• DSHS HIV/STD Program

    Post Office Box 149347, MC 1873
    Austin, Texas 78714

    Phone: (512) 533-3000

    E-mail the HIV/STD Program

    E-mail data requests to HIV/STD Program - This email can be used to request data and statistics on HIV, TB, and STDs in Texas. It cannot be used to get treatment or infection history for individuals, or to request information on programs and services. Please do not include any personal, identifying health information in your email such as HIV status, Date of Birth, Social Security Number, etc.

    For treatment/testing history, please contact your local Health Department.

    For information on HIV testing and services available to Persons Living with HIV and AIDS, please contact your local HIV services organization.

POPS Chapter 12 - STI Clinical Standards

Chapter 12

These standards are based on the following references:

  • Centers for Disease Control and Prevention (CDC) Program Operations Guidelines for STD Prevention, Medical and Laboratory Services, (2001) (or latest version),

  • CDC Division of STD Prevention Funding Announcement;

  • CDC Sexually Transmitted Diseases Treatment Guidelines, 2015 (or latest version) and addendums;

  • Department of State Health Services (DSHS) Client Services Standards for Public Health and Community Clinics, (2004);

  • CDC Expedited Partner Therapy (EPT) in the Management of Sexually Transmitted Diseases, (2006) and;

  • DSHS Expedited STD Management Implementation Guide (2013);

  • DSHS Cephalosporin-Resistant Gonorrhea Plan for Texas; and

  • Trafficking Victims Protection Act of 2000 (Pub.L.No. 106-386), as amended, and 19 U.S.C. 1591; and Texas Medical Board and the Texas Board of Nursing.

 

12.1 Accessibility/Clinic Environment

  1. The clinic facility is physically accessible in accordance with the Americans with Disabilities Act.

  2. The clinic is accessible from residential areas through public and private transportation. Signage is clear and easy to understand without being conspicuous.

  3. Clinic hours and staffing are sufficient to accommodate clients, with a minimal number of clients turned away. The clinic assesses the demand for STD services periodically in order to adjust the hours of operation and staffing levels. The clinic is open during lunch and staff arrival, departure, and lunch times are staggered.

  4. 90% of clients who come in during normal operating hours are examined and/or tested and treated as medically appropriate.

  5. The number of clients not seen the day they seek services is documented daily and is analyzed periodically to determine appointment and staffing needs of the clinic.

  6. A client satisfaction survey is conducted annually; the information obtained is used to improve services.

  7. No client is denied care because of his/her inability to pay. Fees should be minimal or based on a sliding scale.

  8. The clinic bills 3rd party payers to the extent possible.

  9. Persons referred by a Disease Intervention Specialist (DIS) are not assessed a fee for evaluation and treatment if they are unable to pay.

  10. The waiting area is welcoming.  There is an assortment of client education materials available (e.g., posters, videos, pamphlets, etc.). Information relevant to diverse communities (e.g., Spanish language materials, LGBT health related information, and other community specific brochures and publications) promotes a welcoming environment.

  11. The public and non-clinic personnel do not have routine access to the clinic area. Non-clinic personnel do not use the area to access other areas of the building.

  12. Examination rooms are clean and private and have adequate equipment and supplies for physical examinations and specimen collection for both male and female genitalia.

  13. The number of examination rooms is adequate to accommodate the number of clinicians (at least one room per clinician) and to serve clients promptly. 

 

12.2 Range of Services

  1. Clinicians are able to accurately diagnose and treat bacterial STDs (i.e., syphilis, gonorrhea, and chlamydia). The clinic should be able to diagnose HIV through a lab test.

  2. If a clinic has the ability and the resources to perform microscopy, clinicians diagnose and treat, or provide prescriptions to treat, vaginitis and other common, non-reportable genital infections.

  3. The clinic offers confidential opt-out HIV counseling and testing at the time of the STD visit in accordance with DSHS HIV and STD Program Operating Procedures and Standards, Chapter 4, HIV Testing in STD Clinics, so clients do not have to visit separate clinics or make an additional appointment for an HIV test.

  4. Medications are provided/administered for reportable bacterial infections, (e.g., syphilis, gonorrhea, and chlamydia).

  5. Expedited STD Services are offered, including:

  6. Primary prevention counseling and condoms are provided to all clients.

  7. If clinicians perform Pap smears, protocols for follow-up of abnormal results conform to AASCCP Guidelines of 2012 and ACOG recommendations of 2012, or most current version/s.

