Download Introductions - STD Prevention Online

Working With HIV Care Providers:
The California/San Diego
Experience
Jessica Frasure-Williams, MPH
Syphilis Elimination Coordinator,
California Project Area
Tom Gray
Syphilis Elimination Liaison,
San Diego, CA
STD Control Branch
Working With HIV Care Providers: The
California/San Diego Experience
California Project Area
– Provider Visitation Rationale
– Screen, Test, Diagnose and Prevent: A Clinician’s
Resource for STDs in Gay Men and other MSM
– One Counties Experience
San Diego County Provider Outreach and Education
– San Diego Epidemiology
– Medical Provider Trainings and Presentations
– Clinician and Dental Health Professionals Posters
– Monthly STD Report
– Provider Visitation Program
STD Control Branch
Why work with HIV care providers in California?
• Interview record review indicated that at least 14% of
cases had symptoms present at a clinical visit that were
missed or misattributed (2005, CPA)
• Provider reporting of infectious syphilis is not timely
(Jan-Jun 2010)
– <20% reporting within 1 day of exam
– 38% reporting within 7 days of exam
• Sexual history-taking and STD screening among HIVinfected persons may be inconsistent
• Historic challenges with providers supporting partner
services
• High proportion of P&S syphilis and gonorrhea cases
are co-infected with HIV
STD Control Branch
Proportion of Gonorrhea Cases Coinfected with HIV, California 2009
50
All
45
MSM only
Percent of cases
40
35
30
25
20
15
10
5
0
Northern
Region
Bay Area*
San Francisco
Central
Region
Southern
Region*
Los Angeles
*Bay Area excludes San Francisco, Southern Region excludes Los Angeles.
STD Control Branch
Proportion of California P&S Syphilis
Cases Co-infected with HIV, 2002-2009
70
Percent of cases
60
51.7
47.2
50
40
All
30
MSM only
20
10
0
2002
2003
2004
2005
2006
2007
2008
2009
STD Control Branch
P&S Syphilis Cases by Provider Type,
California, 2009
EIP/HIV Care
Facility
16%
Private Provider
42%
STD Clinic
15%
Family Planning
2%
Public Clinic
21.3 %
EIP = Early Intervention Program
Public Clinic
Correctional
Facility
4%
STD Control Branch
SCREEN, TEST, DIAGNOSE & PREVENT:
A CLINICIAN’S RESOURCE FOR STDs IN GAY MEN AND OTHER MSM
www.stdcheckup.org
STD Control Branch
The Provider Side
• Resource to improve clinician’s knowledge, skills, and
comfort around routine, periodic screening for and
diagnosis of STDs in gay men and other MSM
– Spiral-bound toolkit and box with accompanying materials
– stdcheckup.org website
• Clinic based campaign aimed at raising patients
awareness regarding the asymptomatic nature of STDs
and the need for frequent testing
STD Control Branch
Contents of the MSM Toolkit
The spiral-bound toolkit contains information on:
• STD Screening
• Clinical Evaluation and Management
• Enhancing the Care Setting
• STD/HIV Partner Services
• Public Heath Reporting
• Resources and References
Additional enclosed Job Aids include:
• Coding guidelines for vaccine preventable hepatitis
• Primary and Secondary syphilis algorithms
• STD Treatment guidelines for HIV-infected adults
…and more!
STD Control Branch
Pilot Evaluation
• Pilot of STD-Prevent was conducted in 2007 in clinics
in 7 counties
• Pre & Post survey of providers implementing the
initiative
– Assess acceptability, appropriateness, & usefulness of
materials
– Barriers to implementation
– Topics that are not addressed in materials
• Lab screening totals six months prior, two months
during and six months following the evaluation phase
• 25 anonymous surveys of patients in clinic waiting
rooms
– Assess appropriateness & acceptability of clinic based
awareness raising materials
STD Control Branch
Pilot Evaluation (2)
Outcome Evaluation
Post-Toolkit Survey Data:
CDC STD Treatment Guidelines:
 Increases seen in proportion of providers reporting having referred to
the guidelines, and in those guidelines having guided their patient care
in the past year.
