Outreach HIV/STD Program Effectively Screening in “Hot Spots” of Baltimore City P.Burnett¹ ², M. Crawford ¹, G.Olthoff ¹ ², D. Freeman¹ ² ¹Baltimore City Health Department; ²Centers for Disease Control and Prevention, Atlanta GA The findings and conclusions in this presentation are those of the authors and do not necessarily represent the views of the CDC/ATSDR.

Background In 1997. Baltimore had the highest rate of Primary and Secondary syphilis in the country. Intervention measure resulted in a steady decline in rates from 1998 –2002. In the summer of 2003 case rates begin to rise and previous intervention strategies were failing to stop the increase.

The Challenges Assure data collection and analysis is timely and meaningful Apply this analysis to develop or improve targeted interventions Locate resources (staff, money, supplies, vehicles) to direct new or improved intervention initiatives. Achieve community cooperation and participation

Data analysis and collection STD*MIS was the data collection system currently in use. The system had deficiencies in the collection of all meaningful risks data and data related to geographical location of sexual encounters. Much of the information collected in partner notification interviews was captured on the hard copy but not entered into STD*MIS. Analysis of this information was dependent on manual review delaying timeliness of response and reducing consistency in analytical techniques.

Solution A revised interview record was developed which provided additional social/sexual information needed to target interventions STD*MIS was enhanced utilizing “local use” tables to collect all the interview data electronically Management was able monitor the profile of the outbreak daily and adjust resources accordingly

Action Plan Data analysis revealed that a significant portion of early syphilis was occurring among Commercial Sex Workers (CSW), CSW Clients and MSM. Abuse of alcohol, cocaine and heroin (IVDU) were common co-factors. An active outreach program focusing on the areas of the city identified as CSW “strolls” and areas where infected individuals frequented was implemented

Logistics A fulltime day time outreach team was formed consisting of a supervisor, three outreach workers and a driver/outreach worker. An evening/weekend outreach team was formed using existing STD Prevention staff of Disease Intervention Specialists, Outreach workers, phlebotomists and support staff.

Two vehicles were acquired – an unmarked white cargo van that could easily maneuver in high risks areas and a retrofitted RV which had been used in a HIV Prevention pilot project that was no longer funded. Staff received training in active outreach techniques. The vehicles were stocked with blood screening supplies, condoms, literature, incentives and referral information for clients seeking drug abuse assistance or other social programs.

Data Collection for Outreach Activities Efficient collection of information obtained during outreach was a challenge. Initially each clients require completion of an intake form, lab form, lab label, informed consent form, and HIV “bubble” form. Completion of all these forms delayed the process and limited the number of clients served. An automated data collection system did not exist

Solutions Through the use of the “clinic visit” table in STD*MIS and local use tables all outreach data was entered into our existing management information system. One comprehensive form was developed capable of gathering all client data, serving as a lab request and obtaining informed consent. This reduced the time required with each client from approximately 20 minutes to under 5.

Community Partners The program had several contracts with community partners utilizing syphilis elimination funds. These partners were encouraged to participate in the enhanced outreach activities. A staff member coordinated the exchange of data to assist them in targeting outreach. Training on active outreach techniques was provided to all interested partners. Outreach partners were provided the comprehensive outreach form and the data from their activities was included in STD*MIS

Prioritizing Outreach Areas named by infected patients during syphilis interviews Areas named by non-infected partners or associates of syphilis patients Areas named by HIV infected patients Known areas frequented by prostitutes and drug users Areas with previously high numbers of disease being identified Events targeting high risk populations Drug treatment programs Health Fairs and similar events

Baltimore City Health Department STD/HIV Prevention Outreach Project 9/04* – 12/31/07 *Outreach Program initiated 9/1/04

HIV Findings YEAR HIV TESTS WESTERN BLOT + POSITIVITY RATE 2004 2130 88 4.1 2005 8344 533 6.4 2006 14835 975 6.6 2007 12435 763 6.1   These numbers reflect both new infections and previous infections. All positives are receiving follow-up to assure adequate access to care.

Syphilis Findings

Self Identified Risk Factors Among Clients Screened August 2004 – December 2007 MSM CSW CSW CLIENTS TEST 1912 1828 3385 HIV+ 215 174 305 P&S 20 15 EARLY LATENT 22 31 13 TOTAL SYPHILIS 88 68 58

Self Identified Drug Use Among Clients Screened August 2004 – December 2007   ALCOHOL COCAINE/CRACK HEROIN IVDU MARIJUANA TESTS 10134 7696 7444 5443 6676 HIV+ 1116 1309 1199 1189 581 P&S 31 33 30 27 26 TOTAL EARLY 87 57 86 71 67 ALL SYPHILIS 143 84 130 101 95

Ongoing Outreach Program Success of effort is strongly influenced by the ability to utilize information obtained from infected and affected individuals to target timely outreach activities. The data gained through outreach is valuable in evaluating program success and provide additional direction to future activities.

Lessons Learned Pay attention to detail when preparing for outreach activities - making sure staff, vehicles and SCREENING SUPPLIES are adequate. Set your goals high and believe you can reach them. The difference between a good outreach team and a great one is their belief in the project and passion for it.

Conclusion Outreach screening geared toward “at risk’ populations will have a positive impact on disease prevention. The most effective screening strategy must be sensitive to the needs of the community and be a cooperative effort between the Health Department and Community Partners.

Special Acknowledgement of Our Community Partners Sisters Together and Reaching (STAR) Johns Hopkins Bayview Care-A-Van Healthcare for the Homeless Peoples Community Health Centers Gay, Lesbian, Bisexual, and Transgender Community Center of Baltimore (GLCCB) Baltimore Black Gay Pride