Integrated STD/HIV Partner Services: Role of Technology

1. Integrated STD/HIV Partner Services: Role of Technology Kees Rietmeijer, MD, PhD Internet and STD Center of Excellence Denver Public Health Department Colorado School of Public Health

2. Integration • Partner Services • Role of Technology

4. 2009 2005 Where the Program Collaboration “rubber” Hits the Service Integration “road”

5. Program Collaboration and Service Integration

6. PCSI in Denver STD Clinic • Comprehensive STD Services • HIV Testing

7. HIV/RPR Ratio and HIV Positivity Rate by Period January 2005 - October 2006 0.96 1.00 HIV(+) Rate 0.92 1.5% (HIV:RPR) Ratio 0.86 0.79 0.80 0.8% 0.7% 0.6% 0.5% 0.60 0.0% Period I: Jan 2003 - Period II: Dec 2003 - Period III: Jun 2004 - Period IV: Apr 2005 - Nov 2003 May 2004 Mar 2005 Oct 2006 HIV:RPR Ratio Period HIV+ Rate Normalizing HIV Testing • > 10,000 HIV (rapid) tests per year • > 100 new HIV positives year • 40% of all new HIV+ in Denver • 25% of all new HIV+ in Colorado

8. PCSI in Denver STD Clinic • Comprehensive STD Services • HIV Testing • Hepatitis A and B Vaccine • Hepatitis C Testing • Family Planning Services

9. Partner Services

10. Semantics….. • In the world of STDs: • “Contact Tracing” • “Partner Notification” • “Epidemiological Treatment” (“Epi-Treat”) • In the world of HIV • “Partner Counseling and Referral Services” (PCRS) • “Post-Exposure Prophylaxis”

12. Partner Services - Goal “… the goal of partner services is to maximize the number off partners who are notified of their exposure to HIV, syphilis, gonorrhea or chlamydia and who are treated or linked to medical, prevention, and other services.” MMWR 2008;57, RR-9

13. Why Integration of Partner Services? • Coordination of prevention services is guiding force behind PCSI • Standard of practice in many jurisdictions • Resource sharing • Post-HAART evolution in HIV prevention philosophy • Focus on early diagnosis and linkage to care • Dually-infected patients (e.g., syphilis and HIV) • Prevent conflicting messages • Principles of partner services do not differ substantially among diseases

14. CDC Recommendations • Active health department involvement through disease intervention specialists (DIS) • Newly diagnosed HIV • Early syphilis • Limited involvement: selected high priority cases of • Gonorrhea • Chlamydia MMWR 2008;57, RR-9

15. High Priority Index Cases • Pregnant women • Male index patients with pregnant partners • High risk behaviors • Multiple sex partners • Injection drug use • HIV-STI co-infection • Recurrent STIs MMWR 2008;57, RR-9

16. High Priority Cases - HIV • High viral load (> 50,000) • Acute HIV infection

17. High Priority CasesSyphilis, Gonorrhea, Chlamydia • Clinical signs or symptoms  higher transmission rate • Infected persons from core areas

18. Partner Services Challenges • High-intensity intervention • Need for prioritization • Most cases of gonorrhea and chlamydia cannot be served by DIS

19. Partner ServicesPossible Solutions • Patient-initiated referrals • Contact cards result in a 50% referral rate • Expedited partner therapy • Demonstrated to reduce re-infection for gonorrhea and chlamydia • Uptake varies by setting • Role for this approach in HIV prevention? • Use of “new media” • Internet • Mobile phones / text messages

20. Role of Technology

21. The Facebook Phenomenon New York Times March 29, 2009

22. Cell phone growth in the United States Source: CTIA – The Wireless Association.

23. Cell Phone & Text Messaging Use Among STD Clinic Patients Clinic Survey Results Presented at ISSTDR, 2007

24. Why Use Technology? • It’s the way people communicate • E-mail addresses and chat room “handles” may be the only contact information • Reach partners in the same environment where they hooked up • Ease of communication • Can communicate anonymously

