key: cord-0995668-866ppq41
authors: Braunstein, Sarah L; Slutsker, Jennifer Sanderson; Lazar, Rachael; Shah, Dipal; Hennessy, Robin R; Chen, Shirley; Pathela, Preeti; Daskalakis, Demetre C; Schillinger, Julia A
title: Epidemiology of reported HIV and other sexually transmitted infections during the COVID-19 pandemic, New York City
date: 2021-06-16
journal: J Infect Dis
DOI: 10.1093/infdis/jiab319
sha: 68db17ff633dd914e97167af1e2fdd833bc150f8
doc_id: 995668
cord_uid: 866ppq41

Early in the COVID-19 crisis, a statewide executive order (“PAUSE”) severely restricted the movement of New Yorkers from March 23-June 7, 2020. We used NYC surveillance data for HIV, chlamydia, gonorrhea, and syphilis to describe trends in diagnosis and reporting surrounding PAUSE. During PAUSE, the volume of positive HIV/STI tests, and diagnoses of HIV, chlamydia, gonorrhea, and syphilis declined substantially, reaching a nadir in April before rebounding. Some shifts in characteristics of reported cases were identified.

New York City (NYC) experienced an early, explosive first wave of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, and its related disease syndrome, COVID-19 [1] . To reduce spread of SARS-CoV-2 and mitigate its consequences, New York State (NYS) issued a "stay at home" order ("PAUSE") closing non-essential businesses, banning non-essential gatherings, and restricting public transportation use during March 23-June 7, 2020, in NYC [2] ; restrictions were lifted in a phased manner thereafter. PAUSE coincided with dramatic declines in population mobility and disruptions to the healthcare system, including limiting operations at NYC's public Sexual Health Clinics (SHC).

The STI-HIV syndemic in NYC has been characterized using population-based data [3, 4] . In recent years, HIV cases have declined in NYC while bacterial STI have increased. There are an estimated 92,000 people living with HIV (PWH) in NYC [5] (9% of PWH nationally) [6] . Among the 1,772 people newly diagnosed with HIV in NYC in 2019, the majority were aged <40, Black or Latino/Hispanic, and men who report sex with men (MSM) [5] . NYC rates of reported bacterial STI, including chlamydia (914.1 cases per 100,000 population in 2019), gonorrhea (347.5), and primary and secondary (P&S) syphilis (23.9), exceed national averages, and-like HIV-disproportionately affect people of color and MSM [7] .

We used both case and laboratory test data from the NYC Department of Health and Mental Hygiene's (DOHMH) HIV and STI surveillance systems to describe trends in diagnosis and reporting of these infections in NYC during the first wave of the COVID-19 pandemic and accompanying PAUSE. A c c e p t e d M a n u s c r i p t 5

Laboratories accepting specimens from NYC residents are required to report all positive tests for HIV and reportable bacterial STI, including chlamydia, gonorrhea and syphilis, to the NYS Electronic Clinical Laboratory System (ECLRS). Providers are required to report new diagnoses of HIV and these bacterial STI directly to DOHMH*9,10+. Primary data sources for this analysis were NYC's HIV and STI surveillance registries, which include laboratory-and provider-reported data, and data gleaned from case investigation. 

To allow direct comparison between the number of tests reported to the HIV program and those reported to the STI program, test reports were drawn from ECLRS. Analysis was restricted to positive or reactive tests for HIV, chlamydia, gonorrhea, and syphilis received by DOHMH with specimen collection dates from January-July in 2019 and 2020. Reported laboratory tests for STI were deduplicated using the accession number for a submitted specimen (e.g., a single serum specimen with multiple different positive serologic tests for syphilis was a single testing event in the analytic dataset).

A c c e p t e d M a n u s c r i p t 6

Laboratory-confirmed COVID-19 case counts were obtained from NYC's COVID-19

Surveillance system (February 29, 2020-July 2020) [11] .

A new HIV diagnosis was defined by a positive HIV diagnostic test by an NYC provider for a previously unknown case in NYC. During PAUSE, in-person investigations of positive HIV diagnostic tests were curtailed; therefore, new diagnoses reflect only those investigations that could be completed remotely. HIV surveillance data in this analysis were reported to DOHMH by September 21, 2020.

New diagnoses of STI (cases) were defined using Council of State and Territorial

Epidemiologists (CSTE) criteria [12] . Positive chlamydia or gonorrhea tests were counted as new diagnoses; detection of the same infection at multiple anatomic sites or repeated detection at the same site was counted as a single case if specimens were collected within 30 days. Possible new syphilis diagnoses were investigated throughout PAUSE. STI data in this analysis were reported to DOHMH by October 11, 2020.

