Collaboration between Collaboration between Health Departments and Health Departments and

CommunityCommunity--Based Based Healthcare Organizations: Healthcare Organizations: A Case Study of SuccessA Case Study of Success

Robert K. Bolan,Robert K. Bolan,11 MD, Ellen T. Rudy, PhD,MD, Ellen T. Rudy, PhD,22Swanand D. Tilekar,MSc,MPHSwanand D. Tilekar,MSc,MPH11,, Christine Christine Wigen, MD,MPH,Wigen, MD,MPH,22 Peter R. Kerndt, MD, MPHPeter R. Kerndt, MD, MPH22

1 1 LA Gay & Lesbian Center LA Gay & Lesbian Center (LAGLC) and the (LAGLC) and the 22Los Angeles County (LAC) Sexually Transmitted Los Angeles County (LAC) Sexually Transmitted Disease Program (STDP)Disease Program (STDP)

BENEFITS OF COLLABORATIONBENEFITS OF COLLABORATION

The technical expertise and organization The technical expertise and organization skills of a public health departmentskills of a public health department

–– plusplus

The passion of a CBO and its community The passion of a CBO and its community credibilitycredibility

–– togethertogether

SHAPE RESEARCH AND HELP SHAPE RESEARCH AND HELP MAKE IT RELEVANTMAKE IT RELEVANT

Increasing the likelihood that resultant Increasing the likelihood that resultant programs will have sustainability and programs will have sustainability and effectiveness effectiveness

OVERVIEWOVERVIEW

LAGLC and LAC STDP LAGLC and LAC STDP have worked have worked together for OVER 35 together for OVER 35 yearsyears

With the consultation With the consultation of STDP, in October of STDP, in October 2005 LAGLC 2005 LAGLC integrated its STD integrated its STD clinic and HIV clinic and HIV Testing & Counseling Testing & Counseling programs to form:programs to form:

THE SEXUAL HEALTH PROGRAM

OVERVIEWOVERVIEW

With integrationWith integration–– Emphasis on the importance of testing for Emphasis on the importance of testing for

both HIV and STIs at every visitboth HIV and STIs at every visit

–– Data sharing between LAGLC and STDPData sharing between LAGLC and STDP

–– Increase in number of collaborative projectsIncrease in number of collaborative projects

EPIDEMIOLOGY OF SEXUALLY EPIDEMIOLOGY OF SEXUALLY TRANSMITTED INFECTIONS AMONG MSM AT TRANSMITTED INFECTIONS AMONG MSM AT

LAGLC SHPLAGLC SHP

LAGLC SHP serves as the sentinel surveillance site LAGLC SHP serves as the sentinel surveillance site to monitor STIs among MSM in LACto monitor STIs among MSM in LAC

Significant STD Morbidity facts from LAGLC SHP:Significant STD Morbidity facts from LAGLC SHP:–– DxDx’’d 14% of early syphilis cases in LAC in 2008d 14% of early syphilis cases in LAC in 2008–– Over 1000 cases of GC, 950 cases of CT per yearOver 1000 cases of GC, 950 cases of CT per year–– Approximately 200 cases of recent HIV infections per Approximately 200 cases of recent HIV infections per

yearyear–– 52 acute HIV infections between Feb 2006 and June 52 acute HIV infections between Feb 2006 and June

2009 (median HIV VL 466,386)2009 (median HIV VL 466,386)

COLLABORATIVE PROJECTSCOLLABORATIVE PROJECTS

Pooled Nucleic Acid Amplification Test Pooled Nucleic Acid Amplification Test (NAAT) for diagnosing acute HIV(NAAT) for diagnosing acute HIV

PatientPatient--collected rectal swab for GC collected rectal swab for GC and CT evaluationand CT evaluation

CommunityCommunity--Embedded Disease Embedded Disease Intervention Specialist (CEDIS)Intervention Specialist (CEDIS)

