Public Health HIV/STD Control in the US in the Era of TASP: 90-90-90 and Beyond Matthew Golden, MD, MPH February 2nd, 2018 UCSD HIV & Global Health Rounds

2. University of Washington !
Public Health Capacity Building Center
Last Updated: January 31 , 2018
Matthew Golden, MD, MPH
Professor of Medicine, University of Washington
Director, PHSKC HIV/STD Program & UW Public Health
Capacity Building Center
Public Health HIV/STD Control in the US in the
Era of TASP: 90-90-90 and Beyond

3. Overview
Overarching themes:
• Surveillance & population-level evaluation
• What is the infrastructure we need for success?
Background
• The national HIV prevention plan
• Prevention and care in King County, WA
Topical Areas:
• The HIV Care Continuum & Data to Care
• HIV testing and PrEP
• HIV/STI Field Services

4. CDC RFA PS 18-1802
Integrated HIV Surveillance & Prevention
• Surveillance and monitoring
• Community-level prevention – condoms, syringe
services
• HIV testing and diagnosis
• Use of surveillance to improve engagement with care
(Data–to-Care)
• Prevention for HIV- persons – PrEP
• Identify and respond to transmission cluster

5. King County HIV Care Continuum & Trends in HIV Viral
Suppression* 2006-16
• In 2015, King County reached the World Health
Organization 90-90-90 goal
• Perhaps the first urban area in the U.S. to achieve this
milestone
*HIV RNA <200 copies/ml
Percentage of Diagnosed Persons with
HIV Who were Virally Suppressed, King
County, WA 2006-16
King County HIV Care Continuum, 2016
91% of diagnosed!
82% of diagnosed!
Source: Buskin S. Glick, S. Bennett A. PHSKC

6. Monitoring Progress:
King County, WA 2016 Surveillance Dashboard
Objective 2020 Goals King County 2014-16 Assessment
National King
County
2014 2015 2016
Diagnosis, Testing & PrEP
HIV diagnosis rate (per 100,000) ↓25% ↓25%* 11.0 10.0 8.6 On Pace
HIV testing
Known HIV status
Late diagnosis
Recent HIV testing (MSM)
90%
-
-
95%
<20%
75%
92%
24%
66%
92%
23%
70%
93%
24%
68%
One Pace
Goal Not Met
Goal Not Met
PrEP Use (high-risk MSM) - 50% 9% 26% 37% On Pace
HIV Care
Linked HIV Care 1 month 85% 90% 93% 90% 93% Goal Met
Viral suppression 80% 90% 79% 81% 82% Goal Not Met
Homelessness - <5% 14% 12% 11% Goal Not Met
Disparities (viral suppression)
African American
White (non Hispanic)
- No
Disparity
72%
81%
75%
84%
79%
83%
Goal Not Met* WA State
goal 50%↓

7. The!HIV!Care!Con-nuum!&!Data!to!Care!

8. Percent
Sources: MMWR 2014, CDC Care Continuum Factsheet 2017, San Diego DOH (W. Tilghman)
HIV Care Continuums
80
62
41
29
45
39
29
85
75
48 49
92
79
55
87
83
78
93
90
83
76
0
10
20
30
40
50
60
70
80
90
100
Diagnosed Linked to Care Retained in Care* Virally Suppressed
US 2010 Sub-Saharan Africa 2013
US 2014 San Diego 2016
UK 2016 King County 2016

9. Why is King County So Different?
• Different population
• Different public health and care
• Different data
Is King County So Different?

