1. The Case for PrEP: STD and HIV epidemiology in Santa Clara County
Courtesy CDC Public Health Image Library
Courtesy CDC Public Health Image Library
Photograph: Dr David Phillips/Getty Images/Visuals Unlimited
The Case for PrEP: STD and HIV epidemiology in Santa Clara County
PrEP: Making HIV Prevention Easy. October, 2017
Sarah C. Lewis, MD, MPH
STD/HIV Controller & Assistant Public Health Officer
Santa Clara County Public Health Department

2. Disclosure Information Sarah C. Lewis, MD MPH
SAMPLE OF SPEAKER DISCLOSURE SLIDE
Disclosure Information Sarah C. Lewis, MD MPH
I have no financial relationships to disclose.
I will discuss off label use of NAATs.

3. Learning Objectives
Understand local epidemiology of HIV and STDs in SCC
Identify patient populations at risk for HIV and STDs SCC based on epidemiology and screening recommendations
Recognize benefit of PrEP for prevention of other STDs

4. Overview Epidemiology of STDs in Santa Clara County
Recommendations for HIV Screening and Prevention
Bacterial STDs and the Power of Screening

5. Epidemiology of STDs in Santa Clara County
2016 Summary Data

6. Pop quiz!
Which of the following statements most accurately describes the current epidemiologic STD trends in Santa Clara County?
New prevention and treatment options have contributed to overall declining rates of chlamydia, gonorrhea, and syphilis in SCC and nationally.
Despite increases in surrounding counties, rates of chlamydia, gonorrhea, and syphilis are stable or falling in SCC, likely due to increased healthcare access.
Surveillance reporting shows rising rates of chlamydia, gonorrhea, and syphilis, along with persistent disparities by race, ethnicity, gender, and gender of partners.
Data suggest rising rates of chlamydia, gonorrhea, and syphilis in SCC, but these are most likely confounded by new testing guidelines and increased access to care.

7. Pop quiz!
Which of the following statements most accurately describes the current epidemiologic STD trends in Santa Clara County?
New prevention and treatment options have contributed to overall declining rates of chlamydia, gonorrhea, and syphilis in SCC and nationally.
Despite increases in surrounding counties, rates of chlamydia, gonorrhea, and syphilis are stable or falling in SCC, likely due to increased healthcare access.
Surveillance reporting shows rising rates of chlamydia, gonorrhea, and syphilis, along with persistent disparities by race, ethnicity, gender, and gender of partners.
Data suggest rising rates of chlamydia, gonorrhea, and syphilis in SCC, but these are most likely confounded by new testing guidelines and increased access to care.

8. Chlamydia case counts and rates in Santa Clara County, 2010-2016
Sources: 1. SCC Public Health Department, AVSS ( ), CalREDIE ( ), data as of March, 2017, and are provisional; 2. State of California, Department of Finance, State and County Population Projections by Race/Ethnicity and Age, , December 15, 2014

10. Sources: 1. SCC Public Health Department, AVSS ( ), CalREDIE ( ), data as of March, 2017, and are provisional; 2. State of California, Department of Finance, State and County Population Projections by Race/Ethnicity and Age, , December 15, 2014

11. * Due to large proportions of missing race/ethnicity information, unknown race/ethnicity cases were redistributed based on the proportions of the known race/ethnicity cases with consideration of age. Rates and counts based on imputed race/ethnicity need to be interpreted with precautions.
Sources: 1. SCC Public Health Department, CalREDIE (2016), data as of March, 2017, and are provisional; 2. State of California, Department of Finance, State and County Population Projections by Race/Ethnicity and Age, , December 15, 2014

12. * Includes primary, secondary and early latent syphilis cases.
Sources: 1. SCC Public Health Department, AVSS ( ), CalREDIE ( ), data as of March, 2017, and are provisional; 2. State of California, Department of Finance, State and County Population Projections by Race/Ethnicity and Age, , December 15, 2014

13. * Include primary, secondary and early latent syphilis cases.
Sources: 1. SCC Public Health Department, AVSS ( ), CalREDIE ( ), data as of March, 2017, and are provisional; 2. State of California, Department of Finance, State and County Population Projections by Race/Ethnicity and Age, , December 15, 2014

14. HIV epidemic in Santa Clara County
As of 2016:
Cumulative HIV/AIDS cases first reported in SCC*: 6,179
AIDS: 4,801
Alive: 3,669
People living with HIV/AIDS†: 3,208
2,648 (83%) SCC cases
560 (17%) out of jurisdiction cases
In 2016:
134 new cases
% of people alive: 59%.
* Based on residency at diagnosis; † Based on most current address;
Source: Santa Clara County Public Health Department, eHARS data as of May, 2017 and are provisional

