1. Community Embedded Disease Intervention Specialist (CEDIS) Program: The LA Gay & Lesbian Center Experience

2. Traditional Partner Notification:
Partner Services
Community-Embedded Disease Intervention Specialist (CEDIS) Program
How many people are familiar with partner services? How many people apply PS?
Familiar with the Community-Embedded Disease Investigator Program?
I will give a brief background on both subjects.
Traditional Partner Notification:
LAC providers/labs submit CMRs to STDP
Routed and assigned to PHIs/PHN
PHIs contact cases to elicit partner information
Community-Embedded DISs (CEDIS) are:
stationed at diagnosing clinic for timely interviewing
Peers of the community and part of the CBO staff

3. Partners….. unaware of their risk
Partner services primary benefit is to let partners who are unaware of their risk know they may be exposed to an STD/HIV.
Cases can reveal partners names anonymously.
Early identification and treatment thus leading to Disease Interruption.
unaware of their risk

4. Past Present Future PCRS and the Health Dept Low Participation
CEDIS:Syphilis/HIV
Disease
Interruption/
Linkage to Care (LTC)
Future
CEDIS:
GC/CT
Disease Interruption/
Reduction of HIV Infections
This is the slide to talk about the overview of the presentation.
History of Partner Services – PCRS. Relying on Counselors for PCRS. Problem - busy, high volume. No time to really focus on PCRS.
PHI Follow-up – low participation
Began current CEDIS program 2008.
And how LAGLC plans to expand the CEDIS program

5. CEDIS Program in Los Angeles
Adapted after Howard Brown Clinic, Chicago
Employed by and stationed in the Sexual Health Department of LA Gay & Lesbian Center (LAGLC)
Unique to LA County CEDIS Program:
CEDIS made Health Officer of LAC Dept. Public Health Division of HIV & STD Programs (DHSP)
Trained to same standards as LAC DSHP Public Health Investigator (PHI)
Review and QA of work by LAC
Department of Public Health - Division of HIV and STD Programs 5

6. Benefits of Partner Notification
Notify partners confidentially
Partners may not be aware of their risk
Earlier testing, counseling, and linkage to care (LTC)
Potential to reduce STI rates in community

7. High STD/HIV morbidity
14% of Early Syphilis cases in Los Angeles dx out of LAGLC
55% of these cases also HIV co-infected
Approximately 300+ new HIV cases dx out of LAGLC per year
The CEDIS was started at LAGLC because the Sexual health clinic is the highest diagnosing clinic for syphilis in Los Angeles County as well as high rates of new HIV and other STDS.
This is why the CEDIS program was needed at GLC.

8. Traditional PHI/DIS Flow
Client is tested/treated with Provider
Labs and Rx are submitted to County Health Department within 7days
If new infection, case is assigned to PHI for interview
PHI calls or conducts field visit for interview
Re-Ix conducted/LTC

9. CEDIS Flow 1 Client meets with counselor for Risk Assessment/Triage
Client submits labs (blood, urine, etc.). If symptomatic, client is sent to provider for exam
Provider sends client to CEDIS for presumptive interview (Ix)
Client receives Rx
Re-Ix conducted over phone/LTC
Streamlining. One person (CEDIS) handles the results, PN. Making client feel more comfortable and having a point person they can depend on.

10. CEDIS Flow 2 CEDIS calls client with positive results
Client meets with CEDIS for Ix/Risk Assessment
Client sent to provider for exam
Client receives Rx
Re-Ix conducted over phone/LTC

11. Traditional Vs. CEDIS at LAGLC
20-fold increase in interview w/in 7 days
Lost to Follow-up 4%(CEDIS) vs. 28% (Traditional)

12. Time to Interview for Early Syphilis Cases
CEDIS Started in 2008
Here is our evidence of our immediate and continued success. Transition into working with MSM at gay clinic.
20-fold increase in interview w/in 7 days
Lost to follow-up: % (CEDIS) vs 28% (Trad)

13. PARTNERS NAMED Partner Index: 2007 (0.56) 2009 (1.91) 3-fold increase
Before CEDIS Vs. First Full Year Trained CEDIS

14. 2010 Early Syphilis Partner Services
CEDIS
Health Department
For every
10 cases interviewed
12 partners are named
7 partners are preventively treated.
For every
10 cases interviewed
6 partners are named
2 partners are preventively treated

15. 15 new HIV positives 75 new ES 37 new gonorrhea 41 new chlamydia
2010 CEDIS Disease Interruption
Newly Identified
Preventively treated
15 new HIV positives
75 new ES
37 new gonorrhea
41 new chlamydia
135 Early Syphilis
64 gonorrhea
63 chlamydia

16. Identifying GC/CT Infections
49 of the 340 partners notified in 2009 for syphilis exposure tested negative for syphilis, but positive for GC,CT, or both.
Identifying and treating GC and CT infections can lead to the prevention of contracting HIV and syphilis.
These are just co-infections. We expect huge success when program expands to GC/CT.

