std control branch working with hiv care providers: the california/san diego experience jessica...
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STD Control Branch
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 HIV-infected 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 Co-infected with HIV, California 2009
0
5
10
15
20
25
30
35
40
45
50
NorthernRegion
Bay Area* San Francisco CentralRegion
SouthernRegion*
Los Angeles
All
MSM only
*Bay Area excludes San Francisco, Southern Region excludes Los Angeles.
Per
cent
of
case
s
STD Control Branch
Proportion of California P&S Syphilis Cases Co-infected with HIV, 2002-2009
47.251.7
0
10
20
30
40
50
60
70
2002 2003 2004 2005 2006 2007 2008 2009
All
MSM only
Per
cent
of
case
s
STD Control Branch
P&S Syphilis Cases by Provider Type, California, 2009
EIP/HIV Care Facility
16%
STD Clinic15%
Family Planning2%
Correctional Facility
4%
Public Clinic21%
Private Provider42%
Public Clinic21.3 %
EIP = Early Intervention Program
STD Control Branch
www.stdcheckup.org
SCREEN, TEST, DIAGNOSE & PREVENT: A CLINICIAN’S RESOURCE FOR STDs IN GAY MEN AND OTHER MSM
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 ToolkitThe 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 EvaluationPost-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 EvaluationLaboratory 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: 45.2 tests Post-toolkit mean: 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: 44.6 tests Post-toolkit mean: 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 post-toolkit 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
0
50
100
150
200
250
300
350
400
450
1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Year
Ca
ses
Other
Men who have sex with men
424
2323
346 346
268
P&S syphilis cases, by year and MSM status — San Diego County,
1988–2009
• San Diego County, 2003–2009: 82% among MSM
STD Control Branch
P & S Syphilis Cases Co-Infected with HIV, by Year — San Diego County, 2000–2009
0
10
20
30
40
50
60
70
80
90
100
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Year of Report
Pe
rce
nt
MSM All Cases
51%
46%
STD Control Branch
Primary & Secondary Syphilis Cases by Provider Type — San Diego County, 2009
HIV Care/EIP Facility
20%
Community Health Clinic
3%
Correctional Facility
1%
Emergency Room
3%Other
2%
Planned Parenthood
1% Military5%
County STD Clinic38%
Private MD/HMO27%
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 [email protected]
510-231-7823
• Tom [email protected]
619-692-8835