This workshop is designed to talk about the impact of STDs on youth under the age of 25. This workshop will discuss the importance of sexual health screenings, partner management, and current data around STD morbidity rates. We will also talk about current STD clinical recommendations for the treatment of gonorrhea, chlamydia, and syphilis. Participants will engage in an interactive activity where they will sharpen their skills on effective partner management strategies.

1. Best Practices in STD
Follow Up + Case
Management
Friday May 10th, 2019
Neha Saxena, MPH
Community Embedded Disease Intervention Specialist
Andre Molette
Community Embedded Disease Intervention Specialist

2. Presenter Disclosures
The following personal financial relationships with
commercial interests relevant to this presentation
existed during the past 12 months:
 Neha Saxena
 No relationships to disclose
 Andre Molette
 No relationships to disclose

3. Essential Access Health
Sexual + Reproductive Health Programs
 Champions and promotes quality sexual +
reproductive health care for all
 Partners with the CA STD Control Branch and LA
County Division of HIV/STD Programs
 Implements best practices in STD prevention and
case management statewide

4. Presentation Overview
1. STD Epidemiology + Best Practices
2. Community Embedded Disease Intervention
Specialist Program
3. Group Activity

5. STD Epidemiology

6. STD Basics
Bacterial
 Chlamydia
 Gonorrhea
 Syphilis
Viral
 HIV (Human Immunodeficiency Virus)
 HSV (Herpes Simplex Virus I & II)
 HBV (Hepatitis B Virus)
 HPV (Human Papillomavirus)
Other
 Trichomoniasis (protozoan)
 Crabs (Pubic Lice)
Source: County of San Diego, HIV, STD, Hepatitis Branch of Public Health Services, HHSA
Curable, if
diagnosed.
Can have serious,
long term effects.
Not curable.
Treatment is available
to manage symptoms.

7. National

8. Why Diagnose and Treat STDs?
 >19 million STDs in U.S. annually
 Health care cost – $15.6 billion
 Health complications associated with untreated infections
 Leading infectious cause of infertility in the U.S.
 Neonatal HIV, herpes simplex virus (HSV) and congenital
syphilis –newborns and infants
 Increased risk of HIV transmission
 Nearly half of all STDs occur in young people ages 15-24
Satterwhite et al, 2013; Owusu-Edusei et al, 2 013
Satterwhite CL, et al. Sexually transmitted infections among U.S. women and men: Prevalence and
incidence estimates, 2008. Sex Transm Dis 2013; 40(3): pp. 187-193.
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.

9. Untreated
genital CT or
GC infection
Acute PID
Silent PID
Infertility
Ectopic
pregnancy
Chronic
Pelvic Pain
Risks to untreated women
National Network of STD/HIV Prevention Training Centers; Pelvic Inflammatory Disease (PID). October 2011.
20-60%
25%
25%
18%

10. California

11. [CATEGORY
NAME]
67.4%
[CATEGORY
NAME]
25.4%
[CATEGORY
NAME]
35.4%
[CATEGORY
NAME]
35.4%
[CATEGORY
NAME]
28.9%
[CATEGORY
NAME]
0.6%
Syphilis
7.2%
Reported STD Cases, Los Angeles
County, 20161
N=86,896
1 2016 data are provisional due to reporting delay.
Source: LA DPH Division of HIV and STD Programs

13. Chlamydia Incidence Rates Among
Youth Ages 15-19, 2016
Source: CA DPH STD Control Branch
* No cases reported or statistically unstable rates.

15. Gonorrhea Incidence Rates Among
Youth Ages 15-19, 2016
* No cases reported or statistically unstable rates.
Source: CA DPH STD Control Branch

16. Chlamydia Rates, Females by Race/Ethnicity &
Age Group (in years) California, 2013
Source: California Department of Public Health, STD Control Branch

17. Chlamydia, Female Incidence Rates by
Race/Ethnicity and Age Group in CA, 2016
Source: CA DPH STD Control Branch

18. Gonorrhea Rates Among Females by Age
Group and Race/Ethnicity, 2016
Source: LA DPH Division of HIV and STD Programs

19. Gonorrhea, Female Incidence Rates by
Race/Ethnicity and Age Group in CA,
2016
Source: CA DPH STD Control Branch

20. Services Minors in CA Can Receive
Without Parent/Guardian Consent
Birth Control (except sterilization) Minors of any age
Pregnancy Services Minors of any age
Abortion Minors of any age
STD Services Minors 12yrs and older
HIV Testing Minors 12yrs and older
Sexual Assault Care Minors of any age
Alcohol/Drug Counseling Minors 12yrs and older
Outpatient Mental Health Treatment Minors 12yrs and older
California Minor Consent Laws
Duplessis V, Goldstein S and Newlan S, (2010) Understanding Confidentiality and Minor Consent in California:
A Module of Adolescent Provider Toolkit. Adolescent Health Working Group, California Adolescent Health Collaborative.

