Syphilis Elimination:Syphilis Elimination:

Reasons for Hope?Reasons for Hope?

Kevin O’ConnorKevin O’Connor

DSTDPDSTDP

October 7, 2010October 7, 2010

Topics

Syphilis in the South CSPS DSTDP efforts with health departments Reasons for hope

2003

Rate per 100,000population

Guam 1.2

Puerto Rico 5.8

Virgin Is. 0.9

<=0.2

0.21-4.0

>4.0

(n= 6)

(n= 39)

(n= 8)

VT 0.2NH 1.2MA 1.9RI 2.2CT 1.7NJ 1.5DE 1.3MD 5.6

3.7

1.4

3.0 1.9

4.4 1.0

4.2

7.3

0.9

1.4

4.1 1.0

0.3

0.71.3

6.2

0.1

1.0

1.4

1.7

2.6

0.8

0.24.7

2.9

3.7

3.2

0.2

1.8

1.2

1.1

1.6

2.0

0.3

3.7

3.9

0.41.9

2.5

0.2

0.7

0.0

Rate per 100,000population

<=0.20.21-4.0>4.0

VT 0.2 NH 1.5 MA 2.1 RI 3.1 CT 0.9 NJ 2.0 DE 0.9 MD 5.7

Guam 0.6

Puerto Rico 5.2 Virgin Is. 2.7

(n= 5)(n= 44)(n= 4)

2.5

0.2

3.4 1.9

3.7 0.9

3.9

6.8

1.1

1.1

3.0 0.8

0.4

0.9 0.8

4.1

0.6

2.5

0.9

1.4

1.1

0.0

0.6 0.6

3.8

3.0

1.8

0.3

1.7

1.8

1.4

1.3

2.3

0.3

2.3

3.0

0.6

1.1

1.4

0.1

0.3

0.0

2008

2005

>4/100K

.21-4/100K

<.2/100K

Rates per 100K Pop

2000

Charting the US P&S Syphilis Epidemic

Rate per 100,000population

<=.2.21-4>4

VT 0.0 NH 0.2 MA 1.1 RI 0.4 CT 0.5 NJ 0.9 DE 1.2 MD 5.8

Guam 0.6

Puerto Rico 4.5 Virgin Is. 2.7

(n=14)(n=29)(n=10)

2.8

0.0

4.0 4.1

1.0 0.3

2.7

5.2

0.2

0.1

3.4 5.9

0.4

0.2 2.1

4.8

0.1

3.3

0.3

4.9

0.5

0.0

0.1 0.3

0.9

0.7

6.3

0.0

0.6

3.5

0.4

0.6

5.9

0.0

9.7

2.0

0.1

1.8

1.1

0.2

0.9

0.2

Rate per 100,000population

Guam 3.5

Puerto Rico 4.2

Virgin Is. 0.0

<=0.2

0.21-2.2

>2.2

(n= 4)

(n= 23)

(n= 27)

VT 1.8NH 1.5MA 3.3RI 1.7CT 1.0NJ 2.6DE 1.9MD 6.7DC 24.8

9.7

0.1

5.0 7.3

6.0 2.6

5.7

9.6

2.3

0.5

4.3 2.2

0.5

1.12.2

16.5

0.8

2.1

2.2

6.3

3.8

0.7

0.83.0

2.2

6.3

3.2

0.0

3.1

2.4

0.7

2.2

2.2

0.1

6.7

5.9

0.93.4

2.8

0.7

1.2

0.6

N Carolina:N Carolina:Syphilis Rates by Gender, 2005-Syphilis Rates by Gender, 2005-

20092009

7.6

9.5 9.3 8.7

16

3.1 3.7 3.1 2.4

4.5

0

2

4

6

8

10

12

14

16

18

2005 2006 2007 2008 2009

Ra

te p

er

10

0,0

00

Male Female

Rate ratios: 2.4 2.6 3.0 3.6 3.6

84%↑

88%↑

Communicable Disease Surveillance Unit

N Carolina:N Carolina:Co-morbidity (early syphilis & Co-morbidity (early syphilis &

HIV)HIV)

