Role of HIV Partner Counseling & Referral Services (PCRS) in Identifying New HIV Infections among Partners to HIV Co-Infected Syphilis Cases Rilene A. Chew, MPH Phoenix Smith, MSW; Michael Samuel, DrPH; Gail Bolan, MD California Department of Public Health, STD Control Branch National STD Prevention Conference – Chicago, IL March 12, 2008 Good morning – I’m Rilene Chew and I’m an epidemiologist with the California STD Control Branch. Today I’m going to DISCUSS California’s experience with the HIV Partner Counseling & Referral Services program, also known as PCRS. I will describe it in the context of syphilis case management, and the role that PCRS has had in newly identifying HIV infections among partners to HIV co-infected syphilis cases.

Background I: Early Syphilis in California Early syphilis in California has been increasing since 1999 Majority of early syphilis cases are male, predominantly among men who have sex with men (MSM) - 61% of MSM cases report being HIV co-infected Syphilis facilitates HIV transmission and acquisition Partners to HIV co-infected syphilis cases are at risk for both syphilis and HIV infection, if not already HIV positive The number of early syphilis cases in California has been increasing since 1999. The majority of these cases have been male and predominately among men who have sex with men. Approximately 61% of MSM cases report being co-infected with HIV. We are concerned about this high proportion of HIV co-infection among syphilis cases because syphilis is a facilitator of HIV transmission and acquisition. This means partners to HIV co-infected syphilis cases are at risk not only for syphilis infection, but also HIV, if not already HIV positive.

Case Management and Partner Notification Process for HIV Co-infected Syphilis Case Lab Slip / CMR Health Dept. Case Management New Early Syphilis Case PCRS offer for HIV co-infected Syphilis Interview Record PCRS Original Client Form Disease Intervention Specialists (DIS) Health dept. assisted follow-up for syphilis exposure Health dept. assisted follow-up for HIV exposure In California, Disease Intervention Specialists, or DIS, are trained to conduct syphilis case management and partner notification. All early syphilis cases reported to the health department are interviewed by DIS using the California Syphilis Interview Record. DIS use this form to ask about self-disclosed HIV status, to elicit information on sex and needle-sharing partners, and to offer health department assistance with notifying partners of syphilis exposure. If cases do accept health-department assistance, partners are initiated on a syphilis field record for DIS follow-up. If an early syphilis case is also co-infected with HIV, MOST DIS are also trained to offer PCRS and complete the PCRS original client form. The PCRS program in California offers HIV-infected individuals the option of patient referral, dual referral, or health department assistance with notifying partners of HIV exposure. If cases accept health department assistance, partners ARE INITIATED ON A SEPARATE HIV FIELD RECORD for DIS follow-up. For co-infected syphilis cases, HIV and syphilis partner notification and testing are done concurrently. Partner Notification Syphilis Partner Field Record HIV Partner Field Record

Objectives Assess utilization of PCRS by HIV co-infected syphilis cases in California Project Area* Assess PCRS and syphilis partner outcomes for HIV co-infected syphilis cases who accepted health dept services Compare PCRS and syphilis partner outcomes Therefore, our objectives were as follows: To assess utilization of PCRS by HIV co-infected syphilis cases reported in the California Project Area, which includes cases for the entire state, … except San Francisco and Los Angeles, who are responsible for PCRS and syphilis case management in their own local health jurisdictions. Our second objective was to assess PCRS and syphilis partner outcomes for those HIV co-infected syphilis cases who accepted health-department assistance with partner notification. Lastly, we compared PCRS and syphilis partner outcomes. *California Project Area excludes San Francisco & Los Angeles health jurisdictions

Methods I: HIV Co-Infected Syphilis Cases Interviewed early syphilis cases from January-Sept 2007, California Project Area Self-reported HIV co-infected cases - concurrent: 0-30 days before syphilis diagnosis or after syphilis diagnosis - previous: > 30 days before syphilis diagnosis Our evaluation was based on interviewed early syphilis cases, because HIV status is based on self-disclosure. Due to data concerns regarding quality and completeness, we looked at syphilis cases interviewed between January and September 2007. We THEN categorized HIV co-infected cases as either concurrent or previous HIV positive cases, depending on the time between a case’s HIV and syphilis diagnosis. The 30 day window in the definitions was to account for small lapses between HIV and syphilis testing dates.

