Do 1 Thing - Dr. Stacey Trooskin


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Dr. Stacey Trooskin's presentation on the Do 1 Thing HIV & HCV testing initiative, as seen at the April 2013 RWPC meeting.

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  • N=900
  • HIV confirmatory  Western blot HCV confirmatory  PCR quant Assist client, go to appts, follow up Uninsured still a big challenge. Tried to overcome by creating avenue for individuals to receive insurance. Safety net of health center if uninsurable
  • Do 1 Thing - Dr. Stacey Trooskin

    1. 1. Stacey B. Trooskin, MD PhDAssistant ProfessorDrexel University College of MedicineUsing Community-Engaged Research toUsing Community-Engaged Research toAddress Racial and GeographicAddress Racial and GeographicDisparities in HIV and HCV InfectionDisparities in HIV and HCV Infection
    2. 2. Racial Disparities in HIV InfectionRacial Disparities in HIV Infection• African Americans represent 14% of thepopulation and 45% of HIV infections• African Americans are more likely to presentlater in the course of their infection and havehigher rates of AIDS-related mortality• Traditional behavioral risk factors don’t explaindisparities– More limited access to HIV testing, lower insurancerates– Structural and social factors– Complex sexual networks
    3. 3. Geographic DisparitiesGeographic Disparities• In many urban areas, a fewneighborhoods account for alarge share of HIV infections• HIV infections cluster• Some neighborhoods haveHIV infection rates similar tosub-Saharan Africa• Maps tell us where to focusintensive prevention andtreatment efforts Source: AIDSVu
    4. 4. • Philadelphia has infection rates 5 times the national average• Heterosexual epidemic• Zipcode 19143 (in Southwest Philadelphia) is the second mostpopulous zipcode in the city (60,000 people)– 86% African American, 30% people < poverty line• Zipcode 19143 has the 2ndhighest number of people livingwith HIV/AIDS (1,014 individuals in 2010)– Approximately 1.8% seropositivity• Rates of Hepatitis C (HCV) in 19143 unknown, but likely high• 19143 has few medical and health resourcesHIV & HCV in SouthwestHIV & HCV in SouthwestPhiladelphiaPhiladelphia
    5. 5. Rates of Persons Living with HIV/AIDS by ZipCode and Census Tract, 2009Source: AIDSVu
    6. 6. Do One Thing OverviewDo One Thing Overview• Southwest Philadelphia, PA is a medically underserved area with highrates of HIV and HCV infection & few HIV and HCV testing & treatmentservices• Do One Thing is a testing, linkage to care and treatment campaign thatstimulates demand for and provides HIV and HCV testing and treatmentacross an entire zipcode• Do One Thing includes:• A large-scale social marketing and media campaign• Community outreach and mobilization• Partnerships with business, community organizations, and faith institutions• A partnership with a federally qualified health center in SouthwestPhiladelphia to routinely offer HIV testing to all patients over age 13• Rapid HIV and HCV testing in a mobile unit, door-to-door testing in 4 censustracts• Community service and volunteerism• Monitoring and evaluation
    7. 7. Location, location, location!Location, location, location!Do One Thing in Southwest PhiladelphiaDo One Thing in Southwest Philadelphia
    8. 8. Social Marketing CampaignSocial Marketing Campaign
    9. 9. Social Marketing CampaignSocial Marketing Campaign• Website:• Texting service• Yard signs, door knockers, door to dooroutreach• Palm cards• Street outreach• Twitter feed with map of mobileunit of of mobile unitlocations
    10. 10. Community Mobilization:Community Mobilization:BusinessesBusinesses
    11. 11. Community Mobilization:Community Mobilization:BusinessesBusinessesCommunity Pharmacy Corner Market Cafe
    12. 12. Routine HIV Testing at theRoutine HIV Testing at theHealth Annex, a FQHCHealth Annex, a FQHC
    13. 13. Victories and Challenges withVictories and Challenges withRoutine Testing in Clinical SettingRoutine Testing in Clinical SettingClinical Challenges and Lessons learned• Policy Change: Leadership is most important factor• Integrated Model: Know your patient flow and model– NP clinical model with MAs testing model• EMR Enhancement• Staff and Provider Training• Financial incentives
    14. 14. Victories and Challenges withVictories and Challenges withRoutine Testing in Clinical SettingRoutine Testing in Clinical SettingClinical Challenges and Lessons learned• Offer rate has plateaued at 70%– Next step: incentivize acceptance rateimprovements• High decline rate: most commonly cited reasonsare “recently tested” and “wasn’t expecting anHIV test”• Behavioral risk profiles: most new positives have“no identified risk;” most are young, AfricanAmerican women• Lower seropositivity than expected: 0.4%• 95% linkage and retention in care rate; has beensustained over time
    15. 15. Community Service: Our VolunteersCommunity Service: Our Volunteers
    16. 16. Do One Thing Door To DoorDo One Thing Door To DoorHIV/HCV Testing CampaignHIV/HCV Testing Campaign
    17. 17. Non-Clinical Testing on MobileNon-Clinical Testing on MobileMedical UnitMedical Unit
