- [Elizabeth] Good afternoon everyone.
My name is Elizabeth Olson.
I'm with the California
Prevention Training Center.
Can you all please raise
your hands if you can hear me
or put a little note in the chat box.
Okay.
Great.
Well, welcome everyone.
Welcome to our STD Expert
Hour Webinar Series.
Today, we are going to be speaking
about delivering sexual health services
in the time of COVID-19.
We have our two faculty members here today
that you can see here
on the camera with us.
First I'd like to introduce Dr. Ina Park.
Dr. Park is the Medical Director
for the California
Prevention Training Center.
She's an Associate Professor
in the Department of Family
and Community Medicine at UCSF,
as well as a consultant
for the Centers for Disease
Control and Prevention
in the division of STD Prevention.
She also cares for patients
at the San Francisco City Clinic.
Dr. Park was a coauthor
of the upcoming 2020 CDC
STD Treatment Guidelines.
And she's also the author
of a forthcoming book
on the hidden role of STDs
in our lives and society.
It's titled "Strange Bedfellows:
Adventures in the Science, History,
and Surprising Secrets of STDs."
It's gonna be published by
Macmillan in February of 2021.
We also have with us today,
Dr. Rosalyn Plotzker.
She is also Clinical Faculty
at the California
Prevention Training Center.
She's an Assistant Professor
in the Department of Epidemiology
and Biostatistics at UCSF.
She is also a Public
Health Medical Officer
at the California
Department of Public Health
and STD Controls.
So, we wanna go over a few
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over the California
Prevention Training Center
in case you are new with us today.
We are a national training center
that delivers innovative training
and capacity building assistance
to both public and private
healthcare providers.
We are funded by the CDC to
provide collaborative services
for a wide spectrum of
medical health promotion,
and community professionals
who are serving people
and communities impacted
by HIV and STD.
Next slide please.
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of Prevention Training Centers.
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prevention training centers
throughout the country
doing similar work as we do.
Our service area includes
California, Nevada, New Mexico,
Arizona, and Hawaii.
For the CME today,
the CME is approved for one credit
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And so with that,
I'm going to hand it over to
Dr. Park and Dr. Plotzker.
And they're going to
turn off their webcams,
so you guys get a bigger screen,
but we wanted to make sure
they're able to wave hello to you.
Thank you all for joining us today.
- Thank you, Elizabeth.
Hello and goodbye.
We're gonna turn off our cameras
and then let me advance the slides.
And yes you are hopefully
you're at the right webinar,
"Delivering Sexual Health
Services in the Time of COVID-19."
And again, we have nothing to disclose.
And so we're gonna start with a brief poll
and Elizabeth, hopefully
will launch the poll.
And the question is,
how has your clinic
delivering services right now,
number one, are you doing
most clinical encounters
in person?
Number two, are you doing
sort of half and half
telehealth in-person services?
Number three, would you say you're doing
most of your clinical
encounters over telemedicine?
Or number four, are you
guys completely shut down
and not actually offering services?
Or number five, maybe
it's not applicable to you
because you don't work
in a clinical setting?
- Okay.
It looks like it's about
half and half of telehealth
and in-person services
with the remainder about 25% in-person
and 20% telemedicine.
- Okay.
That's really interesting
because I've now given this talk,
this is the third time in
different forms or another,
and we certainly have
seen an evolution of folks
who are offering at least
some of their services
via telehealth.
That makes a lot of sense,
given what's going on.
And let me advance.
So, I'm gonna start off
by just pointing you out
to a resource,
since we are talking
about delivering sexual health services
and that certainly does include treatment
for sexually transmitted infections.
Just so you know, the CDC
did issue interim guidelines
for how to treat people based on syndrome.
So, penile discharge, vaginal discharge,
someone presenting with a genital ulcer,
in case you may not have opportunity
to do a full workup in diagnostic
workup and physical exam,
there are some guidelines
for treating presumptively,
and we're gonna talk a little bit more
about what that means.
And there is a link on the slide
and you're gonna be receiving
that of course as well
when you receive the
slide deck after this.
Roz.
- Yeah.
So, this is also a sample template.
And basically this is
just kind of to outline
who is a good candidate to
be seen by telemedicine,
who needs to be seen in
person and how urgently,
and also what can be postponed
or just taken care of
with a quick phone call.
So, just to walk you
through this a little bit.
Things that can be postponed
are basically your routine care,
meaning routine STI screening, pap smears.
A lot of colposcopy can also be deferred
as well as second and third
doses for HPV vaccine.
So, all of those can be postponed for now.
For birth control methods,
those can be refilled just
with a simple phone call.
So, that is a pretty
easy one to take care of.
In terms of telemedicine,
the types of things
that you can handle via telemedicine,
either over the phone or with video
would include contraceptive counseling
as well as counseling for DMPA-SQ
which includes instructions for patients
who are opting to do the
self-injection for that.
We'll talk about this in depth,
but syndromic treatment
of STIs and for UTIs
is also something that's
reasonable to do over the phone.
And you can also do PEP and
PrEP intake over the phone.
The labs, you still need to do in person,
but the intake itself you
can do via telemedicine.
In terms of the in-person
things that are in orange,
the ones that are less acute
and can just be scheduled as available
are patients who would
either need their IUD
or implant either placed or removed
as well as DMPA intramuscular injections.
And so those are typically
done either at the clinic
or via curbside.
However, those are less urgent,
and so those can be done just
as a scheduled appointment,
as they are available.
The things that are the most acute
and should really have
the patient seen in a day
are things that are symptomatic,
including rectal pain or bleeding
and periods and discharge that is rectal.
And then vaginally, if you
have non-menstrual bleeding
or pain,
which could be either PID
or an IUD complication,
those also need to be seen the same day.
