New research presented at
the National STD Prevention Conference underscores significant challenges
in reducing the toll of STDs. Among the most pressing challenges highlighted
at the conference are signs of emerging resistance to a common gonorrhea
treatment, and gaps in STD screening, counseling and care in some health
care settings. Addressing these and other challenges must be a priority
in order to make further progress in preventing and treating STDs.
Emerging Resistance to Gonorrhea Treatment
Cipro-Resistant
Gonorrhea Increasingly Common in the Western United States. Recent
increases in the proportion of gonorrhea cases resistant to the class
of fluoroquinolone antibiotics,
which include ciprofloxacin, ofloxacin, and levofloxacin, are raising
concerns that these antibiotics may eventually lose their effectiveness
as a front-line treatment for the disease. Cipro-resistant gonorrhea – which
is resistant to all fluoroquinolone antibiotics – already constitutes
a substantial proportion of total gonorrhea cases in Hawaii and Southeast
Asia. Examining non-Hawaii data from CDC’s Gonococcal Isolate Surveillance
Project (GISP), CDC’s Susan Conner and Susan Wang, M.D., identified
41 Cipro-resistant cases from 1991 through 2000 in the United States.
The proportion of gonorrhea cases that were Cipro-resistant – while
still small – doubled from 0.1 to 0.2 percent between 1998 and 1999
and remained constant in 2000. Nearly two-thirds of the cases were
concentrated in four areas on the West Coast: Seattle (10 cases),
Orange County, Ca. (7), San Francisco (5), and San Diego (5). Among
22 patients who were asked about their travel histories, half had
either traveled recently in a foreign country or had a sexual partner
with recent foreign exposure. The emergence of resistant strains
on the West Coast may result from contracting gonorrhea while traveling
in the Pacific region. Abstract
69, "Characteristics
of Patients Infected with Ciprofloxacin-Resistant Neisseria gonorrhoeae
in the Continental United States, 1994-2000," Poster,
Monday, March 4, 7:00 p.m.
Gaps in STD Screening, Counseling, and Care
STDs Not Addressed in Many Doctor Visits. More than one
in four primary care clinicians surveyed at two large managed care
organizations said
they lacked the time to discuss or address STDs during patient visits,
according to data compiled by CDC’s Kathleen Irwin, M.D., and colleagues
at those managed care organizations. Of 743 clinicians surveyed,
28 percent said that finding time for STD care and counseling was "problematic" or "highly
problematic." While researchers were encouraged that a significant
proportion of surveyed clinicians did not identify time constraints
as a barrier to STD care, the survey findings underscore the need
to address this issue in order to expand STD services to all patients.
Clinicians at the two managed care organizations in Colorado and
Minnesota also identified several other challenges to STD prevention
in their organizations, including: limited time and staff to assess
STD risk behavior; limited staff to counsel patients on risk behavior;
limited staff to provide notification and testing for patients’ partners;
and lack of policies on the notification and treatment of partners.
The survey also revealed that clinicians with the most STD-related
experience were less likely to view these and other STD care and
counseling issues as problematic. Abstract
240, "Leading Barriers to STD Care in Two Managed Care Organizations:
Final Results of a Survey of Primary Care Clinicians," Poster, Monday,
March 4, 7:00 p.m.
STD Services
Inadequate Under Many Managed Care Plans. CDC’s
Kathleen Irwin, M.D., presented a review of studies to date on the
extent of STD services offered
by clinicians affiliated with managed care organizations. The analysis
of commercial and Medicaid managed care plans reviewed in six studies
identified four areas of STD prevention services most in need of
improvement: STD screening of asymptomatic, at-risk patients; assessments
of sexual risk behavior; counseling to reduce risk behavior; and
services for partners of people with STDs. For example, one study
of clinicians affiliated with several hundred commercial managed
care plans found that half of 7,924 pregnant women continuously covered
for prenatal care did not receive syphilis tests during pregnancy.
Routine prenatal syphilis screening is recommended for all pregnant
women to prevent perinatal transmission. A separate study found that
only three of 20 managed care organizations recommended that adolescents
receive screening for chlamydia, a preventive service that is recommended
by CDC and numerous national clinical organizations.Abstract 241, "Utilization
and Quality of STD Services in Managed Care Organizations: A Synthesis
of Recent Research," Oral Presentation, Thursday, March
7, 8:00 a.m.
Public Sector
Family Planning Clinics do a Better Job at Chlamydia testing in Young
Women. The California Department of
Health Services found that public family planning providers test
a much higher percentage of young women for chlamydia than their
colleagues in the private sector. The authors examined claims data
for 522,847 15- to 26- year old women over a one-year period in 1999
and 2000. Fully 68.4 percent of young women who went to Family PACT
(Planning Access Care Treatment) public family planning clinics were
tested, as compared to 53.2 percent of the women who sought services
in the private sector. The analysis also revealed that public providers
were much more likely to use amplified nucleic acid tests, which
are much more sensitive than other testing methods. Seventy-three
percent of tests ordered by the public clinics were of this type,
as opposed to only 37 percent of those ordered by private providers.
According to CDC recommendations, all women under age 25 should be
screened annually for chlamydia, which is the most commonly reported
infectious disease in the United States, and is the leading cause
of preventable infertility.Abstract 435, "Chlamydia
Screening and Test Type Utilization in California Publicly Funded
Family Planning Services," Oral Presentation, Wednesday,
March 6, 10:00 AM.
5
March 2002 
