Florida s HIV Testing Efforts

Florida s HIV Testing Efforts Mara Michniewicz, MPH Prevention Program Manager Florida Department of Health (DOH) Bureau of Communicable Diseases HIV/AIDS Section Florida Comprehensive Planning Network Meeting Tampa, FL November 8, 2018 Division of Disease Control and Health Protection 1

HIV Testing Overview Centers for Disease Control and Prevention (CDC) HIV Prevention Grant for Health Departments Funding Period: January 1, 2012 December 31, 2017 Final year (2017) award: $34.7 million HIV testing in health care and non-health care settings HIV testing in all 67 county health departments (CHDs) Over 1,400 registered HIV test sites Division of Disease Control and Health Protection 2

Total HIV Tests Conducted under CDC HIV Prevention Grant, Florida, January 2012 December 2017 HIV Prevention Grant (CDC-PS-12-1201) Total Tests All Positives (% seropositivity) New Positives (% seropositivity) All Tests (Health Care and Non- Health Care Settings) 2,271,540 22,272 (0.98%) 8,796 (0.38%) Health Care Settings Only 1,375,074 11,257 (0.81%) 4,201 (0.31%) Non-Health Care Settings Only 896,466 9,399 (1.05%) 4,595 (0.51%)

HIV Tests Conducted and Positivity Rates, Florida, January 2012 December 2017 450,000 400,000 350,000 300,000 408,119 1.0% 428,293 1.0% 413,063 379,747 1.0% 1.0% 367,811 340,495 1.1% 1.0% # Tests 250,000 200,000 150,000 100,000 0.9% 0.9% 0.9% 0.8% % Positive 50,000 0 2012 2013 2014 2015 2016 2017 # HIV Tests % Positivity 0.7% Division of Disease Control and Health Protection 4

% Positive 5.00 4.50 4.00 3.50 3.00 2.50 2.00 1.50 1.00 0.50 HIV Seropositivity by Sex and Race/Ethnicity, Florida, 2002 2017 0.00 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 White Male Black Male Hispanic Male White Female Black Female Hispanic Female Division of Disease Control and Health Protection 5

HIV Tests Conducted in Health Care Settings by Race/Ethnicity, Florida, January 2012 December 2017 (N=1,375,074) 0.2% 1% 4% American Indian/Alaska Native 25% Asian Black/African American 43% Hispanic Native Hawaiian/Pacific Isle 0.1% White 27% Multiracial/Other

HIV Tests Conducted in Health Care Settings by Site Type, Florida, January 2012 December 2017 (N=1,375,074) 2% Community Health Centers 7% 16% Correctional Facility Clinics Emergency Departments 25% 8% Inpatient Hospitals Other Clinical Settings 8% Pharmacy-based Clinics Primary Care Clinics (Other than CHCs) 7% 0.005% 27% 0.3% STD Clinics Substance Abuse Treatment Facilities TB Clinics Division of Disease Control and Health Protection 7

Newly Diagnosed HIV-Positive Tests in Health Care Settings by Site Type, Florida, January 2012 December 2017 (N=4,201) 2% Community Health Centers 5% 22% Correctional Facility Clinics Emergency Departments 35% Inpatient Hospitals 14% 7% 0.1% 6% Other Clinical Settings Primary Care Clinics (Other than CHCs) STD Clinics Substance Abuse Treatment Facilities 9% TB Clinics Division of Disease Control and Health Protection 8

Newly Diagnosed HIV-Positive Tests by Race/Ethnicity, Non-Health Care Settings, Florida, January 2012 December 2017 (N=4,595) 0.3% 1% 0.2% 3% White 22% Black/African American 28% Hispanic American Indian or Alaska Native Asian 46% Native Hawaiian or Pacific Isle Multiracial/Other Division of Disease Control and Health Protection 9

Total HIV Tests among Florida Counties Performing Greater than 10,000 per Year, January 2012 December 2017 120,000 100,000 80,000 # Tests 60,000 40,000 20,000 0 BROWARD DUVAL HILLSBOROUGH MIAMI-DADE ORANGE PALM BEACH PINELLAS 2012 2013 2014 2015 2016 2017 Division of Disease Control and Health Protection 10

HIV Testing Data, 2017 Division of Disease Control and Health Protection 11

Total HIV Tests and HIV-Positive Tests by Sex, Florida, 2017 Total HIV Tests (N=340,520) 0.3% 1% Total HIV-Positive Tests (N=2,929) 1% 1% Female 19% 51% 48% Male Transgender Missing Data 79% Division of Disease Control and Health Protection 12

