1. New York City Department of Health and Mental Hygiene (NYC DOHMH)
STD Testing at Emergency Contraception Visits: New York City STD Clinics,
Shoshanna Handel, MPH
New York City Department of Health and Mental Hygiene (NYC DOHMH)
Bureau of STD Control
Good afternoon.
Disclaimer: The findings and conclusions of this presentation have not been formally disseminated by the Centers for Disease Control and Prevention and should not be construed to represent any agency determination or policy.

2. Background 1: Unintended Pregnancy
½ of pregnancies in the US are unintended
3.1 million in 2001
Healthy People 2010 Goal : reduce to 30%
Unintended pregnancies carry risks:
Health (physical and mental)
Social
Economic
No form of contraception is 100% effective
Let’s start by considering the public health challenges presented by unintended pregnancy, which is defined as a pregnancy that is mistimed or unwanted at the time of conception.
Half of all pregnancies in this country- over 3 million each year- are estimated to be unintended.* The goal set by the Healthy People 2010 initiative is to decrease the 50% to 30%.
Unintended pregnancies pose health, social, and economic risks. Preventing unintended pregnancies is complicated - no form of contraception is 100% effective, accidents happen, and so – unfortunately- does rape and coercive sex.
(*Finer 2006, Perspectives on Sexual and Reproductive Health).

3. Background 2: About EC Emergency Contraception (EC)
Emergency = Used AFTER sex
Contraception = PREVENTS pregnancy
not an abortifacient!
Emergency contraception, or EC, is an important strategy for preventing unintended pregnancies. EC refers to any method used to prevent pregnancy AFTER unprotected sex has happened. Please note that EC PREVENTS a pregnancy from starting. It does NOT cause an abortion- it prevents the need for one.

4. Background 3: Pills Formulated for EC
Plan B ® = FDA-approved in 1999
2 pills; high dose of progestin
Effective up to 120 hours post-exposure
Effectiveness decreases over time
AKA: “the morning-after pill”
Over-the-counter (August 2006)
For those 18 and over
Minors still need Rx
Costs $30-$70
Covered by some insurance, including Medicaid
In the United States, the most common method of EC is to take a high dose of the hormones found in regular oral contraceptive pills. The only FDA-approved pills specifically formulated for EC use are known by the brand name Plan B. A package of Plan B contains two pills with a high dose of progestin.
Plan B can be used to prevent pregnancy by any woman who has had unprotected sex in the past 5 days, or 120 hours, with no contraindications. The sooner a woman uses Plan B after sex, the more effective it is. If taken immediately, it is about 89% effective. Plan B is often referred to as “the morning-after pill” because of this time frame.
Nationally, Plan B was made available for OTC sale to anyone aged 18 and over in August of Minors still need a prescription. In NYC, EC costs anywhere from $30-$70 in pharmacies, although it’s covered by some insurance plans, including Medicaid.
Plan B is the only product that NYC STD clinics provide for EC. For the rest of this presentation, when I refer to EC, I am referring to Plan B.

5. Background 4: EC in NYC STD Clinics
Unprotected heterosexual intercourse
STD risk
Pregnancy risk
In 10 NYC DOHMH STD clinics since 2005
FREE
To women
No advance provision
Walk-in MD visits
It makes sense to offer services for preventing unintended pregnancies and for addressing STDs to women who report unprotected heterosexual intercourse, since they are at risk for both.
The New York City Department of Health and Mental Hygiene’s Bureau of STD Control operates 10 STD clinics. These NYC STD clinics offer comprehensive STD services, HIV testing and partner notification, and several other types of health services. Family planning services are limited to EC provision and referrals for family planning care.
These clinics have offered EC since late They provide it for free to women at the time they need it at walk-in clinic visits. At our clinics, all women must see a physician to get EC.

