Say AHHH! : STDs in Maine

Say AHHH! : STDs in Maine Emer S. Smith, MPH Maine Center for Disease Control & Prevention HIV, STD, & Viral Hepatitis Program October 6, 2014

Review of STDs In Today s Talk... Epidemiology (Maine & U.S.) Trends among adolescents Clinical Manifestations (brief) Screening and Treatment Recommendations Cost/Access to Testing & Treatment Public Health Response Resources

DISCLAIMER I will be using some medical terms in this presentation, which may be confusing. I will try my best to explain what these mean in simple terms when I catch them. If you are unsure of the meaning of a term or if you have any questions, please ask! If I cannot answer your question at the time, we ll put it in a parking lot and revisit it....with the help of Google.

Scope of the Problem STDs are common 19 million new cases annually in the U.S. 1 in 2 sexually active young people will get an STD by the age of 25 Young people account for half (50 percent) of all new STIs, although they represent just 25 percent of the sexually experienced population Many STDs are asymptomatic Many STDs are undiagnosed, untreated, or incurable Complications include infertility, chronic pain, prenatal complications and illness in newborns, severe illness, cancer, and death Centers for Disease Control. (2013). http://cdc.gov/std

HPV, HSV NON REPORTABLE STDS

Herpes (HSV 1/HSV 2) Estimated 776,000 new cases annually (CDC) Prevalence: 1 in 6 persons 16 49 years old Asymptomatic or mild symptoms 81.1% of people with HSV infection are unaware of infection Centers for Disease Control. (2013). http://cdc.gov/std

Age Adjusted Herpes Simplex Virus Type 2 Seroprevalence According to the Lifetime Number of Sex Partners, by Race/Ethnicity and Sex on NHANES in 1999 2004 Xu F et al. (2006). JAMA, 296(8):964 973. 7

NHANES HSV1&2 Seroprevalence 100 HSV Serop revalence ( % ) 90 80 70 60 50 40 30 20 10 HSV2 1988-94 HSV2 1999-2004 HSV2 2005-08 HSV2 2007-10 HSV1 1976-80 HSV1 1988-94 HSV1 1999-2004 HSV1 2007-10 0 12 or 14-19 20-29 30-39 40-49 50-59 60-69 70-74 or >=70 Age Group (Years) Johnson et al. NEJM 321:7-12, 321, 1989 Schillinger et al. STD 31:753-60, 2004 Fleming et al. NEJM 337:1105-11, 1997 Xu et al. JAMA 296:964-73, 2006 Xu et al. MMWR 59:456-9, 2010 Bradley et al. JID 209:325-33, 2014 23% decline in HSV1 seroprevalence between early 200o s and late 200o s.

HSV Screening Type specific HSV serology testing Patients presenting for STD evaluation especially if multiple partners, HIV infected and MSM at risk of HIV Not recommended for routine prenatal or universal screening Viral detection by culture and PCR are the preferred tests for persons presenting with Genital Ulcer Diseases All patients with genital ulcers should be evaluated with a serologic test for syphilis and a diagnostic evaluation for genital herpes Centers for Disease Control. (2013). http://cdc.gov/std

HSV Treatment All patients with initial genital HSV should receive treatment Episodic therapy for recurrent HSV Multiple regimens shorten course of recurrence if started early Long term suppressive therapy safety and efficacy documented For more information, see CDC STD Treatment Guidelines Centers for Disease Control. (2013). http://cdc.gov/std

Human Papilloma Virus Estimated annual incidence of sexually transmitted HPV infection is 14.1 million More than 40 HPV types can infect the genital tract, divided in to two types based on cancer association Low risk types (nononcogenic) associated with genital warts and mild Pap test abnormalities (Type 6 & 11) High risk types (oncogenic) associated with moderate to severe Pap test abnormalities, cervical dysplasia and cervical cancer, and other cancers (Type 16 & 18) Most genital HPV infections are transient, asymptomatic, and have no clinical consequences. Centers for Disease Control. (2013). http://cdc.gov/std

HPV Prevalence of High risk and Low risk Types Among Females Aged 14 59 Years; NHANES, 2003 2006 From: http://www.cdc.gov/std/stats12/figures/45.htm

