Improving access and patient outcomes for sexually transmitted infections in the US

[Claudia Marquez] Thank you everyone for joining us. Today, we're gonna be discussing, obviously, sexual health, but we're gonna be looking at innovative strategies for enhancing access to our patients for STI testing, as well as just shedding light on some of the promising technologies and potential approaches that we're looking at to possibly impact patient lives, as well as public health outcomes. 

So, the speakers today, I am very honored to be joining these ladies today. We have, at the end of the row, Dr. Bobby Van Der Po. She is a Professor of Medicine and Public Health at the University of Alabama at Birmingham. (Bobby laughing) And we have, (chuckling) directly next to me, Dr. Casey Pinto, she is an Assistant Professor at the Department of Public Health Sciences, Division of Epidemiology at Penn State. 

So, thank you again for joining us, oh! And I am Claudia Marquez, I am a Molecular and Infectious Diseases Scientific Liaison with Roche Diagnostics. So again, thank you for joining us today, and I'd really like to open this talk, which is talking about the amount of STIs that we're seeing in the United States right now. So currently, the CDC estimates, and this is as of 2022. There are one in five people with an STI, as you can see up on this slide here. And over the last two few years, we continue to see these numbers drastically increase. So Casey, what do you think about what the current challenges are for managing STIs, and what is contributing to this rise?

So, the biggest challenge across the board (chuckling) is money. Our government has been cutting financing towards this year over year. But there's lots of other things contributing. Second, I would say accessibility for people to get tested. And that is not just the ability to access the testing itself, but the ability to access the testing that they choose. So, or their ability to not feel stigma in accessing the testing that they choose.

And if I can jump in on that, I would say that, think about this meeting. How many sessions are there at this meeting? And in your head, raise your hand if you've ever had sex! But I bet that's every one of you. But yet, how many sessions are focused on sexual health? I think maybe three. And so, it's really unfortunate, but at the institutional level, we stigmatize these diseases so much that how can we fight them, right? How can people access care when their providers won't talk to them about their sexual health? My primary care doc ask me every time I go in if I've committed suicide. And I said, "No, I'm still here, I'm good." But how many times has he asked me about my sexual health? This many. And that's our problem in this country. And if our providers won't offer these options to us, we have to find alternate ways of getting these tests to people. (people chattering distantly) 

Yes, thank you very much, Bobby. And that leads into, if you can see this slide behind me here, you can see that we've started a puzzle, and it's not complete, right? And there's a lot of other puzzle pieces that we're still trying to fill in that gap. And that's what we think about when we think about sexual health, and actually identifying these cases in the United States. So, what are the different options that currently exist in STI testing today, and when are they appropriately used? Casey? (Casey sighing) 

So, the different options for testing, patients can go to see their primary care provider, they can go, is that, are you asking like?

[Claudia] No, yes, absolutely

Okay, yeah. So, patients can go and see their primary care provider to get tested, but they also have to feel comfortable seeing their primary care provider to get tested, and a lot of patients aren't comfortable with that. I just gave a talk to a group of nurses who are in, they oversee long-term care facilities, nursing homes, and they're really concerned about the rise in STIs. And one of their concerns was the medical director there, patients were coming to them and saying, "Hey, I'm concerned I'm having sex." And their provider was like, "No, you're not." No, no you're not." And they're like, "No, (chuckling) really, I really am." He's like, "I'm not having sex so you're not having sex." (Barbara laughing) And I was like. 

[Barbara\] "Well I'm not having sex with you." (Casey laughing)

I was like, "Oh my gosh!" So, these are the barriers we're running into, like nurses can't override their medical director who provides care for all of the patients in this nursing home. So like, this is one of the barriers to them getting treatment, so they they can't seek care there, so they might seek care somewhere else. So, they might turn to maybe telemedicine if they have someone that can help them access it, right? Or if they have the money, or their health insurance covers it, they might turn to online to order some sort of direct to consumer testing, if they have the money, (chuckling) or if they have the internet, if they can access it. And again, these are all things that people need access, money, insurance coverage for, to access these. I don't wanna monopolize.

