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.