Community-embedded disease intervention specialist program for syphilis partner notification in a clinic serving men who have sex with men

Delivering Partner Services to Reduce Transmission and Promote Linkage to Care: Process Outcomes Varied for Chlamydial Infection, Gonorrhea, HIV, and Syphilis Cases

CONTEXT

Partner services for HIV and sexually transmitted diseases, a public health intervention activity recommended by the Centers for Disease Control and Prevention, includes counseling, partner notification, linkage to care, and referral to other services.

OBJECTIVE

A time study of partner services case investigations documented differences in times to process HIV/sexually transmitted disease cases.

SETTING

Cases were from 9 local and regional sites in New York.

PARTICIPANTS

Fifty-two partner services disease investigators documented 542 randomly selected cases (271 chlamydial infections, 162 gonorrhea, 48 HIV, and 61 syphilis cases) assigned between June and September 2014. Cases were the unit of the analysis and represented 6.9% of all partner services investigations in 2014.

DESIGN

Cases were selected via stratified random sampling of infections assigned to staff. For each case, disease investigators completed a standard time study form to document the time spent on specific tasks and other outcomes. Kruskal-Wallis tests for continuous variables and χ tests for categorical variables assessed variation in outcomes across infection type.

MAIN OUTCOME MEASURES

Outcomes included minutes spent on specific tasks (such as medical provider and index case outreach, travel, and partner notification), days the case remained open, disposition codes, and number of partners reached.

RESULTS

Case processing times varied, with HIV and syphilis tasks taking more minutes (P < .001) and cases staying open for more days (P < .001). Partners were notified in 33% of cases overall, with more notifications in syphilis (44%). Most time (median = 77%) was spent on index cases and 2% (median) on partner notification, with a wide range across cases.

CONCLUSIONS

Given their chronic resource constraints, public health agencies must identify efficient methods to allocate resources, including which infections to prioritize. Documenting how workers allocate time across cases is essential to improving the effectiveness and efficiency of this program and generating the data to model return on investment.

John K, Browning C, Medina MM, Morse A, Chan PA. Partner notification outcomes after integration of an on-site disease intervention specialist at a sexually transmitted disease clinic

BACKGROUND

Partner notification services (PNS) are highly effective in reducing transmission of sexually transmitted diseases (STDs). We assessed outcomes of PNS before and after integration of an on-site disease intervention specialist (DIS) at a publicly-funded STD clinic.

METHODS

From August 2014 to December 2015, patients testing positive for infectious syphilis or gonorrhea at the Rhode Island STD Clinic were referred to on-site DIS for partner notification. Data on PNS outcomes were reviewed for eight months before integration of DIS at the clinic and compared to eight months after.

RESULTS

Of the 145 index patients referred for PNS during the study period (n = 58 before DIS integration, n = 87 after), 86% were interviewed. DIS integration resulted in a significantly greater proportion of index patients interviewed overall (92% versus 76%, p<0.01), on the day of diagnosis (85% versus 61%; p<0.01), and in person at the STD clinic (64% versus 11%; p<0.01). However, there was no significant difference in number of sexual partners named or treated.

CONCLUSIONS

Integrating DIS at a publicly-funded STD clinic resulted in a greater number of index cases interviewed, a greater number interviewed in person, and a greater number interviewed on the day of diagnosis. Challenges remain in identifying and engaging partners for treatment.

Comparison of In-Person Versus Telephone Interviews for Early Syphilis and Human Immunodeficiency Virus Partner Services in King County, Washington (2010-2014)

BACKGROUND

The relative effectiveness of in-person versus telephone interviews for human immunodeficiency virus (HIV)/sexually transmitted disease partner services (PS) is uncertain.

METHODS

We compared outcomes of in-person versus telephone PS interviews for early syphilis (ES) and newly diagnosed HIV in King County, Washington from 2010 to 2014. We used multivariable Poisson regression to evaluate indices (number of partners per original patient [OP]) for partners named, notified, tested, diagnosed, and treated (ES only). Analyses controlled for OP age, sex, race/ethnicity, sexual orientation, time to interview, place of diagnosis, and staff performing interviews.

