1. Syphilis and HIV screening initiatives in North Carolina jails Lynne A. Sampson PhD, MPH HIV/STD Update September 25, 2008

2. Background Epidemiology of Syphilis and HIV in the United States

3. Syphilis — Reported cases by stage of infection: United States, 1941–2006 Data from CDC STD Report, 2006

4. 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.

7. 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

8. 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)

9. 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

10. 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

11. North Carolina Screening Projects

12. HIV and Early Syphilis (PSEL) rates in NC

13. 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)

14. NC Reported Early Syphilis (PSEL) Cases

15. PSEL Rates in SEP Counties

16. 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

18. 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

19. 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

22. 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

23. 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

27. 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

28. 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