Contact: David A. Katz, [email protected]
Sexually Transmitted Disease Partner Services Increase HIV Testing
Among Men Who Have Sex with Men
Matthew R. Golden1,2,3, David A. Katz1,3, David Kern4, David Heal4, Roxanne P. Kerani1,3, Julia C. Dombrowski1,3
Departments of Medicine1 and Epidemiology2,University of Washington, Seattle, USA; HIV/STD Program, Public Health – Seattle & King County3, Seattle, USA; Washington State Department of Health4, Olympia, USA
Methods
Revised Abstract
BACKGROUND: MSM with bacterial sexually transmitted infections (STI) are at elevated risk for HIV
infection. Only approximately half of such men are HIV tested at time of their STI diagnosis or treatment. We
instituted and evaluated a program promoting HIV testing through public health STI partner services (PS).
METHODS: Starting in May 2011, state and local health departments in WA State, USA, revised PS programs
with the objective of providing PS to all MSM with early syphilis, gonorrhea or chlamydial infection and
ensuring that all MSM without a prior HIV diagnosis tested for HIV. PS staff recorded HIV testing as an explicit
PS outcome. We compared the percentage of MSM without a prior HIV diagnosis who tested for HIV within
four weeks of their STD diagnosis or treatment in the period before (January 2010-April 2012) and during the
revised program (May 2012-August 2014). HIV infection was ascertained through matching with HIV
surveillance data. Proportions of MSM receiving PS, HIV testing and newly diagnosed with HIV were
compared between the two periods using chi-square tests and logistic or log-binomial regression.
RESULTS: Among MSM without a prior HIV diagnosis, 2008 (62%) of 3253 in the pre-intervention period
and 3712 (76%) of 4880 in the intervention period received PS (p<.001). The proportion of MSM receiving PS
who tested for HIV increased from 63 to 91% concurrent with the intervention (p<.001). Men who received PS
were more likely to be newly HIV diagnosed then men who did not receive PS in both the pre-intervention
(0.93 vs. 2.5%, p=.002) and the intervention periods (1.4 vs. 2.4%, p=.050). The percent of all MSM newly
diagnosed with HIV in the state who had a concurrent STI diagnosis increased from 6.6 to 13% (p<.0001).
Among all MSM with bacterial STD (including those who did not receive PS), 61 (1.9%) in the pre-intervention
period and 104 (2.1%) in the intervention period were newly diagnosed with HIV infection (p=.42). On
multivariable analysis, being newly diagnosed with HIV was independently associated with being diagnosed
with early syphilis, rectal gonorrhea, and urethral gonorrhea, but not with intervention period.
CONCLUSIONS: Promoting HIV testing through STI PS is feasible and increases HIV testing among men at
high risk for HIV infection. It is uncertain whether the increase in HIV case-finding among MSM with bacterial
STI observed concurrent with our intervention reflects an intervention effect, or a more general increase in
simultaneous STI and HIV testing among MSM.
Background
• US CDC estimates that 34% of men who have sex with men (MSM)
living with HIV are unaware of their infection
• MSM with bacterial sexually transmitted infections (STI) are at
elevated risk for HIV infection
• Only ~50% of such men are HIV tested at time of their STI diagnosis or
treatment (Bradley et al. AIDS Behav. 2013;17(3):1205-10)
Partner Services Intervention
• Medical providers in Washington State complete STI case report forms
that include gender of sex partner, allowing health departments to identify
MSM for potential intervention
• Provide PS to all MSM with early syphilis, gonorrhea, or
chlamydial infection
• Used HIV and STI surveillance data from Washington State from
1/1/2010-10/20/2014
public health STI partner services in Washington State.
‘
Definition
Recorded by PS
staff
May 2012-Sep 2014
%
3253
-
4880
-
80%
Early syphilis^
347
11%
448
9%
60%
Rectal GC
413
13%
758
16%
Urethral GC
857
26%
1130
23%
Pharyngeal GC
484
15%
1047
21%
Rectal CT
561
17%
1265
26%
Urethral CT
1121
35%
1245
26%
95
3%
282
6%
Diagnosed in King County (incl. Seattle)
2201
68%
3440
70%
Diagnosed by HIV/STI specialty provider*
1749
54%
2832
58%
Number of extragenital STIs increased during intervention period
•
King County MSM were more likely to be diagnosed by an MSM/HIV specialty
provider than MSM in other jurisdictions (74% vs. 17%, respectively)
• HIV incidence decreased and STI diagnoses increased during the
study period, possibly affecting ability to detect increase in HIV
case-finding
95%
40%
100%
HIV tested
Newly HIVdiagnosed
80%
Tested for HIV within 14
days of STI diagnosis,
at time of treatment, or
as a result of PS
Newly diagnosed with
HIV at time of STI
diagnosis, treatment,
or PS
60%
Self-report by case or
medical record review
HIV surveillance
match, medical record
review, case self-report
Intervention
68%
55%
39%
Specialty
Provider
Non-Specialty
# tested
838
1970
129
549
75
230
222
618
Total cases
1090
2071
236
628
111
246
571
767
*Among those receiving partner services
HIV/STI specialty providers were more likely to test MSM for HIV at time of
STI diagnosis or treatment before and during the intervention (p<0.001)
Increase in HIV testing among PS recipients associated with the intervention
remained significant when adjusting for diagnosing provider type, county of
residence, and STI diagnosis and anatomic site (p<0.001)