6. Study Objective & Definitions
Describe EC-request visits
Patient age
STD testing and positivity
EC-request visit = pt. asks for EC (triage or MD)
EC-only visit = no other services requested
EC-plus visit = additional services requested
STD testing = Chlamydia and gonorrhea (CT/GC)
The objective of the analysis I’m about to present was to characterize EC visits to NYC STD clinics, with respect to patient age, STD screening done, and positivity rates.
We defined an EC-request visit as any visit at which the patient specifically asked for EC either at triage or during her time with the physician. We differentiated between EC-only visits, at which the patient asked only for EC and nothing else, and EC-plus visits, at which the patient asked for EC as well as some other kind of service or services.
We focused the analysis on testing for chlamydia and gonorrhea only.

7. Methods Study Period: Oct. 2005 – Apr. 2007 (19 months)
Study Population: Women (age ≥12)
Data Source: Electronic Medical Records
Visit-based analysis
Reasons for Visit / Chief Complaints
Age
Urine / endocervical NAATs and
GC culture on cervical, anal, and oral specimens
The study period included the 19 months from Oct through April 2007.
The study population included all women who came to one of the NYC STD clinics during the study period. The clinics only accept patients who are aged 12 and over.
The study used electronic medical record data, and was a visit-based analysis, as opposed to a patient-based analysis.
We used data on “Reasons for Visit” and “Chief Complaints” to identify EC-request visits. To identify the outcomes of interest, we looked at data on patient age and on urine or endocervical nucleic acid amplification tests (or NAATS) and GC cultures performed – and their results – at those visits.
DO NOT READ- These are the parameters:
Ct: NAATS: urine or cervical
GC: NAATS: urine or cervical
       Cultures: cervical, anal or oral
I did not look at anorectal CT NAATS (only anorectal GC cultures).

8. Results 1: EC-Request Visits
3,758 women made 4,657 EC-request visits
19% repeats
66% (3,068 / 4,657) EC-only visits
EC demand at NYC DOHMH STD clinics
Visits to STD clinics by women in 2006: 48,691
Est. EC-request visits per year: 2,940
6% of women’s visits are for EC (1 in 17)
We found that a total of 3,758 women made 4,657 EC-request visits. That means 19% of all requests were repeats. EC was the ONLY reason for 2/3 of the EC- request visits, showing that the majority of women who come to STD clinics for EC do not present with STD-related concerns.
To give you a sense of what these numbers mean about the scale of EC demand at the NYC STD clinics,
There are approximately 49,000 visits to the clinics by women per year, and at about 3,000 of these the woman specifically asks for EC.
That means that 6% - or 1 in 17 - of the clinics’ visits by women are for EC. This proportion does vary between the 10 clinics.

9. Proportion of EC-Requests, by Age Group
Results 2: Patient Age
Median age at EC request = 21
Range: 13-49
12% (566 / 4,657) EC-requests by women <18
77% (3,570 / 4,657) of requests by women ≤ 25*
Proportion of EC-Requests, by Age Group
The median age at EC-request visits was 21. However, there were requests for EC made by women from across the reproductive age range. 12% of the EC-requests were made by women younger than 18, who can not buy EC over-the-counter.
As most of you know, CDC recommends annual CT/GC screening for all sexually active women aged 25 and younger.
Over ¾ of EC-requests were made by women in this age group.

10. Results 3: CT/GC Testing & Positivity
Visit Type
No.
% Tested for CT/GC
% Positive for CT/GC
All EC-requests
4,657
27%
(1,259/4,657)
12%*
(149 / 1,259)
EC-only
3,068 4%
(135 / 3,068) 7%
(9 / 135)
EC-plus
1,589
71%
(1,124/1,589)
12%
(140 / 1,124)
This table shows CT/GC testing and positivity among all EC-request visits and then among EC-only and EC-plus visits.
Overall, 27% of EC-request visits included testing for chlamydia/gonorrhea. Where testing was done, 12% had positive results!
However, the proportions tested and positive vary quite a bit between EC-only and EC-plus visits. When we look at the EC-only visits, which you’ll remember are over 2/3 of the visits, only 4% included testing for Ct/Gc, but 7% of those tested were positive.
Among EC-plus visits, 71% were tested and 12% were positive. The high rate of testing at EC-plus visits is due to the other reasons for the visits indicating a need for testing.
Let’s consider what this tells us about the potential added value of expanding CT/GC testing at EC-only visits, which had such a low proportion tested. If we were to screen all women making EC-only visits, assuming that the 7% positivity rate that we observed among those who were tested would hold, we’d detect an additional 130 cases of CT/GC per year
* 11% (133 / 1,259) CT positive
2% (26 / 1,259) GC positive

