Minnesota Department of Health Highlights from the Sexually Transmitted Disease (STD) 2014 Surveillance Report Minnesota Department of Health STD Surveillance System www.health.state.mn.us/std

Minnesota Department of Health Announcements

Minnesota Department of Health STDs in Minnesota Rate per 100,000 by Year of Diagnosis, 2004-2014 The rate of chlamydia in MN reached an all time high at 375 per 100,000. This is an increase of 6% from 2013. The rate of gonorrhea in MN is the highest in the past decade at 77 per 100,000. This is an increase of 5% from 2013. The rate of primary and secondary syphilis is also the highest it’s been in the past decade at 4.8 per 100,000. This is an increase of 33% from 2013. * P&S = Primary and Secondary Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

STDs in Minnesota: Number of Cases Reported in 2014 Minnesota Department of Health STDs in Minnesota: Number of Cases Reported in 2014 Total of 24,599 STD cases reported to MDH in 2014: 19,897 Chlamydia cases 4,073 Gonorrhea cases 629 Syphilis cases (all stages) 0 Chancroid cases Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

Minnesota Department of Health CHLAMYDIA STDs in Minnesota: Annual Review

Minnesota Department of Health Chlamydia in Minnesota Rate per 100,000 by Year of Diagnosis, 2004-2014 375 per 100,000 229 per 100,000 Chlamydia has continued to increase over the past decade. There has been a 64% increase from 2004 to 2014. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

Minnesota Department of Health Chlamydia Infections by Residence at Diagnosis Minnesota, 2014 Total Number of Cases = 19,897 All counties in Minnesota are affected by chlamydia. There were at least 2 cases in all counties. Roughly a third of the cases are in the cities of Minneapolis and St. Paul, a third in the Suburban area surround the cities, and a third in Greater Minnesota. Suburban = Seven-county metro area including Anoka, Carver, Dakota, Hennepin (excluding Minneapolis), Ramsey (excluding St. Paul), Scott, and Washington counties. Greater MN = All other Minnesota counties outside the seven-county metro area. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

Age-Specific Chlamydia Rates by Gender Minnesota, 2014 Minnesota Department of Health Age-Specific Chlamydia Rates by Gender Minnesota, 2014 The rates of chlamydia went up in both males and females in 2014. Females continue to have higher rates of chlamydia than males in age groups 39 and under. In 2014 the males have higher rates in the 40 and over age groups. The rate in males increased more than the rate in females in 2014. The highest rates of chlamydia continue to be in females 20-24 year of age at 3188 per 100,000. The age group with the largest increase in rate was males 30-39 at a 23% increase over 2013. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

Minnesota Department of Health Chlamydia Rates by Race/Ethnicity Minnesota, 2004-2014 2014 rates compared with Whites: Black = 9x higher American Indian = 4x higher Asian/PI = 2x higher Hispanic = 2.5x higher There continues to be disparities in rates of chlamydia. The Black/African American population has rates that are 9 times higher than that of whites. The rate in the Black/African American population was 1587 per 100,000 compared to the rate in the White population at 178 per 100,000. The American Indian population had a rate that was 4 times higher at 780 per 100,000 The Asian/Pacific Islander population had a rate that was 2 time higher at 312 per 100,000 The Hispanic/Latino population, which can be of any race, had a rate that was 2.5 times higher at 440 per 100,000 * Persons of Hispanic ethnicity can be of any race. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

Minnesota Department of Health GONORRHEA STDs in Minnesota: Annual Review

Minnesota Department of Health Gonorrhea in Minnesota Rate per 100,000 by Year of Diagnosis, 2004-2014 The rate of gonorrhea in MN is the highest in the past decade at 77 per 100,000. This is an increase of 5% from 2013. The rate continues to climb after a decrease from between 2007-2010. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