And I think too, if you conceptualize this, like with the youth, where we have really the highest rates of these diseases, right? What different obstacles do youth face? Because if you're 16 years old and you're going to an OB-GYN with your mother, are you gonna talk about your own sexual behaviors? Nah, not at all. So, how can they access this? And you could go online, and you could order a test kit, collect it at home, and send it in for testing. But is your mom gonna see that box come in the mail, right? And so, you can get these kits on Amazon! But Amazon will actually deliver to drop off points, so you can go and pick the kit up. So, there are more options, but the Amazon kits can run from a 100 to $200, I'm talkin' about a 16-year-old! She doesn't have that kinda money! So if we wanna make this accessible, urgent cares are another place where a lot of this is becoming common because it feels a little more anonymous. You might have to pay out of pocket, but you might also get a rapid test, because we now do have these point of care tests, so you can go in and you can talk to somebody, and immediately get tested, and if you have something, immediately get treated. So, they're not sending all of these prescriptions to your house, and you're not having to explain to your mom why you're going over to the pharmacy, but it can all be taken care of in one place. So, I think the online ordering is not optimized yet, but could be a good strategy if we can make it affordable and accessible, as Casey said. And I also think the point of care testing, when we could talk about sex, just think at the MinuteClinic at a Kroger's or a Walmart, or a Walgreen, or a CVS, if you could go in there and get a rapid test, you could take care of everything right then right there, wouldn't that be wonderful, right? Giving more options to more people, that's the goal.

And this would actually help alleviate the ERs, whose patients are going into ERs, to get screened for STIs. And this is one of the biggest burdens I'm seeing. Patients are going to the ER and saying, "I am having sex, I want an STI test," and they're getting chlamydia and gonorrhea. Because those are the tests they can treat right then, and they don't have to follow up on the results. So, I can treat you now, and then if it's positive, it doesn't matter because I treated you and you're gone. So, they're not ordering HIV, they're not ordering syphilis, maybe they're ordering trich if they're thinking about it. 'Cause they can just give you Flagyl on the way out the door. And this is the barrier I'm running into trying to get ERs to just even consider these additional testing. If I promise I'll follow up on them in my STI clinic. If you can't get a hold of them, just send 'em to me, I'll take care of it, I promise. But it's another barrier and might help alleviate some of that if we can get these tests in other places, we can diagnose more, decrease the rate of transmission if we catch 'em earlier. Yep, and that leads perfectly into my next question. So, I really wanted to focus on meeting the patients where they are. And one of the big things that you just mentioned was that a lot of individuals have to get their general medical care at an emergency room. So if we can expand these testing options with something like a point of care test, how do you think that'll help us? You've pretty much answered the question, but can you just expand a little bit, I know Casey, you meet a lot of patients when you're driving out in rural Pennsylvania that don't have access to transportation or childcare. So, how do you think point of care will help address the needs of these patients as well? Yeah, so and actually, some of my colleagues are doing some work with migrant workers. So, they're taking these vehicles out, and these migrant workers who work in the fields, so they might not be there the next time they come back, they might have a different group of migrant workers, they may have gone back to wherever they're from. So, they'll go out, they could do the testing right there and find out whether or not they're positive and treat them on the spot, or at least tell them like, "Hey, you have this, you're positive for HIV or you're positive for syphilis, and I don't know what stage it is so I can treat you here." Or if they're asymptomatic and they have chlamydia, I can just go ahead and treat you 'cause you've tested positive. It makes it easier than having to drive two hours back out to this farm where you're only having a yield of one, and the farming owner doesn't want you to come back more than once, (chuckling) because this takes time away from them working in the field. They've only agreed to you coming one time. So, that's one of the barriers there.

