2. Bugs, Drugs, Dollars and Tests Making the Most of Scarce Resources for Chlamydia and Gonorrhea Screening and Treatment

3. Gonorrhea — Rates by sex: United States, 1981– 2002 and the Healthy People 2010 objective

4. Chlamydia - Rates by sex: United States, 1984–2002

5. Median Chlamydia and Gonorrhea Positivity among Women 15-24 tested in Family Planning Clinics across the US, 2000-2002 Percent Source: CDC Surveillance Reports, 2000-2002

6. Median Chlamydia and Gonorrhea Positivity among Women 16-24 entering the National Job Training Program, 2000-2002 Percent Source: CDC Surveillance Reports, 2000-2002

7. What’s wrong with this picture? Chlamydia and Gonorrhea Tests 24.1 million CT tests 24.8 million GC tests Chlamydia Infections Reported: 834,555* Estimate: 2.8 million Gonorrhea Infections Reported: 351,852* Estimate: 718,000 * Reported To CDC in 2002

8. Food for Thought Are data driving program funding decisions? (cost-effectiveness, prevalence, access, risk) How does history/tradition/politics influence funding decisions? What are our program goals? How can programs optimize resource allocation for optimal disease intervention?

9. Objectives of the Session: –Present cost effectiveness data of different screening and treatment strategies –Discuss how programs have used data to improve screening coverage and increase screening criteria adherence –Demonstrate how screening and cost data can influence program strategies and funding allocations

10. Presenters Dorothy Gunter, CDC Bartholomew Abban, CDC Beth Butler, Pennsylvania DOH Bobbie McDonald, Wisconsin State Laboratory of Hygiene Thomas L. Gift, CDC Lisa Schamus, Arizona Family Planning Council Charlotte Kent, San Francisco DOPH

12. A Unified Optimal Resource Allocation Model for Screening and Treating Chlamydia Trachomatis and Neisseria Gonorrhoeae Among Asymptomatic Women Bartholomew Abban Research Fellow Centers for Disease Control and Prevention

13. Study Objective Determine the optimal combination of screening coverage, test selection and treatment for CT and GC in asymptomatic women; specifically  At what prevalence is it cost-saving to screen a population for CT or GC?  Is it more beneficial to screen with more sensitive but more expensive tests?  Is presumptive treatment cost-saving?

14. What test(s) should be used? Should risk-group(s) be screened for CT, or GC, or both? Should patient be dual-treated? What treatment(s) should be used? Clinical Management Decision

15. Model Variables Prevalence, by age group Rate of dual infection, by age group Test performance parameters and cost Treatment efficacy and cost Sequelae costs What test(s) should be used? Should risk-group(s) be screened for CT, or GC, or both? Should patient be dual-treated? What treatment(s) should be used?

16. Clinical Alternatives Considered 1. Screen and treat for CT only 2. Screen and treat for GC only 3. Screen and treat for both CT and GC 4. Screen and treat for CT only and presumptively treat for GC 5. Screen for and treat for GC only and presumptively treat for CT For each risk-group the following strategies are possible:

17. Methods The optimal strategy was defined as one that maximized  the number of women cured or  the cost-saving value (cost of averted PID minus screening and treatment costs for CT and/or GC) Selective screening based on readily ascertained risk-factor: Age 4 tests each for CT and GC, including dual test(s) 2 treatment regimens for CT and 3 for GC A mixed integer optimization model for a hypothetical cohort of 1000 asymptomatic women

18. Model Assumptions All women who visited the clinic lacked symptoms of CT and GC infections A strategy could allow the screening of selected age groups or all patients Return rate for treatment was assumed to be the same for all age groups Test and treatment for each infection were the same for all age groups

19. Test Positivity at which Screening is Cost-saving PID cost (US $) Pathogen (Test type) CT (Pace 2) GC (Culture) GC (PCR) 14345.1%2.4%4.9% 19003.7%1.8%3.6% 41311.7%0.8%1.6% Sensitive to PID cost

