STD Partner Services for MSM Can Be Used to Promote PrEP and - - PowerPoint PPT Presentation

IUSTI 2018 World & European Congress 30 June 2018

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

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 cases at time of STD diagnosis HIV testing for partners SMS testing reminders PrEP referrals Identify PLWH inadequately 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 Outcome Number needed to interview (NNTI) to:

• Diagnose 1 new HIV case
• Refer 1 person to PrEP
• Identify 1 PLWH who is inadequately engaged in care

Calculated as: Number interviewed for PS ÷ Number with

• utcome

Stratification by STD diagnosis Syphilis = Primary/secondary vs. early latent Gonorrhea = Rectal vs. urethral vs. pharyngeal

Outcome Definitions

Outcome Definition & Measurement NNTI Numerator New HIV diagnosis

• Newly diagnosed with HIV at or

following PS interview

• Based on PS record + HIV diagnosis

date in HIV surveillance HIV-negative MSM interviewed for PS PrEP referral

• Accepted PS-based referral to PrEP

care HIV-negative MSM interviewed for PS Inadequate engagement in HIV care Case self-reported either:

• Not currently on ART OR
• If missing ART status:
• no HIV provider OR
• no care visit in last 6 months and

no future visit MSM living with HIV interviewed for PS

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

GC = gonorrhea

2205 (63%) interviewed for PS 3523 (70%) without prior HIV diagnosis 767 (52%) interviewed for PS 1476 (30%) with prior HIV diagnosis 4999 early syphilis and GC diagnosed among MSM 444 (20%) accepted PS PrEP referral 0 (0%) newly HIV-diagnosed as a result of PS 39 (5.1%) reported inadequate engagement in HIV care Case-finding NNTI = ∞ PrEP Referral NNTI = 5.0 Engagement in Care NNTI = 19.7

HIV Case-Finding

• No new HIV diagnoses as a result of PS
• 32 (1.5%) of PS recipients were newly diagnosed with HIV

P&S = primary and secondary. GC = gonorrhea

1.5% 3.6% 1.0% 1.4% 0.8% 0.7% 0.0% 1.0% 2.0% 3.0% 4.0% Overall P&S Syphilis Early Latent Syphilis Rectal GC Urethral GC Pharyngeal GC % newly diagnosed with HIV

New HIV diagnoses at time of STD among MSM PS recipients without a prior HIV diagnosis

PrEP Promotion

*Based on a random sample of cases diagnosed in 2016 (Katz et al, CROI 2018)

NNTI:

• 1 PrEP referral = 5.0 (3.8 P&S syphilis-5.4 pharyngeal GC)
• 1 PrEP initiation* = 9.6

1066 (48%) already on PrEP 1066 (94%) offered PrEP referral 1139 (52%) not on PrEP 2205 HIV-negative MSM interviewed for PS 444 (42%) accepted PrEP referral 56% initiated PrEP*

Promoting Engagement in HIV Care

NNTI to identify 1 person inadequately engaged in care

• Overall = 19.7
• Range = 10.3 P&S syphilis vs. 22-26 other infections

657 (94%) on ART 39 (6%) inadequately engaged in care 696 (91%) assessed for HIV care/ART status 767 MSM with prior HIV diagnosis interviewed for PS 9 (23%) no provider/visit 30 (77%) not on ART

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 County

• Field services staff
• PrEP clinic staff
• Christina Thibault
• Tigran Avoundjian

CDC Division of STD Prevention

• Brandy Maddox

Funding & Support

• CDC AAPPS Evaluation Supplement

& Minority AIDS Initiative

• Washington State DOH Office of

Infectious Disease

• Public Health – Seattle & King

County HIV/STD Program