Syphilis Elimination: Reasons for Hope? Kevin O’Connor DSTDP October 7, 2010

Topics Syphilis in the South CSPS DSTDP efforts with health departments Reasons for hope

>4/100K.21-4/100K <.2/100K Rates per 100K Pop 2000 Charting the US P&S Syphilis Epidemic

N Carolina: Syphilis Rates by Gender, Rate ratios: %↑ 88%↑ Communicable Disease Surveillance Unit

N Carolina: Co-morbidity (early syphilis & HIV)

Georgia P&S Syphilis by Race

Tennessee: HIV Co-Infection in Syphilis Cases

Southern Syphilis Summary Significant changes in syphilis epidemiology: Shift from heterosexual to MSM Rapid increase in HIV co-infection among MSM Increasing among young African American MSM Conclusion – SE should be part of a comprehensive STD/HIV prevention effort for MSM

CSPS New Directions Use data to drive program Identify, then address health disparities Added emphasis on program evaluation → improvement Performance Measures (PM) Program Improvement Plans (PIP) Evidence Based Action Plans (EBAP) Are SE interventions working? Are they effective? Consider potential strategies for program improvements How well are interventions targeted towards at risk populations?

Current SE Activities Surveillance - ID populations at risk Partner Services Partner Services Internet Partner Services (IPS) Internet Partner Services (IPS) Management and Oversight: clear standards and expectations, supervisory review, engagement and support by managers Management and Oversight: clear standards and expectations, supervisory review, engagement and support by managers DIS embedded in HIV Care; gay-friendly clinics DIS embedded in HIV Care; gay-friendly clinics DIS liaisons with key agencies to develop strong relationships DIS liaisons with key agencies to develop strong relationships Community Engagement - community coalitions focusing on STD/HIV, media campaigns, STD in HIV CPG, Online outreach Community Engagement - community coalitions focusing on STD/HIV, media campaigns, STD in HIV CPG, Online outreach STDP as part of HIVP services for MSM STDP as part of HIVP services for MSM Targeted Screening - based on epi/surveillance Targeted Screening - based on epi/surveillance ROUTINE STD screening in HIV Care ROUTINE STD screening in HIV Care Ensure access to clinical services - Ensure access to clinical services -

SE Activities Start Stop Improve Enhance Target Collaborate

DSTDP Efforts

DSTDP Efforts to Address Syphilis, Program Improvement Webinars on SE topics 9 Program Improvement Webinars on SE topics “Syphilis in the South” webinar “Syphilis in the South” webinar CDC Field team deployed to outbreak in Cincinnati, Ohio (Aug/Sept. 2010); AZ (2009); Houston (2008) CDC Field team deployed to outbreak in Cincinnati, Ohio (Aug/Sept. 2010); AZ (2009); Houston (2008) Epi-Aids: Texarkana, Arkansas; Phoenix, Arizona Epi-Aids: Texarkana, Arkansas; Phoenix, Arizona Rapid Ethnographic Assessments in Phoenix, Arizona and North Carolina Rapid Ethnographic Assessments in Phoenix, Arizona and North Carolina Program Performance Site visits (PPSV): Virginia, Tennessee, Mississippi, New Jersey, California (San Diego). Outcome – over 82 recommendations for syphilis –related program improvement made across all program domains (Surveillance, PS, Medical/lab Services, Evaluation, etc.) Priority focus on HIV care providers in areas with significant MSM morbidity Program Performance Site visits (PPSV): Virginia, Tennessee, Mississippi, New Jersey, California (San Diego). Outcome – over 82 recommendations for syphilis –related program improvement made across all program domains (Surveillance, PS, Medical/lab Services, Evaluation, etc.) Priority focus on HIV care providers in areas with significant MSM morbidity Return PPSV to Puerto Rico and Louisiana (New Orleans, Shreveport) Return PPSV to Puerto Rico and Louisiana (New Orleans, Shreveport). 2010

DSTDP Efforts to Address Syphilis, Comprehensive program review in Albuquerque, New Mexico – significant focus on syphilis prevention and control activities. Comprehensive program review in Albuquerque, New Mexico – significant focus on syphilis prevention and control activities. Focus on EBAPs /other PM data – are strategies implemented effectively ? Are at-risk targeted? Are ineffective/inefficient strategies modified or stopped? Focus on EBAPs /other PM data – are strategies implemented effectively ? Are at-risk targeted? Are ineffective/inefficient strategies modified or stopped? Best Practices Initiative – over 50 potential BP related to syphilis prevention and control submitted. Goal is to link those in need with those who have demonstrated success. Best Practices Initiative – over 50 potential BP related to syphilis prevention and control submitted. Goal is to link those in need with those who have demonstrated success. Congenital Syphilis – PTB/ESB ID HMAs; PCs assess current status of CS efforts in HMAs with CS or high female morbidity. PCs are working with project areas on CS program improvement, where needed. Congenital Syphilis – PTB/ESB ID HMAs; PCs assess current status of CS efforts in HMAs with CS or high female morbidity. PCs are working with project areas on CS program improvement, where needed. IPS TA IPS TA Individual TA for project areas Individual TA for project areas

Reasons for Hope

Epi  ‘Signs of declines’ in provisional surveillance data from SE: TX, NYC, AL, & SF …although increases are occurring in OH, Chicago, WA, and KY Enhanced Efforts PS  Strengthened procedures, supervisions, and oversight: KY  Relocation of DIS: L.A.  IPS: AL, AZ, SF, MA, MO, NC, & PR. Many other areas Screening  ROUTINE STD screening in HIV Care  Epi-based TARGETED screening (inc. collaboratively w/ HIVP)

Thoughts on STDs & HIV STDs among MSM is an HIV Prevention issue STDP should be an core element of MSM HIVP Rectal STDs are a strong predictor of HIV sero-conversion HIV-/+ MSM with an STD should receive prompt HIVP services Sexually active MSM should be routinely screened for STDs (blood test for syphilis, rectal screen for CT/GC) HIV Care providers should routinely screen for STDs

Distribution of 2007 & Projected 2008 SEE Funding* by Project Areas in Rank Order of P&S Morbidity** *Total 2007 SEE funding = $19,083, Projected SEE Funding based on $19,000,000. **P&S Morbidity is an average of P&S Cases for 2005 and Mean Investment = $477, Mean Investment = $463,414.63

Proposed SEE Funding Formula For HMAs Funding is based on 2 components: 1)a base of $150,000; and 2)a proportion of remaining available funds based on the % of reported P&S cases for all HMAs for the two prior years for which data are available For post-HMAs Funding will include base funding for two years during the “post-HMA” transition period.