20. Results – FP Clinic Total Program Cost † Screening Coverage Test#Cured Cost- saving † 17,437 CT (all) GC (all)BDPT-Dual 53.3-1,391 15,635 CT (all) GC (all) BDPT-CT culture 52.6192 14,214 CT (all) GC (  24, pres. ) Pace 2CT culture 51.91,432 11,458 CT (all) GC (none) BDPT-CT - 49.63,483 7,668 CT (  24) GC (pres.) BDPT-CT - 43.85,229 ‡ CT (2.3 - 10.6%), GC (0.4 - 1.2%), GC with CT (30.0 - 46.0%) † All costs in US dollars (2003)|BDPT – Becton Dickinson Probe Tec ‡ Optimal cost-saving strategy|pres. – presumptively treat

21. Results – STD Clinic Total Program Cost † Screening Coverage Test#Cured Cost- saving † 18,878 CT (all) GC (all)BDPT-Dual 97.810,578 16,928 CT (all) GC (all) BDPT-Dual Culture 92.811,020 12,788 CT (  20) GC (  20)BDPT-Dual 85.412,934 12,757 CT (  20, pres.) GC (all) BDPT-CT Culture 83.012,245 8,331 CT (all) GC (all)Pace 2C 82.015,849 ‡ CT (3.0 – 12.5%), GC (2.0 – 8.1%), GC with CT (20.0 – 45.5%) † All costs in US dollars (2003)|BDPT – Becton Dickinson Probe Tec ‡ Optimal cost-saving strategy|pres. – presumptively treat

22. Limitations The alternative of screening and treating for CT and screening CT- positives for GC was not considered Published range of values for direct cost attributable to PID is wide: (1,433 – 5,000) Repeat infections were not considered STD positivity among asymptomatic women may be lower than reported values

23. Conclusions Optimal control strategy varies with CT and GC positivity, CT-GC co-infection rates, total program budget, test costs and PID cost A switch from one test to another may not yield significant change in number of cures Influence of treatment cost on overall program cost is minimal The optimal control strategy from a cost- saving perspective and from a number-of- cures perspective may vary The model provides a flexible tool to analyze different scenarios when identifying a control strategy for CT, GC or both

24. Acknowledgements Guoyu Tao Tom Gift Kathleen L. Irwin Dorothy Gunter Susan DeLisle Stuart Berman Susan Wang Debra Mosure Robert Johnson Bobbie McDonald

26. To Screen or Not to Screen… Pennsylvania’s Reality Beth Butler Infertility Prevention Program Coordinator Pennsylvania Department of Health STD Program

27. A Snapshot of Pennsylvania (exclusive of Philadelphia) The PA Project Area is comprised of STD, Family Planning, and Integrated FP/STD clinics –About 70% of of the STD clinics are integrated into Family Planning Sites STD Clinics –Majority of clinics are contracted providers. –Contracts require patients to be screened for gonorrhea, chlamydia, and syphilis –County and Municipal Health Departments and State Health Centers are covered under the same statute

28. STD Testing in Pennsylvania STD Clinics, County and Municipal Health Departments, and Integrated STD Clinic sites provide universal testing to STD patients who come in for “free and confidential STD testing” Communicable Disease Act in PA requires all those who present in an STD Clinic to receive STD services

29. What the STD Data Demonstrate 46,431 females were tested for chlamydia in STD clinics in 2002 5,624 females over age 30 were tested in STD clinics in 2002 12.1% of the females tested in STD clinics were over 30 years of age

30. Female Universal Chlamydia Screening in STD Clinics (Region III IPP Database 2002) 4.22% 1.40% 3.88% < 30 40,807 tests 1,724 pos >=30 5,624 tests 79 pos

31. Family Planning Screening Family Planning clinics participating in the Region III Infertility Prevention Project screen patients who come into the clinic seeking other medical attention (such as birth control and annual exam) The screening criteria applied to Family Planning patient screening is currently: –All women under age 30 who receive a pelvic exam should be routinely screened

32. What the FP Data Demonstrate 79,749 female Family Planning patients were screened for chlamydia in 2002 10,009 female Family Planning patients over age 30 were screened in 2002 12.5% of the total female Family Planning patients screened were beyond the current screening criteria

