HIV/AIDS is a significant public health issue in the United States. The Centers for Disease Control and Prevention (CDC) estimates that 1.2 million people aged 13 years old and older are now living with HIV infection, and an additional 50,000 new HIV infections occur every year. One out of eight people with HIV are unaware of their infection. There are tremendous disparities in HIV prevalence. Men who have sex with men bear a greater burden of HIV, accounting for about 63% of all new infections. The estimated number of new HIV infections was greatest among young MSM and HIV disproportionately affects young African American MSM.
As our understanding of HIV/AIDS grows and effective treatments are developed, more focus is put on the needs for enhanced HIV services. In the old model, HIV prevention and HIV care services function separately. This separation was inefficient and compromises the quality of HIV services. To address the limitations of this practice, Champaign-Urbana Public Health District (CUPHD) has 1) increased program capacity, 2) increased HIV testing, 3) increased access to partner services, and 4) increased linkage to medical care through a merger of HIV prevention and HIV care staff. The ultimate goals are to improve the quality and continuum of HIV care, achieve cost sharing through the integration, and reduce the rate of transmission of HIV. To successfully integrate prevention and care services, the practice developed a quality improvement plan based on the National Association of County and City Health Officials’ (NACCHO) strategic planning guide. The primary activity of the merger was to cross-train CUPHD staff to provide both prevention and care services. Staff received both onsite and offsite training. This integration increased current staff capacity to provide both prevention and care services.
Champaign-Urbana Public Health District
Integrating HIV Prevention and Care Services
CUPHD, recently accredited by the Public Health Accreditation Board (PHAB) in 2014, is the local public health authority for the Cities of Champaign and Urbana and Champaign County, Illinois. Champaign County is located in east central Illinois and is 998.39 square miles with a population density of 201.8 people per square mile. Champaign County is an exemplar micro-urban community and a statewide leader in progressive education, health care, government, high technology, light industry and agriculture. In 2013 the US Census Bureau estimated the population to be 204,897 residents, a 1.9% increase since 2010. CUPHD has a mission to improve the health, safety and wellbeing of the community through prevention, education, collaboration, and regulation. With a budget of over $11 million and a staff of 120, CUPHD has expanded to meet countless needs in the Champaign-Urbana community. CUPHD has a multi-disciplinary staff with expertise in program design, implementation and evaluation. CUPHD has accomplished employees in outreach, health education, nursing, epidemiology, finance, information technology, social marketing, and public relations.
Over the past 3 decades, a portfolio of proven strategies have been developed to reduce the risk of HIV transmission, including HIV testing, partner services, antiretroviral therapy, substance abuse treatment, access to condoms and sterile syringes, and screening and treatment for other sexually transmitted infections (CDC, 2011). However, like the nation's health care system, the current HIV prevention and care delivery system is fragmented at best. Evidence-based approaches to HIV prevention and care are not well integrated or coordinated. For example, HIV prevention and HIV care staff at CUPHD worked independently. Prevention staff and care staff worked separately with the same client populations, and there was little communication between staff. When a client presented for services, the prevention staff would test the client for HIV and provide preventive services only. If the client tested positive for HIV, the prevention staff could not provide adequate follow-up care services due to program constraints and lack of training in care services. Rather, the HIV prevention staff would refer the client to HIV care staff for engagement in medical care. Because the two systems were not allowed to share information, it was impossible to know whether adequate follow-up was administered to those who tested positive for HIV. This lack of coordination also made it difficult to provide prevention services for those persons living with HIV, again due to program constraints and lack of training in prevention services among care specialists.
Prior to the integration, HIV prevention staff conducted: HIV Counseling and Testing; Partner Services; Risk Reduction Counseling; Harm Reduction Counseling, including syringe exchange; and STD testing with HIV negative or unknown status persons. Staff performed these services in the agency and in outreach settings including the gay bar. This staff provided HIV prevention services through the CUPHD STD clinic with clients at an increased risk for HIV infection. HIV care staff focused their efforts on persons living with HIV disease. This staff coordinated medical appointments for HIV care and laboratory services. Care staff assisted clients with medical adherence and in understanding their HIV related laboratory services. Adequate housing with financial assistance, as needed, was provided. CUPHD provides financial assistance for medical care, dental care, adequate housing, nutritional needs, and mental health services for HIV positive persons who quality for this assistance under the HRSA guidelines. CUPHD employs four HIV positive peers that conduct client engagement services with clients to encourage adherence to medical care.