And I think the other perspective is, now we're talking about people going to where people are like the migrant workers, and we're doing similar projects in rural Alabama, where we're taking community health workers and giving them point of care tests, and saying "Go out, and anybody that you think is potentially somebody who could suffer from these infections or potentially needs to be tested," we're really focusing a lot right now on syphilis testing in women of reproductive age, because our congenital syphilis rates in this country are embarrassingly awful. And until we go to people, we can't expect people to take time off of work to find transportation, to find daycare, and all of those things, just to go into a doctor, and then have the doctor say, "Oh I'm gonna send this off to the lab and I'll let you know next week, and you can come back then." That's not an option. That's not the way that we have to approach this. We have to go to where people are, and we have to do it with a variety of options. I do think the self collected mail-in option, while it's not an immediate result, is a usable option for a lot of people. And so, we just need all these different choices like anything, it's like we're not all wearing the same outfit, right? We don't all want the same options for this testing either. So, we have to be mindful of how we can treat people with respect and recognize their circumstances, and the context they live and work in, and get them what they need. 'Cause these diseases are treatable. I mean it's just, it's sad that in this country, we have some of the highest rates in the world. Absolutely. And Bobby, again, it's like we practice this. (Bobby laughing) You mentioned another word that's been coming up quite a bit when I'm out in the field doing clinician education to folks like Casey and other providers that we see around the United States is, what does point of care testing mean for the laboratory? So Bobby, you run the lab at University of Alabama Birmingham, and is this gonna take anything away from the centralized laboratory? What do you think as a laboratory director? Yeah, no I think point of care testing is just another portal to get people understanding that tests can really help improve patient management. And sometimes, those tests have to be done in the lab, but think about a point of care test. Let's just say for chlamydia gonorrhea, if you test negative for that but you had symptoms, somebody's probably gonna collect a specimen and send it to the lab to test for other diseases, right? Because something's going on, you've got something. But even if you have a positive test, but it only tests, let's say there's a test out there that's just for chlamydia. But chlamydia likes to run with tricks, it likes to play with gonorrhea, it happens to be in people who have syphilis. So if you test positive for something, you may have been exposed to other things, and this point of care test didn't cover all the bases. So again, collect a specimen, send it off to the lab, we're never gonna go out of business, we're doing just fine. The point of care (chuckling) tests are only gonna help patients get the care that they need, and then potentially get follow-up care as well. Yeah, but you have to think, you say the labs are just fine, they're just fine because there's a new disease like every 10 years. (chuckling) (Barbara laughing) I mean, in the '80s, HIV, we had chlamydia-(Barbara) In the '80s and chlamydia, right? Yeah and chlamydia. And then, now we have mycoplasma genitalium. I mean, something new is going to come and we need the lab to be on board to help us find those, so. And we need the lab to help, like for example, if we have a point of care test that identifies gonorrhea in somebody, we would really like to know that antimicrobial profile, wouldn't we? But that's not gonna happen at the point of care. Now, 10 years from now, I'll be wrong, right? And we'll be doing all this in a 32nd test, maybe from a breathalyzer for all I know. But the point is right now we're not there yet, so right now, if somebody tests positive for GC, you need to be sending a sample to the lab. The same thing with Mycoplasma genitalium, about 85% of the infections are resistant to azithromycin, which is the most commonly used drug for chlamydia in this country. But, so you need a resistance profile if you're gonna treat that disease effectively. So yeah, the lab, we are just fine. (speakers laughing)

And one thing I'd like to point out here is you can see on the screen behind me, so 90% of STI diagnoses actually come from outside of STD clinics. So, based on these numbers, and this is something that we all have spoken about for many, many years, who should be tested for STIs? All of us, come on! People who have sex! That's as much definition as we need. If you have sex, you should be able to have happy, healthy sex. And that means taking care of your healthcare at least once a year. It's not a big deal. There are guidelines out there to tell people you know who to test, but if you're a provider, I think you only need to ask about three questions. Do you have any complaints about your sexuality that you think we should talk about that I can help you with? Are you having any symptoms today? Do you have a new partner? I don't care if it's one partner, I don't care if it's a hundred partners, I don't need to know your business. I need you to tell me if you got a new partner because that happens to be a risk. And if you answer yes to any of those things, well, let's just get you tested to make sure everything's cool. And the good news is it's always good news. If a person doesn't have anything, yay, you're doing everything well, you're protecting yourself, carry on. If a person has something, yay! We found that we can treat it. Take care of yourself. You don't have to have downstream consequences, you don't have to share this with your friends, right? So, it's always good news and we have to get over this. Oh my god, I don't know how to tell my patient they have chlamydia! It's pretty easy, you got chlamydia, we're done now. 

And Casey, you see a lot of patients, so are those conversations difficult to have? I mean, I'm probably not the person to ask 'cause I have these conversations all the time, so they're not hard for me at all. (Barbara chuckling) But the people I teach to have these conversations, it just takes practice. So, when I talk to my colleagues, it just takes a little bit of practice. I often have them maybe role play with someone, and say things like, "Ask the really tough questions and really answer those questions honestly." And once you do it a couple times, it gets a lot easier. But I wanted to echo what Bobby said where, "I don't think you should just do it with someone who has a new partner," mainly because I see a lot of STIs in monogamous couples. 

Oh, for sure. So, I think that it would be nice to have testing, like it's just to decrease the stigma, like guidelines, like hey! We do this every so many years in monogamous couples. Sure! Like, I know a gay couple who are as monogamous as they can be, and they get screened every year just 'cause they're gay. Just because they're gay, they get screened every single year, they both are in a monogamous relationship, and that's just the way it is, and they just accept that. So, I feel like other relationships should be similar. I agree. Thank you so much. And as we tie things up here and open the panel for questions, is there anything that you'd like to say that I have forgotten to ask that you'd like to tell our wonderful audience here at ADLM? Go forth and test! Ooh. (audience laughing) Okay, thank you very much, Bobby and Casey. (audience clapping) And now, we're gonna open up the floor to any questions that you may have for our panelists. (people chattering) If you have a question for this panel, please raise your hand, and I will bring a microphone to you, thank you. Somebody has to ask a question or we're just gonna sit up here and feel foolish. (Claudia giggling) Hi, so I'm not from the States. So, in the States, there's no opt out. If you go into urgent care or hospital admissions, there's no opt out of being tested? No, no. Where are you from? Jamaica. 

