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Syphilis and HIV screening initiatives in North Carolina jails

Syphilis and HIV screening initiatives in North Carolina jails. Lynne A. Sampson PhD, MPH HIV/STD Update September 25, 2008. Background Epidemiology of Syphilis and HIV in the United States. Syphilis — Reported cases by stage of infection: United States, 1941–2006.

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Syphilis and HIV screening initiatives in North Carolina jails

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

  2. BackgroundEpidemiology 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.

  5. 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

  6. 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)

  7. 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

  8. Jail Prison Level of oversight Local (County or City) State or Federal Inmate Population Persons charged with crimes & awaiting trial Persons convicted of crimes with short sentences (< 1 year) Persons convicted of crimes and sentenced to  1 year Duration of stay < 24 hours to 1 year 1 year to life Goal of STD screening programs Form of community screening Maintain health of inmate population Characteristics of Jails & Prisons

  9. North Carolina Screening Projects

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

  11. 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)

  12. NC Reported Early Syphilis (PSEL) Cases

  13. PSEL Rates in SEP Counties

  14. 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

  15. 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

  16. 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

  17. 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

  18. 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

  19. 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

  20. 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

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