1. STD Control Branch Working With HIV Care Providers: The California/San Diego Experience Jessica Frasure-Williams, MPH Syphilis Elimination Coordinator, California Project Area Tom Gray Syphilis Elimination Liaison, San Diego, CA

2. STD Control Branch Working With HIV Care Providers: The California/San Diego Experience California Project Area –Provider Visitation Rationale –Screen, Test, Diagnose and Prevent: A Clinician’s Resource for STDs in Gay Men and other MSM –One Counties Experience San Diego County Provider Outreach and Education –San Diego Epidemiology –Medical Provider Trainings and Presentations –Clinician and Dental Health Professionals Posters –Monthly STD Report –Provider Visitation Program

3. STD Control Branch Why work with HIV care providers in California? Interview record review indicated that at least 14% of cases had symptoms present at a clinical visit that were missed or misattributed (2005, CPA) Provider reporting of infectious syphilis is not timely (Jan-Jun 2010) –<20% reporting within 1 day of exam –38% reporting within 7 days of exam Sexual history-taking and STD screening among HIV- infected persons may be inconsistent Historic challenges with providers supporting partner services High proportion of P&S syphilis and gonorrhea cases are co-infected with HIV

4. STD Control Branch Proportion of Gonorrhea Cases Co- infected with HIV, California 2009 *Bay Area excludes San Francisco, Southern Region excludes Los Angeles. Percent of cases

5. STD Control Branch Proportion of California P&S Syphilis Cases Co-infected with HIV, 2002-2009 Percent of cases

6. STD Control Branch P&S Syphilis Cases by Provider Type, California, 2009 Public Clinic 21.3 % EIP = Early Intervention Program

7. STD Control Branch www.stdcheckup.org SCREEN, TEST, DIAGNOSE & PREVENT: A CLINICIAN’S RESOURCE FOR STDs IN GAY MEN AND OTHER MSM

8. STD Control Branch The Provider Side Resource to improve clinician’s knowledge, skills, and comfort around routine, periodic screening for and diagnosis of STDs in gay men and other MSM –Spiral-bound toolkit and box with accompanying materials –stdcheckup.org website Clinic based campaign aimed at raising patients awareness regarding the asymptomatic nature of STDs and the need for frequent testing

9. STD Control Branch Contents of the MSM Toolkit The spiral-bound toolkit contains information on: STD Screening Clinical Evaluation and Management Enhancing the Care Setting STD/HIV Partner Services Public Heath Reporting Resources and References Additional enclosed Job Aids include: Coding guidelines for vaccine preventable hepatitis Primary and Secondary syphilis algorithms STD Treatment guidelines for HIV-infected adults …and more!

10. STD Control Branch Pilot Evaluation Pilot of STD-Prevent was conducted in 2007 in clinics in 7 counties Pre & Post survey of providers implementing the initiative –Assess acceptability, appropriateness, & usefulness of materials –Barriers to implementation –Topics that are not addressed in materials Lab screening totals six months prior, two months during and six months following the evaluation phase 25 anonymous surveys of patients in clinic waiting rooms –Assess appropriateness & acceptability of clinic based awareness raising materials

11. STD Control Branch Pilot Evaluation (2) Outcome Evaluation Post-Toolkit Survey Data: CDC STD Treatment Guidelines:  Increases seen in proportion of providers reporting having referred to the guidelines, and in those guidelines having guided their patient care in the past year. Sexual History Taking:  Reported sexual history taking behaviors remained at high levels both pre- and post-Toolkit. STD Screening Practices:  Providers reported very high levels of routine and risk-based STD screening at both pre- and post-Toolkit timepoints. Change not discernible from survey data. Awareness of HIV Partner Counseling and Referral Services (PCRS):  Awareness of PCRS increased from 57% of respondents at pre-Toolkit timepoint to 100% of respondents post-Toolkit.

12. STD Control Branch Pilot Evaluation (3) Outcome Evaluation Laboratory Data: (6 months prior and 6 months post) Syphilis Serologic Screening (RPR):  Pre-toolkit mean: 210.0 tests  Post-toolkit mean: 258.7 tests Mann-Whitney U yielded p=0.005. Limitations: Number patients seen per month unknown. Data are for all male patients seen, not stratified by MSM. Positive RPR requires confirmatory testing (e.g. TP-PA). Gonorrhea Testing:  Pre-toolkit mean: 45.2 tests  Post-toolkit mean:62.2 tests Mann-Whitney U yielded p=0.051. Limitations: Number patients seen per month unknown. Data are for all male patients seen, not stratified by MSM or site tested (e.g. urethral, rectal, etc.). Chlamydia Testing:  Pre-toolkit mean: 44.6 tests  Post-toolkit mean:60.7 tests Mann-Whitney U yielded p=0.10. Limitations: Number patients seen per month unknown. Data are for all male patients seen, not stratified by MSM or site tested (e.g. urethral, rectal, etc.).

13. STD Control Branch Limitations  All survey data results based on self-report with relatively small sample of respondents at the four sites (14 completed pre-toolkit survey, 9 completed post- toolkit survey).  Potential for change may have been low due to a relatively high-performing health care provider pool.  Laboratory data based on aggregate counts for all male patients for whom data were available; there was no way to stratify by MSM status.

