MOTIVATION TO PREVENT STIS When we STI staff call people who have been diagnosed with a sexually transmitted infection, we want to make sure they and their partners have been treated. We also want to help them figure out how they can avoid from getting infected again. Motivational Interviewing (MI) is an evidence-based counseling technique that can be used to help clients find their internal motivation to change their behavior. With some excellent help from Susan Webb-Lukomski, the STI/HIV team has been practicing some MI skills. The four general principles of MI (from www.motivationalinterview.org) are: ¾ Express empathy (let person know you hear them, you care) ¾ Develop discrepancy (the difference between what they want and what they do) ¾ Roll with resistance (allow people to experience their resistance to change) ¾ Support self-efficacy (let the person be responsible for him/herself) The conversation might go like this: First, the business of the call Did you get your meds? Did you take your meds? Who are your partners? Can I help make sure they have been treated? And a bit of education... Then... On a scale of 1-10, with 10 being the highest, how important is it to you not to get another STI in the future? People almost always choose a 9 or 10. It sounds like you have a goal for yourself to not get another STI. That s really great to hear. On that same 1-10 scale, how confident are you that you can achieve that goal? If they give a low number, it gives us some space to talk about what steps they might take to increase their confidence. If they give a high number, it lets us talk about the specific steps they are going to take to change their behavior. If someone is resistant to planning change, we might say, Changing is hard, and there are positives we all get out of our behaviors, even when they are not good for us. We emphasize that the client is in charge and needs to be the one who decides whether to change. They are the ones who will decide if they will change. Obviously, this is a loose framework for the discussion. We are flexible and sometimes we can t do any of this line of discussion. Motivational Interviewing gives us some new tools to create a collaborative approach to STI follow-up, and we re excited to explore the concept more. PAGE 1
STI DISPARITIES PROJECT We reported on this project in our May 2010 newsletter. As you might recall, there is a large difference in incidence rates of Chlamydia between White and African-American Dane County residents. Since that time, we have moved from looking at what is known nationally to gaining a better understanding of the local situation and about what we can do to decrease this inequity. With the help of Woodie Mogaka, a UW student, and a small grant from the WI DHS STI Program, we have been able to hold 2 focus groups. We asked African- American men, ages 18 24 years to answer some questions that will help us better understand local factors contributing to this disparity. We ll soon begin examining how we can use what they told us to better our services and to decrease infection rates. The work group also is looking at how we can improve Chlamydia screening rates for all women. According to CDC, the cornerstone of Chlamydia prevention is screening young females for infection. The U.S. Preventative Services Task Force recommends that all sexually active nonpregnant young women under age 25 years and older non-pregnant women who are at increased risk be screened annually for Chlamydia. We ll keep you posted as we continue to address this important issue. GONORRHEA TREATMENT RESISTANCE IS GROWING Drug-resistant strains of gonorrhea have increased since the 1980s. In 2009, 23.5% of isolates collected from sampled locations in the U.S. were resistant to penicillin, tetracycline, ciprofloxacin, or some combination of these antibiotics. Now, only the cephalosporins (i.e., ceftriaxone) are recommended and available for the routine treatment of gonorrhea in the United States. A recent increase in resistance to azithromycin is troubling. In some cases, such as with patients who might be allergic to cephalosporin drugs, azithromycin is used alone. If it must be used alone, the person should be retested after treatment to assure that they were cured of infection. At this time, CDC recommends using azithromycin with a cephalosporin, preferably ceftriaxone, to increase efficacy and possibly hinder cephalosporin drug resistance. The STI-HIV Team plays a role in decreasing this drug resistance by working with medical care providers to assure that the correct meds are prescribed. PAGE 2
