Syphilis Time to Treatment at Publicly Funded Sexually Transmitted Disease Clinics Versus Non-Sexually Transmitted Disease Clinics--Maricopa and Pima Counties, Arizona, 2009-2012.

Delays in syphilis treatment may contribute to transmission. We evaluated time to treatment for symptomatic patients with syphilis by clinical testing site in 2 Arizona counties. Fewer patients were tested and treated at publicly funded sexually transmitted disease clinics, but received the timeliest treatment; these clinics remain crucial to syphilis disease control.

Use of the Historical Limits Method to Detect Increases in Primary and Secondary Syphilis, Arizona 2011-2014: An Exploratory Study.

BACKGROUND: Increasing numbers of reported primary and secondary (P&S) syphilis cases in the United States suggest the need for improved surveillance methods. An outbreak detection method using reported syphilis test results, which can be counted before the conclusion of a syphilis case investigation, could lead to timelier outbreak detection. METHODS: The historical limits comparison method was used to compare the number of positive rapid plasma reagin results reported during 2011-2014 with data for the preceding 3 years. An outbreak alert was generated when the monthly count of positive rapid plasma reagin quantitative results was greater than the historical mean plus 2 standard deviations for 2 consecutive months. RESULTS: Three outbreak alerts occurred during 2011-2014. The first alert occurred in December 2012 in Maricopa County (Phoenix area). Primary and secondary cases subsequently increased from 10 in January 2013 to 15 in March followed by 5 months of consecutive increases. A second alert was generated for Maricopa County in May 2014. Primary and secondary cases increased from 29 in May to 42 in July 2014. Reported cases remained elevated for approximately 7 months after the second alert. In December 2013, an outbreak alert occurred for Pima County (Tucson area). The number of reported P&S syphilis cases in Pima County increased from 6 in February to 15 in March. Counts of reported cases remained elevated for approximately 6 months after the alert. CONCLUSIONS: Use of historical limits comparison method based on syphilis laboratory results can provide an outbreak alert before increases in reported cases of P&S syphilis.

Chlamydia and gonorrhea diagnosis, treatment, personnel cost savings, and service delivery improvements after the implementation of express sexually transmitted disease testing in Maricopa County, Arizona.

BACKGROUND: The demand for low-cost sexually transmitted disease (STD) services in Maricopa County (Phoenix area) is high. Improved methods for STD/HIV testing are needed to increase the number of patients receiving testing. OBJECTIVES: The present study sought to evaluate an STD/HIV express testing (ET) option for patients identified as being at lower risk for infection. METHODS: Clients reporting current STD symptoms, contact to an infected partner, or health department referral were identified via questionnaire and routed to a traditional provider visit (PV); those not reporting these situations were routed to ET (laboratory-only). Demographics, treatment completion, and treatment intervals were compared among patients diagnosed as having chlamydia and gonorrhea through ET and PV encounters in September 2008 to July 2011. Personnel costs were compared for each of the 2 visit types. The number of clinic turn-aways for the 2-month time interval before the start of the program was compared with the 2-month interval at the end of the evaluation. RESULTS: Of the 36,946 clients seen at Maricopa County Department of Public Health, 7466 (20.2%) were patients seen through express visits. Overall chlamydia and gonorrhea positivity was lower among ET patients (527/7466; 7.1%) as compared with those tested through PVs (6323/29,480; 21.4%). Treatment completion rates were comparable but were higher among patients seen through PVs (99%) as compared with ET (94%). A savings of $2936 per 1000 patients seen was achieved when 20% of clients were routed through ET. Clinic turn-aways decreased significantly, from 159 clients during the 2 months before implementation of ET to 6 patients during the last 2 months of evaluation (96% reduction). CONCLUSIONS: This ET system included an effective patient routing process that provided an efficient way to increase access to STD testing among persons at lower risk, at a reduced cost per patient, while maintaining high treatment coverage.

Epidemiology of syphilis among Hispanic women and associations with congenital syphilis, Maricopa county, Arizona.

OBJECTIVE: We investigated factors associated with high rates of congenital syphilis among Hispanic infants in Maricopa County, AZ. METHODS: Using 2004-2008 syphilis case report data from the state and county health departments, we examined characteristics of pregnant and nonpregnant women with syphilis and their male partners. RESULTS: During 2004-2008, 970 women were reported to have syphilis: 49% were Hispanic (of whom 49% were non-US citizens), 27% were white, 13% were black, and 8% were American Indian/Alaskan Native. Although 16% of Hispanic noncitizens reported drug use or high-risk sexual behaviors, 64% of these women had a male sex partner who reported drug use or anonymous sex. Hispanic women with syphilis were more likely to be pregnant (37%) than white (15%) or black women (13%) (P < 0.05), and were overrepresented among pregnant women with syphilis. Pregnant Hispanic noncitizens were treated later than pregnant Hispanic citizens (median 28 weeks gestation vs. 21 weeks, P = 0.01). CONCLUSIONS: Innovative congenital syphilis prevention strategies that are relevant to Hispanic women are warranted. Strategies should address the reproductive health and prenatal care needs of Hispanic women, and may include interventions for their male partners.

