WELCOME! The Center for HIV/AIDS Care and Research (CHACR) at Boston Medical Center A Model of Integrated Programs: Public Health and Clinical Care Encourage audience to ask questions as the presentation goes.

Agenda Background Sexually Transmitted Diseases (STD)/Public Health Clinic Integrated Counseling, Testing and Referral Services (ICTR) Linkage to Care

South End/Roxbury map BMC BMC is on the border of the South End & Roxbury Accessible by public transportation

Campus Map STD Clinic

Definition of Our Roles: within the Department of Infectious Diseases – Center for HIV/AIDS Care and Research Vanessa Sasso Manager HIV CTR Project TRUST, 721 Massachusetts Avenue Glory Ruiz Manager Public Health/STD Clinic Center for Infectious Diseases, Dowling Ground

Timeline 1996 2007 1943 1987 2003 2004 1943- Boston City Hospital (BCH) awarded the STD clinic grant by Massachusetts Department of Public Health (MDPH) 1987- BCH awarded the HIV testing grant by MDPH ATS= “anonymous testing site” 1996- Boston University/BCH merger = Boston University Medical Center 2003- hepatitis testing starts at Project TRUST CTS= “comprehensive testing site” 2004 Rapid HIV testing (Project TRUST- pilot site for MDPH) Free hepatitis vaccines administered at the Center for Infectious Diseases BMC awarded CDC prevention grant to create Project Umbrella 2007 ICTR starts Human Papilloma Virus vaccine administered at the STD clinic B02B World War II: “The Most Extensive Syphilis Case Finding Program in the History of the World” Laura McGough Johns Hopkins University, Baltimore, MD Background: Previous research has emphasized the importance of the biomedical model, first Ehrlich’s “magic bullet” followed by penicillin, in the campaign to control STDs during WWII. This paper re-examines the strategies undertaken by public health officials during WWII in order to determine what policies were adopted during this period, regarded as one of the “successes” of twentieth century STD control. Objectives: To evaluate the successes and failures of one of the largest STD control efforts in US history Methods: The records of the US Public Health Service (USPHS) at the National Archives were read, along with relevant publications from the 1940s Results: Despite initial conflict with the Armed Forces, by 1943 the USPHS and the Armed Forces cooperated in an effort to reduce the prevalence and incidence of STDs among soldiers as well as the civilian population. The result was an STD control program that integrated prevention, treatment, surveillance, research and education. Rapid Treatment Centers (RTCs), primarily for the treatment of women, were opened as early as 1942. The rationale behind these centers was that civilian women served as a reservoir of infection for soldiers. Early publicity focused on how the RTCs would treat prostitutes, a strategy that undermined the effectiveness of the centers in reaching out to infected women not engaged in prostitution. Because the American public regarded STDs primarily as a problem of prostitution, USPHS officials expressed concern that public support for the backbone of the STD control program—contact tracing and case holding—could be undermined. Conclusions: Control of STDs during WWII cannot be attributed to the introduction of penicillin therapy alone, but to the combination of case finding, education, prophylaxis, and surveillance with treatment. Implications for Programs, Policy, and/or Research: Comprehensive STD control programs are more effective than treatment alone. Songs: 1943- “Sunday, Monday or Always” by Bing Crosby 1987- “Walk like an Egyptian” by The Bangles 1996- “One Sweet Day” by Boyz II Men & Mariah Carey, “La Macarena” was number 3!!! 2003- “Crazy in Love” by Beyoncé 2004- “Yeah!” By Usher, feat. Li’l Jon & Ludacris 2007- “No One” by Alicia Keys (this week)

(Gilead, other pharmaceuticals) Hospital Funding Women’s Center HIV Pharmacy Adherence HIV Clinic HIV Medical Case Management HIV Nursing HIV Clinical Research Pediatric ID Travel Clinic Public Funding (MDPH, CDC, NIH, HRSA, etc) Private Funding (Gilead, other pharmaceuticals) Hospital Funding HIV Home Health International/ Refugee Clinic Diagram explains all the services offered at the Center for Infectious Diseases (CID) For the purposes of this presentation, we will focus on the ones in green and blue, which explain how these services are integrated and work together in a seamless way Patients are not aware of the multiple funding streams supporting their care. HIV Counseling and Testing ICTR Clinic Support Staff HIV Prevention and Education STD Nursing Public Health STD Clinic

HIV CTR Sites at BMC Drop-in Center Headquarters (MDPH) Social Networking Project (CDC) Public Health STD Clinic (CDC) Urgent Care Center/ED (MDPH) Drop-in Center Headquarters (MDPH) Women’s Center (Gilead) Adult Primary Care Clinic (MDPH) CTR program consists of a team of 12 counselors who are stationed all over the hospital as well as the community. For this presentation, we’ll focus on the sites in blue. Our team reflects the diverse population that we serve in terms of racial/ethnic background and sexual orientation. Multilingual STD and CTR staff (explain languages spoken). Collaboration: Glory covers the CTR at the STD clinic for Spanish and Portuguese speakers. Inpatient Medical Service (MDPH) Community Based Sites (CDC) MALE Center Family Van Dimock Detox Boston Center for Refugee Health & Human Rights Van Outreach CAB Detox Needle Exchange Van

