2024 STI Prevention Conference: Innovative STI Testing and Management

introduction-background[00:00] Introduction and Background

Hello, everyone. My name is Meena Ramchandani. I'm an infectious disease physician at the University of Washington in Seattle. This podcast is dedicated to an STI [sexually transmitted infections] literature review for health care professionals who are interested in remaining up to date on the diagnosis, management, and prevention of STIs. 

In this episode, we'll review some oral abstracts presented at the STI Prevention Conference that was held in September 2024 in Atlanta, Georgia. There were great abstracts presented at the conference. It will be interesting to hear research updates as time goes on, either published in the medical literature or presented to the next conference in 2026. We're going to focus on innovative places for STI testing and management for this discussion. I thought these were helpful to hear about as they can be applicable to a variety of health care settings or jurisdictions, even perhaps something you could incorporate into your practice. We'll go through a brief summary of a few oral presentations on this topic that were discussed at the conference.

[Note: The abstracts are available in the 2024 STI Prevention Conference Abstract Book.]

abstract-1[01:04] Abstract #1

The first oral presentation we're going to talk about was presented by Anna Madsen from Oak Ridge Institute for Science and Education, and the title of her talk was Out of the clinic: A local health department and community pharmacy collaboration to address STIs. And so, in this project, five local health departments partnered with community pharmacies to provide STI care in Virginia from 2022 to 2024. Some previous data had shown that in Virginia, STI infections have doubled from 2018 to 2021, with a 26% increase in gonorrhea cases and a 52% increase in syphilis cases. And so, this program allowed for increased STI capacity through pharmacy referral for patients with a positive chlamydia or gonorrhea test, EPT [expedited partner therapy] eligible partner, or a latent syphilis diagnosis. These additional services that took place at pharmacies were at no cost to the patient and included additional business evening and weekend hours for STI treatment, injectable, or take-home treatment options. This included HIV postexposure prophylaxis as well as expedited partner therapy. 

In this pilot project, there were 105 patients referred to pharmacy partners from 2022 to 2024, 8 patients with syphilis, 31 patients with gonorrhea, and 58 with chlamydia. Another 8 patients had other STI/HIV care management that was needed. What they found is that 92 patients received STI treatment, 16 linked to HIV PrEP, 12 doses of benzathine penicillin G were given out for syphilis, and 21 EPT partners were treated. 

It seems like the model to implement STI services into pharmacy practices can actually increase availability and make things easier for patients, which is nice.

abstract-2[02:55] Abstract #2

Dr. Plotzker from the California Department of Public Health presented on Expanding prenatal care access for congenital syphilis prevention: The Pregnancy Connections Clinic. What they had found previously is that in California, 52% of mothers with congenital syphilis infants had delayed or no prenatal care; 38% had methamphetamine use, and 23% were unhoused. And so, they started this pilot program in San Joaquin County to improve prenatal care for these individuals. San Joaquin County was chosen because they had 77 cases of prenatal syphilis and 40 cases of congenital syphilis in 2019, and the majority of these mothers were experiencing homelessness and/or methamphetamine use. 

Prior to starting the program, they gathered data through structured interviews with this high-priority population around what features of a prenatal clinic would best support them and then implemented these into the prenatal care clinic that they designed. These included a harm reduction approach, open access and flexibility with appointments, shorter wait times, a cell phone that was given to provide for communication, gift cards, and then also a mobile outreach team.

Pregnant patients were referred from a variety of health care settings, and over the course of this pilot program, they were able to enroll 40 patients from 2022 to 2024. Sixty-eight percent of the patients had unstable housing, 73% a substance use disorder, 45% were pregnant with syphilis, and many met multiple eligibility criteria. For example, they had syphilis with unstable housing or syphilis, unstable housing, and a substance use disorder all at the same time. Thirty-five percent of the patients who enrolled were white, 30% Black, and 28% Latina or Hispanic. Now, focusing on STIs, of the 18 pregnant patients with a current syphilis diagnosis, all of them had late latent syphilis or syphilis of unknown duration. 