11. Results 4: CT/GC Testing & Positivity at EC-Request Visits, by Age Group
33%
This chart shows testing and positivity rates at EC-request visits by age at the time of EC-request visit.
The pair of bars on the left shows testing and positivity at EC-request visits by women aged 25 and younger. You’ll remember that this is actually 77% of all EC-request visits. (3,570 / 4,657)
The pair of bars on the right shows testing and positivity at EC-request visits by women over 25.
Note that the positivity among the younger group was 14% - twice the 7% positivity found among women over 25 who were tested at the time of their EC-request visit.
DON’T READ:
25% (900/3,570) of EC-request visits by women <=25 included tests; 14% (123/900) positive
33% (359/1,087) of EC-request visits by women >25 included tests; 7% (26/239) positive
25%
14% 7%

12. Limitations “Reason for Visit” data can be incomplete or inaccurate
Did not include visits where EC received, but not recorded as requested
Anorectal CT testing not assessed in this analysis
As I mentioned earlier, the results I just presented rely on data about patients’ “Reason for Visit” to identify EC-request visits. Keep in mind that this data can be incomplete or inaccurate, depending on how fully a patient discloses their reasons for the visit and how thoroughly the clinic staff asks for and records these reasons.
Visits during which EC was not recorded as a Reason for the Visit or as a Chief Complaint, but where the patient received EC, were excluded from this analysis.*
Another possible limitation of the analysis is that anorectal testing for chlamydia was not assessed, and therefore the results listing “percent tested” could be slight undercounts.
*845 visits.

13. Conclusions Substantial % of visits by women are for EC
Most EC-requests are by women who meet age criteria for CT/GC screening
Few EC-request visits include testing for CT/GC
High CT/GC positivity among those tested
EC-Request Visits = Missed opportunity for CT/GC testing
With those limitations in mind, we concluded that a substantial proportion of visits to NYC DOHMH STD clinics by women are for EC. Although most women requesting EC meet age criteria for CT/GC screening, and have had recent unprotected sex, few EC-request visits included CT/GC testing.
These findings plus the high rates of CT/GC found among those who were tested, indicate that EC-request visits are an important opportunity to improve STD detection and treatment in NYC, and that screening more women for CT/GC when they request EC is a priority.

14. Comparing Testing and Positivity at EC-Request Visits During Study Period and Follow-up Period
Last October, we changed our clinic protocol to try to increase the proportion of EC-request visits where CT/GC testing is done. Previously, the protocol prioritized expedited EC provision. Now, CT/GC testing is actively offered at all EC-request visits.
We looked at testing done and positivity rates during the 3 months after we changed the protocol, and compared this to what we had seen during the study period. This chart shows the before and after picture.
During the follow-up period we succeeded in doing CT/GC screening at 57% - in comparison to the previous 27% - of EC-request visits. The positivity rate among those tested remained high at 10%.
DO NOT READ:
In the follow up period, we detected 42 cases of CT/GC. If we had only screened 27%, we would have detected 20 cases. 22 additional cases in 3 mo. were detected.