Minnesota Department of Health Gonorrhea Infections in Minnesota by Residence at Diagnosis, 2014 Total Number of Cases= 4,073 The majority of the gonorrhea cases, 35%, continue to be residents of the City of Minneapolis. The next highest area is the Suburban area at 27%. However, Greater Minnesota saw the largest increase in the number of cases from 2013 at 21%. Suburban = Seven-county metro area including Anoka, Carver, Dakota, Hennepin (excluding Minneapolis), Ramsey (excluding St. Paul), Scott, and Washington counties. Greater MN = All other Minnesota counties outside the seven-county metro area. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

Age-Specific Gonorrhea Rates by Gender Minnesota, 2014 Minnesota Department of Health Age-Specific Gonorrhea Rates by Gender Minnesota, 2014 The rates of gonorrhea went up in males and down females in 2014. For the first time in the past decade males have higher rates of gonorrhea than females. Females continue to have higher rates of gonorrhea than males in age groups 24 and under. In 2014 the males have higher rates in the 25 and over age groups. The rate in males increased from 2013 by 23%. The highest rates of gonorrhea continue to be in females 20-24 year of age at 362 per 100,000. However, the males in this age group are second highest at 361 per 100,000. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

Minnesota Department of Health Gonorrhea Rates by Race/Ethnicity Minnesota, 2004-2014 2014 rates compared with Whites: Black = 18x higher American Indian = 7x higher Asian/PI = 0x higher Hispanic = 2x higher There continues be even larger disparities in gonorrhea compared to chlamydia. The Black/African American population has rates that are 18 times higher than that of whites. The rate in the Black/African American population was 543 per 100,000 compared to the rate in the White population at 31 per 100,000. The American Indian population had a rate that was 7 times higher at 217 per 100,000. The Hispanic/Latino population, which can be of any race, had a rate that was 2 times higher at 75 per 100,000. The rate among the Asian/Pacific Islander population was roughly the same as the White population at 39 per 100,000. * Persons of Hispanic ethnicity can be of any race. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

Minnesota Department of Health Gonorrhea Rates by Race/Ethnicity Minnesota, 2004-2014 You can see the increase in rates that has occurred in the American Indian population since 2010 more clearly after removing the Black/African American data. This is an increase of 210% since 2010. * Persons of Hispanic ethnicity can be of any race. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

Minnesota Department of Health SYPHILIS STDs in Minnesota: Annual Review

Syphilis Rates by Stage of Diagnosis Minnesota, 2004-2014 Minnesota Department of Health Syphilis Rates by Stage of Diagnosis Minnesota, 2004-2014 Rates of all stages of syphilis increase from 2013 to 2014. The overall syphilis rate is up to 11.9 per 100,000. Of concern is the increasing rate of primary and secondary syphilis which is now up to 4.8 per 100,000. * P&S = Primary and Secondary Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

Minnesota Department of Health Primary & Secondary Syphilis Infections in Minnesota by Residence at Diagnosis, 2014 Total Number of Cases = 257 Over half of all primary and secondary syphilis cases reside in the City of Minneapolis. The suburban area has 28% of the cases, St. Paul has 14% of the cases, and Greater Minnesota only has 7% of the cases. Suburban = Seven-county metro area including Anoka, Carver, Dakota, Hennepin (excluding Minneapolis), Ramsey (excluding St. Paul), Scott, and Washington counties. Greater MN = All other Minnesota counties outside the seven-county metro area. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

Minnesota Department of Health Age-Specific Primary & Secondary Syphilis Rates by Gender, Minnesota, 2014 Males have higher rates of primary and secondary syphilis than females in all age groups. The rate in males is 11 times higher than females. This difference has decreased since 2011 where males had a rate that was 27 times higher than the females. The 20-24 yr old males have the highest rate at 27.7 per 100,000 The 25-29 yr old females have the highest rate of the female population at 3.2 per 100,000 Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

