1. Prevalence of Rectal Chlamydia and Gonorrhea Before and After Implementation of Routine Rectal Screening
Ellen T. Rudy Sexually Transmitted Disease Program Los Angeles County Department of Public Health

2. Objective
To describe the detection of rectal chlamydia and gonorrhea before and after implementation of a routine rectal screening program
To describe key components of the implementation process that lead to a successful and sustainable program
My objective is two-fold today because there are two stories. First it is to present

3. Key Participants Sarah Guerry, MD, Medical Director, STDP
Christine Wigen, MD, Assistant Medical Director, STDP
Precious Stallworth, Sexual Health Manager, LAGLC
Elisa Clay, NP, Nurse Practitioner, LAGLC
Bob Bolan, Medical Director, LAGLC
Peter Kerndt, Director STDP
Los Angeles Public Health Laboratory

4. Background
Los Angeles County STD Program and LAGLC long-standing relationship
CDC 2006 STD Treatment Guidelines: rectal CT/GC testing for all men who report receptive anal sex in past year
Provider-collected NAAT rectal swab was the standard
Symptoms only primary criteria for testing
Perceived barriers to implementation of routine rectal screening program:
Interference with clinic flow
Patient acceptability
Screening only settings
Provider compliance
This is the background

5. Solution: Self-Collected Rectal Swabs
Have been shown to be effective in HPV type-specific results (Lampinen, T, CID, 2006)
Initiated an evaluation of reliability of self-collected vs provider-collected rectal swabs
Results (Wigen et al) presenting Wednesday at afternoon poster session
This is the background

6. Methods and Timeline
Two populations of patients pre- and post-evaluation
Pearson chi-square test to compare differences
Before
Evaluation
After
Aug 1, 2007-Oct 15, 2007
Nov 1, Jan
April 1, June 26, 2007
Computed Pearson chi-square test to compare prevalence of testing and prevalence of positive infection before and after.
Provider-collected swabs only
Provider- and self- collected swabs
Primarily self-collected swabs
2614 Clinic Visits
2403 Clinic Visits

7. Los Angeles Gay & Lesbian Center
49% White
33% Hispanic
8% African American
10% Other
78% Gay
11% Bisexual
9% Heterosexual
1% Transgender/transsexual
Talk about the demographics of the clinic. May include behavioral and clinical

8. Behavioral and Clinical Characteristics
31% reported some type of symptom at visit
26% reported anal receptive sex at last sexual encounter
4.4 mean number of partners in past 3 month
range (0 – 300 partners)

9. Proportion Screened for Rectal CT/GC Among Clients Reporting Receptive Anal Sex
What percent of persons reporting receptive anal sex were tested? 13% missing data before; 7% missing data afterwards; Compared with urethral GC about 78% of incoming clients.

10. Proportion Tested for Rectal CT/GC Among Clients With and Without Symptoms
What percent of persons reporting receptive anal sex were tested?

11. Number of Cases of Rectal CT/GC Detected
Study#
Month/Year
Question:
Almost a two-fold increase in the detection of rectal chlamydia. Indicates that the increase in testing may have lead to more disease detection. Was it just increase in testing.
What percentage of testers reported anal receptive sex: Before and after

12. Proportion of Rectal CT/GC Positives
Before 26 out of 259; After 169 out of 1372;
Question:
Almost a two-fold increase in the detection of rectal chlamydia. Indicates that the increase in testing may have lead to more disease detection. Was it just increase in testing.
What percentage of testers reported anal receptive sex: Before and after
N=259
N=1372
N=259
N=1372

13. Summary Findings High prevalence of rectal CT/GC
Three-fold increase in screening
Six-fold increase in rectal CT cases detected
Three-fold increase in rectal GC cases detected
Symptoms not associated with rectal CT was associated with rectal GC
Now that we have useful data, our data shows:

14. Lessons Learned of the Implementation Process
Persistence
Compatibility with clinic’s needs
Sense of ownership
Collaboration
Adequate resources
User-friendly communication and feedback
Value in the program
Adapted from Sullivan G, Duan N et al.
2005. Psychiatric Services 56: 53.

15. Conclusion
Implementation of CDC guidelines for men reporting anal receptive sex is critical due to the high prevalence of rectal CT/GC
Significant detection of rectal disease with implementation of routine screening
Finding sustainable solutions is worth the effort

16. Ellen T. Rudy1 erudy@ladhs.org (213) 744-3056
Never discourage anyone...who continually makes progress, no matter how slow. Plato Greek author & philosopher in Athens (427 BC BC)
Ellen T. Rudy1 (213)
Christine Wigen1, Elisa Clay2, Sarah Guerry1, Bob Bolan2, Jason Hall2, Peter Kerndt1
1Los Angeles STDP; 2 LAGLC

17. Mantel-Haenszel Odds Ratio and 95% Confidence Intervals
Symptoms vs. No Symptoms
Rectal Chlamydia
Before: 1.26 ( )
After: ( )
Test for Homogeneity of OR: P=0.96
Rectal Gonorrhea
Before: 0.86 ( )
After: ( )
Test for Homogeneity of OR: P=0.11

18. Mantel-Haenszel Odds Ratio and 95% Confidence Intervals
Reported Anal Receptive Sex vs None
Rectal Chlamydia
Before: 1.14 ( )
After: ( )
Test for Homogeneity of OR: P=0.37
Rectal Gonorrhea
Before: 1.53 ( )
After: ( )
Test for Homogeneity of OR: P=0.95