15. Next Steps Continued evaluation of yield of this approach
Describe repeat EC patients
Look for prevention opportunities
EC education in clinic waiting rooms
Increase clinic capacity to provide EC
Improve referrals to family planning services
We will continue evaluating the success of this approach over time.
We are also beginning to use electronic medical record data to describe the phenomenon of repeated visits for EC. While 96% of EC-request patients during our study period asked for EC 3 times or less, there is a small group of women who request EC more frequently, and these women may have unaddressed needs for family planning or other services.
We believe that many of our STD patients are unfamiliar with EC and therefore don’t ask for it even when they could benefit from it. We’ve added some new educational materials to the clinic waiting rooms, and have incorporated a brief statement about EC in the routine presentations done in the waiting rooms.
Growing awareness of EC could increase the demand for it in our clinics. We’re working on increasing our clinics’ capacity to provide EC by exploring the possibility of providing EC at express visits which do not include time with a physician.
In order to better meet our patients’ needs for preventing unintended pregnancy, we are also developing an improved referral system to comprehensive family planning services.

16. Acknowledgements Dr. Julia Schillinger (jschilli@health.nyc.gov)
Jessica Borrelli
Meighan Rogers
Steve Rubin
Dr. Susan Blank
Thelma Williams
I want to acknowledge my colleagues who made this analysis possible.

17. Thank you!!! background Shoshanna Handel shandel@health.nyc.gov
And I want to thank all of you for your attention.
I welcome questions and comments.
Shoshanna Handel

18. Supplemental Slides

19. NYC STD Clinics 10 clinics Free ≥12 years old No appointments
No insurance needed
Immigration status not
checked
114,685 visits in 2007
Services include:
STD testing and treatment
HIV testing and counseling
Partner notification
Free condoms
Hep A & B vaccine
Nicotine patches
Pap tests
Emergency contraception!
The city department of health operates 10 dedicated STD clinics, with branches in all five boroughs of the city. All of the STD clinics offer completely free and confidential services to anyone aged 12 or older who walks in the door. Our patients don’t need money, insurance, or an appointment to be seen. Because of this, the wait times are often very long. In 2007, there were almost 115,000 visits to the clinics.
The STD clinics provide testing and treatment for all STDs, as you would imagine, but they also provide a number of other services, including rapid HIV testing and counseling, partner notification, free condom distribution, Hepatitis A screening and Hep B vaccine. In recent years the STD clinics have been providing several services that are not strictly STD related, such as nicotine replacement therapy, pap tests, and my favorite- emergency contraception.

20. Relative Burden of EC Demand at NYC DOHMH BSTDC Clinics
There is notable range in EC demand between the BSTDC clinics. The Jamaica clinic sees the highest demand, with 1 in 11 visits by women being for EC. The lowest demand is at the Staten Island clinic where just 1 in 34 visits by women are for EC.
Because of the volume of their patient load, the Ft. Greene and Chelsea clinics see the second and third highest number of EC-request visits, even though they rank in the middle in terms the proportion of visits by women that are for EC.
1 From analysis of EMR data, 10/05-4/07
2 From BSTDC clinic utilization data for 2007

21. EC Resources http://ec.princeton.edu/
Here are some useful websites if you want more information about EC initiatives, which you might find interesting and which are also appropriate for anyone seeking EC info.

22. Understanding EC Effectiveness
If 100 women had unprotected sex (sex without using birth control) in the fertile part of their cycle (when an egg is most likely to leave the ovary), about 8 of those women would become pregnant.
If those same 100 women took progestin-only EC, only 1 would become pregnant.

23. Many people still don’t know about EC…
There have been various campaigns to raise awareness about EC, but many people still don’t know about it, or have misconceptions about it. We often hear that people think EC causes abortions, which makes it unacceptable to them.
This map comes from a recent DOHMH report, and shows that only about half of NYC high school students have heard of EC. This tells us that many of our STD patients probably lack knowledge of EC, even though we do have many patients who know to ask for it.
From: NYC DOHMH Vital Signs (Aug. 2007) “Teen Sexual Activity and Birth Control Use in New York City”

24. Project STAY Brochure (Trifold, front and back)
This brochure, with matching posters, is part of our effort to increase awareness of EC among our patients. It was created by a CBO called Project STAY, which works on adolescent sexual health issues in NYC.
(Trifold, front and back)