10. Different Populations 2016
King County,
WA
San Diego U.S.
Size 2,149,970 3,317,749 322,726,018
Pop. Growth 2010-13 ↑1.3% ↑1.2% ↑0.7%
Median household income $78,800 $66,529 $57,617
Percent Poverty 10.7% 14% 15.1%
Percent Adults with BA or higher (age
>25)
49% 36.5% 30.3%
Race/Ethnicity*
White
Black
Asian
Hispanic
73%
8%
17%
9%
64%
5%
11%
32%
76%
14%
6%
17%
Percent Uninsured 8.3% 12.2% 11.7%
Percent PLWHA Women 11% 8% 24%

11. HIV Laboratory Surveillance
Provider
orders CD4
or viral load
Laboratory
reports CD4
and VL
results
Health
department
matches results
to an HIV case
or investigates
New
case
Existing
case in
jurisdiction
Out-of-
jurisdiction
Not HIV
De-identified data
to CDC
Inter-state
Deduplication

12. Accounting for Migration Decreases "Out of Care"
Estimates
47%
moved
7% died
8%
unknown
38%
In-county
Buskin SB et al, STD 2014
N=2573

13. Many People Who Appear to Be Out of Care are Not
Cases with no CD4
or VL for ≥12 months 3866
51% moved
or died
+
20% in care
47-88% of cases found not to
be out of care upon
investigation
6 state collaborative
(AK, ID, MT, OR, WA, WY
Louisiana
Massachusetts
Maryland
New York State
Tennessee
Based on Presentations at the National HIV Prevention Conference, Atlanta, GA, Dec 6-9, 2016 from:
Brantley (1910), Nagavedu (2231), Cassidy-Stewart (1650), Tesoriero (1484), Morrison (1503),
Dombrowski.
Similar findings have been reported from health department
investigators throughout the U.S.
Slide Courtesy J. Dombrowski

14. Output of person-matching across DC, MD, and VA eHARS
databases:
Person
matches
across
jurisdictions:
Exact
Very
High
High
Medium
High
Medium
Very
Low
Total
DC-MD* 4013 5907 53 268 645 482 11 368
MD-VA* 856 2343 11 117 377 865 4569
VA-DC* 1064 3340 15 149 438 529 5535
Total 5933 11 590 79 534 1460 1876 21 472
*Bidirectional reporting results (i.e., DC-reported MD matches were equal to MD-reported DC-1"
matches; etc.)2"
>90% validated by
jurisdictional review
~50% not found
through CDC de-
duplication (RIDR)
Quantifying the churn effect in the DC metropolitan region using a
novel privacy and data sharing technology (Abstract 1999)
Anne Rhodes et al., Virginia Dept. of Health

15. Data to Care (DtC)
• If our problem is that people
are out of care, the solution
is to find them and link them
to care
• HIV is reportable – including
HIV RNA and CD4
lymphocyte results – so we
should know who is out of
care
• DtC - Use of surveillance
data to promote increased
engagement in care
• CDC now requires for all
health departments

16. Data to Care Strategies
Health
Department
HIV Clinic Patient
Data in
Data back
Patient
Health
Department1.
2.
Madison Clinic
Data to Care
approach
Public Health –
Seattle & King
County Data to
Care approach

17. Impact of Data to Care on Re-engagement in HIV care
822 eligible cases
Public Health – Seattle & King
County Data to Care Program
(includes OOC & unsuppressed)
Madison Clinic Data to Care
Program (after surveillance match)
157 eligible cases
162 (20%) had viral
suppression reported
before contact attempted
40 (25%) relinked
before contact
attempted
117 cases initiated
374 contacted (56%)
69 had viral suppression
reported in 12 months
(10% of initiated cases)
38 (32%) contacted
20 relinked to care
(17% of initiated cases)
662 cases initiated

18. Data to Care
Project
Eligible Cases
(including those virally
suppressed before
contact attempts)
Achieved
Outcome
Achieved
Outcome Before
Contact
Relinked
HIV Clinic
(Madison Clinic)
157 116 (74) 89 (77%)
Virally Suppressed
Surveillance-based
(PHSKC)
822 301 (37) 161 (53%)
*Number of eligible cases in this table differs from earlier slides because this group includes persons with no CD4 or VL reported for ≥12 months and persons with VL>500 at the
time of last report
Over half of the successful outcomes occurred before we contacted
the patient.
Did our efforts make an impact?
Many persons who achieve successful outcomes do so in the
absence of an intervention

