Stacey B. Trooskin, MD PhDAssistant Professor

Drexel University College of Medicine

Using Community-Engaged Research to Using Community-Engaged Research to Address Racial and Geographic Address Racial and Geographic

Disparities in HIV and HCV InfectionDisparities in HIV and HCV Infection

Racial Disparities in HIV InfectionRacial Disparities in HIV Infection• African Americans represent 14% of the

population and 45% of HIV infections• African Americans are more likely to present

later in the course of their infection and have higher rates of AIDS-related mortality

• Traditional behavioral risk factors don’t explain disparities– More limited access to HIV testing, lower insurance

rates– Structural and social factors – Complex sexual networks

Geographic DisparitiesGeographic Disparities• In many urban areas, a few

neighborhoods account for a large share of HIV infections

• HIV infections cluster• Some neighborhoods have

HIV infection rates similar to sub-Saharan Africa

• Maps tell us where to focus intensive prevention and treatment efforts

Source: AIDSVu

• Philadelphia has infection rates 5 times the national average• Heterosexual epidemic• Zipcode 19143 (in Southwest Philadelphia) is the second most

populous zipcode in the city (60,000 people)– 86% African American, 30% people < poverty line

• Zipcode 19143 has the 2nd highest number of people living with HIV/AIDS (1,014 individuals in 2010)– Approximately 1.8% seropositivity

• Rates of Hepatitis C (HCV) in 19143 unknown, but likely high• 19143 has few medical and health resources

HIV & HCV in Southwest HIV & HCV in Southwest PhiladelphiaPhiladelphia

Rates of Persons Living with HIV/AIDS by Zip Code and Census Tract, 2009

Source: AIDSVu

Do One Thing OverviewDo One Thing Overview• Southwest Philadelphia, PA is a medically underserved area with high rates of

HIV and HCV infection & few HIV and HCV testing & treatment services

• Do One Thing is a testing, linkage to care and treatment campaign that stimulates demand for and provides HIV and HCV testing and treatment across an entire zipcode

• Do One Thing includes:• A large-scale social marketing and media campaign• Community outreach and mobilization • Partnerships with business, community organizations, and faith institutions• A partnership with a federally qualified health center in Southwest Philadelphia to

routinely offer HIV testing to all patients over age 13• Rapid HIV and HCV testing in a mobile unit, door-to-door testing in 4 census tracts• Community service and volunteerism• Monitoring and evaluation

Location, location, location!Location, location, location!Do One Thing in Southwest PhiladelphiaDo One Thing in Southwest Philadelphia

Social Marketing Campaign Social Marketing Campaign

Social Marketing CampaignSocial Marketing Campaign

• Website: 1nething.com

• Texting service

• Yard signs, door knockers, door to door outreach

• Palm cards

• Street outreach

• Twitter feed with map of mobile unit of of mobile unit locations

Community Mobilization: Community Mobilization: BusinessesBusinesses

Community Mobilization: Community Mobilization: BusinessesBusinesses

Community Pharmacy Corner Market Cafe

Routine HIV Testing at the Routine HIV Testing at the Health Annex, a FQHCHealth Annex, a FQHC

Victories and Challenges with Victories and Challenges with Routine Testing in Clinical SettingRoutine Testing in Clinical Setting

Clinical Challenges and Lessons learned• Policy Change: Leadership is most important factor• Integrated Model: Know your patient flow and model

– NP clinical model with MAs testing model

• EMR Enhancement• Staff and Provider Training• Financial incentives

Victories and Challenges with Victories and Challenges with Routine Testing in Clinical SettingRoutine Testing in Clinical Setting

Clinical Challenges and Lessons learned• Offer rate has plateaued at 70%

– Next step: incentivize acceptance rate improvements

• High decline rate: most commonly cited reasons are “recently tested” and “wasn’t expecting an HIV test”

• Behavioral risk profiles: most new positives have “no identified risk;” most are young, African American women

• Lower seropositivity than expected: 0.4%• 95% linkage and retention in care rate; has been

sustained over time

Community Service: Our Volunteers Community Service: Our Volunteers

Do One Thing Door To Door Do One Thing Door To Door HIV/HCV Testing Campaign HIV/HCV Testing Campaign

Non-Clinical Testing on Mobile Non-Clinical Testing on Mobile Medical UnitMedical Unit

Demographic Percentage Gender Female 45%

Male 54.4%

Transgender .6%

Race African American 90%

African 3%

Other 7%

Education Less than high school 20%

High School 50%

Some college/AA 21%

4 year college 8%

Household Income <$10,000/yr 43%

$10,000-15,000/yr 15%

$15,000-20,000/yr 12%

>$20,000/yr 30%

Employment Unemployed 37%

Part-time 15%

Disabled 11%

Full-time 31%

Other 6%

Demographic PercentageHealth Insurance Status

None 37%

Medicaid 36%

Private 18%

Other (Medicare, Veterans, etc)