Total HIV Tests by Race/Ethnicity, Florida, 2017 (N=340,520) 0.2% 1% 26% Amer Indian/Alaskan Asian Black 40% Hispanic 0.1% 1% 8% Missing/Refused Multiracial Native Hawaiian/ Pac Isle 24% White Division of Disease Control and Health Protection 13

Total HIV Positive Tests by Race/Ethnicity, Florida, 2017 (N=2,929) 0.3% 1% 19% Amer Indian/Alaskan Asian 0.03% 1% 2% 46% Black Hispanic Missing/Refused Multiracial 31% Native Hawaiian/ Pac Isle White Division of Disease Control and Health Protection 14

Total HIV Tests and HIV-Positive Tests by Age Group, Florida, 2017 Total HIV Tests (N=340,520) Total HIV-Positive Tests (N=2,929) 0% 3% 15% 4% 7% <13 21% 13% 13-19 20-29 31% 30-39 37% 40-49 18% 24% 50+ 27% Division of Disease Control and Health Protection 15

HIV Seropositivity Rates by Self-Reported Risk Behaviors, Florida, 2017 Sex for Drugs STD Diagnosis Sex with Other Sex with IDU Sex with HIV IDU MSM Refused to discuss risk Missing Data No Identifiable Risk Heterosexual MSM/IDU 0.2% 0.5% 0.5% 0.3% 0.6% 0.6% 1.1% 1.7% 2.3% 3.4% 5.6% 7.3% 0.0% 1.0% 2.0% 3.0% 4.0% 5.0% 6.0% 7.0% 8.0% Division of Disease Control and Health Protection 16

HIV Seropositivity among Females by Age Group and Race/Ethnicity, Florida, 2017 1.2% 1.1% 1.0% % Positive 0.8% 0.6% 0.4% 0.2% 0.0% 0.0% 0.0% 0.0% 0.0% 0.5% 0.4% 0.2% 0.2% 0.2% 0.8% 0.7% 0.5% 0.4% 0.4% 0.3% 0.2% <13 13-19 20-29 30-39 40-49 50+ White Black Hispanic 0.5% Division of Disease Control and Health Protection 17

HIV Seropositivity among Males by Age Group and Race/Ethnicity, Florida, 2017 3.0% 2.8% 2.5% 2.5% 2.3% % Positive 2.0% 1.5% 1.0% 0.5% 0.0% 1.6% 1.4% 1.5% 1.5% 1.3% 1.2% 1.3% 1.1% 0.6% 0.7% 0.6% 0.0% 0.2% 0.0% 0.0% <13 13-19 20-29 30-39 40-49 50+ White Black Hispanic Division of Disease Control and Health Protection 18

Positivity Rates among Persons Testing Positive for the First Time by Sex and Race/Ethnicity, Florida, 2017 1.2% 1.1% 1.0% 0.8% 0.8% % Positive 0.6% 0.4% 0.5% 0.3% 0.2% 0.2% 0.1% 0.0% White Male White Fem Black Male Black Fem Hisp Male Hisp Fem Division of Disease Control and Health Protection 19

HIV Test by Test Type and Positivity Rates, Florida, 2017 1.20% positivity (N=340,520) 5% 0.90% positivity 23% 0.80% positivity 72% Rapid Blood Oral Division of Disease Control and Health Protection 20

Public/Private Partnerships Gilead FOCUS Project In 2017: Over 67,000 HIV tests (1.6 percent positivity) and Over 66,000 hepatitis C (HCV) tests (4.3 percent positivity) Eleven partners with 24 locations Six new partners in development Division of Disease Control and Health Protection 21

10/30/2018 Division of Disease Control and Health Protection 22

Program Highlights Increased provider awareness and education on: Routine, opt-out HIV screening Integrated screening Opt-out HIV/STD screening for pregnant women Screening for pre-exposure prophylaxis (PrEP) Revised Florida s HIV testing statute in health care settings (i.e., opt out) Development of resources for routine HIV screening Revisions to DOH Rapid HIV Test Site Guidelines Division of Disease Control and Health Protection 23

