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 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 Population King County, Washington All MSM diagnosed with early syphilis & gonorrhea Time period Cases diagnosed from Jan 2016-Dec 2017 Data source Outcome Matched HIV/STD surveillance and PS data 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 outcome 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 PrEP referral Inadequate engagement in HIV care Newly diagnosed with HIV at or following PS interview Based on PS record + HIV diagnosis date in HIV surveillance Accepted PS-based referral to PrEP 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 HIV-negative MSM interviewed for PS HIV-negative MSM interviewed for PS 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 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 HIV-diagnosed as a result of PS 444 (20%) accepted PS PrEP referral 39 (5.1%) reported inadequate engagement in HIV care Case-finding NNTI = PrEP Referral NNTI = 5.0 Engagement in Care NNTI = 19.7 GC = gonorrhea
% newly diagnosed with HIV HIV Case-Finding No new HIV diagnoses as a result of PS 32 (1.5%) of PS recipients were newly diagnosed with HIV 4.0% New HIV diagnoses at time of STD among MSM PS recipients without a prior HIV diagnosis 3.6% 3.0% 2.0% 1.0% 1.5% 1.0% 1.4% 0.8% 0.7% 0.0% Overall P&S Syphilis Early Latent Syphilis Rectal GC Urethral GC Pharyngeal 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 ART 9 (23%) no 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 Funding & Support - CDC AAPPS Evaluation Supplement & Minority AIDS Initiative - Washington State DOH Office of Infectious Disease - Public Health Seattle & King County HIV/STD Program Public Health Seattle & King County - Field services staff - PrEP clinic staff - Christina Thibault - Tigran Avoundjian CDC Division of STD Prevention - Brandy Maddox