Tom Mickey

Improving partner services by embedding disease intervention specialists in HIV-clinics.

Background/Objectives: Notifying partners of HIV-infected persons and referring them for testing and treatment is an effective method of disease control and identification of undiagnosed STD and/or HIV. To improve partner elicitation interviews, disease intervention specialists (DIS) were placed in 3 HIV clinics during 2008 and 2009. Methods: We reviewed the Arizona state STD surveillance database for 2007 to identify the providers (outside of the public STD clinics) reporting the highest number of syphilis cases. DIS were placed in the clinics for half a day per week (2 clinics) or on an on-call basis (1 clinic) to deliver penicillin and interview patients. We calculated changes in the number of patients interviewed, days elapsed from specimen collection to treatment (time to treatment), days elapsed from specimen collection to initial DIS contact (time to interview), and number of reported and locatable partners from these 3 clinics before and after the clinic placement of DIS. Results: Before the placement of clinic-based DIS, 219 syphilis cases were diagnosed at the 3 clinics (January 2006 through January 2008). After DIS placement, 115 syphilis cases were diagnosed (February 2008 through September 2009) for a total of 334 cases in this analysis. A greater percent of patients completed a partner elicitation interview during the period of DIS placement (94% after vs. 81% before, P = 0.001). There were increases in the average number of locatable partners (1.1 after vs. 0.6 before, P = 0.004) and an increase in the average number of partners exposed and brought to treatment (CDC Disposition A) or infected and brought to treatment (CDC Disposition C) (0.6 after vs. 0.3 before, P = 0.02), and the time to interview decreased (18 days before vs. 9 days after, P = 0.02). Conclusions/Implications: Placing DIS within community HIV clinics improved partner services. STD and/or HIV programs should consider this method to improve partner notification.

Needle in a haystack: the yield of syphilis outreach screening at 5 US sites-2000 to 2007.

BACKGROUND Screening for syphilis has been performed for decades, but it is unclear if the practice yields many cases at acceptable cost, and if so, at which venues. We attempted a retrospective study to determine the costs, yield, and feasibility of analyzing health department-funded syphilis outreach screening in 5 diverse US sites with significant disease burdens. METHODS Data (venue, costs, number of tests, reactive tests, new diagnoses) from 2000 to 2007 were collected for screening efforts funded by public health departments from Philadelphia; New York City; Washington, District of Columbia; Maricopa County, Arizona (Phoenix); and the state of Florida. Crude cost per new case was calculated. RESULTS Screening was conducted in multiple venues including jails, shelters, clubs, bars, and mobile vans. Over the study period, approximately 926 258 tests were performed and 4671 new syphilis cases were confirmed, of which 225 were primary and secondary, and 688 were early latent or high-titer late latent. Jail intake screening consistently identified the largest numbers of new cases (including 67.6% of early and high-titer late-latent cases) at a cost per case ranging from

Opportunities for the prevention of congenital syphilis in Maricopa County, Arizona.

144 to

Chlamydia and gonorrhea diagnosis, treatment, personnel cost savings, and service delivery improvements after the implementation of express sexually transmitted disease testing in Maricopa County, Arizona.

3454. Data quality from other venues varied greatly between sites and was often poor. CONCLUSIONS Though the yield of jail intake screening was good, poor data quality, particularly cost data, precluded accurate cost/yield comparisons at other venues. Few cases of infectious syphilis were identified through outreach screening at any venue. Health departments should routinely collect all cost and testing data for screening efforts so that their yield can be evaluated.

Epidemiology of syphilis among Hispanic women and associations with congenital syphilis, Maricopa county, Arizona.

