National Coalition of STD Directors (NCSD) 2010 Annual Meeting San Antonio, Texas October 8, 2010

1. Targeting Gonorrhea Counseling and Sex Partner Services to African Americans Using Zip Codes and Fee-for-Service Reimbursement National Coalition of STD Directors (NCSD) 2010 Annual Meeting San Antonio, Texas October 8, 2010 Charlie Rabins, MPH Illinois Department of Public Health, STD Program Springfield, Illinois

2. Background • Prevention Concerns • Reported gonorrhea decreased 57% from 1986 to 1996 in Illinois excluding Chicago but subsequently increased 54% from 1996 to 2007 despite implementation of CT screening program in 1995 with combo CT/GC NAATs. • Health Equity Concerns • African Americans accounted for 76% (6,992 of 9,215) of reported cases in 2008* • Reported case rate per 100,000 population among African Americans was 37 times greater than among whites* * Illinois Excluding Chicago – among cases where race is known

3. Reported Gonorrhea CasesIllinois (Excluding Chicago) 1986 – 2010* IPP CT/GC NAAT Screening Implemented Targeted Partner Services Implemented IPP CT/GC DNA Probe Screening Implemented * 2010 Projected based on January – August 2010

4. Illinois Excluding Chicago Reported STD Case Rates in 2008Disparity Between Racial/Ethnic Groups

5. Effect of Counseling & Partner Services on Gonorrhea Transmission Dynamics Anderson and May postulated that an STD will continue to spread/reproduce among sexually active persons in a community if the average probability of transmission per sex partner contact (times) the average duration of infection (times) the average number of sex partners per unit of time is greater than one. R0 = (ß x D x c) R0 -Average number of secondary cases generated in a population by a primary case ß - Average probability of transmission per sexual contact (GC=0.5) D – Average duration of infectiousness (GC= 0.5 years) C - Average number of sexual partners per unit time Source: STDs, Holmes et. al. , 3rd Ed., 1999 Chapter 3. Roy M. Anderson

6. Study Objective -1 • Determine if providing targeted patient counseling and sex partner referral services (PCRS) for gonorrhea in selected Zip Codes and reimbursing local health departments (LHDs) on a fee for service basis for PCRS results in a reduction in gonorrhea incidence among African Americans.

7. Study Objective -2 • Determine baseline outcomes and potential performance measures for gonorrhea counseling and sex partner services conducted by LHD public health nurses and disease intervention staff.

8. Methods - 1 • 2007 GC incidence data analyzed - targeting services in selected Zip Codes could predominantly reach African Americans without stigmatizing by race. • Received CDC and IDPH approval to use $202,500 in 2007 federal STD grant carry forward funds for the project with some restrictions. • 6 LHDs selected based on: 1) at least 60% of total city GC cases among African American; 2) representing different geographic areas of state; and 3) ≥ 80% of cases in 6 of fewer zip codes per LHD.

9. 2007 Reported Gonorrhea Cases in Six Cities Selected for the GC PS* Project The 6 Project Site Cities Accounted for 25% of Reported GC Cases in 2007 in Illinois Excluding Chicago. * PS = Partner Services

10. Illinois Cities in Gonorrhea Counseling and Partner Services Project Rockford Peoria Danville Champaign East St. Louis Carbondale

11. Methods - 2 • Fee-for-Service model selected to reward performance but modified to meet CDC and IDPH funding requirements. • $50 per case counseled in clinic • $100 per case counseled by phone or in field • $100 per case resulting in ≥ 1 newly treated infected sex partner • Developed Cx record, web-based data entry, protocol and PCRS Cx algorithm (See Referenced Items) • 2-hour GC PCRS webinar trainings conducted* * GC/CT counseling and partner services training presentation available on www.stdpreventiononline.org website in GC Control Group

12. Results

13. Targeted GC Counseling and Sex Partner Services All Outcomes - 1: February – December 2009

14. Targeted GC Counseling and Sex Partner Services All Outcomes – 2: February – December 2009 CP = Critical Period (60 Days Prior to Positive GC Test Cx = Counseled, Rx = Treatment

15. Targeted GC Counseling and Sex Partner Services All Outcomes - 3: February – December 2009

16. Targeted GC Counseling and Sex Partner Services Outcomes By Sex: February – December 2009 Rpt= Reported, Cx = Counseled, SP = Sex Partners, Tx/Rx = Test/Treatment, Init = Initiated CP = Critical Period (60 Days Prior to Positive GC Test)

17. Targeted GC Counseling and Sex Partner Services Outcomes By Race/Ethnicity: February – December 2009 Rpt= Reported, Cx = Counseled, SP = Sex Partners, Tx/Rx = Test/Treatment, Init = Initiated CP = Critical Period (60 Days Prior to Positive GC Test)

18. Targeted GC Counseling and Sex Partner Services Outcomes By Age Group: February – December 2009 Rpt= Reported, Cx = Counseled, SP = Sex Partners, Tx/Rx = Test/Treatment, Init = Initiated CP = Critical Period (60 Days Prior to Positive GC Test)

19. Targeted GC Counseling and Sex Partner Services Outcomes By Cx Setting: February – December 2009 Rpt= Reported, Cx = Counseled, SP = Sex Partners, Tx/Rx = Test/Treatment, Init = Initiated CP = Critical Period (60 Days Prior to Positive GC Test)