Minnesota Department of Health Primary & Secondary Syphilis Rates by Race/Ethnicity Minnesota, 2004-2014 The rates of primary and secondary syphilis are 7 times higher in the Black/African American population than that of the White population. The rates of primary and secondary syphilis in the Black/African American population are 23.8 per 100,000 compared to 3.6 per 100,000 in the White population. The rates in the Hispanic/Latino population are 8.8 per 100,000 which is 2.4 times higher than the White population. The rates in the Asian/Pacific Islander population are 6.8 per 100,000 which is 2 times higher than the White population. The rates in the American Indian population are 3.0 per 100,000 which is slightly lower than the White population. * Persons of Hispanic ethnicity can be of any race. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

Minnesota Department of Health Topics in the spotlight: Chlamydia and Gonorrhea among Adolescents and Young Adults (15-24 years of age) Early Syphilis Among Men Who Have Sex With Men in Minnesota STDs in Minnesota: Annual Review

CHLAMYDIA AND GONORRHEA AMONG ADOLESCENTS & YOUNG ADULTS Minnesota Department of Health CHLAMYDIA AND GONORRHEA AMONG ADOLESCENTS & YOUNG ADULTS (15-19 year olds) (20-24 year olds) STDs in Minnesota: Annual Review

Minnesota Department of Health Chlamydia Disproportionately Impacts Youth MN Population in 2010 (n = 5,303,925) Chlamydia Cases in 2014 (n = 19,897) Chlamydia disproportionately impacts youth. The 15-24 year olds make up only 14% of the population, but account for 66% of all chlamydia cases reported. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

Minnesota Department of Health Gonorrhea Disproportionately Impacts Youth MN Population in 2010 (n = 5,303,925) Gonorrhea Cases in 2014 (n = 4,073) Gonorrhea disproportionately impacts youth. The 15-24 year olds make up only 14% of the population, but account for 51% of all gonorrhea cases reported. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

Minnesota Department of Health Gonorrhea Rates Among Adolescents & Young Adults† by Gender in Minnesota, 2004-2014 The rates of gonorrhea are higher in females compared to males in the 15-24 year old age group. As I mentioned before, this has changed in all of the age groups above 24, where males have higher rates than females. We saw a decline in the rates of female adolescents & young adults this year for the first time since 2011. Rate=Cases per 100,000 persons based on 2010 U.S. Census counts. † Adolescents defined as 15-19 year-olds; Young Adults defined as 20-24 year-olds. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

Minnesota Department of Health Gonorrhea Rate Among Adolescents and Young Adults† by Race, Minnesota, 2014 There are still disparities in rates among the adolescent and young adults. The Black/African American population has higher rates than all other races and ethnicities in both males and females. Rate=Cases per 100,000 persons based on 2010 U.S. Census counts. † Adolescents defined as 15-19 year-olds; Young Adults defined as 20-24 year-olds. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

Minnesota Department of Health Topic of Interest: Early Syphilis Among Men Who Have Sex With Men in Minnesota STDs in Minnesota: Annual Review

Early Syphilis† by Gender and Sexual Behavior Minnesota, 2004-2014 Minnesota Department of Health Early Syphilis† by Gender and Sexual Behavior Minnesota, 2004-2014 MSM=Men who have sex with men † Early Syphilis includes primary, secondary, and early latent stages of syphilis. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

Early Syphilis† Cases Among MSM by Age Minnesota, 2014 (n=283) Minnesota Department of Health Early Syphilis† Cases Among MSM by Age Minnesota, 2014 (n=283) Mean Age = 36 years Range: 17 to 72 years Early syphilis in men who have sex with men is found in all age groups. The 20-24 year old men who have sex with men has the highest number of cases. The ages range from 17 to 72. The average age is 36. MSM=Men who have sex with men † Early Syphilis includes primary, secondary, and early latent stages of syphilis. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

Early Syphilis† (ES) Cases Co-infected with HIV, 2006-2014 Minnesota Department of Health Early Syphilis† (ES) Cases Co-infected with HIV, 2006-2014 37% of all early syphilis cases are co-infected with HIV. 50% of all men who have sex with men early syphilis cases are co-infected. MSM=Men who have sex with men † Early Syphilis includes primary, secondary, and early latent stages of syphilis. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