14. STD Control Branch HIV Care Provider Visitation Program, County A, Summer 2008 A local program identified the need to conduct provider visitation to increase offers of HIV Partner Services Providers were visited by local STD Controller and local communicable disease specialist Improved relationships with local health department Observed improved provider case reporting during visitation program

15. STD Control Branch Proportion of providers reporting P&S syphilis cases within one day of exam, County A, Jan 2008-June 2010

16. STD Control Branch Provider Outreach and Education in San Diego County

17. STD Control Branch Provider Outreach and Education San Diego Epidemiology Medical Provider Trainings and Presentations Clinician and Dental Health Professionals Posters Monthly STD Report Provider Visitation Program

18. STD Control Branch 424 23 346 268 P&S syphilis cases, by year and MSM status — San Diego County, 1988–2009 San Diego County, 2003–2009: 82% among MSM

19. STD Control Branch P & S Syphilis Cases Co-Infected with HIV, by Year — San Diego County, 2000–2009 51% 46%

21. STD Control Branch Primary & Secondary Syphilis Cases by Provider Type — San Diego County, 2009

22. STD Control Branch Medical Provider Trainings and Presentations Presentations to clinicians, mid-levels, and other providers serving populations at-risk for STDs in San Diego on STD screening and treatment recommendations, and disease trends –Audiences: University student health services, HIV providers, dental health professionals, HMOs, and military and family planning medical staff

23. STD Control Branch Medical Provider Trainings and Presentations February 2010, Partnered with the California STD/HIV Prevention Training Center and the Pacific AIDS Education Training Center to offer trainings to local medical providers COURSE TITLECOURSE SIZE STD Overview for Clinicians76 Wet Mount9 Male and Female Genital Exam Skills15 Ask, Screen & Intervene: Incorporating HIV/STD Prevention into the Medical Care of Persons Living with HIV 17

24. STD Control Branch Clinician and Dental Health Professionals Posters January 2010, released two posters targeting medical providers and dental health professionals that can further raise the awareness of P & S symptoms Goals: educate medical providers about P & S symptoms, and encourage screening and testing which can facilitate increased diagnosing and treatment of syphilis in the infectious stages December 2010, posters were updated and will be delivered to medical providers by CDIs and during provider visits.

25. STD Control Branch Clinician and Dental Health Professionals Posters

26. STD Control Branch County of San Diego Monthly STD Report September 2009 - switched from quarterly trend reports to the community to a monthly report Format has adjusted based on feedback in a user survey sent out with the report each month Report is sent to an email distribution list of over 500 individuals

27. STD Control Branch Provider Visitation Program May 2010, County of San Diego started a formal provider visitation program Overarching Focus: –early detection, disease reporting, and partner services (HIV & syphilis) Provider visitation team: –Ken Katz, STD Control Officer –Heidi Aiem, Clinic Services Coordinator –Tom Gray, Syphilis Elimination Liaison

28. STD Control Branch Provider Visitation Program Priority providers have been identified by members of the team and in consultation with disease investigation staff Once a provider is identified for a visit: –Initial contact is made, visit is set-up –STD morbidity for that provider is analyzed –Provider visitation team meets to discuss priority topics

29. STD Control Branch Initial Provider Visit Visits have typically followed a standard format: –Introductions are made –Brief review of local epidemiology –Provider specific data is shared –Priority topics are addressed –Provider is asked about their experience with the County of San Diego –Identification of follow-up items –Visit ends and provider is thanked for their time

30. STD Control Branch Provider Visit Follow Up Interaction is logged in the provider visitation tracking sheet County of San Diego disease investigation staff is assigned to deliver any materials that were needed by the provider

31. STD Control Branch Tracking Log A provider visit tracking log is maintained by the provider visitation team. The following is documented each time contact is made: –Date –Contact type (visit, phone, email) –Person contacted –County staff making contact –Reason for contact –Topics discussed –Materials delivered –Follow-up needed

32. STD Control Branch HIV Medical Provider #1 June 2010, a member of one of the largest medical groups in San Diego is identified by the provider visitation team as a priority visit due to incomplete reporting During the provider visit reporting is discussed and the HIV medical provider states that it might be best if the STD Control Officer discusses this with the head of infectious diseases for the medical group September 2010, provider visitation team meets with the head of infectious diseases (via telephone) to discuss reporting An email from the head of infectious diseases is sent out to the medical group detailing out reporting

33. STD Control Branch HIV Medical Provider #2 May 2010, A private HIV medical provider was identified as a priority visit due to his large patient panel Visit was set-up and conducted During the visit the medical provider shared that it was problematic for him to maintain a stock of bicillin which led to treatment delays County of San Diego staff offered to provide small amounts of bicillin every few months As of December 2010, bicillin has been delivered twice

34. STD Control Branch Questions?

35. STD Control Branch Contact Information Jessica Frasure-Williams Jessica.Frasure@cdph.ca.gov 510-231-7823 Tom Gray Tom.Gray@cdph.ca.gov 619-692-8835