Li-Gang Yang, MD, MS, Joseph D. Tucker, MD, MA Guangdong Provincial STD Center

1. A Twin Response to Twin Epidemics:Integrated Syphilis/HIV Testing at STI Clinics in Guangdong Province China Li-Gang Yang, MD, MS, Joseph D. Tucker, MD, MA Guangdong Provincial STD Center UNC Chapel Hill School of Medicine Harvard Medical School

2. Guangdong Province

3. Syphilis and sexually transmitted HIV in Guangdong Province 5000 4500 4000 3500 Guangdong Province reported cases 3000 2500 2000 1500 1000 Sexually transmitted HIV cases 500 0 Primary syphilis cases 2003 2004 2005 2006 2007 Year

4. 60 50 Total syphilisincidence (per 100,000total population) 40 Congenital syphilis incidence (per 100,000 live births) 30 20 10 0 1985 1990 1995 2000 2005 2010 35.3 13.3 Reported overall syphilis and congenital syphilis incidence per 100,000 population and per 100,000 live births respectively. Data are from the National Center for STD Control and Prevention in Nanjing, China.

5. 60 50 Total syphilisincidence (per 100,000total population) 40 Congenital syphilis Incidence (per 100,000 live births) 30 20 10 0 1985 1990 1995 2000 2005 2010 35.3 Primary & Secondary Syphilis Comparison: United States (2005) – 2.9/100,000 PRC (2005) – 5.6/100,000 13.3 Reported overall syphilis and congenital syphilis incidence per 100,000 population and per 100,000 live births respectively. Data are from the National Center for STD Control and Prevention in Nanjing, China.

6. Clinic-Level Availability of free rapid HIV tests Physician-Level Age, sex, medical training Guidelines, clinic norms, and doctor incentives Dyadic Interpersonal HIV stigma, syphilis stigma Alone or accompanied Individual-Level HIV training, syphilis training Marital status Prior testing Age, sex, income Social Ecological Framework*: Determining HIV test uptake** * Choice of framework based on data from STI physicians (Tucker et al, BMC Public Health, 2010), policy experts (Tucker et al, Bulletin of WHO, 2010), and high risk groups (Wang et al, AIDS & Behavior, 2008). ** Defined as receipt of HIV test results by an STI patient at an STI clinic.

7. Clustered observations among patients seeing the same physician Generalized Estimated Equations (GEE) • Other methods that treat clustering as a nuisance • More difficult to alter variance structures or characterize level-1 and level-2 interactions Multi-level modeling (MLM) • Substantive and technical advantages when dealing with clustered data. • Logit MLM can be used to describe binomial outcome (HIV test uptake as dichotomous outcome): logit (πi) = log [ πi / (1- πi)] = β0j+ β1xij β0j = β0+ u0j

8. Plum Blossom Project • Free rapid syphilis & free rapid HIV testing available at each STI clinic. • 3 cities, 6 clinics - 62 physicians recruited 2061 STI participants. • STI physicians filled out a survey with three domains – sociodemographics & training background, responses to clinical vignettes, and HIV/syphilis stigma. • STI patients filled out a survey with seven domains. Physicians filled out a 10 item refuser form for those who did not want to be tested for HIV. • Participation was voluntary and no incentives were provided to patients or physicians for participating. Rapid syphilis testing does not require trained lab personnel.

9. Syphilis & HIV Comparison of syphilis/HIV testing among those who filled out the complete Plum Blossom Survey (n = 1792). *Spearman correlation coefficient comparing responses to respective syphilis and HIV items.