RESULTS

For ES, 682 and 646 OPs underwent in-person and telephone interviews, respectively. In-person syphilis PS were associated with higher indices of partners named (in-person index [IPI], 3.43; telephone index [TI], 2.06; adjusted relative risk [aRR], 1.68; 95% confidence interval [CI], 1.55-1.82), notified (IPI, 1.70; TI, 1.13; aRR, 1.39; 95% CI, 1.24-1.56), tested (IPI, 1.15; TI, 0.72; aRR, 1.34; 95% CI, 1.16-1.54), and empirically treated (IPI, 1.03; TI, 0.74; aRR, 1.19; 95% CI, 1.03-1.37), but no difference in infected partners treated (IPI, 0.28; TI, 0.24; aRR, 0.93; 95% CI, 0.72-1.21). For HIV, 358 and 489 OPs underwent in-person and telephone interviews, respectively. In-person HIV PS were associated with higher indices of partners named (IPI, 1.87; TI, 1.28; aRR, 1.38; 95% CI, 1.18-1.62), notified (IPI, 1.38; TI, 0.92; aRR, 1.24; 95% CI, 1.03-1.50), and newly diagnosed with HIV (IPI, 0.10; TI, 0.05; aRR, 2.17; 95% CI, 1.04-4.50), but no difference in partners tested (IPI, 0.61; TI, 0.48; aRR, 1.15; 95% CI, 0.88-1.52).

CONCLUSIONS

Although in-person syphilis PS were associated with some increased PS indices, they did not increase the treatment of infected partners. In contrast, in-person HIV PS resulted in increased HIV case finding. These data support prioritizing in-person PS for HIV and suggest that in-person PS for syphilis may not have major public health benefit.

Partner Notification Outcomes for Men Who Have Sex With Men Diagnosed With Syphilis Referred to Partner Notification Officers, Melbourne, Australia

BACKGROUND

We examined the extent of partner notification for men who have sex with men (MSM) who were diagnosed with syphilis, and offered referral to a partner notification officer (PNO), to assist them with informing recent sexual partners.

METHODS

Between October 2013 and March 2015, MSM diagnosed with syphilis at the Melbourne Sexual Health Centre were routinely offered a referral to a PNO. The outcomes of this intervention were evaluated including the proportion of men who accepted PNO services and the number of sexual partners informed by the PNO.

RESULTS

There were 380 MSM diagnosed with syphilis. Those with primary or secondary syphilis reported a total of 813 partners over 3 months and those with early latent syphilis reported a total of 1400 partners over 12 months. Sixty nine percent of index men (n = 262) had documented discussion of partner notification, 34% (n = 128) accepted PNO referral, and 28% (n = 105) were contacted by the PNO, 58 of whom reported they had already notified partners themselves. Only 14 index men (4%) provided the PNO with contact details for 28 partners, 25 of whom were notified by the PNO. Among those interviewed, the most common barrier to partner notification was the presence of anonymous partners and absence of contact details for partners.

CONCLUSIONS

Despite offering an effective PNO service in our centre, ultimately only 4% of MSM with syphilis had at least 1 partner notified by the PNO with patients declining the PNO service and anonymous partners posing the major barriers. Alternative patient initiated methods for improving partner notification for syphilis among MSM using newer communication technologies are required.

Adaptation of the HIV Care Continuum as a Method for Evaluating Syphilis and Gonorrhea Disease Control Activities in Los Angeles County

BACKGROUND

Treatment verification and contact elicitation are core approaches used to control the spread of sexually transmitted diseases (STDs). Methodology adapted from the HIV care continuum is presented as an evaluation and communication tool for STD control activities.

