# Presentation: 682273

## 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

**Notes:**
Good afternoon. My name’s Rheta Barnes and I’ll be moderating the symposium.  The topic of this symposium is formative research on the feasibility of STD control for HIV prevention that has been conducted in 3 Southern cities.  What we’re going to do this afternoon is to give you an overview of the projects as a whole and present findings for each of the individual sites.  Dr. Farley on New Orleans, Dr. Rompalo on Baltimore, and Dr. Leone on Raleigh.  First we’d like to acknowledge some of the other folks who have worked on this project.  The investigators in each of the 3 cities who are not presenting today – Debbie Cohen in New Orleans; David Rose, & Emmanuel Nwokolo in Baltimore; and Bill Miller, Kim Fox, and Evelyn Foust in Raleigh, the CDC project officers – Katy Irwin and Mary Kamb, and my predecessor as CDC project manager Maysoun Freij.  So first, I’ll give you some background on the projects.

## 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**

**Notes:**
Impetus for studying the feasibility of STD control for HIV prevention comes from clinical and lab data indicating that STDs increase HIV transmission efficiency in 2 ways
- STDs increase the susceptibility of HIV-uninfected persons 
and 
- STDs increase the infectivity of HIV- infected persons

Another impetus for these demonstration projects was the community intervention trial in Mwanza, Tanzania that showed a 42% reduction in HIV incidence over 2 years in intervention communities that implemented enhanced STD diagnosis and treatment

## 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**

**Notes:**
The question remains - are STD control strategies feasible for preventing HIV transmission in the U.S. where, compared with Tanzania
there are important differences 
- in population demographics, mobility, and healthcare status
- where there is better STD and HIV access to care and services
and  
- where there is lower STD and HIV prevalence and incidence

## 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?**

**Notes:**
In 1998 CDC began a formative research study to assess:
-the effectiveness of STD control to prevent HIV acquisition and transmission
and 
-the feasibility of improving access to and quality of STD services as an HIV prevention strategy
We hoped to answer 3 main questions:
First, in what settings does STD/HIV co-infection - that is concurrent infection with STD and HIV - occur?  if we were able to find populations where STD and HIV infection currently merged, those subgroups would be the highest priorities for prevention efforts now.
Second, are STD control strategies feasible in these settings?
And finally, what are the gaps in STD diagnosis and treatment services in these settings.  If we were able to find out why STDs weren’t being diagnosed and/or treated, we could target our interventions to address those needs.

## 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**

**Notes:**
Areas that were eligible to apply for the RFA were those with 
a 1996 gonorrhea case rate greater than 200 per 100,000
or
a 1996 primary and secondary syphilis case rate greater than 9 per 100,000
and 
a continuing high incidence of gonorrhea or syphilis 
In addition to these criteria, eligibility was restricted to the 65 project areas receiving federal STD prevention funds

## Gonorrhea - 

- 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

**Notes:**
This map gives you an idea of which states were eligible.  Gonorrhea rates greater than 200 per 100,000 are shown in red.  Almost all the states with high gonorrhea rates are clustered in the southeastern US.

## Primary and secondary syphilis -

- 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

- 0.0

- 0.3

- 0.4

- 0.8

- 0.0

- 0.3

- 0.4

- 0.2

- 0.2

- 0.7

- 0.0

- 0.3

- 30.4

- 1.4

- 2.4

- 1.6

- 5.9

- 0.3

- 0.2

**Primary and secondary syphilis -**
**Rates by state: US, 1996**

- 5.5

- 4.8

- 1.1

- 3.6

- 4.2

- 9.6

- 10.5

- 10.9

**Notes:**
This map gives you an idea of which states were eligible based on relatively high rates of syphilis in 1996.  The states shown in red had P&S syphilis prevalence rates greater than 9 per 100,000. As with gonorrhea, the states with high rates of syphilis are located in the southeastern US

## 3 sites in areas with high prevalence 

**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**

**3 sites in areas with high prevalence **
**of HIV, gonorrhea, & syphilis**

**Notes:**
This map shows several things:
Our 3 study sites - Baltimore, Raleigh, and New Orleans - noted by the blue stars are all in the southeastern United States, where STDs and HIV are highly concentrated. 
Also on the map are areas with high prevalence of syphilis - shown in yellow.
Areas with high gonorrhea prevalence - in red.
And areas with high prevalence of heterosexual HIV- shown in light green.

## Methods

**Three research questions**
**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?**
**No common study protocol**

**Notes:**
Sites were asked to assess the 3 research questions.  Since these were demonstration projects designed to examine the feasibility of STD control for HIV prevention, we did not develop a common study protocol.  Instead each site developed its own protocols based on assessment of the needs of their individual communities.

## 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

**Notes:**
To answer our first question: In what settings does STD/HIV co-infection occur, the sites used several methods to identify settings with high STD and/or HIV prevalence 
-analysis of existing STD & HIV surveillance data to pinpoint specific high risk groups 
-geographic mapping to pinpoint specific areas with high STD prevalence
- and working with non-governmental organizations in the community to identify high risk groups and settings where members of high risk groups were likely to go for health care

Sites performed STD and HIV screening using the tests listed here:
not  all of the sites tested for all the STDs listed
Herpes and syphilis testing were not performed in the New Orleans and Baltimore sites mainly because blood draws weren’t feasible at the venues where they screened

- sites also analyzed existing STD and HIV prevalence data from STD and HIV clinics

