1. Effectiveness of a Highly Mobile, Incidence-Based, Community Outreach Screening Program Chris Serio-Chapman, BS STD/HIV Outreach Coordinator Baltimore City Health Department Baltimore, MD

2. Background In 1997 Baltimore led the nation in the rate of Primary and Secondary Syphilis (P & S). Despite significant progress in decreasing the prevalence of Syphilis from 1998-2002 the rates were still above the national rates and the goal of eliminating Syphilis in the United States. In 2003 the P & S rates in Baltimore began to climb again and if the trend observed in the first half of 2004 had continued Baltimore would have experienced 1997 rates by the end of the year.

3. Baltimore City Health Department Primary and Secondary Syphilis Rates 1997 – 2004

4. Outbreak Response The Baltimore City Health Department (BCHD) implemented its outbreak response plan to intervene in the increase. A key component of this plan was to expand “real time” targeted outreach

5. Response An outreach team was formed to spearhead this effort. The team’s main objective was to take to the city streets and provide testing and screening for Syphilis and HIV. The team would set up screening sites on city street corners in the same fashion as you would a lemonade stand.

6. Screening Goal The Outreach team was given the charge to serologically test 1200 individuals via street outreach in a 3 month time period. This goal was based on the fact that in any year prior to 2004, outreach testing yielded only about 2000 tests per year.

7. Location, Location, Location (Not just important in real estate anymore!) Locations for screening would be incidence based. In order to do this type of outreach, there would be a necessity for daily communication between all of the management players including the Assistant Program Manager, Field Operations Manager, Front Line Supervisors and the Outreach Coordinator.

8. Need for Mobilization An unmarked cargo van was purchased and designed for street outreach. The van was equipped with special lighting and blinds to ensure patient confidentiality. The back area of the van was left open so blood could be drawn on the van. The team also made use of a retro-fitted RV for evening outreach as well as larger screening events and special events. The RV was equipped with a bathroom, large waiting area and 2 lab spaces for phlebotomy.

9. Building a Team Initially the Outreach Team consisted of 2 outreach workers and 1 supervisor. We were trained according to Maryland AIDS Administration and BCHD guidelines including certifications in HIV Counseling, and phlebotomy. The team also received the BCHD’s Syphilis training.

10. Approach to Outreach The team was groomed to be assertive as outreach workers. In the past outreach performed at the city level was often passive. Workers relied on patients to approach them regarding testing and screening services.

11. Course of Action-traditional hours During warm weather months the team “hit the streets” and tested on street corners as well as on front stoops. During cold weather months the team sought partnerships with local shelters, soup kitchens, recovery houses and prisoner assistance programs who would allow us to test their program participants inside their facilities.

12. Course of Action non-traditional hours The evening and weekend outreach team was a combination of DIS staff and health department employees willing to work overtime after hours. Our staff also collaborated with Community Based Organizations to provide joint screening or to use their facilities during inclement weather.

13. Screening Challenges At the onset of testing 1.No uniform system existed for the management of data including risk information 2.The outreach team had to return to the site or refer clients to the STD clinic to give results 3.Each client tested required the completion of four forms and a lab slip

14. Solutions STD*MIS was modified to collect all screening data A call back system was implemented to allow clients to phone for test results. Positive tests were initiated to DIS for follow-up Forms were revised reducing the number of forms to one form and a lab slip

15. Syphilis Results During the first 12 months of screening our outreach team tested 8,179 individuals total. Of that; 7, 930 were screened for Syphilis. As a result, we identified 7 cases of P & S Syphilis, 15 cases of early latent syphilis and 15 cases of unknown duration. The overall RPR positivity rate was 2.9% due to previous patient histories of syphilis infection

16. HIV Results Out of the 8,179 individuals tested by the outreach team, 7,605 were tested for HIV. The results of the tests were 394 patients with positive HIV western blot results for a 6.4% positivity rate. Due to state-specific HIV surveillance issues, it was difficult to establish how many of these were new infections. All HIV + persons are assessed for either interview and partner notification or referred directly to Minority AIDS Initiative Outreach to facilitate access to primary care.

17. Self Reported Risk Data

18. Benefit One of the greatest successes of the newly formed outreach team can’t be measured in numbers or in statistical data. The overall image of the health department in the community has been greatly improved. People now feel like the health department is accessible and caring. Communities are grateful for our presence and interest in them.

19. Conclusion A Health Department Outreach Program can have a significant positive impact on both syphilis and HIV prevention in the community when well organized and focused on high risk populations. A key to the success is for the Health Department to function as a Community Based Organization.

20. Special acknowledgement of contributors to this presentation Jamaal, Abdul (1) Burnett, Phyllis (1)(2) Olthoff, Glen (1)(2) Freeman, Denise (1)(2) (1) Baltimore City Health Department (2) Centers for Disease Control and Prevention