HPV associated Cancers in the US, 2006 2010 Cancer site Average number of cancers per year in sites where HPV is often found (HPV associated cancers) Both Male Female Sexes Percentage probably caused by HPV Number probably caused by HPV Male Female Both Sexes Anus 1,549 2,821 4,370 91% 1,400 2,600 4,000 Cervix 0 11,422 11,422 91% 0 10,400 10,400 Oropharynx 9,974 2,443 11,629 72% 7,200 1,800 8,900 Penis 1,048 0 1,048 63% 700 0 700 Vagina 0 735 735 75% 0 600 600 Vulva 0 3,168 3,168 69% 0 2,200 2,200 TOTAL 12,571 20,589 33,160 81% 9,300 17,500 26,700 Individual cells may not sum to total due to rounding. Centers for Disease Control: http://www.cdc.gov/cancer/hpv/statistics/cases.htm

HPV associated Cancers in the US, 2006 2010

Observed and Projected Incidence Rates: Selected HPV Associated Cancers Chaturvedi A K et al. JCO 2011;29:4294-301

HPV Screening & Treatment Screening When is an HPV Test appropriate? Triage of ASC US Pap result (if age > 21) Co test with Pap in women age 30+ Very selective follow up situations When is it NOT appropriate? STD screening Diagnosis of genital warts Screening in women under 30 Any use in women under 21 Testing in males ASC H, LSIL or higher grade lesions Before vaccination Treatment No best or curative therapy All therapies have potential side effects and high recurrence rates Consider: Provider s experience Patient s preference and abilities Size, number, and location of warts Potential side effects Availability and expense of therapy

Summary of HPV4 Vaccine Efficacy Data Population Endpoint Efficacy* % (CI) Females 16 26 years HPV 16/18 CIN2 98% (93 100) VIN/ValN 2/3 100% (83 100) Genital Warts 99% (96 100) Males 16 26 years AIN 2/3 75% (9 96) Genital Warts 89% (65 98)? Penile Cancer??? Oropharyngeal Cancer?? * Per protocol populations Abnormal Cells (cancer precursors) VIN = vulvar intraepithelial neoplasia ValN = vaginal intraepithelial neoplasia AIN = anal intraepithelial neoplasia

Rates of HPV Vaccination U.S. For girls who received at least one dose of HPV vaccine, coverage increased between 2012 and 2013 (53.8% in 2012 vs. 57.3% in 2013). Receipt of the recommended three doses increased, but still remained low from 2012 to 2013 (33.4% in 2012 compared to 37.6% in 2013). For boys, there was an increase for at least one dose of HPV vaccine (from 20.8% in 2012 to 34.6% in 2013) 13.9% of boys aged 13 17 years received all three recommended doses of HPV vaccine in 2013 (compared to 6.8 % in 2012).

Rates of HPV Vaccination Maine For girls who received at least one dose of HPV vaccine, coverage decreased between 2012 and 2013 (61.7% in 2012 vs. 60.2% in 2013). Receipt of the recommended three doses increased from 41.8% in 2012 to 45.8% in 2013. For boys, there was a substantial increase for at least one dose of HPV vaccine (from 25.3% in 2012 to 42.2% in 2013) 17.6% of boys aged 13 17 years received all three recommended doses of HPV vaccine in 2013 (compared to 12.1 % in 2012).

ACIP HPV Vaccine Recommendations Population Gender Age Recommendation Females 11 12 (as young as 9) Routine vaccination with either HPV4 or HPV2 13 26 Routine catch up vaccination either HPV4 or HPV2* Males 11 12 (as young as 9) Routine vaccination with HPV4 13 21 Routine catch up vaccination HPV4 22 26 Permissive recommendation HPV4 MSM & HIV+ 22 26 Routine catch up vaccination HPV4 males * Irrespective of history of abnormal Pap, HPV, genital warts For more information, visit http://www.cdc.gov/vaccines/ MMWR, May 28 2010; 59(20):626 629, 630 632 MMWR, December 23 2011; 60(50):1705 8

Chlamydia, Gonorrhea, Syphilis, HIV REPORTABLE STDS

Chlamydia trachomatis CHLAMYDIA

Chlamydia Rates by Age and Sex, United States, 2012 From: http://www.cdc.gov/std/stats12/figures/5.htm

Trends in Reported Chlamydia Cases in Maine, 2009 2013 4000 3500 3000 2500 2000 1500 1000 500 2443 2586 1713 1814 730 768 3413 3439 3094 2150 2422 2405 944 989 1031 0 2009 2010 2011 2012 2013 Total Male Female Maine Centers for Disease Control. (2014). http://mainepublichealth.gov/std

Cases per 100,000 500 450 400 350 300 250 200 150 100 50 0 Chlamydia Case Rate per 100,000, 2004 2013 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Maine U.S. Northeast

