The Number of Interviews Needed to Yield New Syphilis and Human Immunodeficiency Virus Cases Among Partners of People Diagnosed With Syphilis, North Carolina, 2015

The Organization, Content, and Case-Finding Effectiveness of HIV Assisted Partner Services in High HIV Morbidity Areas of the United States

BACKGROUND

The contemporary effectiveness of assisted partner notification services (APS) in the United States is uncertain.

SETTING

State and local jurisdictions in the United States that reported ≥300 new HIV diagnoses in 2018 and were participating in the Ending the Epidemic Initiative.

METHODS

The study surveyed health departments to collect data on the content and organization of APS and aggregate data on APS outcomes for 2019. Analyses defined contact and case-finding indices (i.e., sex partners named and newly diagnosed per index case receiving APS) and estimated staff case-finding productivity.

RESULTS

Sixteen (84%) of 19 jurisdictions responded to the survey, providing APS outcome data for 14 areas (74%). Most health departments routinely integrated APS with linkage of cases and partners to HIV care (88%) and pre-exposure prophylaxis (88%). A total of 19,164 persons were newly diagnosed with HIV in the 14 areas. Staff initiated APS investigations on 14,203 cases (74%) and provided APS to 9937 cases (52%). Cases named 6799 partners (contact index = 0.68), of whom 1841 (27%) had previously diagnosed HIV, 2202 (32%) tested HIV negative, 541 (8% of named and 20% of tested partners) were newly diagnosed with HIV, and 2215 (33%) were not known to have tested. Across jurisdictions, the case-finding index was 0.054 (median = 0.05, range 0.015-0.12). Health departments employed 292 full-time equivalent staff to provide APS. These staff identified a median of 2.0 new HIV infections per staff per year. APS accounted for 2.8% of new diagnoses in 2019.

CONCLUSIONS

HIV case-finding resulting from APS in the United States is low.

Outcomes of Traditional and Enhanced Gonorrhea Partner Services in the Strengthening the US Response to Resistant Gonorrhea Project, 2017 to 2019

INTRODUCTION

The Centers for Disease Control and Prevention implemented Strengthening the US Response to Resistant Gonorrhea (SURRG) to build local detection and response capacity and evaluate responses to antibiotic-resistant gonorrhea outbreaks, including partner services for gonorrhea. We evaluated outcomes of traditional partner services conducted under SURRG, which involved (1) counseling index patients and eliciting sexual partners; (2) interviewing, testing, and treating partners; and (3) providing partner services to partners newly diagnosed with gonorrhea. We also evaluated outcomes of enhanced partner services, which additionally involved interviewing and testing partners of persons who tested negative, and social contacts of index patients and partners.

METHODS

We analyzed partner services investigation data from 8 jurisdictions participating in SURRG from 2017 to 2019. We summed total index patients, partners from traditional partner services, and partners and contacts from enhanced partner services, and calculated partner services outcomes among partners and contacts. We also visualized sexual networks from partner services data.

RESULTS

Of 1242 index patients identified, 506 named at least 1 sexual partner. Traditional partner services yielded 1088 sexual partners, and 105 were newly diagnosed with gonorrhea. Enhanced partner services yielded an additional 59 sexual partners and 52 social contacts. Of those partners and contacts, 3 were newly diagnosed with gonorrhea. Network visualization revealed sparse networks with few complex partnership clusters.

CONCLUSIONS

Traditional partner services for gonorrhea may be useful for eliciting, notifying, and diagnosing partners of index patients in an outbreak setting. Enhanced partner services are unlikely to be effective for eliciting, notifying, and diagnosing a substantial number of additional people.

Intersection of Syphilis and HIV Networks to Identify Opportunities to Enhance HIV Prevention

BACKGROUND

HIV and syphilis infection continue at disproportionate rates among minority men who have sex with men (MSM) in the United States. The integration of HIV genetic clustering with partner services can provide important insight into local epidemic trends to guide interventions and control efforts.