HOW THE LIFE OF A TEEN GETS IN THE WAY OF TAKING CARE OF HER HEALTH Day 1: A 15 year old girl, let s call her Annie, visits her clinic for birth control and is tested for STIs. She reports no symptoms and receives no treatment at that visit. Day 14: PHMDC receives a report that Annie has chlamydia and gonorrhea. The clinic has tried to locate her for treatment, with no luck. The case is assigned to Cindy Matzinger. Day 15: The school nurse provides Cindy with a private place to meet Annie. Cindy gives her information about STIs and her need for treatment and offers a cab ride to the clinic so she can get the treatment which includes an injection of antibiotic. Annie says she d rather take the bus there and will do so. Day 20: The clinic reports that Annie has not come in. They continue to try to reach her. Cindy asks the school nurse to have Annie call 243-0411 (the STI Line). Day 22: Annie, with the school nurse s help, calls the STI Line. The PHMDC staff reinforces the importance of treatment and offers transportation assistance. Annie again declines a cab, stating she can get to the clinic by bus. Day 26: The clinic reports that Annie still had not been treated. Cindy and the clinic manager make a plan to switch to an oral antibiotic. Cindy calls the school nurse who has Annie call her. Annie says that her mother is making her come straight home from school, but that she ll go to the clinic today, for sure. Day 27: Annie still has not been to the clinic. Cindy calls her at school and gets her permission to pick up the meds at the pharmacy and to deliver them to her. Cindy meets Annie in the school nurse s office where she refuses to drink that water. The school nurse literally chases the student down the hall to her preferred drinking fountain and observes her taking her antibiotics. Cindy notifies the clinic that this 15 year old high school student is finally treated for her dual infection. It took 2 weeks and the work of Cindy, the school nurse, clinic nurse and a team member consulting on the STI line but we got the infections treated. PAGE 3
NEEDLE EXCHANGE AT PHMDC Why We Do It: In 1997, the National Institutes of Health Consensus Panel on HIV Prevention stated: An impressive body of evidence suggests powerful effects from needle exchange programs... Studies show reduction in risk behavior as high as 80%, with estimates of a 30% or greater reduction of HIV in IDUs (injection drug users). In addition, needle exchange programs (NEPs) have been shown to be an effective way to: ¾ Link IDUs with public health services, including TB and STI screening and treatment, and to ¾ Refer to substance abuse treatment. Studies also show: ¾ NEPs do not encourage drug use; ¾ IDUs will use sterile syringes if they can obtain them; ¾ NEPs are cost effective. How We Got Started: Our Needle Exchange intervention started with Madison Department of Public Health (MDPH) doing a community assessment and working with community leaders. MDPH started offering needle exchange as part of its HIV Prevention Program in 1996. At the time, it was the only NEP in the area. Within the next year, AIDS Network and AIDS Resource Center of Wisconsin (ARCW) started larger needle exchange programs in the southern region, including Dane County. Currently PHMDC, AIDS Network and ARCW continue to provide this service. All three agencies work together and formally meet twice a year. AIDS Network and ARCW submit data to PHMDC quarterly. Every year PHMDC also submits information about our program to a survey which compiles national NEP data. PAGE 4 How It Works: PHMDC offers needle exchange on a walk-in basis at all PHMDC HIV Testing clinics. There is no enrollment process. We give new syringes on a one for one exchange, but a small number will be given if the client has none to exchange. Tourniquets, cotton filters, alcohol wipes, bandaids and cookers are available, as well other risk reduction information. HIV, HBV and HCV screening, and immunizations are also offered. Staff makes referrals for TB testing, STI testing and to other community resources such as food pantries and housing, in addition to drug treatment. We are the smallest of the three NEPs in the area. In the last two years all three have seen a steady increase in demand for this service. In 2010 PHMDC served 457 clients, up from 241 in 2009. This trend appears to be continuing in 2011. Did you know that PHMDC does Hepatitis C testing? Screening for Hepatitis C is available at all walk-in HIV Test clinics. ¾ Refer to our schedule on the PHMDC website or our HIV test cards. Who can get tested? ¾ Uninsured with any of the following risks for Hepatitis C: Injected drugs even if it was once or twice a long time ago Received a blood transfusion or organ transplant before 1992 Had a sexual partner who has HCV Shared needles for tattooing or piercing Were told your mother had HCV before you were born Had a positive screening test (antibody test) and need to have a confirmatory PCR done If we identify a new hepatitis C case, an STI nurse provides routine communicable disease followup for hepatitis C when giving the positive test results.
MEET THE TEAM... Back Row: Amanda Kita-Yarbro, Maria Ramirez Torres, Sara Mader, Beth Menke, Cindy Matzinger, Rika Dombrowski Front Row: Allison Reyes, Mary Jo Hussey, Diana Love, Cheryl Robinson, Hershey Barnett-Bridges PHMDC STI LINE All STI and HIV questions answered 8am to 5pm, Monday - Friday ¾ How can I get treated free? ¾ Is there a fact sheet on HIV? ¾ What treatment for someone with allergies? PAGE 5