What they found over the course of this pilot program is that 94% completed the appropriate treatment for syphilis, and one person, that's why it's 94%, actually moved out of the county. That's a huge accomplishment, especially for this patient population, where it's a challenge to get all three doses of benzathine penicillin in a timely way. At the time of the oral abstract presentation, they had 13 delivered infants exposed to syphilis, but all of them were born to parents who had been adequately treated for syphilis during pregnancy, and so a NICU [neonatal intensive care unit] admission was not needed in 77% of these cases. 

So, this program shows that low barrier care models for prenatal care are a great way to increase services for underserved pregnant populations, including those with syphilis or at high risk of acquiring syphilis during pregnancy.

abstract-3[05:46] Abstract #3

Along similar lines, Allison Decker [NP, MPH] from San Francisco Department of Public Health discussed Evaluating an electronic health record optimization tool to improve syphilis treatment for patients lost to follow-up. This is a situation that is familiar to many health departments where patients need syphilis treatment but are lost to follow-up or just not able to be found, and it can cause anxiety and be quite time-consuming. So, what they did is they developed a few workflows in this project to improve syphilis screening and management. One that I'll point out was improvements in electronic medical record to facilitate syphilis screening and treatment for patients who were lost to follow-up. The electronic medical record that they used was EPIC, which is used by many health care facilities nationwide. They created a tool in EPIC to notify providers that a patient was lost to follow-up but also needed syphilis treatment. They then documented the details of the case, including the treatment needed for the provider, with the option to manually resolve the alert once the treatment was completed, so the provider didn't have to contact anyone for more information. It was already put into the system of what needed to be done for that patient in regards to their syphilis treatment. Over the 2.5 years that they did this program, 276 alerts were added, and 148 (or 54%) had the alert removed or showed the evidence of treatment in the STI registry.

Now granted, an alert removed is a proxy for completed syphilis treatment, but if the correlation holds, that's a large proportion of individuals, especially since 55% were experiencing homelessness and difficult to find or contact. This seems like a great way to support management of syphilis patients lost to follow-up or those that are just difficult to find without making the coordination of care burdensome to already taxed health care providers. It also seems it can be easily implemented into a variety of electronic medical record systems.

abstract-4[07:45] Abstract #4

Dr. Rahman from the CDC presented Virtual partner services: Is this the future of partner notification? Now, for some background, partner services for syphilis involves interviewing people diagnosed with syphilis to enable partner notification of exposure and then facilitate access to testing and treatment for the partner. These interviews are typically conducted in person or by phone with a disease intervention specialist or DIS. Some studies have shown that in-person partner service interviews for syphilis are associated with increased syphilis contact indices, where more partners are elicited and increased HIV case finding, compared to telephone interviews. The idea is that the DIS can build a better rapport and trust with the in-person interview, but this method requires patients to come to clinic or DIS to go into the field, which can be challenging and time-consuming, especially with the high caseloads in large geographical areas covered by the DIS.

In 2022, two public health regions in Louisiana highlighted the option of virtual partner services in addition to in-person or phone interviews for patients with syphilis. The virtual partner services were done by video conferencing in a virtual meeting room. In the timeframe of almost two years, 1,187 early syphilis cases were reported, and 782 (or 66%) were interviewed: 26% were interviewed in person, 50% by phone, and 24% by virtual video.

What they found in this pilot project was that for the in-person interviews, 183 partners were identified, and this resulted in a partner index of 0.9. The partner index is a number of partners initiated per case. Telephone interviews identified 117 partners, which resulted in a partner index of 0.3, so a lot less than the in-person interviews. And what they found is that the virtual video interviews identified 132 partners, which showed a partner index of 0.6, so higher than the telephone interviews.

Now, when reviewing the treatment index or the numbers of partners treated per case, virtual interviews were the same as in-person interviews, with a treatment index of 0.3. Telephone interviews had lower treatment index of 0.1. So overall, what they found is that partner services for syphilis might benefit by offering virtual options. It might not be relevant for every patient, especially if a patient doesn't have access to a smartphone or a computer. But in this study, virtual partner services actually resulted in higher indices, both for the number of partners initiated or treated per syphilis case, than phone interviews.

abstract-5[10:37] Abstract #5

Now turning to the next oral presentation. What if we could provide individuals with 24/7 access for supplies? Erin Brown presented a talk titled Your choice: 24/7 access to sexual reproductive and drug user health supplies via harm reduction vending machines in Rhode Island. So, this was a two-year pilot project where six harm reduction by public health and one naloxone-only vending machine. They were installed on a rolling basis at different locations in Rhode Island with no cost to access supplies. They were co-located with Sharps Disposal Kiosks, and in order for clients to access supplies, they required enrollment and a unique client ID, and clients could access a certain quantity of supplies per week. These supplies included fentanyl test strips, hygiene or menstrual kits, ponchos, a pregnancy test, in addition to safe sex, safe injection, and naloxone kits. What was available was pretty comprehensive. The safe sex kits included 10 condoms and packets of lubricant.