The lack of integration of HIV prevention and care was inefficient and compromised quality of HIV services. The integration allows staff to provide the full array of HIV prevention and care services at the time of the client visit. To address the limitations of previous practice, CUPHD has 1) trained existing prevention staff to conduct Ryan White Care services, 2) trained existing HIV care staff to conduct HIV Prevention activities, and 3) increased medical treatment adherence counseling, including surveillance activities. The ultimate goals are to improve the quality and continuum of care, achieve cost sharing through the integration, and reduce the rate of HIV transmission.
The primary activity of the merger was to cross-train staff to provide both HIV prevention and HIV care services. Staff received both onsite training and offsite training by the Illinois Department of Public Health (IDPH). Staff was cross-trained to conduct HIV Counseling and Testing; Partner Services; Linkage to Care services; Ryan White Medical Case Management Services; Risk Reduction Counseling; Harm Reduction Counseling, including syringe exchange; and STD Screening including phlebotomy skills. One additional staff was cross-trained to provide all of these activities, with the exception of Ryan White Services, in addition to Disease Intervention Services (DIS).
Following the integration of these two program teams, a person newly diagnosed with HIV infection could remain with the same CUPHD staff while receiving the HIV test result, through the partner services process, and then be linked to medical care through Ryan White services or their primary care provider. A staff conducting a home visit to provide care services can now provide HIV testing to a partner of the HIV positive client. CUPHD now provides quality HIV prevention services to persons living with HIV disease during the routine medical case management visits. STD testing is routinely offered to HIV positive persons and partner services is now an ongoing services rather than just at the time of HIV diagnosis.
By creating seamless services from HIV testing to entry into medical care for HIV positive clients, our HIV care services are more efficient and effective. Six HIV care staff completed the IDPH seven day HIV Counseling, Testing and Partner Services training over the course of a year’s time. This staff was trained on-site to conduct harm reduction counseling, STD screening, phlebotomy skills, and surveillance activities. Two HIV Prevention staff was trained on-site for several weeks to provide HIV care services.
The design and implementation of the practice involved a number of important stakeholders including HIV prevention and care program directors, members of the teams that were being merged, administration of CUPHD, and community partners and clients. Peer navigators and staff from other agencies in the community who serve the same target population provided input on the current services, recommendations for change, and support to others in the community affected by HIV/AIDS.
Existing staff was incorporated into this new model of care. Existing grant funds were used to develop the staff skills needed for this merger. Staff recorded the time spent in each discipline to the corresponding cost center in the on-line time management system. No new staff was added in response to this merger. Staff spent approximately 160 hours in onsite training to provide care services. In addition, training for prevention activities included 60 hours of on-site training and 40 hours of required IDPH training on HIV Counseling and Testing and Partner Services. The intention was to keep this merger low cost and sustainable to be able to replicate to other communities. We do not anticipate any additional on-going cost to this program. There were no indirect costs associated with this merger.
HIV in the U.S.
The inefficiency and lack of coordination of the previous HIV prevention and HIV care services has been recognized in the newest strategic plan of the CDC 's of HIV/AIDS Prevention 2011-2015. In the strategic plan, the CDC highlighted the importance of prioritizing the allocation of prevention resources, careful monitoring and constant re-evaluation, and intensive and sustained collaboration and coordination with partners. It recommended a comprehensive approach to HIV care that emphasizes prevention with people living with HIV and linkage to and retention in care. Accordingly, the CDC 's new mandates now require programs to document and report complete referrals and care linkages. The CDC’s “High-Impact HIV Prevention: CDC’s Approach to Reducing HIV Infections in the United States” documents the plan that CUPHD adopted.