METHODS

We evaluated contact networks of index persons defined as minority men and transgender women diagnosed with early syphilis and/or HIV infection between 2018-2020 in two North Carolina regions. HIV clusters were constructed from pol sequences collected through statewide surveillance. A combined "HIV-risk" network, which included persons with any links (genetic or sexual contact) to HIV-positive persons, was evaluated by component size, demographic factors, and HIV viral suppression.

RESULTS

In total, 1,289 index persons were identified and 55% named 1,153 contacts. Most index persons were Black (88%) and young (median age 30 years); 70% had early syphilis and 43% had prevalent HIV infection. Most people with HIV (65%) appeared in an HIV cluster. The combined HIV-risk network (1,590 contact network and 1,500 cluster members) included 287 distinct components; however, 1,586 (51%) were in a single component. Fifty-five percent of network members with HIV had no evidence of viral suppression. Overall, fewer index persons needed to be interviewed to identify one HIV-positive member without viral suppression (1.3 versus 4.0 for contact tracing).

CONCLUSIONS

Integration of HIV clusters and viral loads illuminate networks with high HIV prevalence, indicating recent and ongoing transmission. Interventions intensified towards these networks may efficiently reach persons for HIV prevention and care re-engagement.

Ending the HIV Epidemic: Contributions Resulting From Syphilis Partner Services

BACKGROUND

There is a high level of coinfection with human immunodeficiency virus (HIV) among persons diagnosed with syphilis in the United States. Public health workers at state and local health departments help inform exposed partners to sexually transmitted disease (STD)/HIV infections to facilitate early testing and treatment (partner services). The federal initiative, Ending the HIV Epidemic (EHE), identifies 4 key strategies: diagnose, treat, prevent, and respond. This study describes the contributions of syphilis partner services to the EHE strategies in a county prioritized by the EHE plan.

METHODS

A retrospective record review of reported early syphilis cases (less than 1 year's duration) between 2016 and 2018 in the Indianapolis area was conducted to determine the extent of new HIV diagnoses, retention in HIV care, and other evidence-based HIV prevention interventions occurring after provision of syphilis partner services.

RESULTS

A total of 752 partners to early syphilis were attempted to be notified of exposure. There were 1,457 case patients and partners that received STD/HIV prevention counseling; 400 partners received STD treatment, 352 partners learned their HIV status, and 22 received new HIV diagnoses, with 68% retained in medical care and 60% virally suppressed. Two thirds of partner services were completed within 21 days. New HIV positivity among partners to HIV-negative syphilis case patients was 3.5% and 14% among HIV-positive syphilis case patients.

CONCLUSIONS

Partner services for syphilis was an effective method of addressing the EHE strategies, resulting in persons at risk tested, STD treatment provided, behavioral prevention counseling provided, and new HIV cases identified, leading to retention in medical care and viral suppression.

Unnamed Partners From Syphilis Partner Services Interviews, 7 Jurisdictions

BACKGROUND

Reducing transmission depends on the percentage of infected partners treated; if many are missed, impact on transmission will be low. Traditional partner services metrics evaluate the number of partners found and treated. We estimated the proportion of partners of syphilis patients not locatable for intervention.

METHODS

We reviewed records of early syphilis cases (primary, secondary, early latent) reported in 2015 to 2017 in 7 jurisdictions (Florida, Louisiana, Michigan, North Carolina, Virginia, New York City, and San Francisco). Among interviewed syphilis patients, we determined the proportion who reported named partners (with locating information), reported unnamed partners (no locating information), and did not report partners. For patients with no reported partners, we estimated their range of unreported partners to be between one and the average number of partners for patients who reported partners.

