Syphilis and HIV screening initiativesin North Carolina jails

Lynne A. Sampson PhD, MPH

HIV/STD UpdateSeptember 25, 2008

BackgroundEpidemiology of Syphilis and HIV

in the United States

Syphilis — Reported cases by stage of infection: United States, 1941–2006

Cases (in thousands)

P&SEarly LatentTotal Syphilis

0

120

240

360

480

600

1941 46 51 56 61 66 71 76 81 86 91 96 2001 06

Data from CDC STD Report, 2006

Primary and secondary syphilis — Rates: Total and by sex: United States, 1987–2006 and the Healthy People 2010 target

Note: The Healthy People 2010 target for P&S syphilis is 0.2 case per 100,000 population.

Rate (per 100,000 population)

MaleFemaleTotal2010 Target

0

5

10

15

20

25

1987 89 91 93 95 97 99 2001 03 05

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

Syphilis, HIV and Incarceration

• High prevalence in populations screened in US jails and prisons:– Syphilis

• Women: 1 – 22 % • Men: <1 – 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)

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

Characteristics of Jails & Prisons

Maintain health of inmate population

Form of community screening

Goal of STD screening programs

1 year to life< 24 hours to 1 yearDuration of stay

Persons convicted of crimes and sentenced to 1 year

Persons charged with crimes & awaiting trial

Persons convicted of crimes with short sentences (< 1 year)

Inmate Population

State or FederalLocal

(County or City)

Level of oversight

PrisonJail

North Carolina Screening Projects

HIV and Early Syphilis (PSEL) rates in NC

0

5

10

15

20

25

30

35

40

2000 2001 2002 2003 2004 2005 2006 2007

Ra

te /

10

0,0

00

po

p

PSEL-men

PSEL-women

HIV-men

HIV-women

CDC National Plan to Eliminate Syphilis

• 1998 – CDC identified 28 US Counties that reported over 50% of ALL P&S 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 P&S cases <1000 and 90% US Counties reporting no new

cases by 2005– Not reached (in 2004 US P&S cases n=7,980)

NC Reported Early Syphilis (PSEL) Cases

0200400600800

10001200140016001800

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

SEP Counties All Other

PSEL Rates in SEP Counties

0

20

40

60

80

100

120

140

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Durham

Forsyth

Guilford

Mecklenburg

Robeson

Wake

STATE

NC Syphilis Elimination Jail Screening Program

• Screen for syphils (n=7 jails) and HIV (n=2 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

Syphilis Analysis

• Study population– Male and female inmates screened for syphilis in 7 NC jails

2002-2005 (n=24,010)

• Outcome– new syphilis case

• Descriptive Analyses– Frequencies, distributions, missing values– Demographic, risk factors, outcomes– Unadjusted OR and 95% CI for each covariate and outcome

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

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

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

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

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