1. STD Testing Protocols, STD Testing, and Discussion of Sexual Behaviors in HIV Clinics in Los Angeles County Melanie M. Taylor MD, MPH Los Angeles County STD Program

2. Acknowledgements Tracie McClain MD, MPH Bessie Brown Getahun Aynalem MD, MPH Lisa Smith DrPH Peter Kerndt MD, MPH Tom Peterman MD, MSc

3. Early Syphilis Los Angeles County

4. HIV Seropositivity Among Early Syphilis Cases, 2001-2003

5. HIV In Los Angeles 45,000 persons living with AIDS or HIV aware of status* An estimated additional 9,000 persons with AIDS or HIV that are unaware of status* *Office of AIDS Programs and Policy. Los Angeles County Department of Health Services. HIV Prevention Plan Addendum. 2003

6. Objectives To evaluate knowledge of syphilis epidemic among HIV care providers To determine STD screening practices in HIV care clinics To quantify use of STD screening/testing protocols in HIV care clinics To evaluate the frequency and nature of discussion of sexual behaviors in HIV clinics

7. Study Design/Methods In-person or phone interview performed by one interviewer 17 Question Survey Results analyzed using SPSS Clinics received: Patient information cards for 6 STDs, CA STD treatment guidelines, MMWR: Prevention for Positives, Posters of primary and secondary syphilis symptoms, STD reporting forms

8. Sample Summary Survey Respondents: N = 36* Represented Clinics: N = 48 Represented HIV Care Providers: N = 184 Represented Patients: N = 28,119 * Medical Directors allowed to complete surveys for multiple sites under their direction

9. Survey of Clinical Care Representatives from 48 Clinics Enrolling >50 HIV Patients Clinician Type% of Sample Medical Directors31 Clinic Directors 3 HIV/AIDS Program Coordinators11 Physicians 33 Nurse Practitioners17 Physician’s Assistants 3 Medical Assistant 3

10. Types of Clinics Public Private HMO Hospital/University Community Based Organization

11. 31% Hospital/ University 10% Public 20% Clinic Types Private/HMO 38% Source: LAC DHS STD Program; N=44,205

12. Knowledge of Syphilis Epidemic When asked about LA syphilis rates, 100% spontaneously reported they were higher. 97% thought they were higher than the national average.

13. Clinics Performing STD Testing at the First Visit STD TestNumber (%) Syphilis48 (100) Chlamydia32 (67) Gonorrhea32 (67) Herpes0 (0) HPV (Pap Smears)7 (15) Trichomoniasis3 (6) Hepatitis screen (A, B, C)48 (100)

14. Use of a Written STD Protocol Clinical PracticeNumber (%) Use of STD testing protocol 24 (50) Protocol Based on: CDC Guidelines3 (13) LAC STD Program Screening Recommendations 4 (17) Standardized Electronic Sexual Risk Assessment 9 (38) Other3 (13) Unknown5 (21)

15. Activities of Clinics Reporting Use of Written Protocols (WP) for STD Testing ActivityWP Use WP Non-UseOR(95%CI)P Value Asymptomatic Testing Every 3-6 months: Syphilis 20 (83)14 (58)3.6 (0.9-13.7)0.055 GC/CT 7 (79)6 (25)1.2 (0.3-4.4)0.5 Patients asked about unsafe sex behavior at each visit 24 (100)0 (0)2.2 (1.4-3.4)<0.001

16. Written Protocol Use by Clinic Type Clinic Type WP UseWP Non-UseOR (95% CI)P Value Early Intervention Program** 22 (92) 11 (46)13.0 (2.5-68.1)0.001 CBO15 (63) 0 (0)2.7 (1.6-4.5)<0.001 HMO0 (0) 7 (29)0.7 (0.5-0.9)0.009 Hosp/Univ2 (8) 3 (13)0.6 (0.1-4.2)1.0 Private2 (8) 9 (38)0.2 (0.03-0.8)0.04 Public5 (21) 5 (21)1.0 (0.2-4.0)0.6

18. Questions Frequently Included in Sexual Risk Assessments -Have you practiced unsafe/unprotected (without a condom) sex since your last visit? -Have you have unprotected oral, anal, or vaginal sex since your last visit? -Do/did you use a condom when you have/had sex? -If unsafe sex, what was the HIV status of your partner(s)?

19. Questions Frequently Included in Sexual Risk Assessments -If unsafe sex, was your partner(s) aware of your HIV status? -Have you used any recreational drugs that were linked to your sexual activity? -Was your sexual interaction with an anonymous partner(s)? If anonymous, where did the sexual interaction take place? (bathhouse, sex club, via internet contact, other) -What type of sex practices do/did you engage in? -Have you had sex with men, women or both?

20. Conclusions Written protocols for STD testing may promote sexual risk assessment questioning among HIV providers These written protocols may insure STD testing per CDC/IDSA guidelines for HIV positive persons at sexual risk

21. Limitations Actual experience of the patients was not evaluated Sample size limited some analyses Unable to determine the values of sexual risk questions in predicting disease 9/48 (19%) clinics operated by one organization and may have skewed the results.

22. LA County Recommendations for STD Screening among HIV Positive Persons