The Case for PrEP: STD and HIV epidemiology in Santa Clara County Courtesy CDC Public Health Image Library Courtesy CDC Public Health Image Library Photograph: Dr David Phillips/Getty Images/Visuals Unlimited The Case for PrEP: STD and HIV epidemiology in Santa Clara County PrEP: Making HIV Prevention Easy. October, 2017 Sarah C. Lewis, MD, MPH STD/HIV Controller & Assistant Public Health Officer Santa Clara County Public Health Department

Disclosure Information Sarah C. Lewis, MD MPH SAMPLE OF SPEAKER DISCLOSURE SLIDE Disclosure Information Sarah C. Lewis, MD MPH I have no financial relationships to disclose. I will discuss off label use of NAATs.

Learning Objectives Understand local epidemiology of HIV and STDs in SCC Identify patient populations at risk for HIV and STDs SCC based on epidemiology and screening recommendations Recognize benefit of PrEP for prevention of other STDs

Overview Epidemiology of STDs in Santa Clara County Recommendations for HIV Screening and Prevention Bacterial STDs and the Power of Screening

Epidemiology of STDs in Santa Clara County 2016 Summary Data

Pop quiz! Which of the following statements most accurately describes the current epidemiologic STD trends in Santa Clara County? New prevention and treatment options have contributed to overall declining rates of chlamydia, gonorrhea, and syphilis in SCC and nationally. Despite increases in surrounding counties, rates of chlamydia, gonorrhea, and syphilis are stable or falling in SCC, likely due to increased healthcare access. Surveillance reporting shows rising rates of chlamydia, gonorrhea, and syphilis, along with persistent disparities by race, ethnicity, gender, and gender of partners. Data suggest rising rates of chlamydia, gonorrhea, and syphilis in SCC, but these are most likely confounded by new testing guidelines and increased access to care.

Pop quiz! Which of the following statements most accurately describes the current epidemiologic STD trends in Santa Clara County? New prevention and treatment options have contributed to overall declining rates of chlamydia, gonorrhea, and syphilis in SCC and nationally. Despite increases in surrounding counties, rates of chlamydia, gonorrhea, and syphilis are stable or falling in SCC, likely due to increased healthcare access. Surveillance reporting shows rising rates of chlamydia, gonorrhea, and syphilis, along with persistent disparities by race, ethnicity, gender, and gender of partners. Data suggest rising rates of chlamydia, gonorrhea, and syphilis in SCC, but these are most likely confounded by new testing guidelines and increased access to care.

Chlamydia case counts and rates in Santa Clara County, 2010-2016 Sources: 1. SCC Public Health Department, AVSS (2010-2011), CalREDIE (2011-2016), data as of March, 2017, and are provisional; 2. State of California, Department of Finance, State and County Population Projections by Race/Ethnicity and Age, 2010-2060, December 15, 2014

Sources: 1. SCC Public Health Department, AVSS (2010-2011), CalREDIE (2011-2016), data as of March, 2017, and are provisional; 2. State of California, Department of Finance, State and County Population Projections by Race/Ethnicity and Age, 2010-2060, December 15, 2014

* Due to large proportions of missing race/ethnicity information, unknown race/ethnicity cases were redistributed based on the proportions of the known race/ethnicity cases with consideration of age. Rates and counts based on imputed race/ethnicity need to be interpreted with precautions. Sources: 1. SCC Public Health Department, CalREDIE (2016), data as of March, 2017, and are provisional; 2. State of California, Department of Finance, State and County Population Projections by Race/Ethnicity and Age, 2010-2060, December 15, 2014

* Includes primary, secondary and early latent syphilis cases. Sources: 1. SCC Public Health Department, AVSS (2010-2011), CalREDIE (2011-2016), data as of March, 2017, and are provisional; 2. State of California, Department of Finance, State and County Population Projections by Race/Ethnicity and Age, 2010-2060, December 15, 2014

* Include primary, secondary and early latent syphilis cases. Sources: 1. SCC Public Health Department, AVSS (2010-2011), CalREDIE (2011-2016), data as of March, 2017, and are provisional; 2. State of California, Department of Finance, State and County Population Projections by Race/Ethnicity and Age, 2010-2060, December 15, 2014

HIV epidemic in Santa Clara County As of 2016: Cumulative HIV/AIDS cases first reported in SCC*: 6,179 AIDS: 4,801 Alive: 3,669 People living with HIV/AIDS†: 3,208 2,648 (83%) SCC cases 560 (17%) out of jurisdiction cases In 2016: 134 new cases % of people alive: 59%. * Based on residency at diagnosis; † Based on most current address; Source: Santa Clara County Public Health Department, eHARS data as of May, 2017 and are provisional