And then finally, sexual
assault is something
that needs to be evaluated immediately.
So, those patients should all
be seen right away in-person.
- And Roz, one thing I wanted to add
was that we're gonna talk a
little bit about how people
have done some work
around the in-person labs
for PrEP intakes a little bit
later on in the presentation.
- Yep. Okay.
- Let me advance the slides.
- So, Ina, I mentioned
syndromic treatment.
How would you define syndromic
treatment and explain it?
- So, syndromic management is something
I think many of us are
not comfortable with
because we like to know
what we're treating,
but this would be treating
based on the best guess
of what you think the patient has
and without the use of laboratory tests.
And this certainly happens quite a bit
in the developing world.
And of course that happens for us as well
when we have patients who walk in
who clearly need something that day,
and we don't know exactly what they have.
And this approach works pretty well
for penile-urethral
chlamydia and gonorrhea.
It works okay for BV,
especially if you also have the assistance
of pH paper to help.
It can work for candida vaginitis
if the patient has classic symptoms
and a classic-appearing discharge.
For genital herpes, it's
really plus or minus.
Some studies have shown
actually pretty good concordance
with laboratory diagnosis
and then others have
shown that it's terrible.
So, it's really hard to say,
but I can tell you what's not great.
When someone comes in
with vaginal discharge,
the predictive value of sort of being able
to diagnose gonorrhea and
chlamydia is pretty poor.
And the issue is that, as you know,
when someone comes in with
nonspecific discharge,
it could be any number of things,
and so there's many
false positives possible,
and you can overtreat folks
and you can get the diagnosis wrong.
But we are dealing with
this to a certain extent
in the time of COVID-19.
And so, Roz, I mentioned
about vaginal discharge
being challenging.
And so how are people evaluating folks
with vaginal discharge remotely?
And is that even possible?
- Yeah, no, it's definitely possible.
And a lot of it, like you said,
is similar to what we would do in clinic
that we can do over the phone
with the exception
that we can't actually
evaluate it ourselves.
But we can talk to
patients and try and gauge
based on the characteristics
of the discharge,
what might be going on.
So, for patients who have had BV
or have had yeast infections in the past
and they get them every couple months
and they recognize them,
then one of the things that
you can do over the phone
is just talk with them about the symptoms
and they can tell you,
"This feels a lot like when
I had a yeast infection
a couple months ago,"
or, "I get BV every now and then."
And I think that given this
setting and this situation,
it's reasonable to do treatment
based on a recurrence of BV
or a recurrence of vaginal candidiasis,
if it's recognized by the patient.
That said, for a patient
who has a new problem,
they have some vaginal discharge
that they don't recognize
or don't associate with
a previous experience,
that you would need to have
a more thorough history
and then figure out
which empiric treatment
would be appropriate.
So, and you'll see this
in a chart coming up,
but basically if you have a patient
who has malodorous discharge,
and that is suggestive of
either BV or trichomoniasis,
then you can treat that with metronidazole
and that's 500 milligrams BID for a week,
and that will treat either
BV or trichomoniasis.
And if you have somebody
who is describing something
that's more irritated and itching,
and the discharge is white,
typical of a yeast infection,
that you could treat
with either fluconazole
150 milligrams PO,
or you can do the three-day
topical antifungal treatment.
And that would be just
treating for a yeast infection.
In terms of sampling,
you know this,
obviously if we're doing
this over the phone,
we're not able to do pelvic exams,
so we can't really appreciate
the the odor ourselves
and we can't do wet mounts right there.
However, some clinics are
using a curbside strategy
for doing pick-up and drop-off
for vaginal discharge.
And so they basically have these kits.
And what the kit contains
is a stopper plastic
or glass tube.
And that has about a cc
of fresh saline in it
and then it also contains a sterile swab
that's a cotton swab.
And so these patients can pick up the kit
and then they can go do a home swab
where they basically
self-swab the vaginal walls
and then put the swab into the tube
and then cap tube and bring
it back to the clinic.
And they wanna bring it
back as soon as possible,
so that it's a fresh sample.
And then it could be
evaluated with a microscopy
by the clinicians in clinic,
if they have access to that.
So, that is one option.
And then you could find out
if there are clue cells,
if there's yeast,
if you see trich,
and that can help have a
more specific diagnosis.
And this can also be used
if you want somebody to do
a self-swab for GC/CT NAAT.
And that would, of course
require that the patient
use the appropriate
specimen collection kit,
but that's also an option.
Next slide.
- Yeah, and can I just mention
something really quick?
- Oh, yeah, of course.
- The last time we gave this talk,
I don't know,
folks have asked about,
well, what if the patient drove up
or someone drove them
and they just collect in their car
and then immediately give it back?
And I said, absolutely, I
think that would be fine.
- Yeah.
Or if they don't wanna do it in their car,
but there's a restroom nearby,
they can go do it there.
That's fine too.
- Yeah.
- And so this is probably
gonna remind a lot of you
of when you were in training
where we have all these
different vaginitis findings
and then the quality of the discharge.
So, for candida there is itching,
sometimes there's burning,
A is itching, B is burning.
Usually neither odorous
nor frothy, usually white.
So, that's a typical yeast infection.
Trichomoniasis, you would have itching,
usually not burning.
And then you would have odor
and you would have sort of frothy quality
and it can be yellow, sometimes white.
So, not as specific.
For BV, usually the patient
does not report itching
or burning,
but they do have that characteristic odor
and it's frothy
and can be considered kind of
looking like homogenized milk
or white.
Discriminative inflammatory vaginitis,
which is rarer finding it,
or is a rarer condition,
can be uncomfortable.
It can be itching and burning.