Methods II: PCRS Partner Outcomes HIV co-infected syphilis case interview records were matched to PCRS offer forms using unique ID PCRS offers were matched to initiated HIV partner field records using unique ID Assessment of HIV partner outcomes: # notified # previous positive # tested # newly identified positive To assess PCRS outcomes, we took our identified HIV co-infected syphilis cases and matched their interview records to their PCRS offer forms using a unique ID. Cases with no matching PCRS form were dropped from analysis. PCRS offer forms were then matched to initiated HIV partner field records and assessed for partner outcomes, including: - the number of partners notified of their HIV exposure; - of those notified, the number of previous HIV positives and the number tested for HIV; - and of those tested, the number of partners with newly identified HIV infections.

Methods III: Syphilis Partner Outcomes HIV co-infected syphilis case interview records were matched to initiated syphilis partner field records using unique ID Assessment of syphilis partner outcomes: # notified # previously treated # tested # infected, treated # infected, not treated # preventive Rx # no preventive Rx To assess syphilis partner outcomes, we again took our co-infected syphilis cases and matched their interview records to initiated SYPHILIS partner field records. Similar to PCRS, we looked at the number of partners notified, and of those notified, the number who were previously treated and the number tested. Then of those tested, we looked at the number who were infected and whether they received treatment, and also the number who received preventive treatment.

1078 early syphilis cases (72% MSM) Results I: HIV Co-infection among Interviewed Early Syphilis Cases, California Project Area, Jan-Sept 2007 1078 early syphilis cases (72% MSM) 959 (89%) interviewed 402 HIV positive of known duration, (52%, excluding unknown/refused) 51 (13%) concurrent positive 351 (87%) previous positive partners: 331 named; 3125 anonymous We identified 1078 early syphilis cases in the CPA between January and September 2007, 72% of cases being MSM. 959 or 89% of cases were interviewed and 402 were HIV positive, or 52% if we exclude cases with unknown or refused status. Of these 402 co-infected cases, 13% reported they were concurrently diagnosed with HIV and syphilis, while 87% were previous HIV positives. Also, 331 total partners were named with enough locating information to provide health department notification of syphilis exposure, if requested. In contrast, 3125 anonymous partners were reported, highlighting how many partners lack enough identifying information to conduct any partner notification activity. These partners were based on the interview period, or the time interval during which syphilis transmission occurred.

Results II: Serostatus of Partners, as Reported by Interviewed HIV Co-Infected Early Syphilis Cases, CPA Jan-Sept 2007 Concurrent Positive Previous Positive # Co-Infected Cases N=51 % N=351 Serostatus of Partners in past 12 months All Positive 2 4% 83 24% Positive + Neg/Unk 14 27% 108 31% Negative + Unknown 7 14% 18 5% All Unknown 21 41% 12 3% All Negative 4 8% Refused/Missing 3 6% 36 10% Next we looked at serostatus of partners, as reported by the original patients, to get an idea of how much serosorting might be going on among our co-infected cases. This is an important factor to consider because cases whose partners are already known to be HIV positive may be less likely to accept PCRS. However, only 4% of concurrent positives and 24% of previous positives reported that all their partners were already known to be infected with HIV. This indicates that a high proportion of cases in either group had at least one partner who could potentially benefit from PCRS follow-up, since their status was either unknown, negative, or missing.

Results III: PCRS for HIV Co-Infected Interviewed Early Syphilis Cases, CPA Jan-Sept 2007 Total # Co-Infected Cases 402  # Documented PCRS Offer on Syphilis Interview Record 231  # Clients choosing Health Dept Partner Notification 13  # Partners Initiated 21 This table shows that of our 402 co-infected syphilis cases, 231 had a documented PCRS offer. This indicates a low proportion of co-infected cases are offered PCRS; this could be due to a variety of different factors. For example, PCRS offers are often made, but if cases decline or do not choose health department assistance, an offer is never documented. Also, MOST DIS are trained to offer PCRS, but not all. But if we look at the 231 clients offered PCRS, only 13 cases or 5.6% accepted health department assistance with notifying partners of HIV exposure. So it seems there is low utilization of HEALTH DEPARTMENT partner notification among those offered PCRS. <We did a similar analysis excluding cases who reported their partners were already HIV positive, but while the numbers were less, there was no substantial impact on the proportion of cases offered or on PCRS partner outcomes.>

Results IV: Syphilis Partner Outcomes for HIV Co-Infected Interviewed Early Syphilis Cases, CPA Jan-Sept 2007 Total # Co-Infected Cases 402  # Cases choosing Health Dept Syphilis Partner Notification 195  # Partners Initiated 361 In comparison, 195 or 49% of 402 co-infected syphilis cases accepted health-department assistance with notifying partners of their syphilis exposure. From those 195 cases, 361 partners were initiated for DIS follow-up, demonstrating more utilization of health department assistance in notifying partners of syphilis exposure, as opposed to HIV exposure.