  8. If pregnancy tests are performed, protocols for follow-up and referral are in place (e.g., prenatal care, family planning).

  9. Preparing for multi-drug resistant Neisseria gonorrhea:

    • When a treatment failure is suspected, the clinic collects urethral cultures from persons with male genitalia and cervical cultures from persons with female genitalia.

    • Cultures are collected from all reported sites of exposure (i.e., urethral, cervical, rectal and pharyngeal)

    • Clinicians have an identified infectious disease expert to consult in the event antibiotic resistance is suspected or confirmed.

    • The clinic has a relationship with a reference laboratory and a well-defined procedure for susceptibility testing when resistant gonorrhea is suspected.

    • There is a procedure in place for reporting suspected or confirmed antibiotic resistance to the proper health authorities.

  10. Trained and knowledgeable personnel promote adult immunizations (e.g., HPV, Hepatitis A, Hepatitis B immunizations as appropriate). Routine Hepatitis B immunizations are offered to all unimmunized clients, regardless of risk factors. A system is in place to refer clients for subsequent injections if they do not want to return to the STD clinic.

  11. Confidential counseling and testing for STDs, including HIV, are not denied because a client refuses other STD services.

  12. Written policies and procedures are in place for the referral of clients with HIV positive test results for early intervention services (e.g., continuing medical evaluation, tuberculosis and immune system testing, treatment, case management, and support group counseling).

  13. When clients are referred to other health services, appointments for high priority referrals are confirmed. High priority referrals include 1) HIV Medical Care/Early Intervention services, 2) desensitization services for women who are pregnant who require treatment for syphilis and who give a history of a penicillin allergy, 3) congenital syphilis (790) treatment, and 4) prenatal care for women who are pregnant.

 

12.3 Client Considerations

  1. Client confidentiality is maintained. The clinic uses a system other than names when calling clients from waiting areas.

  2. Clinic personnel are courteous, non-judgmental and respectful of clients. Staff maintain cross-cultural awareness and display cultural sensitivity. Clinic personnel are sensitive to the needs of persons who are transgender and gender non-conforming. This includes providing an option for clients to list preferred names and pronouns on intake documentation, consistent reference to the client by preferred names and pronouns even when the client is not present, access to gender-segregated areas such as restrooms in accordance with the client’s gender identity, and access to gender-specific dressing gowns and other items as appropriate to the client’s gender identity. Staff understand that there may be a need to use the client’s legal name or gender, rather than his/her preferred name or gender, for third party billing, prescriptions and/or referrals.

  3. An adequate portion of the clinic staff is bilingual in order to facilitate services to those clients who do not speak English.

  4. The clinic has security protocols in place and reviews them with staff annually and upon hire. Security protocols cover workplace violence, terrorism, fire, disaster response, bomb threats, violent and abusive persons, etc.

  5. Medications/prescriptions and client education materials are offered to all persons who are heterosexual and diagnosed presumptively, or who have a positive gonorrhea/chlamydia result to deliver to his/her partner(s). (Patient-Delivered Partner Therapy, PDPT, see Section 12.8.2 - 1."Management of sex partners").

  6. Telephone reports of STD test results follow written clinic procedures to ensure confidentiality. Test results are available any day the clinic is open. Automated electronic systems are an acceptable method to notify clients of negative test results.

  7. Positive HIV test results are not given over the telephone or by way of an automated results system.

 

12.4 Registration Process

  1. Registration information is obtained in a confidential manner.

  2. The “expected-in” file is checked for every person at every visit as part of the registration process. “Expected-in” is a record file of individuals referred to the clinic by a DIS or who are being sought by a DIS.

  3. At check-in clients are triaged and offered Express services (see Section 12.5.2) if they are deemed appropriate candidates.

  4. DIS referrals and follow-up visits (as defined in clinic protocols) are seen before walk-in clients.

 

12.5 Clinic Flow – Appointment and Walk-in Systems

  1. Appointment systems should not create barriers for clinic access. The clinic uses a hybrid appointment system of scheduled appointments and walk-in appointments. The clinic has systems in place to assess and modify client visits to assure clients are seen in one hour or less. Clients receive the appropriate level of care suitable for their individual situation.

  2. The clinic offers low risk and asymptomatic clients an “Express” option for evaluation and treatment. “Express Services” include urine testing for gonorrhea and chlamydia (male and female) and a blood draw for HIV and syphilis.