Usually neither malodorous nor frothy.
And what you'll see is profuse discharge,
that's either green or white.
And then, physiologic, normal discharge,
not itchy, not burning
and is usually just
white normal discharge.
So, stepping away from yeast and BV,
should clients, Ina, be treated for GC/CT,
if there's vaginal discharge?
And then also what about penile discharge?
- Yeah.
So, Roz, there was a lot of
discussion at CDC about this,
about whether or not empiric treatment
for GC/CT should be recommended.
And right now because just discharge,
even if the characteristics
of the discharge,
predicting GC/CT is very hard.
So, the guidelines do not
recommend empiric treatment
for GC/CT when patients
have vaginal discharge.
And so, again, as you mentioned before,
tests for GC/CT before treatment,
and then of course the exception
would be the patient has a known contact,
then you'd be treating empirically anyway.
But when we get to penile discharge,
the CDC guidelines do
recommend empiric treatment.
And of course we know
that penile discharge
could be gonorrhea chlamydia,
could just be NGU mycoplasma.
It could be a lot of things.
And what they recommend right now
is if you're able to do
an in-person evaluation,
use your standard ceftriaxone.
And then they actually
recommend using doxycycline
twice a day for seven days
in case chlamydia is there
because the efficacy against chlamydia
is a little bit better with doxy.
There's been several studies
since the last treatment
guidelines that have shown that.
Also, if you can't see a person
for IM treatment in person,
then the recommendation
is to actually treat
with cefixime 800 milligrams.
People on this webinar are gonna notice
that's twice as much as
it's normally recommended
for PO medication.
Just so folks know,
there's a tendency towards
using more cephalosporins
for presumptive GC treatment,
you'll see probably some changes
in the forthcoming treatment guidelines.
And so in the interim, they
doubled the cefixime dose
and also added doxy to cover chlamydia.
And so, we mentioned that
folks with vaginal discharge
might be able to be presumptively treated
for some things
and tested then for
gonorrhea and chlamydia.
But what if a client is having
pelvic pain or dyspareunia,
is that something that you
think can ever be evaluated
via telemedicine?
- So, like I mentioned in the first table
that we talked about,
or I guess technically the second table
where, who needs to be seen in person,
if somebody has pain,
that patient could have PID.
And so for this, you do need
to evaluate them in person.
So, you would need to refer
them to have a pelvic exam
and be seen in person.
And we do not recommend
treating that empirically.
And so, yeah,
I think that's the one
situation of vaginal discharge
that you absolutely need a pelvic exam.
- Yup.
And I think as I'm attending
this telemedicine learning series
from the Department of
Health and Human Services,
and they universally agreed
that any abdominal pain pretty much
just needs to be seen in person,
whether it's in a male, female,
or regardless of gender.
- Yeah.
Okay.
So, stepping away from
discharge for a minute, (laughs)
how can a client with
vulvar irritation or a rash
be evaluated remotely?
- Okay.
So, we have some good options here.
When you have folks who obviously
have a history of
recurrent genital herpes,
those are folks treated empirically,
and we often just do
refills over the phone
or call in refills for
aciclovir or valaciclovir.
For rashes, there's a lot
of precedent with this,
with teledermatology.
And we would recommend,
or what is recommended, I guess,
is submitting a cell phone photograph
of the genital skin rash.
There is a billing code here.
It can be covered as a virtual check-in.
The billing code is provided here.
And essentially that covers
the remote evaluation
of either video from the patient or images
including interpretation
within 24 business hours.
So, there is precedent for this.
Teledermatology has been going
on for quite a long time.
And so, that is continuing
and even more so during the pandemic.
And just so you know,
in terms of what protections are in place
for folks who are practicing this way,
HHS Office of Civil Rights
issued a statement back in March,
which is still true.
I went back and made sure
that they haven't updated this,
that a lot of people in
the beginning, especially,
were using these non-HIPPA
compliant platforms
and that HHS said that they
would not impose penalties
for HIPAA violations.
If folks are trying to in good faith,
giving provision of telehealth
services during this time.
And so, folks have basically
delivered telehealth
via Apple FaceTime, Google
Hangouts, Zoom and WhatsApp,
which is obviously
allowing for live chatting.
And then of course, like texting pictures
to provider's business
phones or personal phones
that has happened.
What is not acceptable
would be doing any sort
of patient interaction
on a public facing platform.
And so, if you want to
read the HHS regulations
on telehealth,
there's an FAQ page,
which is linked there.
Okay.
So, staying on the topic
of teledermatology,
what about if clients have
genital or anal ulcers, Roz?
- So, like you mentioned,
recurrent genital herpes,
you can treat empirically.
So, we would call in a refill
and you can talk with
the patient on the phone
and just confirm this is in the same place
where they usually get herpes,
this feels exactly the way
it feels when you get herpes.
So, for patients who
have recurrent herpes,
you can treat that.
Oh, can you go back?
- Yes, I'm sorry.
- That's okay
For a new ulcer,
that in-person exam is best,
but if that's not possible,
then the main thing that
you wanna think about is
if the ulcer is painful or not.
And that's because a painful ulcer
versus a non-painful ulcer
is one of the key things that can help you
differentiate herpes
from a syphilitic ulcer.
If you have a photograph of the ulcer,
then it's always helpful to see it.
But in terms of pain,
patients presenting with painful ulcers
especially ones where there's multiple
and especially if they're bilaterally,
then those are more likely
to be genital herpes.
Meanwhile, ulcers that are painless,
and especially if there's just one,
although sometimes syphilis can present
with more than one primary ulcer,
but if there's a single painless ulcer,
that is more likely to be
a primary syphilis chancre.
Next slide.
