Revision of Region II IPP Screening Criteria May 16, 2007 Region II IPP Advisory Committee Meeting Cicatelli Associates Inc. New York City

Region II IPP Strategic Plan  PRIORITY 1: Target/Expand Chlamydia Screening to Young Sexually Active Women and Men at Risk for Infection in Public and Private Settings. GOAL: All at risk men and women under the age of 25 will be screened at least annually. GOAL: All at risk men and women under the age of 25 will be screened at least annually. OBJECTIVE 1A: Revise regional screening criteria for females so that screening is targeted to the most at-risk populations by October 2007.OBJECTIVE 1A: Revise regional screening criteria for females so that screening is targeted to the most at-risk populations by October 2007.

Screening Workgroup Members  Eileen Crayne (NJ DHSS STD)  Debbie Polacek (NJFPL)  Jennifer Howard (PPGNNJ)  Steve Rubin, Preeti Pathela, and Julie Schillinger (NYC DOHMH STD)  Alison Muse (NYS DOH STD)  Gale Burstein (Erie County DOH) Facilitator  Kelly Opdyke (CAI - Infrastructure)

Region II Minimum Selective Screening Criteria* Title X Clinics  All women ≤ 24 years of age attending the clinic for an initial or annual visit will be screened for chlamydia STD Clinics  All women ≤ 29 years of age attending the STD clinic will be screened for chlamydia *Region II IPP, 2003 Protocols & Guidelines

Current Limitations of Screening Criteria & Proposed Revisions Areas of Consideration:  Client Age  Clinic Site Type  Pelvic Exam  Re-Screening  Males  Local Prevalence  Test Technology  Females ≥26 years

Criteria: Client Age Current Limitation  Criteria do not address screening among females age 25 years age bracket does not correspond with USPSTF or CDC criteria (<26 yrs); clients age 25 omitted age bracket does not correspond with USPSTF or CDC criteria (<26 yrs); clients age 25 omitted Proposed Revision  Criteria based on national standards all sexually active females age ≤25 yrs (i.e. <26 yrs) Includes expanding screening to females age 25 in Family Planning

Criteria: Clinic Site Type Current Limitation  Criteria do not address screening in sites other than STD or FP Proposed Revision  Criteria no longer specific to site type, but should consider local prevalence data

Criteria: Pelvic Exam Current Limitation  Screening contingent on pelvic exam Proposed Revision  Expanded to include limited service clients (no pelvic exam) using urine-based NAAT

Criteria: Re-Screening Current Limitation  Criteria do not address re-screening of positives (as per national guidelines) Proposed Revision  Expanded to include recommendation for re-screening positive females within 3-12 months as per CDC guidelines

Criteria: Males Current Limitation  Criteria do not address screening of males Proposed Revision  Provision for screening sexually active young males in high-prevalence settings

Criteria: Local Prevalence Current Limitation  Criteria do not address targeted screening based on local prevalence Proposed Revision  Recommendation for sites to adjust age criteria based on local age-specific prevalence (≥2%)

Criteria: Test Technology Current Limitation  No mention of preferred diagnostic test methodology Proposed Revision  Recommendation to use NAAT, as per CDC lab guidelines

Criteria: Females ≥26 Yrs Current Limitation  No guidance on testing in females outside of age criteria Proposed Revision  Recommendation for clinical considerations for testing females age 26 and over

Region II Minimum Selective Screening Criteria - Proposed  The Region II Infertility Prevention Project Chlamydia Screening Workgroup has developed selective screening criteria for chlamydia based on national recommendations provided by the CDC in the 2006 STD Treatment Guidelines ( -and-cervicitis.htm#uc4). -and-cervicitis.htm#uc4http:// -and-cervicitis.htm#uc4  Providers should follow CDC guidelines for screening and treating pregnant women.

Region II Minimum Selective Screening Criteria - Proposed FEMALESScreening  Annually screen all sexually active females ≤ 25 years of age for chlamydia. Re-Screening  All females, regardless of age, should be retested for chlamydia 3 months after being treated for a positive chlamydia test, or when they next present for care within the following 3-12 months.

Region II Minimum Selective Screening Criteria - Proposed MALES  Screening of sexually active young males should be considered in clinical settings with a high prevalence of chlamydia (e.g., adolescent clinics, job corps, correctional facilities, and STD clinics).

Recommendations for Implementation: Use of Limited Resources  Programs must consider implementation of these recommendations in relation to program resources, including fiscal, personnel, and technological.  The program’s aim should be to achieve the highest level of disease identification within this context.

Recommendations for Implementation: Test Technology  Use of highly sensitive and specific NAAT (nucleic acid amplification tests) is strongly recommended (  Use of urine-based NAAT can facilitate non- invasive screening of females who do not require a pelvic exam, as well as males.

Recommendations for Implementation: Local Age-Specific Prevalence  Sites with an age-specific chlamydia prevalence rate of less than 2% * should consider further targeting screening criteria based on local prevalence data.  Conversely, sites with an age-specific chlamydia prevalence rate of greater than 2% * may consider expanding criteria.  *Adjusted for laboratory test type.

Recommendations for Implementation: Clinical Considerations Risk History  Multiple sex partners in last 90 days  New sex partner in last 90 days  STD infection in past year  Contact to STD  Possible non- monogamous partner Clinical Findings  Friable Cervix  Mucopurulent Cervicitis  Cervical motion/Tenderness  Pelvic Inflammatory Disease (PID)  Urethritis  New STD diagnosis  Bacterial Vaginosis Testing of females ≥26 years of age with one or more of the following documented risk factors or clinical findings may be clinically indicated:

Recommendations for Implementation: Test of Cure  Except in pregnancy, test-of-cure (repeat testing 3–4 weeks after completing therapy) is not recommended for persons treated with the recommended or alterative regimens, unless therapeutic compliance is in question, symptoms persist, or re-infection is suspected.

Rationale  CDC STD Tx and Lab Guidelines  USPSTF Ct screening recommendations  NCQA HEDIS measure for Ct screening  ACOG Pap guidelines for females <21 yrs  California Over 20 Study preliminary findings  Regional IPP data on high Ct prevalence among walk-in pregnancy test clients  CDC Males Screening Consultation outcomes

Breakout Groups Pro’s – Con’s  Science  Promotes Targeted Use of Limited Resources  Ease of Implementation

Next Steps  Which of the proposed revisions should be adopted?  What are the pros and cons to consider?  What other information do we need to move forward?  Region II IPP Screening Workgroup.