Harlan Rotblatt Melanie Taylor, MD, MPH Jorge Montoya, PhD Peter R. Kerndt, MD, MPH

1. Harlan Rotblatt Melanie Taylor, MD, MPH Jorge Montoya, PhD Peter R. Kerndt, MD, MPH Sexually Transmitted Disease Program Los Angeles County DHS Gunther Freehill Mario Perez Eduardo Alvarado, MPH Office of AIDS Programs and Policy Los Angeles County DHS TheIntegrationofSexually Transmitted Disease Testing &HIV Counseling and TestingLos Angeles County, 2002

2. 2001 2002 2003 Primary & Secondary Syphilis By Sexual Orientation & Month Of Diagnosis,2001-2003 (Through November, n=956) Cases *Does not include cases lacking partner information Source: LAC-DHS, Early Syphilis Surveillance Summary – as of December 31, 2003

3. Early Syphilis Cases By HIV Serostatus & Sexual Orientation, 2001 – 2003 (n=724) Sexual Orientation Source: LAC-DHS, Early Syphilis Surveillance Summary – as of December 31, 2003

4. Why Do We Need STD/HIV Integration? • Public Health Opportunity • Other STDs can facilitate HIV infection and transmission • HIV infection can facilitate STD transmission and increase severity of sequelae • STD diagnosis and treatment can reduce HIV in a population • Enhance prevention efforts (some HIV prevention strategies less effective for other STDs) • Some strategies can be integrated (e.g., partner notification)

5. Why Do We Need STD/HIV Integration? • Overlapping Risk Groups • Client Convenience • Potential Cost Efficiencies • Funder Expectations

6. HIV Risk Assessment Chronic Patient Tx Testing: Anonymous and Confidential Complex Care Prevention Essential STD Screening Curable Patient and Partner Tx Testing: Confidential Only Simple Treatment Prevention Important Varying Philosophies and Perspectives: Disease Issues

7. HIV Contract Services for System of Care Mandated, Formal Community Planning Targeting Priority Populations Multiple funding issues (e.g., housing) STD PH System, Limited Contracts Limited, Informal Community Planning Broad Screening of Risk Groups Discrete funding requirements Varying Philosophies and Perspectives: Program Issues

8. Implementation Challenges • Risk Assessment: Focus, Intensity • Funding and Reimbursement • Data Collection and Reporting • Treatment and Partner Notification • Confidential vs. Anonymous Testing • Blood vs. Other Fluid Screening

9. The L.A. County Experience: Background • HIV/STD Integration Workgroup • Formed initially in response to PPC request, October 2002 • Includes: • OAPP • STDP • Co-Chairs from Counseling and Testing Task Force • Co-Chairs from PPC • Work Group identified several possible areas for integration • Priority opportunity: LAC HIV Counseling and Testing • Other possible opportunities: • Prevention for Positives • More holistic approach to MSM health care

10. Offering STD Testing Through HCT Contractors: Implementation Issues • Protocols • Training • HCT Contracts • Funding • Records • Data • Results, Treatment and Follow-up

11. Protocols • For HCT contractors that emphasize MSM • Priority for SPA 4 (highest syphilis morbidity) • STD tests to be included: • Syphilis (serology) • NAAT urine test (Aptima-2) for chlamydia and gonorrhea • Anonymous vs. confidential • STD testing available for • Confidential HIV-testers • HIV-positives (no HIV test)

12. Training - for HCT Contractor Staff • Training needs: • STD 101 • STD counseling • Phlebotomy (for syphilis) • CT and GC urine collection protocols • Lab forms and intake paperwork • Implementation • Free from STDP • 85 total trained

13. HCT Contracts • Existing contracts allow STD counseling, referral, and testing • OAPP Letter to HCT Contractors, 11/12/02 • Encouraged STD counseling and referral • No funds for “stand alone” STD testing • Referred contractors to STDP to discuss STD testing • Needed contract changes to change reimbursement structure

14. Funding • Lab (PHL) costs: STDP to pay, with existing funding • Staff costs: • Need mechanism to reimburse for staff time • HCT contracts are fee-for-service • If no funding to cover staff time performing STD tests, STD testing = opportunity cost • Created reimbursement schedule, with input from HCT contractors • $10 for syphilis serology • $5 CT/GC urine test • $5 for results (phone or in-person)