Rates of syphilis among women and congenital syphilis have declined nationally since the early 1990s.1 The National Syphilis Elimination Plan has focused on decreasing racial disparities among syphilis diagnoses.2 Despite this national emphasis and decreasing rates, congenital syphilis cases continue to be overrepresented in minority populations.3 Arizona ranked the highest for congenital syphilis (CS) case rates in the United States for the years 2003, 2004, and 2005.3–5 Despite a steady reduction in primary and secondary syphilis among women in Arizona, rates of CS have remained high. Most of congenital syphilis cases diagnosed in Arizona during the previous 5 years were born in Maricopa County to Hispanic women. Compared to live births, infants born with congenital syphilis in Maricopa County during 1998– 2002 were more likely be born to: mothers of minority race or ethnicity, unmarried mothers, uninsured mothers, and mothers who did not receive prenatal care (PNC).6 The high rate of CS cases during 2000–2005 prompted us to acquire additional information to identify risk factors that might be used to guide interventions targeting women of childbearing age at risk for syphilis and medical providers in Maricopa County and the rest of Arizona. State health department records were reviewed for cases of congenital syphilis diagnosed in Maricopa County from 2000 to 2005. Demographic variables (maternal age, race, infant date of birth), reason for diagnosis, type of diagnosis (stillbirth vs. live birth), receipt of PNC, and number of PNC visits were collected from health department records and from the Centers for Disease Control and Prevention (CDC) Congenital Syphilis (CS) Case Investigation and Report (CDC Form 73.126) submitted for each case. CS cases were defined according to CDC surveillance case definitions for confirmed and presumptive congenital syphilis and syphilitic stillbirths as specified in the CDC Form 73.126 and according to the CDC CS algorithm. Cases were grouped for local use in prevention planning into categories based on contributing factors to the diagnosis. Hospital delivery, prenatal, and laboratory records were reviewed for mothers who gave birth to infants with congenital syphilis near the time of delivery. Demographic variables collected included: age, race or ethnicity, citizenship status, insurance status, marital status, history of PNC, number of prenatal visits, and behavioral risk factors of drug use and prostitution. All mothers of infants with congenital syphilis were interviewed near the time of diagnosis as part of routine case investigation to determine treatment status and to elicit partners requiring testing and treatment. Risk factor information including citizenship, marital status, drug use during pregnancy, exchange of drugs or money for sex, and recent incarceration was collected from these interview records. Disease surveillance, data collection, evaluation, and analysis are ongoing public health surveillance activities, and thus are not subject to review by institutional review boards. Data were analyzed using SPSS v 13.0 (SPSS Inc., Chicago, IL). Chi-square analysis was used to determine univariate correlates of significance. During 2000–2005, 5808 cases of syphilis were reported to the Arizona Department of Health Services. Of these, 2190 (38%) were diagnosed among women, and 4401 (76%) were diagnosed in Maricopa County. A total of 1807 women were diagnosed with syphilis in Maricopa County, of whom 894 (49%) were of Hispanic ethnicity and 341 (19%) of whom were pregnant at the time of diagnosis (Fig. 1). Of the pregnant women with syphilis in Maricopa County, 235 (69%) were of Hispanic ethnicity. During 2000–2005, 161 cases of CS were reported to Arizona Department of Health Services, 131 (81%) of which were diagnosed in Maricopa County. Ninety-five (73%) of the 131 cases were HisPresented, in part, at the International Conference on Women and Infectious Diseases. Abstract 59. March 2006. Atlanta, GA. Correspondence: Melanie Taylor, MD, MPH, Arizona Department of Health Services, Office of Infectious Disease Services, 150 N. 18th Ave., Suite 140, Phoenix, AZ 85007-3237. E-mail: taylorm@azdhs.gov. Received for publication March 16, 2007, and accepted September 9, 2007. The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention. From the *Division of STD Prevention, National Center for HIV, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia; †Arizona Department of Health Services, and ‡Maricopa County Department of Public Health, Phoenix, Arizona Sexually Transmitted Diseases, April 2008, Vol. 35, No. 4, p.341–343 DOI: 10.1097/OLQ.0b013e31815bb335 Copyright

Protecting adolescents' right to seek treatment for sexually transmitted diseases without parental consent: The Arizona experience with senate bill 1309

Background The demand for low-cost sexually transmitted disease (STD) services in Maricopa County (Phoenix area) is high. Improved methods for STD/HIV testing are needed to increase the number of patients receiving testing. Objectives The present study sought to evaluate an STD/HIV express testing (ET) option for patients identified as being at lower risk for infection. Methods Clients reporting current STD symptoms, contact to an infected partner, or health department referral were identified via questionnaire and routed to a traditional provider visit (PV); those not reporting these situations were routed to ET (laboratory-only). Demographics, treatment completion, and treatment intervals were compared among patients diagnosed as having chlamydia and gonorrhea through ET and PV encounters in September 2008 to July 2011. Personnel costs were compared for each of the 2 visit types. The number of clinic turn-aways for the 2-month time interval before the start of the program was compared with the 2-month interval at the end of the evaluation. Results Of the 36,946 clients seen at Maricopa County Department of Public Health, 7466 (20.2%) were patients seen through express visits. Overall chlamydia and gonorrhea positivity was lower among ET patients (527/7466; 7.1%) as compared with those tested through PVs (6323/29,480; 21.4%). Treatment completion rates were comparable but were higher among patients seen through PVs (99%) as compared with ET (94%). A savings of

Viral Loads Among HIV-Infected Persons Diagnosed With Primary and Secondary Syphilis in 4 US Cities: New York City, Philadelphia, PA, Washington, DC, and Phoenix, AZ.

