Viral Hepatitis Integration An Update of State-Based Programs Joanna Buffington, MD, MPH Division of Viral Hepatitis National Hepatitis Coordinators’ Conference San Antonio, Texas January 2003

Outline Background VHIP update Why integration makes sense National Hepatitis C Prevention Strategy State-based integration programs VHIP update What have we learned? Where do we go from here?

Why Integrate Viral Hepatitis Prevention with Other Programs (HIV, STD, Corrections, Substance Abuse)? Existing programs serve populations at risk for multiple infections, including viral hepatitis Routes of transmission overlap Without integration Missed opportunities for prevention Continued transmission of viral hepatitis

HBV Infection and Immunization Coverage, by Site (YMS Phase I) 27 HBV Infection (%) Immunization coverage (%) 6 16 Seattle, 1997-98 13 12 12 11 6 San Francisco, 1994-95 New York, 1997-98 11 Baltimore, 1996-98 5 11 Los Angeles, 1994-95 3 9 Dallas, 1994-95 5 Miami, 1995-96

Hepatitis C Coordinator National Hepatitis C Prevention Strategy State Model of Partnership in Prevention STD Programs Immunization (Hepatitis B Coordinator) Laboratory Medical Services Surveillance Hepatitis C Coordinator Advocacy Groups; CBOs CPGs Corrections HIV/AIDS Prevention Drug Treatment State Plan

Chronology: CDC Funding for State-Based Hepatitis Integration Activities 1997 – 1 Program: San Diego Hepatitis B Demonstration 1999 – 3 Viral Hepatitis Integration Projects (VHIP) 2000 – 15 VHIPs 16 health department hepatitis C coordinators 2001-2002 – continuations and total of 48 coordinators; 3 Indian Health Service sites funded 2002 4 new adolescent VHIPs funded CSTE state planning grants: 8 states Indian Health Service hepatitis C coordinator contract (HIV dollars) for VHIP evaluation 2003???

Hepatitis C Coordinators Goal – a focus for integration by supporting a coordinator to work with existing programs towards integrated hepatitis activities 48 positions funded through ELC (most are filled); 1 IHS, 1 PHPS Selected accomplishments

Written State Plans Completed, published: California Consensus planning: New Mexico In progress: Maryland (draft on-line) Massachusetts (draft recommendations from state hepatitis C advisory committee) CSTE-funded planning: CT, LO, VT, MN, CO, WI, NYS, ME (ME also has needs assessment on-line) Others state plans underway: MI, TX City/Local Plans underway: San Francisco, Baltimore, Santa Barbara (CA)

Viral Hepatitis Integration Projects: VHIP Goals Determine the feasibility of integrating hepatitis prevention services into existing programs serving high risk populations Identify the most effective strategies and venues to reach and provide services to clients at high risk for hepatitis A, B, and C virus infections

VHIP – Primary Settings STD Clinics San Diego Colorado Houston Multnomah (OR) NYC Illinois VA (HIV integrated) HIV CT Erie County Seattle/King Cty, WA Correctional Health Colorado (jail) Rhode Island (prison) San Francisco (jail) Substance Abuse Multnomah Cty San Diego New Mexico IHS NCI, Thunderbird Other MN, MT, MA, Phoenix

VHIP STD Clinic Venues Experience to Date San Diego has the longest experience – and others are following: successful hepatitis B vaccination delivery with high first dose coverage rates; targeted HCV testing can efficiently identify HCV-infected persons; hepatitis A vaccination delivery?