Sexual History Taking:
 Reported sexual history taking behaviors remained at high levels both
pre- and post-Toolkit.
STD Screening Practices:
 Providers reported very high levels of routine and risk-based STD
screening at both pre- and post-Toolkit timepoints. Change not
discernible from survey data.
Awareness of HIV Partner Counseling and Referral Services (PCRS):
 Awareness of PCRS increased from 57% of respondents at pre-Toolkit
timepoint to 100% of respondents post-Toolkit.
STD Control Branch
Pilot Evaluation (3)
Outcome Evaluation
Laboratory Data: (6 months prior and 6 months post)
Syphilis Serologic Screening (RPR):
 Pre-toolkit mean:
210.0 tests
 Post-toolkit mean:
258.7 tests
Mann-Whitney U yielded p=0.005. Limitations: Number patients seen per month unknown. Data are for all male
patients seen, not stratified by MSM. Positive RPR requires confirmatory testing (e.g. TP-PA).
Gonorrhea Testing:
 Pre-toolkit mean:
 Post-toolkit mean:
45.2 tests
62.2 tests
Mann-Whitney U yielded p=0.051. Limitations: Number patients seen per month unknown. Data are for all male
patients seen, not stratified by MSM or site tested (e.g. urethral, rectal, etc.).
Chlamydia Testing:
 Pre-toolkit mean:
 Post-toolkit mean:
44.6 tests
60.7 tests
Mann-Whitney U yielded p=0.10. Limitations: Number patients seen per month unknown. Data are for all male
patients seen, not stratified by MSM or site tested (e.g. urethral, rectal, etc.).
STD Control Branch
Limitations
 All survey data results based on self-report with
relatively small sample of respondents at the four sites
(14 completed pre-toolkit survey, 9 completed posttoolkit survey).
 Potential for change may have been low due to a
relatively high-performing health care provider pool.
 Laboratory data based on aggregate counts for all
male patients for whom data were available; there was
no way to stratify by MSM status.
STD Control Branch
HIV Care Provider Visitation
Program, County A, Summer 2008
• A local program identified the need to conduct
provider visitation to increase offers of HIV
Partner Services
• Providers were visited by local STD Controller
and local communicable disease specialist
• Improved relationships with local health
department
• Observed improved provider case reporting
during visitation program
STD Control Branch
Proportion of providers reporting P&S syphilis
cases within one day of exam, County A,
Jan 2008-June 2010
STD Control Branch
Provider Outreach and
Education in San Diego County
STD Control Branch
Provider Outreach
and Education
• San Diego Epidemiology
• Medical Provider Trainings and
Presentations
• Clinician and Dental Health
Professionals Posters
• Monthly STD Report
• Provider Visitation Program
STD Control Branch
P&S syphilis cases, by year and MSM
status — San Diego County, 1988–2009
450
424
400
350
Cases
300
250
346 346
Other
Men who have sex with men
268
• San Diego County, 2003–2009: 82% among MSM
200
150
100
50
0
23 23
1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Year
STD Control Branch
P & S Syphilis Cases Co-Infected with HIV,
by Year — San Diego County, 2000–2009
100
MSM
All Cases
90
80
70
Percent
60
50
51%
46%
40
30
20
10
0
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
Year of Report
STD Control Branch
Primary & Secondary Syphilis Cases by
Provider Type — San Diego County, 2009
County STD
Clinic
38%
Private MD/HMO
27%
Emergency
Room
3%
Other
2%
Planned
Parenthood
1%
Military
5%
HIV Care/EIP
Facility
20%
Community
Health Clinic
3%
Correctional
Facility
1%
STD Control Branch
Medical Provider Trainings and
Presentations
• Presentations to clinicians, mid-levels, and other
providers serving populations at-risk for STDs in
San Diego on STD screening and treatment
recommendations, and disease trends
– Audiences: University student health services, HIV
providers, dental health professionals, HMOs, and
military and family planning medical staff
STD Control Branch
Medical Provider Trainings and
Presentations
February 2010, Partnered with the California STD/HIV
Prevention Training Center and the Pacific AIDS Education
Training Center to offer trainings to local medical providers
COURSE TITLE
COURSE SIZE
STD Overview for Clinicians
76
Wet Mount
9
Male and Female Genital Exam Skills
15
Ask, Screen & Intervene: Incorporating HIV/STD
Prevention into the Medical Care of Persons Living
with HIV
17
STD Control Branch
Clinician and Dental Health
Professionals Posters
•January 2010, released two posters targeting medical
providers and dental health professionals that can further
raise the awareness of P & S symptoms
•Goals: educate medical providers about P & S
symptoms, and encourage screening and testing which
can facilitate increased diagnosing and treatment of
syphilis in the infectious stages
•December 2010, posters were updated and will be delivered
to medical providers by CDIs and during provider visits.