Rates of HIV/AIDS diagnoses among individuals 13+, 2010 – 2016 Note: since number of cases younger than 13 is very small, only presented those with ages 13+. This will also be easier to compare to the national data. Overall the total rate for diagnoses of HIV decreased from 2010-2016 after an increase from 2013-2014 Highest rates are among males ages 13 and older that are nearly 6 times the rates among females in 2016 Among males ages 13 and older, the total rate for diagnoses decreased except for an increase between 2013 and 2014 and then decreased from 2014-2016 Among females ages 13 and older, the total rate for diagnoses decreased from 2010-2014 and then slightly increased from 2014-2016. The rate was the same in 2010 and 2016. However this may be due to smaller case numbers so this should be taken into consideration Source: 1. Santa Clara County Public Health Department, eHARS data as of May, 2017; 2. State of California, Department of Finance, State and County Population Projections by Race/Ethnicity and Age, 2010-2060, Sacramento, California, February 2017

Number of MSM cases* by selected age group, 2010 – 2016 *MSM includes both MSM only and MSM who are also IDU On average, among MSM cases between 2010 and 2016, 66% of MSM cases were younger than 40 at diagnosis. Increasingly more HIV diagnoses are among MSM Ages 20-29 than any other age group. * Include MSM, MSM & IDU. Source: Santa Clara County Public Health Department, eHARS data as of May, 2017, and are provisional.

Number of MSM cases* by race/ethnicity, 2010 – 2016 On average, among MSM cases between 2010 and 2016, nearly one half (45%) were Hispanics, one-third (31%) were whites, 16% API, and 5% blacks. 1. Number of African American and Asian/Pacific Islander MSM cases remained relatively low and stable over time. 2. Fewer white MSM were diagnosed between 2010 and 2016, the number of cases decreased by half. 3. For Hispanic/Latinos, the number of HIV diagnosis decreased from 2010 to 2013 but then increased sharped in 2014 and 2015, and then decreased last year. * Include MSM, MSM & IDU. Source: Santa Clara County Public Health Department, eHARS data as of May, 2017, and are provisional.

Who were more likely to be diagnosed late*? Older age groups (ages 40+) 44% (ages 40+) vs. 23% (ages <40) People of color 37% (AA), 35% (API), 34% (Hispanic) vs. 25% (White) IDU and individuals acquiring through heterosexual transmission 44% (IDU) and 45% (Heterosexual) vs. 26% (MSM) and 28% (MSM&IDU) Foreign-born 42% (foreign-born) vs. 27% (U.S.-born) Among cases diagnosed in 2010-2015: People more likely to be tested late 1. Ages 40 and older 2. African Americans, Asian/Pacific Islanders 3. IDU and Heterosexual transmission 4. Foreign Born * Statistically significant with p < 0.05 Source: Santa Clara County Public Health Department, eHARS data as of May, 2017.

Percentage of people living with HIV with STD† Santa Clara County, 2016 STD infections were not self reported. Co-infections were identified by matching the list of PLWH in 2016 and cases diagnosed with STD in 2016 only infectious syphilis is included 10.4% of people living with HIV were infected with an STD overall Chlamydia was the most diagnosed individual STD with 5.2% of people living with HIV co-infected † People ages 13 and older chlamydia, gonorrhea, early syphilis (primary, secondary and early latent) diagnosed in 2016. A person with multiple episodes of one disease in the year will be only counted once for the disease. * Include primary, secondary and early latent syphilis cases. ** The percentage of overall STD diagnosis is lower than the sum of the percentages of chlamydia, gonorrhea and early syphilis because one person may be diagnosed with multiple diseases. Source: 1. Santa Clara County Public Health Department, eHARS data as of May, 2017, 2. Santa Clara County Public Health Department, CalREDIE (2016), data as of March, 2017, and are provisional

HIV Screening and Prevention Making HIV Prevention Easy

Who should be screened for HIV? All patients ages 13 – 64 years in all health-care settings. All patients who seek evaluation and treatment for STDs. All pregnant patients in 1st trimester; again in 3rd trimester and at delivery if at high risk. MSM annually and up to q3 months if at high risk. NO need for separate written consent. (Opt-out)

HIV Prevention Treatment as Prevention (TasP) depends on diagnosis and linkage Pre-Exposure Prophylaxis: Can be provided in primary care settings Navigation help for clients: 408-792-3750 Clinical consult for providers: 855-HIV-PrEP (Monday – Friday: 8am to 3pm) STD/HIV Controller: 408-792-5051 Resources for providers: Stay Tuned!