0

10

20

30

40

50%

of

Sy

ph

ilis

ca

se

s w

/ HIV

males

females

Georgia P&S Syphilis by Georgia P&S Syphilis by Race 2005-2009Race 2005-2009

0

100

200

300

400

500

600

700

800

900

2005 2006 2007 2008 2009

White

Black

Others

Cases

Tennessee: Tennessee: HIV Co-Infection in Syphilis HIV Co-Infection in Syphilis

CasesCases

0%

10%

20%

30%

40%

50%

60%

MSM Hetero males Females

Percent of HIV Co-Infection

2008 2009 thru 5/31/2010

Southern Syphilis Summary Southern Syphilis Summary

Significant changes in syphilis epidemiology:

Shift from heterosexual to MSM Rapid increase in HIV co-infection among MSM Increasing among young African American

MSM

Conclusion – SE should be part of a comprehensive STD/HIV prevention effort for MSM

CSPS New Directions

Use data to drive program Identify, then address health disparities Added emphasis on program evaluation →

improvement Performance Measures (PM) Program Improvement Plans (PIP) Evidence Based Action Plans (EBAP)

Are SE interventions working? Are they effective? Consider potential strategies for program improvements How well are interventions targeted towards at risk

populations?

Current SE Activities Surveillance - ID populations at risk

Partner ServicesPartner Services Internet Partner Services (IPS)Internet Partner Services (IPS) Management and Oversight: clear standards and expectations, Management and Oversight: clear standards and expectations,

supervisory review, engagement and support by managerssupervisory review, engagement and support by managers DIS embedded in HIV Care; gay-friendly clinicsDIS embedded in HIV Care; gay-friendly clinics DIS liaisons with key agencies to DIS liaisons with key agencies to develop strong develop strong relationshipsrelationships

Community Engagement Community Engagement - community coalitions focusing - community coalitions focusing on STD/HIV, media campaigns, STD in HIV CPG, Online outreachon STD/HIV, media campaigns, STD in HIV CPG, Online outreach STDP as part of HIVP services for MSM STDP as part of HIVP services for MSM

Targeted Screening Targeted Screening - based on epi/surveillance - based on epi/surveillance ROUTINEROUTINE STD screening in HIV Care STD screening in HIV Care

Ensure access to clinical services Ensure access to clinical services - -

SE Activities

Start Stop Improve Enhance Target Collaborate

DSTDP EffortsDSTDP Efforts

DSTDP Efforts to DSTDP Efforts to Address Syphilis, 2009-Address Syphilis, 2009-

20102010   9 Program Improvement Webinars on SE topics 9 Program Improvement Webinars on SE topics “ “Syphilis in the South” webinar Syphilis in the South” webinar CDC Field team deployed to outbreak in Cincinnati, Ohio (Aug/Sept. CDC Field team deployed to outbreak in Cincinnati, Ohio (Aug/Sept.

2010); AZ (2009); Houston (2008)2010); AZ (2009); Houston (2008) Epi-Aids: Texarkana, Arkansas; Phoenix, ArizonaEpi-Aids: Texarkana, Arkansas; Phoenix, Arizona Rapid Ethnographic Assessments in Phoenix, Arizona and North Rapid Ethnographic Assessments in Phoenix, Arizona and North

CarolinaCarolina

Program Performance Site visits (PPSV): Virginia, Tennessee, Program Performance Site visits (PPSV): Virginia, Tennessee, Mississippi, New Jersey, California (San Diego). Mississippi, New Jersey, California (San Diego). Outcome – over 82 Outcome – over 82 recommendations for syphilis –related program improvement made across all recommendations for syphilis –related program improvement made across all program domains (Surveillance, PS, Medical/lab Services, Evaluation, etc.) program domains (Surveillance, PS, Medical/lab Services, Evaluation, etc.) Priority focus on HIV care providers in areas with significant MSM morbidityPriority focus on HIV care providers in areas with significant MSM morbidity

Return PPSV to Puerto Rico and Louisiana (New Orleans, Shreveport). Return PPSV to Puerto Rico and Louisiana (New Orleans, Shreveport). 20102010

DSTDP Efforts to DSTDP Efforts to Address Syphilis, 2009-Address Syphilis, 2009-

20102010   Comprehensive program review in Albuquerque, New Mexico Comprehensive program review in Albuquerque, New Mexico

– significant focus on syphilis prevention and control – significant focus on syphilis prevention and control activities.activities.

