Information for Policymakers

Chlamydia Focus Group March 10, 2001, New Haven, Connecticut

The goal of the group was to explore barriers to chlamydia testing and treatment and to explore possible solutions for feasibility and effectiveness to reduce the incidence of the disease in Connecticut.

The group included eight participants plus the facilitator -- fifteen year old girl, a pediatrician specializing in adolescent medicine, a gynecologist, a state senator, a medical student, a provider from a school-based health center, an expert on chlamydia and an expert on confidentiality. While they ate, the participants were given a one-page fact sheet on Chlamydia which is attached, before the group began.

Barriers mentioned included:

• Fears about confidentiality - It was emphasized that the chlamydia test answers a very scary question. Teens worry that their parents might find out that they had a test.
• Poor judgment - Adolescents are not always logical. A story was told about a community court worker who noticed a boy shifting in his seat and seemed to be uncomfortable. After questioning, he revealed that he had been experiencing pain in his genital area for a few weeks. When asked why he didn't see someone about it, he stated that he couldn't have an STD because his partner was 15 and he was sure she had no other partners. In fact he had gonorrhea.
• Mythology about what kinds of people have STDs -- One participant noted that in an adolescent's mind it makes no sense to use protection from STDs - you wouldn't have sex with someone you thought might have a disease, even using a condom.
• Confusion about what the test covers - Teens may feel that if they get tested for one STD, they have been tested for all STDs.
• Fear of other health problems - A teen might find out that she doesn't have chlamydia, but does have HIV or diabetes. While this was seen as a positive effect by adults, the teenager in the group felt that most kids don't want to know. They prefer to "stay dumb" and continue to believe that they are invincible.
• Knowledge of the disease - While most teens know that chlamydia is an STD, they often don't know about the effects of infection or that it is usually silent (no symptoms). Kids will not talk to anyone about their lack of information; will not seek it out.
• Boys are particularly naive - Many boys know nothing about the disease and rely on their partners to protect their own health.
• Peer pressure to have sex - Pressure is very strong, and at younger and younger ages. "Virgin" is a dirty word. The media uses sex to sell, but it is not balanced with responsible messages.
• Lack of supervision - It is easy to keep sex (and lots of other things) secret from parents. "You don't know all the nooks and crannies of our bodies, even though you made those nooks and crannies." Parents have no idea what their kids are doing when they aren't there, even "good kids".
• Victorian attitudes about sex - There is a perception that STDs are a "punishment" for doing something wrong. "Who wants to know that?"
• Access and cost of tests - While it was noted that students in schools with school-based health centers have access to confidential, free testing and treatment, concerns were raised about students at other schools and those who aren't in school.
• Old test was invasive and often inaccurate - Many providers don't know about the newer, more accurate urine test. However that test requires either overnight mail or a courier to deliver the sample to the state lab (the old swab test could be mailed).
• The need for an immediate answer - Most kids don't want to wait days for results. Then begins the "follow up nightmare" as described by one provider.
• Test accuracy - False positives are a serious problem with the less accurate test now in wide use. False positives often lead to painful, untrue accusations and divorce or the end of a relationship.
• Boys often rely on their partners to be tested - The current test in many settings is very unpleasant, especially for boys. Many come into a clinic for treatment, saying that their partner tested positive. They do not want a test, just treatment.
• Partner notification - This is a huge barrier, evoking lots of anxiety. Delay expands the epidemic. Teen girls are very reluctant to tell their partners that they tested positive - concerns that it will get "all over school", especially if they have to tell more than one person. They are also concerned that they will be blamed for infecting their partner. Girls wait for the "right moment" to tell him and it never comes.
• Reinfection -- Often girls who test positive do not tell their partner, do not fully understand the nature of the infection, or are pressured by hormones and/or boyfriends to have sex again with the same partner, and become re-infected.
• Provider education - Many providers do not offer the test and do not know that there is a less invasive, more accurate test available.