METHODS

Sexually transmitted disease surveillance and program data for Los Angeles County in 2013 were used to construct a 2-part continuum to examine syphilis (all stages) and gonorrhea outcomes among index patients and elicited contacts. The Index Case Continuum (Part 1) assesses the proportion of patients who were treated, assigned for interview, interviewed, and provided name and locating information for at least 1 contact. The Elicited Contact Continuum (Part 2) assesses the proportion of contacts who were located, interviewed, and treated.

RESULTS

Among 3668 patients with syphilis, 97% (n = 3556) were treated, 72% (n = 2633) were interviewed, and 25% (n = 920) provided name and locating information for at least 1 contact. The corresponding numbers for 12,541 gonorrhea cases were 95% (n = 11,936), 45% (n = 5633), and 16% (1944), respectively. Among the 1392 contacts elicited from syphilis cases, 53% (n = 735) were either interviewed or determined to not need an interview and 43% (n = 595) were treated. The corresponding numbers for the 2323 contacts elicited from gonorrhea cases were 53% (n = 1221) and 46% (n = 1075), respectively.

CONCLUSIONS

Adaptation of the HIV continuum is a useful tool for evaluating treatment verification and contact elicitation activities. In Los Angeles County, this approach revealed significant drop-offs in the proportion of index cases naming contacts and in the proportion of contacts who are interviewed and treated.

Syphilis Experiences and Risk Perceptions Among Repeatedly Infected Men Who Have Sex with Men

CONTEXT

In urban areas of the United States, syphilis is a major public health issue for men who have sex with men, despite widespread efforts to curtail a growing epidemic; repeated infections are not uncommon in this population. The ways that men who have sex with men experience and conceptualize syphilis, and how their attitudes and beliefs impact their risk for infection, are poorly understood.

METHODS

In-depth interviews were conducted in 2010-2011 with 19 Los Angeles County men aged 21-54 who reported having male sex partners and had had two or more early syphilis infections within the previous five years. Interview transcripts were analyzed inductively to uncover themes.

RESULTS

Participants had considerable knowledge about syphilis symptoms, transmission and consequences, and most felt that syphilis was a highly stigmatized disease. They had had 2-5 infections in the past five years, and the majority believed they were at risk for another infection because of their sexual risk behaviors. Many had a sense of fatalism about being infected again, and some expressed that this possibility was an acceptable part of being sexually active. Concern about syphilis often decreased as men experienced more infections. Most participants reported short-term sexual behavior changes after a syphilis diagnosis to prevent transmission; however, few were willing to make long-term behavior changes.

CONCLUSIONS

Additional qualitative studies of men who have sex with men should be conducted to better understand the continuing syphilis epidemic and to help identify the most promising intervention strategies.

Sexually transmitted infection clinics as safety net providers: exploring the role of categorical sexually transmitted infection clinics in an era of health care reform

BACKGROUND

For many individuals, the implementation of the US Affordable Care Act will involve a transition from public to private health care venues for sexually transmitted infection (STI) care and prevention. To anticipate challenges primary care providers may face and to inform the future role of publicly funded STI clinics, it is useful to consider their current functions.

METHODS

Data collected by 40 STI clinics that are a part of the Sexually Transmitted Disease Surveillance Network were used to describe patient demographic and behavioral characteristics, STI diagnoses, and laboratory testing data in 2010 and 2011.

RESULTS

A total of 608,536 clinic visits were made by 363,607 unique patients. Most patients (61.9%) were male; 21.9% of men reported sex with men (MSM). Roughly half of patients were 20 to 29 years old (47.1%) and non-Hispanic black (56.2%). There were 212,765 STI diagnoses (mostly nonreportable) that required clinical examinations. A high volume of chlamydia, gonorrhea, and HIV testing was performed (>350,000 tests); the prevalence was 11.5% for chlamydia, 5.8% for gonorrhea, 0.9% for HIV, and varied greatly by sex and MSM status. Among MSM with chlamydia or gonorrhea, 40.1% (1811/4448) of chlamydial and 46.2% (3370/7300) of gonococcal infections were detected at extragenital sites.

