Best Practices for STD Treatment and Partner Follow-Up

Best Practices for STD Treatment and Partner Follow-Up Amanda Gill, MS, South Dakota Department of Health Sarah Weninger, MPH, North Dakota Departmen...
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Best Practices for STD Treatment and Partner Follow-Up

Amanda Gill, MS, South Dakota Department of Health Sarah Weninger, MPH, North Dakota Department of Health IHS Public Health Conference August 5, 2016; Bismarck ND ©2014 MFMER | slide-1

Disclosure We have no actual or potential conflict of interest in relation to this program/presentation.

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Learning Objectives • Describe One Goal of Partner Services. • Identify Three Core Functions of Conducting Partner Services. • Identify Two Basic Counseling Skills. • Describe Two Methods of Expedited Partner Therapy (EPT).

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Nationally, 41.2% of Students Have Had Sexual Intercourse. 2015 – Youth Risk Behavior Survey: • Ever Had Sexual Intercourse – 41.2% • ND: 38.9%; 54% of Seniors • SD: 40.1%; 64.2% of Seniors (2013 Data)

• 56.9% Used a Condom During Last Sexual Encounter • ND: 61.4%; SD: 60%

• 1 in 5 Students Used Alcohol/Drugs Before They Last Had Sex • ND: 18.7%; SD: 24.4% • Only 1 out of 10 have been tested for HIV • ND: 9.1% (5.5% Freshman, 12.4% Seniors) Testing: HIV or STDs • SD: 13.2% (8.9% Freshman, 19.6% Seniors) Testing: HIV or STDs Reference: http://www.cdc.gov/healthyyouth/data/yrbs/pdf/2015/ss6506_updated.pdf - National Data ND YRBS: https://www.nd.gov/dpi/SchoolStaff/SafeHealthy/YRBS/ SD YRBS: https://doh.sd.gov/documents/statistics/YRBS_Sexual_Behaviors.pdf

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Prevention, Education, & Treatment

THEN ….

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…AND NOW.

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Healthcare Providers Have Important Responsibilities in Regards to Sexual Health of Their Patients. • Decrease the STD burden by scaling up STD screening by private providers. • Have the “sex talk”– symptoms, prior STD history, risk, anatomic sites, partners. • Make the most of your urine. • Treat – according to CDC’s updated treatment guidelines. • Evaluate and treat all patients’ sex partners from the previous 60 days. • Suspected GC treatment failure – obtain cultures and call state STD program • Provide sexual health education, counseling, and condoms to patients. • Report STD’s, treatment, and partner information to the state STD program

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Use These 3 Key Components of Infection Management.

Behavioral Counseling

Clinical Management

Partner Services

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6 of 10 STD Infections are Lost Throughout Care Continuum. Piot-Fransen model : How many infections are lost on the way to cure? Infections in the community

1,000

Aware of symptoms

70%

700

Use health services

80%

560

Infected suspected by clinician

90%

504

Infection confirmed

96%

484

Treatment prescribed

95%

460

Treatment obtained

90%

414

Treatment taken

90%

372

Treatment effective = cured

98%

365

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Appropriate Clinical Management Begins with Screening At-Risk Patients.  Screen sexually active females < 25yrs – annual CT and GC.  Screen MSM - yearly for CT, GC, Syphilis, HIV.  More often if multiple or anonymous partners.  Screening for Syphilis  HRH and MSM – at least annually, more often if many partners  Pregnant women – SD is currently a high morbidity state – screen 3x’s during pregnancy  HIV + persons need routine screening for all STD’s.  Persons exposed to or diagnosed with an STD: Need HIV Screening  Test and presumptively treat  patients who have UTI/STD symptoms or who have been exposed  Test men who are partners of +’s,  Persons 13 to 64 – at least 1 HIV test in their lifetime.  More often if at increased risk. Reference: CDC STD Treatment Guidelines: http://www.cdc.gov/std/tg2015/default.htm

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Chlamydia Screening is Recommended for All Sexually Active Women Under 25 Yrs.

Reference: http://www.cdc.gov/std/tg2015/screening-recommendations.htm

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Those Screened for Chlamydia are often Screened for Gonorrhea.

Reference: http://www.cdc.gov/std/tg2015/screening-recommendations.htm

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Syphilis Pregnant Women and MSM are Highest Priority for Syphilis Screening.

Reference: http://www.cdc.gov/std/tg2015/screening-recommendations.htm

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All Individuals Between 13-64 Should be Tested for HIV.

