Eradicating HIV and STDs in Oregon: End HIV Oregon Initiative

1. HIV/STD/TB SectionChristy Hudson, MSWHIV Services CoordinatorJosh FerrerSTD/HIV Prevention Technical ConsultantHeidi Behm, RN, MPHTB Controller/Nurse Consultant PUBLIC HEALTH DIVISIONHIV/STD/TB Section

2. HIV ProgramsChristy Hudson, MSWHIV Services CoordinatorChristy.j.hudson@state.or.us

3. Is HIV still a relevant public health topic?

4. Is HIV still a relevant public health topic?

5. Is HIV still a relevant public health topic?

6. The End HIV Oregon Strategy • End HIV Oregon introduced on World AIDS Day, 2016. • Oregon’s commitment to ending new HIV transmissions in Oregon, hopefully within 5 years. • Introduced vision, strategy, and report card. • Aligns with goals set out in State Health Improvement Plan and National HIV/AIDS Strategy www.EndHIVOregon.org

7. End HIV Oregon Vision Oregon’s Vision: We envision an Oregon where new HIV infections can be eliminated and where all people living with HIV have access to high-quality care, free from stigma and discrimination.

8. End HIV Oregon Testing is Easy Prevention Works Treatment Saves Lives

9. End HIV Oregon Baseline Report Card Our Baseline: • Only 35% of adult Oregonians have ever been tested for HIV. • Unknown: We currently don’t know how many people are on PrEP or how many providers are delivering it. Our First-Year Goals: • More than 50% of adult Oregonians will report having HIV testing. • 100 new medical providers across Oregon will be added to the national PrEP Provider directory. • 85% of HIV- partners of HIV case management clients and HIV- MSM diagnosed with syphilis will be referred to PrEP navigation services.

10. End HIV Oregon Baseline Report Card Our Baseline: • 68% of people receiving HIV treatment are virally suppressed. • 69% of people who test positive for HIV are linked to medical care within 1 month. Our First-Year Goals: • 80% of people receiving HIV treatment will be virally suppressed. • 80% of people who test positive for HIV will be linked to medical care within 1 month.

11. What type of support and technical assistance is available for my county?

12. What type of support and technical assistance is available for my county?

13. How can my health department play a role in End HIV Oregon? • Be listed as a supporter on End HIV Oregon website • Make End HIV Oregon materials available at your locations • Support routine, universal HIV screening in your county (health departments, jails, CCOs, FQHCs, schools, etc.) • Partner with Ryan White funded agencies (HIV Alliance, EOCIL, Cascade AIDS Project, Partnership Project, Multnomah, Linn/Benton, Crook, Deschutes, Hood River, Jefferson, Polk and Tillamook counties) • Provide outreach and partner service systems • Provide education and training around PrEP • Join the HIV/STD/VH Integrated Planning Group (IPG)!

14. What resources are available? EndHIVOregon.org Healthoregon.org/hiv Healthoregon.org/hivprevention Oregonreminders.org Aids.gov Thebody.com Aidsetc.org – AIDS Education & Training Centers (AETC) OHA, HIV Program Staff

15. STD ProgramJosh FerrerSTD/HIV Prevention Technical ConsultantJoshua.s.ferrer@state.or.us

16. Why STDs matter • First, third, and fifth most common reportable diseases in Oregon • 1st: Chlamydia (17,425 cases in 2016) • 3rd: Gonorrhea (4,353 cases in 2016) • 5th: Syphilis (810 cases in 2016) • Increase risk for acquisition and transmission of HIV • The cost of STDs to the US health care system is estimated to be as much as $16 billion annually • Significant health disparities – disproportionate impact on youth, people of color, men who have sex with men, HIV+ individuals • Untreated STDs can lead to infertility, reproductive health problems, fetal and perinatal health problems, and other serious long-term health issues

17. Chlamydia Incidence by County of Residence, Oregon 2016

18. Gonorrhea Incidence by County of Residence, Oregon 2016

19. Reported Cases of Gonorrhea, Oregon 2010–2016

20. Early Syphilis* Incidence by County of Residence, Oregon 2016 *includes primary, secondary, and early latent stage infection

21. Reported Cases of Syphilis*, Oregon 2010–2016 *cases staged as primary or secondary

22. What are the state priorities for STDs? • Promote annual chlamydia/gonorrhea screening of women aged 15–24 by health care providers • Promote routine syphilis screening for men who have sex with men • Promote use of expedited partner therapies by health care providers and local health departments • Reduce rate of gonorrhea infections in Oregon residents to 72 cases/100,000 • 2015 baseline 80.4 cases/100,000 • Reduce rate of infectious syphilis rates in Oregon residents to 11 cases/100,000 • 2015 baseline 14.1 cases/100,000

23. Technical assistance and support • The Oregon STD Program offers an array of TA and support:

24. Technical assistance and support • What we do not provide: • Routine staffing • Full range of medications to treat STDs • Routine clinical consultations • Don’t hesitate to call us with questions about difficult, challenging, or unique cases but routine clinical questions/advice should be directed to your Nursing Supervisor and Health Officer

