5Modeling/ Health Results Measures MaximizingGlobal SynergiesCDC Goals and Strategic ImperativesDrug UsersSurveillance/StrategicInformationNational Center forProgram IntegrationHIV/AIDS, Viral Hepatitis, STD, and TB PreventionMSMHealth DisparitiesAssociate DirectorDirectorfor CommunicationsKevin FentonAssociate Directorfor Program IntegrationSusan RobinsonrDeputy DirectorSusan DeLisleAssociate Director(Acting)Associate Directorfor Health DisparitiesReducingHealth DisparitiesHazel D. Deanfor Science(Acting)Raul RomagueraTerry ChorbaCorrectionsProgramIntegrationAssociate DirectorAssociate Directorfor Planning & PolicyManagement Officialfor Laboratory SciencesCoordinationSal ButeraEvaMargoliesMichael MelneckDivisionsDr. Kevin Fenton, Center Director, has established 3 programmatic priorities and PCSI is one of 2 domestic program priorities.The boxes on the sides represent 8 Cross-Center working groupsGlobal AntenatalHIV/AIDS PreventionHIV/AIDS PreventionViral HepatitisSTDTuberculosisGlobal AIDSModeling/ Health Results MeasuresIntervention ResearchSurveillance &PreventionPreventionEliminationProgram& SupportEpidemiologyDirectorDirectorDirectorDirectorDirectorDirectorRobert JanssenRobert JanssenJohn WardJohn DouglasKenneth G. CastroDeborah Birx
6HIV/AIDS, Hepatitis, STD and TB Common determinants Similar or overlapping at-risk populationsDisease interactionsCommon transmission for HIV, hepatitis and STDsSTDs increase risk of HIV infectionClinical course and outcomes influenced by concurrent diseaseSocial determinantsPoor access to, and quality of, health careStigma, discrimination, homophobiaSocioeconomic factors, such as povertySome commonalities for the center’s diseases:--Similar or overlapping at-risk populations--Disease interactionsCommon transmission for HIV, hepatitis and STDs, e.g., sexual risk behaviorsSTDs increase risk of HIV infectionClinical course and outcomes influenced by concurrent diseaseSocial determinantsPoor access to, and quality of, health careStigma, discrimination, homophobiaSocioeconomic factors, such as povertyPrevention and controlEffective interventions exist to reduce the burden of TB, viral hepatitis, most STDs, and HIVChallenges in funding, delivery, monitoring and quality of prevention services6
7Program Collaboration and Service Integration (PCSI) Operating Definition:A mechanism of organizing and blending inter-related health issues, separate activities, and services in order to maximize public health impact through new and established linkages between programs to facilitate the delivery of services7
8Program Collaboration and Service Integration (PCSI) Integration should be focused at the field or client level where the interface between the system and the consumer takes place.Integration results in more holistic services for clients, regardless of the agency structure.8
9Program Collaboration and Service Integration (PCSI) Goal:Provide prevention services that are holistic, sciencebased, comprehensive, and high quality to appropriatepopulations at every interaction with the health caresystem.Vision:Remove barriers to and facilitate adoption of servicedelivery integration at the client level by aligningNCHHSTP activities, systems, and policies with thisgoal.
