Best Practices: HIVSyphilis Partner Services

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Best Practices HIV/Syphilis Partner Services

• Peter R. Kerndt, MD, MPH
• Director, Sexually Transmitted Disease Program
• Los Angeles County Department of Public Health

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Traditional PN approaches

• Provider Disclosure
• Health department (DIS\PHI)
• Clinician or case manager
• Patient (Self) Disclosure
• Dual Disclosure
• Client Provider
• Contract Disclosure
• Client Provider

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Barriers\Challenges to PN\PS

• CDC guidelines
• POGs vs. PCRS PN vs. PS
• Data systems
• STD MIS PEMS eHARS local reporting and case
  management systems
• Resources
• Personnel
• Training
• Community perception
• Normative vs. cohesive

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Priority for PS

• Acute HIV Infection
• Syphilis case or serology per reactor grid
• Pregnant w/ any STD
• New HIV
• HIV w/ STD

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Reasons for PCRS Administrative Closure2000 -
2006 (N2620)

• N
• Unable to Locate 1211 46.2
• Insufficient Information 289 11.0
• Unable to Interview (too ill) 351 13.4
• Deceased 147 5.6
• Previously Worked Case 264 10.1
• Management Decision 159 6.1
• Time factor gt 2 years 172 6.6
• Unknown reason 27 1.0

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Follow-up of 1016 Initiated Partners962 (94.7)
were counseled 650 (69.6) were eligible for
HIV testing
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Partner Follow-up

• 1016 partners followed-up
• 962 located (95) and counseled
• 32 already HIV
• 8 new positives of those located (79/962)
• 387 tested (40)
• 20 new positives of those tested (79/387)
• 41 new positives were previous negative (32/79)
• 59 new positives were not previous tested
  (47/79)
• 80 were negatives of those tested (308/389)

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HIV Tested Partners, 2000 -2006, (N387)
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PCRS Partner Referrals, 2000 - 2006 (N3845)
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Percent of ES Cases that Named gt1 Partner, Los
Angeles County, 2005 (N1282)
Source LAC Department of Public Health Sexually
Transmitted Disease Program
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Percent of ES Cases that Named gt1 Partner by
Gender, Los Angeles County, 2005, (N1282)
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Percent of ES Cases that Named gt1 Partner by
Race, Los Angeles County, 2005, (N1282)
1 cases (Am Ind/Alas. Nat.) , 3 cases (Mixed)
and 54 (unknown race/ethnicity) are excluded
because of small number
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Percent of ES Cases that Named gt1 Partner by
Sexual Orientation, Los Angeles County, 2005,
(N1282)
3 cases were WSMW and are excluded because of
small number
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Percent of ES Cases that Named gt1 Partner by HIV
Status, Los Angeles County, 2005, (N1282)
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How Do Patients Feel About Health Department PCRS
Provider Disclosure?

• Golden et.al. JAIDS 32 196-202 2003 Seattle
  surveyed persons w/recently reported HIV
• 84 Agreed (somewhat/strongly) the health
  department should routinely offer everyone
• diagnosed with HIV help in notifying
• their partners
• 20 Would want help notifying at least one
• partner from the last six months

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Newer PS approaches

• Internet-based approaches
• Self notification or internet partners
• Public health (DIS) notification of internet
  partners w/ or w/o prior index notification
• PS based in community organizations
• Howard Brown Model
• Peer driven clustering

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Internet-based PS approaches

• JAMA 2000 SF Klausner, et al
• AOL chat room notification after link to a
  syphilis cluster
• MMWR 2004 Los Angeles County
• Case notifies 13/16 partners w/ 7 responses
• DIS notifies 111/134 partners w/ 29 responses

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Internet-based PS approaches

• Online self notification
• www.Inspot.org

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www.inSPOTLA.org

• Potentially important tool to interrupt
  transmission
• Promotes STD and HIV testing and treatment
• Promotes connection to community agencies and
  services

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InSPOTLA.org

• More than 60 clinics and other agencies listed as
  testing and resource referrals
• Mutual benefit to agencies
• Increase linkage to agency website
• Increase clinic referrals
• Promote special agency services (e.g., rapid HIV
  testing)
• Enhance patient benefits

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www.inSPOTLA.org Usage, 2006
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InSPOTLA Website Usage Statistics May
December 2006 (average)

• Avg. site visits per day 152 (104-221)
• E-cards sent per month 392
• Recipients per e-card 1.6
• Click-throughs per month 162 (25 avg.)
• Sent anonymously 85
• Sent w/ personal message 77

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Percent e-cards Sent, by Disease, Dec 2005- Dec
2006
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Syphilis PS based in a CBO The Howard Brown
ModelGreatzer, Beau et al, CDC STD Prev Conf
2006

• Study population, 2002-03
• 232 early syphilis cases were included in the
  analysis
• CDPH investigated 108 (46.6) cases
• HB investigated 124 (53.4) cases
• No significant differences in total cases,
  demographics, or stage of disease

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Syphilis case results CDPH\Howard Brown

• Lost to follow-up (coded as 999)
• CDPH 43/108 cases (39.8)
• HB 6/124 cases (4.8)
• plt0.01
• Time from treatment to interview for cases not
  lost to follow-up, in median number of days
• CDPH 26 days
• HB 1 day

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Partner Elicitation Results CDPH\Howard Brown

• Cases with at least one partner elicited
• CDPH 29/108 (26.9)
• HB 63/124 (50.8)
• plt0.01
• Total partners elicited 191
• CDPH 50 (26.2)
• HB 141 (73.8)
• plt0.01
• Partner index (elicited partners/cases assigned)
• CDPH 0.463
• HB 1.14

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Conclusions

• PS identifies persons that have not received
  HIV/STD counseling and testing services
• PS identifies persons with previously undetected
  HIV infection
• PS creates opportunities for linking HIV infected
  to care
• PS provides opportunities for accessing
  previously diagnosed, high-risk, HIV-positive
  persons for referral into prevention case
  management
• PS encourages/supports HIV-negative partners to
  change risky behaviors

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Conclusions

• PS is an important component of PH response
• Integrated systems that provide PS are likely to
  be most effective
• Innovative strategies that use new technologies
  will be required to reach subpopulations
• CBO-based PS may increase the number of contacts
  identified and the timeliness of referral to
  treatment
• CBO-based PS may increase community support for PS

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Peter R. Kerndt, MD, MPHDirector, Sexually
Transmitted Disease ProgramLos Angeles County
Department of Public Healthwww.lapublichealth.org
/std [phone]pkerndt_at_ph.lacounty.gov