21. Confidentiality Best Practices
 Let patients (and parents) know your confidentiality
protocol before and during the visit
 Explain that confidentiality is part of the highest
standard of care
 Normalize by stating that it is every patient’s right

22. STD Clinical
Recommendations
Screening

23. Sexual Risk Assessment
5 P’s
 Past STDs
 Partners
 Practices
 Prevention
 Pregnancy Planning and Prevention
Provider comfort level in asking sexual health questions
influences patients’ willingness to disclose information
about their sexual practices.

24. Assessing Sexual Behavior
 Begin by reinforcing confidentiality
 Use age/development-appropriate questions:
 “Some of my patients who are your age have started
feeling attracted to boys, girls, or both. Have you ever
been attracted to any boys or girls?”
 “Some of my patients your age have started dating.
Have you started dating?”
 “Some of my patients your age have started having
sex. Have you had sex?”
 Do not make assumptions about sexual orientation or
sexual practices/experience

25. CDC Screening Guidelines
*All sexually active persons 13 and older should be screened at least once for HIV.
Population Screening Recommendation
Young women (<24)
• Annual screening for chlamydia
• Annual screening for gonorrhea
Older women (25+) and Men • Screening based on risk
Pregnant women
• Syphilis, HIV, chlamydia,
gonorrhea and hepatitis B
Men who have sex with men
• Screening at least once year for
syphilis, chlamydia, gonorrhea,
and HIV

26. Risk Based Screening
STD risk factors include:
 Prior STD infection in past 24 months
 Inconsistent condom use (<100)
 Multiple partners in past year
 Knowledge/suspicion that recent partner has multiple partners
 New sexual partner in past 3 months
 Exchanging sex for drugs or money in past year
 Other factors, such as high prevalence at practice site

27. Missed Opportunities in STD Screening
 Pregnancy test only
 Emergency Contraception
 Contraception Follow-Up
 Refills
 Depo-Provera Shot
 Extragenital Screening
 Rectal
 Pharyngeal

28. Extragenital Screening
Patton, et al, Clinical Infectious Diseases, 2014
Extragenital Gonorrhea and Chlamydia Testing and Infection Among Men Who
Have Sex With Men – STD Surveillance Network, United States, 2010-2012

29. Contacting Patients
 As soon as a positive test result is received, the patient’s
medical record should be reviewed by a designated staff
 A first attempt to contact the patient should be made
within 72 hours of receipt of their positive result
 At least 3 attempts ideally should be made within 5
days.
 All attempts should be documented on patient
electronic or paper chart (provide best practices on
documentation)
Source: Region IX Infertility Prevention Project Chlamydia Clinical Guidelines, February 2009

30. STD Clinical
Recommendations
Treatment

31. Antibiotic Resistant Gonorrhea

32. STD Treatment Guidelines 2015

34. Counseling Positive Patients
What your patients need to know:
 Discuss importance of sexual history
 Emphasize CT/GC are sexually transmitted
 Ensure medication is taken properly
 NO SEX for 7 days after you AND your
partner(s) have been treated
 Discuss all options for partner treatment
 Recommend retest in 3 months

35. STD Clinical
Recommendations
Partner Notification

36. Partner Notification
 Treat ALL partners within the last 60 days from testing
or onset of symptoms
 Notify patient that they may be contacted by the
Health Department to discuss
 Infection
 Treatment
 Partner notification
 Follow Up care (retesting, treatment, PrEP, etc.)
 Referrals to other services

37. Partner Management Options
 Patient brings partner to clinic (BYOP)
 Patient-delivered partner therapy (PDPT)
 Patient tells partner to get exam, test and
treatment (patient referral)
PDPT is Legal in California
2001 - law allows CT partner treatment
2007 - law allows GC partner treatment

38. Patient Delivered Partner Therapy
(PDPT) Distribution Program
 Program provides free CT + GC medication to eligible
clinic sites + local health jurisdictions (LHJs)
 Participating clinic sites and LHJs dispense the medication
to patients diagnosed with CT/GC who give the
medication to their sex partner(s) for treatment
 Eligible clinics must:
 Be located in California
 Serve a population at risk for STDs
 Serve an uninsured or underinsured population
 Provide index patient treatment for CT + GC
 Participate in 340B program

39. PDPT Distribution Program Contact
FOR LOS ANGELES
Krissy Leahy
Sexual + Reproductive Health
Coordinator
213.386.5614 x4512
kleahy@essentialaccess.org
FOR REST OF CALIFORNIA:
Erin Crowley
Sexual + Reproductive Health
Program Manager
510.486.0412 x2324
ecrowley@essentialaccess.org
For more information, visit http://www.essentialaccess.org/pdpt

40. STD Clinical
Recommendations
Rescreening

41. Dangerous: Complications become
more likely with each repeat infection

42. Why Does Re-infection Occur?
 Sex with untreated partner
 Sex with new partner
 Sex too soon after taking medication
 Other important factors:
 Power differential between patient & partner(s)
 Intimate partner violence
 Other socio-economic factors