15. Rates of HIV/AIDS diagnoses among individuals 13+, 2010 – 2016
Note: since number of cases younger than 13 is very small, only presented those with ages 13+. This will also be easier to compare to the national data.
Overall the total rate for diagnoses of HIV decreased from after an increase from
Highest rates are among males ages 13 and older that are nearly 6 times the rates among females in 2016
Among males ages 13 and older, the total rate for diagnoses decreased except for an increase between 2013 and 2014 and then decreased from
Among females ages 13 and older, the total rate for diagnoses decreased from and then slightly increased from The rate was the same in 2010 and However this may be due to smaller case numbers so this should be taken into consideration
Source: 1. Santa Clara County Public Health Department, eHARS data as of May, 2017; 2. State of California, Department of Finance, State and County Population Projections by Race/Ethnicity and Age, , Sacramento, California, February 2017

16. Number of MSM cases* by selected age group, 2010 – 2016
*MSM includes both MSM only and MSM who are also IDU
On average, among MSM cases between 2010 and 2016, 66% of MSM cases were younger than 40 at diagnosis.
Increasingly more HIV diagnoses are among MSM Ages than any other age group.
* Include MSM, MSM & IDU.
Source: Santa Clara County Public Health Department, eHARS data as of May, 2017, and are provisional.

17. Number of MSM cases* by race/ethnicity, 2010 – 2016
On average, among MSM cases between 2010 and 2016, nearly one half (45%) were Hispanics, one-third (31%) were whites, 16% API, and 5% blacks.
1. Number of African American and Asian/Pacific Islander MSM cases remained relatively low and stable over time.
2. Fewer white MSM were diagnosed between 2010 and 2016, the number of cases decreased by half.
3. For Hispanic/Latinos, the number of HIV diagnosis decreased from 2010 to 2013 but then increased sharped in 2014 and 2015, and then decreased last year.
* Include MSM, MSM & IDU.
Source: Santa Clara County Public Health Department, eHARS data as of May, 2017, and are provisional.

18. Who were more likely to be diagnosed late*?
Older age groups (ages 40+)
44% (ages 40+) vs. 23% (ages <40)
People of color
37% (AA), 35% (API), 34% (Hispanic) vs. 25% (White)
IDU and individuals acquiring through heterosexual transmission
44% (IDU) and 45% (Heterosexual) vs. 26% (MSM) and 28% (MSM&IDU)
Foreign-born
42% (foreign-born) vs. 27% (U.S.-born)
Among cases diagnosed in :
People more likely to be tested late
1. Ages 40 and older
2. African Americans, Asian/Pacific Islanders
3. IDU and Heterosexual transmission
4. Foreign Born
* Statistically significant with p < 0.05
Source: Santa Clara County Public Health Department, eHARS data as of May, 2017.

19. Percentage of people living with HIV with STD† Santa Clara County, 2016
STD infections were not self reported. Co-infections were identified by matching the list of PLWH in 2016 and cases diagnosed with STD in 2016
only infectious syphilis is included
10.4% of people living with HIV were infected with an STD overall
Chlamydia was the most diagnosed individual STD with 5.2% of people living with HIV co-infected
† People ages 13 and older chlamydia, gonorrhea, early syphilis (primary, secondary and early latent) diagnosed in A person with multiple episodes of one disease in the year will be only counted once for the disease. * Include primary, secondary and early latent syphilis cases. ** The percentage of overall STD diagnosis is lower than the sum of the percentages of chlamydia, gonorrhea and early syphilis because one person may be diagnosed with multiple diseases. Source: 1. Santa Clara County Public Health Department, eHARS data as of May, 2017, 2. Santa Clara County Public Health Department, CalREDIE (2016), data as of March, 2017, and are provisional

20. HIV Screening and Prevention
Making HIV Prevention Easy

21. Who should be screened for HIV?
All patients ages 13 – 64 years in all health-care settings.
All patients who seek evaluation and treatment for STDs.
All pregnant patients in 1st trimester; again in 3rd trimester and at delivery if at high risk.
MSM annually and up to q3 months if at high risk.
NO need for separate written consent. (Opt-out)

22. HIV Prevention
Treatment as Prevention (TasP) depends on diagnosis and linkage
Pre-Exposure Prophylaxis:
Can be provided in primary care settings
Navigation help for clients:
Clinical consult for providers: 855-HIV-PrEP (Monday – Friday: 8am to 3pm)
STD/HIV Controller:
Resources for providers: Stay Tuned!