25. Use of Technology - Examples • Use e-mail address as another means of communication for DIS • Development of web-sites as an adjunct to traditional PN • Online outreach in chat rooms • Use of MySpace and other existing social networking sites • Stand-alone web-based programs • Use of mobile cell phones and text messaging

26. Available at www.ncsddc.org and at www.stdpreventiononline.org

27. www.internetinterventions.org

28. www.internetinterventions.org

29. Online PN: Sample E-Mail

31. Creating a Profile

32. Online PN - InSpot

34. Partner Services and SMSThe Next Frontier • Why? • Text messaging is quickly becoming the preferred method of communication for a growing population • Since 2007, mobile phone subscribers send and receive more text messages than phone calls • Inter-connectivity: • Mobile-to-mobile • Internet-to-mobile • Email-to-mobile

35. Partner Services and SMSThe Next Frontier • Considerations • Goal should be to motivate recipient to communicate via voice • Confidentiality issues • Text messages can be viewed by other people • Sender should be in a place/situation to be able to respond to voice call-backs • Security issues • Cell phones have call/text logs – need for secure storage • Etiquette development

36. Use of Technology for Partner Services • The Good News: many innovative approaches • The Not-So-Good News: lack of thorough evaluation • Does it work? • Is it cost-effective? • Are there downsides?

37. 1400 1200 1000 800 Users 600 400 200 0 Jul Oct Apr Apr Feb Feb Jun Dec Jun Jan Jan Mar Mar Nov May May Aug Sept Use of Online Partner Services ProgramColorado, 2008 - 2009 # Website Users Radio PSA Newspaper advertisement Banner advertising Clinic intervention

38. Recognition of Online Partner Services ProgramDenver Metro Health Clinic, 2008 - 2009 % Recognition 35 Clinic Survey 1 Clinic Survey 2 30 25 Radio PSA 20 Newspaper advertisement % Recognition 15 Banner advertising 10 Clinic intervention: Posters; flyers; info on clinic website, linkage to online results program; contact cards with site information for all patients diagnosed with gonorrhea or chlamydia. 5 0 Jul Oct Apr Apr Feb Feb Jun Dec Jun Jan Jan Mar Mar Nov May May Aug Sept

39. Recognition of Online Partner Services ProgramDenver Metro Health Clinic, 2008 - 2009 % Recognition 35 Clinic Survey 1 Clinic Survey 2 30 25 Radio PSA 20 Newspaper advertisement % Recognition 15 Banner advertising 10 Clinic intervention 5 5% Recognition 5% Recognition 0 Jul Oct Apr Apr Feb Feb Jun Dec Jun Jan Jan Mar Mar Nov May May Aug Sept

40. How DMHC Patients Would Notify Their Partners if Diagnosed with an STI • Face-to-Face 89% • Telephone 37% • Text Message 11% • Email/Internet 5% • Written note/letter 4% • Would not tell 2.5% Denver Metro Health Clinic 2008 - Unpublished

41. Conclusions • New technologies for partner services are appealing and may play a role in enhancing the notification, evaluation, and treatment of STI/HIV-exposed partners • However, their role may ultimately shown to be limited as the intent to notify partners may only be influenced in a small part by the method of message delivery • More emphasis needs to be placed on behavioral interventions that affect the psychological and sociological determinants of partner communication

42. Integrative Model of Behavioral Prediction: A Reasoned Action Approach Fishbein. Med Decis Making 2008; 28; 834

43. Things are getting more serious between Paul and Jasmine, but Paul “slips” and has a sexual encounter with Teresa. Teresa gets an STD and tells Paul. Now Paul has to tell Jasmine. Video Interventions for Partner Communication

44. Acknowledgements

50. Place holder:Slideshow uploaded on STDPreventionOnline.org