33. Female Family Planning Positivity Data (Region III IPP Database 2002) Percent

34. The Cost of Screening Outside the Screening Criteria in Family Planning 10,009 tests @ $11.90 per test = $109,107 (includes all costs associated with analyzing amplified CT/GC combination tests at the contract lab) The positivity in this group is 1.18% 118 positives were detected Increased chance of giving a false positive test result

35. Cost of Diagnostic Testing The goal is to reduce the percentage of screening over 30 from its current level of approx 12% to 5% allowing for diagnostic testing of this group—due to risk factors, clinician discretion, and the like If only 5% were over 30, approximately 4,000 specimens would be collected at a cost of $47,600 Overall testing costs could decrease by $61,507 The cost savings could be used for screening more significantly at risk populations

36. Project Area Goals for Screening Utilizing Region III IPP Data, reduce the screening criteria to under 25 years of age in clinics with low positivity (under 1.0%) in the 25- 29 year old age range Lower the percentage of female patients in family planning screened for chlamydia beyond the screening criteria to 5%

37. Why 5% Above the Criteria 5% is an initial benchmark for the PA Project Area It is not feasible to completely cut out screening above the criteria This allows for clinician discretion and ability to make choices for their clients Future data will determine where the benchmark will go

38. Our Process so Far Family Planning Agencies have distributed clinic by clinic data regarding screening outside the criteria to IPP participating clinics Training has been conducted by Family Planning Agencies to make clinics aware of the costs of screening outside the criteria Memos have been sent to clinics reminding FP clinics to adhere to the screening criteria At site visits, the clinicians and managers are reminded of the screening criteria

39. Examination of Data The project area partners met in July 2003 to discuss the screening data * It was found that the 2002 data were missing some positives * The data need to be clean and inclusive before it can be used for planning purposes The project area partners made a commitment to examine data issues and quality assurance of data

40. Next Steps Review of data collection and reporting practices continues Family Planning agencies will continue to educate clinicians and clinic managers The contract between Family Planning and the STD Program contains language regarding diagnostic testing vs. screening Clinics will be required to check off diagnostic testing when testing patients in clinic who exceed the screening criteria or the clinic will be responsible for payment for the test

41. What PA Has Learned Changing practices will be a slow process Prevalence data must be used to demonstrate where screening efforts should be focused Data must be valid to be used when making programmatic changes There will always be some screening outside the criteria The screening criteria in FP cannot at this time be put into effect in STD All Project Area Partners need to be committed to the process

43. Chlamydia and Gonorrhea Screening in Wisconsin Use of Selective Screening Criteria to Get the Most from Limited Resources Bobbie McDonald Wisconsin State Laboratory of Hygiene

44. Development of SSC in WI SSC for CT in WI Family Planning since 1980’sSSC for CT in WI Family Planning since 1980’s Used locally-derived data to establish SSCUsed locally-derived data to establish SSC –Age alone identified too many low-risk individuals Too many total tests (before NAAT) Low positivity in many areas “Universal” screening studies with enhanced data collection, at selected sites“Universal” screening studies with enhanced data collection, at selected sites –Positivity with clinical, demographic, behavioral data Studies in 1985 (rural, CT-DFA, GC culture); ’86 (urban, GC culture, CT culture, EIA & DFA) 1990 (GC culture, CT EIA/DFA), 1996-97, (CT-EIA, LCR & PCR) & 2001-02 (SDA)Studies in 1985 (rural, CT-DFA, GC culture); ’86 (urban, GC culture, CT culture, EIA & DFA) 1990 (GC culture, CT EIA/DFA), 1996-97, (CT-EIA, LCR & PCR) & 2001-02 (SDA)

45. “Standard” SSC in WI Family Planning Females Chlamydia Partner risk (past 90d)Partner risk (past 90d) –New partner –Multiple partners –Partner w/multiple partners ContactContact SymptomaticSymptomatic History of STDHistory of STD Protocol testingProtocol testing Age <19 (Milwaukee only)*Age <19 (Milwaukee only)* –Added after 1997 study Gonorrhea Contact Symptomatic History Positive for Chlamydia –on this specimen Note: GC criteria not originally based on data from this population