3 (20%) Located, Refused Testing 4 (33%) Newly Identified HIV Results V: PCRS Partner Outcomes for HIV Co-Infected Interviewed Early Syphilis Cases, CPA Jan-Sept 2007 21 Partners Initiated 20 (95%) Partners Notified 5 (25%) Previous Positive 12 (80%) Tested 3 (20%) Located, Refused Testing However, evaluation of PCRS partner outcomes, albeit small numbers, demonstrates interesting results. Again, a total of 21 partners were initiated from 13 original clients. Of those 21 partners, 95% were notified by DIS of potential HIV exposure. - Of those notified, 5 individuals, or about a quarter turned out to be previous positives. - Of the remaining 15 partners, 12 or 80% were tested for HIV. Three partners refused the offer to be tested. - Of the 12 partners tested, 5 or 42% were new negatives, meaning first time testers - and 4 partners or a third of those tested were newly identified HIV infections. 5 (42%) New Negative 4 (33%) Newly Identified HIV 3 (25%) Still Negative

Results VI: Syphilis Partner Outcomes for HIV Co-Infected Interviewed Early Syphilis Cases, CPA Jan-Sept 2007 361 Partners Initiated 283 (85%) Partners Notified 63 (22%) Previous Rx 169 (77%) Tested 51 (23%) Not Tested Evaluation of SYPHILIS partner outcomes showed that of the 361 partners initiated, 283 or 85% were notified by DIS. Of those notified, 22% were previously treated; of the remaining partners, 77% were tested. - Of those tested, 32 partners or 19% were infected and brought to treatment. - Only one infected partner was not treated. - But while there weren’t a high number of new syphilis infections found, 64% of tested partners received preventative treatment due to DIS follow-up. 1 (1%) Infected, No Rx 32 (19%) Infected, Treated 109 (64%) Preventive Rx 27 (16%) No Preventive Rx

Conclusions PCRS partner outcomes show high proportion tested and newly identified HIV infections (4 of 12 tested) - first-time HIV testing for at-risk individuals Syphilis partner outcomes show high proportion tested and preventively treated Few HIV co-infected syphilis cases accepted health dept PCRS partner notification services (13 of 231) - not all partner outcomes can currently be tracked in California (e.g. – patient referral) Large volume of anonymous partners In conclusion, we found that of partners who receive PCRS services, a high proportion are tested and previously unknown HIV infections are being identified. Also, PCRS seems to offer an important service of first-time testing for at-risk individuals. Syphilis partner outcomes also show a high proportion tested. And while fewer partners were new syphilis infections, a high proportion were preventatively treated. However, we did identify low utilization of health-department PCRS services among HIV co-infected syphilis cases. And it may be that patient self-referral of partners and DIS discussion of HIV testing is occurring, but we cannot currently track those partner outcomes in California. Lastly, we saw a large volume of reported anonymous partners among our HIV co-infected syphilis cases, who do not have enough identifying information for DIS to initiate partner notification of either syphilis or HIV exposure.

Next Steps Identify barriers and facilitators of health dept PCRS services Integration of health dept PCRS messages into STD/ HIV marketing materials to enhance client utilization of health dept services Integration of PCRS data elements into syphilis interview records Develop more effective partner management methods for locating and notifying anonymous partners In response to this evaluation, some next steps we’ve started taking are as follows: First: To identify barriers and facilitators of health department PCRS service through statewide assessment of provider and clients Second: To integrate health department PCRS messages into STD/HIV marketing materials to enhance client utilization of health-department services. Third: To integrate PCRS data elements related to partner disclosure decisions into our existing syphilis interview record. This not only eliminates the burden of paperwork for our DIS, but we also hope it will help answer some questions around why HIV co-infected syphilis cases may not be accepting PCRS. Lastly, we need to develop more effective partner management methods for locating anonymous partners.

Acknowledgements Contact Information: Rilene A. Chew, MPH Epidemiologist STD Control Branch California Dept. of Public Health 850 Marina Bay Parkway, Richmond, CA 94804 rilene.chew@cdph.ca.gov 510.620.3410 Office of AIDS PCRS: Fern Orenstein, M.Ed. Felicia Noonis, MPH, CHES Enrique Coons Joel de Vera Moncada California Department of Public Health: Romni Neiman Disease Intervention Specialists Denise Gilson Stacey Holly Berlene Osafo-Mensah