## MethodsWhere STD & HIV Prevalence Was Assessed 

**Notes:**
These methods led the sites to assess prevalence of STD & HIV in 2 main types of settings - those that do not usually screen for STD or HIV - called special screening settings 
and those that usually offer some STD or HIV screening - called routine screening settings
This slide shows the special screening sites and routine screening sites where screening was performed for each site. 
Looking at the special screening sites:
- All of the sites screened in public emergency departments
- New Orleans & Baltimore screened in private emergency departments
- New Orleans screened in a public dental clinic, a community-based organization (CBOs) for homeless youth, and several educational facilities serving young, low-income students 
-Baltimore screened in two CBOs serving high-risk populations Medical settings, such as emergency departments and a dental clinic 
Looking at the routine screening sites:
-All the sites screened in HIV care clinics
-Raleigh screened at HIV Testing and Counseling sites
-And 
-Baltimore and Raleigh analyzed existing surveillance data from their STD clinics

## MethodsAre STD control strategies feasible in these settings?

**Notes:**
One of the ways we assessed the feasibility of offering STD/HIV screening in specific settings where screening isn’t usually offered, was by looking at how many persons were screened
and
how many of those screened tested positive for STDs or HIV
[reference to Tom & Peter’s presentations of feasibility assessments]
This slide categorizes each setting by the relative number of persons screened – high volume settings and low volume settings. The overall STD prevalence and HIV prevalence are given for each setting. STDs were found in all settings regardless of the volume of persons screened in the setting. 
We don’t have data yet for the ED screening in Raleigh. 
Looking just at the high volume settings, HIV was found in 3 of these settings -the public and private emergency departments in New Orleans and the public ED in Baltimore.
No HIV was found in the other two high volume settings, the dental clinic and the college in New Orleans. 
Looking just at the low volume settings, HIV was found in 2 of these settings.  The CBO serving IDUs, where it is likely that  some of the HIV infection was not sexually acquired.  And the private ED in Baltimore where only 17 persons were screened. 
To assess feasibility, we also looked at how many persons returned for treatment.  The rate of return was similar for all sites and ranged from 50-60%.

## Methods 

**Symptom Recognition**

**Care Seeking for Symptoms**

**Access to Appropriate Care**

**Effective Treatment Prescribed**

**Ecology of Infection**

**Behavior Leads to Exposure**

**Exposure**

**Infection**

**Infection**

**Symptoms**

**Seeks Care**

**Access Appropriate Care**

**STD Diagnosis Considered**

**STD Diagnosis Considered**

**Diagnosis Correct**

**Correct Diagnosis**

**Effective Treatment Prescribed**

**Comply With Treatment, Cured**

**Patient Cured**

**Exposed Partner(s) Treated**

**Symptoms**

**Methods **
**What are the gaps in STD services?**
**Piot-Fransen Model of STD Management**

**Notes:**
Our last research question was “What are the gaps in STD diagnosis and treatment services?”  To guide our assessment of gaps in STD services we used the model developed by Piot & Fransen to conceptualize the steps required to detect, treat, and prevent STD. 
Each bar on the histogram (point) represents a potential point for intervention through STD care management and other public health interventions, to reduce acquisition of STDs and to detect and treat asymptomatic and symptomatic infections. 
The progressively shorter bars represent the decreasing number of persons with STD who get into STD care at each step.  So each bar shows where gaps in STD management may occur. 
The first bar (point) represents all of the people who through their behavior are exposed to an STD, the second bar (point) represents the smaller proportion of exposed people who become infected.  Some of the persons infected will develop symptoms (point).  Of those who develop symptoms, a proportion will recognize their symptoms (point) and some of those people who recognize their symptoms will seek care (point).  And so on until the last bar, - the number of people who are cured and have exposed partners who are treated.  According to the Piot-Fransen model, only a small fraction of all the persons who become infected with STD (point), will actually be cured and  have exposed partners who receive treatment.

## Methods

**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**

**Notes:**
In terms of the Piot-Fransen model we examined STD management gaps corresponding to the intervention points highlighted in green
Why are persons with untreated STDs not treated?
Is it because they have no symptoms or because their symptoms are not recognized
Is it because they do not seek care or because they do not access appropriate care
Is it because an STD diagnosis is not considered or because a correct diagnosis is not made
Or is it because effective treatment is not prescribed

## MethodsPotential Gaps in STD Diagnosis & Treatment

**Notes:**
This slide compares the 6 STD diagnosis and treatment services gaps assessed - these gaps are listed in the 1st column (point) for each site and the venues or population groups in which each gap was assessed in each site.  
As part of their STD/HIV screening in community and medical venues New Orleans and Baltimore conducted a survey to assess awareness of asymptomatic infection, symptom recognition, STD care seeking behavior and accessibility or availability of STD services (point) .
[Reference to Tom’s 
New Orleans also abstracted a proportion of the medical charts of persons who indicated on the survey that they had been diagnosed with an STD during the past year to assess gaps related to STD diagnosis and treatment (point) 
Raleigh took a different approach.  They conducted focus groups with adolescents and young adults to assess awareness of asymptomatic infection, symptom recognition, STD care seeking behavior and accessibility or availability of STD services (point).
In addition to using focus groups to assess accessibility or availability of STD services, they also surveyed insurance companies and HMOs  to assess their coverage of STD services (point) 
To assess gaps related to STD diagnosis and treatment, they surveyed insurance companies and HMOs and providers at both the individual and the group practice level concerning policies, protocols, diagnostic and treatment practices for STDs (point) 

That gives you background on the study and an idea of the general methods the sites used to answer the research questions.  Now Dr Tom Farley is going to talk about....

## Slide 16