2936 per 1000 patients seen was achieved when 20% of clients were routed through ET. Clinic turn-aways decreased significantly, from 159 clients during the 2 months before implementation of ET to 6 patients during the last 2 months of evaluation (96% reduction). Conclusions This ET system included an effective patient routing process that provided an efficient way to increase access to STD testing among persons at lower risk, at a reduced cost per patient, while maintaining high treatment coverage.

Assessing compliance with a county board order for third trimester syphilis screening in Maricopa County, Arizona

Objective: We investigated factors associated with high rates of congenital syphilis among Hispanic infants in Maricopa County, AZ. Methods: Using 2004–2008 syphilis case report data from the state and county health departments, we examined characteristics of pregnant and nonpregnant women with syphilis and their male partners. Results: During 2004–2008, 970 women were reported to have syphilis: 49% were Hispanic (of whom 49% were non-US citizens), 27% were white, 13% were black, and 8% were American Indian/Alaskan Native. Although 16% of Hispanic noncitizens reported drug use or high-risk sexual behaviors, 64% of these women had a male sex partner who reported drug use or anonymous sex. Hispanic women with syphilis were more likely to be pregnant (37%) than white (15%) or black women (13%) (P < 0.05), and were overrepresented among pregnant women with syphilis. Pregnant Hispanic noncitizens were treated later than pregnant Hispanic citizens (median 28 weeks gestation vs. 21 weeks, P = 0.01). Conclusions: Innovative congenital syphilis prevention strategies that are relevant to Hispanic women are warranted. Strategies should address the reproductive health and prenatal care needs of Hispanic women, and may include interventions for their male partners.

Viral Loads among Young HIV-Infected Men with Early Syphilis

In 2010, Senate Bill 1309 included language to repeal an existing Arizona law that enables minors younger than 18 years of age to seek diagnosis and treatment of sexually transmitted diseases (STDs) without parental consent. Numerous implications were identified that would have stemmed from parental consent provisions originally proffered in Senate Bill 1309. These implications included diminished access to essential health services among minors, exacerbated existing health disparities, increased health-care spending costs, and thwarted efforts to curb the spread of STDs. Lastly, minors would have been deprived of existing privacy protections concerning their STD-related medical information. This case study describes how collaborative advocacy efforts resulted in the successful amendment of Senate Bill 1309 to avert the negative sexual and reproductive health outcomes among adolescents stemming from the potential repeal of their existing legal right to seek STD treatment without parental consent.

Syphilis Time to Treatment at Publicly Funded Sexually Transmitted Disease Clinics Versus Non-Sexually Transmitted Disease Clinics--Maricopa and Pima Counties, Arizona, 2009-2012.

Background:Incident syphilis among HIV-infected persons indicates the ongoing behavioral risk for HIV transmission. Detectable viral loads (VLs) among coinfected cases may amplify this risk. Methods:Primary and secondary cases reported during 2009–2010 from 4 US sites were crossmatched with local HIV surveillance registries to identify syphilis case-persons infected with HIV before or shortly after the syphilis diagnosis. We examined HIV VL and CD4 results collected within 6 months before or after syphilis diagnosis for the coinfected cases identified. Independent correlates of detectable VLs (≥200 copies/mL) were determined. Results:We identified 1675 cases of incident primary or secondary syphilis among persons with HIV. Median age was 37 years; 99.5% were men, 41.1% were African American, 24.5% were Hispanics, and 79.9% of the HIV diagnoses were made at least 1 year before syphilis diagnosis. Among those coinfected, there were no VL results reported for 188 (11.2%); of the 1487 (88.8%) with reported VL results, 809 (54.4%) had a detectable VL (median, 25,101 copies/mL; range, 206–3,590,000 copies/mL). Detectable VLs independently correlated with syphilis diagnosed at younger age, at an sexually transmitted disease clinic, and closer in time to HIV diagnosis. Conclusions:More than half of syphilis case-persons identified with HIV had a detectable VL collected within 6 months of the syphilis diagnosis. This suggests virologic and active behavioral risk for transmitting HIV.