25. EC Requests EC Request = EC a Reason for Visit (RV) or
a Chief Complaint (CC)
EC = the ONLY RV for 66% of requests
4,657 requests by 3,758 women
~245 per month
~2,940 per year
An EC request visit is defined as a visit for which EC is listed as a Reason for Visit (given to the triage staff) or a Chief Complaint (given to a doctor). These visits represent demand for EC by women who have the knowledge and the motivation to specifically seek EC.
The vast majority of these visits had EC in the Reason for Visit (only 212 had EC noted in the CC but NOT the RV). EC was the ONLY reason for visit for 2/3 of the requests, showing that the majority of women who come to STD clinics for EC do not present with STD-related concerns.
In total, there were 4,657 EC requests by 3,758 women. That means that 899 EC requests, or 19% of all requests, were repeats, a phenomenon that we will be exploring in more detail in the future.
You can see here how the number of EC requests we found translates into overall monthly and annual averages, but this masks huge differences in EC demand between the clinics.

26. EC Received 4,695 visits where EC in Dx&Tx 82% had requested EC
Now let’s look at visits where EC was received, as defined by EC being noted in the Diagnosis and Treatment field.
There were 4,695 visits where EC was received- just a few more than the 4,657 visits where EC was requested.
Of the visits where EC was received, 82% also had EC marked as requested. This proportion is almost exactly the same as the 83% of EC requests that ended up in EC being marked as received. What this tells us is that the vast majority of EC visits include both a specific request for EC on the part of the patient AND successful provision of EC on the part of the STD clinic. However, the visits where EC is either requested or received, but not both, are especially interesting. Visits where EC is requested but not received might reveal something about barriers to EC accessibility, and visits where EC is received but not requested might give us insight into the role of STD clinics in educating women about EC.

27. Determining EC Eligibility – BSTDC Electronic Medical Record

28. EC Eligibility - 1 79% of visits: EC eligibility not marked
69% of requests had pt marked as eligible
Only 3% marked as ineligible
1/4 missing eligibility documentation
64% received EC
We thought that our data on EC eligibility would help us understand the relationship between EC requests and EC received. An eligible woman would have had unprotected sex in the past 72 hours and would not desire pregnancy. We used the data on eligibility that was available, but found that it was often missing. This had to do with a problem in the way the EMR was organized, which has now been fixed.
Looking at EC requests, 69% showed that the patient was EC eligible, 3% showed that the patient was INELIGIBLE, and the rest were missing eligibility data. Of those where EC eligibility data were missing, 64% received EC which shows that they were, in fact, eligible (we assume). It would be helpful to have data to clarify how frequently EC requests are made by a women who are ineligible, and the characteristics of such women, because we may be called on to find other ways to meet their needs.

29. EC Eligibility - 2 44% eligibility (where EC not requested)
1,026 visits
¾ of these received EC
44% Projections:
15,900 eligible visits where eligibility not assessed
9,120 eligible visits where pt. never saw MD
We think eligible women leave clinics without EC, but could we manage a heavier load?
We were interested in how many of our women patients who do NOT specifically request EC are eligible for EC at the time of their clinic visit.
We found that 44% of the visits where EC was not requested, but where EC eligibility status was documented, were in fact by EC eligible women. This means that STD clinic doctors successfully determined that a patient was eligible for EC even though she herself had not requested EC at over 1,000 visits during the 19 months we studied. ¾ of these visits resulted in EC being dispensed. This suggests that our clinic staff empower many women in NYC who might not fully understand their options to prevent unwanted pregnancies.
But the next question was whether there might be ways to expand our impact…
We projected the 44% eligibility rate onto visits where eligibility was not assessed, and visits where the patient never saw a doctor to even have the chance to be assessed. You can see that the number of these visits where the patients may have been EC eligible but was never assessed are huge- totaling over 25,000.
Of course, the 44% eligibility rate that this number is based on may not be fair, since doctors may have been more likely to assess eligibility for women who you had reason to believe would be eligible. Nevertheless, this is our best estimate, and it certainly implies that many women who come into our clinics while eligible for EC leave without getting it. At least some of these women probably would accept EC if it were offered, thus reducing their chances of having an unwanted pregnancy.
Finding ways to get EC to more of our eligible patients has been a topic of debate for a while. Until now, only doctors have been able to do EC assessment and dispensing in our clinics, despite the fact that EC is OTC for adults. This presented a problem because the doctors are chronically overworked and the wait times for patients are notoriously long, so adding more EC service provision to their days seemed unfeasible. I’m not sure how the clinics ended up with the rule about only doctors giving out EC, but recent legal investigations have finally shown us that there is no legal reason why other types of clinic staff couldn’t give out EC to adult patients. Now that we know this, we will consider how we might do a better job of finding EC eligible patients and offering EC to them.