New HIV Diagnoses Among MSM with Bacterial STIs
75%
20%
63%
Secondary
denominator
N/A
All cases
Cases tested for HIV
•
Bivariable
analysis
Pearson’s chisquare test
Pearson’s chi-square
test
Pearson’s chi-square
test
•
Multivariable
analysis
Log-binomial
regression
Log-binomial
regression
Poisson regression,
offset for HIV incidence
HIV tested
(All cases)
22
HIV tested
(PS recipients)
Newly HIVdiagnosed
The percent of MSM receiving PS and tested for HIV significantly increased with
implementation of the intervention
Although more MSM with bacterial STIs were newly HIV-diagnosed during the
intervention period (104 v. 61 pre-intervention), the proportion of all STI cases
diagnosed with HIV did not increase significantly (RR = 1.14, 95% CI: 0.83-1.56)
•
2.2%
2%
17 20
Gonorrhea Chlamydial
infection
Pre-intervention
•
• MSM with bacterial STI are at high risk for having undiagnosed
HIV infection
1.5%
1%
1.2% 1.0%
0%
Syphilis
Received PS
Conclusions
3%
0
0%
All cases
22
p=0.42
1.9% 2.1%
• Promoting HIV testing through STI PS had greater impact on HIV
testing and case-finding in non-HIV/STI specialty providers,
particularly outside of Seattle
6.3%
4%
53
31
40%
• More MSM with bacterial STIs were newly HIV-diagnosed during
the intervention period, and there was a trend towards an increase
in the proportion of all STI cases diagnosed with HIV
5%
20
10
• Refocusing STI PS was associated with increased receipt of PS and
HIV testing at time of STI diagnosis/treatment among MSM with
bacterial STIs
6.9%
6%
91%
62%
PS recipients
7%
30
76%
% of STI Cases HIV-Diagnosed
Summary
8%
40
40%
Non-Specialty
Other WA State
50
p<.001
Specialty
Provider
King County
•
• Ascertainment of testing HIV negative at time of STI diagnosis &
time of HIV test (before v. after PS) improved concurrent with
intervention
• Observational study so cannot adjust for all potential confounding
60
p<.001
81%
0%
Partner Services Delivery, HIV Testing, and HIV CaseFinding among MSM with Bacterial STIs
Pre-Intervention
94%
87%
77%
20%
•
•
Intervention
100%
N
*HIV/STI specialty provider = STD clinic, HIV/STI testing program, or medical provider
specializing in HIV or STI care
All cases of
bacterial STI among
MSM
Primary
denominator
Jan 2010-Apr 2012
Pre-Intervention
%
p<.001
Interviewed for PS
by public health
staff
Intervention
Number of HIV Diagnoses
• Intervention = May 2012 – August 2014
Received PS
partner services
Pre-Intervention
N
• Pre-Intervention = January 2010 – April 2012
Ascertainment
We instituted and evaluated a program promoting HIV testing through
• Most HIV testing and diagnosis occurs prior to PS interview,
particularly in specialty settings  difficult to distinguish between
impact of changes in provider or MSM testing behavior (also
targeted by public health intervention) and direct PS delivery
^Early syphilis = primary, secondary, or early latent
• Pre/post analysis comparing MSM diagnosed during pre-intervention
and intervention periods of equal duration (28 months):
• HIV testing is generally not an objective of STI PS
Objective
Percent of MSM with Bacterial STIs Tested for HIV
Infection at Time of STI Diagnosis or Treatment*
Pharyngeal CT
Outcomes & Analyses
• STI partner services (PS) may provide an opportunity to ensure these
high risk men are tested for HIV, yet:
• Few public health departments provide PS to persons with STIs
other than syphilis and HIV and
Characteristics of 8133 MSM Diagnosed with Bacterial
STIs in Washington State, January 2010-August 2014
Sexually transmitted infection
Data Sources
• Bimonthly manual review of STI cases without eHARS match but
with indication of HIV infection in STI surveillance data
Limitations
Total cases in MSM
• Ensure that all MSM and partners without a prior HIV diagnosis
were tested for HIV
• Weekly automated probabilistic matching algorithm based on legal
and alias names, date of birth, and sex
Results (cont.)
Characteristic
• In May 2012, health departments in WA State revised PS programs to:
• STI surveillance and partner services data are matched with HIV
surveillance data (eHARS) as follows:
Results
Syphilis
Gonorrhea Chlamydial
infection
• Promoting HIV testing through STI partner services is feasible and
increases HIV testing among MSM
• Our findings suggest that making HIV testing an explicit partner
services outcomes can increase HIV case-finding.
Intervention
Adjusted for diagnosing provider type, county of residence, STI diagnosis and
anatomic site, and temporal trends in HIV incidence, the intervention was
associated with a 1.34-fold increase in the proportion of STI cases newly
diagnosed with HIV (95% CI: 0.97-1.83; p=.07)
The proportion of new HIV diagnoses among MSM in WA State concurrently
diagnosed with an STI increased from 6.6% (61/930) pre-intervention to 13%
(104/797) in the intervention period (RR = 1.99, 95% CI: 1.47-2.69; p<.0001)
Acknowledgments
This program and its evaluation were supported by the U.S. Centers for Disease Control and Prevention (CDC
PS12-1201), the Washington State Department of Health, and Public Health – Seattle & King County. We would
like to thank Jason Carr at the Washington State Department of Health for providing estimates from HIV
surveillance and Dr. James Hughes at the University of Washington for statistical support. This research was also
supported by the the University of Washington Center for AIDS Research, a National Institutes of Health-funded
program (P30 AI027757).