STD Partner Services for MSM Can Be Used to Promote PrEP and Identify People Living with HIV Who are Inadequately Engaged in Care David A. Katz , Julia C. Dombrowski, Dawn Spellman, Teal R. Bell, Matthew R. Golden IUSTI 2018 World & European Congress 30 June 2018
STD Partner Services (PS) • Offered to people diagnosed with bacterial STDs and their partners • Historical objectives: - Ensure appropriate treatment for index case - Elicit, notify, test, and treat partners Decrease STD transmission and morbidity • Practices vary internationally - In US, provided widely for syphilis, infrequently for GC/CT • Concern that effectiveness may be declining • Opportunity to provide population-based HIV prevention
Integrating HIV Prevention into STD PS HIV testing for HIV testing for SMS testing cases at time of partners reminders STD diagnosis Identify PLWH inadequately PrEP referrals engaged in care & (re)link PrEP = pre-exposure prophylaxis; PLWH = people living with HIV
Objectives • Aim 1: Evaluate use of PS for early syphilis and gonorrhea among MSM to: - Ensure HIV testing at time of STD diagnosis - Provide referrals to PrEP care - Identify PLWH who are inadequately engaged in care • Aim 2: Assess differences in efficiency of PS-based HIV prevention by STD diagnosis
Methods Setting King County, Washington Population All MSM diagnosed with early syphilis & gonorrhea Time period Cases diagnosed from Jan 2016-Dec 2017 Data source Matched HIV/STD surveillance and PS data Number needed to interview (NNTI) to: - Diagnose 1 new HIV case - Refer 1 person to PrEP Outcome - Identify 1 PLWH who is inadequately engaged in care Calculated as: Number interviewed for PS ÷ Number with outcome Stratification by Syphilis = Primary/secondary vs. early latent STD diagnosis Gonorrhea = Rectal vs. urethral vs. pharyngeal
Outcome Definitions Outcome Definition & Measurement NNTI Numerator • Newly diagnosed with HIV at or New HIV following PS interview HIV-negative MSM • diagnosis Based on PS record + HIV diagnosis interviewed for PS date in HIV surveillance • Accepted PS-based referral to PrEP HIV-negative MSM PrEP referral care interviewed for PS Case self-reported either: • Not currently on ART OR Inadequate • If missing ART status: MSM living with HIV engagement in • no HIV provider OR interviewed for PS HIV care • no care visit in last 6 months and no future visit ART = antiretroviral therapy
MSM with Early Syphilis & Gonorrhea, 2016-17 N % (of 4999 total) STD diagnosis Syphilis – Primary/Secondary 555 11% Syphilis – Early latent 513 10% Gonorrhea - Rectal 1867 37% Gonorrhea - Urethral 1334 27% Gonorrhea - Pharyngeal 1969 39% Prior HIV diagnosis 1476 30% Diagnosed in STD clinic 1206 24% Age 15-24 812 16% 25-34 2056 41% 35+ 2130 43%
Overall HIV Prevention Outcomes 4999 early syphilis and GC diagnosed among MSM 3523 (70%) without prior HIV diagnosis 1476 (30%) with prior HIV diagnosis 2205 (63%) interviewed for PS 767 (52%) interviewed for PS 0 (0%) newly 444 (20%) 39 (5.1%) reported inadequate HIV-diagnosed accepted PS engagement in HIV care as a result of PS PrEP referral Case-finding PrEP Referral Engagement in Care NNTI = ∞ NNTI = 5.0 NNTI = 19.7 GC = gonorrhea
HIV Case-Finding • No new HIV diagnoses as a result of PS • 32 (1.5%) of PS recipients were newly diagnosed with HIV New HIV diagnoses at time of STD among MSM PS recipients without a prior HIV diagnosis % newly diagnosed with HIV 4.0% 3.6% 3.0% 2.0% 1.5% 1.4% 1.0% 0.8% 0.7% 1.0% 0.0% Overall P&S Syphilis Early Latent Rectal GC Urethral GC Pharyngeal Syphilis GC P&S = primary and secondary. GC = gonorrhea
PrEP Promotion 2205 HIV-negative MSM interviewed for PS 1066 (48%) already on PrEP 1139 (52%) not on PrEP 1066 (94%) offered PrEP referral 444 (42%) accepted PrEP referral 56% initiated PrEP* NNTI: - 1 PrEP referral = 5.0 (3.8 P&S syphilis-5.4 pharyngeal GC) - 1 PrEP initiation* = 9.6 *Based on a random sample of cases diagnosed in 2016 (Katz et al, CROI 2018)
Promoting Engagement in HIV Care 767 MSM with prior HIV diagnosis interviewed for PS 696 (91%) assessed for HIV care/ART status 657 (94%) on ART 39 (6%) inadequately engaged in care 30 (77%) not on 9 (23%) no ART provider/visit NNTI to identify 1 person inadequately engaged in care • Overall = 19.7 • Range = 10.3 P&S syphilis vs. 22-26 other infections
Limitations • Relied on self-reported ART/care status • Unable to determine effect on (re)linkage to HIV care • Intervention relied on: - Robust local HIV prevention and care infrastructure - Ability to identify MSM prior to case assignment May limit ability to replicate program • Potential effect of interventions limited by successes in HIV prevention and care - Met 90/90/90 objectives - Declining HIV incidence (50% over last decade) - High PrEP coverage
Summary & Conclusions • HIV care and prevention outcomes can be successfully integrated into STD PS • Among MSM in King County: - primarily useful for PrEP promotion - some success identifying PLWH inadequately engaged in HIV care - not effective for HIV case-finding among index cases • In areas with less HIV infrastructure or higher incidence, may have more benefit but be harder to implement • Health departments should consider expanding the scope and objectives of STD PS to include HIV prevention
Acknowledgments Public Health – Seattle & King Funding & Support County - CDC AAPPS Evaluation Supplement & Minority AIDS Initiative - Field services staff - Washington State DOH Office of - PrEP clinic staff Infectious Disease - Christina Thibault - Public Health – Seattle & King - Tigran Avoundjian County HIV/STD Program CDC Division of STD Prevention - Brandy Maddox
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