25. Columbia Patrick Washington Sherman Abdon Clatsop Gilliam Hood River Multnomah Phone & fax numbers Patrick Dinwiddie (Portland office) Schedule: Tue-Fri, 7am-5:30pm Desk 971-673-0168 Fax 971-673-0178 Cell 503-784-0241 Email patrick.dinwiddie@state.or.us Abdon Correa (Salem office) Schedule: Mon-Fri, 8am-5pm Desk 503-378-6902 Fax 503-378-6923 Cell 503-510-2316 Emailabdon.correa@state.or.us Umatilla Tillamook Wallowa State DIS Assigned Counties Morrow Union Yamhill Clackamas Wasco Lincoln Polk Marion Wheeler Baker Jefferson Benton Linn Grant Crook Lane Deschutes Coos Douglas Harney Malheur Lake Multnomah County DIS Staff Curry Josephine Desk 503-988-3702 Fax 503-988-5533 Klamath Jackson Last updated 04/11/2017

26. Things to keep an eye on… • Gonorrhea rates in Oregon and gonorrhea treatment resistance • Suspected gonorrhea treatment failure? Call us! • Oregon’s continuing syphilis epidemic & risk for congenital syphilis • Need for extra-genital gonorrhea and chlamydia screening • Use of expedited partner therapy for gonorrhea and chlamydia • HIV and STDs as interrelated conditions • HIV is an STD!

27. Helpful resources • healthoregon.org/std • syphaware.org • cdc.gov/std • cdc.gov/std/treatment (2015 CDC STD Treatment Guidelines) • stdccn.org (STD Clinical Consultation Service)

28. Tuberculosis ProgramHeidi Behm, RN, MPHTB Controller/Nurse ConsultantHeidi.behm@state.or.us

29. Tuberculosis • Airborne disease • Approximately 70 – 80 cases of TB disease per year in Oregon • Approximately 1 multidrug resistant case per year in Oregon. • Latent TB infection vs. TB disease

30. Latent TB Infection • Person is not sick, not infectious • Is not reportable (optional to enter into Orpheus) • LHDs are not required by program element to test for LTBI or treat unless B waiver, contact to case or transfer (even these could be referred out with LHD oversight)

31. TB Disease • Sick. • Can be in any body site. • May be infectious, if disease is pulmonary • Typical treatment is 6-9 months. If multidrug resistant, 18-24 months. • Many patients have comorbidity such as diabetes, substance abuse, mental illness or HIV. • 50-60% of Oregon cases are foreign born. • Can be stressful, complex, expensive and difficult for LHD to manage. Staff will need your support!

32. TB Disease- program element requirements • Must assign a case manager (usually RN) to assess in person monthly and ensure appropriate care/treatment by either LHD or outside provider. • Patient must be on directly observed therapy (DOT). • If pulmonary, laryngeal or pleural must have contact investigation. • Detail: https://public.health.oregon.gov/ProviderPartnerResources/LocalHealthDepartmentResources/Documents/pe/PE%202015-2017/PE%2003%20TB%20Services__FINAL_060415.pdf

33. DOT (directly observed therapy) • Patient must be observed taking pills Monday- Friday (no weekend or holidays). • LHD must ensure DOT takes place and is done correctly…but… • Does not need to be done by LHD. • Options: video/virtual (careful about HIPPA) EMS pharmacy school nurse or college clinic employee health patient comes to your clinic be creative!

34. Contact Investigation • Because TB is airborne can be large (100 +). • Follow-up is complex requiring two rounds of testing, possible chest x-ray and 12 weeks-9 months treatment. • Focus on close family and friends first. • Call us before starting a large investigation in jail, school, workplace, etc. May not be needed! • Questions about exposures in healthcare settings can be forwarded directly to me.

35. OHA TB Program Staff • Heidi Behm, RN, MPH – first person to call! 971-673-0169 heidi.behm@state.or.us program lead, all clinical consultation, questions about regulation (jails, hospitals, skilled nursing facilities), budget, triennial review • Kiley Ariail, MPH– TB Epidemiologist data requests and analysis, follow-up missing data, contact investigation, genotyping, Orpheus, • Gayle Wainwright – Office Assistant tracking of invoices, expenses, chest x-ray reimbursement, TB drug orders, B waivers • Kevin Winthrop, MD, MPH – contracted medical consultant, OHSU infectious disease

36. What TB Program OHA Provides • TB drugs at no cost • Reimbursement for chest x-ray • Incentive and enabler program for patients -Fred Meyer stored value cards or -reimbursement for expense such as housing, transportation -must use form to request BEFORE expense incurred • Special needs request funds -financial support for unique situations: large contact investigation, outbreak, multidrug resistant patient, involuntary isolation -$10,000 maximum first request -must use form to request BEFORE expense incurred

37. What TB Program OHA Provides continued… • Training • Limited onsite technical assistance as needed (usually for large contact investigations) • Clinical consultation to you or medical providers. It’s okay to call me! • Some direct funding based upon case count and formula

38. What cannot provide • Ongoing staffing (there’s only 3 of us!) • Legal consultation on involuntary isolation and quarantine (your county counsel should speak with Shannon O’Fallon) • Payment for all costs associated with managing a TB case • Payment for all costs related to involuntary isolation • Payment for medical costs or patient medical bills other than chest x-ray and TB drugs • We rely on you to know your community and locally available resources

39. Plan ahead for future problems! • How will you house a homeless patient? What motel might accept a patient with an infectious disease? (we can pay bill, but LHD needs to find the housing) • How can you surge staff if needed? OT, other staff, temp. agency? (we can fund temporary staffing, but LHD needs to know how they will surge) • What will you do if a patient or contact has no medical provider? H.O., FQHC? • What will you do if patient is non adherent to plan? Do you know when or how to implement legal interventions?

40. Questions? • Heidi Behm 971-673-0169 heidi.behm@state.or.us