RESULTS

Among 29,719 syphilis patients, 23,613 (80%) were interviewed and 18,581 (63%) reported 84,224 sex partners (average, 4.5; 20,853 [25%] named and 63,371 [75%] unnamed). An estimated 11,138 to 54,521 partners were unreported. Thus, 74,509 to 117,892 (of 95,362-138,745) partners were not reached by partner services (78%-85%). Among interviewed patients, 71% reported ≥1 unnamed partner or reported no partners; this proportion was higher for men who reported sex with men (75%) compared with men who reported sex with women only (65%) and women (44%).

CONCLUSIONS

Approximately 80% of sex partners were either unnamed or unreported. Partner services may be less successful at interrupting transmission in networks for men who reported sex with men where a higher proportion of partners are unnamed or unreported.

Barriers, Facilitators, and Cost of Integrating HIV-Related Activities Into Sexually Transmitted Disease Partner Services in Jackson, Mississippi

BACKGROUND

Many US health departments now integrate HIV-related outcomes (e.g., relinkage to HIV care and preexposure prophylaxis [PrEP]) into sexually transmitted disease (STD) partner services (PS) programs. We sought to determine the barriers, facilitators, and cost of integrating these activities into PS.

METHODS

From 2016 to 2018, the Mississippi State Department of Health integrated 3 new activities into STD PS: HIV testing for partners of HIV-negative men who have sex with men with gonorrhea/chlamydia, relinkage to HIV care for STD PS recipients previously diagnosed with HIV, and PrEP referrals. We conducted direct observations and interviews with disease intervention specialists (DIS) in Jackson to assess barriers and facilitators to implementing these activities. We completed time and motion studies with 8 DIS and case tracking forms for 90 unique cases to estimate the incremental staff time and associated personnel cost of added services compared with a standard PS case.

RESULTS

Disease intervention specialists were optimistic about integrating HIV-related activities but noted disparate data systems, nonsystematic documentation, and lack of training as barriers. The mean time for a standard STD PS case without HIV-related activities was 195 minutes (cost, $77.69/case). The cost to conduct PS for HIV-negative men who have sex with men with gonorrhea/chlamydia was 36% higher than a standard case. Integrating relinkage to care and PrEP referrals resulted in a 44% and 20% increase in cost, respectively.

CONCLUSIONS

Integrating HIV care relinkage and PrEP referrals into STD partner services was generally acceptable by DIS and added marginal cost per case. Coupling these cost metrics with an assessment of the effectiveness of these activities can inform prioritization of partner services activities.

Integrating Human Immunodeficiency Virus Testing Into Syphilis Partner Services in Mississippi to Improve Human Immunodeficiency Virus Case Finding

BACKGROUND

Mississippi has the 10th highest rate of new human immunodeficiency virus (HIV) infections in the United States. The Mississippi State Department of Health (MSDH) integrated partner HIV testing into syphilis partner services (PS) in 2014, but the effectiveness of this as an HIV case finding strategy has not been evaluated.

METHODS

We identified all early syphilis (primary, secondary, and early latent) case records reported from July 1, 2014, to December 31, 2016, excluding case records for people concurrently newly diagnosed with HIV. Among sex partners of these people, we identified new diagnoses of early syphilis and HIV. We calculated the number needed to interview as the number of syphilis index case patients interviewed divided by the number of partners newly diagnosed with early syphilis or HIV.

RESULTS

A total of 1535 (95%) of the 1619 early syphilis index case patients were interviewed for PS. These case patients named 2267 partners, of whom 1868 (82%) were contacted by MSDH. Among partners, 1508 (81%) tested for syphilis and 745 (56%) of 1321 partners not previously diagnosed with HIV were tested for HIV. Partner services identified 696 new early syphilis case patients (46%) and 24 (3.2%) new HIV case patients among partners. Sixty-four index case patient interviews were needed to identify 1 new case of HIV, and 2 interviews were needed to identify 1 new case of syphilis among partners.

CONCLUSIONS

Syphilis PS allowed MSDH to interact with 1592 men who have sex with men over a 30-month period and was effective for identifying people newly infected with early syphilis and HIV. Increasing HIV testing among partners of syphilis case patients could increase HIV case finding in Mississippi.