Years

Reference: http://www.cdc.gov/std/tg2015/screening-recommendations.htm

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Partner Services are Essential to Treating STD/HIV Patients. • Partner Services is a program designed to provide a broad array of services that should be offered to those with STDs and/or HIV. They include: • Partner notification • STD/HIV testing, treatment and other relevant services • Prevention counseling • Hepatitis screening and vaccination • Treatment and/or linkage to medical care for those living with HIV

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Prevention & Control Strategy

Identify Infections

Treat Patient

Treat Partners

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Partner Services: The Interview. Provide Education. Collect Partners. Risk Reduction.

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Patient Interviews Provide Several Opportunities to Improve Health. • Allows To Patient To Inform Patients Anonymously Without Revealing Own Disease Status • Relieves Patient Of Responsibility To Notify Partners • Offers Peace Of Mind To Patient By Fulfilling Ethical Responsibility To Partners • Opportunity For Behavior Change • Linkages To Other Needed Social And Medical Services

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There are Several Items that Need to be Discussed in a Patient Interview. • Introduction; Disease Comprehension, Sex Partners, Risk Reduction • CHART Method:

C – Complications of Untreated Disease H – HIV Connection A – Asymptomatic Infection R – RE-infection T – Transmission – All modes

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Other Options for Interview: Self – Interview.

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Counseling Skills.

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Counseling Sessions are Not One Size Fits All. • Counseling is communication, verbal and nonverbal, made in response to and in the presence of feeling. It is the work of supporting someone in making decisions when his/her willingness or ability to act is affected by his/her feelings • Counseling is different from education. Good counseling does not equal good information giving. • Good counseling is “client-centered.” • Counseling is not solving the client’s problems.

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Counseling Concepts 1. Focus On Feelings. 2. Manage Your Own Discomfort. 3. Set Boundaries.

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Establish Boundaries as a Counselor. Caretakers: • Fail to set appropriate boundaries • Cannot manage their own discomfort • Take responsibility for their clients’ issues and circumstances • Feel that they must “fix” their clients’ problems

Caregivers: • Set appropriate boundaries • Manage their own discomfort • Help clients prioritize issues through support and encouragement • Do not take ownership of clients’ problems

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Basic Counseling Skills 1. Open-ended Questioning 2. Attending 3. Offering Options, Not Directives 4. Giving Information Simply

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Communication Occurs Two Ways. Non-Verbal

Verbal

Body Language

Encourage

Eye Contact

Ask questions

Space

Restate

Time/Touch

Summarize

BEST EARS ! ©2014 MFMER | slide-27

Questioning Aims to be Open and Non-Judgemental. OPEN ENDED

POLITE IMPERATIVES

Who…?

Give Me…?

What…?

Tell Me…?

When…?

Show Me…?

Where…?

Explain to me…?

Why…?

Describe…

How…?

(Silence)… AVOID!

Are There?

Will You?

Is There?

Did You?

Do You?

Can You?

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Tips for the What,

How, Where, When, Who

 Have the “sex talk” with patients.  Test based on symptoms, exposure, prior STD history, at risk populations, etc.  Test based on body site of exposure.  Know your testing options.  Know your testing and treatment recomendations.  Make the most of your urine.  It’s ok to preventatively treat symptomatic persons.  Talk about partners.  Report patient and partner information to DOH

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Risk Reduction Plan: Aim to Reduce a Client’s Risk of Exposure. • Establish and/or improve patient’s perception of risk • What do you think your chances are of getting this infection again? • Identify and support patient’s previous behavior changes • What types of things have you been able to do in the past to help keep yourself safe from infection? • Negotiate a simple, realistic and incremental plan for reducing risk . • What one or two things could you do to help protect yourself from getting an infection in the future?

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Partner Management Test. Treat. Prevent Re-Infection.

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Discussion of Sex Partners Transitional Phrase for Clinicians (Example) “Now that we’ve talked about how serious the disease can be if left untreated, let’s talk about how to privately get any partners that you’ve had within the last couple months tested and/or treated. We can do this a few different ways…..”

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The Minimum Recommended for Partner Management Counseling.  Abstain from sex for at least 7 days after treatment  Re-testing recommendations  Chlamydia – 3 to 4 months after treatment  Gonorrhea – 3-4 months after treatment or 1 week after treatment with alternative regimen  Syphilis -- 6 and 12 months after treatment

 Stress importance    

Of not being treated Of not contacting all partners = re-infection Where the partner(s) can seek care All person’s diagnosed with a STD should be screened for HIV

 Discuss partner notification/treatment options    

Patient notifies partner Clinic notifies partner Expedited Partner Therapy (EPT) DOH assistance in notifying

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Interview Periods are Different for each STD. Disease

Interview Period

Chlamydia

60 Days Before Onset of Symptoms/Specimen Collection Date Through Date of Treatment

Gonorrhea

60 Days Before Onset of Symptoms/Specimen Collection Date Through Date of Treatment

Primary Syphilis

90 days prior to date of onset of primary lesion through date of treatment

Secondary Syphilis

6.5 months prior to date of onset of secondary symptoms through date of treatment

Early Latent Syphilis

1 year prior to start of treatment

HIV

1 or 2 Years before date of first positive HIV test through date of interview. All current of former spouses during 10 years before diagnosis.

