1. Integration of STDs: Aligning STD and HIV Prevention Romni Neiman Assistant Branch Chief, STD Control Branch California Department of Pubic Health Merge Ahead January 31-February 2, 2016

2. Overview of Presentation  Overview of STD  STD as a Co-Factor for HIV Transmission  STD Services as HIV Prevention  Partnership and Prioritization

3. Overview of STD

4. Chlamydia Gonorrhea Early Syphilis 18.7 (N=7,191) 116.8 (N=44,974) 453.4 (N=174,557) Chlamydia, Gonorrhea, and Early Syphilis California Incidence Rates, 1990–2014 Rev. 7/2015

5. Rate per 100,000 population Age Group Incidence Rates of Chlamydia, Gonorrhea, and Early Syphilis by Age Group (in years) and Gender, California, 2014 Rev. 7/2015

6. Rate per 100,000 population Incidence Rates of Chlamydia, Gonorrhea, and Early Syphilis by Race/Ethnicity and Gender, California, 2014 Note: NA/AN = Native American/Alaskan Native, A/PI = Asian/Pacific Islander Race/Ethnicity Rev. 7/2015

7. Number of Gonorrhea Cases by Region, Gender, and Year California, 2005–2014 Rev. 7/2015

8. California United States CA=18.7 Early Syphilis* California versus United States Incidence Rates, 1941–2014 Rev. 7/2015 US=12.5 * Includes primary, secondary, and early latent syphilis.

9. Early Syphilis*, Incidence Rates by County California, 2014 Rev. 7/2015 * Includes primary, secondary, and early latent syphilis.

10. Early Syphilis*, Cases by County California, 2014 Rev. 7/2015 * Includes primary, secondary, and early latent syphilis.

11. Early Syphilis*, Cases by Gender California, 1996–2014 ALL MALE FEMALE MEN WHO HAVE SEX WITH MEN Rev. 7/2015 * Includes primary, secondary, and early latent syphilis.

12. Number of Early Syphilis* Cases by Region, Sexual Orientation, and Year California, 2005–2014 Rev. 7/2015 * Includes primary, secondary, and early latent syphilis. MSM=Men who have sex w/men, MSW=Men who have sex w/women, MSUnk=Men of unknown sexual orientation

13. So What… STDS are curable, right?!?

14. Syphilis Is BAD… For Men (disease complications) Women & Children (maternal-child transmission, fetal demise)

15. Syphilis Natural History Incubation Period 3-4 weeks Incubation Period 3-4 weeks 2-6 weeks After 3-8 weeks lesions disappear spontaneously 2-20 years Neurosyphilis can occur at any stage 25% 30% 30-50% Exposure1010 2020 LatentTertiary Courtesy: Susan Philip, SF DPH & UCSF

16. Early Neurosyphilis Case Series of HIV+ MSM in 4 US Cities, 2002-2004, N=49 SyndromeN%Median # hospital days % Persistent at 6 months (n=37) Cranial nerve dysfn Ocular Auditory Both Other 25 6 1 2 51% 12% 2% 4% 6 17 1 32% 50% 100% 0% Acute meningitis612%717% Vascular / CVA24%1150% Headache &/or AMS714%140% TOTAL49100%7 days30% MMWR 2007; 56(25):625 Cities: LA, SD, Chicago, NYC 47% w/ secondary syphilis

17. California CA=19.6 Congenital Syphilis in Infants < 1 Year of Age California versus United States Incidence Rates, 1963–2014 2020 Objective (9.6) Note:The Modified Kaufman Criteria were used through 1989. The CDC Case Definition (MMWR 1989; 48: 828) was used effective January 1, 1990. California data prior to 1985 include all cases of congenital syphilis, regardless of age. United States Rev. 11/2015 US=11.6

18. Congenital Syphilis in Infants < 1 Year of Age Incidence Rates by County, California, 2014 Note: Rates are based on very small numbers of cases. Rev. 7/2015

19. Congenital Syphilis in Infants < 1 Year of Age Number of Cases by County, California, 2014 Rev. 7/2015

20. Early Syphilis Rate per 100,000 FemalesNumber of Congenital of Childbearing Age (15-44 years)Syphilis Cases Congenital Syphilis Cases in Infants < 1 Year of Age versus Female Early Syphilis* Incidence Rates California, 2005–2014 Rev. 7/2015 * Includes primary, secondary, and early latent syphilis.

