M. Jacques Nsuami, MD, MPH Stephanie N. Taylor, MD Treatment and Follow Up in School-Based Sexually Transmitted Disease Screening Programs M. Jacques Nsuami, MD, MPH Stephanie N. Taylor, MD LSU Health Sciences Center, New Orleans, LA 9/16/2019

School and students’ participation in the New Orleans STD Screening Program # of Schools Tested Chlamydia Gonorrhea 1995-1996 Fall 3 1662 106   Spring 627 33 1996-1997 1721 71 28 1375 55 23 1997-1998 8 3851 325 61 1998-1999 12 6020 464 119 1999-2000 13 6080 578 2000-2001 2869 355 93 2001-2002 3069 346 66 2002-2003 7 2235 274 67 2003-2004 2229 285 53 2004-2005 9 2169 258 52

Prevalence of chlamydia among 9-12th graders in the New Orleans STD Screening Program

Prevalence of gonorrhea among 9-12th graders in the New Orleans STD Screening Program

Treatment and Follow up in School STD Screening Programs Providing treatment and follow up to individuals screened for a health condition is a key component of any screening program. There is no justification for screening if treatment and follow up cannot be provided. Treating students who test positive for CT/GC in school settings is conceivably more efficient because students can be easily located. However, there is no single best approach to locating or notifying infected students of their test results and scheduling treatment in schools. What may work in one school may not work or may not be accepted in another school, even within the same school district. Processes for treatment are often negociated on a school-by-school basis. Flexibility remains the key.

Following Results Notification All programs Offer in-school single dose observed therapy for CT/GC to all students testing positive and who are located in school; Return to each school generally multiple days to locate students needing treatment; Treatment sessions include STD counseling.

In-School Treatment Baltimore -SBHCs Indian Health Service -Nurses Office -IHS Clinic New Orleans -Office in a SBHC New York City -Any other available private space Philadelphia -Counselors Office

Following Results Notification All programs Collaborate with local health services/departments to treat students who are not located in school, those who refuse in-school treatment, or prefer to be treated by their private physician; -Indian Health Service: coordination between tribe, IHS, and the local health department is critical to ensure no one falls through the cracks. -New Orleans: the Medical Director of the STD Clinic is also the Medical Director of the School-Based STD screening program. -New York City, Philadelphia: a policy for expediting HS student treatment is in place in the City STD Clinics. City STD Clinics and DIS are of great assistance to school-based STD screening programs.

Patient Follow Up Students treated in school Baltimore: are instructed to return to the SBHC for retesting after 3 months. New Orleans, New York City: are referred to the STD Clinic to seek additional STD evaluation including HIV testing; NO: are not offered in-school retesting at 3 month but all are encouraged to be tested every year regardless of their previous participation and test results. NYC: are offered retesting 3-4 months after treatment in schools with SBHCs (through the SBHC). Philadelphia: may be offered in-school retesting 3-4 months after treatment when staffing and school schedule permit.

Patient Follow Up Students not located and treated in school Indian Health Service: Coordinates between tribe, IHS, and the local health department to ensure no one falls through the cracks. New Orleans, New York City, Philadelphia: are referred to DIS for field follow up.

Partner Notification and Follow Up Students treated in school New Orleans, New York City, Philadelphia: are interviewed to elicit partner information. Partners who attend school and located in school are tested for CT/GC (New York City) and offered treatment (New Orleans, New York City, Philadelphia); are referred to the city STD Clinic for further STD evaluation including HIV testing (New Orleans, New York City).

Partner Notification and Follow Up Partners not in school and/or not located New York City: are contacted by phone if possible, and if not located by phone, in person visits are made to their school or home. Once located, partners are given information about their exposure to an STD, then given information to go to the Clinic for treatment.

Partner Notification and Follow Up Partners not in school and/or not located New Orleans, Philadelphia: Elicited partner information is given to DIS who initiates notification of exposure and follow up to the city STD clinic. At the STD clinic, partners undergo routine STD evaluation and management (New Orleans) or are seen in an expedited visit (Philadelphia).

Location of treatment for positives detected in the Philadelphia High School STD Screening Program

Time before treatment (days) Time before treatment in the New Orleans High School STD Screening Program School Year Total treated* Time before treatment (days) % treated within 30 days Mean Median 2001-2002 2002-2003 2003-2004 2004-2005 Total 137 223 229 222 811 21 25 23 17 22 19 15 86.1% 80.0% 83.4% 95.5% 83.8% *Students with documented date of treatment

Conclusions School-based STD screening programs generally achieve high treatment rates; Treatment usually require strong collaboration with local health services, and tremendous amount of time and personnel; In inner-city schools, treatment is frequently delayed by high absentee and truancy rates; Protocols to ensure high partner notification and treatment have been difficult to develop, which partly contributes to high rates of reinfections among students;1 Collectively, these programs demonstrate that schools provide unique opportunities to control STDs among adolescents. 1Gaydos CA et al., Sex Transm Dis. 2008;35:233-237

Acknowledgements Panelists: Special Thanks: Lenore Asbel, MD, Philadelphia, PA Lori de Ravello, Albuquerque, NM Charlotte A. Gaydos, DrPH, Baltimore, MD Meighan Rogers, MPH, New York City, NY Special Thanks: Greta Anschuetz, MPH, Compiled data on location of treatment in the Philadelphia School Screening Program