46. Selective Screening in WI: 2002 & 2003* *first 3 quarters of 2003 Positivity: All Tests Positivity Meeting SSC % Tests Meet SSC % Positives Meet SSC 2002 CT 30812 9.2%10.2%79.5%88.8% GC 18194 3.5%5.6%48.4%76.6% 2003* CT 25224 9.7%10.9%77.9%86.9% GC 10013 4.6%6.3%67.7%92.8%

47. Evaluating SSC SSC effectiveness can be influenced by changes in technology, prevalence, funding, other factorsSSC effectiveness can be influenced by changes in technology, prevalence, funding, other factors Key issue in performing the universal screening study in 2002: dual testing for CT- GCKey issue in performing the universal screening study in 2002: dual testing for CT- GC –Technology changes, marketing packages have increased GC screening despite low GC prevalence –Epidemiology of GC varies across state, region Major urban area: 56.5% of GC testing, 85.6% of positivity No locally-derived, evidence-based SSC for GCNo locally-derived, evidence-based SSC for GC

48. 2002 Universal Screening Study Followed model of previous studiesFollowed model of previous studies –Offered testing to all clients in selected clinics, with questionnaire; analyzed positivity data with risk data Able to minimize costsAble to minimize costs –Previous relationships with clinics, screening already established; main expense was additional testing Confirmed that SSC identified highest riskConfirmed that SSC identified highest risk –Study Positivity, On vs. Off SSC: CT 8.4% vs. 2.9% GC 3.8% vs. 0.4% GC 3.8% vs. 0.4% Age criteria alone still inefficient; <26 identifies 96.4% of infections, by testing 89.2% of patientsAge criteria alone still inefficient; <26 identifies 96.4% of infections, by testing 89.2% of patients Efficiently targeting expansion would require use of additional dataEfficiently targeting expansion would require use of additional data

49. Clinic Distribution FP clinics in nearly every county in WI –43 of 67 “rural” –24 urban, semi-urban Study clinics favored urban, semi- urban –Keep clinic number manageable –Obtaining enough positive results

50. Universal Study: CT Data SSC Level Pts. Meeting SSC %(#) CT Positive %(#)Sensitivity (% of all pos.) Positivity in added group Non-Milwaukee (7) ‘Standard’ ‘Standard’ 57.8% 57.8%(2193)6.8%(149)78.4%-- ‘Std.’ + < 19 ‘Std.’ + < 19 68.8% 68.8%(2610)6.4%(166)87.4% 4.1% (17) ‘Std.’ + < 26 ‘Std.’ + < 2689.6%(3399)5.4%(183)96.3% 2.2% (17) Milwaukee (3) ‘Std.’ + < 19 ‘Std.’ + < 19 74.2% 74.2%(2009)10.1%(202)88.2%-- ‘Std.’ + < 23 ‘Std.’ + < 23 83.2% 83.2%(2251)9.6%(216)94.3% 5.8% (14) ‘Std.’ + < 26 ‘Std.’ + < 2688.9%(2406)9.2%(221)96.5% 3.2% (5)

51. Universal Study: GC Data SSC Level Pts. Meeting SSC %(#) GC Positive %(#)Sensitivity (% of all pos.) Positivity in added group All Clinics 43.9% 43.9%(2853)3.8%(107)89.2%(107/120)-- Rural (3 clinics) 26.2% 26.2%(201/767)0%(0)---- “Semi-Urban” (4) ‘Standard’ GC SSC ‘Standard’ GC SSC41.1%(1244)2.7%(33)89.2%(33/37)-- Standard CT+ <19 71.9% 71.9%(2176)1.7%(37)100% 0.4% (4/932) Milwaukee (3) ‘Standard’ GC SSC ‘Standard’ GC SSC 52.0% 52.0%(1408)5.3%(74)89.2%(74/83)-- Standard CT+ <23 83.6%(2264)3.7%(83)100% 1.1% (9/856)