Program Highlights, continued In 2017: Added 31 new publicly-funded HIV testing sites Central Office conducted 51 rapid HIV testing trainings and certified 701 new HIV counselors Over 70 contracts with community-based and health care organizations included HIV testing (approximately $11 million) Revisions to DH1628 data collection form for PrEP Electronic HIV test resulting pilot project Division of Disease Control and Health Protection 24

INSTI rapid HIV test pilot Future Projects In-Home rapid HIV test pilot Increase routine HIV screening in CHD STD and Family Planning clinics Increase integrated screening (STDs and HCV) Improve automation of HIV testing data collection Analysis of HIV test data from private labs Division of Disease Control and Health Protection 25

Florida s PrEP and npep Initiatives Mara Michniewicz, MPH Prevention Program Manager Florida Department of Health (DOH) Bureau of Communicable Diseases HIV/AIDS Section Florida Comprehensive Planning Network Meeting Tampa, FL November 8, 2018 Division of Disease Control and Health Protection 26

Florida s Plan to Eliminate HIV Transmission and Reduce HIV-related Deaths Implement routine HIV and Sexually Transmitted Infections (STI) screening in health care settings and priority testing in non-health care settings Provide rapid access to treatment and ensure retention in care (Test and Treat) Improve and promote access to antiretroviral preexposure prophylaxis (PrEP) and non-occupational post-exposure prophylaxis (npep) Increase HIV awareness and community response through outreach, engagement, and messaging 27

PrEP and npep Implementation in CHDs Integration of PrEP services in all 67 county health department (CHD) STD and Family Planning clinics by December 2018 Technical assistance to CHDs for npep service delivery Expedited npep delivery challenged by CHD hours of operation Collaborative npep delivery models Division of Disease Control and Health Protection 28

PrEP and npep Implementation in CHDs, continued CHDs can provide either a 30, 60, or 90-day supply of Truvada for PrEP (at no charge to client) PrEP protocols and clinic guidance developed by HIV/AIDS Section Medical Unit Majority of CHDs working towards same-day PrEP initiation 10/30/2018 Division of Disease Control and Health Protection 29

PrEP and npep Implementation in CHDs, continued As of September 30, 2018, 41 of 67 (61%) CHDs are providing PrEP services Over 1,800 PrEP clients have been served to-date* An additional 19 of 67 (28%) CHDs report making npep available Over 100 npep clients have been served to-date* * Cumulative number of clients enrolled in PrEP at the CHDs. DOH-Okaloosa began providing PrEP services in 2015; and DOH-Miami-Dade began providing PrEP services in 2016. DOH Health Management System (HMS) PrEP and npep codes were initiated in July 2017. Division of Disease Control and Health Protection 30

CHDs Participating in PrEP (as of 9/30/2018) (N=41) Division of Disease Control and Health Protection 31

PrEP Implementation Activities Timeline DOH 4-Key Component Plan developed; PrEP Consultation conducted (June) Creation of additional PrEP navigator positions within CHDs PrEP/nPEP Provider Toolkits and guidelines created PrEP/nPEP modules added to HIV 500/501 1 st CHD PrEP Survey (July) State Surgeon General s initiative for statewide PrEP availability in all CHDs 1 st PrEP Institute held 2 nd PrEP Institute (May) 3 rd & 4 th PrEP Institutes (August) 2015 2016 2017 2018 HIV/STD Workshop conducted with DIS (November) PrEP/nPEP questions added to HIV testing form PrEP/nPEP Provider Directory developed PrEP/nPEP HMS service codes PrEP meds purchased 2 nd CHD PrEP Survey (February) Division of Disease Control and Health Protection 32

PrEP/nPEP within Community-Based Organizations Total of 38 community-based high-impact prevention (HIP) providers funded From January 1 September 30, 2018, 21 of the 38 (55%) providers reported 1,896 PrEP referrals and 387 clients receiving PrEP During this same period, 10 of the 38 (26%) providers reported 107 npep referrals and 87 clients receiving npep Division of Disease Control and Health Protection 33

Florida PrEP Institutes Collaboration with CDC Capacity Building Provider Network (CPN); San Francisco Department of Public Health Three-day interactive agenda Four regional PrEP Institutes conducted in 2018, with a total of 67 CHDs and over 170 attendees Division of Disease Control and Health Protection 34