30. Potential Additional Positive Results per Year, Est.
Results 4: Annual Potential Additional CT/GC Infections Detected with Expanded Testing
Visit Type
No.
% Tested for CT/GC
% Positive for CT/GC
Potential Additional Positive Results per Year, Est.
EC-only
3,068 4% 7%
126
EC-plus
1,589
71%
12% 31
This table shows how many additional cases of CT/GC we might be able to detect each year if we were to do testing at all EC-request visits, assuming the same positivity rates would hold.
If we were to project the 12% positivity rate that we saw among all CT/GC tests done at EC-request visits onto all of 4,657 EC-request visits during the study period, that would yield an additional 254 positive results detected per year.
The same type of projection of the observed CT/GC positivity rate among tests done at EC-only request visits would yield 126 more positive results per year.
Projecting the 12% positivity rate onto all EC-plus request visits would yield an additional 31 positive results per year.

31. Repeat EC Requests, 10/05 – 4/07 71% = 1 visit 89% ≤ 2 visits
This chart shows the number of patients that requested EC once, twice, three-times, etc. during our study period. You can see that most patients only requested EC once, and almost all patients requested EC less than 5 times in 19 months. While the frequent EC requesters are few, they probably represent a high-need group.
71% 1 visit
89% ≤ 2 visits
96% ≤ 3 visits
98% ≤ 4 visits
186 patients >= 4 visits in 19 mo.
60 patients >= 5 visits in 19 mo.

32. Follow Up Use of findings:
Changed clinic protocol to actively offer CT/GC test at all EC-request visits
11/07-01/08: CT/GC Testing & Positivity by EC-Request Visit Type
Visit Type
No.
% Tested for CT/GC
% Positive for CT/GC
All EC-requests
734
(100%)
57%
(419 / 734)
10%
(42 / 419)
EC-only
288
(39%)
26%
(76 / 288) 9%
(7 / 76)
EC-plus
446
(61%)
77%
(343 / 446)
(35 / 343)
Last October, we changed our clinic protocol to try to increase the proportion of EC-request visits where CT/GC testing is done. Previously, the protocol prioritized expedited EC provision. Now, CT/GC testing is actively offered at all EC-request visits.
This table shows that we’ve succeeded in doing CT/GC screening at 57% - in comparison to the previous 27% - of EC-request visits. The positivity rate among those tested remained high at 10%.
What was different in recent months was that the majority of EC-request visits also included other reasons for the visit. This is probably due to a change in the way the clinics are recording reasons for visit rather than an actual change in patient demands. 32

33. 11/07-01/08: CT/GC Testing & Positivity at EC-Request Visits, by Age Group
This chart shows that during the follow-up period, the majority of EC-requests were made by women aged 25 and younger. (80%) The positivity rates for CT/GC remained much higher among women 25 and under than among women who are older than 25.
(N=734)
(N=585)
(N=149)

34. Need for Anorectal CT/GC Testing Among Women Patients at BSTDC Clinics
8% of female visits to BSTDC clinics report receptive anal sex  
6% of year old female visits
8% of year old female visits
See poster at this conference by JA Schillinger et al.