10. Patient reasons for HIV test refusal (n=1299)

11. Physicians reasons for not offering HIV testing to all patients (n=62) Low prevalence of disease 18 (29.0%) Not currently recommended by guidelines 12 (19.4%) Not enough time in my clinic 5 (8.1%) I am worried about HIV stigma affecting my patients 4 (6.5%) I cannot provide adequate HIV follow-up services 3 (4.8%) I feel uncomfortable or inadequately trained to deliver a new HIV diagnosis 2 (3.2%) I feel uncomfortable or inadequately trained to discuss HIV risk behaviors 1 (1.6%) Not my responsibility 1 (1.6%) Physician non-offer of HIV testing

12. Physician non-offer of HIV testing Physicians reasons for not offering HIV testing to all patients (n=62) Low prevalence of disease 18 (29.0%) Not currently recommended by guidelines 12 (19.4%) Not enough time in my clinic 5 (8.1%) I am worried about HIV stigma affecting my patients 4 (6.5%) I cannot provide adequate HIV follow-up services 3 (4.8%) I feel uncomfortable or inadequately trained to deliver a new HIV diagnosis 2 (3.2%) I feel uncomfortable or inadequately trained to discuss HIV risk behaviors 1 (1.6%) Not my responsibility 1 (1.6%)

13. Multi-level model of HIV testing refusal The following factors were significantly associated with HIV test refusal in a two level binomial logit model: • Married (compared to all unmarried and not currently married) • Previous HIV testing (compared to those who have never been tested for HIV before) • Alone (compared to those who attended the STI clinic accompanied) • Participated in last two months (compared to first three months)

14. Physician-level predictors • Physician-level variance accounted for 28.4% of all variance assuming level-1 variation is that of standard logistic distribution (3.29). • None of the physician-level factors significantly improved the best MLM model: age, sex, HIV training, medical training, HIV stigma (using a validated instrument), number of patients evaluated, city.

15. Factors associated with HIV test refusal (p<0.05): Married (OR 13.9) Prior HIV testing (OR 9.6) Alone (OR = 1.9) High income (OR = 1.8) HIV test refusal

16. Factors associated with HIV test refusal (p<0.05): Married (OR 13.9) Prior HIV testing (OR 9.6) Alone (OR = 1.9) High income (OR = 1.8) Factors associated with syphilis infection (p<0.05): Married (OR 3.0) Prior HIV testing (OR 3.1) Women (OR 2.4) Aged 40-60 (OR 1.7) HIV test refusal

17. “SEEK” - Expanding syphilis/HIV testing in China • The effects of a massive one-time compulsory HIV testing effort have lapsed (Wu et al., Science, 2006). • HIV VCT centers have been plagued by poor test uptake (Ma et al., AIDS, 2000). • Antenatal testing promising (Zhou et al., FRLBE105) although this represents a population with less sexual risk. • TB institute testing with high HIV test uptake (Wang et al., Int. J. Tuberc. Lung Dis, 2010) but probably less associated with early HIV infections. • STI-clinic based testing reaches a higher risk group in the setting of a sexual health infrastructure with the capacity to respond (Tucker et al., BMC Health Services, 2010).

18. Conclusions • Routine syphilis testing at STI clinics in China represents an opportunity to expand routine HIV testing. • Interpersonal factors (accompanied, marital status) influence individual HIV test uptake and may be leveraged to expand testing. • Multi-level modeling can be useful for analyzing clustered observations and accounting for hierarchical data structures.

19. Thank You Huizhou STI Clinic Xiao-Xiong Huang Hua Peng Sen-Miao Zhang Fang-Mei Chen UNC School of Medicine* Myron S. Cohen** Gail Henderson US NIH Fogarty Center* Sten Vermund Harvard University Arthur Kleinman SV Subramanian Rochelle Walensky Martin K. Whyte London Advisors Rosanna Peeling (LSHTM) Sarah Hawkes (UCL) *Main funders **Main mentor China National STD Control Center (Nanjing) Xiang-Sheng Chen Yue-Pin Yin Jin Bu Guangdong Provincial STD Control Center Bin Yang Ligang Yang Song-Ying Shen Cheng Wang Xuqi Ren Tinglu Ye Helena Chang Jiangmen Skin Hospital Zheng-Jun Zhu He-Kun Lu Bao-Yuan Zhang Shu-Jie Huang Xue-Ling Tan Wei-Jun Deng Xinhui District STI Clinic Jian-Xin Yu Yun Feng Jing-Feng Huang