1. HIV/STD Surveillance in Tennessee: A fully integrated model
Thomas J. Shavor, MBA, MPH
Epidemiology Director
HIV/STD Surveillance & Data Management
Tennessee Department of Health
Good afternoon,
My name is Thom Shavor, and I am the Director of HIV/STD Surveillance & Data Management for the Tennessee Dept. of Health. My talk this morning describes how HIV/STD Surveillance operations within Tennessee are integrated within our Surveillance program and within our HIV/AIDS/STD Section.

2. Surveillance Integration in Tennessee
Definition- Combining all aspects of HIV/STD surveillance activities in order to attain a close and seamless coordination of information/services between:
Groups within HIV/STD Surveillance & Data Management (Group Level Integration)
Program areas within HIV/STD Section (Program Level Integration)
The term “integration” is defined on Wikipedia as a “process of combining or accumulating”. Using a management point of view, I chose to define integration in this case from as:
combining all aspects of HIV/AIDS/STD Surveillance activities in order to attain a close and seamless coordination of information/services between:
Groups with HIV/AIDS/STD Surveillance (Group Level Integration)
Program areas within the HIV/AIDS/STD Section (Program Level Integration)”

3. Tennessee: a short snapshot
2007 Population: 6,054,830 (Source: U.S. Census)
Approx. 1,000 new HIV/AIDS diagnoses/year (Source: Tennessee HARS)
13,521 living with HIV/AIDS as of 12/31/06 (Source: Tennessee HARS)
High historical STD rates (Source 2005 CDC STD Surveillance Report)
8th highest rates of Chlamydia
13th highest rates of Gonorrhea
10th highest rates of P&S Syphilis
Now, I don't often have the chance to address a national audience, so I wanted to take a minute to describe Tennessee in the context of HIV/STD infection.
In 2007, TN had approx. 6,054,830 residents.
We average about 1,000 new HIV/AIDS cases per year, which gives TN an HIV/AIDS incidence rate of 16.5/100,000.
We have approximately 13,521 people living with HIV /AIDS in our state.
And in a change to what you see on the screen, the recently released (2006) STD ranking place TN with the 9th highest CT rates, 10th highest GC rates, & the 8th highest P&S Syphilis rates.

4. Brief Historical Timeline
1982- Tennessee began collecting AIDS case data
1986- Tennessee established an AIDS program within the Bureau of Health Services
1987- AIDS reporting becomes mandatory
1992- HIV reporting becomes mandatory
2001- The STD Prevention, HIV Prevention, and Ryan White programs merged to become the HIV/STD Section
2003- Current organization finalized
In 1982, Dr. Gary Swinger from the Tennessee Dept. of Health began collecting AIDS case data from patients seen by health care providers statewide.
Four years later, (1986) the TN Dept. of Health established an AIDS program within the Bureau of Health Services.
The following year (1987), the TN State legislature made AIDS reporting mandatory by all health care providers practicing in TN.
In 1992, HIV reporting became mandatory as well.
In 2001, the STD, HIV, and AIDS programs merged to become the HIV/AIDS/STD Section. This new organization no longer answered to the state epidemiologist, but to the newly-created HIV/AIDS/STD Program Manager.
In 2003, our current organization structure was approved.

5. Levels of Integration Integration occurs at 2 levels:
Surveillance level- Core, Incidence, CTS, PEMS (?), Behavioral Surveillance, STD Surveillance, Chlamydia Infertility, and Program Evaluation groups occur within a single unit (housed in a secure area within our section)
2. Program level- HIV/AIDS/STD Surveillance section is integrated with the HIV/STD Prevention, Ryan White, and IT Support programs within the section.
As a fully-integrated surveillance program, our staff are linked within 2 distinct dimensions or levels:
The first level is the Surveillance Level. Here, all aspects of HIV/STD surveillance , such as Core HIV surveillance, STD surveillance, HIV Counseling & Testing, and Chlamydia Infertility, are managed by the HIV/STD Surveillance Director (ME ), and housed within a single, secure area of our building.
The second level involves integration at the Program Level. At this level, our staff receive funding from other program areas, (such as STD, HIV Prevention, and Ryan White), and are intimately involved in the decision-making processes of these programs.

6. Group Level Integration
This picture illustrates group level integration within the HIV/STD Surveillance & Data Management Program.
As you can see, the Surveillance Director provides managerial and programmatic oversight to all employees assigned to these various programs.
While this organizational structure makes it very convenient for the Surveillance Director to manage all of these programs, it does place a significant burden of responsibility on his/her shoulders, simply due to the number of program areas overseen.

7. Program Level Integration
Surveillance & Data Management
HIV/STD
Prevention Program
Ryan White Program
This next slide denotes the extent of Program Level integration within the Tennessee Dept. of Health’s HIV/AIDS/STD Section.
Within this framework, the HIV/STD Surveillance & Data Management, Ryan White, and HIV/STD Prevention programs share staffing resources and physical space within an small area on a single floor of our office building. In fact, all staff members are no more than a half minutes’ walk from each other.
Information Technology (IT) staff used to be managed by the Surveillance Director. However, in May 2007, the TN Health Dept. reorganized all of its IT services under a single umbrella organization called OITS (Office of Information Technology Services). While these staff still receive funding from HIV Surveillance, their daily supervision comes from an IT manager.