Oh well, I'm moving there then. (people chuckling) (people chattering distantly) Thank you for the introduction, I just have one question, and you mentioned about the point of care for this sexual disease. So, what type of sample type is much easier to accept? Guess sometimes, especially for the female, the swabs, it's very difficult. And so, I am just wondering, so for the clinics, what sample type is more acceptable or comfortable? So, I don't think the swabs are very difficult, we have patients self collect them. In the clinic, I give the patients the option. If you don't want me to do an exam, you can self collect, I'll look at it under the microscope, we'll send it to the lab. Patients will self collect, just like, I'm like, if you can put a tampon in, you can self collect a swab, I tell 'em how to do it, they do it. I get really great samples, I've never had one rejected. 

And Bobby can tell you about all the research out there on vaginal self collection. (speakers chuckling) I sure can. But I think, remember too that we're not trying to collect high vaginal swabs or cervical vaginal swabs. That swab tip just has to get wet, these are super sensitive molecular tests. So, because they're amplifying the product and dead DNA is fine, we don't need live bugs, and we don't need a lot of bugs. So, even a lot of people in Western Europe use labial samples, which don't actually go internally. So, you have lots of options that make patients comfortable with sampling. And if you're serving a population of anybody who has anal sex, again, those swabs don't really have to go in anywhere, they just have to get wet and moist, and so they have to go around like the perineum. And so, again, people can collect these samples themselves, and it gives people some sense of control over the fact that they're participating in their own healthcare. And so, actually, self collection is a really positive thing, and it's super easy to do. 

Okay, thank you. Hello. What about brushes? Do you use any brushes for self collection or it's only swabs? We only use swabs for chlamydia, gonorrhea, trichomonas, and mycoplasma. If you're trying to add self collect for HPV on there as well, then you probably do want a brush. But that sample can still be used in most of the STI, bacterial ones too. So if you're using a brush, it's fine. But again, those women, if you're doing HPV via molecular testing, you're not trying to get a cervical sample, so you have to make sure that these women don't feel pressure to really insert it far up. Just tell them, choke up on the bat, put your finger up here, so that you can't put it in too far, and then there won't be any pain associated with it. You like that choke up on the bat- Hello. (people chattering distantly) What do you think about Doxy PEP in terms of prevention? Okay, now what does Doxy PEP have to do with diagnostics? (speaker laughing) But if you wanna see a session, we're doing a session tomorrow morning at 10:30, and Doxy PEP will be a major topic of discussion, as will self collection at home. Okay- So, come see us tomorrow. Yeah, sure. (Claudia chuckling) But I love it. Yes, thank you- If you're asking. (Casey chuckling) Oh. (people chattering) How about the urine sample? Men or women, people with a penis or people with a vagina? Both. Urine from whom? Yeah, but I'm saying, how about the urine sample, it's okay? Okay, if you have urine from a penis, it works great. Okay. If a person has a vagina, ask them to sample it. We lose about 20% of our positives using urine from people with a vagina. Thank you for a very insightful session. I wanted to ask you a question, like in your experience, like the state which you are explaining that everybody should do the screening for STIs, like how long will it take? Because today it is not, we do not do the screening for the entire population, we do it for the select key population. And like, the way you explained for people, like men sleeping with men, we do more screening. So, in your opinion, how long this journey will take is that we, everybody, of either both the sexes can do regular screening at least once in a year. How long will it take? That's the question I wanted to ask. So right now, in the US for women under the age of 25, it's recommended every year. So, it's about once a year. If you've been positive, for example, for chlamydia, the recommendation is that you be tested again three to six months later because the reinfection rates tend to be high, and that's because unfortunately, we don't always get partners treated. But I think your question was how long until we actually see screening regularly for the over 25? (audience member speaking indistinctly) Money. Money, yeah. I think it's a problem of money, and we're seeing other countries that do annual screening that are on like nationalized healthcare, we're seeing them go away from annual screening, so I'm not convinced it will happen here, but I think that it's something that we should look for and push for. But I just think there's enough conservative push that it will be hard to pass. It'll be hard to get funding for it. It'll be hard to get funding, it'll be hard to get it pushed through the guidelines as a recommendation. Any additional questions for Bonnie, Casey, and Claudia? All right, let's give them a hand, thank you very much for this conversation.