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

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

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

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

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

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

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.

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

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.

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

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

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: 4% (CEDIS) vs 28% (Trad)

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

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 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

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.

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

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

Preventive Index for ES cases Year

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

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

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

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 2010. But HIV is a different disease. Talk about the patients reaction. What you have learned.

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.

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.

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

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.

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.

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.

How to offer Partner Services Phone numbers/Phone records Addresses Screen names/Emails 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.

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.

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

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

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.

Culturally Sensitive Issues

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.

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.

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.

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

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.

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.

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.

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.

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?

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. Email me for info on how to obtain MH log-on.

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/email 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 email and seeked testing and tx themselves.

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

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.

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.

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.

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.

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

Thanks… Contact Information: Johnny Cross Jcross@lagaycenter.org 55