POWER: Prevention and Outreach to Women at Elevated Risk of Syphilis to Address Congenital Syphilis

As the most populous county in the United States, Los Angeles County (LAC) is home to an estimated 9,861,224 residents as of 2022. The County's urban, suburban and rural communities span over 4,000 square miles and comprise 88 incorporated cities and approximately 140 unincorporated areas. LAC is among the most ethnically and economically diverse regions in the nation with immigrants making up over a third of the County's population. An estimated 69,144 Angelenos are homeless on any given night and over 14,000 inmates are housed in county jails - the largest jail system in the U.S., leading to a large population of individuals cycling in and out of the jail system daily. Mortality is perpetuated by methamphetamine and fentanyl overdoses, co-occurring epidemics, and social inequities. Social inequities (beyond those impacting health care access and quality, including but not limited to economic stability, education access and quality, neighborhood safety and built environment, and social and community factors) have influenced the rise in sexually transmitted diseases (STD) over the last decade.

Syphilis rates in LAC are rising at levels not seen in over 30 years, with increases most stark for women, with a 750% increase since 2012. In 2021, LAC had 123 infants who were diagnosed with congenital syphilis (CS) and 18 syphilitic stillbirths. To effectively prevent and eliminate CS, the LAC Department of Public Health (Public Health) needs a strengthened and collaborative effort to prevent new CS cases.  Suboptimal syphilis screening among people who could become pregnant, particularly those not receiving regular health care services, has been identified as a key contributor to congenital syphilis.

Public Health's Division of HIV and STD Programs (DHSP) has set out to identify non-traditional syphilis screening strategies to test and treat women of reproductive age who may have undiagnosed syphilis. In this manner, any case of syphilis detected could be considered a case of CS averted.  DHSP has conducted key informant interviews with colleagues from a variety of community-based organizations (CBO) to women with substance use disorder and/or women experiencing mental health challenges and/or women experiencing homelessness, including providers who deliver harm reduction services and homeless healthcare services.  As a result of this focused effort, DHSP has developed three screening strategies: 1) a CBO-DPH Paired Model, whereby Public Heath staff provide HIV and STD testing in the field in partnership with a CBO with strong ties with the target population, 2) a CBO-DPH Transition Model, where Public Health staff work with CBOs to integrate HIV and STD testing within their service delivery setting with the goal to train and transition testing responsibilities to CBO staff, and; 3) a Homeless Healthcare Provider Model, where Public Health staff provide technical assistance, training, support and testing supplies to homeless healthcare providers to incorporate testing into their care model.

For the CBO-DPH Paired Model, Public Health partnered with a CBO providing advocacy and harm reduction services to cis-gender women of reproductive age engaging in transactional sex and their partners in an area of downtown Los Angeles known for sex work.  As part of this partnership, regular outreach events were coordinated to provide low barrier STD and HIV testing and treatment to existing clients and other individuals experiencing homelessness in the surrounding area.  All services provided have used field-based approaches, including mobile units, instrumented lab tests, point of care tests, case management, incentives, provider evaluation and treatment services, when indicated.

For the CBO-DPH Transition Model, Public Health identified a CBO whose leadership team expressed interest in integrating rapid HIV and STD testing into their syringe support program (SSP), that provides harm reduction services to persons who inject or smoke drugs, namely opiates and methamphetamine. While the organization already offered HIV testing as part of other programing targeting men who have sex with men and transgender persons; the organization, needed assistance integrating testing for HIV and STD into their SSP program that served a separate clientele.  Public Health provided technical assistance, training, and quality assurance protocols to the organization's leadership team; both entities agreed that it would be beneficial for Public Health to perform testing at the SSP, have the SSP staff shadow the LAC DPH staff, and then eventually transition testing responsibility to the SSP staff with some Public Health oversight during a defined transition period.

For the Homeless Health Care (HHC) Provider Model, Public Health partnered with a local County operated homeless healthcare program.  The HHC team received temporary COVID-19 funding to support vaccination efforts among people experiencing homelessness (PEH).  Public Health DHSP appealed to the HHC provider to integrate HIV/STD testing into their services. During the course of four months, the HHC provider conducted several health outreach events to sheltered and unsheltered PEH, integrating HIV and STD testing and treatment alongside vaccination, showers, harm reduction services (safe injection and smoking supplies, Narcan, and contingency management), wound care kits, safer sex kits, and general health care services.

The success of these models demonstrated how critical it is to work in partnership with community-based service providers trusted by the target population; the opportunities for integrating HIV and STD testing within existing service models, and the potential for high yield services targeted to sub-populations at elevated risk for infection.  Public Health DHSP continues to explore opportunities with additional CBOs and HHCs to further expand syphilis testing among women at elevated risk for infection.

Website: http://ph.lacounty.gov/dhsp/

As stated earlier, syphilis rates in LAC are rising at levels not seen in over 30 years, with increases most stark for women, with a 750% increase since 2012.  While syphilis cases continue to be diagnosed throughout LAC, higher concentrations of diagnoses occur in the Downtown Los Angeles and South Los Angeles areas of the County.  In 2021, LAC had 123 infants who were diagnosed with CS and 18 syphilitic stillbirths.

