Kelsey.Owsley@health.mo.gov

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