Syphilis and HIV screening initiatives in North Carolina jails

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Syphilis and HIV screening initiativesin North
Carolina jails

• Lynne A. Sampson PhD, MPH
• HIV/STD Update
• September 25, 2008

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BackgroundEpidemiology of Syphilis and HIV in
the United States
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Syphilis Reported cases by stage of infection
United States, 19412006
Data from CDC STD Report, 2006
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Primary and secondary syphilis Rates Total and
by sex United States, 19872006 and the Healthy
People 2010 target
Note The Healthy People 2010 target for PS
syphilis is 0.2 case per 100,000 population.
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Syphilis and HIV Epidemiology

• Mode of transmission
• Synergy
• Subpopulations at risk
• Trade sex for drugs or money
• Use cocaine
• Use injection drugs
• History of incarceration

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Syphilis, HIV and Incarceration

• High prevalence in populations screened in US
  jails and prisons
• Syphilis
• Women 1 22
• Men lt1 6
• HIV
• Women 1 26
• Men 1 16
• Associated with behaviors that are associated
  with incarceration
• Trading sex for drugs or money
• Use of illegal drugs, especially cocaine
  (syphilis) and injection drug use (HIV)

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Why Screen in Jail?

• Risk profile of current cases
• Population outside of health care system
• Revolving population (50 bond out in less than 2
  days)
• Available for education and treatment

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Characteristics of Jails Prisons
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North Carolina Screening Projects
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HIV and Early Syphilis (PSEL) rates in NC
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CDC National Plan to Eliminate Syphilis

• 1998 CDC identified 28 US Counties that
  reported over 50 of ALL PS Syphilis Cases in US
• 5 of these Counties are in NC (Forsyth, Guilford,
  Mecklenburg, Robeson, Wake)
• Durham added to SEP effort by State of NC
• All 6 Targeted for Elimination
• US PS cases lt1000 and 90 US Counties reporting
  no new cases by 2005
• Not reached (in 2004 US PS cases n7,980)

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NC Reported Early Syphilis (PSEL) Cases
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PSEL Rates in SEP Counties
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NC Syphilis Elimination Jail Screening Program

• Screen for syphils (n7 jails) and HIV (n2
  jails)
• Screening staff access inmates in the jail and
  offer education and screening
• Risk questionnaire
• Blood sample(s) for testing
• Data linked to surveillance records to determine
  case status and stage of syphilis infection

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Syphilis Analysis

• Study population
• Male and female inmates screened for syphilis in
  7 NC jails 2002-2005 (n24,010)
• Outcome
• new syphilis case
• Descriptive Analyses
• Frequencies, distributions, missing values
• Demographic, risk factors, outcomes
• Unadjusted OR and 95 CI for each covariate and
  outcome

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Syphilis Analysis

• Modeling
• Logistic regression for clustered data to account
  for multiple observations for individuals
• Separate models for males and females
• Reference Model
• Variables with bivariate associations p? 0.25
• Other variables from literature
• Reduced Model
• Backward elimination
• Examine area under ROC curves to assess change
• Goal is to achieve parsimonious, easy to use model

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HIV Analysis

• Study population
• M/F inmates screened for syphilis in 2 NC jails
  2002-2005
• Include only first observation for each
  individual
• Outcome
• HIV infection, new syphilis case, either
  infection
• Descriptive Analyses
• Frequencies, distributions, missing values
• Demographic, risk factors, outcomes
• Unadjusted OR and 95 CI for each covariate and
  outcome

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HIV Analysis

• Modeling
• Multivariable logistic regression
• Single model that includes gender
• Reference Model
• Variables with bivariate associations p? 0.25
• Other variables from literature
• Reduced Model
• Backward elimination
• Examine area under ROC curves to assess change
• Goal is to achieve parsimonious, easy to use model

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Summary of Analyses

• Syphilis
• Screened women much more likely to have new
  syphilis cases
• Difficult to predict risk among women
• Among men, STD history, race/ethnicity, and age
  are associated with new syphilis cases
• HIV
• Women and men who have sex with men much more
  likely to be infected with HIV
• HIV testing history, race/ethnicity, and age are
  associated with HIV infection

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New Directions

• Funding sources for jail screening have changed
  radically
• Syphilis Elimination funds decreased
• Expanded HIV Testing funds now available
• Expansion of original SEE screening projects to
  include new jails
• Plan to use previous data to inform new screening
  efforts