  3. Persons who are asymptomatic, heterosexual contacts to gonorrhea and/or chlamydia may be evaluated and treated via express services.

  4. High priority clients who must be examined the same day include:

    • DIS referrals

    • Women who are pregnant

    • Contacts to syphilis and HIV

    • Persons who are experiencing symptoms of infection (e.g., discharge, pain, fever, lesions, etc.)

    • Certain high risk individuals (e.g., MSM, persons who exchange money or drugs for sex).

  5. Walk-in clients who cannot be accommodated the same day because of time constraints are offered express testing and/or treatment. If they require or request an exam, they are given a next day appointment or they are provided with a list of STD medical resources including eligibility requirements (e.g., urgent care clinics, family planning clinics, and private physicians) and encouraged to call for an appointment.

  6. Client stops are kept to a minimum (i.e., the client moves through not more than three stations - registration, lab, and clinical care). Clinicians provide oral and/or injectable medications to their clients in order to minimize the number of stops the client makes.

  7. A client flow analysis is conducted at least every other year to provide a systematic understanding of where bottlenecks in clinic flow occur and to ensure corrections are made to alleviate them.

 

12.6 Medical Records

  1. Medical records contain sufficient demographic and clinical evaluation information to enable DIS to identify the client and to readily interpret the examining clinician’s clinical findings, assessment, and management.

  2. Administrative and clinic forms have the option for clients to list preferred names, pronouns, sex at birth, and gender identity (e.g., male, female, trans/transgender). Clinic staff refer to clients according to the clients’ preferences and document in the chart, while recognizing the potential need to use legal name or gender for third party billing and prescriptions.

  3. STD programs follow written procedures for the management of medical records that include forms management, organization of the medical record, records security, record retention, and proper disposal. Policies comply with the Health Information Portability and Accountability Act (HIPAA) and state and national rules and regulations that pertain to HIV/STD information. (See records management policies at www.dshs.texas.gov/retention).

  4. The clinic has established work settings and procedures to safeguard records from being seen by unauthorized persons and to prevent unauthorized persons from overhearing conversations about protected health information and clients.

  5. A trained individual, who is knowledgeable of state and national STD/HIV rules and HIPAA regulations, is assigned the responsibility to manage the release of records due to subpoena, court order, etc. This person should track all matters relating to requests to view medical records.

  6. When PDPT is provided to a client, the number of doses is documented in the index client’s medical chart. The names of the partners receiving medication are not written in the index client’s chart. A medical chart is not required for sexual partners who receive PDPT.

  7. Provision of EPT/PDPT/FDT is recorded in a log and includes index client’s name, date of birth, date given, number of doses given, name of medication and strength, lot number, and expiration date.

 

12.7 Clinic Management Structure – Clinic Manager/Medical Director

  1. The clinic manager has adequate training/experience in health care management, clinic management, personnel management, and public health to develop and implement clinic goals, policies, and procedures; manage personnel; orchestrate all clinic functions; and ensure quality of care.

  2. The medical director has specialized training in STD care, is available for consultation during clinic hours and ensures the overall quality of clinical services.

  3. Training resources are made available to managers and medical directors to strengthen their STD knowledge if needed.

 

12.8 Clinic Manuals

 

12.8.1 Personnel Policies

  1. Job descriptions and performance standards are provided for all staff members. These descriptions and standards should include:

    • qualifications and training requirements for each position

    • the role each position plays in the operation of the clinic

    • a description of the essential tasks required for each position

    • the mechanism for performance evaluation, and                                 

    • the respect, consideration, and attitudes expected to be conveyed to clinic clients.

  2. Non-licensed personnel who provide Express STD services are appropriately trained and approved to collect specimens.

  3. Policies regarding employee health (e.g., injury surveillance, blood-borne pathogen exposure, tuberculosis screening, and hepatitis B vaccination) are consistent with state and local employee health regulations and are clearly written and enforced.

  4. Written policies and procedures are in place to conduct quality assurance, including chart review, client satisfaction surveys, staff development, and related training activities. Written policies and procedures are in place to describe disciplinary actions that will be taken if an employee violates a policy/procedure.

  5. Written policies and procedures are in place to require and document training of all staff regarding suspected sexual child abuse screening and reporting.