POOLED NAAT TESTING FOR ACUTE HIVPOOLED NAAT TESTING FOR ACUTE HIV

20062006--07 LAGLC participated in CDC07 LAGLC participated in CDC--funded multifunded multi--site NAAT studysite NAAT study

LAGLC dxLAGLC dx’’d 82% (33/40) of acute cases d 82% (33/40) of acute cases found in LA county found in LA county

Patient and staff acceptability was highPatient and staff acceptability was high NAAT testing now integrated into routine NAAT testing now integrated into routine

HIV testing HIV testing

2007 VALIDATION AND DEMONSTRATED 2007 VALIDATION AND DEMONSTRATED FEASIBILITY OF PATIENTFEASIBILITY OF PATIENT--COLLECTED COLLECTED

RECTAL GC/CT SWABSRECTAL GC/CT SWABS

Adding selfAdding self--collected rectal swabs has been associated with a collected rectal swabs has been associated with a 284% increase in rectal screening and a 145% increase in +CT 284% increase in rectal screening and a 145% increase in +CT Rectal and a 112% increase in +GC RectalRectal and a 112% increase in +GC Rectal

2007 Total New Visits (N=9,877)

Positive n (%)

2008 Total New Visits (N=10,078)

Positive n (%)

Laboratory Test N (%)** n (%) n (%)** n (%)Chlamydia Urethra 7295 (74) 363 (5) 7665 (76) 331 (4) Rectal 1840 (19) 249 (14) 7079 (70) 611 (9)Gonorrhea Urethra 7295 (74) 306 (4) 7665 (76) 274 (4) Pharyngeal 7214 (73) 471 (7) 7520 (75) 358 (5) Rectal 1840 (19) 207 (11) 7079 (70) 440 (6)

COMMUNITYCOMMUNITY--EMBEDDED DISEASE EMBEDDED DISEASE INTERVENTION SPECIALIST (CEDIS) INTERVENTION SPECIALIST (CEDIS) PROGRAM IN LOS ANGELESPROGRAM IN LOS ANGELES

Innovative strategy for notifying partners of Innovative strategy for notifying partners of STI and/or HIV index cases (partner services)STI and/or HIV index cases (partner services)

Modeled after Howard Brown Clinic, ChicagoModeled after Howard Brown Clinic, Chicago Established in Los Angeles in 2008Established in Los Angeles in 2008 Organization of CEDIS Program: Organization of CEDIS Program:

–– Employed by and stationed at LAGLC SHP for Employed by and stationed at LAGLC SHP for timely interviewing of clientstimely interviewing of clients

–– Peer of the community and staff at LAGLCPeer of the community and staff at LAGLC–– Technical training at STDPTechnical training at STDP–– Daily schedule at LAGLCDaily schedule at LAGLC

OVERALL BENEFITS OF PARTNER OVERALL BENEFITS OF PARTNER NOTIFICATIONNOTIFICATION

Partners notified confidentiallyPartners notified confidentially Partners may not be aware of their riskPartners may not be aware of their risk Earlier testing, counseling and linkage to Earlier testing, counseling and linkage to

carecare Heighten partners sense of susceptibility Heighten partners sense of susceptibility

and vulnerability to infectionand vulnerability to infection Potential to reduce STI ratesPotential to reduce STI rates

BENEFITS OF PARTNER NOTIFICATION BENEFITS OF PARTNER NOTIFICATION BY CEDISBY CEDIS

Notification is by an employee of the Notification is by an employee of the trusted CBO where testing and other trusted CBO where testing and other services are obtainedservices are obtained

Reduce the time to interview of index Reduce the time to interview of index casecase

Interviewer is most commonly a peer Interviewer is most commonly a peer of the person being interviewedof the person being interviewed

CHALLENGES TO PARTNER CHALLENGES TO PARTNER NOTIFICATION NOTIFICATION

Acceptance by clientAcceptance by client Anonymous partnersAnonymous partners Negative effect on relationshipsNegative effect on relationships Clients with repeat infectionsClients with repeat infections