Focus on EBAPs /other PM data – are strategies implemented Focus on EBAPs /other PM data – are strategies implemented effectively ? Are at-risk targeted? Are ineffective/inefficient effectively ? Are at-risk targeted? Are ineffective/inefficient strategies modified or stopped?strategies modified or stopped?

Best Practices Initiative – over 50 potential BP related to Best Practices Initiative – over 50 potential BP related to syphilis prevention and control submitted. Goal is to link syphilis prevention and control submitted. Goal is to link those in need with those who have demonstrated success.those in need with those who have demonstrated success.

Congenital Syphilis – PTB/ESB ID HMAs; PCs assess Congenital Syphilis – PTB/ESB ID HMAs; PCs assess current status of CS efforts in HMAs with CS or high female current status of CS efforts in HMAs with CS or high female morbidity. PCs are working with project areas on CS morbidity. PCs are working with project areas on CS program improvement, where needed.program improvement, where needed.

IPS TAIPS TA Individual TA for project areasIndividual TA for project areas

Reasons for HopeReasons for Hope

Reasons for HopeReasons for Hope

EpiEpi ‘‘Signs of declines’ in provisional surveillance data from SE: TX, Signs of declines’ in provisional surveillance data from SE: TX,

NYC, AL, & SF NYC, AL, & SF …although increases are occurring in OH, …although increases are occurring in OH, Chicago, WA, and KYChicago, WA, and KY

Enhanced EffortsEnhanced Efforts

PSPS Strengthened procedures, supervisions, and oversight: KYStrengthened procedures, supervisions, and oversight: KY Relocation of DIS: L.A.Relocation of DIS: L.A. IPS: AL, AZ, SF, MA, MO, NC, & PR. IPS: AL, AZ, SF, MA, MO, NC, & PR. ManyMany other areas other areas

ScreeningScreening ROUTINE STD screening in HIV Care ROUTINE STD screening in HIV Care Epi-based TARGETED screening (inc. collaboratively w/ HIVP) Epi-based TARGETED screening (inc. collaboratively w/ HIVP)

Thoughts on STDs & HIVThoughts on STDs & HIV

STDs among MSM STDs among MSM is an is an HIV Prevention issueHIV Prevention issue

STDP should be an core element of MSM HIVP Rectal STDs are a strong predictor of HIV sero-conversion HIV-/+ MSM with an STD should receive prompt HIVP

services Sexually active MSM should be routinely screened for

STDs (blood test for syphilis, rectal screen for CT/GC) HIV Care providers should routinely screen for STDs

Distribution of 2007 & Projected 2008 Distribution of 2007 & Projected 2008 SEE Funding* by SEE Funding* by

Project Areas in Rank Order of P&S Project Areas in Rank Order of P&S Morbidity** Morbidity**

*Total 2007 SEE funding = $19,083,197. 2008 Projected SEE Funding based on $19,000,000.**P&S Morbidity is an average of P&S Cases for 2005 and 2006

$-

$200,000

$400,000

$600,000

$800,000

$1,000,000

$1,200,000

$1,400,000

$1,600,000

$1,800,000

Project Area

Actual SEE Funding 2007

Total Proposed SEE Funding 2008

2007 Mean Investment = $477,079.93

2008 Mean Investment = $463,414.63

Proposed SEE Funding FormulaProposed SEE Funding Formula

For HMAs For HMAs Funding is based on 2 components:Funding is based on 2 components:

1)1) a base of $150,000; and a base of $150,000; and 2)2) a proportion of remaining available funds based on the % of a proportion of remaining available funds based on the % of

reported P&S cases for all HMAs for the two prior years for reported P&S cases for all HMAs for the two prior years for which data are availablewhich data are available

For post-HMAs For post-HMAs Funding will include base funding for two years during the “post-Funding will include base funding for two years during the “post-

HMA” transition period.HMA” transition period.