52. Updated SSC: All FP Sites Clinic Set - # (%of CT; GC tests) CT Pos* (#; %of +) GC Pos* (#; %of +) CT Criteria GC Criteria Milwaukee-7 (29.5; 44.5%) 13.7% (1884;43.1%) 6.4% (716/75.2%) Add Age <23 No Change Semi-Urban-7 (22.0; 18.7%) 7.8% (806;18.4%) 3.1% (145/15.2%) Add Age <19 No Change Midsize cities-10 (22.6; 15.7%) 8.1% (860;19.7%) 1.4% (55/5.8%) Add Age <19 Limited “Rural”- 43 (25.9; 21.2%) 6.8% (822;18.8%) 0.7% (36/3.8%) No Change Limited *Positivity includes all testing Jan 2002 - June 2003; 46841 CT tests, 25128 GC tests

53. Adherence to SSC Cost Incentives: criteria is required to obtain a “no-charge” CT or GC testCost Incentives: criteria is required to obtain a “no-charge” CT or GC test –SSC recorded on test request form, entered into lab data system –positivity can be monitored by SSC variables “Reflex” GC Testing: adding a GC test when CT is positive (cases when no other GC SSC is met)“Reflex” GC Testing: adding a GC test when CT is positive (cases when no other GC SSC is met) –Identifies a small subset of otherwise low-risk patients with a relatively high yield of GC –Improved ‘buy-in’ and adherence to GC SSC –GC Positivity: Reflex GC: 4.6% (16/348) Combo CT-GC: 3.2% Combo CT-GC: 3.2%

54. Summary: Evolution of SSC in WI Goal: detecting the maximum number of infections using available resourcesGoal: detecting the maximum number of infections using available resources Decisions about lab test selection and screening levels are influenced by many factorsDecisions about lab test selection and screening levels are influenced by many factors –Resources, technology, prevalence/risk, number of patients in need of services, politics/history Use of specific, targeted criteria is possible and effectiveUse of specific, targeted criteria is possible and effective –Simplest criteria (age) not always ‘best’ –Differences in epidemiology within program area –Data, training, incentives can improve buy-in and adherence

56. The Cost-Effectiveness of Treating Women Diagnosed with Gonorrhea for Both Gonorrhea and Chlamydia Thomas L. Gift, PhD Centers for Disease Control and Prevention

57. Routine Dual Treatment CDC 2002 Treatment Guidelines: –Dual treatment of women diagnosed with gonorrhea (GC) for both GC and chlamydia (CT) instead of testing for CT can be cost-effective if 10% - 30% of women with gonorrhea (GC) also have CT –Is it also cost-effective to treat women for both GC and CT if they are also tested for CT? GC test positive, CT test negative

58. A Cost-Effectiveness Comparison of Three Alternatives * 1) Dual Treatment –Test women for GC, treat those testing positive for both GC and CT 2) Test –Test women for GC and CT, treat based on test results Treat women positive for GC for GC only Treat women positive for CT for CT only 3) Test & Dual Treatment –Test women for GC and CT Treat women positive for GC for both CT and GC Treat women positive for CT for CT only *Gift et al. Sex Transm Dis. 29:542-550, 2002

59. Conclusions Dual treatment is not a substitute for testing for CT in most settings If ≥ 10% of women with GC also infected with CT, dual treatment in addition to testing is cost-effective Dual treatment will increase over- treatment

60. Model Limitations Model assumed some form of GC testing in all options Model did not address whether testing for GC as an addition to testing for CT cost-effective

61. Screening for CT and GC in Jails * Model examined three alternatives: 1) Symptom-based presumptive treatment –Symptomatic inmates who request treatment treated for both CT and GC 2) Screen for CT only 3) Screen for both CT and GC –Both screening alternatives assumed nucleic acid amplification testing (NAAT) on urine specimens 4) Screen for both CT and GC plus dual treatment –As before—treat GC positives for both CT & GC *Kraut-Becher, et al. 2004 (unpublished)