    18. 18. Demographic PercentageGender Female 45%Male 54.4%Transgender .6%Race African American 90%African 3%Other 7%Education Less than high school 20%High School 50%Some college/AA 21%4 year college 8%Household Income <$10,000/yr 43%$10,000-15,000/yr 15%$15,000-20,000/yr 12%>$20,000/yr 30%Employment Unemployed 37%Part-time 15%Disabled 11%Full-time 31%Other 6%DemographicPercentageHealth InsuranceStatusNone 37%Medicaid 36%Private 18%Other (Medicare,Veterans, etc)9%Sexual Orientation(self-report)Heterosexual 89%Gay/Lesbian 6%Bisexual 5%
    19. 19. Risk Behavior PercentageMultiple sexual partners 22%Believe partner has multiple sexualpartners24%Ever injected drugs 6.7%Ever used crack or cocaine Cocaine 15%Crack 14%Tattoos 49%If tattooed, received tattoo attattooparty24%Ever tested for HIV? 85%Ever tested for HCV? 36%Reported venue for testing for HCV Doctor’s Office 56%Reported reason for testing for HCV Participant asked for the test 41%Doctor Recommended 33%Other 26%
    20. 20. Clinical and Non-ClinicalClinical and Non-ClinicalHIV Testing TrendsHIV Testing Trends• Clinical Settings– Tested 2,100 people for HIV in clinical settings– Health Annex (FQHC) seropositivity: 0.4%– Greatest challenge: 55% decline rate• Non Clinical Settings– Tested 900 people for HIV in non-clinical settings• 1.3% HIV seropositivity– Tested 350 people for HCV in non-clinical settings since December2012• 4.8% HCV seropositivity
    21. 21. Linkage to Care ProtocolOraQuick® rapid HCVantibody test reactiveOraQuick® rapid HCVantibody test reactiveConfirmatory test ispositiveConfirmatory test isnegative x 2D1T staff notifiespatient and providescounselingD1T staff notifiespatient : counseling +insurance statusInsured with aprimary care providerReferralInsured with no knownprimary care providerPCP visit followed byreferralUninsured with noprimary care providerSocial worker works w/clients to gaininsurance + then refersOraQuick® rapid HIVantibody test reactiveD1T staff immediatelylinks patient to HIVcare within 24-48 hrsIfuninsur-able,refer tohealthcenterRepeat test  Blooddraw for confirmatoryWestern blotRepeat test  Blooddraw for confirmatoryHCV PCR quantRepeat test  Blooddraw for confirmatoryHCV PCR quant
    22. 22. Preliminary linkage to HIV carePreliminary linkage to HIV caretrends: Non-clinical Testingtrends: Non-clinical Testing12 People Tested Preliminary Positive10 confirmedpositives2 discordantconfirmatory results8 known positives 2 new diagnoses4 currently in care1 LTFU6 being linked tocare1 awaitingviral loadresults
    23. 23. Demographic characteristics of HIV-positiveDemographic characteristics of HIV-positivepatients in non-clinical settingpatients in non-clinical setting• Average age HIV+ = 44 years old• African American• Transmission risk factors: MSM (2),Heterosexual (5), no identified risks (5)• 2 co-infected with HCV
    24. 24. Preliminary Linkage to Care Trends forPreliminary Linkage to Care Trends forNon-clinical Testing: HCVNon-clinical Testing: HCV17 People Tested Preliminary Positive13 chronically infected 2 cleared virus10 previously known 3 new diagnoses1 currently in care 2 in process oflinkage10 linked to careoutreach services2 uninsured 10 have insurance2 with insurancepending6 referralspending4awaitingreferrals2 awaiting results
    25. 25. • Average age is 52• One third are NOT in baby boomer birth cohort• Mode of transmission: no identified risk (7),IDU/cocaine use (7), Heterosexual (1)• 2 co-infected with HIV• Tattooing in unregulated environmentsDemographic Trends of HCV positiveDemographic Trends of HCV positivePatients in non-clinical SettingPatients in non-clinical Setting
    26. 26. • Continuing Quality Improvement (CQI) is critical• Many are known HIV and HCV positive and not in care• Comprehensive campaign is a way to raise awareness,fight stigma and re-engage patients in care• Biggest challenge in non-clinical setting: retaining HIVpatients in care• Biggest HCV challenge: payment and linkage– insurance and referrals for HCV careLessons Learned and ImplicationsLessons Learned and Implications
    27. 27. • Biggest challenge in clinical setting: high decline rate• 74% of patients testing for HIV at clinic were women; menmore frequently decline HIV testing in clinical setting• More new diagnoses in clinical settings than non-clinicalsettings• Offering HIV and HCV testing together may enhance testingrates• Street and door to door outreach is effective, especially forreaching youth and men• High HCV seropositivity rate; few clients are in care• Volunteers reduce staff costs and enhance sustainabilitySurprising FindingsSurprising Findings
    28. 28. WhatWhat is next?is next?• Enhancing routine testing at FQHC– Boost our offer rate and reduce our decline rate• Develop a complete neighborhood-based diagnosis,treatment and care cascade• GIS mapping of hotspots for HIV and HCV• Trial comparing control and treatment neighborhoods• Cost-effectiveness study• Complete program evaluation, including improvementsfrom baseline• Mapping transmission using HIV sequences atneighborhood level
    29. 29. • Principal InvestigatorAmy Nunn, ScDBrown University• Gladys Thomas, Project Director• Gilead Sciences• Health Annex partners• 80 Volunteers• The Southwest Philadelphia communityAcknowledgementsAcknowledgements