10Principles of Effective PCSI AppropriatenessEffectivenessFlexibilityAccountabilityAcceptability
11Barriers to Service Delivery Integration (Summarized from reports, briefs, literature) Restrictive and inflexible use of categorical fundsPrescriptive program announcements and discordant reporting requirementsBurdensome and inefficient “administrivia”Lack of harmony, consistency, synchronization of data collection and surveillanceLack of integrated prevention guidelinesInsufficient translation, integration of science and programInsufficient support, both technical and financial, for cross training, evaluation and dissemination of best practices
12CDC Consultation on PCSI Overall meeting objectives To advise NCHHSTP on the development of Program Collaboration and Service Integration (PCSI) activities over the next five yearsAssist in establishing priorities for PCSI; short term and longer termIdentify what CDC can do to assist local PCSI effortsIdentify what CDC can do to improve its own efforts toward PCSI
13CDC Consultation on PCSI Process for Identifying PCSI Participants Planning Committee of national organizationsNCSD, NASTAD, NTCA, Hep. C Coord., UCHAPS, CSTE, NNPTCPeer selection process for Non-CDC members, obtained diversity using selection criteria:Large and small size programs (both in funding and population)Integrated and non-integrated programs (structurally and service delivery)Urban and rural states; High morbidity and lower morbidity states/citiesEquity across diseases (HIV, TB, STD, viral hepatitis)NCHHSTP Divisions nominated surveillance breakout session participants, DHAP nominated 5 CBOs for consultation
14CDC Consultation on PCSI Attendees Broad range of external and internal stakeholders (approx.125)Grantees – 7 from each program, 5 CBO’s (LGBT, corrections, substance abuse, AF/AM women)NNPTC, RTMCC, AETCCSTE and 3-4 state surveillance coordinators from each programCHAC, ACET representationRepresentatives from each NCHHSTP DivisionOther federal agencies (e.g. HHS,HRSA, SAMSHA, OPA, )Non federal partners (e.g. ASTHO, NACCHO, ASHA)40 Project areas/jursidictions represented
15External Consultation Charge Obtain top three priorities in…..Opportunities for PCSI implementationPolicy improvements related to opportunitiesPerformance measures for levels of service integrationWorkforce development and training needs15
16Priority Opportunities Integrated surveillance and data effortsIntegrated training effortsIntegrated funding16
171. Integrated Surveillance and Data Integrated surveillance reportsStandards for sharing of dataGuidelines for integrated data with common demographics, variables, and definitionsAddress confidentiality issues – create a gold standardSurveillance systems that work with and across programs
182. Integrated Training efforts Flexible funding for trainingIntegrated and comprehensive guidelinesProgram announcements that include common language and objectives to address Center’s diseasesTraining centers required to have integrated training curricula
193. Integrated fundingIntegrative program announcements (PA’s) (leverage integration through PA’s)Collaboration on program announcements and post award managementIncentives for state and federal funding to support integrationIncentives for “in-kind funds” and/or require matching fundsReprioritization of funds at CDC levelReporting and evaluation componentsFund pilots or demonstrations
20Addressing Barriers to PCSI Meeting Report, presentations on webDevelop a national policy framework for PCSIGreen paper è White paper èSpring, 2008Stakeholder input è OngoingExplore funding for program collaboration and service integrationAnalyze budget authorities è InitiatedExplore opportunities for seed moneyRealignment of funds to support PCSI demos/ evaluation
21Addressing Barriers to PCSI (continued) Harmonize and synchronize data collection and surveillanceEstablish cross center work group èCompletedPublish integrated annual surveillance reports è 2008Develop common standard for confidentiality and sharing of surveillance and program data èInitiatedPublish STD/HIV integrated interview record èCompletedHarmonize Partner Services GuidelinesSTD/HIV Partner Services guidelines èJune, 2008
22Addressing Barriers to PCSI (continued) Develop integrated prevention guidelinesCommission workgroups to develop guidelinesCross-Center workgroups established on: Program integration, Corrections, MSM, Drug users, SurveillanceCoordinate CDC program announcements and reporting requirementsEnsure new program announcements promote program integration èGoals architecture; consistent languageReview PAs to ensure PCSI includedè New SOP’s in place (2 completed)
23Addressing Barriers to PCSI (continued) Provide support, both technical and financial, for cross training, evaluation and dissemination of best practicesCollaborate with National Training CentersMeeting scheduled June, 2008
24Areas for future work Widening circle of engagement on PCSI Involving community prevention servicesSummarize wealth of evidence and experienceWorking with specialist partnersCDC level activitiesDevelop implementation planDevelop research, monitoring, and evaluation strategyState, city and local partner activitiesConversations, mobilization, support and engagementCreate opportunities for sharing promising practices
25Next Steps Meeting Report, presentations on web Winter 2008 Winter 2008Publication of NCHHSTP Action Plan for PCSISpring 2008Publication of NCHHSTP white paper on PCSIOngoingEngagement with partnersIntegration “tracks” at national meetings
29CDC NCHHSTP Organizational Chart Global AIDS ProgramDivision of Sexually Transmitted DiseasesDivision of Viral HepatitisDivision of HIV/AIDS PreventionDivision of TB Elimination
30NCHHSTP Programmatic Imperatives Program Collaboration and Service Integration Definition: Integration - A mechanism of organizing and blending inter-related health issues, separate activities, and services in order to maximize public health impact through new and established linkages to facilitate the delivery of servicesIntegration should be focused at the field or client level where the interface between the system and the consumer takes place.Integration results in more holistic services for clients, regardless of the agency structure.