Characteristics of Early Syphilis† Cases Among MSM, Minnesota, 2014 Minnesota Department of Health Characteristics of Early Syphilis† Cases Among MSM, Minnesota, 2014 Gay and bisexual men account for 76% of cases among men. 79% of cases among MSM are White, but a disproportionate number of cases (11%) are African American. 56% in the City of Minneapolis and 26% live in the suburbs 50% of cases are also infected with HIV. MSM=Men who have sex with men † Early Syphilis includes primary, secondary, and early latent stages of syphilis. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

Minnesota Department of Health SURVEILLANCE SUMMARY

Summary of STD Trends in Minnesota Minnesota Department of Health Summary of STD Trends in Minnesota From 2004-2014, the chlamydia rate increased by 64%. The rate of gonorrhea increased by 5% between 2013 and 2014. Rates of reported syphilis increased in 2014 compared to 2013 by 18%. Minnesota has seen a resurgence of syphilis over the past decade, with men who have sex with men and those co-infected with HIV being especially impacted. Persons of color continue to be disproportionately affected by STDs. STD rates are highest in the cities of Minneapolis and Saint Paul. However, chlamydia and gonorrhea cases in the Twin Cities suburbs and Greater Minnesota account for 61% of the reported cases in 2014. Adolescents and young adults (15-24 years) have the highest rates of chlamydia and gonorrhea, making up 64% of new infections in 2014. Between 2013 and 2014, early syphilis cases increased by 24%. Men who have sex with men comprised 76% of all male cases in 2014; cases among women are continuing to increase. Data Source: Minnesota STD Surveillance System STDs in Minnesota: Annual Review

Future Updates to STD Reporting New case report form to accommodate changes in treatment guidelines will be available when CDC releases the changes Case report form is be able to be filled out on a computer and printed to be mailed or faxed in All cases co-infected with HIV/Gonorrhea, HIV/Syphilis, and Early Syphilis will be continue to be assigned to MDH Partner Services for follow-up Starting in April 2015 all Gonorrhea cases have the potential for being contacted by MDH for additional follow-up

For more information, contact: STD Surveillance Data Dawn.Ginzl@state.mn.us, 651-201-4041 MDH Partner Services Program Brian.Kendrick@state.mn.us, 651-201-4021

Syphilis: Deciphering the Great Imitator Cynthia Lind-Livingston Syphilis Lab Surveillance Coordinator STD/HIV and TB Section Minnesota Department of Health To contact me: email – cindy.lind@state.mn.us or telephone – 651-201-4024

Objectives Transmission Staging Diagnosis Testing Treatment

Transmission Contact with infectious, moist lesion(s), most commonly during oral, anal or vaginal sex 30-50% risk of infection per exposure to early (primary or secondary) syphilis Less common through casual skin to skin contact Cannot be spread by use of toilet seats, swimming pools, hot tubs, shared clothing or eating utensils.

Transmission (cont) Mother-to-child transmission Perinatal transmission can occur: At any time during pregnancy At any stage of the disease Chance of vertical transmission by stage of infection Primary syphilis = 50% Early latent syphilis = 40% Late latent syphilis = 10% Tertiary syphilis = 10%

Stages of Syphilis Primary: Chancre Appears 10-90 days after infection, on average 21 days Typically single, painless, clean-based lesion with rolled edges Appears at site where infected person’s lesion contacted person Resolves/heals without treatment

Stages of Syphilis (cont) Secondary: Occurs 3-6 weeks after primary chancre Rash (75-90%) Generalized lymphadenopathy (70-90%) Constitutional symptoms (headache, nausea, weight loss, vomiting, sore throat, slight fever) (50-80%) Mucous patches (5-30%) Condyloma lata (5-25%) Patchy alopecia or hair loss (10-15%) Symptoms of nuero-involvement (1-2%)