VHIP HIV CTS Experience to Date Most health departments offer HIV CTS within STD clinic settings Challenges outside STD clinic settings: Many stand-alone HIV CTS are provided by CBOs With oral HIV test capability, rare outreach CTS with capacity to offer blood test for HCV infection Clinical services limited; no staff licensed to administer vaccines Anonymous testing CBOs not yet funded through VHIP dollars for integration; HIV Programs and CDC funding are moving towards this, however Unless part of clinical services (e.g., STD), blood drawing and vaccination may be limited Anonymous testing issues – Potentially high volume of “worried well” low risk persons Tracking and recall for vaccine doses is a major problem

VHIP Correctional Health Substance Abuse Venues Highest concentration of high risk clients Prisons may offer best setting for comprehensive services Jail settings more challenging, may be more likely to succeed if directly under Dept of Health (e.g., San Francisco, Denver) Substance abuse settings – still exploring Wide variety of types of services (e.g., in-patient, outpatient, street outreach) NEP – brief encounters Mobile vans, outreach – no clinical staff Pre-vaccination screening may be cost-effective (additional time, infrastructure for blood draw) Lack of electronic data bases for tracking

What Have the VHIPS Accomplished? Collaboration HIV, STD, epidemiology/communicable disease, immunizations Corrections Substance abuse Community Planning Groups Mental health Staff training/cross-training Protocols established Collaboration: all VHIPs report collaboration between HIV and STD and communicable diseases sections within the health departments; more than half report collaboration with correctional health and substance abuse sections; community planning groups (HIV); A few report collaborations with mental health sections ALL have done substantial cross training of staff in different programs; most have established clinic protocols for integrating hepatitis vaccination and or C counseling/testing into settings

What Have the VHIPS Accomplished? Is Integration Feasible? STD clinics? Yes. HIV CTS? Depends. Corrections? Yes, challenging. Substance abuse services? ?? Street outreach, with good access for services – maybe; anonymous testing services – maybe not the best setting. Substance abuse – too early to say

What Have the VHIPS Accomplished? Have we identified the most effective strategies and venues for reaching and providing services to clients at high risk for hepatitis A, B, C? offered the most experience and data; key barriers to implementation and success have been identified Large numbers of persons at high risk for HBV infection who will accept vaccination, given ready access on-site. May not have large proportion of clients who are MSM or IDUs, but large overall volume may still be good way to reach persons (especially IDUs) not likely to access other types of care Remaining barriers: adult vaccine funding; busy clinics; priorities; staffing

Most Effective Strategies and Venues? STD clinics barriers = funding for adult vaccine, staffing, competing priorities in busy clinics HIV CTS (separate from STD) may be more challenging Corrections settings appear excellent venues for accessing high risk clients, especially IDUs Substance abuse prevention, treatment settings Limited experience thus far; wide variety of setting types especially if anonymous HIV testing services are the main service More experience is needed to identify best venues and strategies to access MSM for vaccination services (A, B) Corrections: More experience is needed to identify best strategies for jail vs prison vs other detention programs for services Politics, turf, infrastructure, funding remain key barriers

VHIP Barriers Expected Lack of money for adult vaccine Lack of money for hepatitis C testing Lack of referral mechanisms and access for persons identified with HCV infection Separate funding streams Politics and turf

Additional VHIP Barriers Identified Data systems for tracking/evaluation Lack of standard outcome measures, definitions; lack of adherence to current guidelines Administrative/legislative: hiring freezes, legal issues (e.g., parental consent for under-18) Time with client; competing priorities One-stop shopping requires multi-talented (trained) staff On-site logistics for vaccine administration (licensed personnel, storage)

Integrating prevention services for viral hepatitis, HIV/AIDS, STDs, and substance abuse is GOOD PUBLIC HEALTH

NASTAD, HIV Prevention Bulletin, “Greater integration of services is essential, since it is a disservice to clients who may have multiple risks and/or multiple morbidities, to focus on only a single disease rather than to view clients as whole human beings.” NASTAD, HIV Prevention Bulletin, September 2001 “Integrating Viral Hepatitis into HIV/AIDS /STD programs” END WITH A QUOTE

What can WE do? Look for opportunities to Collaborate Build on existing strengths Cross train staff Navigate turf and funding issues Help communicate recommendations MMWRs 2002 STD Rx Guidelines Report and share experiences [READ] Need to add bullet on the need to integrate STD and hepatitis into the Comprehensive HIV Prevention Plan for the jurisdiction. The CPG could play an important role in improving program and collaboration if these topics we addressed in the plan. Even if HIV prevention $ can’t fund activities like immunizing MSM, just recommending it in the plan should help achieve this and other goals.