STD and HIV Emerging Issues

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STD and HIV Emerging Issues

• Gail Bolan MD
• Chief, STD Control Branch
• CA Department of Health Services
• Assistant Clinical Professor
• Department of Medicine, UCSF

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Overview of Complications ofSexually Transmitted
Diseases
Fetal Wastage Low Birthweight Congenital
Infection
Upper Tract Infection
Systemic Infection
STDs
Infertility Ectopic Pregnancy Chronic Pelvic Pain
Cervical Cancer
HIV Infection
Potentially Fatal
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STD MorbidityCalifornia and United States 2002
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10 Core Public Health Functions and STD Activities
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10 Core Public Health Functions and STD Activities
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STD Prevention and Control Strategies

• Education and counseling (primary prevention)
• Project Respect
• Identification of asymptomatic persons (secondary
  prevention)
• Screening
• HEDIS
• Identification of symptomatic persons (secondary
  prevention)
• Effective diagnosis and treatment (secondary
  prevention)
• Test Performance Characteristics
• Empiric Treatment
• Partner Management (primary and secondary
  prevention)
• Vaccination ( ideally primary prevention)

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Syphilis Reported cases US, 19412001
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Primary and secondary syphilis - County rates,
1998
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Syphilis Overview of Stages
30 5-50 years
1º
2º
Latent
3º
Early Syphilis
Late Syphilis
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Epidemiologic Vulnerability of Syphilis

• No animal reservoir
• Long incubation period
• Limited infectiousness
• Low cost and widely available diagnostic tests
• Single dose therapy
• No antimicrobial resistance

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Syphilis EliminationPublic Health Importance

• Important, measurable health outcomes
• Substantial cost savings
• Annual cost savings of 1 billion
• Supports multiple public health goals
• Reduction of racial disparities
• Infectious disease control, including HIV
  prevention
• Bio-terrorism preparedness
• Reproductive health and infant health
• Identifies opportunities to improve public health
  infrastructure
• Focus for critical collaboration between
  communities health departments
• Addresses unfinished history broken trust

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Primary Secondary Syphilis Cases by Gender,
California, 19962002
Rate per 100,000
ALL MALE
known MSM
FEMALE
5/03 Provisional Data - CA DHS STD Control Branch
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Risk Characteristics of MSM PS Syphilis Cases,
California 1999-2002
1 Percentage excludes unknown
5/03 Provisional Data - CA DHS STD Control Branch
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Gonorrhea Rates by Gender, California, 19932002
Rate per 100,000
Source California Department of Health
Services, STD Control Branch
Provisional Data 05/16/2003
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Gonococcal Isolate Surveillance Project (GISP),
Percent of Neisseria Gonorrhoeae Isolates with
Decreased Susceptibility or Resistance
to Ciprofloxacin, California Sites, 19912002
Note Resistant isolates have MICs 1 µg
ciprofloxacin/mL. Isolates with decreased
susceptibility have MICs of 0.125 0.5 µg
ciprofloxacin/mL. STD Clinic Sites Long Beach,
Orange, San Diego, San Francisco Source
California Department of Health Services, STD
Control Branch
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Gonococcal Isolate Surveillance Project (GISP) -
Location of participating clinics and regional
laboratories United States, 1998
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Gonorrhea Treatment Genital Rectal Infections
in Adults

• Recommended regimens
• Cefixime 400 mg PO x 1 or
• Ceftriaxone 125 mg IM x 1 or
• Ciprofloxacin 500 mg PO x 1 or
• Ofloxacin 400 mg PO x 1 or
• Levofloxacin 250 mg PO x 1
• PLUS if chlamydia is not ruled out
• Azithromycin 1 g PO x 1 or
• Doxycycline 100 mg PO BID x 7 d

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Why Chlamydia Why Now?

• Most common communicable disease reported disease
  in California
• Over 100,000 reported cases in 2001
• Over 75 of cases are seen in the private sector
• Significant health consequences
• Most common cause of preventable infertility
• Facilitates sexual transmission of HIV
• New technology new opportunity
• Urine tests single dose treatment easier to
  reach, treat cure at-risk populations
• HEDIS increases private sector interest
• Potential public/private partnership

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Chlamydia Action Coalition

• A State-Wide Public/Private Partnership
• funded by the
• California HealthCare Foundation
• www.ucsf.edu/castd

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Chlamydia Screening HEDIS Measure

• The Measure the percentage of Medicaid and
  commercially enrolled women 15 through 25 who
  were identified as sexually active, who were
  continuously enrolled during the reporting year,
  and who have at least one test for chlamydia
  during the reporting year.
• Number tested

Number of sexually active
Denominator may exclude plan employees to
protect confidentiality Source CDC, NCHSTP,
DSTDP
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Chlamydia HEDIS Data Warehouse

• Centralized Data Warehouse with Electronic
  Transmission of Chlamydia Screening Data
• Collection of HEDIS numerator data
• Prevalence Monitoring
• Coordinate with ELR of communicable diseases

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HIPAA Basics

• What is HIPAA?
• Health Insurance Portability and Accountability
  Act
• Provides the first national standards for
  protecting the privacy of health information
• HIPAA Privacy Rule regulates how certain
  entities, called covered entities, use and
  disclose certain protected health information
  (PHI)

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Who is Covered?

• Three types of covered entities
• health plans, (e.g., Medicaid, Medicare, and the
  Veterans Health Administration)
• health-care clearinghouses, (billing service,
  repricing company, or community health
  information system)
• health-care providers who transmit health
  information in electronic form in connection with
  certain transactions (e.g., physicians,
  hospitals, and clinics)

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Impact on Public Health

• Public health uses PHI to identify, monitor, and
  respond to disease, death, and disability among
  populations
• Privacy Rule expressly permits PHI to be shared
  by covered entities for specified public health
  purposes
• Public health authority may also be a covered
  entity in some cases

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Permitted PHI Disclosures Without Authorization

• Where required by law
• PHI can be disclosed to public health authorities
  and their authorized agents for public health
  purposes
• Health research
• Abuse, neglect, or domestic violence
• Law enforcement
• Judicial and administrative proceedings.
• Cadaveric organ, eye, or tissue donation purposes
• For oversight activities authorized by law
• Worker's compensation

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Included Public Health Activities

• reporting of disease or injury
• reporting vital events (e.g., births or deaths)
• conducting public health surveillance,
  investigations, or interventions
• reporting child abuse and neglect
• monitoring adverse outcomes related to food
  (including dietary supplements), drugs,
  biological products, and medical devices

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Requirements for Covered Entities

• Accounting for Public Health Disclosures
• Covered entity must be able to provide a patient
  an accounting of disclosure even for disclosures
  permitted or required by law
• Notice of Privacy Practices
• individuals have the right to adequate notice of
  the uses and disclosures of PHI that may be made
  by the covered entity, as well as their rights
  and the covered entity's legal obligations
• Minimum Necessary Standard
• directs covered entities to limit the amount of
  information disclosed to the minimum necessary to
  achieve the specified goal

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Rapid HIV Testing

• A key strategy of the Advancing HIV Prevention
  Initiative is to use rapid HIV tests to expand
  HIV testing outside clinical settings.

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Reactive Control
Positive HIV-1
Positive
Negative
Read results
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STD Resources for Clinicians

• California STD/HIV Prevention Training Center
• www.stdhivtraining.org
• CDC Treatment Guidelines
• www.cdc.gov/std/treatment
• California Chlamydia Action Coalition
• www.ucsf.edu/castd
• CA STD Control Branch
• www.dhs.ca.gov/ps/dcdc/STD/stdindex.htm