C. trachomatis Infection In Males: Urethritis mucopurulent, mucoid or clear urethral discharge, dysuria (painful urination) Incubation period unknown (probably 5 10 days in symptomatic infection) In Females: Cervicitis Mucopurulent endocervical discharge Edematous cervical ectopy with erythema and easily induced bleeding ( angry protruding cervix ) Urethritis Dysuria (painful urination), pyuria (cloudy urine) Centers for Disease Control. (2013). http://cdc.gov/std

Neisseria gonorrhoeae GONORRHEA

Gonorrhea Rates by Year, United States, 1941 2012 From: http://www.cdc.gov/std/stats12/figures/11.htm

Gonorrhea Rates by Age and Sex, United States, 2012 From: http://www.cdc.gov/std/stats12/figures/16.htm

Gonorrhea Case Reports in Maine 400 458 300 200 100 118 96 143 162 273 246 0 2007 2008 2009 2010 2011 2012 2013 Case Total Female Male Maine Centers for Disease Control. (2013). http://mainepublichealth.gov/std

140 Gonorrhea Case Rate per 100,000, 2004 2013 Cases per 100,000 120 100 80 60 40 20 0 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Maine U.S. Northeast

N. gonorrhoeae infection In Males Urethritis Typically purulent or mucopurulent urethral discharge, may be clear or cloudy Often accompanied by dysuria Epididymitis In Females Cervicitis mucopurulent or purulent cervical discharge, easily induced cervical bleeding Urethritis Other symptoms: Abnormal vaginal discharge, intermenstrual bleeding, dysuria, lower abdominal pain, dyspareunia (pain during sex) Centers for Disease Control. (2013). http://cdc.gov/std

CT/GC Complications Pelvic Inflammatory Disease (PID) May be asymptomatic May present with lower abdominal pain, discharge, dyspareunia, irregular menstrual bleeding and fever Epididymitis Accessory gland infection Bartholin s glands Skene s glands Fitz Hugh Curtis Syndrome Perihepatitis Centers for Disease Control. (2013). http://cdc.gov/std 33

Extragenital Gonorrhea Anorectal infection Symptoms: anal irritation, painful defecation, constipation, scant rectal bleeding, painless mucopurulent discharge, tenesmus (feeling the need to defecate), and anal itching. Usually asymptomatic. Mucosa may appear normal, or purulent discharge, erythema, or easily induced bleeding may be observed with anoscopic exam Pharyngeal infection Most often asymptomatic, but symptoms, if present, may include pharyngitis, tonsillitis, fever, and cervical adenitis Centers for Disease Control. (2013). http://cdc.gov/std

Proportion of CT and GC infections MISSED among 3398 asymptomatic MSM not identified if screening only urine/urethral sites, San Francisco, 2008 2009: Chlamydia Gonorrhea 23% 5% 77% 95% Identified MISSED Marcus et. al (2011), Sexually Transmitted Diseases, 38: 922 4.

Anatomical Site of Infection Portland STD Clinic, 2012 #Pos. CT Tests CT Pos. Rate #Pos. GC Tests GC Pos. Rate Vaginal/Urethra (1202 clients, 1343 73 6.1% 27 2.2% tests) Oral (371 Tests) 5 1.35% 20 5.93% Anal (343 Tests) 25 7.29% 12 3.5%

Chlamydia trachomatis & Neisseria gonorrhoeae SCREENING FOR CT/GC

CT Screening Recommendations: Females Sexually active women age <26 years: annually >26 years old: if risk factors are present Repeat re testing of all women 3 4 months after treatment for C. trachomatis infection, or when they next present for care within 12 months (especially for adolescents). Pregnancy: Screen all at first prenatal visit. At third trimester if <25 years or at increased risk Centers for Disease Control. (2013). http://cdc.gov/std 38

CT Screening Recommendations: Males Insufficient evidence to recommend routine screening in most men Should be considered in clinical settings with high prevalence of CT (i.e. teen clinics, correctional facilities, STD clinics) MSM (men who have sex with men) Urethral testing for insertive MSM intercourse in preceding year Rectal, oropharyngeal testing for men who indicate receptive MSM sex in preceding year Centers for Disease Control. (2013). http://cdc.gov/std

GC Screening Wide screening is not recommended.** USPSTF recommends screening all sexually active women for GC if they re at increased risk of infection. MSM same as chlamydia: Triple dip : Urethral testing for insertive MSM intercourse in preceding year; Rectal, oropharyngeal testing for men who indicate receptive MSM sex in preceding year Pregnancy: Screen all pregnant women at the first prenatal visit. Pregnant women aged <25 years and those at increased risk for chlamydia should be screened again in the third trimester. Centers for Disease Control. (2013). http://cdc.gov/std