As the congenital syphilis crisis in LAC worsens year to year, its effects are being increasingly concentrated in the most vulnerable groups, namely women of reproductive age suffering from concurrent substance use disorder, mental health challenges, and experiencing homelessness.  Fifteen to twenty percent of women diagnosed with early syphilis in LAC report methamphetamine use, a rise from less than 5% ten years ago.  An analysis of CS cases in LAC over the past five years show that pregnant people whose children are diagnosed with CS commonly report actively using methamphetamine (50%), experiencing homelessness (40%), and not receiving recommended health care services, including 58% of pregnant people receiving late or no prenatal care.  In addition, DHSP has observed that up to three quarters of the women whose infants are classified with CS have had other children taken into custody of the Department of Children and Family Services (DCFS).  This prior experience with DCFS and the trauma associated with these interactions challenge the trust of these individuals and further complicate relationships with Public Health partners and other healthcare providers – likely contributing to reduced healthcare utilization.  Combined, these factors contribute to inconsistent, late or no prenatal care, which in turn results in a delayed or missed diagnosis of syphilis in pregnancy and in turn results in the newborn infant being affected by CS.

Historically, most sexually transmitted disease (STD) case finding has been based in the delivery and receipt of services in a health care provider setting, with health care providers being encouraged to increase screening efforts and health care consumers being encouraged to actively seek out screening.  testing.  DHSP has recognized the importance of seeking out and supporting alternative STD screening models, as the existing approach that relies on women at elevated risk for STDs to seek out screening services through traditional health care providers has been insufficient.   DHSP has established a programmatic partnership with the Sheriff's Department to offer syphilis testing in the dormitories that house justice involved individuals; an intervention that has resulted in a good yield identifying previously undiagnosed cases of syphilis. 

DHSP has set out to identify new strategies to offer HIV and STD testing to women with substance use disorder (particularly methamphetamine use) and/or women experiencing homelessness.

A common public health practice to offer testing outside of traditional healthcare settings has involved the use of a mobile vans.  Data from programs operating internationally has shown success in low- and middle-income countries, however, the extrapolation to high-resource settings has not been well evaluated, based on a review of the literature.  Our local experience suggests that the use of mobile vans to offer HIV and STD testing has had limited success.  First, van or outreach events that are limited to offering HIV and STD services, contribute to stigma and judgement.  Secondly, services delivered from mobile vans may be perceived as inferior compared to services delivered from brick-and-mortar sites.  To help overcome these obstacles and to ensure that members of the target sub-populations (particularly members of racial and sexual or gender minorities and persons with substance use disorder) we maintain that mobile HIV/STD services would be best received if they were offered in the context of other services and in collaboration with trusted CBO or healthcare partners.

These collaborations underscore the importance of Public Health partnering with service providers with well-established reputations and experiences serving the target sub-populations.  Without the assistance of CBO staff, it remains unlikely that as many clients would access services at a Public Health-operated mobile van.  Like their sexual minority counterparts, clients who access SSP services have also been similarly and historically marginalized.  As such, by capitalizing on the high levels of trust these programs have with SSP clients, DHSP has integrated testing into their existing services to have the greatest program impact.  The HHC team has a strong reputation among many unsheltered PEH which lead to higher service utilization rates; and the service integration has destigmatized the offer and receipt of HIV and STD screening services.

The goal of the effort is to prevent as many CS cases as possible, with the specific objective of identifying non-traditional strategies to test and treat women of reproductive age who may have undiagnosed syphilis.  While DHSP took the lead on the planning and implementation for this project, both in the formative work and the implementation, the involvement and collaboration of the community partners was critical.  

LAC DPH conducted key informant interviews with colleagues from a variety of community-based organizations including syringe service providers and homeless healthcare providers, who serve women with substance use disorder and/or women experiencing mental health challenges and/or women experiencing homelessness.  Interviewees were identified based on prior collaborations, current role or through referrals from other stakeholders.  The interviews were semi-structured in nature and designed to elicit information on client service preferences and review the feasibility and acceptability of alternate testing models in the proposed settings.

DHSP conducted interviews over a nine-month period.  Within four months of the start of key informant interviews, the first opportunity to pilot a new screening strategy surfaced from an interview with a CBO that provides advocacy and harm reduction services for persons who are engaging in transactional sex work in downtown Los Angeles (Skid Row).  The CBO representative reported a possible cluster of syphilis cases in the target area, after two of their clients engaging in sex work and experiencing homelessness tested positive for syphilis (following psychiatric hospital admission) and a third client with reported but untreated syphilis.  Within two weeks, DHSP mobilized a team to deliver street-based testing services in a location proximal to the client's encampment site and actively promoted the testing event in the area up to the testing day.