PrEP Capacity Building Trainings, 2018 PrEP in Communities of Color training by AIDS Project Los Angeles (APLA) Orlando, April 30 May 1 PrEP Navigation trainings by National Community Health Partners (NCHP) Tampa, July 25 Miami, July 27 Orlando, August 27 PrEP-based Motivational Interviewing by PROCEED Orlando, September 10 11 Miami, September 13 14 Delivery of PrEP Services for LGBTQ Populations by APLA Ft. Lauderdale, August 23 & 24 (two, one-day trainings) Cultural Competency with a PrEP Element by APLA (TBD, October) 10/30/2018 Division of Disease Control and Health Protection 35

PrEP/nPEP Provider Toolkits Provider Resources PrEP Plan of Action npep Plan of Action Taking a Sexual History Fact Sheet Diagnosing and Treating Bacterial STIs in Men who have Sex with Men (MSM) Fact Sheet PrEP Triage Fact Sheet PEP Triage Fact Sheet Patient Resources Counter Card Display Brochures (English and Spanish) Posters (English and Spanish) Division of Disease Control and Health Protection 36

PrEP/nPEP Provider Toolkits, continued Division of Disease Control and Health Protection 37

PrEP/nPEP Provider Toolkits, continued Division of Disease Control and Health Protection 38

PrEP Directories FL DOH PrEP Provider Directory (includes npep also) https://flhiv.doh.state.fl.us/clinicsearch/floridaprepnprep ClinicSearch.aspx National PrEP Databases https://preplocator.org/ https://www.pleaseprepme.org/ https://www.pleaseprepme.org/florida Division of Disease Control and Health Protection 39

Florida PrEP Users by Year, 2012 2016 (N=13,337) 6,000 5,638 5,000 4,000 4,081 3,000 2,000 1,829 1,000 838 951 0 2012 2013 2014 2015 2016 Source: AIDSVu/Gilead PrEP Data released March 6, 2018 Division of Disease Control and Health Protection 40

CHD PrEP Client Data Data sources: DOH Health Management System (HMS) Local PrEP Data Reports (Okaloosa, Miami-Dade, and Broward counties) DOH HMS Data Reporting Period: 7/01/2017 9/30/2018 Division of Disease Control and Health Protection 41

CHD PrEP Clients by Month*, Florida 2,000 1,800 1,838 Number of Clients 1,600 1,400 1,200 1,000 800 600 400 200 0 132 18 46 61 138 168 220 327 431 541 632 796 1,087 1,278 1,438 *Cumulative numbers for clients enrolled in PrEP services at CHDs. Division of Disease Control and Health Protection 42

CHD PrEP Clients by Gender, Florida (N=1,838) 24% Female Male 76% Division of Disease Control and Health Protection 43

800 700 CHD PrEP Clients by Age Group, Florida (N=1,838) 720 Number of PrEP Clients 600 500 400 300 200 100 111 552 249 159 48 0 13-19 20-29 30-39 40-49 50-59 60 and Older Age Groups Division of Disease Control and Health Protection 44

CHD PrEP Clients by Race/Ethnicity, Florida (N=1,838) 2% 31% 5% 27% American Indian/Alaska Native Asian/Hawaiian Pacific Islander Black Hispanic Multiracial/Other 35% White Division of Disease Control and Health Protection 45

CHD PrEP Clients by Gender and Race/Ethnicity, Florida (N=1,838) Females Males 0% 2% American Indian/Alaska Native 36% 48% Asian/Hawaiian Pacific Islander Black Hispanic 29% 21% Multiracial/Other 6% 3% 13% White 42% 10/30/2018 Division of Disease Control and Health Protection 46

CHD PrEP Clients by Payor Source, Florida (N=1,838) 34% Private Insurance Medicaid 58% Medicare Uninsured 7% 1% Division of Disease Control and Health Protection 47

Next Steps Work with STD Section to increase PrEP referrals from Disease Intervention Specialists Modify data systems for PrEP referral data collection Develop PrEP materials specifically for women Amend minors consent to STD treatment statute Refine CHD PrEP HMS reports to include: PrEP retention data Transgender data Mode of exposure/risk category data 10/30/2018 Division of Disease Control and Health Protection 48

Florida s Partnership for Care (P4C) Project Outcomes Mara Michniewicz, MPH Prevention Program Manager Florida Department of Health Bureau of Communicable Diseases HIV/AIDS Section, Prevention Program Florida Comprehensive Planning Network Meeting Tampa, FL November 8, 2018 Division of Disease Control and Health Protection 49

