Photograph Dr David PhillipsGetty ImagesVisuals Unlimited Courtesy CDC Public Health Image Library The Case for PrEP STD and HIV epidemiology in Santa Clara County PrEP Making HIV Prevention Easy October 2017 ID: 777331
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Courtesy CDC Public Health Image Library
Photograph:
Dr
David Phillips/Getty Images/Visuals Unlimited
Courtesy CDC Public Health Image Library
The Case for
PrEP: STD and HIV epidemiology in Santa Clara County
PrEP: Making HIV Prevention Easy. October, 2017
Sarah C. Lewis, MD, MPH
STD/HIV Controller & Assistant Public Health Officer
Santa Clara County Public Health Department
Slide2Disclosure InformationSarah C. Lewis,
MD MPH
I have no financial relationships to disclose.I will discuss off label use of NAATs.
Slide3Learning ObjectivesUnderstand local epidemiology of HIV and STDs in SCCIdentify patient populations at risk for HIV and STDs SCC based on epidemiology and screening recommendations
Recognize benefit of PrEP for prevention of other STDs
Slide4OverviewEpidemiology of STDs in Santa Clara County Recommendations for HIV
Screening and PreventionBacterial STDs and the Power of Screening
Slide52016 Summary DataEpidemiology of STDs in Santa Clara County
Slide6Pop quiz!Which of the following statements most accurately describes the current epidemiologic STD trends in Santa Clara County?
New prevention and treatment options have contributed to overall declining rates of chlamydia, gonorrhea, and syphilis in SCC and nationally.
Despite increases in surrounding counties, rates of chlamydia, gonorrhea, and syphilis are stable or falling in SCC, likely due to increased healthcare access.Surveillance reporting shows rising rates of chlamydia, gonorrhea, and syphilis, along with persistent disparities by race, ethnicity, gender, and gender of partners.Data suggest rising rates of chlamydia, gonorrhea, and syphilis in SCC, but these are most likely confounded by new testing guidelines and increased access to care.
Slide7Pop quiz!Which of the following statements most accurately describes the current epidemiologic STD trends in Santa Clara County?
New prevention and treatment options have contributed to overall declining rates of chlamydia, gonorrhea, and syphilis in SCC and nationally.
Despite increases in surrounding counties, rates of chlamydia, gonorrhea, and syphilis are stable or falling in SCC, likely due to increased healthcare access.Surveillance reporting shows rising rates of chlamydia, gonorrhea, and syphilis, along with persistent disparities by race, ethnicity, gender, and gender of partners.Data suggest rising rates of chlamydia, gonorrhea, and syphilis in SCC, but these are most likely confounded by new testing guidelines and increased access to care.
Slide8Chlamydia case counts and rates in Santa Clara
County, 2010-2016
Sources: 1. SCC Public Health Department, AVSS (2010-2011), CalREDIE (2011-2016), data as of March, 2017, and are provisional; 2. State of California, Department of Finance, State and County Population Projections by Race/Ethnicity and Age, 2010-2060, December 15, 2014
Slide9Slide10Sources: 1. SCC Public Health Department, AVSS (2010-2011),
CalREDIE
(2011-2016), data as of March, 2017, and are provisional; 2. State of California, Department of Finance, State and County Population Projections by Race/Ethnicity and Age, 2010-2060, December 15, 2014
Slide11* Due to large proportions of missing race/ethnicity information, u
nknown race/ethnicity cases were redistributed based on the proportions of the known race/ethnicity cases with consideration of age. Rates and counts based on imputed race/ethnicity need to be interpreted with precautions.
Sources: 1. SCC Public Health Department, CalREDIE (2016), data as of March, 2017, and are provisional; 2. State of California, Department of Finance, State and County Population Projections by Race/Ethnicity and Age, 2010-2060, December 15, 2014
Slide12* Includes primary, secondary and early latent syphilis cases.
Sources: 1. SCC Public Health Department, AVSS (2010-2011),
CalREDIE (2011-2016), data as of March, 2017, and are provisional; 2. State of California, Department of Finance, State and County Population Projections by Race/Ethnicity and Age, 2010-2060, December 15, 2014
Slide13* Include primary, secondary and early latent syphilis cases.
Sources: 1. SCC Public Health Department, AVSS (2010-2011),
CalREDIE (2011-2016), data as of March, 2017, and are provisional; 2. State of California, Department of Finance, State and County Population Projections by Race/Ethnicity and Age, 2010-2060, December 15, 2014
Slide14HIV epidemic in Santa Clara County
As of 2016:
Cumulative HIV/AIDS cases first reported in SCC*: 6,179
AIDS: 4,801
Alive: 3,669
People living with HIV/AIDS
†
: 3,208
2,648 (83%) SCC cases
560 (17%) out of jurisdiction cases
In 2016:
134 new cases
* Based on residency at diagnosis;
† Based on most current address;
Source: Santa Clara County Public Health Department, eHARS data as of May, 2017 and are provisional
Slide15Rates of HIV/AIDS diagnoses among individuals 13+
, 2010 –
2016Source: 1. Santa Clara County Public Health Department, eHARS data as of May, 2017; 2. State of California, Department of Finance, State and County Population Projections by Race/Ethnicity and Age, 2010-2060, Sacramento, California, February 2017
Slide16Number of MSM cases* by selected age group,
2010 – 2016
* Include MSM, MSM & IDU. Source: Santa Clara County Public Health Department, eHARS data as of May, 2017, and are provisional.
