A Framework For The Integration of HIV Prevention Services in Family Planning Programs

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Women and HIV/AIDS. HIV/AIDS epidemic in the US increasingly has the face of a woman. In 2003:Females age 13-19 accounted for 50% of HIV cases reportedFemales age 20-24 accounted for 37% of HIV cases reportedThe average duration from HIV infection to the development of AIDS is 10 years.71% of wo

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A Framework For The Integration of HIV Prevention Services in Family Planning Programs

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1. A Framework For The Integration of HIV Prevention Services in Family Planning Programs Sue Gadon, MPA and Dawn Middleton, BS Cicatelli Associates, Inc. New York, New York OPA Title X Grantee Meeting September 18, 2006

2. Women and HIV/AIDS HIV/AIDS epidemic in the US increasingly has the face of a woman. In 2003: Females age 13-19 accounted for 50% of HIV cases reported Females age 20-24 accounted for 37% of HIV cases reported The average duration from HIV infection to the development of AIDS is 10 years. 71% of women received an AIDS diagnosis between the ages of 25-44 70% of AIDS diagnosis among women are due to heterosexual transmission Females age 20-24 years, heterosexual transmission account for 82% of all new AIDS cases Females age 13-19 years, heterosexual transmission accounted for 63% of all new AIDS cases

3. Title X HIV Integration 2001-Present Title X clinics continue to serve as critical sites for integration of HIV prevention services. Title X HIV Integration sites have demonstrated growth in efficiency and effectiveness of HIV Prevention activities over time. Since 2001: 23% increase in HIV tests provided 58% return for results rates for conventional testing in 2001 and 68.3% return rates in 2005 30% of all tests in 2005 were Rapid HIV Tests with a 98% return for results rate 94.7% of all HIV + clients linked to care throughout the lifetime of the project Site expansion from 30 sites in 2001 to 60 sites in 2005

4. The rate of test positivity has ranged from approximately 0.3 to 0.5 across periods. The overall positivity rate is reported as 0.4%. We see this as a substantial positivity level for the family planning setting which supports the need for ongoing HIV integration. We recognize that the positivity rate can reflect multiple factors, including the expanded level of HIV testing, the extent to which at-risk and higher prevalence populations have been targeted, data reporting accuracy, and actual burden of disease. The rate of test positivity has ranged from approximately 0.3 to 0.5 across periods. The overall positivity rate is reported as 0.4%. We see this as a substantial positivity level for the family planning setting which supports the need for ongoing HIV integration. We recognize that the positivity rate can reflect multiple factors, including the expanded level of HIV testing, the extent to which at-risk and higher prevalence populations have been targeted, data reporting accuracy, and actual burden of disease.

5. Framework for HIV Integration Leadership Buy-in at all levels Fiscal Cost Billing and Reimbursement Laboratory Technology Conventional Testing Rapid Testing Protocols/Guidelines Confidentiality Medical Records Integrated Medical Records Visit Encounter Forms, Consent Forms, Lab Logs Documentation

6. Framework for HIV Integration Staff Readiness and Training Attitudes Skills (training, job aids) Supervisory Support Visit Design Workflow When is the HIV test offered? When are HIV test results delivered? Staff Roles and Responsibilities Who offers the HIV Test to the client? Who delivers HIV test results to the client? Educational Materials Linkages and Referrals Clients who are HIV+ and those who are “high risk”

7. Framework Application: Project A Title X Grantee with 4 delegate agencies and 12 clinical sites. Leadership: grantee convened an “HIV Delegate Roundtable” to garner buy-in and identify and address steps to integration. Protocols/Guidelines: developed guidelines to support provision of HIV testing/counseling services at clinical sites Medical Records: developed lab log to record provision of rapid test and test results.

8. Framework Application: Project B Free-standing Adolescent Clinic in urban setting: Conducted a Patient Flow Analysis (PFA) as a tool to inform the development of systems to support integration of HIV Rapid Testing. Utilized PFA data to inform when and who should offer/conduct a rapid HIV test and who should deliver test results. Staff time spent Face-to-Face with client % of time staff spend with clients Client waiting time prior to seeing staff

9. Project B – PFA Data Medical Assistants were identified to conduct rapid test due to the following: Average time per patient under 5 minutes % of time in face-to-face contact with patients 6% Average waiting time prior to staff was low at 4 minutes. Medical Assistant had a confidential lab space to administer test

10. Enduring Challenges Disproportionate HIV burden among African American and Latino women: 25% of the US population and represent 80% of female AIDS diagnosis through 2004. Increase Utilization of Rapid HIV Testing Enhancing Application of Integration Concepts in Clinical Settings Continuum of “Client Centered Risk Reduction Prevention Counseling” Integrated assessment of risk for unintended pregnancy, HIV, STDs, sexual coercion, domestic violence, family involvement, “ABC’s”

11. New Challenges New CDC Strategy to Incorporate HIV Testing as a Routine Part of Care in Traditional Medical Settings: Routine, voluntary HIV screening for all persons 13-64 in health care settings, not based on risk or prevalence Opt-out HIV testing with opportunity to ask questions and option to decline, include HIV consent with general consent for care Prevention counseling not required Implementation State and local regulations should be reviewed and revised as needed. Low prevalence settings: consider “sunset provision” if HIV prevalence shown to be <0.1% Training (need for 3-5 day HIV Pre/Post Test Certification Program?) Special consent no longer needed Implementation and Sustainability will depend on streamlined systems and supportive financing and reimbursement systems.

12. Tools to Support HIV Integration Applying the HIV Integration “Framework” to new and enduring challenges Utilizing data to assess implementation and impact: FPAR Data, Title X Administrative Databases Title X HIV Integration Data Change is Constant Creating systems that support improvement/change Performance Improvement Teams, Leadership Teams “Plan-Do-Act-Study” Teams Relationship-based Outreach Social Network Strategies to reach “at risk” women

13. Support and Technical Assistance Office of Population Affairs Title X Regional Training Centers http://opa.osophs.dhhs.gov/titlex/ofp-training-grantees-listing.html Social Network Strategies http://www.cdc.gov/hiv/resources/guidelines/snt/overview.htm

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