STD and HIV Emerging Issues Gail Bolan MD Chief, STD Control Branch CA Department of Health Services Assistant Clinical Professor Department of Medicine, UCSF

Overview of Complications of Sexually Transmitted Diseases Fetal Wastage* Low Birthweight* Congenital Infection* Upper Tract Infection Systemic Infection STDs Infertility Ectopic Pregnancy* Chronic Pelvic Pain HIV Infection* Cervical Cancer* * Potentially Fatal

STD Morbidity California and United States 2002

10 Core Public Health Functions and STD Activities Advocacy, strategic planning and guidelines Develop policies and plans that support efforts Community mobilizationMobilize community partnerships and action Health EducationInform and empower people about health issues Screening and DIS follow-upDiagnosis and investigate health problems SurveillanceMonitor health status STD Prevention ActivitiesPublic Health Functions

10 Core Public Health Functions and STD Activities Research Research new insights and innovative solutions Evaluation Evaluate the effectiveness, accessibility, and quality of services Staffing and staff developmentEnsure competent workforce Access to and provision of quality care Link people to services and ensure provision of care when unavailable Legislation and RegulationsEnforce laws and regulations STD Prevention ActivitiesPublic Health Functions

STD Prevention and Control Strategies Education and counseling (primary prevention) –Project Respect Identification of asymptomatic persons (secondary prevention) –Screening –HEDIS Identification of symptomatic persons (secondary prevention) Effective diagnosis and treatment (secondary prevention) –Test Performance Characteristics –Empiric Treatment Partner Management (primary and secondary prevention) Vaccination ( ideally primary prevention)

Syphilis — Reported cases: US, 1941–2001

Primary and secondary syphilis - County rates, 1998

Syphilis: Overview of Stages 1º 2º 3º Latent 30% 5-50 years Early SyphilisLate Syphilis

Epidemiologic Vulnerability of Syphilis No animal reservoir Long incubation period Limited infectiousness Low cost and widely available diagnostic tests Single dose therapy No antimicrobial resistance

Syphilis Elimination: Public Health Importance Important, measurable health outcomes Substantial cost savings –Annual cost savings of ~1 billion Supports multiple public health goals –Reduction of racial disparities –Infectious disease control, including HIV prevention –Bio-terrorism preparedness –Reproductive health and infant health –Identifies opportunities to improve public health infrastructure Focus for critical collaboration between communities & health departments Addresses unfinished history & broken trust

Primary & Secondary Syphilis Cases by Gender, California, 1996–2002 Rate per 100,000 ALL MALE FEMALE known MSM 5/03 Provisional Data - CA DHS STD Control Branch

Risk Characteristics of MSM P&S Syphilis Cases, California /03 Provisional Data - CA DHS STD Control Branch 1 Percentage excludes unknown

Rate per 100,000 Source:California Department of Health Services, STD Control Branch Gonorrhea Rates by Gender, California, 1993–2002 Provisional Data 05/16/2003

Gonococcal Isolate Surveillance Project (GISP), Percent of Neisseria Gonorrhoeae Isolates with Decreased Susceptibility or Resistance toCiprofloxacin, California Sites, 1991–2002 Note: Resistant isolates have MICs ≥ 1 μg ciprofloxacin/mL. Isolates with decreased susceptibility have MICs of – 0.5 μg ciprofloxacin/mL. STD Clinic Sites: Long Beach, Orange, San Diego, San Francisco Source: California Department of Health Services, STD Control Branch

Gonococcal Isolate Surveillance Project (GISP) - Location of participating clinics and regional laboratories: United States, 1998

Gonorrhea Treatment Genital & Rectal Infections in Adults Recommended regimens: n Cefixime 400 mg PO x 1 or n Ceftriaxone 125 mg IM x 1 or n Ciprofloxacin 500 mg PO x 1 or n Ofloxacin 400 mg PO x 1 or n Levofloxacin 250 mg PO x 1 PLUS if chlamydia is not ruled out: n Azithromycin 1 g PO x 1 or n Doxycycline 100 mg PO BID x 7 d

Why Chlamydia & Why Now? Most common communicable disease reported disease in California –Over 100,000 reported cases in 2001 –Over 75% of cases are seen in the private sector Significant health consequences –Most common cause of preventable infertility –Facilitates sexual transmission of HIV New technology = new opportunity –Urine tests & single dose treatment = easier to reach, treat & cure at-risk populations HEDIS increases private sector interest –Potential public/private partnership

Chlamydia Action Coalition A State-Wide Public/Private Partnership funded by the California HealthCare Foundation

Chlamydia Screening HEDIS Measure The Measure: the percentage of Medicaid and commercially enrolled women 15 through 25 who were identified as sexually active, who were continuously enrolled during the reporting year, and who have at least one test for chlamydia during the reporting year. Number tested Number of sexually active * * Denominator may exclude plan employees to protect confidentiality Source: CDC, NCHSTP, DSTDP

Centralized Data Warehouse with Electronic Transmission of Chlamydia Screening Data –Collection of HEDIS numerator data –Prevalence Monitoring Coordinate with ELR of communicable diseases Chlamydia HEDIS Data Warehouse

HIPAA Basics What is HIPAA? –Health Insurance Portability and Accountability Act –Provides the first national standards for protecting the privacy of health information –HIPAA Privacy Rule regulates how certain entities, called covered entities, use and disclose certain protected health information (PHI)

Who is Covered? Three types of covered entities –health plans, (e.g., Medicaid, Medicare, and the Veterans Health Administration) –health-care clearinghouses, (billing service, repricing company, or community health information system) –health-care providers who transmit health information in electronic form in connection with certain transactions (e.g., physicians, hospitals, and clinics)

Impact on Public Health Public health uses PHI to identify, monitor, and respond to disease, death, and disability among populations Privacy Rule expressly permits PHI to be shared by covered entities for specified public health purposes Public health authority may also be a covered entity in some cases

Permitted PHI Disclosures Without Authorization Where required by law PHI can be disclosed to public health authorities and their authorized agents for public health purposes Health research Abuse, neglect, or domestic violence Law enforcement Judicial and administrative proceedings. Cadaveric organ, eye, or tissue donation purposes For oversight activities authorized by law Worker's compensation

Included Public Health Activities reporting of disease or injury reporting vital events (e.g., births or deaths) conducting public health surveillance, investigations, or interventions reporting child abuse and neglect monitoring adverse outcomes related to food (including dietary supplements), drugs, biological products, and medical devices

Requirements for Covered Entities Accounting for Public Health Disclosures –Covered entity must be able to provide a patient an accounting of disclosure even for disclosures permitted or required by law Notice of Privacy Practices –individuals have the right to adequate notice of the uses and disclosures of PHI that may be made by the covered entity, as well as their rights and the covered entity's legal obligations Minimum Necessary Standard –directs covered entities to limit the amount of information disclosed to the minimum necessary to achieve the specified goal

Rapid HIV Testing A key strategy of the Advancing HIV Prevention Initiative is to use rapid HIV tests to expand HIV testing outside clinical settings.

PositiveNegative Reactive Control Positive HIV-1 Read results

STD Resources for Clinicians California STD/HIV Prevention Training Center CDC Treatment Guidelines California Chlamydia Action Coalition CA STD Control Branch