19. Time
Implementation of Data to Care Program in Seattle-King
County: Stepped Wedge Cluster Randomization
Dr. B
Dr. A
Dr. C
Dr. D
AnalysisEndDate
AnalysisStartDate
Patients of Dr. A
Intervention Start Date =
Doctor ContactedControl
Period
Intervention
Period
Order of doctor clusters
randomly assigned

20. Time to Viral Suppression According to Intervention vs. Control Period
(excluding deaths and relocations, N=822)
Dombrowski et al, IAS 2015 & STD, in press
Control
Intervention
%withunsuppressedor
missingviralload
Days since case identification
Hazard ratio 1.18 (95% CI: 0.83 – 1.68)
Principal Finding of Stepped Wedge Cluster
Randomized Trial

21. Bove, JAIDS 2016
Clinic-Based Data to Care: Significant
Difference but Effect Size is Small
Madison Clinic, Seattle
Time to first return clinic visit: Intervention
vs. historical controls (N=1399)
HR: 1.7 (95% CI: 1.2 – 2.3)
Uganda, Kenya, Tanzania
Time to first return clinic visit in a
randomized, controlled trial (N=5781)
13.3%
10.0%
Bershetyn et al, CID 2017

22. Where does this leave us?
• DTC improves public health surveillance data
• The recall list approach seems unlikely to make a
substantial public health impact
• Other places in the US might be different, but the
problems with surveillance data are universal
– Need to prioritize cases differently
• Bigger problem: We spent a lot of effort trying to
relink patients to the same system that failed to
engage them in the first place.
We need to spend less time trying to change our
patients, and more time trying to change our health
care system

23. The MAX Clinic: HIV Care for the Hardest-to-Reach
Patients
Low-Threshold Care
Walk-in access to
- medical care
5 afternoons/wk
- case managers
5 days/wk
Direct phone line to MAX
case managers (no
phone tree)
Text message
communication
Harm reduction
approach
Incentives
Snacks each visit,
$10 meal vouchers
1x/wk
Bus pass
$25 - visit + blood
draw q 2 months
$50 – VL<200 q 2
months
High Intensity
Outreach Support
Non-medical case
managers (Public
Health)
Medical case
managers (Madison)
Coordinated Care & Case
Management
Madison Clinic and
Public Health – Seattle &
King County STD Clinic
Day Program with
adherence support
Housing case managers &
supportive housing facilities
Jail release planners
Office-Based Opioid
Treatment Team
Components of the MAX Clinic (Evolved Substantially Over 2 Years)

24. Characteristics of Patients Enrolled in the First Two Years
of the MAX Clinic (N=95)
Characteristic N (%)
CD4<200 cells/mm3 44 (46%)
Illicit substance or unhealthy alcohol use 81 (86%)
Methamphetamine 56 (59%)
Mental illness 68 (71%)
Unstable Housing 62 (65%)
Sub use or mental illness or unstable housing 90 (95%)
Sub use + mental illness + unstable housing 43 (45%)
Documented history of incarceration 55 (58%)

25. Max Clinic Enrollment 2015-2017 Max Clinic Viral Suppression 2015-2017
Trends in Max Clinic Enrollment and Viral Suppression,
2015-2017

26. MAX Clinic: Controlled Analysis
Viral suppression among the first 50 MAX patients and the Standard-of-Care Clinic
(N=100) in the 12 months post-compared to 12 months pre-baseline
MAX
pre
MAX
post
Control
pre
Control
post
Viral suppression, N% 10 (20) 41 (82) 51 (51) 65 (65)
Within group pre-post comparison,
RR (95% CI)*
4.1 (2.3 – 7.2) 1.3 (1.0 – 1.6)
Between group pre-post comparison,
RR (95% CI)*
3.2 (1.8 – 5.9)
*Generalized estimating equations controlling for housing status, substance use, and psychiatric diagnoses
• Dombrowski J (unpublished)

