1. Costing & Time & Motion Study of STD Partner Services in Washington State Epidemic Characteristics Drive Costs
Rachel A. Silverman, PhD, ScM, David A. Katz, PhD, MPH, Carol Levin, PhD, MSc, Teal R. Bell, MPH, Dawn Spellman, MA, Lisa St. John, MBA, Med, Evelyn Manley Rodriguez, Matthew R. Golden, MD, Ruanne V. Barnabas, DPHil, MBChB, MSc

2. Background Significance
CDC recommends STD partner services (PS) to prevent disease & transmission
Given increased HIV risk associated with STDs, STD PS can be used to promote HIV prevention & treatment
Resource needs are not well understood
Aims
Evaluate the resource needs (financial costs and time), activities, and areas to improve efficiency of STD PS in Washington State.

3. STD PS Programs in Washington State
Disease intervention specialists (DIS)
Conduct telephone-based interviews of STD cases & partner notification (field work last resort)
All syphilis, MSM with gonorrhea (GC) & chlamydia (CT), & some heterosexual cases
Often focus on specific disease and/or risk group
Enhanced STD PS Activities
Offer expedited partner therapy (EPT) to heterosexuals with GC/CT
Promote HIV testing
Identify/refer eligible clients for pre-exposure prophylaxis (PrEP)
Promote linkage/re-linkage to HIV-care for HIV infected clients
Full-Time Staff (40 hrs/wk)
DIS
Administrative
King
5.4 1
Pierce
3.1
0.4
Spokane
2.7
0.3
Study Sites: 3 High disease burden jurisdictions representing geographic & epidemic diversity
Public Health – Seattle & King County
Tacoma-Pierce County Health Dept
Spokane Regional Health District
King
Pierce
Spokane

4. Data Collection Qualitative Time & Motion Study:
Captures detailed information on process & duration of tasks for service delivery.
Interviews & independent observations: Estimate personnel time on activities.
Individual case time-tracking: Staff record activities and time spent per case.
Financial expenditures (salaries, overhead, etc.) on STD PS program.
Surveillance & STD PS Data: number of people impacted by PS.
What was not collected:
Resources not specific to STD PS (e.g. STD clinic work).
Resources for HIV-only cases.

5. STD Epidemic Diversity Across WA State
Total Population Size
King
2,149,970
Pierce
861,312
Spokane
499,072
In King & Pierce, most syphilis cases are MSM vs. heterosexual in Spokane (many methamphetamine users).
Most GC are MSM in King.
Most CT cases are heterosexual in all jurisdictions.
MSM: Men who have sex w/ men

6. Percent of Reported STD Cases Receiving PS Cases assigned and interviewed by DIS
Almost all syphilis cases assigned
Spokane highest % interviewed
Most GC cases assigned in King & Pierce
Pierce highest % interviewed
Most CT cases are not assigned

7. Time Study Results – Percent of Total Time Spent on PS Activities
Variation in time for activities across locations and STD
Syphilis 8%
19%
22%
10%
31%
17%
41%
11% 6%
34%
22% 6%

8. Estimated Total Time Allocated per Case
Spokane spends over 4x the time on Syphilis
and twice the time on GC/CT than King & Pierce.
(recall higher % of HET case, many methamphetamine users in Spokane, very hard to reach)
Epidemic Characteristics
King
Pierce
Spokane
% MSM
Syphilis:
88%
82%
38%
GC/CT:
27% 6% 5%

9. Average Across Jurisdictions
Individual Case Tracking Large Variability Across cases, locations, and STD
Staff & STD
Average Across Jurisdictions
Range Overall
Case
Partner
Administrative GC/CT
9-18 min -
2-70 min
DIS GC/CT
33-37 min
15-33min
min
7-58 min
DIS Syphilis
min
16-52 min
min
6-127 min
Complicated, high priority cases take lots of time!
In Spokane, heterosexual syphilis cases required 3x amount of time vs. MSM (271 vs 71min).
Methamphetamine users required 5x that of MSM (388 vs. 71 min).

10. Time spent on Enhanced STD PS Activities Spent relatively small amount of time on these activities vs. overall work
EPT for heterosexuals GC/CT: <5 minutes per case
HIV test discussion & verification: <2 minutes per case
HIV linkage to care discussion & verification: <2min per case
PrEP discussion: <2min per case
Observed
during interview
Depends on other existing programs in the community
Providers test for HIV, refer & prescribe PrEP at time of STD test/diagnosis
Health departments with PrEP coordinator for referrals (King & Spokane) require minimal DIS work time
Pierce reported DIS spent minutes per referral for 3-6 clients per week for PrEP referrals and initiation/linkage (no department coordinator), compared to a few minutes in other locations to refer clients to coordinator (self report)

11. Total Financial Expenditures of STD PS Programs (2016)
King
Pierce
Spokane
$798,141
$416,098
$400,758
King County twice the expenditures vs. Pierce & Spokane
Salaries & Benefits ~80% of Costs
Lifetime cost of HIV treatment >$400,000

12. Total Costs Per Case Interview Varies by location & STD
Total Costs Per Case Interview Varies by location & STD. Syphilis cases costs most per service.
Total Cost per interview
Syphilis: $526-$2,210
Gonorrhea: $219-$484
Chlamydia: $164-$547
Results similar to a costing analysis of PS in New York State in 2014:
Cost per interview:
Syphilis: $1,072
Gonorrhea: $608
Chlamydia: $635
Johnson, et al. (2017)
Johnson BL, Tesoriero J, Feng W, Qian F, Martin EG. Cost Analysis and Performance Assessment of Partner Services for Human Immunodeficiency Virus and Sexually Transmitted Diseases, New York State, Health Serv Res. 2017 Dec;52 Suppl 2: doi: / Epub 2017 Aug 11.

13. What to Consider for STD PS program development, implementation, & improved efficiency
Disease burden & population characteristics (are clients hard to reach?).
Methods to locate contact clients (phone/text, fieldwork, Facebook, dating apps).
Case reporting efficiency quality from providers (paper vs. electronic reporting).
Access to electronic medical records.
Access to restricted database (e.g. Accurint ®).
Data sharing between DOH and other local jurisdictions (e.g. syphilis serology data, jurisdiction level data for neighboring counties).
Database (simple and efficient?).
Greater efficiency➔ more time spent tracking/contacting clients ➔ more disease prevention

14. Conclusions
Large variability in resource needs within & across STD infection type & jurisdictions.
Casework for syphilis costs more than GC/CT
Integrating HIV related interventions often required relatively little additional effort
Costs per outcomes are comparable to other programs with similar objectives.
Results inform resource needs & areas to improve efficiency
Results can inform math models balancing program costs & benefits to estimate cost-effectiveness over time
Given lifetime cost of an HIV case is ~$400,000 (1-2x annual cost of local STD PS in WA), efforts to treat & prevent STDs associated with HIV & integrating HIV-related interventions within STD PS can be cost-effective. Can justify diversifying funding streams by utilizing HIV funds for STD treatment & prevention.

15. Acknowledgements
DIS & Admin Staff at Public Health – Seattle King County, Tacoma-Pierce County Health Department, Spokane Regional Health District for their participation
STD PS Supervisors: Dawn Spellman, Evelyn Manley Rodriguez, Lisa St. John
Ruanne Barnabas
David Katz
Matt Golden
Carol Levin
Teal Bell
Tom Gift
Health Economics Impact Study Team (HEIST)
Center for AIDS Research (CFAR)
Work is supported by the U.S. Centers for Disease Control & Prevention (Grant: 3H25PS W1)