In response to the CDC 's “High Impact Prevention” plan, a careful evaluation of the current HIV service delivery at CUPHD was conducted. It was decided to merge the HIV prevention and HIV care staff and services. CUPHD HIV leadership developed a quality improvement plan based on NACCHO strategic planning guide to successfully create a seamless HIV service delivery system from HIV testing to entry into medical care for HIV positive clients. According to our knowledge, this merger is the only one of its kind in public health. The current practice is better in several ways. The merged system improves efficiency and effectiveness, improves clients' retention in services, increases linkage to care for HIV positive persons, allows for prevention activities with HIV positive persons, and conforms better with the CDC 's direction. Integration of services is an evidence-based approach, recommended by leading health bodies such as the CDC, HRSA, The Henry J. Kaiser Foundations, NASTAD, and independent researchers across the United States (CDC, 2011; HRSA, 2011;Henry Kaiser Foundation, 2004).
The current CUPHD practice is a timely response to the CDC's goal of creating a future free of HIV. Following the CDC’s “High Impact Prevention” model, CUPHD has identified activities in Biomedical Interventions; Public Health Strategies; Behavioral Interventions; Structural Interventions; and Social Marketing that are now offered in HIV services programming. The increase in the number of staff with the necessary skills to deliver these interventions has increased the capacity of the CUPHD HIV services program. The new coordinated care system is one step forward toward achieving a future without HIV.
Biomedical interventions are highlighted and include Pre-Exposure Prophylaxis (PrEP) to clients most at risk for HIV infection. PrEP is an exciting new HIV prevention tool that has been shown to be very effective in preventing new HIV infections. PrEP used daily is more than 92% effective in preventing HIV acquisition. PrEP is a powerful tool in HIV prevention and even more effective when combined with other prevention strategies. In addition to PrEP, CUPHD staff provides STD testing and treatment to HIV negative and HIV positive clients. Treatment adherence counseling is highlighted in PrEP and Anti-Retroviral Therapy (ART) for CUPHD clients.
In June 2015, CUPHD’s nursing and HIV services staff received extensive training on PrEP from the AIDS Foundation of Chicago and IDPH. After this training, reviewing the CDC’s guidance for initiating PrEP, and consulting with other agencies providing the service, CUPHD opened an onsite PrEP clinic. PrEP is prescribed to clients meeting appropriate risk criteria. Client received a personalized risk assessment; receive risk reduction counseling; and education about adherence and side effects during their initial PrEP session. PrEP clients complete laboratory screening for Hepatitis B and creatinine clearance for kidney function, as well as a rapid HIV antigen/antibody test. The CUPHD medical director and nurse practitioner provide prescriptions for Truvada for PrEP, and HIV services staff works with clients to ensure that they have benefits to pay for medication, through health insurance, Medicaid, or the pharmaceutical medication assistance programs.
STD testing and treatment is offered to both HIV positive and negative clients. CUPHD provides STD services onsite all day each weekday. In addition, CUPHD has an offsite evening clinic one night a week for clients who cannot access services at the main clinic. STD testing is offered in all mobile outreach and during gay bar outreach. STD testing is normalized during routine visits for HIV care services. Since the merger, CUPHD has cross trained two STD clinic nurses to conduct services in both the PrEP clinic and to increase STD testing and treatment in HIV services. These nurses now split their time between STD clinics and HIV services. The integration of services continues at CUPHD with the understanding that integrated services are more efficient and allow for better service delivery. Clients can now access more services with one staff person instead of being bounced between various staff in various programs.
Another biomedical intervention that has been expanded since the merger is treatment adherence strategies to engage HIV positive individuals in medical services. Efforts to identify HIV positive individuals who are aware of their status and to engage them in HIV medical care has become a priority at CUPHD. Research has shown that engaging HIV positive persons in medical care reduces HIV transmission potential through HIV viral suppression. This staff conducts surveillance activities for persons who are previously diagnosed with HIV but are not active in HIV medical care. IDPH generates a roster of persons who are HIV positive but have not had viral load testing in the past six months or have been recently diagnosed with an STD. CUPHD staff conducts DIS investigations to locate these individuals and assist in addressing their barriers to accessing HIV medical care.
