US Virgin Islands IPP: Use of Limited Resources Taetia Phillips-Dorsett, MS Territorial Director, USVI DOH STD/HIV/TB Program Region II IPP Advisory Meeting November 1, 2006

USVI IPP Program Operations Publicly Funded IPP Screening Venues: – STD Clinics, FP Clinics, Prenatal Sites, Community Health Centers Treatment: – $6.00/dose for Azithromycin – FY2006 local govm’t allotment for STD meds=$8,000 ($7,360 actually spent) Test Technology: – Gen-Probe APTIMA CT/GC Combo – Cost: $14.00 per test Budget: – USVI has been actively addressing budget issues related to securing and forwarding payment to the New Jersey DHSS for laboratory screening services.

USVI IPP Screening Criteria Because of budget challenges USVI did not follow the recommended Region II IPP Screening Criteria from March 2005 through July In March of 2005, in consultation with CDC, the USVI issued a memo to all participating clinical sites to test clients in the following categories: – Pregnant Females – Symptomatic Individuals, and – Contacts to persons confirmed with Gonorrhea and Chlamydia

Impact of March 2005 Criteria Overall decline in test volume and case identification: 28% decline in testing volume – from 4,453 tests in CY2004 to 3,207 tests in CY % reduction in identification of positive CT cases – from 597 cases in CY2004 to 476 cases in CY % reduction in identification of positive GC cases – from 129 cases in CY2004 to 59 cases in CY2005

Impact of March 2005 Criteria (cont’d) Marked decline in test volume and case identification in FP and among females: 50% decline in testing of females in FP clinics – from 2,103 tests in CY2004 to 1,061 in CY % decline in testing among females age – from 2,003 tests in CY2004 to 1,392 tests in CY % reduction in identification of positive CT cases in FP – from 236 cases in CY2004 to 159 cases in CY % reduction in identification of positive GC cases in FP – from 44 cases in CY2004 to 17 cases in CY2005.

# of CT/GC Tests* Among Females by HCPT and Year, USVI IPP (N = 10,055) *Includes tests with valid (positive or negative) CT results only.

Chlamydia Positivity* Among Females by HCPT and Year, USVI IPP (N = 10,055) *Adjusted for change in lab test type in 2003 from PACE to APTIMA N = 3,199 N = 3,988 N = 2,868

Gonorrhea Positivity* Among Females by HCPT and Year, USVI IPP (N = 10,089) *Adjusted for change in lab test type in 2003 from PACE to APTIMA N = 3,211 N = 3,999 N = 2,879

Implications of Underscreening FP sites in particular noted that they were not able to screen new clients who had never had a chlamydia test because they did not fit the March 2005 criteria. A clinical provider at the largest FP site on St. Croix noted a dramatic increase in diagnosis of PID for uninsured women: she recorded more than twice as many cases of PID in the first 5 months of 2006 (17 cases) as she recorded in all of CY2005 (8 cases). In addition, staff expressed concern about the increased risk of HIV acquisition in the face of an undetected and untreated Chlamydial infection.

Preliminary Analysis of # Tests Needed to Support Implementation of New Criteria VenueScreening CriteriaAnnual # Tests MalesFemales STDAll<29 yrs630 FPNone<24 yrs1,200 Other Sites (CHC) None<24 yrs600 PrenatalNoneAll ages 1 st & 3 rd trimester 700 (CY2005 data) TOTAL (excluding Prenatal)2,430 Note: Current IPP budget can support 2,600 tests annually.

Plan for Test Kit Allocation and Revised Screening Criteria – July 2006 VenueScreening CriteriaAnnual # Tests MalesFemales STDAll<29 yrs800 (625 swab, 175 urine) FPNone<24 yrs1,200 Other Sites (CHC) None<24 yrs600 PrenatalNoneAll ages 1 st & 3 rd trimester Supported by local STD funds TOTAL (excluding Prenatal)2,600 Note: Current IPP budget can support 2,600 tests annually.

Additional Guidelines for Screening Venues (FP, STD, & CHC) – July 2006 Treat all symptomatic females and males -Males to be tested only at STD clinic sites DO NOT test symptomatic clients DO NOT test clients outside age criteria Recommendation (FP): – Offer each client meeting criteria only 1 free IPP test per year. – FP to identify funds for additional screening once IPP allotment has been exhausted – Creation of an STD screening the STJ DOH clinic to ensure availability to males for both screening & treatment on island with most limited resources

Next Steps Monitor implementation of revised guidelines Monitor test kit allocation system Identify additional sources of funding needed to expand screening program and maintain screening in prenatal clinics - VI Gov has allotted $35,000 suppl. funding for ~2,500 additional tests territory wide - VI Gov has allotted $22,000 suppl. funding for purchase of STD related medications bringing total budget to $30,000 (4x prior year funding). This will allow for routine distribution of meds supply to clinics. Explore evidence of increase in PID - FP currently monitoring in STX, STD clinics have begun monitoring