27. HIV Surveillance & Data to Care:
Conclusions
• Our system of care is not failing, though it needs to be better and the
emphasis on increasing engagement in care is well justified
• HIV surveillance data is often not good enough to estimate the care
continuum or to serve as an efficient basis for public health outreach
– King County may not really be that much of an outlier
– Highlights the need to improve surveillance – DtC does that!
• Evidence supporting the currently advocated national approach to DtC is
weak and discouraging
- Surveillance directed outreach may not be the answer
- Greater focus on identifying unsuppressed persons when we encounter
them (i.e. Inpatients, ED, jail)
• Clinical infrastructure may need to change if we are going to make the
next step in improving the HIV care continuum
- Max Clinic experience is encouraging - Very intensive and expensive

28. HIV!Tes-ng!&!PrEP!

29. Improving Community-Wide HIV/STI Control
Infrastructure
• Success in combating generalized STI epidemics (e.g.
chlamydia, HSV, HPV) and in identifying heterosexuals and
non-gay identified persons with HIV depends on the broad
healthcare system and primary care
– Routine HIV testing as part of primary care
• Success in combating concentrated epidemics of STI require
specialized infrastructure
– Testing of populations at high risk
• Success in testing requires a combination of routine and
targeted HIV testing

30. Promotion of Routine HIV Testing in Medical Settings:
Impact on Testing
• CDC recommends everyone test at least once in their lifetime
• Routine testing is intuitively appealing
• Many studies demonstrate that routine testing in emergency rooms can
identify HIV cases - Not all studies show this
• Much more limited data from primary care settings
10497
21001
0
5000
10000
15000
20000
25000
Opt+in
Opt+out
89,652
210,957
0
50,000
100,000
150,000
200,000
250,000
Opt-in
Opt-out
Southern FQHCs Veteran's Admin.
Source: Goetz MB. JAIDS 2015. Crumby NS. Public Health Reports 2016.

31. Promotion of Routine HIV Testing in Medical Settings:
Impact on Testing & Case-Finding
• Impact on HIV case-finding inconsistent
19
67
0
10
20
30
40
50
60
70
80
Opt.in
Opt.out
412
295
0
100
200
300
400
500
Opt+in Opt+out
Southern FQHCs Veteran's Admin.
Source: Goetz MB. JAIDS 2015. Crumby NS. Public Health Reports 2016.
• Harborview Seattle – EMR-based intervention to increase HIV/HCV
testing increased HIV testing 97% with no change in HIV case-finding
(Golden MR. OFID 2017)

32. Percentage of Reported HIV Cases Occurring in MSM in
U.S. States with Named-Based Reporting*, 2001-2016
*The number of areas included increased from 33 to 46 between 2006 and 2007. MSM includes MSM/IDU
Percent
70% of infections occur in 2% of the population

33. Rates of Primary & Secondary Syphilis per 100,000 in the
United States, 1996-2016
• 89% of all P&S syphilis cases in the
U.S. in 2016 occurred in men
• 81% of male syphilis cases in MSM

34. Building Infrastructure to Confront the MSM
Epidemic
• Building-up primary care for all Americans is critical to
confronting the HIV epidemic
– Routine HIV testing as part of primary care is part of that
– But can we control a highly concentrated MSM epidemic that
way?
• What infrastructure do we need to succeed?

