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Public/Private Sector Collaboration Why Does it Always Seem Like a Square Peg in a Round Hole? Michael Allerton MS Daniel Klein MD Sonja vonColl MA Kaiser Permanente Medical Care Program. What are the Legal, Operational, and Cultural Differences That Make Collaboration Difficult?
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Public/Private Sector Collaboration Why Does it Always Seem Like a Square Peg in a Round Hole? Michael Allerton MS Daniel Klein MD Sonja vonColl MA Kaiser Permanente Medical Care Program
What are the Legal, Operational, and Cultural Differences That Make Collaboration Difficult? Some Examples:
Rapid Testing Prenatal Testing HIV Reporting Risk Assessment Condom Education
BACKGROUND: The Kaiser Permanente Medical Care Program
9 Regions Nationally 8,434,930 Members 14,581 HIV Positive Members
Total California HIV Positive Members Northern California Region 4833 Southern Californian Region 5063 9,896 = .16%
RAPID TESTING: 3 MAIN ISSUES:
RAPID TESTING: 3 MAIN ISSUES: Different Goals/Cross Purpose
RAPID TESTING: 3 MAIN ISSUES: Different Goals/Cross Purpose Competitive Disadvantage
RAPID TESTING: HIV Early Detection Study of Unrecognized Positives- HEDS UP - • Nearly half (43%) of newly diagnosed pts. had AIDS-defining immune deficiency at time of HIV dx.
RAPID TESTING: 3 MAIN ISSUES: Different Goals/Cross Purpose Competitive Disadvantage
RAPID TESTING: 3 MAIN ISSUES: Different Goals/Cross Purpose Competitive Disadvantage Assured Referral
PRENATAL TESTING: 85-95% Of Prenatal Patients Are Tested for HIV at First Prenatal Visit
PRENATAL TESTING: 85-95% Of Prenatal Patients Are Tested for HIV at First Prenatal Visit SYSTEMIC APPROACH
PRENATAL TESTING: 85-95% Of Prenatal Patients Are Tested for HIV at First Prenatal Visit SYSTEMIC APPROACH STRATAGIES FOR NEXT PREGNANCY
PRENATAL TESTING: 85-95% Of Prenatal Patients Are Tested for HIV at First Prenatal Visit SYSTEMIC APPROACH STRATAGIES FOR NEXT PREGNANCY LEGISLATIVE CHALLENGES
HIV REPORTING: Legislative Requirements VS. Operational Efficiencies
HIV REPORTING: Legislative Requirements VS. Operational Efficiencies “DUAL” REPORTING
HIV REPORTING: Legislative Requirements VS. Operational Efficiencies “DUAL” REPORTING SS NUMBER
HIV REPORTING: Legislative Requirements VS. Operational Efficiencies “DUAL” REPORTING SS NUMBER ACTIVE SURVEILLANCE
Case Presentation Background: • 37 y.o. Hispanic woman • Diagnosed with sero-neg SLE on prednisone • Past medical history: • Jan 2002 - thrush • May 2002 – skin ulcers • Jun 2002 – zoster • Jul 2002 – candida esophagitis • Aug 2002 – retinal hemor/occlusion • Aug 2002 – CMV, CD4: 5
Case Presentation Background: • 38 y.o. single Caucasian woman • Past medical history: • headaches, obesity • year of recurrent sinus infections • ER visit for asthma/CXR=atelectasis • admitted "asthma/pneumonia" • CD4: 4 • PCP: +
Benefits of Early Detection Background: • Preserve immune function • Increase disease-free survival • Prevent further transmission • Prevent OIs
Barriers to Effective Risk Assessment • Embarrassment • Lack of Training • Married Patients • NOT Lack of Opportunity
Conspiracy of Vagueness • Vague questions or statements that are never clarified: • Changing the topic without pursuing further HIV risk • Leading questions
Examples of Vagueness Clarification needed • “I consider myself pretty safe in that area…” • “I’ve slowed down in recent years.”
Changing the Topic • Doctor: “Does he use condoms every time?” • Patient: “No,not every time” • Doctor: “Not every time?” • Patient: “ Uh huh” • Doctor: “And you said you’re a smoker, right?”
Leading Questions • Doctor: “OK, sounds like you have acid reflux…so--you’ve never done any IV drugs or anything?” • Doctor: “ and you’ve never traded sex for drugs or anything like that, have you?”
Sexual History Taking • “I would like to ask you some questions related to your sexual health that I ask all my patients.” • “Are you sexually active?--if no, have you ever had sex?”
Sexual History • “Are/were your sexual partners men, women, or both?” • “How many sexual partners have you had in the past 6 months? Before that?” • “Did/do you have vaginal, anal, and/or oral sex”
Sexual History • “Have you ever been diagnosed with an STD or thought you might have one? Has your partner?” • “Have you or your partner ever been tested for HIV or advised to be tested?” • “How do you protect yourself from STDs and HIV?”
FAQ What if my patient is married? • “I’d like to ask you a few questions related to your sexual health. These are questions that I ask all my patients regardless of the type of relationship they are in.” • “How long have you been together? • “Before you were a couple did either of you have sex with other people?”
Recommend Testing • “I think it would be a good idea for you to have an HIV test. Sometimes people can have HIV and be unaware of it.” • Refer patients to receive their results from your CHE or HIV Test Counselor in Health Education. • “We will schedule an appt for you with our CHE/ HIV Test counselor to discuss your test results, prevention strategies, and answer any questions you may have.”
Post Test Counseling • Negative post test counseling is primary prevention! • CHE’s and HIV test counselors help patients: • Evaluate 6 month window • Plan for follow-up and partner testing • Learn strategies to reduce risk
CONDOM EDUCATION: THE DEBATE CONTINUES:
The Appropriate Role of Condoms in HIV Prevention – The “ABC…Z” Approach Willard Cates, Jr., MD, MPH Family Health International Infectious Disease Society of America San Diego, CA October 9, 2003
Estimated Risks from 2 Acts of Unprotected Intercourse Per Week Syphilis Gonorrhea Pregnancy HIV (if cofactors) Chlamydia April Jan. July Oct. Dec. MONTHS
0 5 10 25 50 But If Protected by Condoms Syphilis Gonorrhea HIV (if cofactors) Chlamydia Pregnancy YEARS Source: Cates, STD, 2002;29:350-52
CONDOM EDUCATION: THE DEBATE CONTINUES: PRIVATE SECTOR ROLE
CONTACT INFORMATION: MICHAEL ALLERTONHIV OPERATIONS POLICY LEADEREMAIL: Michael.Allerton@KP.org