9%

Sexual Orientation (self-report)

Heterosexual 89%

Gay/Lesbian 6%

Bisexual 5%

Risk Behavior PercentageMultiple sexual partners 22%

Believe partner has multiple sexual partners

24%

Ever injected drugs 6.7%

Ever used crack or cocaine Cocaine 15%

Crack 14%

Tattoos 49%

If tattooed, received tattoo at tattoo party

24%

Ever tested for HIV? 85%

Ever tested for HCV? 36%

Reported venue for testing for HCV Doctor’s Office 56%

Reported reason for testing for HCV Participant asked for the test 41%

Doctor Recommended 33%

Other 26%

Clinical and Non-Clinical Clinical and Non-Clinical HIV Testing TrendsHIV Testing Trends

• Clinical Settings

– Tested 2,100 people for HIV in clinical settings

– Health Annex (FQHC) seropositivity: 0.4%

– Greatest challenge: 55% decline rate

• Non Clinical Settings

– Tested 900 people for HIV in non-clinical settings

• 1.3% HIV seropositivity

– Tested 350 people for HCV in non-clinical settings since December 2012

• 4.8% HCV seropositivity

Linkage to Care ProtocolOraQuick® rapid HCV antibody test reactive

Confirmatory test is positive

Confirmatory test is negative x 2

D1T staff notifies patient and provides

counselingD1T staff notifies

patient : counseling + insurance status

Insured with a primary care provider

Referral

Insured with no known primary care provider

PCP visit followed by referral

Uninsured with no primary care provider

Social worker works w/ clients to gain

insurance + then refers

OraQuick® rapid HIV antibody test reactive

D1T staff immediately links patient to HIV

care within 24-48 hrs

If uninsur-

able, refer to health center

Repeat test Blood draw for confirmatory

Western blot

Repeat test Blood draw for confirmatory

HCV PCR quant

Preliminary linkage to HIV care Preliminary linkage to HIV care trends: Non-clinical Testingtrends: Non-clinical Testing

12 People Tested Preliminary Positive

10 confirmed positives

2 discordant confirmatory results

8 known positives 2 new diagnoses

4 currently in care

1 LTFU

6 being linked to care

1 awaiting viral load results

Demographic characteristics of HIV-positive Demographic characteristics of HIV-positive patients in non-clinical settingpatients in non-clinical setting

• Average age HIV+ = 44 years old

• African American

• Transmission risk factors: MSM (2), Heterosexual (5), no identified risks (5)

• 2 co-infected with HCV

Preliminary Linkage to Care Trends for Preliminary Linkage to Care Trends for Non-clinical Testing: HCVNon-clinical Testing: HCV

17 People Tested Preliminary Positive

13 chronically infected 2 cleared virus

10 previously known 3 new diagnoses

1 currently in care 2 in process of linkage

10 linked to care outreach services

2 uninsured 10 have insurance

2 with insurancepending

6 referrals pending

4 awaiting referrals

2 awaiting results

• Average age is 52• One third are NOT in baby boomer birth cohort• Mode of transmission: no identified risk (7),

IDU/cocaine use (7), Heterosexual (1)• 2 co-infected with HIV• Tattooing in unregulated environments

Demographic Trends of HCV positive Demographic Trends of HCV positive Patients in non-clinical SettingPatients in non-clinical Setting

• Continuing Quality Improvement (CQI) is critical • Many are known HIV and HCV positive and not in care• Comprehensive campaign is a way to raise awareness,

fight stigma and re-engage patients in care • Biggest challenge in non-clinical setting: retaining HIV

patients in care• Biggest HCV challenge: payment and linkage

– insurance and referrals for HCV care

Lessons Learned and ImplicationsLessons Learned and Implications

• Biggest challenge in clinical setting: high decline rate• 74% of patients testing for HIV at clinic were women; men

more frequently decline HIV testing in clinical setting• More new diagnoses in clinical settings than non-clinical

settings• Offering HIV and HCV testing together may enhance testing

rates• Street and door to door outreach is effective, especially for

reaching youth and men• High HCV seropositivity rate; few clients are in care• Volunteers reduce staff costs and enhance sustainability

Surprising FindingsSurprising Findings

WhatWhat is next?is next?• Enhancing routine testing at FQHC

– Boost our offer rate and reduce our decline rate • Develop a complete neighborhood-based diagnosis,

treatment and care cascade• GIS mapping of hotspots for HIV and HCV• Trial comparing control and treatment neighborhoods• Cost-effectiveness study• Complete program evaluation, including improvements

from baseline• Mapping transmission using HIV sequences at

neighborhood level

• Principal Investigator Amy Nunn, ScD

Brown University• Gladys Thomas, Project Director• Gilead Sciences • Health Annex partners• 80 Volunteers• The Southwest Philadelphia community

AcknowledgementsAcknowledgements