Stages of Syphilis (cont) Latent (Early & Late): No clinical symptoms: only evidence is positive serologic test 60-85% remain asymptomatic for years without treatment Divided into two stages for treatment purposes Early Latent Syphilis : <1 year in duration: Prior negative test result in past year Documented exposure to an early case of syphilis Symptoms consistent with primary and/or secondary syphilis in the past 12 months Two (2) dilution sustained increase in titer

Stages of Syphilis (cont) Late Latent Syphilis: >1 year in duration: No prior negative test result in past year No documented exposure to an early case of syphilis No symptoms consistent with primary and/or secondary syphilis in the past 12 months No two (2) dilution sustained increase in titer

Stages of Syphilis (cont) Tertiary Syphilis 70% of untreated patients remain asymptomatic 30% of untreated patients progress to tertiary stage in 5-20 years ▪ Gummas: destructive lesions of soft tissue, cartilage, internal organs and bone ▪ Cardiovascular involvement: aortic aneurysm, aortic insufficiency ▪ Central nervous system involvement: memory loss, vision issues, unsteady gate, hyporefexia, hearing loss Neuro-involvement Neuro-involvement can occur at any stage of disease Lumbar puncture

Syphilis & HIV Syphilis is a marker for HIV risk Atypical presentation of disease sometimes occurs Multiple ulcers, overlapping stages Higher non-treponemal titers Syphilis facilitates HIV transmission Increased the number of receptor cells Increases HIV viral load in genital lesions, semen or both

Syphilis Diagnosis Clinical Suspicion High Risk Population HIV Positive Annual Physical / STD Screen Pregnant

Syphilis Testing Microscopy Serologic Test for Syphilis (STS) Darkfield Biopsy Serologic Test for Syphilis (STS) Nontreponemal Treponemal

Syphilis Testing (cont) Nontreponemal (VDRL, RPR, USR) Measures antibodies which are not specific to Treponema pallidum Quantitative Reflects disease activity Advantages: Rapid & inexpensive for screening Easy to perform Use in evaluation of patients with symptoms or possible re-infection Use for follow-up assessment after treatment

Syphilis Testing (cont) Disadvantages: Biological false positive reactions (BFPs) Acute infections (Mononucleosis, herpes, viral illness) Chronic Infections (TB, lupus, rheumatoid arthritis) Intravenous drug use False negative reactions Prozone effect Early primary and late latent stages

Syphilis Testing (cont) Treponemal tests (TPPA, FTA-abs, EIA) Specific to T. pallidum More sensitive and specific than non-trep tests More expensive and labor intensive Usually remains positive for lifetime However 15-25% treated during primary state revert to seronegative after 2-3 years Does not correlate with disease activity or treatment

Treatment Early Syphilis Benzathine PCN G 2.4 million units IM once PCN-allergic: Non-Pregnant Doxycycline 100 mg po BID x 14 days Pregnant: Desensitize Benzathine PCN G 2.4 millions units IM once Alternative Therapies Tetracycline 500 mg po QID x 14 days Ceftriaxone 1 gm IM/IV QD x 8-10 days

Treatment (cont) Late-Latent and Unknown Duration: Neuro-involvement Benzathine PCN G 7.2 million units, administered as 3 doses of 2.4 million units IM, at 1 week intervals Neuro-involvement 18-24 million units daily, administered as 3-4 million units IV q 4 hours x 10-14 days

Treatment Response Jarisch-Herxheimer reaction Healing of skin and mucosal lesions Expected four-fold decrease in non-treponemal test titers in 6-12 months, depending on stage

Reporting Providers must report syphilis cases within one working day by completing a Minnesota Confidential STD Case Report (CRC). Reports of reactive results with symptoms consistent with primary or secondary syphilis can be called in immediately to MDH at 651-201-4024.

Resources Available Materials available on our website: www.health.state.mn.us/sep Resources for clinicians, including toolkit for syphilis testing and treatment; Dear Colleague letters and health notices; Resources for the community Archives of provider presentations and links to current awareness campaign materials

Exceptional Sexual Health Services for Adolescents Caring & Connecting: Exceptional Sexual Health Services for Adolescents

Objectives I. Describe foundations of exceptional adolescent-centered sexual health care II. Provide overview of Hennepin County’s MyClinic project and Standards & Best Practices for Comprehensive Adolescent Sexual and Reproductive Health Care.