62. Model Assumptions GC prevalence 3% CT prevalence 8% 33% of GC-infected inmates also have CT 50% of inmates testing positive released before treatment –We assumed no follow-up to ensure treatment with those released Sequelae costs considered were: –Pelvic inflammatory disease (PID) –Neonatal pneumonia & conjunctivitis for CT –HIV transmission attributable to GC or CT

63. 10,000 women 100 with GC & CT700 with CT200 with GC 564 test +81 test + for CT 169 test +19 test - for CT 68 test + for GC 16 test + for GC Half are treated Not shown: -false positives for GC and CT -negative results for GC test -negative results for CT test for women with CT

64. 10,000 women 100 with GC & CT700 with CT200 with GC 564 test +81 test + for CT 169 test +19 test - for CT 68 test + for GC 16 test + for GC Half are treated Not shown: -false positives for GC and CT -negative results for GC test -negative results for CT test for women with CT 9000 uninfected 49 test + for GC 81 test + for CT

65. Conclusions Dual treatment is a cost-saving addition to screening for both CT and GC –Impact is minor, but so is cost Among 10,000 women: –238 women test positive for GC, negative for CT –16 are CT-infected, 222 are not CT-infected –Assuming 50% are treated, 119 treated / 8 infected Is dual treatment cost-saving relative to screening for CT only?

66. Program and Sequelae Costs in 10,000 Women ProgramCT Treated GC Treated Program Cost * Sequelae Cost * Total Cost * No Program / No Rx 000635,000 Presumptive Rx 118528,000556,000564,000 Screen for CT only 3113994,000467,000560,000 Screen for CT and GC 311133174,000430,000604,000 Screen for CT & GC/Dual Rx 319133176,000426,000601,000 * All costs 2002 US dollars; sequelae include PID, HIV infections attributable to CT or GC infection, and neonatal sequelae of CT

67. Program and Sequelae Costs in 10,000 Women ProgramCT Treated GC Treated Program Cost * Sequelae Cost * Total Cost * No Program / No Rx 000635,000 Presumptive Rx 118528,000556,000564,000 Screen for CT only 3113994,000467,000560,000 Screen for CT and GC 311133174,000430,000604,000 Screen for CT & GC/Dual Rx 319133176,000426,000 601,000 * All costs 2002 US dollars; sequelae include PID, HIV infections attributable to CT or GC infection, and neonatal sequelae of CT

68. Program and Sequelae Costs in 10,000 Women ProgramCT Treated GC Treated Program Cost * Sequelae Cost * Total Cost * No Program / No Rx 000635,000 Presumptive Rx 118528,000556,000564,000 Screen for CT only 3113994,000467,000560,000 Screen for CT and GC 311133174,000430,000 604,000 Screen for CT & GC/Dual Rx 319133176,000426,000 601,000 * All costs 2002 US dollars; sequelae include PID, HIV infections attributable to CT or GC infection, and neonatal sequelae of CT

69. Program and Sequelae Costs in 10,000 Women ProgramCT Treated GC Treated Program Cost * Sequelae Cost * Total Cost * No Program / No Rx 000635,000 Presumptive Rx 118528,000556,000564,000 Screen for CT only 3113994,000467,000 560,000 Screen for CT and GC 311133174,000430,000 604,000 Screen for CT & GC/Dual Rx 319133176,000426,000 601,000 * All costs 2002 US dollars; sequelae include PID, HIV infections attributable to CT or GC infection, and neonatal sequelae of CT

70. Program and Sequelae Costs in 10,000 Women * ProgramCT Treated GC Treated Program Cost † Sequelae Cost † Total Cost † No Program / No Rx 000428,000 Presumptive Rx 87167,000376,000383,000 Screen for CT only 2331293,000301,000394,000 Screen for CT and GC 23340173,000290,000 463,000 Screen for CT & GC/Dual Rx 23640173,000289,000 462,000 * Prevalence of CT = 6%, GC = 0.9%; 33% of those with GC have CT † All costs in 2002 US dollars (2002)