21. Gonorrhea is not a friend… Multi-drug-resistant An Emerging Threat Disseminated Gonococcal Infection

22. Most Rectal STD Infections in MSM are Asymptomatic Kent, CK et al, Clin Infect Dis July 2005 Rectal Infections Urethral Infections

23. Urethral-only screening misses most CT/GC infections in MSM. N=3398. San Francisco, 2008-2009. Marcus, et al. Sex Transm Dis. 2011;38(10):922

24. STD as a Co-Factor for HIV Transmission

25. How Does Having an STD increase the Risk of HIV Transmission? If you are HIV+, – Inflammatory conditions increase viral load in secretions, even if blood levels are suppressed – Virus can be cultured from genital ulcers If you are HIV-, – Breaks in epithelial barrier allow viral access – Inflammation increases number and receptivity of target cells

26. STIs as a Biological Co-Factor in HIV Transmission Association of Rectal Gonorrhea with New HIV Diagnosis * Controlled for sexual behavior and perceived partner HIV status Strong, consistent epidemiologic association of HIV acquisition and STI Association persists after controlling for sexual behavior Very consistent with idea of gonorrhea as an important co-factor driving HIV transmission AuthorOR (95% CI) Zetola17 (2.6-111) Craib4.8 (1.8-12.8) Jin*7.1 (2-24.8) Barbee*2.6 (1.2-3.8)

27. Think PrEP: STD Diagnosis is an Indication of HIV Risk 1 in 15 MSM were diagnosed with HIV within 1 year.* Rectal GC or CT 1 in 18 MSM were diagnosed with HIV within 1 year.** P&S Syphilis *STD Clinic Patients, New York City. Pathela, CID 2013:57; **Matched STD/HIV Surveillance Data, New York City. Pathela, CID 2015:61

28. STD Care as HIV Prevention

29. Percentage of All New HIV Diagnoses Made at STD Clinics, 2008 In most U.S. cities, STD clinics are the largest single diagnosing site for HIV

30. HIV Co-Infection Among Interviewed Early Syphilis Cases with HIV Status in CA, 2014 Early Syphilis Cases by Gender and Sexual Orientation % HIV Co-Infected Female4.1 MSF11.9 MSM58.3 MSMW34.9 Note: Data excludes cases not interviewed and those where HIV status unknown. Also excludes LA cases.

31. Reframing STD Disease Intervention as an Opportunity for HIV Prevention Roles for DI/PS with MSM Syphilis Cases GOALSTRATEGIES HIV case finding HIV testing of early syphilis cases HIV PS for HIV co-infected cases HIV testing of partners Linkage to (and Re- engagement with) Care among HIV+ HIV data sharing Linkage to care infrastructure HIV prevention Referral for PrEP Increased STD testing Counseling and referral

32. HIV Status among Early Syphilis* Cases among MSM California Project Area & San Francisco †, 2014 Rev. 11/2015 Note: N=2,251; N does not include HIV status unknown or refused to state: 563 cases in 2014. * Includes primary, secondary, and early latent syphilis. † Los Angeles cases have been excluded as the data does not differentiate HIV results as being new or previous. New HIV Positive  Linkage to HIV care  HIV partner services  Counseling HIV Negative  HIV testing  Education & counseling  Linkage to PEP  Linkage to PrEP Previous HIV +  Re-engagement in care  Prevention counseling  HIV Ptnr services New HIV+ 4%

33. How STD Services Close Gaps in California’s Treatment Cascade Identify new HIV infections Linkage to care Prevention STD testing and treatment

34. Proportion of Newly Diagnosed HIV-Infected Patients who are Linked to Care and Retained in Care by Receipt of Field Services, New York City, 2007-2011 *p<0.001, small differences in multivariate analysis Bocour, et al. AIDS 2013.

35. Partner Services for Linkage to Care Initiation Population- Based PS >90% linkage achieved in King County DIS responsible for linkage to care DIS refer patients to STD clinic for viral load and CD4 testing and linkage coordination Receipt of PS associated with higher linkage to care within 3 months in NYC (79% vs. 66%, P<.0001) (Bocour A. AIDS 2013) Percentage of Persons Newly Diagnosed with HIV in King County with CD4/Viral Load Results < 3months

36. Partnership and Prioritization

37. Opportunities for Integration at the Program Level STD Setting: – HIV Testing – Integrated Partner Services – Linkage or Re-engagement to Care HIV Setting: – STD screening & Treatment – Integrated Partner Services – Linkage or Re-engagement to Care

38. Opportunities for Integration at the Program Level Framing is Key – Lessons learned from chlamydia - a piece of larger adolescent health initiative – A more comprehensive approach for men’s sexual health Partnership is Essential – Identifying areas of intersection and opportunity with other programs – Engagement of private sector providers & medical groups

39. Why Now? Synergy in Program Goals/Objectives – HIV Testing, PS, Treatment – STD Prevention as vehicle for HIV identification and treatment Data Sharing Allowances – HIV Surveillance data available to guide HIV & STD program activities – Inter-jurisdictional data sharing to enhance continuity of care and case management

40. Integrating STD & HIV Prevention Local Solutions Utilize staff strengths – Disease Intervention Specialists (DIS) have skills valuable to HIV prevention and linkage to care Don’t fragment services/build capacity – Community Embedded DIS (CEDIS) in high volume HIV testing and care settings for HIV & STD An eye program synergy – Cross training – Co-funding

41. Seizing the opportunity at the Local Level Where the Rubber Meets the Road in Public Health

42. Dr. Heidi Bauer Jessica Frasure Denise Gilson Romni.neiman@cdph.ca.gov