43. Retesting Recommendations
 All patients at 3 months post-
treatment
 Both CT and GC regardless of
initial diagnosis
 Opportunistic retesting
encouraged at ANY return visit
1-12 months
after treatment
Source: CDPH STD Control Branch, Best Practices for Prevention and Early Detection of Repeat
Chlamydial and Gonococcal Infections: Effective Partner Treatment and Patient Retesting Strategies
Implementation in California Health Care Settings, June 2011

44. CT/GC Management
Screen
Treat
Treat (Partners)
Re-screen
Source: CDPH STD Control Branch, Best Practices for Prevention and Early Detection of Repeat
Chlamydial and Gonococcal Infections: Effective Partner Treatment and Patient Retesting Strategies
Implementation in California Health Care Settings, June 2011

45. The STD/PrEP Connection
 Encourage routine screening for all STDs regardless of HIV
status to see whether a patient has been re-infected with
an STD.
 Patients with positive STD results but negative HIV results
should be informed about PrEP (Pre-Exposure
Prophylaxis) and referred to a PrEP Center for Excellence.
 An open sore is an open door, PrEP helps prevent HIV
infection.
Resources:
www.getprepla.com
https://www.pleaseprepme.org/

47. Community Embedded Disease
Intervention Specialists (CEDIS)
+ Partner Services

48. Partner Services Misconceptions
 STD/Sex Police
False
CEDIS will not arrest any patients for testing positive for an
STD. CEDIS do not enforce safe sex practices; they educate
and encourage safe sex practices.
 Compromise personal information
False
CEDIS abide by HIPAA regulations and ensure patient
confidentiality. Personal patient information is never shared
with anyone but the patient.

49. Partner Services Misconceptions
 Harass patients
False
Truth: CEDIS use various strategies to locate patients and
ensure they have been treated adequately, address any
concerns about an infection, and educate to prevent re-
exposure.
 Disrupt clinic activities
False
Truth: CEDIS contact providers to obtain PT information and
ensure PT has been notified of STD, verify treatment, and
avoid re-exposure by also referring PT’s partners for testing
and treatment.

50. The Process
The Interview
The Investigation
Case Management

51. Index Patient Interview
Contact information
Work/School
Travel
Lifestyle
Relationships
Medical History
Drugs and Alcohol
Incarceration
Sexual History
Other

52. Disease Investigation and Fieldwork
Traditional Fieldwork
 “Boots on the Ground”
 Door to Door
Interactions
 Visiting people in their
communities and/or
spaces
 Medical records
“Digital Fieldwork”
 Social Media
 Dating/Hookup Apps
 California Birth Index
 Text Messaging
 Electronic Medical
Records

53. Case Management
 Assess patient’s understanding of infection
 Conduct risk reduction plan
 Help patient identify risks
 Identify and support past success
 Identify steps to reducing risk
 Problem solve for potential barriers
 Provide necessary referrals and resources for patient use
Source: CDC Passport To Partner Services Participant Manual

54. Case Study

55. Group Activity
Divide group
Read instructions on card
Get a partner
You have 10 minutes
Switch roles

56. Activity
You will be interviewing your patient who tested positive for
gonorrhea. The patient has already been treated. This is a
face-to-face interview and you have 10 minutes to interview
them. Your job is to find out the following information about
their partner(s):
 Name
 Contact information
 Exposure
 Description
Reminders:
 Ask open-ended questions.
 Do not make assumptions.
 Ask specific questions.

57. Case Study
 Patient tested positive for an STD and claimed 12 sexual
partners. 6 partners were anonymous/no information.
 Sexual Partner #1 claimed 10 additional partners. Sexual
Partner #2 claimed 3 additional partners.
 Many sexual partners were tested and treated. Clinics were
able to identify hidden infections including Syphilis, CT, GC
and HIV. Many sexual partners had multiple infections.
 To date, 107 total partners were involved.
 One of your patients may start an investigation/network
very similar to this case.

58. Partner Services at your clinic
 How can your clinic use these techniques to support
patients and notify their partners?
 Who would you identify as the best person to use this
information?

59. When to contact your health department
 Unable to Locate/contact a patient
 Patient not returning for treatment
 Repeat infections
 Patient refusing treatment

60. Digital Programs

63. Essential Access Health Trainings
• Addressing Human Trafficking in Health Care Settings
• Addressing Intimate Partner Violence + Reproductive
Coercion in Diverse Health Settings
• CDC STD Treatment Guidelines
• Family Planning Health Worker Certification
• Integrating Sexual and Reproductive Health into Primary
Care: A Focus on Transgender Patients
• Beyond the Individual Patient: Strategies to Address STD
Health Disparities
www.essentialaccesstraining.org

64. Contact Information
Andre Molette
amolette@essentialaccess.org
(213) 905-3442
Neha Saxena
nsaxena@essentialaccess.org
(213) 407-3389