71. Summary Conclusions The CDC’s dual treatment recommendation: –is cost-saving even when testing separately for CT –on the basis of cost alone, should be considered even when GC prevalence is low The cost saving from dual treatment is not great enough on its own to make screening for GC cost-saving at low GC prevalences

72. Acknowledgements Dual treatment paper authors: Cathleen Walsh, DrPH Anne C. Haddix, PhD Kathleen L. Irwin, MD, MPH Jail screening manuscript authors: Julie R. Kraut-Becher, PhD Anne C. Haddix, PhD Kathleen L. Irwin, MD, MPH Robert B. Greifinger, MD

74. Screening for Chlamydia in Arizona Making the Most of Limited Resources Lisa Anne Schamus Arizona Family Planning Council

75. Outline Background of Arizona Infertility Prevention Project Background of Arizona Infertility Prevention Project Data Sources Data Sources Historic CT Screening Criteria and Rates Historic CT Screening Criteria and Rates Clarification of Screening Criteria (in 1999/2000) Clarification of Screening Criteria (in 1999/2000) Changing clinician testing behavior Changing clinician testing behavior Allocation of new resources Allocation of new resources

76. Background of AZ IPP Collaborative effort between the Arizona Department of Health Services and AZ Family Planning Council (Title X) Collaborative effort between the Arizona Department of Health Services and AZ Family Planning Council (Title X) CDC Funded Arizona Infertility Prevention Project (AZ IPP). CDC Funded Arizona Infertility Prevention Project (AZ IPP). Started in 1995. Started in 1995. Title X began with three ‘Sentinel Sites’ and now includes 40 clinics. Title X began with three ‘Sentinel Sites’ and now includes 40 clinics.

77. Data Sources 1995 to 1999 – Logs from ‘sentinel sites’. Aggregate data for others. 1995 to 1999 – Logs from ‘sentinel sites’. Aggregate data for others. 2000 – Encounter Data from AFPC. 2000 – Encounter Data from AFPC. 2000 – Start of electronic data availability from lab. 2000 – Start of electronic data availability from lab. 2004 – Anticipate having lab data for all participating clinics for entire year. 2004 – Anticipate having lab data for all participating clinics for entire year.

78. Historic CT and GC Screening Criteria Pre – 2000 Screening Criteria for AZ IPP: Pre – 2000 Screening Criteria for AZ IPP: –Screen all women 30 years and younger for Chlamydia and test others as indicated. –Test as indicated for Gonorrhea.

79. CT Positivity Rates by Age Groups and Testing Patterns at 5 ‘Sentinel Sites’, 1998

80. Step One: Change of Screening Criteria for AZ IPP Changed screening criteria for AZ IPP in late 1999: Changed screening criteria for AZ IPP in late 1999: –Screen all female clients 25 and under receiving an exam. –Test others as indicated.

81. CT Screening Coverage in Women Receiving an Exam by Age Group, 2000

82. Changing Clinician Screening Practices Monitored compliance with screening criteria through quarterly reports. Monitored compliance with screening criteria through quarterly reports. Provided clinicians and administrators with detailed feedback from chart audits Provided clinicians and administrators with detailed feedback from chart audits Provided clinicians and administrators with education regarding predictive value of screening test in low prevalence populations. Provided clinicians and administrators with education regarding predictive value of screening test in low prevalence populations.

83. CT Testing: Females 25 and Under Receiving Exams Q1, 2000 vs. Q1, 2003

84. CT Testing: Females 26 and Over Receiving Exams Q1, 2000 vs. Q1, 2003

85. Percentage of Tests by Age Group, AZ Title X Family Planning Clinics, 1998 and 2003 Percent

86. ARIZONA IPP FAMILY PLANNING* NUMBER OF FEMALES CT TESTED AND POSITIVE CASES BY AGE GROUP

87. Allocating New Resources CDC received increase funding in 2002. Specific guidance stated: CDC received increase funding in 2002. Specific guidance stated: –The additional IPP funds distributed in 2002 must be used to expand chlamydia screening and treatment of adolescent and young adult women 25 years old and younger