They found that the vending machines were well utilized by priority populations, and people access the vending machines at all hours of the day or night. The most supplies given out were safer injection kits. Actually, greater than 12,000 kits were given, followed by naloxone kits, fentanyl test strips, and safer sex kits. So, this project has tried to address a syndemic approach to STI management and care to not only help prevent STIs, HIV, and other infectious diseases, but also to prevent overdose deaths and basic needs of individuals accessing the vending machines. The great thing is that clients could access supplies 24/7.

abstract-6[12:17] Abstract #6

And turning to another oral abstract that presented on the harm reduction model. Jen Hecht from Building Healthy Online Communities presented an abstract titled Adding naloxone distribution to an existing online HIV/STI self-testing program in San Francisco. Building Healthy Online Communities was founded in 2014, and it's a consortium of public health organizations working in partnership with dating apps. What they do is they build to help self-sustaining features into the apps to promote healthy and informed choices, and they reach large populations. They also coordinate communication between public health and dating apps. In this program, they had found previously that 22% of MSM [men who have sex with men] using the dating apps reporting having never tested for HIV, and 77% of app users wanted to order home HIV testing through the dating app itself. And so, what they did is they developed a program called Take Me Home, which provides free mailed HIV/STI self-collection and lab-based testing through an online platform.

Take Me Home overall has given out 61,000 HIV/STI self-collection kits. And it's now active in 29 jurisdictions in the U.S. So, what they did in this pilot project was implement an option to add a free naloxone kit to the HIV/STI self-collection kits, which would be mailed to the recipient free of charge. This pilot was a partnership between the Building Healthy Online Communities and the San Francisco Department of Health.

The staff at the San Francisco Department of Health helped with shipping of naloxone to recipients based on the orders received through the Take Me Home platform. When they analyzed the program after about one year, what they found is that 61% or around a thousand orders accepted the offer of a free naloxone kit. That's a large number! And 54% of the group ordering the naloxone kit also asked for hepatitis C test. This group is now looking to expand to additional locations and coordinate free naloxone procurement through state resources, for example, like the California Naloxone Distribution Project. This program has now expanded to Humboldt County in California, and it's actually looking to expand further to other jurisdictions. So, if you're interested in learning more, I suggest you reach out to Building Healthy Online Communities. There is a substantial burden of STIs among people who use drugs, and providing overlapping services are ways to reach these populations and provide them with comprehensive care.

summary[14:50] Summary

To conclude, I'd like to summarize some key points from this session. 

• Partnering with local pharmacies is one innovative way to provide convenient STI care and HIV prevention that can actually increase clinical capacity beyond what health departments are able to provide. 
• Pharmacies are found to be well-equipped for STI care and management. 
• Prenatal low-barrier care clinics, such as Pregnancy Connections Clinic in California, is one model to improve syphilis treatment for pregnant persons from underserved populations. 
• Using the electronic medical record to create an alert with a detailed treatment plan is a creative way to manage syphilis treatment for patients lost to care.
• Virtual partner services are another option for DIS to conduct partner services and seems to have better outcomes than telephone interviews. 
• Vending machines can potentially provide 24/7 access to health supplies for sexual reproductive and drug use with a harm reduction approach. 
• There seems to be demand, interest, as well as uptake, for naloxone kits for persons who are also interested in HIV/STI testing online. 

And so, integrating STI and harm reduction services can be one way to promote health for these populations.

credits[16:04] Credits

This podcast is brought to you by the National STD curriculum, the University of Washington STD Prevention Training Center, and is funded by the Centers for Disease Control and Prevention. Transcripts and references for this podcast series can be found on our website, the National STD curriculum at www.std.uw.edu. Thank you for listening and have a wonderful day.