17. Performance Measures (PM)
PARTNERS INDEX: Ratio of the number of partners named/Cases interviewed
PARTNERS PREVENTIVELY TREATED: Ratio of the number of partners preventively treated/Cases interviewed

18. Partner Index for ES cases
Maybe put at the end and show if necessary. Or you can say in terms of trends and comparison with the
Health department outcomes.
Year

19. Preventive Index for ES cases
Year

20. Benefits Seen From CEDIS Program
20 fold improvement in time to interview within 7 days and 4-fold decrease in lost to follow-up
50% increase in the partners index and 4-fold improvement in partners preventatively treated index

21. National HIV/AIDS Strategy
Released July 2010 by Obama Administration
By 2015, lower the annual number of new infections by 25%
By 2015 increase the number of new HIV diagnosed patients linked to clinical care within 3 months from 65% to 85%.
Identifying HIV Positive patients and LTC

22. LAGLC HIV Positivity Rate
--7,111 HIV tests performed in 2010.
--324 tested HIV Positive
--11,111 HIV tests performed in 2011.
--365 tested HIV Positive
LAGLC HIV Positivity Percentage
Number of clients being tested dramatically rising. Many factors, One major factor is CEDIS birnging partners in. Other is clients feel comfortable at GLC.
Year

23. HIV is a different disease
We began expanding PS to our new HIV positive clients. The reason it has not been a focus is that the initial money to support
This project came from syphilis elimination money. The caseload for syphilis and co-infected HIV cases out of LAGLC was very high. But I currently do all of the acute HIV cases and I have started to pick up recent diagnosed in late But HIV is a different disease. Talk about the patients reaction. What you have learned.

24. In 2010 of the 26 new HIV cases interviewed:
78 partners named
34 partners tested
15 new HIV positives
10 known linked to care
We are making progress. No 2011 numbers but maintained or even got better. All HIV now being interviewed.

25. Partner Services Acceptance, 2010
Percentage Accepted
When I say HIV is a different disease, here is an example. For new HIV cases that I have worked, the acceptance rate is X % lower than for Early syphilis only cases. However, in comparison to the health department new HIV cases the CEDIS is much better. Finally, the hardest group to crack is the previously positive co-infected HIV cases out of our sister clinic, the HIV care clinic. As mentioned earlier about challenges to HIV partner notification, this group is least likely to want to participate.

26. HIV Partner Services: A long road….…
But we are making progress with new grants specifically with LTK and PS for HIV.

27. Reason I’m showing all these numbers…
Reason I’m showing all these numbers…. Being at GLC with this population works. Cartoon. This is how a client may feel at time of tx from a dr. This is the best time to talk to that person about partners. It’s on their mind. They are in front of you. They probably even have questions.
Some programs will collect the data and keep in touch with DIS’.
Be sensitive. Some could consider being a “bottom” emasculating/submissive. May bring up feelings of shame. Our role is to help the person get health care regardless of any personal views. Make sure pt is aware we are here to help them and not to judge them.

28. When to offer Partner Services
Symptomatic
Over phone when disclosing positive results
Time of Rx
Through DIS – Keep patient in loop
High risk patients/“Frequent Flyers”
Offer PS at the office is most effective way to get info. Once leave the office, they don’t want to think about it. Feelings of shame, etc.
-Let pt know a DIS may contact them regarding PS
All high risk pt’s should be offered PS regardless of which infection they test positive for These Very small number can be responsible for spreading a majority of the infections. - Bolan and County Syph Study. Take doxy everyday. Or asking them to be paid to test more often. Etc.