Overall HIV Testing Data Tests Seropositives Seroprevalence 2005 MDPH (PT) & CDC (PU) 7,657 87 1.1% MDPH (PT) & CDC (PU) 7,956 100 1.3% 2007 MDPH (PT) & CDC (PU) 9,608 90 0.94% Averages: Tests: 683 tests/mo Seropositives: ~8 reactives/mo Seroprevalence: 1.13%

HIV testing data at the Public Health/STD Clinic Tests Seropositives Seroprevalence *Aug-Dec/2005 512 6 1.17% 1,735 30 1.73% 2007 1491 15 1.01% *Aug/05- Rapid testing begins at the STD Clinic Averages: Tests: 130 tests/mo Seropositives: ~2 reactives/mo Seroprevalence: 1.35%

So, what does this really mean? More than 1 million reported chlamydia cases set STD record Story Highlights: CDC: 1 million reported chlamydia cases sets U.S. record Gonorrhea rates also up; drug-resistant "superbug" form increasingly seen Rate of congenital syphilis, which babies get from mothers, up first time in 15 years Chlamydia record may be result of better and more intensive screening updated 1:44 p.m. EST, Tue November 13, 2007 BMC STD Clinic’s QRNG: 2006 – TOTAL: 64 cases, 14 were QRNG = 22% 2007, mid September- TOTAL: 41 cases, 5 were QRNG = 12% DIAGNOSIS YEAR MSM STATE BMC RESISTANT GC 2006 N 12 2 Y 52 2007 16 25 3

STD Clinic Data: Name that STD! # of clinic visits June 05*- May 06 2,798 175 77 48 17 1.65% June 05- May 07 2,845 219 71 59 31 1.55% June 07- Jan 08 1,715 115 49 45 18 0.95% Averages: CT: 16 cases/mo* GC: 6 cases/mo* Syphilis: 5 cases/mo Herpes: 2 cases/mo* HIV: 1.33% * CT and GC= explain sites swabbed/samples taken * HSV= explain sampling (culture not blood testing) * Rapid syphilis testing available for patients with bumps or known contacts. * Aug/05- Rapid testing begins at the STD Clinic

Integrated CTR Program HBV & HCV HIV HIV STD Making the public health connection between HIV, Hepatitis and STI’s People come in for HIV CTR and we offer them the other services – you are more likely to have Chlamydia than you are to have HIV, so why not get it checked out while you’re here…. Clients must be asymptomatic – if experiencing symptoms, we refer them directly to the STD Clinic for immediate exam, test and Tx. Gave us the ability to expand our Hep B&C testing – previously there were strict guidelines around who could test Great collaboration between Project TRUST & STD Clinic – because the STD Clinic is first come first serve, with a limited amount of slots - if the STD Clinic has asymptomatic clients they can refer them to Project TRUST and therefore open up slots for the symptomatic clients Hepatitis A & B vaccine STD

Hepatitis C Testing (HCV) Hepatitis ICTR Data For time period June 1, 2007 through Dec 15, 2007 Gonorrhea Chlamydia Tests Done Results Found Positive Results Returned 241 239 188 9   % Returned 78% Prevalence 0.0% 3.7% Syphilis Hepatitis C Testing (HCV) 231 2 182 140 14 103 78.8% 73.6% 0.9% 10.0% ICTR was implemented on June 1st (2007) Thus far we have identified 7 new Chlamydia cases – remember these people were not experiencing any symptoms and came to us for HIV CTR Syphilis case was an old, previously treated case; referred to the STD clinic for further evaluation and testing. RPR for screening- TPPA for specialized testing

Linkage to Care: what happens when we receive a positive… (+) Hepatitis B/C test result (+) STD test result Counselor makes intake appointment with Hepatitis Nurse in CID STD/PH clinic coordinator Hard copy of DPH result given to coordinator Patient examined and treated by STD nurse Follow-up in 2-3 months

Linkage to Care: what happens when we receive a reactive/positive… (+) HIV test result PCRS revisited Confirmatory test drawn On-call Intake Team in the CID alerted: Intake nurse Medical manager, if needed Mental health, if needed Intake appointment scheduled for later date In our outreach venues/community venues, if the client is willing, we transport them via taxi to the CID for intake Patient brought to the CID by HIV counselor Clinic tour/orientation & Intake Continued care 1st MD visit

Center for Infectious Diseases floor plan As mentioned before, HIV and STD testing and care are not the only clinics that are held in the CID: Refugee Travel Hepatitis Prevention, education & support groups Clinical Research

Any questions?

Thank you! Glory Ruiz Manager Public Health/STD Clinic (617)414-5936 glory.ruiz@bmc.org Vanessa Sasso Manager HIV CTR (617)414-5432 vanessa.sasso@bmc.org