Case characteristics in the HIV and STI registries were derived from provider and laboratory reports, medical records, and, for some infections, patient interview. They included: age at diagnosis, sex, race/ethnicity, and address. DOHMH guidelines were used to determine the areabased poverty level for each person [13] .

Finally, reporting facility for each new diagnosis was based on the address and affiliation of the provider documented on the laboratory report. Facilities were categorized as: DOHMH SHC, urgent care center, correctional facility, and hospital. Facilities of other types (largely private medical practices), were classified as "other," and cases without a known reporting facility were classified as "unknown."

A c c e p t e d M a n u s c r i p t 7

We aggregated reported positive HIV, chlamydia, gonorrhea, and syphilis test events by month to examine changes in positive test volume during PAUSE, compared with 2019. For context, we also aggregated confirmed COVID-19 cases in 2020 by month.

To explore changes in epidemiology during PAUSE, we compared distributions of 2020 and 2019 cases, stratified by characteristics of interest. Primary and secondary syphilis cases were the only stages of syphilis included.

This analysis of routinely collected public health surveillance data was not subject to IRB review.

Numbers of positive HIV, chlamydia, gonorrhea, and syphilis tests reported to DOHMH via the ECLRS system in early 2020 were comparable to those reported via the same system for the Ongoing monitoring of the effects of the COVID-19 crisis on the local epidemiology of HIV and STI is critical for informing public health programs and policies. Surveillance data may be the sole data source that can be used to this end, highlighting the importance of establishing and maintaining robust surveillance systems, including electronic laboratory reporting, that can function even during organizational disruption accompanying a major public health crisis. Mandating report of both negative and positive tests can provide a fuller picture and should be considered for some notifiable diseases. HIV and STI programs will need to be responsive to the effects of the COVID-19 crisis, innovating and course-correcting as needed to maintain and restore access to HIV/STI screening, testing and treatment, and to address exacerbated racial and other inequities.

A c c e p t e d M a n u s c r i p t Numbers within a variable may not sum to the total value because of missing or unknown data. 2 For HIV-related data, this variable represents sex assigned at birth with the following options: male and female. For Ct-, GC-, and syphilis-related data, this variable the reported sex for an index patient with the following options: male, female, and transgender. This variable is completed primarily based on provider-and laboratory-reports.

COVID-19 Outbreak

Governor Cuomo Issues Guidance on Essential Services Under The 'New York State on PAUSE' Executive Order

Incidence of Sexually Transmitted Diseases among Persons with HIV

Incidence and Predictors of HIV Infection Among Men Who Have Sex with Men Attending Public Sexually Transmitted Disease Clinics

New York City Department of Health and Mental Hygiene

The Epidemiology of Syphilis in New York City: Historic Trends and the Current Outbreak Among Men Who Have Sex With Men

Rules and Regulations: Part 63 -HIV/AIDS Testing, Reporting and Confidentiality of HIV-Related Information

Accessed

Reporting Diseases and Conditions

COVID-19: Data

National Notifiable Diseases Surveillance System (NNDSS): Surveillance Case Definitions for Current and Historical Conditions

Selecting and Applying a Standard Area-based Socioeconomic Status Measure for Public Health Data: Analysis for New York City

Dear Colleague letter: Current shortage of STI test kits and laboratory supplies

Brief but Efficient: Acute HIV Infection and the Sexual Transmission of HIV

The authors acknowledge staff of the HIV Epidemiology Program within the Bureau of HIV, staff of the Bureau of Sexually Transmitted Infections, including Tim Liao, Kimberly Johnson, and Susan Blank, and staff of the Surveillance and Epidemiology branch within the COVID-19 IncidentCommand System at the NYC DOHMH who contributed to the collection, management, and analysis

A c c e p t e d M a n u s c r i p t A c c e p t e d M a n u s c r i p t Includes cases with a positive HIV diagnostic test that received a "new case" disposition. Includes HIV-Ag/Ab, HIV-Ab, HIV-Ag/Ab-BP, and Western Blot tests. 5 Data as of September 21, 2020. 6 Data as of October 11, 2020. 7 The NYC Department of Health receives HIV reports for patients living both within and outside NYC. For Ct, GC, and syphilis, only new infections among residents of NYC are counted in surveillance data. 8 Individuals with Hispanic/Latino ethnicity, regardless of racial identity, are included in the "Hispanic/Latino" category. All other categories exclude individuals with Hispanic/Latino ethnicity. The "Other" race/ethnicity category includes Native Americans and multiracial, non-Hispanic/Latino individuals.A c c e p t e d M a n u s c r i p t 17 Figure 1