29. How to offer Partner Services
Empowering the individual – take control and responsibility
How many partners during window period
Symptoms
Places met partners
Ask “where” sex occurred
Emergency contacts
-Discuss window periods. Talk about sx. How it’s spread.
Realistic number of partners during that time. 1x per weekend, etc. - Also, if small number, one of these “3” partners must have it if only those during the window period. Only you can help us prevent someone else from possibly unknowingly contracting and/or spreading it.
- Places to meet partners. A4A was big. We got a s/n. Now we know grindr is popular. Trying to find ways in.
-self referrals – give my number to schedule apts… Also stress that Test may not be enough. ALWAYS Re-Ix. Many times person says they will self refer and they believe they will but on reix they say they didn’t and would like you to do it.

30. How to offer Partner Services
Phone numbers/Phone records
Addresses
Screen names/ s
Drug usage/IV drugs
Condom usage
Flyers/Educational materials
Self referrals
Inspot.org
-Take Control - We can stop the infection but we can’t do it without cooperation from the patients.
-Where sex. – If not phone #, still might not be lost cause. PHI/DIS could look for the partner in the field.
In-Spot also shows testing clinics near you.
-Make publications available in waiting rooms, etc. so clients know the program exists.
--self referrals – give my number to schedule apts… Also stress that Test may not be enough. ALWAYS Re-Ix. Many times person says they will self refer and they believe they will but on reix they say they didn’t and would like you to do it.

31. Be Knowledgeable First impressions can make all the difference
Know your patient. Knowledge can help build trust
Understanding and explaining test results
How infections are contracted/spread
Explain Sx and possible long term effects
-PMD offices and STD testing can be stressful.
-Friendly and knowledgeable from the front desk staff and lab techs to the providers.
Gather as much out of chart before speaking to the pt. Pt’s tune you out and get frustrated if they feel like they are just another “number”. Make it personal
Explaining how infections are spread, how the tests work, etc. (ex, my PMD never told me I’d test pos for syph in the future).
- Ex titers – “My dr never told me I’d test positive. I’m coming back here for now on. You know what you are doing”.
-Long term effects for op and potentially for the partners if they do not know they have it.

32. Challenges…. Mistrust Challenges to partner notification
Mistrust of the health department. Not wanting anything to deal with the health department.
-Getting call from HD “After the fact”. Out of sight, out of mind. Staranger on the phone.
Negative effect on relationships
Staffing
Repeatedily infected. - bolan study.
Mistrust

33. Repeat infectors who are indifferent to getting a STD
Repeat infectors who are indifferent to getting a STD. Who have had HIV for many years and who are somewhat blasé about notifying partners.
Can be very frustrating but be nice. Be knowledgeable. Attract more flies with honey. Give referrals and options and your card.
-I’ve had patietns call months or ever years after meeting with me and even though at the time of Oix we didn’t get anywhere, if you make an impression as someone who wants to help, you may have success later down the road.
Indifference

34. Culturally Sensitive Issues
Sexual Orientation
May not identify as “gay”
Avoid medical jargon
Body Language/Bedside manner
We need to be open that some of our patients are gay. Have a dialogue with them. Take que from pt. Top or just receive Oral may not identify as “gay”.
2. Can be sensitive for some. Ask flat out (in calming voice) – Who are you having sex with? Or… Are your partners male, female, or both? -more likely to get an accurate answer over asking gay or straight. - Could also say I want to give you the best care possible so I’d like to have an open and honest discussion.
-some people may not identify as gay even though they are having sex with the same sex.
3. If you know you are talking to someone who is MSM, try to use words they are familiar with. Top/Bottom etc. Too technical and sterile, pt may feel you are out of touch with them and tune you out, may not get info from them.
4. Facial expressions, really listening to client's needs. Do not cut them off….as much as we may feel we are rushed or the info the pt tells us doesn’t apply.

35. Culturally Sensitive Issues

36. Terminology Top/Bottom/Vers Down-low (DL) Cruising Rimming Blouse
Glory Hole
Bareback
Patients pick up on everything even if we don’t realize it - From overhearing providers talking to the counselor/provider’s body language.

37. Gonorrhea/Chlamydia 2011 Percent Positive
Important to know your patients. If gay, rectal testing imperative.
Rectal sx are the least reported sx in terms of GC/CT
Talk about Resistant GC (GISP).
Even putting a graph like this in the waiting room. MSM may see it and request a rectal test.

38. Safe Space Safe Space -- www.equal.org/safe-space-program/
The pink triangle is an internationally recognized symbol of positive gay identity.
The surrounding green circle is an international symbol of acceptance.
Safe Space Stickers. The emblem bears a pink triangle, an internationally recognized symbol of positive gay identity, surrounded by a green circle, an international symbol of acceptance.
Used more in schools but can also apply in the PMD office.