For the CBO-DPH Paired Model, staff who participated included a physician, a disease investigation specialist, and several test counselors.  Staff from the CBO included case managers and syringe service providers.  Similarly for the CBO-DPH Transition Model, DPH staff who assisted included the HIV/STD Testing Manager, lead staff for testing service oversight and quality assurance, testing counselors, data collection staff, and syringe service program staff.  For the HHC Provider Model, DPH staff who assisted included a senior physician, HIV/STD Testing Manager, lead staff for testing oversight and quality assurance, and data collection staff; HHC staff included lead physicians and other intervention staff.  All staff met weekly prior to launching the pilot to review and discuss technical issues including workflow, training, and data reporting.  

LAC DPH supported this project through funding for staff time as well as the provision of rapid test kits. The CBO and HHC provider partners provided in-kind staff support for these efforts.

DHSP set out to identify non-traditional syphilis screening strategies to test and treat women of reproductive age who may have undiagnosed syphilis or other sexually transmitted diseases. We conducted key informant interviews with colleagues from a variety of community-based organizations (CBO) providing harm reduction services and homeless healthcare providers who serve women with substance use disorder (SUD), experiencing mental health challenges, or experiencing homelessness. As a result of this focused effort, LAC DPH was able to develop three screening strategies: 1) CBO-DPH Paired Model, whereby DPH staff provide HIV and STD testing in the field in partnership with a CBO with strong ties with the target population, 2) a CBO-DPH Transition Model, where DPH staff work with CBOs to integrate HIV and STD  testing within their service delivery setting with the goal to train and transition testing responsibilities to CBO staff; 3) Homeless Healthcare Provider Model, where DPH staff provide technical assistance, training, support and testing supplies to homeless healthcare providers to incorporate testing into their care model. We assessed the acceptability, feasibility, and yield of the three innovative testing models. The number of tests and positivity data was collected on LAC DPH testing forms.

In the CBO-DPH Paired Model, LAC DPH partnered with a CBO serving cisgender women of child-bearing age engaging in transactional sex to deliver testing services to their clients and their partners in an area of downtown Los Angeles known for sex work.  Staff provided intake at tables on the sidewalk and patients were examined and treated in the mobile testing unit parked nearby. An LAC DPH physician provided empiric treatment for syphilis and other STDs based on clients' symptoms and history. At this one-day event, 22 individuals agreed to testing, including 10 cisgender women, 1 transgender woman, and 11 cisgender men. Eighteen of these individuals reported being unhoused and unsheltered. Sixteen identified as Black, 4 as White and 2 as Latinx.  Of 21 individual persons screened for syphilis, 9 persons tested positive, and of those, 5 (24%) were identified as newly diagnosed with syphilis. LAC DPH was able to utilize public health surveillance databases to immediately stage 4 people with new syphilis and start them on treatment with injectable or oral antibiotics. Seven patients tested positive for gonorrhea. Follow-up treatment for syphilis and gonorrhea was arranged in coordination with patient and CBO staff. This collaboration demonstrated the feasibility of delivering a CBO-DPH paired street testing model.  Overall acceptability of this model for STD testing was high, however, 16 individuals initially expressed interest in testing but did complete testing. Reasons for not testing included long wait times/loss of interest, competing personal priorities, and discomfort with testing protocols.

In the CBO-DPH Transition Model, LAC DPH partnered with a CBO providing syringe support program services to people who inject or smoke drugs. Over the course of 5 weeks, LAC DPH and SSP staff successfully navigated through implementation challenges to integrate testing into the SSP service workflow. In the first five weeks of SSP staff conducting testing, 17 individuals were tested; 13 individuals were screened for syphilis, of which two tested positive for syphilis. None of the 16 individuals screened for HIV had reactive results. HIV and syphilis treatment data for these cases are not yet available.

In the HHC Provider Model, LAC DPH Partnered with the County's largest homeless healthcare provider to conduct 5 to 10 outreach events per week over a four-month period. The events, targeted to sheltered and unsheltered people experiencing homelessness, offered COVID-19 vaccines, harm reduction services (safe injection and smoking supplies, naloxone, contingency management, wound care kits, and safe sex kits).  Using testing supplies provided by LAC DPH, HHC staff conducted rapid HIV, lab-based syphilis and other STD testing alongside these services. The integration of services reduced the stigma associated with testing.  In total, 424 people were tested for syphilis, with 49 (11%) persons testing positive; of those, 55% were treated within 30 days of the testing event.

Sustainability was an explicit consideration in the planning and implementation of the POWER project. LAC DPH integrated HIV testing into the project allowing DHSP to leverage federal HIV Ending the HIV Epidemic resources for additional support.  If the testing partnerships remain high yield and mutually beneficial, LAC DPH will continue to support testing effort.

LAC DPH continues to explore other settings in which one of the three applicable models could be adapted and implemented.  For the CBO-DPH Paired Model, LAC DPH is exploring reentry programs, women's homeless shelters and relocation settings (e.g., Tiny Homes Villages) and refresh spots (showers and other services for unsheltered PEH). For the CBO-DPH Transition Model, other sites still being explored such as methadone clinics. For the HHC Provider Model, LAC DPH is actively working on creating memorandums of agreement with three new homeless healthcare providers to give them rapid test kits and resources for client incentives.