813 Wake County

Lessons Learned

and

What’s to Come

Community Assessment

• Discussions with Health Department administration and outreach staff

• Individual interviews with STD clinic staff• Meetings with CBOs and Health Task

Forces• Focus groups with Adolescent community

members • GIS mapping of STDs

Gaining Access to the Community

Managers

Outreach CommunityLeaders

Community

Access

Areas of Attention

• Geographic clustering

• Heterogeneity of community

• Institutional barriers

• Screening to diagnose asymptomatic disease • STD/HIV co-infection

Community Outreach - Many Lessons Learned

• Substantial mistrust of "research” • - particularly among the managerial and

outreach levels• - managerial gatekeepers act to “protect” the

community

• Substantial mistrust of "partnerships" between university and county health department

• - concern over lack of community involvement in grant submission

Community Focus GroupsOBJECTIVES

– To identify those factors that serve as barriers to accessing STD/HIV testing in the target population

– To obtain recommendations on how best to facilitate testing and treatment in this population

METHODS• Sample

– N=10 groups

– Recruitment

• Instrument– Based on previous

outreach

– Validity assessed

– 4 issues explored

• Data Collection

• Analysis– Software:

• Qsr NVIVO

• MS Word

– Theory informed

• Pilot tested - In same population

INSTRUMENT: Relevant Questions

BARRIERS

Let’s say you decide that you want to get tested,

what kinds of issues might come up?

RECOMMENDATIONS

…now, think of the ideal, easiest or best way for people to get tested or treated for STDs,

what would it be like?

KEY BARRIERS• Rude staff

• Cost

• Intrapersonal barriers

• Confidentiality Concerns

Key Barriers by Gender

Women

• Rude staff• Cost• Confidentiality• Long wait

Men

• Intrapersonal factors• Confidentiality

concerns• Cost• Addiction• The SWAB!

Barriers:Mistrust

• Substantial mistrust of State and Federal (i.e. CDC) organizations

• - managerial levels uncertain of benefit for community

• - STDs are priority of State/Federal organizations, not community?

RECOMMENDATIONS• Convenient location

• Integrate into other services

• Staff who are trained in sensitivity

• Ensure confidentiality

• Increase outreach efforts

• Welcoming clinic environment

Recommendations

• Increased access to general medical services is considered more important than access to STD services

• Community members want “mainstream” access to care (HMO settings, physician offices, ER), not clinic

Phase IIExpanded STD Screening

• Expanded STD screening and Incident HIV infection in clients obtaining HIV testing in STD clinic

• STD/HIV Testing in County Hospital ED

• STD Screening in HIV Clinic setting

• STD screening in HIV C&T site

HIV INFECTION AND PREVALENT STDs AT TIME OF

HIV TESTINGEstimate the point prevalence of :-HSV-2 (serology) -chlamydial infection, gonorrhea (NAAT) -syphilis (serology) in patients undergoing HIV testing at the Wake County Human

Services STD clinic.

Determine the relationship between concurrent STD diagnosis (symptomatic and asymptomatic) and HIV test result.

Determine incidence of HIV by detuned HIV assay and p24 antigen (Primary HIV)

Infection Rates HIV Test Study in STD Clinic

N GC CT HSV Syph HIV

Male 119 16 (13%)

23 (19%)

41 (34%)

2 (2%)

1 (<1%)

Female 102 9 (9%)

14 (14%)

42 (41%)

0 (0%)

1 (<1%)

Total 221 25 (11%)

37 (17%)

83 (38%)

2 (<1%)

2 (<1%)

HIV Care

Purpose:- Determine the incidence/prevalence of GC, CT, syphilis, TV and HSV-2 in people with HIV who attend the Wake County HIV clinic and other sites for routine care

- Determine the relationship of STD prevalence and HIV status as indicated by CD4 count and viral load.

HIV Care

• Cohort of individuals will be followed for one year

• Baseline and ~ every 3 months– Behavioral data – Blood for syphilis and HSV-2 testing– Urine for GC and Ct testing; TV in men– Self-collected vaginal swab from women for

TV culture

HIV Care

Behavioral Data includes:• Number and type of sexual partners in the previous

three months• HIV serostatus of sexual partnerships• STD infection in sexual partners• Condom use (last time had sex)• Self-report of previous STD symptoms or diagnosis• Interim STD symptoms and possible

diagnosis/treatment elsewhere

HIV Care Study

N GC (%) Ct (%) TV (%) HSV(%) Syph. (%)

Total 67 4 (6%) 1 (1%) 8 (12%) 48 (72%) 10 (15%)

Female 20 0 0 6 (30%) 18 (90%) 0

Male 44 4 (9%) 1 (2%) 2 (5%) 30 (68%) 10 (23%)

HIV/STD Co-Infection Females

N GC Ct TV HSV Syph.

6 X X

12 X

2

HIV/STD Co-Infections Males

N GC Ct TV HSV Syph1 X X X1 X X3 X1 X X6 X X21 X2 X

none 9

Conclusions

• STD screening is feasible in HIV care

• Preliminary results suggests high rates of TV infection in HIV infected

• High Rate of HSV/HIV co-infection

• High Rate of + syphilis serology

813UNC• Bill Miller• Marlene Smurzynski• Trang Nguyen• Dionne Law• Chandra Ford• Betsey TilsonCDC• Kim Fox• Katie Irwin• Rheta Barnes

BARRIER: Rude Staff• #1 barrier for women

• Perceived as– Unprofessional

– Rude

– Prejudicial

“I went to get tested at the HD. I had a nurse there, I’ll never forget…she talked to me like I was a speck of dirt on the floor, because I had had …unprotected sex… When I left there, I was walking down the sidewalk crying cause she made me feel that bad…”

- Homeless female

BARRIERSCost

“…’cause I just went

to have a test done,

and it cost me $15,

and I was like,…A

person in my status,

homeless, I don’t

have that kind of

money.”- homeless female

Intra-personal Factors

perceived riskfear

embarrassment,

shame

denial

BARRIER: Confidentiality Concerns

• Visibility: Being identified by peers

• Confusion : ‘Confidential’ vs. ‘Anonymous’

• Broken Confidentiality: Staff sharing patient information to others in the community

• Privacy: Indiscrete or careless disclosure by staff during patients’ visit

BARRIER:ConfidentialityVisibility

“…I’m in contact with

a lot of women that go

to the Women’s Ctr.,

and if I’m there to do

that, that may not be

something I want

everybody to see.”

-Homeless female

Confidential vs. Anonymous

“The people that are

testing it are going to

know. Somebody else

is going to know, cause

they got to send it here

to get it tested…”

-In-treatment, male SA

Community Identified Priorities

• Cardiovascular disease

• Violence

• HIV infection

HIV Test Study in STD Clinic

N % Eligible % Offered

559 100 # HIV tests

386 70 100 Offered

148 26 38 Declined

6 1 2 Withdrawn,

232 41 60 Total Participants