88. New Screening Criteria, mid-Year 2003 Screen all female clients 25 years and younger: Screen all female clients 25 years and younger: –Pace II for those receiving an exam –Aptima for Pregnancy Test Only Clients and others not receiving an exam Test others as indicated: Test others as indicated: –Pace II for females receiving exam –Aptima for all males and for females not receiving exam

89. Conclusions Successes Successes –Adherence to screening criteria for ‘older’ delegates –In screening high risk populations – In detection of CT cases – Improved data sources

90. Conclusions Continued Challenges and Future Directions Continued Challenges and Future Directions –Limited resources, desire to provide amplified test for all –Continue to improve adherence to screening criteria –Managed Care/Medicaid

92. A Six Year History of Gonorrhea and Chlamydia Screening Guidelines: San Francisco STD Clinic Charlotte Kent San Francisco Department of Public Health

93. Why not test everyone who walks in the door? It is an STD clinic after all! Everyone’s risk of infection might not be the same. Might want to expand services in some sub-populations Fixed or decreasing budgets Need to use limited resources efficiently

94. San Francisco – Background One municipal STD clinic –2003: 21,596 visits –17% women, 37% heterosexual men, 46% MSM 2002 ranking among 63 U.S. metropolitan areas –Gonorrhea : 28th –Chlamydia: 35th –Syphilis:1st Implemented screening guidelines in 1998 (Ciemens et al., STD 2000)

95. Diagnostic Testing vs. Screening Diagnostic testing –Symptoms or signs –Contact to STD –Currently has an STD Screening –Asymptomatic and no reason for diagnostic testing

96. Development of Screening Guidelines - 1998 Established positivity target –2% CT –1% GC Examined positivity in asymptomatics by age, gender/sexual orientation

97. 1997-1998 Results CT prevalence in women older than 30 years < 2% GC prevalence in heterosexual men < 1% Discontinued screening in these populations Reduced GC testing by 16% & CT by 6% Expanded urethral CT screening in MSM

98. 2000-2001 Results GC prevalence < 1% in women older than 30 years Discontinued screening in this population Expanded screening in MSM at rectal and pharyngeal sites

99. Current Screening Guidelines for MSM Urine GC & CT NAAT Rectal GC & CT NAAT, if receptive anal sex last six months Pharyngeal GC & CT NAAT if receptive oral sex last two weeks 2003 positivity by site

100. Current Screening Guidelines for Heterosexual Men Urine CT NAAT –30 and younger only Over screening –43% (2035/4685) GC –54% (1288/2374) CT (>30 years) 2003 positivity by age 1069966n19221288 < 30 >30

101. Current Screening Guidelines for Women Cervical swab for GC culture or urine for GC NAAT if no pelvic –30 and younger only Urine CT NAAT –30 and younger only Overscreening - >30 yrs –52% (279/534) GC –63% (337/534) CT 2003 positivity by age 8721001n279337 < 30 >30

102. Recommendations Areas with low to moderate prevalence of GC & CT should evaluate the efficiency of testing in STD Clinics Minimal data needed to develop guidelines: –Reasons for diagnostic testing (symptoms, signs, STD contact, etc.) –Demographics – age, gender –Behavioral – who have sex with

103. Recommendations Need routine evaluation of guidelines & if changes in: –Populations seeking services –Test technology or pricing –Expansion of specimen type –Resources Non-bundled GC & CT tests need to be made available by manufactures

104. Conclusion Feasible to develop, implement & modify screening guidelines in an STD clinic

105. For More Information Dorothy Gunter, DGunter@cdc.govDGunter@cdc.gov Bartholomew Abban, BAbban@cdc.govBAbban@cdc.gov Beth Butler, bebutler@state.pa.usbebutler@state.pa.us Bobbie McDonald, Bobbie@mail.slh.wisc.edu Bobbie@mail.slh.wisc.edu Thomas L. Gift, TGift@cdc.govTGift@cdc.gov Lisa Schamus, LSchamu@ade.az.govLSchamu@ade.az.gov Charlotte Kent, Charlotte_Kent@dph.sf.ca.us Charlotte_Kent@dph.sf.ca.us