CONCLUSIONS

Sexually Transmitted Disease Surveillance Network clinics served populations with high STI rates. Given experience with diagnoses of both nonreportable and reportable STIs and extragenital chlamydia and gonorrhea testing, STI clinics comprise a critical specialty network in STI diagnosis, treatment, and prevention.

Acceptable interventions to reduce syphilis transmission among high-risk men who have sex with men in Los Angeles

OBJECTIVES

We examined perceptions of and attitudes toward existing and potential syphilis interventions, including case management and Web-based programs, to increase syphilis testing among high-risk men who have sex with men (MSM).

METHODS

Between October 2010 and June 2011, we conducted in-depth interviews with 19 MSM in Los Angeles, California, with repeat early syphilis infections (primary, secondary, and early latent syphilis) within the previous 5 years. We analyzed the interviews inductively to determine the most acceptable potential interventions.

RESULTS

Experiences with health department and community-based standard of care case management were generally positive. The most popular interventions among respondents included a Web site providing information on syphilis and syphilis testing, automated Web reminders to test, being paid to test, free online home testing kits, and preexposure prophylactic medication. Respondents' beliefs that they would continue to practice high-risk sexual behaviors reinforced their reasons for wanting increased accessibility and convenient testing strategies.

CONCLUSIONS

Public health officials should consider participant responses to potential interventions for syphilis, which suggest that high-risk MSM would consider testing more often or using other interventions.

Would targeting increase efficiency of syphilis partner services programs?--Data from New York City, Philadelphia, Texas, and Virginia

BACKGROUND

Targeted partner notification (PN), or limiting PN to groups in which efforts are most successful, has been suggested as a potentially cost-effective alternative to providing PN for all syphilis case-patients. The purpose of this study was to identify index case characteristics associated with highest yield partner elicitation and subsequent case finding to determine whether some groups could be reasonably excluded from PN efforts.

METHODS

We examined index case characteristics and PN metrics from syphilis case management records of 4 sexually transmitted disease control programs--New York City, Philadelphia, Texas, and Virginia. Partner elicitation was considered successful when a case-patient named 1 or more partners during interview. Case finding was considered successful when a case-patient had 1 or more partners who were tested and had serologic evidence of syphilis exposure. Associations between case characteristics and proportion of pursued case-patients with successful partner elicitation and case finding were evaluated using χ2 tests.

RESULTS

Successful partner elicitation and new case finding was most likely for index case-patients who were younger and diagnosed at public sexually transmitted disease clinics. However, most characteristics of index case-patients were related to success at only a few sites, or varied in the direction of the relationship by site. Other than late latent case-patients, few demographic groups had a yield far below average.

CONCLUSIONS

If implemented, targeted PN will require site-specific data. Sites may consider eliminating PN for late latent case-patients. The lack of demographic groups with a below average yield suggests that sites should not exclude other groups from PN.

Opportunities for improving partner notification for HIV: results from a community-based participatory research study

To identify actionable opportunities for improving Partner Notification (PN) for HIV among men who have sex with men (MSM), we characterized the perspectives and experiences of PN among Medical Case Managers (case managers), Disease Intervention Specialists (DIS), and MSM. In partnership with an AIDS service organization and the Connecticut State Health Department, we conducted a focus group of case managers (n = 14) and in-depth interviews with DIS (n = 7) and MSM (n = 24). We found differences between MSM's and providers' (case managers and DIS) perspectives regarding (1) determinants of sexual risk behaviors; (2) considerations impacting HIV disclosure; and (3) barriers to trusting relationships between MSM and providers. Factors impacting MSM perspectives on PN were incompletely appreciated by both case managers and DIS. PN may be improved through improving provider understanding of the complexities for MSM regarding sexual risk behaviors and disclosure and transcending barriers to trusting relationships between MSM and providers.