Integrating PrEP into STD Partner Services in Washington State David Katz, PhD MPH University of Washington Public Health – Seattle & King County NCSD Engage November 16, 2017

STD Partner Services (PS) in Washington State STD PS present an opportunity to provide population-based HIV prevention to people at high risk In 2012, WA State began integrating interventions across HIV prevention/care continuum PrEP referral HIV testing HIV/STI testing reminders Engagement in HIV care Simultaneously prioritized MSM for PS MSM account for >2/3 of HIV infections in WA Facilitated by gender of sex partners on case report

King County PS Program & PrEP Referrals DIS attempt to provide partner services to MSM w/ STIs DIS assess HIV status & PrEP eligibility HIV-negative MSM at high risk1 early syphilis or rectal GC methamphetamine or poppers use sex work HIV-unsuppressed partner Black or Latino HIV-negative MSM at lower risk CT or urethral/pharyngeal GC without behavioral risk Offer referral to PrEP at public health STD clinic or community providers Offer referral to community providers for PrEP 1http://www.kingcounty.gov/healthservices/health/communicable/~/media/health/publichealth/documents/hiv/PrEP-Implementation-Guidelines.ashx

King County STD Clinic PrEP Program Focus on MSM at high risk (risk-prioritized) and Black & Latino MSM (to address inequities in access) PrEP fully integrated – all clinicians can prescribe DIS coordinate the program Counseling, payment assistance applications, HIV/STD screening SMS-based appointment reminder and two-way text system Baseline visit – same day PrEP prescription Follow-up visits every 3 mo. with DIS Clinicians only see patients at intake, then every 6 months

Evolution of PrEP Referral Process Oct 2014 Assess & refer ES to PrEP Rectal GC highest risk of future HIV2 Jan 2016 Refer all, Stratified by risk Black/Latino <PrEP than white MSM4 Practice May 2015 Assess all, Refer ES & rectal GC Apr 2017 Black & Latino MSM eligible for PH PrEP4 Nov 2017 Improve process for trans/non- binary clients Evidence ES highest risk of concurrent STI/HIV dx1 Post-STI HIV incidence2 DOH/PHSKC Guidelines3 1Katz et al. AIDS Patient Care STDs 2016; 30: 208-14. 2Katz et al. Sex Transm Dis 2016; 43: 249-54. 3http://www.kingcounty.gov/healthservices/health/communicable/~/media/health/publichealth/documents/hiv/PrEP-Implementation-Guidelines.ashx. 4Katz et al. CROI 2017, Abstract 89.

Supplemental Database – PrEP Questions

PS Delivery & PrEP Use 7546 STI cases reported among HIV-negative MSM Aug 2014 – Aug 2017 3739 (50%) received partner services 2055 (55%) at high risk for HIV1 1517 early syphilis or rectal GC 538 other risk 1684 (45%) at lower risk for HIV 1840 (90%) had PrEP use assessed 1398 (83%) had PrEP use assessed 907 (49%) on PrEP already 951 (51%) not on PrEP 443 (31%) on PrEP already 976 (69%) not on PrEP 1Does not include Black/Latino MSM with no other risk; criterion added April 2017

PrEP Referral Outcomes Among 539 high risk MSM with STDs who reported not being on PrEP during PS interview, Jan 2016-Aug 2017 Of offered, 18% known to have attended visit* Unable to assess external referrals * Cases 539 466 262 108 86 *Within 3 months of PS interview

Facilitators and Barriers Gender of sex partners on case report Dedicated DIS Existing supplemental database PH PrEP clinic Availability of PrEP in community State drug assistance program Barriers Recorded in separate database Balancing standard PS activities vs PrEP Navigating insurance, assistance program

Prospective Assessment Objectives Assess effectiveness of referrals Inform decision re: additional follow-up post-referral Methods Random sample of MSM not on PrEP from 2016 PS Stratified by high/low risk and did/did not accept referral 3-minute follow-up phone interview to: Asess PrEP use following PS Identify barriers to PrEP/reasons for stopping Determine current interest/eligibility and offer new referrals Current status DIS completed interviews Apr-Sep 2017 Analyses to inform follow-up activities underway

Other Models in WA State Pierce Co. DIS refer to 1 provider group Appointing privileges EMR access ROI to share records PH offers quarterly labs DIS follow-up with patients who do not schedule or attend appointments Spokane DIS refer to PH navigators for persons at high risk for HIV (PAHR) PrEP education, referral, & adherence support Insurance & care linkage Other social/medical needs Refer to and support community providers

Summary & Conclusions STD PS present an opportunity to promote PrEP to a large and diverse population of MSM at high risk for HIV LHJs developed unique approaches to PrEP promotion based on their context and resources King County - Referring MSM to a PH clinic and community providers was successful at promoting PrEP Additional efforts needed to improve delivery and uptake at each step of referral process Ongoing M&E used to improve prioritization and process PrEP promotion should be considered an outcome of STD PS for high risk populations

Acknowledgments CDC DSTDP AAPPS Evaluation Team Funding & Support Teal Bell, Matt Golden, Julie Dombrowski, Zandt Bryan Local Health Jurisdictions Field services teams King: Dawn Spellman, Mike Barry, Christina Thibault, PrEP clinic team Spokane: Lisa St. John Pierce: Evelyn Manley Rodriguez, LaShawn Jones CDC DSTDP Brandy Maddox, Marion Carter Funding & Support CDC AAPPS Evaluation Supplement & Minority AIDS Initiative Washington State DOH Public Health – Seattle & King County