35. Rationale for MSM Specific Clinical Care
• Frequent HIV/STI testing
– Multiple anatomic sites
– Reminders
– Syphilis expertise
• PrEP
• Vaccines
• Substance use and mental health services
• Cultural competence

36. Specialized Clinical Infrastructure for
MSM
• 2014-15 Internet survey of 1413 MSM – recruitment via Facebook
• Florida, Mississippi, North Carolina, Tennessee, WA State, Chicago,
Philadelphia
Interest in Receiving Care Through MSM Specialty Provider
Percent
Source: C. Khosropour (unpublished)

37. Effect of HIV Testing Frequency on HIV Incidence
Number HIV Tests per year (Low and high sexual activity MSM)
Incidence
Source: Cassels S. AIDS 2009

38. 2017 CDC Guidance
CDC concludes that the evidence, programmatic experience, and
expert opinions are insufficient to warrant changing the current
recommendation (annual screening for MSM) to more frequent
screening (every 3 or 6 months).
• Clinicians can also consider the potential benefits of more frequent
HIV screening (e.g., every 3 or 6 months) for some asymptomatic
sexually active MSM based on their individual risk factors, local HIV
epidemiology, and local policies.
• PrEP users – every 3 months

39. STD Testing Guidelines
USPSTF Recommendation
More frequent STD screening (i.e., for
syphilis, gonorrhea, and chlamydia) at 3–
6-month intervals is indicated for MSM,
including those with HIV infection if risk
behaviors persist or if they or their sexual
partners have multiple partners

40. PHSKC & WA State DOH STD/HIV Screening
Guidelines for Men Who Have Sex with Men
HIV/STD screening should be performed annually on all sexually active MSM+
Screening should include the following tests:
• HIV (if patient is not previously known to be HIV infected)
• Serological testing for syphilis
• Rectal nucleic acid amplification tests for gonorrhea & chlamydia (men who report
receptive anal sex only)
• Pharyngeal culture or NAAT for gonorrhea
Repeat HIV & STD testing every 3 months in MSM with >1 of the following risks:
• Diagnosis of a bacterial STD in the prior year
• Methamphetamine or popper use in the prior year
• >10 sex partners (anal or oral) in the prior year
• Unprotected anal intercourse with a partner of unknown or discordant HIV status in the
prior year
• HIV PrEP use
Clinicians should discuss PrEP in HIV-uninfected MSM with any of the above risk factors*
- Recommend PrEP to men with syphilis, rectal GC, or who use methamphetamine or poppers
+ Not indicated in MSM in long-term (> 1 year), mutually monogamous, HIV concordant relationships.
* PrEP may not be indicated if a patient’s sole HIV-infected partner is known to be virologically suppressed for >6 months.

41. New UK Guidelines on Sexual Health of MSM
Criteria for Testing Every 3 months
UAI partners unknown of discordant status prior 12 months (1B)
>10 sex partners last 12 months (1B)
Meth or popper use with sex last 6 months (1B)
GBL, Ketamine, or NPS* with sex 6 months (1C)
Multiple or anonymous partners since last test (1C)
Any unprotected sex (oral, genital or anal) with a new partner
since last test (2D)
NPS=novel
psychoactive
substances

42.
Medical providers should recommend that patients initiate PrEP if they meet the
following criteria:
• MSM or transgender persons who have sex with men with any one of the
following risks:
• Diagnosis of rectal gonorrhea or early syphilis in the prior 12 months.
• Methamphetamine or popper use in the prior 12 months.
• History of providing sex for money or drugs in the prior 12 months.
• Persons in ongoing sexual relationships with an HIV-infected person who is not
on antiretroviral therapy (ART), OR is on ART but is not virologically suppressed
OR who is within 6 months of initiating ART.
http://www.kingcounty.gov/healthservices/health/communicable/hiv/prevention/~/
media/health/publichealth/documents/hiv/PrEP-Implementation-Guidelines.ashx