So, if you do think it's syphilis,
then you wanna arrange to have
a serologic test for syphilis
to monitor the treatment response.
So, that would be your non-Trep test,
which would be the RPR.
And that's the titer that you use
to see how the person
responds to treatment.
So, that would be your baseline titer.
For primary syphilis, if
the patient is not able
to get the benzathine
penicillin IM injection,
which is the first line of treatment,
then the alternative would be
to give them doxycycline
100 milligrams twice a day
for two weeks.
The exception to that is of
course, pregnant patients.
And so, if you have a pregnant patient
who has suspected syphilis,
then they absolutely
need to have IM therapy.
Even if they have a
reported penicillin allergy,
penicillin is really the only treatment
and they would need to be desensitized
if there was an allergy.
So, that's the exception.
But doxycycline is an option
for non-pregnant patients
who have syphilis.
- And Roz, would you agree
that if you strongly suspect syphilis
based on like a really classic appearance,
just go ahead and treat empirically
before their serology is back?
- Yeah, absolutely.
I think that probably a safe way to go
would be to bring them in
and when they have their
treatment, also draw their blood.
And that way you have a
day of treatment titer,
which is ideal in terms of
looking at treatment response.
One of the tricky things people fall into
is that they have the blood drawn
and then the patient
isn't able to get treated
for another couple of weeks.
And so, you don't really
know what their titer was
on the day of treatment
and that complicates interpreting decline.
And also if you do have them come in
and you're able to doing a
thorough neurologic examination,
is always recommended
for people with syphilis.
- And even if you get that
titer when they first come in,
if they had a genital ulcer,
it still might be negative
because 20 to 30% of the time
in primary syphilis the
RPR might be negative,
but you still might've been
right with the diagnosis.
- Yup.
Okay.
So, how should providers
manage rectal symptoms?
I think we might be
coming back to discharge.
So, we might be coming back to discharge
and I'm thinking about rectally,
especially if you're
thinking about GC and CT.
- Yeah, so, rectal symptoms,
obviously ideally an in-person exam
and testing for gonorrhea and chlamydia
if you're suspecting proctitis, is ideal.
But one thing to mention
is we know SARS-CoV-2
can be found in the stool.
And so, it is also reasonable
to do presumptive treatment for proctitis
and have the patient actually
self-collect a swab for GC/CT.
And I also included a link on this slide,
which you guys will also get
that has eight and a half by 11
self-collection posters
that are translated into
Spanish and English.
So, if you need to put
those up in your clinic,
because you want patients to self-collect,
But at any rate, you guys
are gonna recognize these,
the empiric treatment for something
like proctitis-like syndrome
would be to treat again with
cefixime 800 milligrams.
So, double the dose
that's usually recommended
plus doxycycline 100
milligrams for seven days.
Then again, that'll cover GC
and will also cover
chlamydia if it's present.
And then of course, if
the patient is pregnant
or doxycycline is not available,
then you can also use
azithromycin as your second drug.
- And what about the throat
since we're talking about
extra-genital infections?
- Yeah, so, most of the time sore throats
are not gonorrhea and chlamydia,
but some other considerations
is that we also know pharyngeal sampling
can cause patients to gag and cough.
And so again, the self-collection
would be recommended
and would minimize risk to the clinician.
So, here's another link
for bilingual self-collection posters
that you might be able to use.
And so, you could do empiric treatment,
but symptomatic pharyngitis
is so much more likely
to be caused by non-sexually
transmitted bacteria
and viruses.
It can also be a symptom of SARS-CoV-2.
And so, just a sore
throat is not something
that we would typically
just treat empirically.
Of course, if the person's a contact,
that's another story.
Okay, Roz, we've been talking
about this quite a bit,
you and I.
Simply such a thing as safer sex
when it comes to
transmission of SARS-CoV-2
and what advice could we
possibly give to patients
around this?
- Yes, this is the thing
that I get asked about a lot.
And the thing is that
I wanna preface everything I'm saying
with the statement that
sex is physically a...
If you are having sex with another person
and they are with you in the room,
that sex is usually
a very, very physically intimate activity.
And so, the likelihood of you
being within six feet of each other
and exchanging respiratory droplets
is probably gonna be
pretty high regardless.
So, I think that one of
the things to keep in mind,
and I'll talk about this in
this list of safer sex tips,
is just that some people try wearing masks
or try wearing...
I'm not gonna advise putting
a dawning and doffing station
in the corner of your bedroom.
Like, I think that you
just have to keep in mind
the fact that the people
who you have sex with you
are most likely going to be
transmitting droplets with
and that there is not
a lot of good research
about the efficacy of using masks
or adjusting your sexual position
so that you're not facing each other,
even though those things
have been recommended.
There is not a lot of
scientific evidence about that.
So, it's something that
some people are trying.
But all that said, obviously
masturbation using sex toys,
you cannot get SARS-CoV-2
if you are alone.
And the same with video or
sexting, virtual sex, same thing.
One thing that some
people have been doing,
which is a,
I think is a reasonable approach,
is to have selective kissing
or selective sex partners.
So, basically having a
specific group of people
or a specific individual
who is your sex partner
or are your sex partners
and having very, very clear
communication about that
and about what their
risks are for SARS-CoV-2,
what your risks are for SARS-CoV-2,
and figuring out who
your close contacts are.
So, that's the basic stuff.
In terms of barrier methods,
like Ina said,
or Ina, like you said,
the main concern is
about oral anal contact.
And that's because there have been studies
that have found SARS-CoV-2 in stool.
So, ideally you would
avoid oral anal contact,
or you would use a barrier method
if you are doing oral anal sex,
and you would use the barrier method
to minimize the exposure
and risk of transmission.
And then also, washing your
hands before and after sex
is a good practice.
