Integrated STD/HIV Partner Services: Role of Technology Kees Rietmeijer, MD, PhD Internet and STD Center of Excellence Denver Public Health Department Colorado School of Public Health

Integration Partner Services Role of Technology

Where the Program Collaboration “rubber” Hits the Service Integration “road”

Program Collaboration and Service Integration

PCSI in Denver STD Clinic Comprehensive STD Services HIV Testing

Normalizing HIV Testing > 10,000 HIV (rapid) tests per year > 100 new HIV positives year 40% of all new HIV+ in Denver 25% of all new HIV+ in Colorado HIV/RPR Ratio and HIV Positivity Rate by Period January October % 0.8% 0.6% 0.7% Period I: Jan Nov 2003 Period II: Dec May 2004 Period III: Jun Mar 2005 Period IV: Apr Oct 2006 Period Ratio (HIV:RPR) 0.0% 1.5% HIV(+) Rate HIV:RPR Ratio HIV+ Rate

PCSI in Denver STD Clinic Comprehensive STD Services HIV Testing Hepatitis A and B Vaccine Hepatitis C Testing Family Planning Services

Partner Services

Semantics….. In the world of STDs: – “Contact Tracing” – “Partner Notification” – “Epidemiological Treatment” (“Epi-Treat”) In the world of HIV – “Partner Counseling and Referral Services” (PCRS) – “Post-Exposure Prophylaxis”

Partner Services - Goal “… the goal of partner services is to maximize the number off partners who are notified of their exposure to HIV, syphilis, gonorrhea or chlamydia and who are treated or linked to medical, prevention, and other services.” MMWR 2008;57, RR-9

Why Integration of Partner Services? Coordination of prevention services is guiding force behind PCSI Standard of practice in many jurisdictions – Resource sharing Post-HAART evolution in HIV prevention philosophy – Focus on early diagnosis and linkage to care Dually-infected patients (e.g., syphilis and HIV) – Prevent conflicting messages Principles of partner services do not differ substantially among diseases

CDC Recommendations Active health department involvement through disease intervention specialists (DIS) – Newly diagnosed HIV – Early syphilis Limited involvement: selected high priority cases of – Gonorrhea – Chlamydia MMWR 2008;57, RR-9

High Priority Index Cases Pregnant women Male index patients with pregnant partners High risk behaviors – Multiple sex partners – Injection drug use HIV-STI co-infection Recurrent STIs MMWR 2008;57, RR-9

High Priority Cases - HIV High viral load (> 50,000) Acute HIV infection

High Priority Cases Syphilis, Gonorrhea, Chlamydia Clinical signs or symptoms  higher transmission rate Infected persons from core areas

Partner Services Challenges High-intensity intervention Need for prioritization Most cases of gonorrhea and chlamydia cannot be served by DIS

Partner Services Possible Solutions Patient-initiated referrals – Contact cards result in a 50% referral rate Expedited partner therapy – Demonstrated to reduce re-infection for gonorrhea and chlamydia – Uptake varies by setting – Role for this approach in HIV prevention? Use of “new media” – Internet – Mobile phones / text messages

Role of Technology

New York Times March 29, 2009 The Facebook Phenomenon

Cell phone growth in the United States Source: CTIA – The Wireless Association.

Cell Phone & Text Messaging Use Among STD Clinic Patients Clinic Survey Results Do you use a cell phone?84.7% Do you use text messaging on your cell phone? 90.2% Is it OK to contact you via text message?93.5% Presented at ISSTDR, 2007

Why Use Technology? It’s the way people communicate addresses and chat room “handles” may be the only contact information Reach partners in the same environment where they hooked up Ease of communication Can communicate anonymously

Use of Technology - Examples Use address as another means of communication for DIS Development of web-sites as an adjunct to traditional PN Online outreach in chat rooms Use of MySpace and other existing social networking sites Stand-alone web-based programs Use of mobile cell phones and text messaging

Available at and at

Online PN: Sample

Creating a Profile

Online PN - InSpot

Partner Services and SMS The Next Frontier Why? – Text messaging is quickly becoming the preferred method of communication for a growing population – Since 2007, mobile phone subscribers send and receive more text messages than phone calls – Inter-connectivity: Mobile-to-mobile Internet-to-mobile -to-mobile

Partner Services and SMS The Next Frontier Considerations – Goal should be to motivate recipient to communicate via voice – Confidentiality issues Text messages can be viewed by other people Sender should be in a place/situation to be able to respond to voice call-backs – Security issues Cell phones have call/text logs – need for secure storage – Etiquette development

Use of Technology for Partner Services The Good News: many innovative approaches The Not-So-Good News: lack of thorough evaluation – Does it work? – Is it cost-effective? – Are there downsides?

Banner advertising Newspaper advertisement Radio PSA Clinic intervention # Website Users Use of Online Partner Services Program Colorado,

Banner advertising Newspaper advertisement Radio PSA Clinic intervention: Posters; flyers; info on clinic website, linkage to online results program; contact cards with site information for all patients diagnosed with gonorrhea or chlamydia. Recognition of Online Partner Services Program Denver Metro Health Clinic, Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr May Jun % Recognition Clinic Survey 1Clinic Survey 2

Banner advertising Newspaper advertisement Radio PSA Clinic intervention Recognition of Online Partner Services Program Denver Metro Health Clinic, Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr May Jun % Recognition Clinic Survey 1Clinic Survey 2 5% Recognition

How DMHC Patients Would Notify Their Partners if Diagnosed with an STI Face-to-Face89% Telephone37% Text Message11% /Internet 5% Written note/letter 4% Would not tell 2.5% Denver Metro Health Clinic Unpublished

Conclusions New technologies for partner services are appealing and may play a role in enhancing the notification, evaluation, and treatment of STI/HIV-exposed partners However, their role may ultimately shown to be limited as the intent to notify partners may only be influenced in a small part by the method of message delivery More emphasis needs to be placed on behavioral interventions that affect the psychological and sociological determinants of partner communication

Integrative Model of Behavioral Prediction: A Reasoned Action Approach Fishbein. Med Decis Making 2008; 28; 834

Video Interventions for Partner Communication Things are getting more serious between Paul and Jasmine, but Paul “slips” and has a sexual encounter with Teresa. Teresa gets an STD and tells Paul. Now Paul has to tell Jasmine.

Acknowledgements

Place holder: Slideshow uploaded on STDPreventionOnline.org