  6. Written policies and procedures are in place to ensure reportable conditions are routed to the proper surveillance staff in accordance with DSHS HIV and STD Program Operating Procedures and Standards, Chapter 8, HIV/STI Surveillance.


12.8.2 Medical Protocols

  1. Clinic protocols for client care are updated, approved, and co-signed by the delegating physician and all other clinicians annually;

  2. Protocols include, but are not limited to:

    • Client evaluation,                                 

    • Medical management of STDs based on current CDC STD Treatment Guidelines,                                 

    • Medical consultation and referral,                                 

    • Required follow-up after therapy,                                 

    • Counseling/education,

    • Management of sex partners - the clinic offers Expedited Partner Services to all clients who are heterosexual and suspected of, or diagnosed with, gonorrhea and/or chlamydia, including on site treatment of partners who accompany clients, PDPT, and/or FDT. Express clinic visits are available to asymptomatic, heterosexual partners to obtain treatment for gonorrhea and/or chlamydia, and                                  

    • Expanded treatment of contacts and suspects (including self-reported exposures) during local syphilis outbreaks.

  3. Emergency medical protocols are current:

    • One copy of an emergency protocol is kept in the clinic manual and one copy is kept with the emergency supplies.

    • Clinic staff are certified in Basic Cardiac Life Support (BCLS) and automated external defibrillator (AED) use.

    • Emergency equipment, supplies, and medications are checked monthly to ensure they are not depleted or expired. Emergency supplies are sealed when not in use.

    • Mock emergency drills are performed regularly and documented. 

  4. Protocols for occupational exposure of healthcare workers are current and signed by a physician.

  5. Protocols for the safe handling of blood and body fluids (standard precautions) are current according to Clinical Laboratory Improvement Amendments (CLIA)/Occupational Safety and Health Administration (OSHA).

  6. Standing delegation orders (SDOs) (written physician instructions designed for patient populations with specific diseases, disorders, health problems or sets of symptoms) are written, dated, and signed by the medical supervisor, clinicians, registered nurses, licensed vocational nurses and other staff members who function under these orders.

  7. Procedures, protocols and SDOs are updated, approved, and signed annually, and must adhere to all applicable Texas laws, rules and regulations, including those of the Texas Medical Board and Texas Board of Nursing.

 

12.9 Clinician Roles and Performance Standards

  1. Nurses (LVNs,RNs), advanced practice nurses (APNs), and physician assistants (PAs) work in full compliance with established clinic protocols and standing delegation orders.  The examining/treating clinician is responsible for the entire clinical care process for the client(s) he/she is treating, including history taking, physical examination, laboratory specimen collection, diagnosis, treatment, plan for follow-up, and counseling/education.

  2. Non-physician clinicians have adequate physician back up and operate under protocols and SDOs signed by a physician.

  3. Minimum background and training includes:

    • Licensure (e.g., LVN, RN, APN, PA, or physician) or credentials required by the state or locality to perform the functions of an STD clinician. A process to verify current licensure is in place.

    • Clinicians who are new to STD/HIV and/or the clinic are trained and observed by a veteran clinician prior to caring for clients.

    • Within a year of employment, all clinicians must participate in the following trainings:

      • A comprehensive STD Clinician Course through an STD/HIV Prevention Training Center or similar course.*                                                                                                                                                                                                           

      • An HIV/AIDS Update that includes clinical and epidemiologic information about HIV infection.*

      • Gender identity issues, including how to appropriately respond to sexual assault of individuals who are gender non-conforming.

      • Human trafficking and intimate partner violence.

    • Clinicians must receive updates on STD and HIV topics at least every two years.

    *An acceptable alternative to classroom attendance is the use of on-line training materials, e.g., www.std.uw.edu (for STDs) and aidsetc.org/training (for HIV/AIDS).

  4. STD clinical services should be performed in the following manner:

    • Clinicians present an image of sensitivity and competence to the client

    • The medical history and risk assessment are obtained by asking open-ended questions, (e.g. How long, When, How many, What, Describe, etc.).

    • Clinicians examine all appropriate anatomy with professional thoroughness

    • All laboratory specimens are collected and labeled correctly

    • The chief complaint, history of present illness, medical and sexual history, physical examination, laboratory results, diagnosis, treatment plan and treatment provided, counseling/education, follow-up plan, and referrals are accurate and documented in the medical record

    • Counseling messages are specific, clear, and brief, allowing time for client’s questions.