32PCSI Current issues: Adult Hepatitis B Vaccination Initiative Joint PS guidelinesAccess to surveillance dataSTDs among HIV+Addressing health disparities comprehensively
33Often Cited Barriers to Program Integration Restrictive and inflexible use of categorical fundsPrescriptive program announcements and discordant reporting requirementsBurdensome and inefficient “administrivia”Lack of harmony, consistency, and synchronization of data collection and surveillanceLack of integrated prevention guidelinesInsufficient translation and integration of science and programInsufficient support, both technical and financial, for cross training, evaluation and dissemination of best practices
34NCHHSTP Integration Activities Already Underway Joint Project Officer Meetings – quarterlyProgram Integration Meetings – bi-weeklyJoint Branch Chiefs Meetings –quarterlyBranch Seminars - weeklyHepatitis B integration letter and Division commitments (Fenton/Schuchat letter)Joint site visits – listening toursNY, Chicago, CAExternal Consultation on Program Integration
35Collaboration within NCHHSTP HIV testing guidelines – Roxanne Barrow and Franklin FletcherNew HIV testing PA – STD clinics – Chris Lupoi and Ron TurskiAdult hepatitis B immunization action plansPartner services guidePrevention Training Centers (PTCs)Joint Project Officer workgroupMeth workgroup – Susan Arrowsmith
36STD/HIV Program Collaboration and Integration Revised HIV testing guidelinesRoutinize testing in a variety of clinical care settingsConsent advised to be part of general consent for clinical servicesRisk reduction counseling encouraged but not a requirementData systemsSTD interview recordAttempts to enhance linkages between data systems for STD (STD-MIS, STD-PAM) and HIV (PEMS)Partner servicesHarmonize guidance
37Enhanced STD (inc. HIV) interview form STD case reports to CDC lack standardized behavioral variables(e.g., gender of sex partner, drug use, exchanging money/drugs for sex)Needs:add new variables but limit number to avoid burden on field staffharmonize STD and HIV interview forms to decrease duplicationKey new components:gender of sex partnerrecreational drug use (e.g., methamphetamine, Viagra)venues used to meet and have sex with partnersNext steps:integrate variables with DHAP activities (i.e., PEMS)finalize form and methods for training/implementation
38HIV PCRS and STD PN integration Principles for STD partner notification and HIV PCRS are almost identical.Same 11 common principles (plus two extra for PCRS).But differences in HIV vs. STD training and application have led to practical approaches that have different emphases.This has created tension for combined HIV/STD PN/PCRS programs and when programs see persons co-infected with HIV and STD.A CDC working group is integrating the 1998 HIV PCRS guide with the 2000 STD Program Operations Guidelines (POG) Partner Services Chapter.The POG becomes the base document.What is common to HIV and STD partner management remains in the POG.What is unique to HIV is placed in a separate module.The module contains HIV-specific elements from the 1998 PCRS guide.The module contains updated information relevant to HIV PCRS (e.g., case-finding through network-based approaches).The POG Partner Services chapter will be revised concurrently.
