Expanding and Improving STD Services during Resource Limited Times

1. Expanding and Improving STD Services during Resource Limited Times Heather James STD Field Services Supervisor Maricopa County STD Program

2. Four Expanded Services • Express STD Visits • Expedited Partner Therapy • Embedded CDIs in HIV Clinics for partner interviews • Hepatitis B Vaccination in STD Clinic

3. Express STD Visits • STD visits without a medical provider, physical examination or interview • Test only visit includes: • Syphilis serology • HIV test • Combined chlamydia and gonorrhea urine test

4. ET Risk Factor Screening • Answering “Yes” to the following risk factors disqualifies the patient for ET: • Are you experiencing symptoms? • Did someone tell you to come here? • Have you traded sex for drugs or money? • Are you pregnant? • Have you engaged in receptive anal sex in last 3 months? • Have you recently been sexually assaulted?

5. ET Risk Factor Screening STD Screening Triage Assessment Form Frequently Asked Question Form

6. Express STD Visits • Since September of 2008, 2,464 patients have been tested through ET visits • Approximately 14% of STD clinic attendees are channeled through ET • Run by CDI; 2 per clinic • Follow-up results given per regular clinic protocols • No treatment provided at ET

7. STD Clinic AttendanceJanuary – July 2009

8. STD Express TestingClients Tested / Cases

9. Benefits • Shorter wait times (average 1 hour shorter) • Increased number of patients seen during working hours • Projected increase in revenue as Express patients pay same fees ($20) • Many patients prefer this option to seeing a provider

10. Potential Drawbacks • Fewer patients receive presumptive treatment thus, • Possible treatment delays (not yet evaluated) • Requires additional CDI’s in clinic • Some clinic flow changes necessary

11. Expedited Partner Therapy • AZ State Statute (32-1401) allows for treatment of contacts of infectious diseases without a medical exam • Protocols developed for Maricopa County STD Program • Implemented June 2009

12. Expedited Partner Therapy (EPT) • EPT protocol summary • Patients receive diagnosis and treatment for Chlamydia and/or gonorrhea • Patients receive a prescription(s) from the provider to fill at the Maricopa County pharmacy (adjacent to clinic) for partner medication • Patients receive information to give to partner about the medication • Partners are encouraged to seek care for testing

13. Results • Since June 2009, 15 prescriptions have been filled at the Maricopa County pharmacy for EPT • 11 for azithromycin • 4 for cefixime • EPT Protocol has been shared with MIHS clinics

14. EPT Benefits • Patient delivers medication to partner • Reduced re-infection rates • Reduced number of untreated partners (frequently male partners) • Reduces need to track partners for clinic referral for testing and treatment • Medication cost to patient for partner treatment • $7.75 for 1 gram of azithromycin • $9.94 for 400mg of cefixime

15. EPT Potential Drawbacks • Partners do not receive testing • Small risk of adverse reaction to medication though written and verbal information provided through pharmacy

16. Embedded CDIs in HIV Clinics • Rationale • 70% of Maricopa P and S cases are MSM • Approximately 50% are HIV infected • Top 3 syphilis reporting providers for 2007-08 were HIV clinics • Spectrum • McDowell • Pueblo Family

17. Implementation • In early 2008, 2 CDIs identified to work ½ day/week in two clinics and 1 CDI identified to be “on call” in one clinic • CDIs deliver penicillin to 2 of 3 clinics • CDIs perform partner elicitation in the clinic following provider evaluation

18. Evaluated Improvements • Improved time to interview • Higher number of completed interviews • Higher number of partners initiated • Fewer field attempts to locate partners • Higher number of partners brought to treatment • Visibility of public health in private offices

19. Administration of HBV Vaccine in Maricopa STD Clinic • Rationale • Hepatitis B is an STD • Preventable with vaccination (3 shot series) • Highest risk population attending STD clinics • Physical proximity to Immunization Clinic • Staff sharing • Education/administration by immunization staff

20. Implementation • Staff member from Immunization Clinic “solicits” potential vaccinees from the STD waiting area • First shot of series administered in STD Clinic by Immunization staff • Patient receives follow-up dates for remaining 2 injections • Follow-up 2 injections administered at the Immunization Clinic

21. Summary • These four services have expanded care through the Maricopa STD Clinic • Protocols available for other programs • Site visits welcome

22. Contact Information Heather James 602-506-5056 heatherjames@mail.maricopa.gov Questions?