Slide17Number of MSM cases* by race/ethnicity, 2010
– 2016
* Include MSM, MSM & IDU. Source: Santa Clara County Public Health Department, eHARS data as of May, 2017, and are provisional.
Slide18Who were more likely to be diagnosed late*?
Older age groups (ages 40+)
44% (ages 40+) vs. 23% (ages <40)People of color37% (AA), 35% (API), 34% (Hispanic) vs. 25% (White)IDU and individuals acquiring through heterosexual transmission44% (IDU) and 45% (Heterosexual) vs. 26% (MSM) and 28% (MSM&IDU)Foreign-born42% (foreign-born) vs. 27% (U.S.-born)* Statistically significant with p < 0.05
Source: Santa Clara County Public Health Department, eHARS data as of May, 2017.
Slide19Percentage of people living with HIV with STD
† Santa Clara County, 2016
† People ages 13 and older chlamydia, gonorrhea, early syphilis (primary, secondary and early latent) diagnosed in 2016. A person with multiple episodes of one disease in the year will be only counted once for the disease. * Include primary, secondary and early latent syphilis cases. ** The percentage of overall STD diagnosis is lower than the sum of the percentages of chlamydia, gonorrhea and early syphilis because one person may be diagnosed with multiple diseases.
Source: 1.
Santa Clara County Public Health Department, eHARS data as of May, 2017, 2. Santa Clara County Public Health Department, CalREDIE (2016), data as of March, 2017, and are provisional
Slide20Making HIV Prevention EasyHIV Screening and Prevention
Slide21Who should be screened for HIV?All patients ages 13 – 64 years in all health-care settings.All patients who seek evaluation and treatment for STDs.
All pregnant patients in 1st trimester; again in 3rd trimester and at delivery if at high risk.
MSM annually and up to q3 months if at high risk.NO need for separate written consent. (Opt-out)
Slide22HIV PreventionTreatment as Prevention (TasP) depends on diagnosis and linkage
Pre-Exposure Prophylaxis:Can be provided in primary care settingsNavigation help for clients: 408-792-3750Clinical consult for providers: 855-HIV-PrEP (Monday – Friday: 8am to 3pm)
STD/HIV Controller: 408-792-5051Resources for providers: Stay Tuned!
Slide23Rapid rise in PrEP use in the US
But lower uptake in: People of colorAfrican Americans
LatinxYouthTransgender people2014
2013
2012
2012
2013
2014
2015
~80,000
unique individuals started
PrEP
in 2012-2015
738% increase
Slide courtesy of Stephanie
E. Cohen
Slide24% of Adults with PrEP Indication
No. of Adults with PrEP Indication
Slide courtesy of Catherine Koss & Stephanie E. Cohen
Slide25HIV prevention in any roleScreen for HIV and risk factorsScreen for and treat bacterial STDsOffer
PrEP resources in your waiting roomRefer for PrEP Navigation: 408-792-3750
Slide26Making HIV Prevention EasyBacterial STDs:The power of screening
Slide27Who Should be Screened for CT/GC?
CDC 2015 STD
Tx Guidelines www.cdc.gov/std/treatmentPlus: Guidelines for HIV care and PrEP
Slide28High Proportion of Extragenital CT/GC associated
with negative urine test
STD Surveillance Network (n=21,994)Patton et al CID 2014
Slide courtesy of Dr. Ina Park.
Slide29A Majority of Rectal Infections in MSM are Asymptomatic
Chlamydia
n=316
Gonorrhea
n=264
Chlamydia
n=315
Gonorrhea
n=364
Rectal Infections
Urethral Infections
Asymptomatic
Symptomatic
Kent, CK et al,
Clin
Infect Dis July 2005
86%
84%
42%
10%
Slide courtesy of Dr. Ina Park.
Slide30Chlamydia and
Gonorrhea NAAT: Rectal and Pharyngeal Sites
Commercially-available NAATs have not been cleared by FDA for these indicationsThey can be used by laboratories that have undergone validation procedures and met all regulatory requirements for an off-label procedureSimilar validation procedures apply for self-collected specimensMMWR. Mar 14 2014;63(No RR-12):1-19. Slide courtesy of Dr. Ina Park.
Slide31Clinical Guidelines and Consultation
CDC’s STD Treatment Guidelines
www.cdc.gov/std/treatment/ STD Clinical Consult Networkwww.stdccn.org Free CDC STD Treatment Guidelines AppSearch for “STD TX”
Slide courtesy of Dr. Ina Park.
Slide32STDs among PrEP users in
PrEP Demo
26.4% of participants had GC, CT or early syphilis at baseline50.9% had at least one STI during follow-upSTI incidence was high but did not increase over time% infections for which treatment would have been delayed with q6 month, as opposed to q3 month, screeningLiu JAMA Intern Med 2016; Cohen # 870 CROI 2016. Slide courtesy of Dr. Stephanie Cohen
Slide33STDs among PrEP Users at SF Kaiser
Volk et al. CID 2015;
Slide courtesy Dr. Jonathan Volk and Dr. Stephanie Cohen
Slide34Modeling Study of PrEP Impact on STI Incidence
With 40% PrEP coverage and 40% risk compensation.42% and of GC and 40% of CT infections would be averted over the next 10 years.
Jenness et al. CID, 2017.
Slide35ConclusionsBacterial STDs are on the rise in Santa Clara and CaliforniaYoung Latino and Black MSM are at highest risk for HIV in SCC
Self-collected three-site screening can make STD testing fast and easyPrEP prevents HIV and also creates opportunities
to decrease STDs
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