20. Targeted GC Counseling and Sex Partner Services Outcomes By Quarter: February – December 2009 Rpt= Reported, Cx = Counseled, SP = Sex Partners, Tx/Rx = Test/Treatment, Init = Initiated CP = Critical Period (60 Days Prior to Positive GC Test)

21. Targeted GC Counseling and Sex Partner Services Outcomes – 1 By LHD: February – December 2009 Rpt= Reported, Cx = Counseled, SP = Sex Partners CP = Critical Period (60 Days Prior to Positive GC Test)

22. Targeted GC Counseling and Sex Partner Services Outcomes - 2 By LHD: February – December 2009 Rpt= Reported, Cx = Counseled, SP = Sex Partners, Tx/Rx = Test/Treatment, Init = Initiated CP = Critical Period (60 Days Prior to Positive GC Test)

23. Illinois Reported Gonorrhea Among African Americans, 2005 – 2010*Target Cities Compared to Downstate** * 2010 Projected based on reported cases 1-8/2010 ** Downstate = Illinois Excluding Chicago

24. Cost Calculations • $75,450 = Fee for Service Cost for Counseling 754 Infected Persons Resulting in 192 Newly Rx Infected Sex Partners • $393 = Overall Cost per Infected Newly Rx Sex Partner • $246 = Cost for Infected Newly Rx Sex Partner Identified by OP Counseled in Clinic/Time of Rx • $683 = Cost for Identifying Infected Newly Rx Sex Partner Identified by OP Counseled in Field • $645 = Cost for Infected Newly Rx Sex Partner Identified by OP Counseled by Telephone OP = Original Infected Person Counseled

25. Conclusions and Implications - 1 • Number of Critical Period Sex Partners per Case was very Consistent Across Data (~1.4 per case) • Counseling Males May Be More Productive Than Females • Counseling at Time of Rx is almost 2x as Productive as Counseling in Field or by Telephone; and was 2.7 times less costly to Identify Infected Newly Treated Sex Partners • Grants and Contracts Need More Flexibility to Enable Fee for Service

26. Conclusions and Implications - 2 • Counseling Productivity Degraded Over Time Indicating Need for Frequent Feedback to Counselors on Performance and Outcomes • Counseling 20-29 year olds is More Productive than 15-19 year olds • Insufficient Evidence of Reduced Incidence Among African Americans in Target Zip Codes Compared to Other Downstate Communities • Lessons Learned From Pilot Project Facilitated Project Area Wide Expansion of GC/CT PCPS

27. Reported Gonorrhea and Chlamydia Cases Documented Counseling/Partner Services Outcomes Illinois Excluding Chicago: May – August 2010 * Sex Partners Identified in Critical Period per Case Counseled

28. Acknowledgments • Study Co-authors • Steve Holmes • Ed Renier • Administrators and staff at Champaign, East Side, Jackson, Peoria, Vermilion and Winnebago Health Departments • IDPH STD Program staff • Becky Rinozzi • Danny Brikshavana • Wiley Jenkins

29. Questions ? Illinois Department Of Public Health Sexually Transmitted Diseases Program 217-782-2747 Charlie Rabins, MPH Charlie.Rabins@illinois.gov

30. Referenced Items • Map of Gonorrhea Rates in Illinois by County for 2007 • GC PCRS Algorithm • GC PCRS Counseling Record • STD Morbidity Record linked to GC PCRS Cx Record • Web Data Entry Screen for Summary Data • Sample Telephone Scripts • Sample Cost Report for LHDs

31. Jo Daviess Winnebago Stephenson Boone McHenry Lake Carroll Ogle Kane DeKalb DuPage Chicago Whiteside Lee Cook Kendall Will Rock Island Henry Bureau La Salle Grundy Putnam Mercer Kankakee Stark Marshall Knox Livingston Warren Woodford Peoria Iroquois Henderson Tazewell McLean Ford McDonough Fulton Hancock Mason Vermilion De Witt Schuyler Champaign Logan Menard Piatt Cass Adams Brown Macon Sangamon Douglas Morgan Edgar Scott Pike Moultrie Christian Coles Shelby Greene Calhoun Clark Cumberland Macoupin Montgomery Jersey Effingham Jasper Crawford Fayette Bond Madison Clay Richland Lawrence Marion Clinton Wabash St. Clair Wayne Edwards Washington Monroe Jefferson Perry Hamilton White Randolph Franklin Jackson Saline Gallatin Williamson Pope Hardin Union Johnson Pulaski Massac Alexander 2007 Illinois Gonorrhea Rates >300 > 100 - 300 >0 - 100 0 Rate per 100,000 Population

32. Algorithm for Participating LHDs

33. IDPH GC Counseling and Sex Partner Services Data Collection Tool

34. GC Counseling # Morbidity Report Form Used to Link Patient Demographics with GCPS Counseling Record

35. IDPH GCPS Web Data Collection Screen

36. Sample Telephone Counseling Script - 1

37. Sample Telephone Counseling Script - 2

38. GC Counseling and Partner Services ReportAll 6 LHD February – June 2009