    • When patient-delivered partner therapy (PDPT) is offered, the client’s acceptance or refusal of it is documented in the medical record.  If PDPT is provided, the client is counseled and given written information (in the partner’s language whenever possible) and the medication and number of prescriptions provided is documented in the index client’s medical record.

    • Clinicians strictly adhere to standard precautions (previously referred to as universal blood and body fluid precautions).                                                                                                                                                                   

    • Clinicians inform and facilitate a seamless transfer of a client to other team members as appropriate (e.g., DIS, case manager, immunization staff member).

 

12.10 Laboratory Services

  1. All clinics that provide STD services and have an on-site stat laboratory or capacity to perform stat tests must have a current CLIA certificate and be in compliance with CLIA-88.

  2. Stat laboratories should perform the following tests, all of which are classified as moderately complex under CLIA, with the exception of urine pregnancy which are classified as CLIA-waived:

    • Gram stain to detect intracellular gram-negative diplococci and presence of white blood cells to detect urethritis

    • Non-treponemal antibody tests for syphilis (e.g. RPR).

    • Darkfield examination for Treponema pallidum if available

    • Saline wet mount for Trichomonas vaginalis and detection of clue cells of bacterial vaginosis

    • KOH wet mount for the identification of yeast and for amine odor (Whiff) test

    • Pregnancy test

    • Rapid HIV test*, and

    • Rapid treponemal test for syphilis (e.g., Syphilis Health Check)*

    * NOTE:  Some rapid HIV and syphilis tests are CLIA-waived. Please consult the manufacturer’s instructions for the specific test kit.

  3. Preparing for multi-drug resistant gonorrhea:

    • The clinic has a relationship with a reference laboratory and a well-defined procedure for culture and antibiotic susceptibility testing when resistant gonorrhea is suspected.

    • There is a procedure in place for reporting suspected or confirmed antibiotic resistance to the proper health authorities.

 

12.11 Quality Assurance Procedures

  1. A quality assurance committee meets regularly and follows an approved protocol to conduct audits, analyze findings, and develop recommendations.

  2. Medical records are audited regularly (checked against clinic protocols) to determine the appropriateness of diagnoses and treatment and the completeness of documentation.

  3. The quality of stat laboratory procedures is monitored regularly.

  4. Staff interactions with clients are observed regularly by appropriate clinical managers.

  5. A mechanism has been established for receiving, reviewing, and responding to client complaints.

  6. A system is in place to ensure specimens are properly labeled and packed for shipping in accordance with the receiving laboratory specifications.

  7. Semi-annual safety audits are performed to determine appropriate use of electrical equipment, storage of chemical, and first-aid stations.

 

12.12 Sexual Assault and Abuse

  1. Written policies and procedures are in place to describe how the agency determines, documents, and reports instances of suspected child abuse in accordance with Chapter 261 of the Texas Family Code.

  2. Clinic maintains records relating to services to minors under age of 14.

  3. All clinic staff are trained on the provisions of the state child abuse and neglect statute and their obligations at orientation and once a year ( Chapter 261 of the Texas Family Code).

  4. Clinic staff members are trained on applicable STD and HIV confidentiality statutes at orientation and once a year and are sensitive to any limitations on the reporting of supplementary information related to suspected abuse cases.

  5. The clinic has well-developed procedures in place that outline the referral of clients who are victims of alleged child sexual abuse or adult sexual assault who need or request a forensic exam.

  6. A completed checklist for screening for suspected sexual child abuse and reporting is evident in medical records when appropriate and contractually required, in accordance with Chapter 261 of the Texas Family Code.

  7. Clinics have access to a client advocate who maintains links with victim’s assistance programs.

  8. Clinics have a well-defined procedure for assisting and referring victims of human trafficking and intimate partner violence to the appropriate community resources.

The following links are provided to the references on which these standards are based:

 

 

Subchapters

12.1 Accessibility/Clinic Environment

12.2 Range of Services

12.3 Client Considerations

12.4 Registration Process

12.5 Clinic Flow – Appointment and Walk-in Systems

12.6 Medical Records

12.7 Clinic Management Structure – Clinic Manager/ Medical Director

12.8 Clinic Manuals

12.9 Clinician Roles and Performance Standards

12.10 Laboratory Services

12.11 Quality Assurance Procedures

12.12 Sexual Assault and Abuse

Last updated February 1, 2019