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Partner Follow Discuss A Variety Of Options For Partner Up

Notification And Treatment With Each Patient.  Provider-assisted referral  Provider notifies sex partners  Partners go to clinic for test/treat  Patient-referral  Patient notifies sex partners  Partners go to clinic for test/treat

Estimated that ~ 40 % of partners are not treated

 DOH DIS-referral  Patient tells DIS who their partners are  DIS notifies sex partners – Can Utilize Technology  Partners go to DOH or clinic for test/treat  NDDoH: Pregnant Chlamydia, All Gonorrhea, Syphilis and HIV  SDDoH:

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7 Steps for Partner Management. Identify the patient and introduce yourself

Step 1

Assure a private setting

Step 2

Provide notification and process reaction

Step 3

Secure appointment for testing and treatment

Step 4 Step 5

Assess need for referral and linkage to care

Step 6 Step 7

Secure appointment for testing and treatment Assess need for referral and linkage to care

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Patient Referral: What to say? (Sample Client Script)

• “I need to talk to you about something really important. I have an STD. I’ve got…….” • “The doctor told me that you can have serious complications if you don’t get checked out and get medicine. If you don’t get treated I could get this back.” • “You can come to ……. clinic and give a urine sample and get medicine, and you’re done.” • Partner letters with STD info and treatment recommendations to give to health care provider.

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Clinic Referral: What to Say? (Sample Clinic Script) • "Hi, ….. , this is …… from …… Clinic. Can I speak with you for a moment? I want to let you know that you may have been exposed to …….., and I would like you to come down to the clinic for testing and treatment. It is important to take care of this right away, so you do not spread the infection to others. When is the best time for you to come? You can also go to your regular medical provider or to your local Dept. of Health office." • Phone Message – “ Hi….., this is …… from …….Clinic. Give me a call back at ……, I have to discuss an urgent health matter with you.” • "It's a confidential matter and I can't discuss that, we protect everyone's privacy. Again, it's really important to get tested and treated, many people don't even know they have the infection, because there are no symptoms. When is the best time for you to come? You can also go to your regular medical provider or to your local Dept. of Health office."

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Expedited Partner Therapy (EPT) “ EPT is the practice of treating the sex partners of persons with STD’s without an intervening medical evaluation or professional prevention counseling.”

• Patient Delivered Therapy (PDT) • Given meds or a script

• Script called into pharmacy • Pick up meds at providers office – “quick visit” • No need for exam or the expense

• SD Dept. of Health – DIS office walk-in’s (Not Available in ND) ©2014 MFMER | slide-39

EPT IS OK!

(and it works!)

• Randomized control trials have evaluated EPT vs. traditional partner management for CT and GC  More likely to report that all of their sexual partners were treated than those who were told to refer their partners for treatment  EPT associated with: Increased frequency of patient-reported partner notification & treatment Fewer re-infections  Less likely to be diagnosed with a repeat infection at a follow up visit  No evidence of serious adverse events Golden, Matthew R., et al. “Effects of Expedited Treatment of Sex Partners on Recurrence of Persistent Gonorrhea or Chlamydia Infections.” New England Journal of Medicine. 2005; 352:7, 6767-85.

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Q & A’s 1. True or False. Partner Services is a program designed to provide a broad array of services that should be offered to those with STDs and/or HIV. 2. Which of these is NOT a function of Partner Services? • A. Partner notification • B. Prevention counseling • C. Treatment of patients and their partners • D. Only providing STD screening 3. True or False. Expedited Partner Therapy (EPT) is a scientifically proven method that can be used to treat partners of STD patients. ©2014 MFMER | slide-41

Additional Resources.

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www.cdc.gov/std/training/passport-partner-services.htm

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Training

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Training

www.cdc.gov/std/training/onlinetraining.htm

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Training

http://www.cdc.gov/std/training/default.htm

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Contact Us With Questions or Education Requests Amanda Gill, M.S. STD Program Coordinator Office of Disease Prevention South Dakota Department of Health 615 East 4th Street Pierre, SD 57501

 Office: (605) 773-4794  Fax: (605) 773-5509  Email: [email protected]

Sarah Weninger, MPH Viral Hepatitis, HIV and STD Prevention Coordinator North Dakota Department of Health Division of Disease Control 2635 East Main Ave P.O. Box 5520 Bismarck, ND 58506-5520

 Phone: 701-328-2366  Email: [email protected]

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