This surveillance model has been implemented in the local HIV clinic. The HIV clinic now releases a roster of clients that are not medically-adherent for the same surveillance activities. Staff has discovered that it is easier to locate a client who missed a recent HIV related medical appointment rather than wait until the client is reported by IDPH months later. Staff contacts the client and assists in addressing the barriers in attending medical care. This collaboration has enhanced the quality of care that clients receive.
Public Health strategies, HIV testing for unknown status persons and Partner Services for HIV positive persons have also seen growth in the past year. Onsite partner testing for HIV positive clients has reduced barriers to accessing testing. CUPHD now employs nine IDPH trained HIV Counseling and Testing staff, a three-fold increase since before the merger. This staff has received intensive, focused training to conduct HIV Counseling and Testing with those at risk for HIV. This staff is practiced at delivering an HIV positive test result and conducting partner services elicitation. Linkage to Care interventions are now completed by the staff who identifies the newly-diagnosed HIV persons. CUPHD can now provide accurate documentation of engagement in HIV medical care and ongoing follow up.
Risk Reduction Counseling for HIV positive and negative persons is offered at each client visit. CUPHD HIV services staff are trained to provide client-centered counseling to address HIV and STD risk behaviors. Following the “High-Impact Prevention” model, quality risk reduction counseling with HIV positive individuals significantly reduces HIV transmission. CUPHD staff is trained to deliver risk reduction counseling with their HIV positive clients during care related visits. This continuum of care is client centered and beneficial for clients engaged in care services as they receive this intervention while they are receiving other services at CUPHD.
Behavioral Interventions at CUPHD include a long-standing Mpowerment project for African American MSM. This group follows the CDC Effective Behavioral Intervention model and is managed by two peers who are employed by CUPHD. The peers are IDPH trained in HIV Counseling and Testing. The project uses an offsite location for Mgroups and social events. The peers have been trained in PrEP promotion and market the CUPHD PrEP clinic through their bar zaps and small group activities. Peers are integrated into the CUPHD HIV services programming.
CUPHD employs four HIV positive peers that provide treatment adherence strategies to clients accessing care services. Peers engage members of their social networks to reach “harder-to-reach” clients and connect them to medical care. The peers assist HIV positive persons with scheduling and accessing medical appointment, laboratory testing or other health services that are needed to manage HIV disease. Peers engage these members in AIDS Drug Assistance Program (ADAP) enrollment to ensure successful engagement in medical care. Other barriers to medical care are addressed though one on one meetings and in support groups. These peers are a vital piece of the care continuum and reach HIV positive persons in ways that local health department staff cannot.
CUPHD operates with the understanding that all HIV programming must be supported by structural interventions including syringe exchange and condom distribution. CUPHD has provided syringe exchange services since 2001. CUPHD offers comprehensive harm reduction services to participants. Clients access harm reduction supplies (syringes, cotton, water, ascorbic acid, alcohol swabs, band-aids, cookers, condoms, and lubricant) from trained HIV services staff. Sharps containers are labeled with our project logo and offered to all participating clients. Participants who are hesitant to take a sharps container are offered a hard plastic container, often bleach or laundry detergent bottle, for collecting syringes. In addition, CUPHD provides overdose prevention services. Participants are trained in the signs and symptoms of opiate overdose and in rescue breathing. The overdose training includes Naloxone administration, how to continually monitor the overdosing person, and how to contact emergency services.
Condoms are distributed throughout the agency, through mobile outreach, and at the gay bar. Access to condoms is vital in reducing new HIV infections. CUPHD works to ensure that people living with HIV, or who are at risk for HIV infection, have easy access to condoms as a prevention tool. HIV services staff conducts “condom teaching and teach back” with all clients who are seen the CUPHD STD clinic. This prevention skill is taught with clients in Counseling and Testing and Risk Reduction Counseling. While most clients report that they know how to properly use a condom, the intervention often reveals areas for skill improvement.