Better Together Hennepin Initiative Better Together Hennepin is Hennepin County’s Initiative to reduce teen pregnancy and birth in the County. The overarching goal of the project is to provide young people with the four key support, shown in the yellow box, that research tells us are key to helping young people delay pregnancy and develop into healthy adults The initiative directly funds evidence-based programs and works to create systems change that leads to young people having better access to these supports The MyClinic project (previously known as the Adolescent Reproductive Health Care Access Project) was born out of this desire to create systems change, and increase the capacity of clinics to provide exceptional adolescent-centered sexual health care to young people. Modeling our work after the work of others around the country, specifically work being done in New York City, we convened an Advisory Board who then created the Standards and best practices that we are discussing today. Advisory Board is made up of physicians, nurses, clinic managers and administrators - all these roles are key in addressing the way that adolescent clients experience their clinic.

Adolescent-centered care: what makes it unique? So, let’s dive in – what makes adolescent care unique?

Exceptional, adolescent-centered care: Confidential Welcoming Convenient & affordable Respectful & nonjudgmental Comprehensive We’ve organized around these 5 main elements

Services are confidential Clinic makes every effort to guarantee confidentiality and respects young person’s right to consent by: Informing young person of their right to consent Ensuring young person understands consent process Taking every precaution possible in billing for confidential services Allowing for private conversations between client and provider Protecting confidential services when using electronic health records Confidentiality also includes the issue of privacy, for example they have a place for private conversation with the provider Young people have told us that they are also concerned about seeing friends/classmates in the waiting room We know this is a huge challenge that we have to address and it is difficult for clinics particularly in large health care systems but we have to be thinking about this as a barrier to serving young people And be up front with them when we can not guarantee confidentiality

Young people feel welcome Young people feel welcome physically and emotionally in the following ways: All staff show enthusiasm for working with young people Physical environment of clinic is welcoming to adolescents (Posters, magazines, signage) Services offered reflect needs of adolescent clients Young people see their cultural backgrounds and customs reflected in environment and staff Young people need to feel welcome. We do this through the physical environment, but probably more so in how we treat them in the clinic, how are they greeted, are they treated as competent and capable and with compassion And this starts on the phone when they call to make an appointment.

Services are convenient & affordable Clinic hours reflect young people’s availability: After-school, evening, weekend hours Walk-in hours available Fee schedules and billing procedures reflect young people’s income and insurance status: Sliding fee scale MFPP offered Confidentiality in billing practices This one is straightforward We know this can be a challenge when working in larger clinics perhaps, but we know that young people do not always operate as we do as adults. We need to be flexible and available to “catch them” when they are ready

Young people feel respected and heard Clinicians use welcoming and sensitive, non-judgmental questions and language when interviewing, counseling and treating adolescents. When interacting with adolescent clients, clinicians consider the young person’s culture religion ethnicity language sex & gender sexual orientation developmental stage & educational level We discussed our standards with groups of young people and this is the issue that they repeatedly said was most important to them: being treated with respect, and not feeling judged. They want to know they can talk with adults and not feel like we have an agenda that we are driving before they even walk in the room.

Young people get the services they need Clinic staff follow the most current clinical guidelines with regard to pregnancy prevention and STI/HIV prevention and care. Each clinic visit is taken as an opportunity to address the broad range of health care concerns most common to adolescents, including: STI & pregnancy Mental health Substance use Relationship issues Typical growth & development It is critical for clinics to be in line with what the most current research about adolescent services says best fits their needs The other piece is practicing in a way that acknowledges that each opportunity that we see a young person in a clinic is an opportunity to have a broader discussion with them about what they see as the strengths and challenges to their health and well-being. And often we may need to read between the lines of what they are telling us. Since young people are generally healthy, and may only present to clinic for a sports physical, we need to take that sports physical as an opportunity to address sexual activity or ask about substance use We know that in general most young people are sexually active well before they seek care for sexually related care, so we need to take every opportunity we can to address prevention.