Chlamydia trachomatis & Neisseria gonorrhoeae TREATMENT & FOLLOW UP

Treatment of Chlamydia and Gonorrhea Chlamydia Azithromycin 1 g orally in a single dose, OR Doxycycline 100 mg orally twice daily for 7 days Gonorrhea Ceftriaxone 250mg IM once PLUS Azithromycin 1 g orally in a single dose (preferred), OR Doxycycline 100 mg orally twice daily for 7 days Centers for Disease Control. (2013). http://cdc.gov/std 42

Current CT/GC Re screening Recommendations All women and men with CT or GC should be retested ~3 months after initial treatment Re screening should occur whenever patient returns to clinic (regardless of reason for visit), anytime within 1 12 months post treatment Especially adolescents Test of cure is not recommended, except in pregnancy (for CT only) Centers for Disease Control. (2013). http://cdc.gov/std

GC Follow Up After Treatment A test of cure is not recommended if recommended regimen is administered A test of cure is recommended if an alternative regimen is administered (in 1 week) If treatment failure suspected, or if symptoms persist, perform culture for N. gonorrhoeae Any gonococci isolated should be tested for antimicrobial susceptibility at site of exposure Repeat testing in 3 months Centers for Disease Control. (2013). http://cdc.gov/std 44

Partner Management Sex partners should be evaluated, tested, and treated if they had sexual contact with the patient during the 60 days preceding the onset of symptoms or diagnosis of chlamydia. Most recent sex partner should be evaluated and treated even if the time of the last sexual contact was >60 days before symptom onset or diagnosis. Abstain from sexual intercourse until partners are treated and for 7 days after a single dose of azithromycin or until completion of a 7 day regimen. Centers for Disease Control. (2013). http://cdc.gov/std 45

Treponema pallidum SYPHILIS

Syphilis Reported Cases by Stage of Infection: United States, 1941 2011 Centers for Disease Control. (2013). http://cdc.gov/std 47

Primary and Secondary Syphilis Rates by Age and Sex, United States, 2012 From: http://www.cdc.gov/std/stats12/figures/35.htm

Syphilis 40 35 30 25 20 15 10 5 0 Cases in Maine, 2009 2013 38 20 19 14 16 2009 2010 2011 2012 2013 Primarily among white men ages 30 54 in Southern Maine MSM transmission HIV Co infection Maine Centers for Disease Control. (2014). http://mainepublichealth.gov/std

Screening & Treating for Syphilis Screening Guidelines Persons at increased risk (MSM, commercial sex work, unprotected sex, those in correctional facilities) All pregnant women Treatment For Primary, Secondary, or Early Latent: Benzathine penicillin G 2.4 million units IM once Alternate: Doxycycline 100mg 2x daily for 14 days OR Tetracycline 500mg orally 4 times daily for 14 days For Late Latent or Unknown Duration: Benzathine penicillin G 2.4 mu IM for 3 doses at 1 week intervals (7.2 million units total) Alternate: Doxycycline 100mg 2x daily for 28 days OR Tetracycline 500mg orally 4 times daily for 38 days Centers for Disease Control. (2013). http://cdc.gov/std

HAV, HBV, & HCV VIRAL HEPATITIS

Viral Hepatitis (HAV, HBV, HCV) At risk populations include People who inject drugs People who share needles (i.e. tattooing and piercing) MSM Sexually active people at high risk Foreign born People born in Asia (esp. China), Africa, or other high risk countries, and their children Health care workers Travelers http://cdc.gov/hepatitis

Human Immunodeficiency Virus HIV

HIV Epidemiology 1.1 million people living with HIV in U.S. ~50,000 new infections each year 16% unaware they have it 15,500 deaths annually 34 million people living with HIV globally 2.5 million new cases annually 17 million deaths annually Disproportionate Impact Race/Ethnicity, Transmission Category, Geography Centers for Disease Control. (2013). http://cdc.gov/hiv

HIV Transmission Risk Categories in Maine PLWHA 970 186 57 169 295 29 2013 Cases 18 2 3 14 2 0% 20% 40% 60% 80% 100% MSM IDU MSM/IDU Het At Risk Het No Risk Other Maine Centers for Disease Control. (2014). http://mainepublichealth.gov/hiv

140 Maine HIV Diagnoses 1987 2013 120 100 Number 80 60 130 136 129 105 122 106 40 20 82 70 68 89 48 32 45 51 40 39 55 46 59 62 64 46 56 59 54 48 39 0 Maine Centers for Disease Control. (2014). http://mainepublichealth.gov/hiv