43. Medical providers should discuss initiating PrEP with patients with the following
risks:
• MSM and transgender persons who have sex with men with the following risks:
• Unprotected anal sex outside of a long-term, mutually monogamous
relationship with a man who is HIV negative.*
• Diagnosis of urethral gonorrhea or rectal chlamydial infection or in the prior
12 months.
• Persons in HIV-serodiscordant relationships in which the female partner is trying
to get pregnant.
• Persons in ongoing sexual relationships with HIV infected persons who are on
antiretroviral therapy and are virologically suppressed.
• Women who provide sex for money or drugs.
• Persons who inject drugs that are not prescribed by a medical provider.
• Persons seeking a prescription for PrEP.
• Persons completing nPEP
* Unprotected receptive anal sex is associated with a higher risk of HIV acquisition than unprotected insertive anal sex, and some
authorities recommend PrEP to all men who have unprotected receptive anal intercourse outside of a mutually monogamous
relationship with an HIV-uninfected partner3.

44. Elements of an Effective HIV/STD Control
Infrastructure for MSM
• CBOs
• Can be excellent sources of
HIV testing
• Low unit cost
• Often cannot bill – rely on
public health funding
• MSM-focused clinics &
practices
• Typically develop organically,
sometimes with public health
support
• Variably present
• HIV clinics
• Often have not seen HIV-
MSM
• Could expand mission

45. HIV/STD Control Infrastructure: STD Clinics
• Often the largest single source of
syphilis & HIV diagnoses
• Well poised to provide PrEP
• Link between public health outreach
& the medical care system
• Source of sentinel surveillance data
Percentage of STD Clinic Patients
Who are MSM
• Clinics need to improve & be aligned
with public health objectives
• NYC investing $23 million to improve
STD clinics
• Dilemma:
– Safety net provider – Most patients are
heterosexuals, lots of vaginitis
– Public focus – Emphasize HIV, syphilis,
MSM

46. HIV/STD Control Infrastructure: Surveillance &
Monitoring
• Surveillance and monitoring are a key component to the
testing infrastructure
• Monitoring is ideally linked to guidelines and defined goals
• Best monitored using data collected from people with
newly diagnosed HIV
– Identify the people we are diagnosed late
– Which parts of our system find cases and why

47. Monitoring HIV Testing: Late HIV
Diagnosis Based on CD4 Count
• ~25% of persons diagnosed with HIV in King County have a CD4<200 within 1 year
of diagnosis – little change over time
19
3
12 10
23
33
0
20
40
60
80
100
<6 6-12 12-24 24-36 >36 Never
Tested
Percent
Percent of MSM with CD4 <200 at
Time Diagnosis by ITI (n=246)
Percent of All MSM with CD4 <200 at
Diagnosis by ITI (n=246)
23% of persons with CD4<200 have
tested in the prior year
34% of all MSM with CD4<200
have tested in the prior 2 years

48. Monitoring HIV Testing: Inter-test Interval
• Monitoring in MSM focused on time since last HIV- test (HIV inter-test interval)
• Median is low with upper bound of IQR at 20 months
• Median has not changed, but upper bound of IQR has declined

49. Reason for HIV Testing Among Persons Newly Diagnosed with
HIV, King County 2016-17, Stratified by MSM vs Non-MSM
• MSM – 71% tested because of patient initiated testing, acute HIV, STD or partner notification
• Non-MSM – 62% of cases attributable to provider initiated testing or partner notification
Median
ITI
147 226 406 709 539 1955 407
12
37
15 14
8
11
4
2
8
3
29
19
30
8
0
5
10
15
20
25
30
35
40
Acute HIV Patient
Initiated
STD Provider
Initiated
Partner
notification
HIV symptoms Health care
system
MSM Non-MSM

50. End AIDS Washington
1) Routine HIV testing
2) PreP
3) Create healthcare system that
meets the needs of sexual
minorities
4) Access to care – Insurance
5) Housing for PLWHA & those
at high risk
6) Whole person healthcare
7) Healthier WA for Youth
8) Community engagement
- Decrease stigma & disparities
Statewide initiative to reduce HIV diagnoses by 50% in 5 years

