1. Feasibility of STD Control for HIV Prevention: Findings from Three Southern Cities NEW ORLEANS: Thomas Farley & Deborah Cohen BALTIMORE: Anne Rompalo, David Rose, & Emmanuel Nwokolo RALEIGH: Peter Leone, William Miller, Kimberley Fox, & Evelyn Foust CDC: Kathleen Irwin, Mary Kamb, Rheta Barnes, & Maysoun Freij

2. BACKGROUND Clinical and laboratory data indicate that STDs increase HIV transmission efficiency by:  Increasing susceptibility of HIV-uninfected persons  Increasing infectivity of HIV-infected persons Community intervention trial in Mwanza, Tanzania found:  42% reduction in HIV incidence over 2 years in intervention communities that implemented enhanced STD diagnosis and treatment

3. BACKGROUND Are STD control strategies feasible for preventing HIV transmission in the US?  Different population demographics, mobility, and health care status  Better STD and HIV health care access and services  Lower STD and HIV prevalence and incidence

4. To Assess Effectiveness & Feasibility of STD Control to Prevent HIV Acquisition & Transmission:  In what settings does STD/HIV co-infection occur?  Are STD control strategies feasible in these settings?  What are the gaps in STD diagnosis and treatment services?

5. CRITERIA FOR ELIGIBILITY  1996 gonorrhea case rate >200 per 100,000 OR  1996 P & S syphilis case rate > 9 per 100,000 AND  Continuing high incidence of gonorrhea or syphilis  Restricted to 65 project areas with federal STD prevention funds

6. population 140.4 Gonorrhea - Rates by state: US,1996 123.5 89.5 114.4 275.1 (n=27) (n=13) 79.7 149.4 77.2 > 200 (n=10) 158.2 134.0 VT NH MA RI CT NJ DE MD 8.0 13.3 36.0 49.1 103.5 109.8 203.0 229.9

7. 0.1 1.2 2.6 12.4 16.2 14.6 4.0 5.2 1.9 3.4 4.2 12.3 1.3 0.4 0.0 0.3 0.4 0.8 0.0 0.3 0.4 0.2 0.7 0.0 0.3 30.4 1.4 2.4 1.6 5.9 0.3 0.2 VT NH MA RI CT NJ DE MD 0.0 0.1 1.4 0.4 3.1 2.2 4.9 14.5 Primary and secondary syphilis - Rates by state: US, 1996 5.5 4.8 1.1 < 4 4.1 - 9 Rate per 100,000 > 9 population (n=34) (n=7) (n=9) 3.6 4.2 9.6 10.510.9

8. Health Districts with HIV seroprevalence > per 1000 women who bore children Counties with P&S syphilis rates >10 per 100,000 States with gonorrhea rates > 225 per 100,000 New Orleans, LA Raleigh, NC Baltimore, MD 3 sites in areas with high prevalence of HIV, gonorrhea, & syphilis

9. Methods Three research questions 1.In what settings does STD/HIV co-infection occur? 2.Are STD control strategies feasible in these settings? 3.What are the gaps in STD diagnosis and treatment services? No common study protocol

10. Methods Where Does STD/HIV Co-Infection Occur?  To identify high STD & HIV prevalence settings:  analysis of STD and HIV surveillance data  geographic mapping  collaboration with community-based organizations  Screening was performed for:  chlamydia, gonorrhea (urine-based nucleic acid amplification tests)  herpes (dot blot assay) Raleigh  syphilis (rapid plasma reagin) Raleigh  trichomonas (urine or vaginal cultures) Raleigh & Baltimore  HIV (blood, urine, or oral fluid antibody tests)  primary HIV infection (heat-dissociated p24 antigen) Raleigh

11. Methods Where STD & HIV Prevalence Was Assessed

12. Methods Are STD control strategies feasible in these settings?

13. Symptoms Recognized Symptom Recognition Care Seeking for Symptoms Access to Appropriate Care Effective Treatment Prescribed Ecology of InfectionBehavior Leads to Exposure ExposureInfection Symptoms Seeks Care Access Appropriate Care STD Diagnosis Considered Diagnosis Correct Correct DiagnosisEffective Treatment Prescribed Comply With Treatment, Cured Patient CuredExposed Partner(s) Treated Symptoms Methods What are the gaps in STD services? Piot-Fransen Model of STD Management

14. Behavior Leads to Exposure Infection Symptoms Exposed Partner(s) Treated Symptoms Recognized Seek Care Effective Treatment Prescribed STD Diagnosis Considered Diagnosis Correct Comply With Treatment, Cured Methods Potential Gaps in STD Diagnosis & Treatment Examined Access Appropriate Care

15. Methods Potential Gaps in STD Diagnosis & Treatment