Sexual Health Promotion Protecting Health & Improving Lives

1. Sexual Health PromotionProtecting Health & Improving Lives Presenters: Prevention Services Tanisha Pettus, DIS II & Linkage to Care Julie Anderson, DIS II

2. Understanding Public Health • Identifying & addressing public health threats • Enforcing laws that protect the public’s health • Providing services to prevent & control disease

3. Sexual Health PromotionsPrevention Services • Comprised of a group of Disease Intervention Specialists (DIS) mandated by the state of Ohio to follow-up with all HIV/AIDS and Syphilis reportable conditions • Receives all positive lab findings relating to HIV/AIDS and Syphilis • Responsible for following up with reported cases in Franklin County • Works closely with the Ohio Department of Health (ODH) & their Ohio Disease Reporting System (ODRS) • Conduct field investigations & Interviews

4. HIPAA & ORC • Permitted Disclosure: A covered entity may disclose protected health information without the written consent of the patient, for the public health activities and purposes described in the following paragraph: “According to the Ohio Revised Code (ORC), HIV/AIDS and Syphilis must be reported and followed up by public health officials. The reporting system of syphilis or HIV/AIDS supersedes HIPAA guidelines” • House Bill 1 Changes to HIV testing/consent statute • R.C. 3701.242 Informed consent to HIV test; counseling; anonymous testing

5. HIPAA & ORC- Resources • Revised Recommendations for HIV testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings • HIPAAPrivacy Rule and Public Health • Documents can be found at the CDC MMWR website

7. Syphilis & HIV/AIDS Case Management & Reporting Lab & Provider Lab Report CPH ODH IDRS ODRS DIS Client Interview Provider F/U DIS Field Investigation

8. DIS ROLE • Prepare and follow the basic mission of STD control: To prevent the spread of disease and the development of complications • Interview patients infected with STDs • Perform investigative activities to locate & refer for examination and/ or treatment • Ensure that all people who have or have been exposed HIV and/or syphilis are promptly examined and adequately treated • Those who are unaware of their infection are the highest priority to receive disease intervention services

9. DIS ROLE • Once the client has been treated, the DIS will help the client with: • Management of infection • Prevention of future infections • Respond if infected in the future • If the disease is HIV or Acquired Immunodeficiency Syndrome (AIDS), the primary objective of the DIS is: • Prevent the transmission through education and changes in behaviors

10. Partner Services Principle • Client centered • Confidential • Voluntary & non-coercive • Free • Accessible to all people Goals • Provide support to ensure partners are informed in a confidential manner • Provide testing opportunity to partners and provide early L2C, prevention & other services • Reduce future rates of transmission by aiding in early diagnosis and treatment & prevention services (avoid transmission to others by offering partner services)

11. Partner Services • Challenges • Will the services be accepted by patients? • Potential for abuse resulting from partner notification • Potential of negative effects on relationships after partner notification Benefits • DIS can help with partner services • DIS can assist with coaching for persons who prefer to notify partners themselves • Partner services can benefit the community by reducing effects of previously undiagnosed STIs/HIV infection among its members • DIS can provide prevention counseling to reduce risk of acquiring new STIs or transmitting HIV to current or future partners

12. Syphilis Case Management • Avoid sexual contact for 1-4 week after treatment • Follow-up: Clinical and serological evaluation should be performed at 6, 12 and 24 months post treatment • Titer decline of at least fourfold [two dilutions] within 12-24 months of therapy • More frequent evaluation might be prudent if follow-up is uncertain

13. Syphilis Case Management • All sex partner testing/ treatment for those w/in 90 day critical period • All sex partner testing outside 90 day critical period • Increase condom use for future prevention • Out of jurisdiction (OOJ) lab report and partners

14. Scenario #1Patient comes to clinic with penile lesions, past history of syphilis & bed bugs. History of HIV NR in 2012. what do you do? • Order RPR & HIV test • Order HSV culture • Order Dark field • All of the above • Do nothing

15. Individuals with syphilis are at least 2-5 times more likely to acquire HIV if exposed to the virus through sexual contact Individuals with syphilis 2-5x Individuals without syphilis

16. STI’sHerpes VS Syphilis HERPES VS SYPHILIS

17. STI’sGenital Warts VS Secondary Syphilis SECONDARY SYPHILIS VS GENITAL WARTS Or HPV

18. Classic Secondary Syphilis

19. Frequently Reported Risks • Anonymous Sex • Internet- social media- Facebook, Grindr, Adam4Adam, BGC [Black Gay Chat], parties, bathhouses or swingers clubs • Unprotected oral sex • Previous STI diagnosis • Sex with a HIV + person • Sex while intoxicated or high on drugs