STD Control Branch
Clinician and Dental Health
Professionals Posters
STD Control Branch
County of San Diego
Monthly STD Report
•September 2009 switched from quarterly
trend reports to the
community to a monthly
report
•Format has adjusted
based on feedback in a
user survey sent out with
the report each month
•Report is sent to an email
distribution list of over 500
individuals
STD Control Branch
Provider Visitation Program
• May 2010, County of San Diego started
a formal provider visitation program
• Overarching Focus:
– early detection, disease reporting, and
partner services (HIV & syphilis)
• Provider visitation team:
– Ken Katz, STD Control Officer
– Heidi Aiem, Clinic Services Coordinator
– Tom Gray, Syphilis Elimination Liaison
STD Control Branch
Provider Visitation Program
• Priority providers have been identified by
members of the team and in consultation
with disease investigation staff
• Once a provider is identified for a visit:
– Initial contact is made, visit is set-up
– STD morbidity for that provider is analyzed
– Provider visitation team meets to discuss
priority topics
STD Control Branch
Initial Provider Visit
• Visits have typically followed a standard
format:
– Introductions are made
– Brief review of local epidemiology
– Provider specific data is shared
– Priority topics are addressed
– Provider is asked about their experience
with the County of San Diego
– Identification of follow-up items
– Visit ends and provider is thanked for their
time
STD Control Branch
Provider Visit Follow Up
• Interaction is logged in the provider
visitation tracking sheet
• County of San Diego disease
investigation staff is assigned to deliver
any materials that were needed by the
provider
STD Control Branch
Tracking Log
• A provider visit tracking log is maintained by the
provider visitation team. The following is documented
each time contact is made:
– Date
– Contact type (visit, phone, email)
– Person contacted
– County staff making contact
– Reason for contact
– Topics discussed
– Materials delivered
– Follow-up needed
STD Control Branch
HIV Medical Provider #1
• June 2010, a member of one of the largest medical
groups in San Diego is identified by the provider
visitation team as a priority visit due to incomplete
reporting
• During the provider visit reporting is discussed and the
HIV medical provider states that it might be best if the
STD Control Officer discusses this with the head of
infectious diseases for the medical group
• September 2010, provider visitation team meets with
the head of infectious diseases (via telephone) to
discuss reporting
• An email from the head of infectious diseases is sent
out to the medical group detailing out reporting
STD Control Branch
HIV Medical Provider #2
• May 2010, A private HIV medical provider was
identified as a priority visit due to his large
patient panel
• Visit was set-up and conducted
• During the visit the medical provider shared
that it was problematic for him to maintain a
stock of bicillin which led to treatment delays
• County of San Diego staff offered to provide
small amounts of bicillin every few months
• As of December 2010, bicillin has been
delivered twice
STD Control Branch
Questions?
STD Control Branch
Contact Information
• Jessica Frasure-Williams
[email protected]
510-231-7823
• Tom Gray
[email protected]
619-692-8835
STD Control Branch