Viral Hepatitis Integration in an STD Clinic Do Injecting Drug Users Benefit? National Hepatitis Coordinators’ Conference January 26 – 30, 2003 Robin R. Hennessy Karen Schlanger, MPH Isaac Weisfuse, MD, MPH New York City Department of Health and Mental Hygiene

Overview Viral Hepatitis Integration Project (VHIP) in NYC Research Questions Methods Results Conclusions, Discussions and Recommendations

VHIP Project Description Integrate viral hepatitis services in an STD/HIV clinic setting Evaluate the impact of integration Viral Hepatitis Services: Hepatitis A Vaccine Hepatitis B Vaccine (limited screening) Hepatitis C Counseling, Testing and Referral

VHIP Clinic Background Riverside STD Clinic, Upper Manhattan Race/Ethnicity 34% Hispanic 31% Black 25% White 10% Other VHIP project coordinator on site

Clinic and VHIP Census May 2000 – October 2002 30 Months Nearly 30,000 visits not unique patients 6,436 patients received a hepatitis service ~ 1/3 of clinic population Actual patient visits 29,744 Be sure to emphasize that this number is not UNIQUE individuals but number of visits 6436 are unique individuals who have been served by the VHIP

Vaccine Delivery May 2000 – October 2002 Hepatitis A 1,968 doses administered (1,498 1st doses) 34% returned for second dose Hepatitis B 8,566 doses administered (4,683 1st doses) 55% returned for second dose 30% completed series VHIP Return rates are comparable and perhaps slightly better than in similar venues and urban areas

Screening Services May 2000 – October 2002 Hepatitis B 4,479 patients screened 2% (84) chronic carriers 17% (759) immune (resolved past infection) Hepatitis C 2,249 patients screened 8% (179) antibody+ (RIBA confirmed) Prior to August of this year, all patients receiving b vaccine were also screened for surface antigen and core antibody However, our overall percentage of exposure is 19% and the CDC recommendation for pre-vaccination screening is a baseline prevalence of 30%, we no longer offering routing screening but selected screening to IDU, MSM, HIV+, liver disease 1999 blinded sero survey 2% hcv prevalence

Background Reason for asking research question: Hepatitis C testing 6.6% (76/1,146) reported IDU history during pre-test HIV testing 0.5% (20/3,738) reported IDU history during pre-test What’s going on?

Research Questions Does the VHIP bring new clients to the STD clinic – specifically injection drug users (IDU)? Do these “new” clients utilize traditional STD/HIV services?

Methods Data Collection VHIP Database Hepatitis Services (vaccine, screening) Risk Assessments Medical Record Review Reason for visit (symptoms, referral, etc.) Have an STD exam IDU risk assessment STD/HIV (tests, results, diagnosis) HIV CTS Database

Methods Data Sources Data VHIP Database set used for this analysis If IDU history=Yes STD Medical Record Review If HIV test=Yes If a patient reported a history of injection drug use during vaccine visit or HCV pre-test visit, the medical chart was reviewed if HIV test was indicated on medical chart, a link was created to the HIV CTS dataset HIV Counseling and Testing (HIV CTS) Database

Methods Case Definitions Hepatitis services specifically if: Received vaccine only Referral from drug treatment center for hepatitis C testing was recorded STD services specifically if: Complained of symptoms Reason Unknown if: Above criteria not met This will become clear later

Study Population May 2000 – October 2002 202/6,436 (3%) patients receiving hepatitis services reported a history of IDU 20% (40/202) of these patients reported current use Information was collected for ALL 202 IDU patients through either Found 97% of charts! chart review (195) or laboratory/HIV log book (7)

Hepatitis Vaccine (N=202) 31% (62) received hepatitis A vaccine 78% (148) received hepatitis B vaccine Hepatitis is a large health burden for this population 19% hep b exposure overall 8% hep c overall

Hepatitis Screening (N=202) 149 (74%) tested for hepatitis B 46% (69/149) with evidence of past exposure Clinic wide: 15% past exposure 150 (74%) tested for hepatitis C 60% (90/150) tested positive (RIBA+) Clinic wide: 8% 1999 Seroprevalence Study: 2% Hepatitis is a large health burden for this population 19% hep b exposure overall 8% hep c overall