Rapid rise in PrEP use in the US ~80,000 unique individuals started PrEP in 2012-2015 But lower uptake in: People of color African Americans Latinx Youth Transgender people 738% increase From Cohen 2012 2013 2014 2015 2012 2013 2014 Slide courtesy of Stephanie E. Cohen

% of Adults with PrEP Indication No. of Adults with PrEP Indication From Cohen Slide courtesy of Catherine Koss & Stephanie E. Cohen

HIV prevention in any role Screen for HIV and risk factors Screen for and treat bacterial STDs Offer PrEP resources in your waiting room Refer for PrEP Navigation: 408-792-3750

Bacterial STDs: The power of screening Making HIV Prevention Easy

Who Should be Screened for CT/GC? < 25 annually, 25+ if at risk Pregnant (first trimester) Females At least annually Exposed sites: genital, rectal, throat MSM High prevalence settings Hetero males All exposed sites HIV + Every 3 months Patients on PrEP All patients, 3 months after treatment Post-Tx Risk factors: prior infection, new partner in past 3 months, female with MSM partners, > 1 sex partner in past year, exchange sex, AA up to age 30, incarcerated, or incarcerated partner CDC 2015 STD Tx Guidelines www.cdc.gov/std/treatment Plus: Guidelines for HIV care and PrEP

High Proportion of Extragenital CT/GC associated with negative urine test STD Surveillance Network (n=21,994) Slide courtesy of Dr. Ina Park. Patton et al CID 2014

A Majority of Rectal Infections in MSM are Asymptomatic 86% 84% Chlamydia Gonorrhea n=316 n=264 Asymptomatic Urethral Infections Symptomatic 10% 42% Chlamydia Gonorrhea n=315 n=364 Slide courtesy of Dr. Ina Park. Kent, CK et al, Clin Infect Dis July 2005

Chlamydia and Gonorrhea NAAT: Rectal and Pharyngeal Sites Commercially-available NAATs have not been cleared by FDA for these indications They can be used by laboratories that have undergone validation procedures and met all regulatory requirements for an off-label procedure Similar validation procedures apply for self-collected specimens MMWR. Mar 14 2014;63(No RR-12):1-19. Slide courtesy of Dr. Ina Park.

Clinical Guidelines and Consultation Free CDC STD Treatment Guidelines App Search for “STD TX” CDC’s STD Treatment Guidelines www.cdc.gov/std/treatment/ STD Clinical Consult Network www.stdccn.org Slide courtesy of Dr. Ina Park.

STDs among PrEP users in PrEP Demo 26.4% of participants had GC, CT or early syphilis at baseline 50.9% had at least one STI during follow-up STI incidence was high but did not increase over time % infections for which treatment would have been delayed with q6 month, as opposed to q3 month, screening From Cohen As expected, >80% of rectal and pharyngeal infections were asymptomatic; 18% of urethral GC and 65% of urethral CT asx Percent of cases that were asymptomatic at follow-up [n/N (%)] rectal GC: 78/96 (81.3%) rectal CT: 156/173 (90.2%) pharyngeal GC: 106/125 (84.8%) pharyngeal CT: 25/30 (83.3%) urethral GC: 6/33 (18.2%) urethral CT: 34/52 (65.4%) Liu JAMA Intern Med 2016; Cohen # 870 CROI 2016. Slide courtesy of Dr. Stephanie Cohen

STDs among PrEP Users at SF Kaiser From Cohen (95% CI 58-71) And 2 incident HCV infections Summarize: Open label PrEP studies – no overwhelming e/o risk comp at indiv level, but enrolled ppts with high rates of condomless sex to begin with; high but stable STD rates Volk et al. CID 2015; Slide courtesy Dr. Jonathan Volk and Dr. Stephanie Cohen

Modeling Study of PrEP Impact on STI Incidence With 40% PrEP coverage and 40% risk compensation. 42% and of GC and 40% of CT infections would be averted over the next 10 years. From Cohen Jenness et al. CID, 2017.

Conclusions Bacterial STDs are on the rise in Santa Clara and California Young Latino and Black MSM are at highest risk for HIV in SCC Self-collected three-site screening can make STD testing fast and easy PrEP prevents HIV and also creates opportunities to decrease STDs