51. BREE Collaborative
• Statewide initiative to improve
medical care for gender &
sexual minorities
– Screening and standard questions
about sexual behavior, orientation
and gender identity – recorded in
EMR
– Inventory of health practice and
competencies
– Recommended protocols, policies
and practices to improve care
– Implement MSM STD Screening
Guidelines and PrEP
Implementation Guidelines
– Recommend monitored indicators
and outcomes

52. • ~15-20% of all
HIV- MSM in King
County are on
PrEP
• ~35-40% of higher
risk MSM are on
PrEP
• Results largely
concordant across
multiple data
sources
Estimates of PrEP Use In King County, WA, 2016-17
PercentonPrEP
Source: HIV/AIDS Epidemiology Report. WA State DOH/PHSKC. Christine Khosropour, Julia Hood, Darcy Rao, Dawn Spellman, David Katz,
Christina Thibault, Lori Delaney, Jsani Henry, Kelley Naismith, Sara Glick, and Susan Buskin
Building a System to Provide PrEP, King
County, WA

53. 2017 Seattle Pride Survey
What clinic manages your PrEP care?
38.0
6.0
4.0
52.0
Other
Private MSM
Medical Practices
(five practices) • Sources of PrEP
roughly evenly split
between specialty
and non-specialty
sources of care
Pharmacy-based PrEP
STD clinic

54. • Need to focus on high risk persons
• Frequent HIV testing – shorten period of infectiousness
• Ensure PrEP uptake in most affected populations
• Existing US national guidelines are inadequate
• Local public health needs to augment these
• Form the basis for setting goals and measuring success
• Building clinical infrastructure is key for both HIV testing and PrEP
• Requires both routine testing within the wider medical care system, and
a more specialized system that focuses on gender and sexual minorities
• How to best build that infrastructure is uncertain, and will likely vary
throughout the US
• Focus on persons at highest risk should be an opportunity to integrate public
health with the broader health care system
Conclusions: HIV Testing & PrEP

55. Modernizing!HIV/STI!Field!Services!

56. • Contact tracing originally developed in 18th century Scandinavia and
introduced into the US in the 1940s as a means to control syphilis
• Disease Intervention Specialists
• Uptake for HIV highly variable during the first 25 years of the HIV
epidemic
• New WHO guidelines recommend universal provision of PS
• Based on strong evidence from Malawi, Kenya, Cameroon and
Mozambique
• CDC supports provision of partner services to all persons with newly
diagnosed HIV infection
• Evidence from high income nations is relatively weak
• 1 RCT of 74 people in North Carolina in the late 1980s and early
1990s
Background: Field Services

57. 789 Persons Receive HIV PS
HIV Partner Services Outcomes King County, WA
2010-6/13
573 Provide Information about >1 Sex Partner
224 (24%)
Previously HIV+
88 (9%) Newly
Diagnosed HIV+
489 (51%) Tested
HIV-
154 (16%)
Notified
Outcome
Unknown
953 Partners Notified or Previously HIV Diagnosed
1146 Partners Identified
22 (26%) HIV Tested
AFTER Receiving
Partner Services
64 (74%) HIV Tested
BEFORE Receiving
Partner Services
1032 Persons Newly Diagnosed HIV – Effort to Provide PS Initiated
28% of Tested Partners Newly Diagnosed with HIV
NNTI=11.7 – Ignoring when people test
NNTI=46.9 – Incorporating when people test
76%
71%

58. • Case finding efficacy and DIS productivity are quite limited
Modernizing Field Services
Median NNTI Median Cases Per
DIS/Year
New Cases
Identified/Treated
per DIS/Year*
HIV 20 (8.4-50) 34 2.4
Syphilis 10 46 6.2
Syphilis numbers based on infected partners treated. NNTI=Number needed to interview to
identify or treat an infected partner
Case finding efficacy and DIS productivity for HIV and Syphilis in 9 US Health Departments
Why are we so focused on the partners to the exclusion of
everything else?