TWO DATASETS TO EVALUATE PROGRAMTWO DATASETS TO EVALUATE PROGRAM

Compare data before and after CEDIS Compare data before and after CEDIS implementation implementation

Pre dataset represent Pre dataset represent Traditional PNTraditional PN–– Jan Jan –– Dec 2007 Dec 2007 –– 150 ES Cases (102 PS) 150 ES Cases (102 PS)

Post dataset represent Post dataset represent CEDIS PNCEDIS PN–– Jan Jan –– Dec 2008 Dec 2008 –– 142 ES Cases (98 PS)142 ES Cases (98 PS)

Data extracted from STD surveillance Data extracted from STD surveillance systemsystem

TIME TO INTERVIEWTIME TO INTERVIEW

Continued improvement each quarter in 2008

Percent of Cases Interviewed within 7 days-LAGLC

4%9%

5% 3%8%

29%

41%

70%

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

1 2 3 4

Quarter

Perc

enta

ge

2007 - Traditional2008 - CEDIS

LOST TO FOLLOWLOST TO FOLLOW--UPUP

Percentage of Cases Not Interviewed -LAGLC ES Cases

0.000.050.100.150.200.250.300.35

1 2 3 4Quarter

Perc

enta

ge

Traditional - 2007CEDIS - 2008

PARTNERS ELICITED/CASE ASSIGNED)PARTNERS ELICITED/CASE ASSIGNED)

Partner Elicited per Cases Assigned Ratio - LAGLC-ES CASES

1.32

2.11 2.06

1.561.30

1.11 1.00 0.91

0.00

0.50

1.00

1.50

2.00

2.50

1 2 3 4

Quarter

Rat

io 2007 - Traditional2008 - CEDIS

BENEFITS SEEN FROM CEDIS PROGRAM BENEFITS SEEN FROM CEDIS PROGRAM BETWEEN LAGLC AND STDPBETWEEN LAGLC AND STDP

Significant improvement in partner Significant improvement in partner outcomes: time to interview; lost to followoutcomes: time to interview; lost to follow--up; partners elicited, located and notified up; partners elicited, located and notified

Reduced burden of cases at STDPReduced burden of cases at STDP Medical record searches within 1 dayMedical record searches within 1 day BuyBuy--in from CBO staff and communityin from CBO staff and community

MAKING PARTNER NOTIFICATION SOCIALLY ACCEPTABLE

THE PATH AHEADTHE PATH AHEAD

Initiated HIV PN followInitiated HIV PN follow--up at LAGLC in 2009up at LAGLC in 2009 Newly diagnosed HIV cases including acuteNewly diagnosed HIV cases including acute

–– Acute followed up within 48 hoursAcute followed up within 48 hours

Include existing HIV cases coInclude existing HIV cases co--infected with infected with gonorrhea (GC) or chlamydia (CT)gonorrhea (GC) or chlamydia (CT)

Existing HIV cases w/ GC or CT not followedExisting HIV cases w/ GC or CT not followed--up in up in the pastthe past–– Evidence suggests coEvidence suggests co--infected STDs facilitate HIV infected STDs facilitate HIV

transmission transmission ––Fleming et al (1999); Bolan et al (2008).Fleming et al (1999); Bolan et al (2008).

CONCLUSIONSCONCLUSIONS

All 3 collaborative programs integrated All 3 collaborative programs integrated into clinic routine after initial evaluation into clinic routine after initial evaluation found successfulfound successful

BuyBuy--in from CBO staff and community in from CBO staff and community crucial to sustainability of projectscrucial to sustainability of projects

Intent not to control but to respect the Intent not to control but to respect the strengths of each organizationstrengths of each organization

ThanksThanks……

To the diligent staff at LAGLCTo the diligent staff at LAGLC To our collaborators at LAC STD To our collaborators at LAC STD

ProgramProgram