39. Other “Safe Space” Symbols
Human Rights Campaign
Gay Flag
Flag may or may not make others uncomfortable. May not work for you. Which is why HRC or SS may be better than flag depending on the office.
USAF

40. The Interview Education - How infection is contracted/spread
Symptoms & Window periods
Titers
Advise partners to receive Rx in addition to a test
Anonymous notification
Give referrals and options
Give time frame of when Re-Ix may occur
Use familiar language
Give business card
These are just co-infections. We expect huge success when program expands to GC/CT.
Referrals and options. Inspot. Texting. Give my number if they are comfortable talking themselves.

41. These are just co-infections
These are just co-infections. We expect huge success when program expands to GC/CT.
Referrals and options. Inspot. Texting. Give my number if they are comfortable talking themselves.

42. The Re-Interview Check in Linkage To Care for HIV positives
Open ended questions
Text messages
Explain titers again
Re-test
-”Want to check in with you” How are you feeling. Sx gone? Friendly clinic worker. No agenda. Pt’s well being first.
-Also check in regarding our conversation regarding partners.
Open Ended most important here - If they say, I told my partners. Reply with, “how did that go”? Did they tell you their intentions? Testing, tx? Already know?
Pt’s reply to texts more than returning calls.
-Advise a re-test to be sure titer drops.

43. Language Open ended questions Non-judgmental attitude
“When was the last time” Vs. “Have you ever”
“What is your experience with…” Vs. “Do you…”
Non-judgmental attitude
Do not lecture. Listen and respond
Do not take all words at face value
1. Open ended over Yes/No. - When was the last time VS Have you ever. - This normalizes the behavior.
2. Say they have a bf. Still ask are there any other partners. Everyone defines their relationship differently.

44. Drug Usage Methamphetamines Nitrates/Poppers PNP
Meth users more likely to be HIV positive
Meth – More likely to be HIV positive than non-users. If on meth, always have referrals handy that they can take. They may need those materials at a desperate time and it could make the difference.
-Also good to point out that even if the pt is not using, they put themselves at much higher risk by having sex with drug users.
Even if HIV positive – reinfection/spread to others.
Nitrates - Some do not consider this a drug. Important again how to ask the question. What is your experience?

45. Internet/Social Networks
Adam4Adam
ManHunt
Craigslist
BarebackRT.com (BBRT)
Bareback.com
Dudesnude.com
Facebook
Know the sites. Do you meet guys online? Name some of the sites specifically.
SN’s are last resort. Phone numbers are best but this has success too.
me for info on how to obtain MH log-on.

46. Internet Partner Notification Success
67 (36%) ES cases had at least one internet partner
724 internet partners total
117 internet partners initiated
62 internet partners examined
Adam 4 Adam most common website
Smart phones/Text messages/ access lead to rapid return call
Highlight that this was 62 partners that would have been otherwise unattainable.
Probably even more, these are just the people who responded to me. Some may have saw the and seeked testing and tx themselves.

47. Internet/Social Networks
Phone Applications
Grindr
Scruff
Jack’d
Recon
Talk about Grindr. GPS. Only people around out. No way to look someone up.

48. Anonymous partners Anonymous partners Grindr Bath houses
Talk about the overall mission from Public health point of view. Best way to convince them to help is to empower them.
-Your partners are anon but from here on out maybe keep phone numbers etc. Then if in this situation again, we can try to stop the spread rather than repeat the cycle.

49. Texting Google Voice Staying current Quick and easy VM Full
Book appointments
Messages saved on phone
3. pt’s may not want to talk about it. Don’t’ have time to call back. Have conversation, etc. But a simple reply to a text can make the difference.
5. Directions, appoinment time etc.

50. CEDIS program attempts to overcome some of the challenges.
Explain the program. Unlike the traditional health department approach,
The DIS is part of the CBO, a peer of the staff and community. Able to establish
Trust and interview in a timely manner.
The CEDIS is trained however to the same standards as the PHIs and receive technical training and oversight by the heatlh department field services.

53. Expansion of the CEDIS Program
Ensure HIV cases linked to care
Participation among previous HIV positives
Investigate GC/CT infections
1. Goals moving forward.
2. JGC clinic PHI (John Cabeso)
3. GC/CT could cut down risk of HIV. Also GISP.

54. Questions? How might this apply in your setting Ideas for improvement
Other questions

55. Thanks…
Contact Information: Johnny Cross 55