So, and also, I just wanna say the sex
in the time of COVID-19,
this is something that came
from Oregon's End HIV Group
and it's based on some guidelines
that have been put out by New York City.
So, you'll find things like
this floating around online,
coming from different places.
One place is Canada.
Next slide.
So, this is a statement that came out
from the Canadian CDC
which has been getting a lot
of attention in the media.
And it mentioned glory holes.
So, using barriers like walls
that would allow for sexual contact,
but prevent close face-to-face contact.
So, this has been around
social media a lot.
And so I thought it was worth mentioning.
I don't think you need
to do major construction
on your house
in order to like comply with this,
but that was something that got mentioned,
and so I thought it was worth bringing up.
- Yeah.
It's certainly happening
based on my conversations
with patients
that glory holes are coming back public,
sort of glory holes are
coming back up again,
and it would be hard
to contract SARS-CoV-2
from behind a barrier with
just a hole and penis.
- Yep.
- And so, why don't you
share a little bit, Roz,
the data that we do have
about sexual transmission
of SARS-CoV-2,
and where the virus is actually found
in terms of vaginal and semen.
- Yeah.
Yeah, definitely.
And when we think about
sexually transmitted diseases,
we typically think of pathogens,
meaning viruses, bacteria, parasites,
that are found in sexual fluids.
And so, SARS-CoV-2 has
been detected in semen.
However, it was semen of men
who had an acute infection,
meaning recent,
and that they were recovering.
So, that's where they
have found SARS-CoV-2.
So, if it's somebody who is asymptomatic
and unknown
and if they had a negative COVID-19 test,
but then coincidentally,
they found it in semen,
that hasn't been found.
In terms of if it can be transmitted,
if there's a cis man who
has SARS-CoV-2 in the semen
and then has condomless sex with someone,
it's not really known
if the virus can then be
transmitted sexually in that way.
So, respiratory droplets and saliva
are exchanged during sex,
and that is more likely
to transmit the virus
independently of semen.
And then in smaller studies,
and these are studies
that were done in China
amongst this women who
had severe COVID-19,
they sampled vaginal fluid
and they did not find SARS-CoV-2
to in the vaginal fluid.
So, all right.
So, moving on, how can providers use EPT
or expedited partner therapy
for gonorrhea or chlamydia treatments?
- So, I think everybody,
I don't know if everybody
on this webinar's familiar
with expedited partner therapy
for gonorrhea and chlamydia.
It's also used,
at least in the state of California,
also allow for trichomoniasis.
But typically, EPT would be done
by writing a prescription
and the name of the partner
or doubling the dose of
the patient's medications
and then instructing the patient
to give a dose to their partner.
And I think really this
is a critical service
during this time,
to avoid the need for what clients
who might be being seen
in a face-to-face visit,
but are certainly partners,
a face-to-face visit could be avoided
by the provision of EPT.
But one thing around the
CDC's guidance around this
is that they only ever recommended EPT
for cis heterosexual men and women.
And in their interim guidelines,
they did not specify so specifically
who needs to use EPT.
And so I would just say that
as a harm reduction strategy,
I think it could be used for cis men
who have sex with men,
as well as transgender clients
to avoid a face-to-face
visit at this point.
Whether or not this is a
good strategy long-term,
is another question,
but during this time, I
think using EPT liberally
is probably a good idea.
The concern with MSM and
transgender folks is that,
might you be missing HIV
infection, et cetera,
but at least from an
STD's control standpoint,
EPT is a good idea.
So, let's shift gears a little bit,
and we're gonna give lots of examples here
about what people are doing
and when you consider delivering PrEP
via telemedicine, Roz.
- Yeah.
So yeah, there are many that...
We have four examples.
So, the good news is
that PrEP for telehealth
has actually already been
established in multiple states
prior to COVID-19.
So, a lot of things already existed,
which is great because we have models.
So, Please PrEP Me is one example.
And I'll show you that on the next slide,
but basically what happens
is you can do enrollment
and follow-up interviews
for asymptomatic patients over the phone
with a provider and a PrEP navigator.
And then the PrEP-related phlebotomy
obviously has to be done in person,
but that can be done at
a lab at a draw station,
or if the clinic is operating,
you can actually have
people come in specifically
for their blood draws.
Please PrEP Me is an online platform.
So, this is one way to,
you can go to the website,
but basically, it's a telemedicine service
that allows PrEP prescription
via telemedicine.
And these are a couple
telemedicine providers.
So, you have MISTR and
SISTR, Nurx, PlushCare.
And there's this,
I'm having a little trouble reading it
because it's kind of small on my screen,
but it's Virtual PrEP for
Adolescents and Young Adults.
So, these are just some
examples from pleaseprepme.org.
Yeah.
- Just an addition, Roz,
is that pleaseprepme.org
has sort of gathered all of the people
who are doing the work in this space
and on their landing page will show you
the sort of pros and cons
and different considerations
for each of these online providers.
So, they're kind of linking
folks to the online providers
of PrEP.
- Yeah. Yeah.
They're not doing the...
They're not the providers themselves.
Yeah, thank you for mentioning that point.
Then there's,
usually what would happen is
you would get your routine
gonorrhea and chlamydia screening
for asymptomatic patients
and that would either be done
at home with self-swabbing
or it would also happen at
the commercial lab stations.
The one caveat to that
is that whether or not
that lab does rectal
or pharyngeal testing,
is not consistent.
So, there are some labs
that do not do rectal pharyngeal test.
So, that's one component.
Some telePrEP providers
will mail the medication.
Others will fax the prescription
to a local pharmacy.
And then if there's a patient
who develops STI symptoms,
for this kind of patient who is on PrEP,
I would bring them in rather
than do syndromic surveillance.