P4C Project Overview Centers for Disease Control and Prevention (CDC) and Health Resources and Services Administration (HRSA) led project over four years (July 2014 June 2018) Increase collaboration between health departments and community health centers to: Expand provision of HIV testing, prevention, care, and treatment Build sustainable partnerships between health centers and health departments Improve health outcomes among persons living with HIV, especially racial/ethnic minorities Division of Disease Control and Health Protection 50

P4C Overview, continued Florida s P4C health center partners: I.M. Sulzbacher Center (Jacksonville) Health Care Center for the Homeless (Orlando) Genesis Community Health Center (Palm Beach) Broward Community and Family Health (Ft. Lauderdale) Care Resource (Miami-Dade) Community Health of South Florida (Miami-Dade) Division of Disease Control and Health Protection 51

Florida P4C Partners State Health Department Prevention Program Manager Project Coordinator Clinic Coordinator Monitoring and Evaluation Consultant County Health Departments HIV/AIDS Program Coordinators P4C Managers P4C Disease Intervention Specialists (DIS) Community Health Centers P4C Lead Care Team Lead Community Health Centers Six Health Centers P4C Care Teams P4C DIS and HIV Prevention Staff County Health Departments Florida Department of Health, Central Office P4C Core Team Division of Disease Control and Health Protection 52

P4C Project Data Project data period: July 2015 December 2017 Patients newly diagnosed at health centers: 318 Not in Care patients in P4C service areas: 2,267 Not in Care patients linked or re-engaged: 878 10/30/2018 Division of Disease Control and Health Protection 53

Newly Diagnosed Patients at P4C Health Centers and those Interviewed for Partner Services, July 2017 December 2017 140 120 128 130 120 113 # of Patients 100 80 60 40 60 58 20 0 July 2015 June 2016 July 2016 June 2017 July 2017 Dec. 2017 # Newly Diagnosed Patients at Health Centers # Interviewed for PS Division of Disease Control and Health Protection 54

P4C Client Demographics P4C Clients by Sex (N=318) 21% 2% P4C Clients by Race/Ethnicity (N=318) 1% 6% 40% 43% 77% Male Female Transgender 10% Black White Hispanic Multiracial/Other Unknown Division of Disease Control and Health Protection 55

P4C Client Demographics, continued 140 P4C Clients by Age Group (N=318) Number of Clients 120 100 80 60 117 102 55 40 34 20 0 10 19 yrs 20-29 yrs 30-39 yrs 40-49 yrs 50+ yrs 10/30/2018 Division of Disease Control and Health Protection 56

Newly Diagnosed Health Center Patients Interviewed for Partner Services and HIV Testing Positivity Rates among Named Partners, July 2015 December 2017 120% 100% 88.2% 92.3% 96.6% 80% 60% 40% 20% 17.9% 23.6% 40.0% 0% July 2015 June 2016 July 2016 June 2017 July 2017 Dec. 2017 Percentage of Newly Diagnosed Health Center Patients Interviewed for Partner Services HIV Testing Positivity Rates for Partners of Newly Diagnosed Health Center Patients Division of Disease Control and Health Protection 57

Outcomes HIV primary care Routine HIV screening Secure bi-directional data transfers and P4C Dashboard Case conferencing for continuity of care (COC) Health center-specific DIS PrEP referrals, counseling, and provision Division of Disease Control and Health Protection 58

Successes and Best Practices Data sharing Memorandum of Agreement (MOA) template Health center protocols, policies, and procedures for HIV services P4C Dashboard: client search, out-of-care lists, task management Case conferencing for COC services Division of Disease Control and Health Protection 59

HRSA s Health Center Toolkit, July 2018 Provide clear roadmap for service integration Identify best practices for HIV management in primary care Provide tools for building health centers capacity Provide a comprehensive set of educational and instructional materials https://bphc.hrsa.gov/qualityimprovement/pdf/p4c-toolkit-2018.pdf#zoom=125 10/30/2018 Division of Disease Control and Health Protection 60

Sustainability Replicate P4C model in other areas Explore ways to fund P4C activities Future implications for Dashboard (e.g., Data to Care) Disseminate health center best practices for implementation of HIV primary care, routine HIV screening, and PrEP services Develop strategies for retention and viral load suppression in health care settings Division of Disease Control and Health Protection 61

Contact Information Mara Michniewicz, MPH HIV Prevention Manager Mara.Michniewicz@flhealth.gov 850-901-6971 HIV/AIDS Section Bureau of Communicable Diseases Florida Department of Health Division of Disease Control and Health Protection 62