CUPHD has adopted the national social marketing campaign, “Getting to Zero” and put a local spin on it with “CU at Zero”. The campaign has three tenets: Zero new HIV infections; Zero HIV related deaths; and Zero HIV-related stigma. The campaign is particularly useful because it fits well with CUPHD’s integrated services model, as it engages both HIV positive and negative individuals. “CU at Zero” incorporates all of the interventions that are employed at CUPHD to end HIV in our community. Messaging under the “CU at Zero” brand can range from promoting condom use, to PrEP and HIV testing, to treatment adherence, and STD testing for HIV+ people. The campaign differs from traditional “use a condom everytime” campaigns, and parallels efforts happening in larger cities.
CUPHD has evaluated the HIV prevention and care merger since completion. A survey was conducted in December 2014 to evaluate the merger perceived effectiveness from the HIV services staff perspective. The survey was delivered anonymously via SurveyMonkey® and was completed by eight members of the staff. The overall perception of the merger has been positive. The majority of the responses to the survey showed positive attitudes towards the cross-training of staff in prevention and care, and that staff perceived am increase in communication and workflow efficiency. Areas of note are found in the training session effectiveness. Most respondents “agree” and “strongly agree” with statements regarding the perceived value of the training sessions and the way in which the training was delivered. When asked how CUPHD could improve the delivery of the training sessions, a majority of employees asked for more training sessions or follow-up/refresher training sessions to reinforce the various activities.
Areas of improvement that were identified in the staff survey included the integration of the HIV positive peer staff into the overall merger. The staff requested more interaction with the peers to better incorporate their efforts into the work of the integration model. This will be addressed in the next steps in the merger’s progress. Another area for improvement was in increasing the fluidity and speed of communication between staff members. Common among the comments made were improvements for quicker replies to emails, presence of supervisors at meetings, and more open conversations about the tasks, and individual check-ins between staff and supervisors. Though to note, when asked if staff have been working effectively together, most responses were in agreement or strong agreement.
Finally, in terms of staff reporting of client-level concerns, there was very little concern about the way services were being delivered as a merged model. Overall, it would appear the merger is doing well in its first year of progress. The staff is generally pleased with the merger and believes the merger has been effective in combining the prevention care roles. Client satisfaction surveys are conducted bi-annually and address the client perception of the quality of services that they receive.
CUPHD initiated a Quality Assurance (QA) review of the HIV services merger in September 2015 to ensure that goals that were set for the merger have been satisfied. CUPHD has been trained by PHAB to conduct program evaluation using the Kaizen model. The project goals included: 1) increased program capacity, 2) increased HIV testing, 3) increased access to partner services, and 4) increased linkage to medical care through a merger of HIV prevention and HIV care staff. Secondary goals to meet these project goals included: 1) trained existing prevention staff to conduct Ryan White Care services, 2) trained existing HIV care staff to conduct HIV Counseling and Testing Services and Partner Services, and 3) increased medical treatment adherence counseling, including surveillance activities. Results of this QA process will inform HIV services leadership on the next steps toward further integration.
The “High-Impact Prevention” model prioritizes interventions that are cost-effective. HIV testing and condom distribution are strongly supported as cost-effective interventions. Reducing new infections through treatment adherence and risk reduction interventions for persons living with HIV are also prioritized. The CUPHD HIV services plan was developed around these priorities. Providing preventative services to HIV positive persons at the time of care services is more efficient and client centered as clients are not asked to go between the divided staff for needed services.
The merger is a more efficient use of resources and can achieve cost sharing. No new staff was added in this process. This merger fits well with CUPHD’s goal of ensuring that every position within the agency is staffed “three-deep”, meaning that there are at least three employees who can do each job or activity. As staff transition to new employment, CUPHD has more available remaining staff to cover the various HIV services activities which promotes good client services. As staff is hired to work in CUPHD HIV services program, candidates understand that their efforts will be divided between prevention and care.
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