And one of the reasons is
because then when they come in,
you can assess them some for
HIV signs and symptoms as well
and do an HIV test.
And so, that's a benefit
of having PrEP patients
specifically come in,
rather than do syndromic treatment.
Okay.
So, just to go through
a couple of examples,
this one is from St. Louis.
This is a mixed telehealth
in-person approach.
So, in this situation,
the patient who's interested in PrEP
would be proactive and call the clinic.
And then the PrEP counselor
talks with them over the phone
or the video.
They're usually either a
provider or a navigator.
And if they're eligible,
then the patient would come to clinic
and would come to them
clinic only for their labs.
And so they would get their HIV,
their Hep B, their creatinine,
they would get their serology there
and then they would
self-collect their STI.
Like Ina mentioned,
that decreases the risk
of the provider being exposed to COVID-19.
So, the patient isn't
accidentally coughing
or there's potential for rectal exposure.
So, then the provider would
complete the paperwork
for the pharmacy.
And then in terms of followup,
this is assuming that all
of the tests come back
and the patient is able to enroll.
Then the provider does the
paperwork for the pharmacy
and from there,
if there's no in-person
service available for followup,
then the patient can actually do oral HIV
instead of serology.
However, the STI testing
and the creatinine
does need to be done,
and that can be spaced
out every six months.
So, that's what they're
doing in St. Louis.
Next slide.
I think we're going South
to Louisiana, I think.
Yeah.
Okay.
So, Louisiana has a program
that is through Louisiana Health Hub.
This was developed before
COVID-19 to address rural patients
who don't have access to a PrEP provider.
And so what happens there
is that these patients are referred.
They're referred by the parish,
which is a county to the telePrEP program.
Then the PrEP counselor
does the counseling
via video or phone, just like St. Louis.
They also check insurance status.
Then the...
And this is all via lab.
So, there is no specific
clinic in this program.
So, they check the insurance status
and then the patient is
referred to a lab for serology
and urine.
There's a no three-site testing available.
Oh, excuse me.
Well, there's no extra-genital
screening available.
They do urine for GC/CT.
And then there are also some areas
where if a patient is in a rural area
and the lab is far away,
they do have an option for mobile labs
where the labs go to a
place that's in a rural area
and the patient can then go there.
So, that's one thing
that they've implemented,
which is pretty interesting.
Then when the lab results are back,
if they're okay,
then the program has an in-house pharmacy
and that mails the prescription out.
And then the followup
is a similar lab process
to what they did with initiation.
Okay.
And then finally, the last
example is in Baltimore.
And so, Baltimore had a
pretty interesting approach
where,
and this is just a
alternative for followup
that is pretty interesting,
so we wanted to mention it
where when a patient is due
for a PrEP followup visit,
you can use a telehealth visit
in which the provider orders the labs,
and then they have worked out
an arrangement with LabCorp
specific to their region with
their LabCorp representative,
where LabCorp will mail
STD kits to the patient.
And then what the patient does
is the patient does self-swabs,
and I think it includes urine as well.
So, the patient collects all
of the specimens themselves
and then drops off the
STD tests at the lab
where they get their phlebotomy done
and then get their HIV
test plus the creatinine,
if it's due.
And then when the labs are back,
then the PrEP prescription is sent
via electronic medical record.
So, that's another option for followup.
Next slide.
All right.
So, speaking of testing at home,
Ina, do you think that providers
can use these at-home test
kits for routine STIs?
- Certainly.
And there's lots of commercial brokers
who are offering this.
And so, some at-home STI screening kits,
oh, excuse me, I just read my own slide,
are sort of point-of-care
tests with immediate results
or self-sampling them with specimens
mailed to a commercial lab,
which is the more common way to do it.
And there, and I'm gonna show
you a sort of clearing health
for where all the different places
where consumers can get these,
but they're typically
marketed directly to consumers
and through online telehealth providers.
And there is a link at
the bottom of the slide,
which talks about all
the different options
and also has a little widget
built into this web page
where you can select your location,
as well as the patient's insurance status
to tell you what the different
home testing options will be.
And the types of tests
that we've seen offered
through home testing includes
HIV, gonorrhea, chlamydia,
syphilis, trichomoniasis,
for patients that have a vagina.
And one thing I wanted to mention
is that particularly in the case of HIV,
which is for home testing typically done
through dried blood spot,
when it's mailed back to a lab,
dried blood spot testing is excellent
in terms of its
sensitivity and specificity
compared to lab-based testing.
The oral HIV test,
which is sometimes also used
in these home testing kits
is not quite as sensitive
as dried blood spot
or lab-based testing.
But at least from the HIV standpoint,
the dry blood spot testing is excellent.
Syphilis dry blood spot testing
is probably a little too sensitive.
You're probably gonna get
some false positives there.
And there's one laboratory
which is offering RPR testing as well,
which a patient collects blood
inside a little microtainer
and then is separated
and the serum is tested
at their laboratory.
That's offered through some
of the telehealth providers
including Nurx and Building
Healthy Online Communities.
And then of course,
some companies offer
throat and rectal swabs
for gonorrhea and chlamydia
and some folks have also
thrown in hepatitis C.
So, I just wanted to direct everybody
because I think this PD is quite useful.
Kaiser Family Foundation put out
this telemedicine in sexual
reproductive health synopsis.
And page again that
widget that has a finder
for online providers of
sexual health services,
depending on what you're interested in,
what the patient's insurance status is.
So, I recommend that
everybody go to this page
and check it out.
I think it's quite useful.
- Yeah.
And then speaking of paying,
do insurance companies
pay for at-home testing
or at-home screening test kits?
- So, the short answer
is most of the time not.