Opportunities

• Friends - Often friends bring teens in to get tested. In some cases, the friend decides to get tested as well.
• Negative pregnancy tests - Pregnancy tests are also urine tests. It could be routine to test all urines for chlamydia. This reaches a population having unprotected sex.
• Regular check ups - Providers should always offer the test.
• HEDIS now measures HMOs' performance on chlamydia testing. Testing is covered by most insurance.

Potential vehicles for education

• School STD student groups - Roberto Clemente Middle School in New Haven offers such groups -- once a week, run by an APRN -- that are very effective in working through concerns and follow up issues. There is no stigma attached to attending the voluntary group. Both boys and girls share information and emotions easily there.
• Educating boys - Most education targets girls and women. Important to let boys and men know that there is a urine test, and that they may be spreading the disease without knowing they have it. The health effects of infection on men have not been studied. Relying on a partner to be tested is not an effective strategy to protect your health.
• Partner notification education for positive tests - It is critical to fully explain the risks of re-infection. Should offer several models for notification e.g. bring the partner into the clinic for the provider to speak with both of them, role play opportunities to help with telling partners.
• Radio - Music stations are particularly effective for reaching teens.
• Faith community - Some are very open to the issue. It is a trusted environment where information is likely to be believed.
• Peer educators - "Teens learn best from other teens."
• School-based health centers
• Fairs - Community fairs are very popular; something to do on a hot night. It was suggested that STD educators have a booth at these fairs. It is critical to make it fun, include entertainment, food, clowns, face painting, etc.
• Add to curricula of other classes - A successful summer class included a required report on STDs, with pictures. Requiring students to get pictures of diseases made a big impact on kids.
• High visibility PR campaigns - For example, St. Patrick's Day, Valentine's Day. Although these can be controversial, the controversy amplifies awareness.
• Provider education on the new, urine test
• DPH send a letter to all providers about the new test
• AAP regional meetings, conferences
• ACOG District meetings, communications
• Grand Rounds
• Include information on how to talk to teens about sex and STDs
• Create a curriculum and take it around the state
• Hold a conference on STDs - A very successful one-day conference was held in Hartford. It has to be free and give CME credit.
• Emphasize the importance of offering the test - Providers have a lot on their plates. They need to understand how important chlamydia is, and how easy the test can be. Offering the test should be part of every routine exam.
• HMOs must do a better job of informing their providers
• Add chlamydia testing to EPSDT and state reporting.

Other solutions

• Routine re-testing after treatment - Given the low level of partner notice, routine re-testing after six months could help stem the epidemic.
• Increase the schedule of required check ups for school registration - Only one physical is required in high school now. The state could also require one senior year, as children transition from pediatrics to adult providers.

Messages

• There is an accurate, urine test
• Testing is confidential, your parents never need to know
• Testing is free at clinics
• The disease is often silent, there are no signs,
• if you are sexually active you could have it
• It is easily treated
• Protect your future "Pee in a cup, protect yourself"

CHLAMYDIA

• Most common sexually-transmitted bacterial disease
• More than 4 million Americans are infected each year
• The number increased in CT by 18% from 1996 to 1999
• New Haven's infection rate increased by 41% in the early 1990's
• Effective use of condoms reduce risk, but anyone who is sexually active can get the disease
• Usually silent - 75% of women and 50% of infected men have no symptoms or symptoms so mild they do not seek treatment

Health Effects of Chlamydia Infection

• Major cause of pelvic inflammatory disease (PID), 40% of women with untreated chlamydia develop PID
• PID causes infertility in 20% of women, chronic pelvic pain in 18%, and in 9% a life-threatening tubal pregnancy
• Babies exposed to chlamydia during birth can suffer pneumonia and conjunctivitis
• Women infected with chlamydia are at 3 to 5 fold higher risk of contracting HIV
• There has been little study of the effects of chlamydia infection in men

Who gets Chlamydia

• The vast majority of people infected with chlamydia are between 15 and 24 years old
• Blacks are twice as likely as other races to be infected - both in CT and the US

Testing and Treatment

• Is now a very accurate, urine test for chlamydia
• Treated with antibiotics - now there is a one dose, oral option
• Screening works - a study in Seattle found that symptomless women who were screened and treated were 60% less likely to develop PID