Prevalence of Rectal Chlamydia and Gonorrhea Before and After Implementation of Routine Rectal Screening Ellen T. Rudy Sexually Transmitted Disease Program Los Angeles County Department of Public Health erudy@ladhs.org

Objective To describe the detection of rectal chlamydia and gonorrhea before and after implementation of a routine rectal screening program To describe key components of the implementation process that lead to a successful and sustainable program My objective is two-fold today because there are two stories. First it is to present

Key Participants Sarah Guerry, MD, Medical Director, STDP Christine Wigen, MD, Assistant Medical Director, STDP Precious Stallworth, Sexual Health Manager, LAGLC Elisa Clay, NP, Nurse Practitioner, LAGLC Bob Bolan, Medical Director, LAGLC Peter Kerndt, Director STDP Los Angeles Public Health Laboratory

Background Los Angeles County STD Program and LAGLC long-standing relationship CDC 2006 STD Treatment Guidelines: rectal CT/GC testing for all men who report receptive anal sex in past year Provider-collected NAAT rectal swab was the standard Symptoms only primary criteria for testing Perceived barriers to implementation of routine rectal screening program: Interference with clinic flow Patient acceptability Screening only settings Provider compliance This is the background

Solution: Self-Collected Rectal Swabs Have been shown to be effective in HPV type-specific results (Lampinen, T, CID, 2006) Initiated an evaluation of reliability of self-collected vs provider-collected rectal swabs Results (Wigen et al) presenting Wednesday at afternoon poster session This is the background

Methods and Timeline Two populations of patients pre- and post-evaluation Pearson chi-square test to compare differences Before Evaluation After Aug 1, 2007-Oct 15, 2007 Nov 1, 2007- Jan 31 2008 April 1, 2007- June 26, 2007 Computed Pearson chi-square test to compare prevalence of testing and prevalence of positive infection before and after. Provider-collected swabs only Provider- and self- collected swabs Primarily self-collected swabs 2614 Clinic Visits 2403 Clinic Visits

Los Angeles Gay & Lesbian Center 49% White 33% Hispanic 8% African American 10% Other 78% Gay 11% Bisexual 9% Heterosexual 1% Transgender/transsexual Talk about the demographics of the clinic. May include behavioral and clinical

Behavioral and Clinical Characteristics 31% reported some type of symptom at visit 26% reported anal receptive sex at last sexual encounter 4.4 mean number of partners in past 3 month range (0 – 300 partners)

Proportion Screened for Rectal CT/GC Among Clients Reporting Receptive Anal Sex What percent of persons reporting receptive anal sex were tested? 13% missing data before; 7% missing data afterwards; Compared with urethral GC about 78% of incoming clients.

Proportion Tested for Rectal CT/GC Among Clients With and Without Symptoms What percent of persons reporting receptive anal sex were tested?

Number of Cases of Rectal CT/GC Detected Study# Month/Year Question: Almost a two-fold increase in the detection of rectal chlamydia. Indicates that the increase in testing may have lead to more disease detection. Was it just increase in testing. What percentage of testers reported anal receptive sex: Before and after

Proportion of Rectal CT/GC Positives Before 26 out of 259; After 169 out of 1372; Question: Almost a two-fold increase in the detection of rectal chlamydia. Indicates that the increase in testing may have lead to more disease detection. Was it just increase in testing. What percentage of testers reported anal receptive sex: Before and after N=259 N=1372 N=259 N=1372

Summary Findings High prevalence of rectal CT/GC Three-fold increase in screening Six-fold increase in rectal CT cases detected Three-fold increase in rectal GC cases detected Symptoms not associated with rectal CT was associated with rectal GC Now that we have useful data, our data shows:

Lessons Learned of the Implementation Process Persistence Compatibility with clinic’s needs Sense of ownership Collaboration Adequate resources User-friendly communication and feedback Value in the program Adapted from Sullivan G, Duan N et al. 2005. Psychiatric Services 56: 53.

Conclusion Implementation of CDC guidelines for men reporting anal receptive sex is critical due to the high prevalence of rectal CT/GC Significant detection of rectal disease with implementation of routine screening Finding sustainable solutions is worth the effort

Ellen T. Rudy1 erudy@ladhs.org (213) 744-3056 Never discourage anyone...who continually makes progress, no matter how slow. Plato Greek author & philosopher in Athens (427 BC - 347 BC) Ellen T. Rudy1 erudy@ladhs.org (213) 744-3056 Christine Wigen1, Elisa Clay2, Sarah Guerry1, Bob Bolan2, Jason Hall2, Peter Kerndt1 1Los Angeles STDP; 2 LAGLC

Mantel-Haenszel Odds Ratio and 95% Confidence Intervals Symptoms vs. No Symptoms Rectal Chlamydia Before: 1.26 (0.48-3.29) After: 1.29 (0.92-1.83) Test for Homogeneity of OR: P=0.96 Rectal Gonorrhea Before: 0.86 (0.41-1.90) After: 1.79 (1.18-2.71) Test for Homogeneity of OR: P=0.11

Mantel-Haenszel Odds Ratio and 95% Confidence Intervals Reported Anal Receptive Sex vs None Rectal Chlamydia Before: 1.14 (0.50-2.61) After: 1.71 (1.23-2.38) Test for Homogeneity of OR: P=0.37 Rectal Gonorrhea Before: 1.53 (0.73-3.20) After: 1.57 (1.05-2.35) Test for Homogeneity of OR: P=0.95