If you're giving obviously patients kits,
and in the case of the
Baltimore Maryland Clinic,
for example,
where LabCorp actually mailed kits
to the house of the patient,
returns it to the actual,
they're getting their care
still through the actual clinic,
it should be covered,
but these sort of direct-to-consumer
commercial entities,
usually that stuff is not covered.
And one thing I wanted
to mention about that
is that they usually cost
several hundreds of dollars.
And the more organisms you
test for, the higher the cost.
And sometimes there is a charge
just for the kits themselves
and then a separate
charge for the laboratory
to run the test.
So, typically these things
are not covered by HMOs,
by family statement accounting programs,
title 10, et cetera.
So, it's something that is
unfortunately limited to folks
that have a certain amount of income
to be able to cover the costs.
- All right.
So, I do have some clinical resources,
but I did just get a question
that I know it has to
do with home testing.
And so I wanted to just
put this out there now,
and we'll move out to some more questions
after the resources.
But Alison Pinko Binder asks,
do you have to have a home
self-swab for wet PrEP validated?
And so, I would say that's a
really interesting question
because validation does
come up for self-swabs
for GC and CT.
I would say that no, you do
not have to have it validated
because the self-swab for
a wet PrEP specifically
is for microscopy usually
right there in the lab.
But, Ina, what do you think?
- I mean, I don't,
as far as I know, know,
the places that I've
heard that are doing that
did not do a separate validation study
to be able to do that.
That being said, we do know
that if somebody does go home
and collect and then bring
it back to the laboratory,
depending on the amount
of time that that takes,
things like trich will certainly
have a tendency to die off.
And so you might get a false
negative PrEP for trich
for that reason.
But my understanding is that
folks that are doing this
do not do separate validation studies.
- Yeah.
That's what I think too.
Okay.
That said, I think if you
are doing that method,
I think that it's completely reasonable
to take that into account
when you're thinking or when
you're putting it all together
and figuring out how to treat a patient.
So, if you have somebody
who is describing something
that syndromically would qualify as yeast,
and you just don't have
that under the microscope,
it's totally reasonable
to keep that in mind
that this was a self-collected thing.
And so, weigh it differently
when you're making your final diagnosis.
All right.
So, all that said,
there are several clinical
resources available.
This is our don't forget to swab website,
that's about extra-genital
screening for gonorrhea
and chlamydia.
There's a whole tool kit.
There is a national
guidelines for best practices
for STD management section,
which is basically the
CA PTC's Clinical STD
Training Services.
This is what it looks like
in the websites below.
And then lastly, we have the
clinical consultation network.
And so, this is a website
for specific STD management questions.
And so, if you have any complex STDs
that you or your patients
have any complex STDs
and you want to run it by
this consultation line,
then you can enter it at stdccn.gov,
and one of our subject matter
experts will answer it.
Ina and I are both faculty on this
as well as many other
people in California.
And in terms of telehealth
for people who are transitioning
to using telehealth,
there's a really, really great
Telehealth Essentials website
that was made by Essential Access Health.
They've collated a whole list of resources
having to do with technical
assistance for telehealth.
And then there's also a resource.
Let's see if it comes up.
One more resource.
There it is.
Oh. (laughs)
One more resource
is the National Consortium of
Telehealth Resource Centers.
And so, what this is,
is it's essentially,
there are multiple
telehealth resource centers
throughout the country.
And so, if you go to this website,
you can find the
telehealth resource center
that is serving your jurisdiction.
There is one that is
specific for California,
and so they're also available
to offer specific technical assistance
and you can contact them if needed.
Great.
Alright.
- I think I'm gonna turn my camera back on
if that's okay for the time.
- Yeah.
I wanna turn mine on too.
Oh, it's nice to see you again.
- Yeah, nice to see you too.
I'm gonna answer a couple of questions
that I've gotten in the chat box.
And the first is not really a question,
but more of a fact-checking thing
from our friend Tadd Tobias,
who mentioned that
because of funding issues,
the Please PrEP Me live navigation piece
is now no longer funded.
The website is still up.
And so you can find a
free online clinic finder,
as well as the,
I'm sorry,
the clinic finder, as well
as the online PrEP provider.
Content is still there,
but unfortunately the live
navigation is not funded anymore,
which is really too bad.
And then the next
question that I have here
is from Leo Moore,
who asked about using Microsoft Teams
as an acceptable platform
for the telehealth.
And my understanding is
Zoom, WebEx, Microsoft Teams,
any of these that are not public-facing
can be used in the sort of waiver of HIPAA
or lack of enforcement of the violations
that might occur because of this
is it is still possible.
But that being said,
a lot of organizations
who are transitioning over
to doing telehealth more formally,
are getting platforms that
are specifically adaptive
for full care.
So, for example, Zoom has a
regular consumer platform,
and then also they have a
Zoom for healthcare as well.
So, but my understanding is that
you can use any of these
known public-facing video chat platforms.
- Yeah.
And I have one more question from Al Katz,
who is probably the Al Katz in Hawaii.
Hi Al.
And he wrote your...
And I'd love your opinion on this
because I think this is something
that you know a little bit more about.
Your advice for preferred use doxycycline
instead of azithromycin
for male urethritis
differs from PTC's syndrome recommendation
that was provided back in April.
And so, he writes that you noted
that there's evidence
supporting doxy versus azithro
because it has better cure rates for CT.
And so, he wants to know,
should we be using doxy
as opposed to azithromycin
for the chlamydia patients
who we see face-to-face as well.
And should we be using
doxy with ceftriaxone
for the GC patients
we see face-to-face as well?
- Oh.
- Burning questions. (laughs)
- I know.