59. • Partner HIV/STI testing
• Initial linkage to HIV care
• Identification of persons who are out of care and relinkage to HIV Care
• Non-medical case management of high-needs HIV+ patients
• Linkage to PrEP
• Data collection – epidemiologic analyses
• HIV testing history and reason for testing
• Role of immigration in HIV
• Linkage to long acting contraception
• Cluster investigations and interventions
Expanded Field Services Goals

60. Partner Services for Linkage to Care
Initiation Population-
Based PS
• ~95% linkage achieved
in King County,
facilitated via PS
• Receipt of PS
associated with higher
linkage to care within 3
months in NYC (79%
vs. 66%, P<.0001)
(Bocour A. AIDS 2013) &
Seattle (Hood J. AJPH 2017)
• Level of linkage
achieved through PN is
equal to or exceeds that
observed in ARTAS
Percentage of Persons Newly Diagnosed with HIV in King
County with CD4/Viral Load Results < 3 months
Percent

61. Referrals for PrEP Among MSM with Rectal Gonorrhea
or Early Syphilis Receiving Partner Services, King
County, WA September 2014 – June 2016
656 Data Collected
264 (40%) Already on PrEP 392 Potentially Eligible
303 Offered Referral
145 Accepted Referral
66 Initiated PrEP in STD Clinic*
49%
43%21
37
53
0
20
40
60
80
100
2014 2015 2016
Percent MSM Already on PrEP
*Additional patients received PrEP outside of the STD Clinic
780 HIV- MSM Interviewed for PS
84%
77%
Source: Katz D. CROI 2016
Percent
Number Needed to Interview = ~4

62. Engagement in Care & Antiretroviral Therapy Use Among HIV+ Persons with Bacterial
STIs, WA State 2012-15
2521 HIV+ Persons with Bacterial STD Receiving Partner Services
1556 (66%) On ART 448 (18%) Not
Engage with Care or
Off ART
417 (17%)
Uncertain Care
status
Viral suppression ↑ from 25% to 45% among inadequately engaged persons in the 6
months following partner services
Source: Dombrowski J. Khosropour C. Avoundjian T. MSDOH
King County - 5% HIV+ persons receiving STIs partner services in 2017 unsuppressed
Mississippi – 25% of HIV+ persons receiving STI partner services 2017 unsuppressed
Integrating HIV & STI Control:
HIV Engagement with Care

63. • Field services are the potential link between the health care
system and the medical system
• Central role in DtC, linkage to care, PrEP and molecular HIV
surveillance
• In the era of TasP and PrEP, individual-level benefits and public
health priorities are mostly aligned -> DIS are not sex cops
• Field services is dire need of modernization
• Improved efficiency
• New work to align with contemporary goals
Field Services: Conclusions

64. Conclusions
• Reasons for optimism – We’re doing better than we think
we are, and we have a lot of opportunities
• Need to rethink core elements of our infrastructure
– Surveillance & program evaluation
• Greater integration is key
– Clinical infrastructure
• Need for improved program evaluation and science
– Many of the core elements of our programs have a
strong rationales but very weak evidentiary support
– Area ripe for greater health department – university
collaboration

65. Acknowledgements
UW/PHSKC HIV/STI
(including UW PHCBC, HCV-TAC)
Susan Buskin
Julia Hood
Karen Hartfield
Elizabeth Barash
Christina Thibault
Jeff Duchin
John Scott
Meaghan Munn
Tigran Avoundjian
Amy Bennett
Elizabeth Micks
Kent Unruh
Julie Dombrowski
Christine Khosropour
Sara Glick
David Katz
Lindley Barbee
Roxanne Kerani
Darcy Rao
Meena Ramchandani
Becca Hutchinson
Michal Blum
Sam Benson
David Spach
Sheila Lukehart
WA State DOH
Claudia Catastini
Elizabeth Crutsinger-Perry
Mark Aubin