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Syphilis co-infection among persons living with HIV infection in Shelby County, Tennessee: Describing timing of diagnoses and at-risk populations.
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Syphilis co-infection among persons living with HIV infection in Shelby County, Tennessee: Describing timing of diagnoses and at-risk populations.


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  • 1. Syphilis co-infection among persons living with HIVinfection in Shelby County, Tennessee:Describing timing of diagnoses and at-risk populations.Morrell, KRKonnor, RYKmet, JMChapple-McGruder, TDShelby County Health Department, Memphis TN
  • 2. Background• HIV/STD co-infection cannot be assessed at the national level through exact match methods. • HIV/STD data not stored in the same surveillance systems. • No common identifiers for linkage.• Co-infection can be assessed at the local level. • Personal identifiers must be used. Shelby County Health Department
  • 3. Biological Significance• HIV and syphilis co-facilitate transmission of each other. • HIV shedding • Cellular recruitment of HIV susceptible cells • Mucosal barriers breached• Accelerated progression through the syphilitic stages may occur among HIV+ individuals • More likely to progress to clinical neurosyphilis Shelby County Health Department
  • 4. Public Health Significance• Increased prevalence of HIV/syphilis co- infection could represent: • Increases in sexually risky behavior; • Increased transmission of HIV in patients with syphilis.• May indicate need for expanded behavioral interventions targeted to: • Persons testing positive for STDs; • Persons who know their HIV+ status. Shelby County Health Department
  • 5. Number of Syphilis and HIV Cases in Shelby County, 2000-2009 1000 900Number of Cases 800 700 600 HIV 500 Syphilis 400 300 200 100 0 Shelby County Health Department
  • 6. Objectives• Identify the number of persons recently diagnosed (2006-2009) with syphilis/HIV co- infection in Shelby County;• Describe the timing of diagnosis;• Identify populations at an increased risk. Shelby County Health Department
  • 7. Data Sources• Enhanced HIV/AIDS Reporting System (EHARS) • PLWHA (people living with HIV/AIDS) as of Dec. 31, 2009• Sexually Transmitted Disease Management Information System (STDMIS) • Individuals diagnosed with syphilis between 2006- 2009 * Excluded cases <13 years at diagnosis Shelby County Health Department
  • 8. Data Linkage PLWHA Syphilis cases(as of Dec. 31 2009) diagnosed between 2006-2009• Exact match in SAS by: • Last name • First name • Date of birth Shelby County Health Department
  • 9. Defining Co-Infections by Timing of DiagnosisConcurrent diagnosis: < 3 months Syphilis & HIV HIV before Syphilis: > 3 months HIV Syphilis Syphilis before HIV: 3 months - 1 year Syphilis HIV Shelby County Health Department
  • 10. Regression Analysis• Determine factors significantly associated with syphilis co-infection among PLWHA • chi-square analysis • multivariate regression• Variables of interest: • Gender • Race • Age • HIV risk transmission category • Provider type at HIV diagnosis Shelby County Health Department
  • 11. Matching Results 6, 232 PLWHA 2,680 syphilis cases(as of Dec. 31, 2009) (2006-2009) 377 records linked Concurrent HIV before Syphilis diagnosis: Syphilis: before HIV: 135 (36%) 218 (58%) 24 (6%) Shelby County Health Department
  • 12. Timing of Co-Infection DiagnosesConcurrent HIV before Syphilisdiagnosis: Syphilis: before HIV: 135 (36%) 218 (58%) 24 (6%) P&S: 66 (18%) Early Latent: 64 (17%) Late Stage: 88 (23%) Shelby County Health Department
  • 13. Co-infections by Demographics (n=377) Gender Age Race/Ethnicity 3% 1% 12% 15% 10% 25% 50% 88% 96% 13 - 19 20 - 29 30 - 39 40+ Black, not HispanicMale Female White, not Hispanic Hispanic
  • 14. Co-Infections by HIV Risk Transmission Category (n=377) Heterosexual 16% 17% 1% MSM 1% MSM/IDU IDU 65% No reported Risk Shelby County Health Department
  • 15. Co-Infections by Provider Type at HIV Diagnosis (n=377) Public Facility1% 12%5% Hospital Private Facility 7% 49% Correctional Facility 10% Blood Services 16% Federal Facility Unknown Shelby County Health Department
  • 16. Factors Significantly Associated with Co-Infection Variable OR Estimates 95% CI Gender Male 2.5 (1.7, 3.7) Race/Ethnicity (vs. White, not Hispanic) Black, not Hispanic 5.6 (3.2, 9.9) Age (vs. 40+) 13 - 19 years 2.4 (1.5, 3.7) 20 - 29 years 2.1 (1.5, 2.9) Risk Transmission Category (vs. Heterosexual) MSM 2.1 (1.5, 3.1) Provider Type at HIV Diagnosis (vs. Private) Correctional 3.8 (2.2, 6.6) Public 1.9 (1.3, 2.8) Shelby County Health Department
  • 17. Conclusions• Indication of continued risky sexual behaviors: • 18% of linked records are HIV cases diagnosed at least 3 months before P&S syphilis • 6% of linked records are syphilis cases diagnosed at least 3 months before HIV• Need for interventions in the PLWHA population that focus on: • reinforcing consistent condom use; • motivation to practice safer sex. Shelby County Health Department
  • 18. Conclusions• Populations at increased risk for Syphilis co- infection among PLWHA: • Males; • Black, not Hispanic individuals; • MSM; • 13-29 years; • Diagnosed with HIV in public and correctional facilities. Shelby County Health Department
  • 19. Conclusions• Syphilis and HIV testing should be offered concurrently. • Both tests currently offered in Shelby Co. jails and STD clinics. • Other public clinics should be considered for point-of-care testing. Shelby County Health Department
  • 20. Limitations• Indication of continued risky sexual behavior relies on assumption that: • both tests are offered at initial diagnosis; or • DIS staff locate, refer and link to care for additional testing within 3 months.• Limited risk exposure data• Exact deterministic matching Shelby County Health Department
  • 21. Acknowledgements• Shelby County HIV/STD Program • DIS and surveillance staff • Donna Freeman, Supervisor/Nurse Practitioner• Tennessee Department of Health• CDC National Center for HIV, STD, and TB Prevention Shelby County Health Department
  • 22. References1. Centers for Disease Control and Prevention. 1998. HIV prevention through early detection and treatment of other sexually transmitted diseases - United States. MMWR 47(RR-12):1-24. Retrieved from: Funnye A, Akhtar A, Ven D. 2003. Syphilis and Human Immunodeficiency Virus Co-Infection. Journal of the National Medical Association 95(5): 363-382. Retrieved from: Zetola N, Klausner J. (2006). Syphilis and HIV Infection: An Update. Clinical Infectious Diseases 44: 1222-8. Retrieved from: Newman L, Samuel M, Stenger M, Gerber T, Macomber K, Stover J, Wise W. (2009). Practical Considerations for Matching STD and HIV Surveillance Data with Data from Other Sources. National Center for HIV/AIDS, STD and TB Prevention, Centers for Disease Control Public Health Reports. Retrieved from: Shelby County Health Department