So, Al, I can't answer this question
without revealing things that are coming
in the 2020 treatment guidelines,
but I'll just say that the
direction that we're going in
is using doxycycline for all chlamydia
and the direction that
we're going in for gonorrhea
is really to increase the cephalosporins.
And there has been a increasing amount
of azithromycin resistance, unfortunately,
in the Gonococcal Isolate
Surveillance Project.
So, azithromycin is not looking so good.
But I'm not making any statements
about what's coming exactly,
but just to say where things are going.
And if then there...
So, that would be a mistake
if our PID recommendations
do not line up with the CDC's.
So, the PID treatment
recommendations that,
well, there shouldn't be
presumptive treatment,
hopefully a PID, right?
But they should be aligned.
So, I apologize if there
is a mismatch there out.
- All right.
- Oh.
- But more questions.
More questions.
Okay.
- And I have a very similar question.
Can I answer one more?
- Yeah. Yeah.
Good.
- From Gary because it's really similar,
is she noticed the new STD
sort of treatment guidelines,
especially this whole
like doubling of this,
a fixing dose.
So, should we implement those right now
or should we actually be
using the 2015 guidelines?
And so I would say when
you're doing inpatient care,
stick with the 2015 guidelines,
but when you're having to
do syndromic management
where you unfortunately
can't do a full exam
and can't do a full workup
and you're treating presumptively,
let's say for your penile
urethral GC, or CT,
then go ahead and use the,
if you can't do IM medication,
go ahead and use these interim guidelines.
So, using cefixime 800.
But if you have a person in clinic,
then stick with ceftriaxone
250 plus azithro for now.
But then the new guidelines,
if all stars align,
hopefully will be out in
the next like three months,
two to three months.
- Okay.
How many more questions do you have?
I just got, wait three. (laughs)
- Okay, go ahead.
- But I don't know if we
have time for all of them,
so I'll go fast.
So, one question is,
this is a kind of general
question, I think,
that is it safe to do EPT
if the allergy status of
the partner is unknown?
And so, I think that
that's something that is,
ultimately it's up to the
provider if they wanna do that.
I think in general with EPT,
you don't know the status of
the partner of your patients.
And so, you probably
like the best thing to do
would be to explain very clearly here
is exactly what these drugs are called,
here's what they are,
and then if you want to
counsel your patients
and say like, "Make sure
you tell your partners,
these are what these drugs are."
And then if the partner knows
that they have an allergy,
then it is,
they can make an informed decision
about whether or not they take that drug.
They're kind of...
Yeah.
- Oh no, sorry, go ahead, Roz.
- No, no, that's it.
- Oh, I was just gonna say
when EPT was first legalized
in California,
back in 2001 for chlamydia,
there were huge concerns
that there were gonna
be allergic reactions
and the state actually,
they sent out a big
"Dear Colleague" letter,
they set up an email address
and a phone number for people to call
with sort of adverse events with partners.
Because most of the time
you are not gonna know
their allergy status.
So, we would always recommend
including instructions,
as you mentioned, Roz,
for the person who's gonna
be taking the medication,
Just so folks know, they
had that up for 10 years
and they never received any
sort of reports of issues
related to an adverse event for partner.
So just as an FYI.
- Yeah.
And then in terms of recommendations,
so there's a question about
recommendation of test of cure
which we didn't talk about.
I think that for,
in general for tests of cure,
test of cure is recommended
for pregnant patients
for gonorrhea and chlamydia
about three to four weeks
after they're treated.
And then for syphilis,
you do follow-up titers
after treatment.
But Ina, I don't think that
test of cure is different
for syndromic surveillance.
- Not as far as I know.
- Yeah, I think...
So there's that.
And then there's one last question I have
that's from Terry Anderson.
Hi Terry.
That says, just to clarify
for at-home STI testing,
a patient will pay out of pocket
regardless of their insurance status.
So, I think we covered this.
I don't know.
Ina, do you have anything to add for that?
- I'm looking at the new
question was coming in, Roz.
Can you repeat that?
- Oh yeah, of course.
And I think we actually have
to put a cap on the questions
after this one,
after Ina is answering hers.
But just,
so Terry Anderson asked that,
just clarifying for the
at-home STI testing,
a patient would pay out of pocket
regardless of their insurance status.
- Typically, yes.
- Yeah.
- If they're doing it at home
and it's not something that
your clinic has stood up
as a home testing program,
if it's something they're getting
through one of these commercial brokers,
then yes, they're almost
always paying out of pocket.
Although that is not true
for every single one of those providers,
some of them will actually bill insurance
on behalf of the patient,
but some of them,
many of them just require a cash payment.
And then I will end it with,
someone asked about,
if you have a PrEP patient
that's adherent to therapy
and they end up with an STI syndrome,
why would you have to bring them in
versus if they're probably
unlikely to have acute HIV,
if they're been very adherent to PrEP.
And I would agree with that,
I think you could accept urines
and if they,
you know those patients that
are like incredibly adherent
to their medication,
you know they're fine,
then you could do syndromic
management for those folks.
But I think if there's any question
that acute HIV might be involved,
it's probably best to bring someone in
to be able to do an exam
and counseling session.
But we have to go.
We wanna stay.
We can hang out with you guys.
- And thank you to the 200 people
who are still here with us.
Thank you for sticking
around an extra five minutes.
- We are so glad that you
wanna hang out with us,
but you have important
things to do during your day.
And we are so glad that you came.
Thank you so much for attending.
You will be getting an
email about the evaluation.
Give us your honest feedback.
We're very happy that
you guys signed on today.
- Yeah.
Thank you so much.
And if anything comes up,
our email addresses are in
the bottom of the screen.
- Yes, they are.
- Okay.
- Bye everybody.
- Bye.
- Bye.