20. EIA/CIA+ IgG/IgM+ Reverse Sequence Syphilis Screening Need Quantitative RPR or Other Nontreponermal Test RPR - RPR + Titer Provided RPR + Titer Not Provided Need Confirmatory Test (TPPA/FTA/MHA) Follow Syphilis Rector Grid Initiate Field Record TPPA/FTA/MHA - TPPA/FTA/MHA + • Initiate Field Record in the following situations: • Women of child-bearing age (14-44 years of age) • Patient between the ages of 0-39 regardless of gender • Patient with no previous history of syphilis treatment • Patient lives in area with high morbidity of syphilis, CT, or GC STOP Syphilis Unlikely

21. SyphilisRecommended Treatment Guidelines

22. Scenario #2Mother delivered with +IgG, RPR 1:2 no history of syphilis in the past. NR RPR in 1st trimester. What do you do? • Call Health Dept. • Test & treat baby • Treat mom • Consult with ID • All of the above

23. Congenital Syphilis

24. How To Report IDRS HIV Reporting Form Syphilis Reporting Form

25. Prevention • Educate • Empower • Communication & Awareness • Routinely test for HIV/syphilis as apart of comprehensive health care

26. Ryan White Part A PrioritiesEarly Intervention Services • A service provided to those who are newly infected with HIV or individuals who have fallen out of care

27. Linkage to Care (L2C) • The goal of the Linkage to Care (L2C) Program is to assure persons living with HIV are able to access HIV medical care and medications. • People living with HIV who are in medical care and adherent to HIV antiretroviral therapy are less likely to be infectious to others.

28. Linkage to Care • Client completed two medical appointments that include HIV related lab work and a treatment plan • Medical Case Management

29. Anti-Retroviral Treatment and Access to Services (ARTAS) • An individual-level, multi-session, time-limited intervention to link individuals who have been recently diagnosed with HIV to medical care. • Strengths-based Case Management (SBCM) Model • Social Cognitive Theory (self-efficacy) • Humanistic Psychology

30. Barriers to Care • Transportation • Food • Homelessness • Substance Abuse • Mental iIlness • Fear • Financial Resources

31. Ryan White Part A Requirements: • HIV status • Residency • Franklin, Fairfield, Madison, Morrow, Licking, Pickaway, Union, Delaware counties • Income • 300% of the Federal Poverty Level

32. Maintaining Medical Care • Ryan White Medical Case Management • Maintain private health insurance • Market Place navigation

33. Linkage to Care • In 2013, 180 people were enrolled in the Linkage to Care program • 176 cases were closed in 2013 • 167 (95%) attended at least one medical appointment • 154 (88%) attended two medical appointments and were enrolled in medical case management

34. Linkage to Care • From January-March of 2014, 57 people were enrolled in the Linkage to Care program • 33 cases have been closed • 32 (97%) attended at least one medical appointment • 30 (91%) attended two medical appointments and were enrolled in medical case management

35. QUESTIONS ?

36. References • Centers for Disease Control and Prevention [CDC]. (2003). HIPAA privacy rule and public health. Morbidity and Mortality Weekly Report (MMWR), 52, 1-12. • Centers for Disease Control and Prevention [CDC]. (2008a). Partner services FAQs for the public and consumers of partner services activities. Retrieved from http://www.cdc.gov/nchhstp/partners/FAQ-public.html. • Centers for Disease Control and Prevention [CDC]. (2008b).Recommendations for partner services programs for HIV infection, syphilis, gonorrhea, and chlamydia infection. Morbidity and Mortality Weekly Report (MMWR),57(RR-09) 1-63. • Centers for Disease Control and Prevention [CDC]. (2010). Sexually transmitted diseases treatment guidelines, 2010. Morbidity and Mortality Weekly Report (MMWR),59(RR-12) 34-37. • Centers for Disease Control and Prevention [CDC]. (2012). Anti-retroviral treatment access to services (ARTAS) Fact Sheet.  Retrieved from  https://www.effectiveinterventions.org/Libraries/ARTAS_Materials/ARTAS_Fact_Sheetrev_12-0109.sflb.ashx. • Centers for Disease Control and Prevention [CDC]. (2013). Syphilis- CDC fact sheet. Retrieved from http://www.cdc.gov/std/syphilis/stdfact-syphilis.htm. • Centers for Disease Control and Prevention [CDC]. (2014). Sexually Transmitted Diseases. Retrieved from http://www.cdc.gov/std/. • Columbus Public Health. (2008). Celebrating a rich history of public health in Columbus. Retrieved from http://columbus.gov/uploadedFiles/Columbus/Departments/Public_Health/New_Administrators/About_Us/About_CPH/HistoryBrochure.pdf. • Columbus Public Health (2014). Take care down there. Retrieved from http://takecaredowntherecolumbus.com/site/. • Ohio Department of Health STD Prevention Program. (2011). Syphilis physician pocket guide. 1-41. • Smith, W. (2014, March 14).NCDSD Weekly Update 3/10/14 – 3/14/14 [Electronic mailing list message].