15. Records • Lab forms • Need multi-copy form • Minimize counselor time writing ID info • Separate lab copies for each test, plus copy for patient “chart” • Intake forms • Ideally, use one form • Possibly use sticker added to HIV-5 form • Use custom fields to collect sex partner venue data (for STDP syphilis reports)

16. Data • Need to link: • STD results • Demographics • HIV result • Risk behavior data (from HIV-5) • Data linkage field being determined

17. Results, Treatment and Follow-up • Results • In-person or over phone • Phone contact times given at time of test • Treatment • Positives to be referred to LAC DHS STD clinics, or MSM-friendly community clinics for (free) treatment • Follow-up • Reviewing mechanisms to enable STDP to be follow those who test positive, to ensure treatment and partner notification

18. Ongoing Challenges • Balancing HIV Issues and Needs With Other Health Needs of MSM (Including STDs) • HIV service providers represent a key health interface for MSM • Adapting PH Responses (both HIV and STD) for HIV-Positive MSM • HCT Services Designed for Negatives • Need to Address Sexual Risk Among HIV-Positive Men • HIV-Positive MSM Form the Majority of LAC Syphilis Outbreak • Precursor to Increased HIV Transmission?

19. Implementation Experience • 5 CBOs offering STD testing without staff reimbursement since Fall 2002 • Staff reimbursement will start in 2004 • No special problems reported

20. STD Casefinding Through Integration: Example of One CBO Mobile Testing UnitJan – Nov, 2003

21. Prioritization and Allocation Questions • Can we prioritize multiple morbidities in the context of unmet HIV need? • More HIV impact than ever • Greater investment required to meet HIV prevention goals • Co-factors or Co-morbidities – Which contribute more to HIV burden? • STD control helps reduce HIV

22. Ultimate Goal • Find effective ways to coordinate client-centered services within service planning areas and innovate cost-efficient strategies to deliver quality prevention and care throughout Los Angeles County

23. For further information, please contact: Harlan Rotblatt Sexually Transmitted Disease Program LA County Department of Health Services 2615 S. Grand Ave. #500 L.A. CA 90007 Tel: 213-744-5903 Fax: 213-749-9606 Email: hrotblat@co.la.ca.us

24. Further Framing the Issue • Broad Agreement on Principles of Integration • Differences in Planning Experiences • Local Initiatives and Efforts • Additional Program Considerations

25. Differences in Planning Experiences • STD • Disease Control Planning • Health Department and Clinician Driven • Mandated Participation in HIV Planning • HIV • Evidence Based Community Planning • Community and Health Department Partnerships • Mandate and Funding for Planning • Process as Important as Substance

26. Local Initiatives and Efforts: OAPP • Coordinated Prevention Networks • HIV, STD, Hepatitis MTU Programs • Prevention in Public and Commercial Sex Environments • MSM-specific HIV, STD, Hepatitis MTU Program

27. Local Initiatives and Efforts: OAPP • HIV Outpatient Clinics • HIV Counseling and Testing Services • Multiple Morbidity Screening • Risk Reduction and Health Education • Training • Program Monitoring

28. Local Initiatives and Efforts: STDP • Integrated testing in STDP or multi-agency mobile outreaches • Piloted STD/HIV Integrated Prevention Services (SHIPS) at selected HIV test sites • Piloted syphilis testing with HCT contractor mobile van

29. Local Initiatives and Efforts:Next Steps • Wellness Centers: holistic approach to MSM sexual health – 1 yr pilot project • Long-Range Planning: • Assessment of Resources to Provide STD Screening • Resource Allocation for Integrated Services • Training and Capacity Building for PPC to Plan for STD Prevention • Development of Venue-Specific Policies and Procedures for Integrated Services

30. Additional Program Considerations • Ensure that those testing for HIV return for their results even if it means adopting a policy of encouraging confidential over anonymous testing, to ensure appropriate follow-up. • Develop and implement strategies to ensure that HIV-positive persons have the skills, assistance and support to disclose their status to all of their risk partners – past and future.

31. Additional Program Considerations • Commit as HIV planners to learning how drug interdiction efforts can contribute to reducing new HIV transmissions, just as we have come to understand the importance of harm reduction strategies. • Continue to provide leadership for integrating prevention services across HIV and other public health challenges including STD’s, substance abuse, hepatitis and tuberculosis.