Needle in a haystack: the yield of syphilis outreach screening at 5 US sites-2000 to 2007.

BACKGROUND: Screening for syphilis has been performed for decades, but it is unclear if the practice yields many cases at acceptable cost, and if so, at which venues. We attempted a retrospective study to determine the costs, yield, and feasibility of analyzing health department-funded syphilis outreach screening in 5 diverse US sites with significant disease burdens. METHODS: Data (venue, costs, number of tests, reactive tests, new diagnoses) from 2000 to 2007 were collected for screening efforts funded by public health departments from Philadelphia; New York City; Washington, District of Columbia; Maricopa County, Arizona (Phoenix); and the state of Florida. Crude cost per new case was calculated. RESULTS: Screening was conducted in multiple venues including jails, shelters, clubs, bars, and mobile vans. Over the study period, approximately 926 258 tests were performed and 4671 new syphilis cases were confirmed, of which 225 were primary and secondary, and 688 were early latent or high-titer late latent. Jail intake screening consistently identified the largest numbers of new cases (including 67.6% of early and high-titer late-latent cases) at a cost per case ranging from $144 to $3454. Data quality from other venues varied greatly between sites and was often poor. CONCLUSIONS: Though the yield of jail intake screening was good, poor data quality, particularly cost data, precluded accurate cost/yield comparisons at other venues. Few cases of infectious syphilis were identified through outreach screening at any venue. Health departments should routinely collect all cost and testing data for screening efforts so that their yield can be evaluated.

Improving partner services by embedding disease intervention specialists in HIV-clinics.

BACKGROUND/OBJECTIVES: Notifying partners of HIV-infected persons and referring them for testing and treatment is an effective method of disease control and identification of undiagnosed STD and/or HIV. To improve partner elicitation interviews, disease intervention specialists (DIS) were placed in 3 HIV clinics during 2008 and 2009. METHODS: We reviewed the Arizona state STD surveillance database for 2007 to identify the providers (outside of the public STD clinics) reporting the highest number of syphilis cases. DIS were placed in the clinics for half a day per week (2 clinics) or on an on-call basis (1 clinic) to deliver penicillin and interview patients. We calculated changes in the number of patients interviewed, days elapsed from specimen collection to treatment (time to treatment), days elapsed from specimen collection to initial DIS contact (time to interview), and number of reported and locatable partners from these 3 clinics before and after the clinic placement of DIS. RESULTS: Before the placement of clinic-based DIS, 219 syphilis cases were diagnosed at the 3 clinics (January 2006 through January 2008). After DIS placement, 115 syphilis cases were diagnosed (February 2008 through September 2009) for a total of 334 cases in this analysis. A greater percent of patients completed a partner elicitation interview during the period of DIS placement (94% after vs. 81% before, P = 0.001). There were increases in the average number of locatable partners (1.1 after vs. 0.6 before, P = 0.004) and an increase in the average number of partners exposed and brought to treatment (CDC Disposition A) or infected and brought to treatment (CDC Disposition C) (0.6 after vs. 0.3 before, P = 0.02), and the time to interview decreased (18 days before vs. 9 days after, P = 0.02). CONCLUSIONS/IMPLICATIONS: Placing DIS within community HIV clinics improved partner services. STD and/or HIV programs should consider this method to improve partner notification.

Integrating routine HIV testing into a public health STD clinic.

OBJECTIVE: To integrate routine HIV testing into the services offered at a public health department STD clinic and document the rate of acceptance and rate of test positivity during the first 18 months. METHODS: Testing for HIV was added to the array of tests offered to all patients at the Maricopa County STD clinic. Patients were informed of this new option at registration and were provided with a consent form and instructions to read the form and sign it, unless they did not desire testing. STD clinicians were responsible for insuring that questions regarding testing were answered and that consent forms were signed. HIV prevention was integrated into the general STD preventive messages during the clinical encounter. RESULTS: Sixty-eight percent of patients accepted testing (12,176 of 17,875). Of these, 68 were HIV-positive, for a rate of 5.6 per 1,000. The positive rate for men was 8.6/1000 and for women 1.2/1,000. The rate for men who reported having sex with men (MSM) was 63.8/1,000. Fourteen of the HIV-positive MSM were co-infected with syphilis. Of the 68 who were HIV-positive, 58 (85.3%) were successfully located, informed of their test results, and referred for HIV treatment and support services. CONCLUSIONS: HIV testing can be included in the routine battery of tests offered at an STD clinic with high patient acceptance. Routine testing can discover those who are unaware of their HIV-positive status, providing an opportunity for early referral for treatment, counseling to avoid disease transmission, and notification of sexual contacts.