HIV Screening Guidelines All patients ages 13 64 in all health care settings (at least once in lifetime) All adolescents and adults at increased risk for infection should have more frequent screening (annually) MSM People who inject drugs Commercial sex workers Unprotected sex and multiple partners Centers for Disease Control. (2013). http://cdc.gov/hiv

COST OF TESTING & TREATMENT

From http://www.cdc.gov/std/stats/sti estimates fact sheet feb 2013.pdf

From http://www.cdc.gov/std/stats/sti estimates fact sheet feb 2013.pdf

STD Lifetime Cost per New Case Number of Estimated Cases Chlamydia Men $30 1,570,000 Chlamydia Women $364 1,290,000 Gonorrhea Men $79 466,000 Gonorrhea Women $354 354,000 Total Direct Cost for New Cases $516 million $162.1 million HBV $2,667 19,000 $50.7 million HIV $304,500 41,400 $12.6 billion HPV Men $45 7,080,000 HPV Women $191 7,060,000 HSV2 Men $761 420,000 HSV2 Women $621 356,000 $1.7 billion $540.7 million Syphilis $709 55,400 $39.3 million Trichomoniasis $22 1,090,000 $24 million TOTAL 19,738,800 $15.6 billion Owusu Edusei K, et al. The estimated direct medical cost of selected sexually transmitted infections in the United States, 2008. Sex Transm Dis 2013; 40(3): pp. 197 201.

Good News! With the passage of the ACA, there are a number of preventive health services that are available with no copay or coinsurance to the patient, including HIV/STD screening and prevention counseling Un or under insured at risk youth may qualify for no or low cost testing at certain health sites (funded by Maine CDC)

Patient Counseling Study from 2004 showed that patients were satisfied with their care if they had 15 minutes face to face with practitioner Most felt that a follow up visit was helpful to answer questions and clarify key points Much of in the initial information given was not retained 48 hours after visit. Patrick et al. (2004). Sexually Transmitted Infections, 80: 192 7

PUBLIC HEALTH RESPONSE TO STDS

Public Health Interventions Partner Services Patient Delivered Partner Therapy (Expedited Partner Therapy) Biomedical (PEP/PrEP) Outreach Education

Partner Services Services which are offered to people infected with a HIV/STD and their sex or needle sharing partners Locate and notify partners who have been exposed Provide risk reduction counseling for infected individuals Facilitate testing of exposed individuals Follow up on correct treatment of diagnosed individuals

Partner Notification Process Patient tests positive Order of priority HIV, syphilis, gonorrhea Chlamydia: Females: <19, pregnant, or more than one positive in past year Males < 24, or more than one positive in past year Provider elicits partner information and is reported to MCDC If no partners identified by provider, DIS contacts patient to elicit partner info

Partner Notification Process If partners identified, DIS contacts partner to: Inform exposure to STD Educate on risk reduction Provide information on testing location If partner identifies site they will get tested at, DIS will look for/contact site to see if partner has been tested DIS can request partner receive prophylactic treatment from provider

Expedited Partner Therapy EPT is a public health strategy that allows health care providers to give STD diagnosed patients medication and/or prescriptions to deliver to his/her sex partner(s) without a prior medical evaluation or clinical assessment of those partners. Multiple studies have found EPT to decrease rates of CT/GC reinfection and increase the number of sex partners reported to be treated for CT/GC Maine Rules are in the process of approval.

RESOURCES

Resources STD Treatment Guidelines, 2010 Prevention, screening, counseling, management AND treatment guidelines Guide to taking a sexual history Apple/Android App ebook for ipad, iphone, and ipod Touch http://www.cdc.gov/std/treatment/2010/default.htm

Resources CDC National Prevention Information Network http://www.cdcnpin.org/ It s Your Sex Life (IYSL) http://www.itsyoursexlife.com/ American Sexual Health Association http://www.ashastd.org/

Resources CDC STD Training Tools http://www.cdc.gov/std/training/ American STD Association http://www.astda.org/ Sylvie Ratelle STD/HIV Prevention Training Center of New England http://www.ratelleptc.org

Questions? Emer S. Smith, MPH HIV/STD Public Health Educator Emer.Smith@maine.gov 207.287.5193 Sarah Bly HIV/STD Surveillance Coordinator Sarah.Bly@maine.gov 207.287.3297 http://mainepublichealth.gov/std http://cdc.gov/std http://cdc.gov/hiv