MyClinic: Standards of Care for Comprehensive Adolescent Sexual and Reproductive Health Care

Standards of Care http://www.hennepin.us/bettertogether When providing sexual and reproductive health care to adolescents, providers should: Guarantee confidentiality and adolescents’ rights to consent to sexual and reproductive health care. Make services accessible and facilities welcoming to adolescents. Deliver patient-centered care that is sensitive to each adolescent’s culture, ethnicity, community values, religion, language, educational level, sex, gender and sexual orientation. Screen all adolescents for sexual and reproductive health issues, including substance use and mental health concerns, and provide appropriate education, counseling, care or referral. Provide contraceptive methods, including emergency contraception (EC), to adolescents at risk for unintended pregnancy. Provide prevention, testing and treatment of sexually transmitted infections. Offer information, assistance and support for all decisions regarding pregnancy. http://www.hennepin.us/bettertogether 7 Standards that reflect the essential elements we just covered. For each standard, there are specific best practices that reflect the standard. I will go through one of the standards to give you sense of the specificity of the standards. You can access the full standards and best practices on Hennepin County’s web page.

Standard 1: Guarantee confidentiality & adolescents’ right to consent to sexual and reproductive health care Best Practices: Every visit includes an opportunity for a confidential conversation between clinician and adolescent client. Health care records, whether electronic or paper, are set up to protect client confidentiality. Billing procedures are established to ensure client confidentiality. Staff is routinely trained on Minnesota’s minor’s consent and confidentiality laws Confidential contact information for adolescent patients is routinely collected and updated Adolescent clients are encouraged to involve trusted adults in their care. Clinic has a process for obtaining informed consent regarding services covered by MN minor’s consent and confidentiality laws (pregnancy, contraception, STIs, mental health and substance use) Minnesota adolescent consent laws are prominently displayed. As you can see, the best practices address a wide range of opportunities for ensuring confidentiality: during the visit – that you have time alone with the adolescent client, without parent. That they have privacy in the waiting room. in the health care records – particularly an issue for larger systems with electronic health records. There are models emerging for how to handle this. in the billing system – this is an area that really requires larger systems change – changing EOB requirements. Key here is to let young person know limits of your control when they use insurance. client contact outside of the office Each of these areas pose potential threats to confidential care and the young person’s confidence that their privacy is ensured. As an overlay to all of this, however, we know that it is best if a young person has a trusted adult as a partner in their health decisions and care.

Changing clinic practice to adapt to the Standards: MyClinic Self-Assessment Tool

MyClinic Self Assessment Tool Better Together Hennepin has an on-line tool to help providers assess their practice 30+ clinics have completed the assessment tool Key findings to date: All clinics found it helpful Most benefit came from completing tool as a team Even clinics doing great adolescent-centered work found areas for improvement General practice clinics found it a useful starting place Easy to use Contact Katherine Meerse for information about accessing the tool Key findings: All clinics that completed it found it helpful Clinics seemed to benefit most when they completed assessment tool as a team. Even the clinics doing great adolescent-centered work were able to find the tool useful in improving practice or targeting areas for improvement. More “general-practice” clinics found the tool useful in helping them identify areas where they could be better at serving adolescents and potentially get better at attracting adolescent clients. Easy to use.

Contact Information Katherine Meerse, PhD, Manager, Better Together Hennepin Katherine.Meerse@hennepin.us 612-596-0996

Thank you! For more information, contact: STD Surveillance Data Dawn.Ginzl@state.mn.us, 651-201-4041 MDH Partner Services Program Brian.Kendrick@state.mn.us, 651-201-4021 Syphilis Lab Surveillance Cindy.Lind@state.mn.us, 651-201-4024 Better Together Hennepin Katherine Meerse, PhD, Manager Katherine.Meerse@hennepin.us, 612-596-0996