High Impact HIV Prevention in STD Clinics Kees Rietmeijer, MD, PhD CBA Consultant January 18, 2016
High Impact HIV Prevention HIV Infected - Testing - Linkage to Care - Retention and Viral suppression High-risk uninfected - PEP - PrEP Both groups Regular STD testing Behavioral counseling
High Impact HIV Prevention in STD Clinics Rationale STD clinics provide high volume HIV testing - Identify disproportionate numbers of new HIV diagnoses - Have established linkage to care protocols and referral mechanisms They also provide high volume STD testing, including nongenital testing among MSM - Identify highest risk HIV-negative persons who may be candidates for PrEP - Identify highest risk HIV-positive individuals that may or may not be in care and may benefit form re-linkage efforts
Alignment Are STD Clinics aligned with high impact HIV prevention activities? - Are they seeing and focusing on those at highest risk, e.g. MSM of color? - Do they have data systems in place that allow for timely monitoring of services and populations served? - Do they have services in place? HIV testing Linkage and re-linkage to care PrEP (by referral or onsite) STD testing, including non-genital CT/GC
High Impact HIV Prevention in STD Clinics Issues Who provides linkage and re-linkage services? - DIS - Specialized linkage to care staff - Clinicians - Others? Who provides or should provide PrEP services? - Referral - On site provision? Starter packs plus referral On-site PrEP clinics
High Impact HIV Prevention in STD Clinics Proposed Action Steps
Goals and Objectives What role should high impact HIV prevention play in the overall scope of STD clinic activities, including other populations, other STDs, family planning activities, hepatitis prevention? What is the scope of services that are currently provided? Are these in line with intended goals? What are the barriers and possible facilitators to shift priority services? How can shifting priorities be accommodated when resources are limited?
Monitoring Need to have the data to assess current services and monitor progress - Functional EMR and other data systems (lab, communicable disease reporting, DIS data) - Ready access to salient data elements: clinic census, demographics, sexual orientation, testing and results data, treatment, partner services, including EPT - Main questions: Are we seeing the right people for the right reasons?
Re-thinking Clinic Operations Staffing Electronic medical record; other data systems Clinic flow; intake, triage, fast-tracking Billing Services offered Integration with other programs, specifically family planning Stat lab
Clinic Staffing Does clinic staffing meet (changing) service needs? Is current staffing cost-efficient? What other models exist and could they inform changes? - Do current clinic protocols require a certain staffing model? - Could changes in protocols/standing orders allow for other, more efficient models? Triage/Express/Fast-tracking visits can be accommodated by medical assistants Integration with family planning may allow for service shifts (e.g., for vaginitis patients)
Staffing Physician extender models - Clinic protocols and standing orders - What is the most efficient provider mix of MDs, NP s, (A)RNs, MA s? - What level of services can be provided at each level? - Are there legal/other impediments to shift responsibilities?
Electronic Medical Record Problems: - Often built to support billing and not public health functions - Cumbersome, especially when trying to emulate paper records - Typically steep learning curve with loss of productivity Advantages - Potential to increase quality of services - Data collected in uniform way Needs - Ready access to data - Timely analyses
Clinic Flow Intake Triage à Comprehensive vs. Express services What are the service stations during the clinic process? - Taking lab specimens - Provider visit - Results and treatment - DIS / Partner services What are the wait times during the process? Time and Motion studies
Billing Billing and cost recovery from Medicaid and third-party payers is increasingly becoming a reality: - Medicaid expansion - EMRs Models have been developed that may provide guidance
Services Offered Review of services offered and costs associated - Monetary - Non-monetary: wait time; staff burden Appropriateness of services - What is the public health benefit of each service provided? - What stat lab tests are needed?
Integration with Family Planning Many STD and family planning clinics occur side by side and are already integrated in smaller health units Integration makes sense: - Targets similar populations - Family planning already providing basic STD screening - Some STD clinics offering family planning services to all STD patients - Staffing integration provides economies of scale and making more efficient use of higher level staff e.g., NP s providing (same day LARCs) Allows for service shifts, e.g., women with vaginal discharge
STAT Lab What stat tests should be offered and to whom? Who should provide STAT lab services? - Laboratorians - Clinical providers
Conclusions Provision of high impact HIV prevention in STD clinics appropriate and feasible but requires adjustments that differ in each clinic setting Assessment/monitoring is essential to guide and evaluate adjustments and overall outcomes Technical assistance is available from the STD Prevention Training Centers (NNPTC) and HIV Capacity Building Assistance (CBA) providers