Treating STDs During COVID-19

[00:03] Introduction
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 STD [sexually transmitted disease] literature review for health care professionals who are interested in remaining up-to-date on the diagnosis, management, and prevention of STDs.

 [00:23] Background
I’d like to focus this podcast on manuscripts recently published on how to assess and treat STDs during the COVID-19 pandemic. This has been a challenging situation for patients, public health, and health care facilities with trying to balance patient care and safety, as the COVID-19 pandemic has changed how health care is delivered in the U.S. and likely around the world. With regards to the need for STD testing, while there are guidelines for social distancing, and I think for the most part people are distancing more than they normally would, we can’t assume as health care providers that people are not having sex with new partners during this time. A few cities, such as D.C., New York City, and Seattle—those sexual health clinics have already introduced recommendations on how to have safer sex during the COVID-19 pandemic. And, we as providers really need to find a way to preserve access to STD services during this time.

 [01:18] Paper #1

There are limited articles on this topic, but one that just came out by Dr. Travis Sanchez and colleagues in AIDS and Behaviorin April is titled “Characterizing the impact of COVID-19 on men who have sex with men across the United States in April, 2020.” So, interesting features of this study:

1. It was a rapid online survey done over about 10 days from April 2-13, 2020, at the height of the pandemic in the U.S., and it relates the impacts of COVID-19 on sexual health of 1,051 men who sex with men in the U.S.
2. The median age was 35 years; of those who completed the online survey, 70% were White, 9% were Black, and 14% were Hispanic or Latino. Most of them had health insurance.
3. What they found was that while 51% of participants reported a decrease in the number of sex partners, 48% reported no change, and 1% actually reported an increase in the number of sex partners during this time. 
4. They also found that 15% of participants reported an increase in the use of dating and hook-up apps.
5. While 92% reported no change in the use of condoms, 5% of participants reported using less condoms.
6. And 25% of participants said that they had a decreased access to STD testing or treatment, and 18% reported decreased access to HIV testing during this time. 

While this article represents a select group of individuals, it shows that a proportion of patients, at least for the ones who were surveyed, may not be adhering to strict social distancing with regards to new sexual partners. I say the word “may” because the authors and survey did not go into detail what “no change” in the number of sex partners was, and they did not ask participants to quantify the number of sex partners. Therefore, the 48% of MSM (men who have sex with men) that reported no change in sex partners during the COVID-19 pandemic could actually mean that they were only having sex with the person in their household, or very few or no partners. However, 1% of individuals reported an increase in the number of sex partners—and that’s actually what I’m seeing in my clinic as well when I ask patients about their sexual history—and 5% reported using fewer condoms, suggesting that we, as providers, need to continue services targeting PrEP (preexposure HIV prophylaxis) as well as STD treatment during the COVID-19 pandemic. 

 [03:49] Paper #2

The second article I’d like to discuss is “‘Sex in the time of COVID’”: Clinical guidelines for sexually transmitted disease management in the era of social distancing.” This was published by Dr. Lindley Barbee and colleagues in Sexually Transmitted Diseases in July 2020. The recommendations are as follows:

1. One of the recommendations is deferring asymptomatic STD screening visits for a few months while COVID-19 cases remain high in that particular area. 
2. They also recommend treating contacts to STDs and persons with a positive STD result with oral medications. For example:
   1. Contact to syphilis and early latent syphilis (in those who are not pregnant or have neuro symptoms): they can be treated with doxycycline 100 mg twice daily for 14 days; for late latent syphilis, patients can be treated with doxycycline for 28 days.
   2. Those patients who have contact to or [have] nonpharyngeal gonorrhea, they can be treated with a single dose each of cefixime 800 mg and azithromycin 1 gram.
   3. For those patients who are diagnosed with pharyngeal gonorrhea, the recommendations are to treat with cefixime 800 mg twice a day for 2 doses [every 12 hours x 2] along with a single dose of azithromycin 2 grams, so a higher dose of azithromycin.
   4. For those patients who are a contact to or have nonrectal chlamydia, they can be treated either with 1 gram of azithromycin in a single dose, or doxycycline 100 mg twice a day for 7 days.
   5. And for those patients diagnosed with rectal chlamydia, they can be treated with doxycycline 100 mg twice a day for 7 days.
3. Patients with symptoms can be triaged over the phone (for example, using telemedicine or telehealth visits) to see if they really need to come in to clinic for a visit, or they could be treated based on syndromic management of STDs.
4. It’s important to continue to provide in-person clinical care for selected patients—for example, patients with symptoms of an STD, those who are a contact to an STD, those who have any acute HIV symptoms, those with complicated syphilis, or (for example) syphilis in pregnancy.

What this article offers are ideas for STD care in the setting of decreasing in-person clinic visits, if needed, with the caveat that these recommendations do not meet current standards of care, but what they do is provide guidance when clinic visits are just not possible. The operations can be adapted according to how local health care facilities are able to operate in the area, and for your patient population and clinic. 

 [06:30] Paper #3

The third article to discuss is titled “Considerations for STI clinics during the COVID-19 pandemic,” by Siena Napoleon and colleagues that was published in Sexually Transmitted Diseases in July 2020. So, this article includes:

1. General recommendations for health care facilities in the setting of COVID-19. For example, facemask wearing and screening all patients and health care staff for COVID-19 symptoms.
2. The article recommends limiting walk-in appointments and hours of operation, and then prioritizing in-person care for symptomatic patients. 
3. The article talks about using telemedicine and telephone visits to extend PrEP prescriptions for select patients, which is something that we incorporated into our sexual health clinic here in Seattle.
4. And they also talked about optimizing expedited partner therapy per the CDC recommendations.

The recommendations highlighted in this article help to provide patients with continued access to health care services for STDs, and protect both patients and staff during this global pandemic.

[07:37] Summary
STD programs exist in different capacities around the U.S., such as state health departments, private clinics, academic health centers, and there are challenges to providing STD care during the pandemic. On April 6, 2020, the CDC provided guidance for STD programs and clinics to provide effective STD care and prevention during the COVID-19 pandemic, which I encourage you to read, especially with the current medication shortages [CDC]. This CDC guidance also includes recommendations for alternative oral treatment options when only oral medications are available. Given the high number of COVID-19 cases in the U.S., these CDC recommendations are highly relevant for many counties—both to improve patient and staff safety, but also provide adequate STD care and treatment during this challenging time. 

To conclude, here are some key points from this session.

1. People are still having sex during the COVID-19 pandemic and preserving access to STD services is important during this time. 
2. There are recommendations for prioritizing clinic visits for patients with symptoms and complicated disease.
3. Alternative oral options can be an option when only oral medications are available to help treat STDs during this time.
4. Clear counseling should be given at the time of treatment if an oral option is given; and close follow up will be important once in-person clinical care is resumed.

 [09:00] Credits
This podcast is brought to you by the National STD Curriculum, the University of Washington STD Prevention Training Center, and is funded by a grant from 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.

Additional References
Centers for Disease Control and Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Division of STD Prevention. Guidance and resources during disruption of STD clinical services. Atlanta, GA: CDC, September 8, 2020. [CDC]

Bachmann LH, Thorpe P, Bolan H, Mermin J. (Centers for Disease Control and Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention). An open letter to colleagues (guidance to STD prevention programs including STD clinics, United States). April 6, 2020. [CDC]