Viral Loads Among HIV-Infected Persons Diagnosed With Primary and Secondary Syphilis in 4 US Cities: New York City, Philadelphia, PA, Washington, DC, and Phoenix, AZ.

BACKGROUND: Incident syphilis among HIV-infected persons indicates the ongoing behavioral risk for HIV transmission. Detectable viral loads (VLs) among coinfected cases may amplify this risk. METHODS: Primary and secondary cases reported during 2009-2010 from 4 US sites were crossmatched with local HIV surveillance registries to identify syphilis case-persons infected with HIV before or shortly after the syphilis diagnosis. We examined HIV VL and CD4 results collected within 6 months before or after syphilis diagnosis for the coinfected cases identified. Independent correlates of detectable VLs (≥200 copies/mL) were determined. RESULTS: We identified 1675 cases of incident primary or secondary syphilis among persons with HIV. Median age was 37 years; 99.5% were men, 41.1% were African American, 24.5% were Hispanics, and 79.9% of the HIV diagnoses were made at least 1 year before syphilis diagnosis. Among those coinfected, there were no VL results reported for 188 (11.2%); of the 1487 (88.8%) with reported VL results, 809 (54.4%) had a detectable VL (median, 25,101 copies/mL; range, 206-3,590,000 copies/mL). Detectable VLs independently correlated with syphilis diagnosed at younger age, at an sexually transmitted disease clinic, and closer in time to HIV diagnosis. CONCLUSIONS: More than half of syphilis case-persons identified with HIV had a detectable VL collected within 6 months of the syphilis diagnosis. This suggests virologic and active behavioral risk for transmitting HIV.

Viral loads among young HIV-infected men with early syphilis.

High rates of HIV coinfection among men with syphilis suggest HIV transmission opportunities due to biologic and behavioral risk synergy. We abstracted HIV viral loads for HIV-infected males aged 24 years or younger with a diagnosis of early syphilis (ES) in Maricopa County, Arizona, in order to evaluate HIV infectivity. During 2009 to 2012, there were 56 HIV-infected, ES cases meeting the age criteria, of whom 32 (57%) had a detectable viral load performed within 1 year of syphilis diagnosis (median 21 000 copies/mL, range 130-302 844 copies/mL). Only 4 (7%) of the 56 patients had an undetectable viral load (<100 copies/mL) reported within a year of syphilis diagnosis. Twenty (36%) had no reported viral load or a viral load collected after 1 year of syphilis diagnosis. Among this group of young men coinfected with HIV and ES, many had detectable viral loads collected near the time of syphilis diagnosis, suggesting the potential for HIV transmission.

Protecting adolescents' right to seek treatment for sexually transmitted diseases without parental consent: the Arizona experience with Senate Bill 1309.

In 2010, Senate Bill 1309 included language to repeal an existing Arizona law that enables minors younger than 18 years of age to seek diagnosis and treatment of sexually transmitted diseases (STDs) without parental consent. Numerous implications were identified that would have stemmed from parental consent provisions originally proffered in Senate Bill 1309. These implications included diminished access to essential health services among minors, exacerbated existing health disparities, increased health-care spending costs, and thwarted efforts to curb the spread of STDs. Lastly, minors would have been deprived of existing privacy protections concerning their STD-related medical information. This case study describes how collaborative advocacy efforts resulted in the successful amendment of Senate Bill 1309 to avert the negative sexual and reproductive health outcomes among adolescents stemming from the potential repeal of their existing legal right to seek STD treatment without parental consent.

Assessing compliance with a county board order for third trimester syphilis screening in Maricopa County, Arizona.

OBJECTIVES: Due to high rates of congenital syphilis, a Maricopa County board order was issued in 2003 to increase prenatal syphilis screening. The provisions of this order included prenatal syphilis screening during the first prenatal visit, to be repeated during the third trimester, and again at delivery. The purpose of the study was to evaluate syphilis screening practices and barriers to screening among obstetric providers. METHODS: Maricopa County medical providers who delivered at least 21 infants (97.2% of all deliveries) in 2008 according to live birth records were surveyed by telephone. RESULTS: A total of 146 surveys were completed representing 76% (319/421) of the delivering providers and 83% of delivered infants for 2008. All of the represented prenatal care providers reported testing their patients for syphilis at the first trimester, and 284 (89%) reported screening again during the third trimester. CONCLUSIONS: All of the surveyed providers reported screening at least once for syphilis during pregnancy and most reported re-screening during the third trimester as recommended by the Maricopa County board order. Similar public health screening guidance should be considered in areas where congenital syphilis rates are high and/or where syphilis is prevalent among women of childbearing age. A local health order of this type is a simple intervention that can provide practice guidance on emerging health issues.