8. Surveillance Position Funding Sources
Epidemiology Director- 100% HIV Core Surveillance
Prevention Epidemiologist- funded 50% by HIV Prevention/50% by STD Prevention
STD Public Health Advisor (2)- 100% STD Prevention
HIV Epidemiologist- 90% Epi TA/10% Core Surveillance
Ryan White Epidemiologist- 100% Ryan White Program
HIV Surveillance Reps (10)- 10%-100% HIV Core Surveillance (depending on area)
Clerical Support/ICCR(2)- 100% STD Prevention
As you can see, Surveillance personnel are funded by a variety of program areas, though most staff are funded currently through HIV Surveillance.
It should be noted that these positions reflect current 2007 funding streams. As Tennessee was one of the states de-funded for HIV Incidence in next year’s cooperative agreement, our program is currently having serious discussions about:
the level of surveillance services that we can provide based on funding available from CDC
the degree to which other programs (such as STD & Ryan White) would be willing to pay to augment HIV Core Surveillance activities

9. HIV/STD Surveillance Activities
Responsible for providing data for ALL grants, including:
HIV Surveillance
STD Prevention
HIV Prevention
HIV Counseling/Testing
Ryan White (Part A and Part B)
Chlamydia Infertility
Maternal Child Health, TB, and anyone else
Within an Integrated Surveillance Program, team members met the data needs of all programs within the HIV/AIDS/STD Section.
Thus, our staff fulfill the data reporting and interpretation needs for all grants, progress reports, special studies, etc. that are required by CDC, HRSA, & other funding sources.

10. HIV/STD Surveillance Activities-cont.
Manage and analyze data from a variety of databases:
HARS/eHARS
STD*MIS
PTBMIS (Tennessee’s Patient billing system)
PEMS (???)
Ryan White Care-Ware
Chlamydia Infertility database
Joint datasets (HIV Unmet Need, etc.)
We also manage and analyze data from a large variety of datasets, to include:
HARS/eHARS
STD*MIS
PTBMIS (our state’s patient billing information system)
PEMS (whenever that happens!)
Ryan White Care-Ware
Chlamydia Infertility Database
HIV Counseling/Testing System
And many, many more! 

11. Benefits of Integration
Allows for more effective communication within Surveillance groups & between different programs
Helps program staff to see the “big picture”
Has potential to save time (fewer meetings)
Encourages each program area to participate in collaborative projects
Aids in resource planning for future needs
Assists in program evaluation activities
This occurs mainly through formal/informal meetings with other program directors to discuss program activities and needs.
As staff members are involved in a variety of projects at any one time, they get the see how the different parts of public heath work together to ultimately benefit our patients.
Due to our close proximity to one another, our staff are able to share information continuously, thus reducing the needs for unnecessary meetings.
As Surveillance staff prepare data for all of our various programs, managers have a natural inclination to work together on projects, grants, etc.
Integration allows all program managers to be aware of staffing shortages, funding changes, and program needs (especially, IT purchases)
Again, as Surveillance staff analyze all program data, this ENCOURAGES the other program managers to involve us in program evaluation.

12. Challenges of Integration
Cross-training surveillance staff (i.e. “doing more with less”) to perform unfamiliar tasks can lead to major stress!
Managers must attain a greater understanding of how other program areas function.
Breaking down traditional program barriers can be difficult (“my program-your program”)
Explaining “technical” subjects to non-technical people can be frustrating!
Getting programs to pay their “fair share” of Surveillance resources used
Obviously, as budgets decrease and demands from our grantors increase, staff members will get asked to “handle” things they ordinarily didn’t do before. Be prepared to combat these stress-related meltdowns with soft music (anything by Yanni works great), frequent smoke breaks, punching bags, and chocolate!
Learning another program’s operational details (especially when they are especially dysfunctional) can discourage confidence in integration. However, it is important to understand what other programs do so that you understand how it affects YOU.
As people love to horde (and thus control) information, barriers to information sharing (expressed as “my program-your program”) can be hard to break down.
Explaining technical subjects to non-technical people can lead to major frustration. For example, explaining data smoothing techniques to someone who can’t use a mouse is a surefire way to have a bad day!
In TN, HIV Surveillance has a long history of paying for all IT/Epidemiology staff, and I think this is because we were the only staff with data analysis skills. As a result, other programs, such as STD & Ryan White, failed to set aside funds for the people who analyze their data. In our situation, Integration has led to complacency in the budget planning process, and it is something to be guarded against.

13. Integration: Skills needed for success
Organize time/materials/resources
Learning skills outside of your comfort zone
Ensure lines of communication are always open (via regularly scheduled management meetings)
Involve others in grant preparation, program evaluation, routine decisions
PATIENCE!
In my opinion, the 5 most important skills necessary to successfully integrate a Surveillance program are:
Being able to organize your time, materials, and resources will significantly increase your chances of success.
Before our program integrated, I knew very little concerning the world of “ Medicare donut holes”, Individual and Group Level Interventions used in HIV prevention activities, and how HIV Insurance assistance forms should be filled out (and now I do!)
Meet regularly with other program managers and encourage honest and open discussion of perceived opportunities & challenges.
Involve a wide variety of people in your program activities-especially grant preparation, program evaluation, and policy decisions.
And finally, PATIENCE! Integration can be extremely stressful, and it helps to think about the “Big Picture” when someone is telling you why they won’t do something!

14. Does anyone have any questions or comments?
This is a picture of our IT staff after a luncheon celebrating the implementation of STD*MIS in TN.
For those of you who don’t know, STD*MIS is a CDC-developed software application used to manage STD interviews and case information.
At that time. our IT staff included 4 state IT staff, 2 CDC Public Health Advisors, and myself.
Does anyone have any questions or comments?