STD Services (N=202) 149 (78%) were interviewed by a physician 53% (79/149) of these patients denied IDU history when asked by a physician 106 (53%) had an STD exam 43% (46/106) diagnosed with an STD 97 (48%) were tested for HIV 4% (4/97) tested positive

Results Reason for Visit (N=202) 78 (39%) of IDU are known to have visited the STD clinic specifically for hepatitis services 49 vaccine only 29 referred from DTC for HCV testing 92 (45%) Reason Unknown 32 (16%) Symptomatic for an STD This is the money shot – hepatitis brought them into the clinic! Remember we talked earlier about reason for visit

Results Reason for Visit & Services Received From DTC (N=29) Unknown (N=92) Symptoms (N=32) Had STD Exam 20 (69%) 54 (59%) 32 (100%) STD Diagnosis 5 (25%) 18 (33%) 23 (72%) Tested for HCV 29 (100%) 69 (75%) 24 (75%) HCV+ 22 (76%) 43 (62%) 9 (38%) Hep A Vaccine 9 (31%) 29 (32%) 9 (28%) Hep B Vaccine 25 (86%) 71 (77%) 26 (81%) In this slide I try to argue that the “others” are more similar to those who came specifically for hepatitis than to symptomatic clients. Thereby trying to say that perhaps more like 84% idu’s came specifically for hepatitis. DTC and Other do not complain of symptoms … Here note the percentages having exams and dx’s are similar between dtc and other Also note percentage + for HCV I would argue that Others may also be primarily attending for hep services ALSO note that hep a vaccine administration is low across all groups compared to hep b vaccine. Since patients accept hep b is seems clear that they are not being offered hep a as much (probably because md’s are not assessing idu risk consistently)

Results Unexpected Finding 70 patients tested for HCV and HIV on the same day, with the same counselor 84% (59) documented as IDU on HCV form (by the counselor) 29% (20) documented as IDU on HIV form (by the counselor)

Conclusions Recommendation Integrated hepatitis services brings in new IDU clients to the STD clinic – who may not have otherwise visited the clinic At least 40% of IDU came specifically for hepatitis services IDU clients who come to the STD clinic for hepatitis services also utilize and benefit from traditional STD services Recommendation Increase outreach and advertising in DTC, SEP and CBO that provide support to IDU populations

Conclusions Recommendations Physicians do not consistently identify IDU risk Nearly half of IDU were NOT identified by the physician (patient denied history) Only 31% of IDU received the recommended vaccine for hepatitis A Recommendations Might indicate the need to train physicians on eliciting drug history Why? Remember there is still stigma attached to IDU. Also a physician is seen as an authority figure … someone you want to please. Finally, the physician in this clinic is the first person to see the patient and the first to ask the question. By the time they reach a counselor – they have had time to think about the question. Also, the counselor is probably seen as less official, more like a peer.

Conclusions Discussion HIV/HCV counselors do not record IDU risk on HIV CTS consistently Only 34% agreement of IDU history in joint counseling sessions Discussion Hepatitis C counseling appears to increase the identification of IDU risk among patients obtaining HIV testing Which in turn may lead to more specific risk reduction counseling But – the good news is that hep c counseling helps them identify IDU and that may mean (if not great documentation) at least better counseling messages

Discussion Possible reasons for discrepancy HCV form (unlike the HIV form) requires the counselor to answer YES or NO for each risk factor STD counselors may be more comfortable with talking about sexual exposures around HIV rather than drug use

Recommendations Provide counseling staff with more training on IDU Consider providing safer injection brochure to all patients during HIV and HCV counseling session Emphasize these findings when training staff in 2 new STD clinics set to provide hepatitis services (expected March 2003) Continue to monitor and report results to staff Invite the Harm Reduction Coalition to speak to counseling staff

What Have We Done? Remind counselors that IDU continues to be an important risk for HIV Emphasize the need for accurate risk assessment on the HIV CTS Encourage physicians to offer all recommended hepatitis services to IDU patients Have seen preliminary improvements in risk assessment and HIV CTS forms Invite the Harm Reduction Coalition to speak to counseling staff

Acknowledgements Susan Blank, MD, MPH Assistant Commissioner Bureau of STD Control Alan Dunn, MD Physician in Charge Riverside STD Clinic Riverside STD Clinic Staff

New York City Department of Health and Mental Hygiene Contact Information Robin R. Hennessy NYC DOHMH Bureau of STD Control rhenness@health.nyc.gov New York City Department of Health and Mental Hygiene