23. Rapid rise in PrEP use in the US
~80,000 unique individuals started PrEP in
But lower uptake in:
People of color
African Americans
Latinx
Youth
Transgender people
738% increase
From Cohen
2012
2013
2014
2015
2012
2013
2014
Slide courtesy of Stephanie E. Cohen

24. % of Adults with PrEP Indication No. of Adults with PrEP Indication
From Cohen
Slide courtesy of Catherine Koss & Stephanie E. Cohen

25. HIV prevention in any role
Screen for HIV and risk factors
Screen for and treat bacterial STDs
Offer PrEP resources in your waiting room
Refer for PrEP Navigation:

26. Bacterial STDs: The power of screening
Making HIV Prevention Easy

27. Who Should be Screened for CT/GC?
< 25 annually, 25+ if at risk
Pregnant (first trimester)
Females
At least annually
Exposed sites: genital, rectal, throat
MSM
High prevalence settings
Hetero males
All exposed sites
HIV +
Every 3 months
Patients on PrEP
All patients, 3 months after treatment
Post-Tx
Risk factors: prior infection, new partner in past 3 months, female with MSM partners, > 1 sex partner in past year, exchange sex, AA up to age 30, incarcerated, or incarcerated partner
CDC 2015 STD Tx Guidelines
Plus: Guidelines for HIV care and PrEP

28. High Proportion of Extragenital CT/GC associated with negative urine test
STD Surveillance Network (n=21,994)
Slide courtesy of Dr. Ina Park.
Patton et al CID 2014

29. A Majority of Rectal Infections in MSM are Asymptomatic
86%
84%
Chlamydia
Gonorrhea
n=316
n=264
Asymptomatic
Urethral Infections
Symptomatic
10%
42%
Chlamydia
Gonorrhea
n=315
n=364
Slide courtesy of Dr. Ina Park.
Kent, CK et al, Clin Infect Dis July 2005

30. Chlamydia and Gonorrhea NAAT: Rectal and Pharyngeal Sites
Commercially-available NAATs have not been cleared by FDA for these indications
They can be used by laboratories that have undergone validation procedures and met all regulatory requirements for an off-label procedure
Similar validation procedures apply for self-collected specimens
MMWR. Mar ;63(No RR-12):1-19. Slide courtesy of Dr. Ina Park.

31. Clinical Guidelines and Consultation
Free CDC STD Treatment Guidelines App
Search for “STD TX”
CDC’s STD Treatment Guidelines
STD Clinical Consult Network
Slide courtesy of Dr. Ina Park.

32. STDs among PrEP users in PrEP Demo
26.4% of participants had GC, CT or early syphilis at baseline
50.9% had at least one STI during follow-up
STI incidence was high but did not increase over time
% infections for which treatment would have been delayed with q6 month, as opposed to q3 month, screening
From Cohen
As expected, >80% of rectal and pharyngeal infections were asymptomatic; 18% of urethral GC and 65% of urethral CT asx
Percent of cases that were asymptomatic at follow-up [n/N (%)]
rectal GC: 78/96 (81.3%)
rectal CT: 156/173 (90.2%)
pharyngeal GC: 106/125 (84.8%)
pharyngeal CT: 25/30 (83.3%)
urethral GC: 6/33 (18.2%)
urethral CT: 34/52 (65.4%)
Liu JAMA Intern Med 2016; Cohen # 870 CROI Slide courtesy of Dr. Stephanie Cohen

33. STDs among PrEP Users at SF Kaiser
From Cohen
(95% CI 58-71)
And 2 incident HCV infections
Summarize: Open label PrEP studies – no overwhelming e/o risk comp at indiv level, but enrolled ppts with high rates of condomless sex to begin with; high but stable STD rates
Volk et al. CID 2015; Slide courtesy Dr. Jonathan Volk and Dr. Stephanie Cohen

34. Modeling Study of PrEP Impact on STI Incidence
With 40% PrEP coverage and 40% risk compensation.
42% and of GC and 40% of CT infections would be averted over the next 10 years.
From Cohen
Jenness et al. CID, 2017.

35. Conclusions
Bacterial STDs are on the rise in Santa Clara and California
Young Latino and Black MSM are at highest risk for HIV in SCC
Self-collected three-site screening can make STD testing fast and easy
PrEP prevents HIV and also creates opportunities to decrease STDs