40Integration Strategies for MSM ServicesUse the 2006 STD Treatment GuidelinesUse media materials atInform MSM about these recommendationsGet the word out to public and privatepractitionersGet the word to your clinicians, counselorsLink behavioral interventions to clinical servicesPrevention activities targeting MSM shouldinclude the message from the ‘Dear Colleague’ letter
41HIV/STD Integration Strategies HIV CPGs ?? Prevention Plans ¨¨ CBOs¨¨ community membersHIV ¨¨ DEBI ¨ CBOs, HD, communitySTD ¨¨¨ practitioners: private & othersOffer comprehensive clinical services and integrated PNPromote common, comprehensivemessages and services
44HIVP Program Structure CDCCPGDoHHealth Ed/Risk ReductionCounseling &TestingLets take a look at HIV prevention programs…….This is a simplified view, it doesn’t include community planning, evaluation, and lots of other things, but it does show how HIV prevention programs can be divided into Behavioral based Health Education/Risk Reduction (HERR) and Counseling/Testing/Referral (CTR). HERR is largely driven by community planning and implemented in Community Based Organizations (CBO), while CTR is largely Health Department based and staffed by public health professionals.These programs are so far apart, you could drive a BUS through them!
45HIVP Program Structure CDCDoHBehavioralInterventionHIVTestNow think for a moment about your HE/RR programs.You’re probably reaching a lot of your priority population, (probably MSM and IDUs) from the Comprehensive HIV Prevention Plan – developed by your local Community Planning Group (CPG) in those HE/RR programs. But let me ask you – how many of your HE/RR clients actually get from the HERR over here to the CT sites to get an HIV test??[standard answer: not many] well, if we’re not getting HIV clients an HIV test, how can we ever hope to integrate STD or hepatitis into these programs???STD Screening?A & B Vaccinations?
46Suggested Program Structure CDCDoHHE/RRHE/RRHE/RRHE/RRAnother way to think about this would be to build these more medical interventions into our CBO-based behavioral interventions. Let’s say you fund a peer-based 6-step behavioral intervention in these CBOs. Well, how about if we add a bullet and created a 7 step program where the additional session includes CTR, STD screen and appropriate hepatitis immunization, testing, and counseling. This might be achieved by bringing in a public health nurse, or meeting at a clinic facility. Ask the group if they may have suggestions on how to do this..= CTR/STD/Hepatitis services
47Comprehensive Approach to Fighting EVERYTHING! High- Risk IndividualsTest - HIV/STD/HCVImmunize - HAV HBVMedicalEvaluation/Treatment; Partner ServicesHIV +STD +HCV +Status Appropriate Prevention Counseling&Social ServicesIf negativeIf we can do all that, then we’ve adopted the ‘Comprehensive Approach to Fighting EVERYTHING’ or ‘CAFÉ’.[Walk through chart (modified from SAFE) integrating HIV, STD, and hepatitis services].Since this approach is so big, we can call it ‘CAFÉ’ Grande”.[Note that actual services would differ for different risk groups like MSM or IDU.CAFÉ Grande
48CAFÉ Grande Benefits: Clients learn HIV sero-status At risk get HAV & HBV immunizedSTDs identified and treatedOverlapping epidemics are addressedClients get better services/counselingReinforces positive behavior changeAddress scrutiny by documenting servicesIncreases efficiency, improves services, reduces redundancy…[Read all the benefits of CAFÉ Grande].Speaker might want to discuss benefits for both MSM and IDU.MSM - overlapping HIV, Syphilis, HAV and HBV epidemics addressed. Counseling more appropriately based on a more complete medical assessment.IDU -IDU are 10x more likely to have HCV than HIV. Wouldn’t it make more sense to counsel and refer them for the disease they do have?-Do you think their HIV risk behaviors would change if they learned HCV status?
49Reasons to Combine Viral Hepatitis, HIV/AIDS and STD Prevention Routes of transmission & at risk populations overlapMajor public health problemsEffective prevention toolsReferral is inherently inefficientLack of integrated prevention activities leads to transmission of viral hepatitis, syphilis, gonorrhea, chlamydia, and HIVCounseling will be based on a more comprehensive medical & risk assessment
50ConclusionsOffer comprehensive ‘one stop’ service to clients who are being reached but not fully servedLearn to say: ‘HIV/STD/hepatitis’ like its one word!!!
51Strategies and Tools for Program Integration Dear Colleague Letter on comprehensive STD prevention services for MSMHIV Funding for HCV C&TVaccination (using VFC and 317)SAMHSA, correctional based services‘Comprehensive approach’ for IDUIntegrate programs targeting at-risk populations