Targeting Gonorrhea Counseling and Sex Partner Services to African Americans Using Zip Codes and Fee-for-Service Reimbursement National Coalition of STD Directors (NCSD) 2010 Annual Meeting San Antonio, Texas October 8, 2010 Charlie Rabins, MPH Illinois Department of Public Health, STD Program Springfield, Illinois

Background Prevention Concerns  Reported gonorrhea decreased 57% from 1986 to 1996 in Illinois excluding Chicago but subsequently increased 54% from 1996 to 2007 despite implementation of CT screening program in 1995 with combo CT/GC NAATs. Health Equity Concerns  African Americans accounted for 76% (6,992 of 9,215) of reported cases in 2008*  Reported case rate per 100,000 population among African Americans was 37 times greater than among whites* * Illinois Excluding Chicago – among cases where race is known

Reported Gonorrhea Cases Illinois (Excluding Chicago) 1986 – 2010* IPP CT/GC DNA Probe Screening Implemented * 2010 Projected based on January – August 2010 Targeted Partner Services Implemented IPP CT/GC NAAT Screening Implemented

Illinois Excluding Chicago Reported STD Case Rates in 2008 Disparity Between Racial/Ethnic Groups Case Rates Per 100,000 PopulationRate of Disparity InfectionAfrican Americans WhitesHispanicsAfrican Americans vs. Whites Hispanics vs. Whites Chlamydia 1, X3.7 X Gonorrhea X2 X Primary & Secondary Syphilis X3 X

Effect of Counseling & Partner Services on Gonorrhea Transmission Dynamics Anderson and May postulated that an STD will continue to spread/reproduce among sexually active persons in a community if the average probability of transmission per sex partner contact (times) the average duration of infection (times) the average number of sex partners per unit of time is greater than one. R 0 = (ß x D x c) R 0 -Average number of secondary cases generated in a population by a primary case ß - Average probability of transmission per sexual contact (GC=0.5) D – Average duration of infectiousness (GC= 0.5 years) C - Average number of sexual partners per unit time Source: STDs, Holmes et. al., 3 rd Ed., 1999 Chapter 3. Roy M. Anderson

Study Objective -1 Determine if providing targeted patient counseling and sex partner referral services (PCRS) for gonorrhea in selected Zip Codes and reimbursing local health departments (LHDs) on a fee for service basis for PCRS results in a reduction in gonorrhea incidence among African Americans.

Study Objective -2 Determine baseline outcomes and potential performance measures for gonorrhea counseling and sex partner services conducted by LHD public health nurses and disease intervention staff.

Methods GC incidence data analyzed - targeting services in selected Zip Codes could predominantly reach African Americans without stigmatizing by race. Received CDC and IDPH approval to use $202,500 in 2007 federal STD grant carry forward funds for the project with some restrictions. 6 LHDs selected based on: 1) at least 60% of total city GC cases among African American; 2) representing different geographic areas of state; and 3) ≥ 80% of cases in 6 of fewer zip codes per LHD.

2007 Reported Gonorrhea Cases in Six Cities Selected for the GC PS* Project Project Cities # GC Cases By City % GC Cases African American # Target Zip Codes By City # GC Cases in Target Zipcodes % Cases in Target Zipcodes Carbondale12178%19276% Champaign23272%221091% Danville27667%127599% East St. Louis48596%546796% Peoria88079%686098% Rockford82278%581099% Total2,81680%202,71496% The 6 Project Site Cities Accounted for 25% of Reported GC Cases in 2007 in Illinois Excluding Chicago. * PS = Partner Services

Carbondale East St. Louis Champaign Danville Peoria Rockford Illinois Cities in Gonorrhea Counseling and Partner Services Project

Methods - 2 Fee-for-Service model selected to reward performance but modified to meet CDC and IDPH funding requirements.  $50 per case counseled in clinic  $100 per case counseled by phone or in field  $100 per case resulting in ≥ 1 newly treated infected sex partner  Developed Cx record, web-based data entry, protocol and PCRS Cx algorithm ( See Referenced Items )  2-hour GC PCRS webinar trainings conducted* * GC/CT counseling and partner services training presentation available on website in GC Control Group

Results

Targeted GC Counseling and Sex Partner Services All Outcomes - 1: February – December 2009 Outcome#% Reported Cases in Target Zip Codes1,863N/A Reported Cases Documented with Counseling Record1, % Reported Cases in Target Zip Codes Counseled % Cases with Counseling Record that were Counseled % Counseled Cases Counseled in Clinic % Counseled Cases Counseled in Field35 4.6% Counseled Cases Counseled on Telephone %

Targeted GC Counseling and Sex Partner Services All Outcomes – 2: February – December 2009 Outcome#% Critical Period Sex Partners Identified by Infected Persons1,042N/A Critical Period Sex Partners Initiated for Follow-up % Critical Period Sex Partners that were Newly Examined % Initiated Sex Partners Newly Examined % OutcomeRates Critical Period Sex Partners Examined per Case Counseled0.41 CP Sex Partners Newly Examined per Reported Case with Cx Record0.29 Newly Examined Sex Partners Infected Brought to Rx per Case Cx0.25 Newly Examined Sex Partners Infected Brought to Rx per Reported Case with Cx Record 0.18 CP = Critical Period (60 Days Prior to Positive GC Test Cx = Counseled, Rx = Treatment

Targeted GC Counseling and Sex Partner Services All Outcomes - 3: February – December 2009 Outcome#% Newly Examined Sex Partners that were Infected Brought to Treatment % Newly Examined Sex Partners Testing Negative and Preventatively Treated8527.6% Newly Examined Sex Partners Treated and not Tested185.8% Newly Examined Sex Partners Testing Negative and Not Treated134.2% Sex Partners Referred to Other Health Jurisdiction for Follow-up656.2% Sex Partners Infected and Previously Treated1029.8% Sex Partners Unable to Locate or Refused Exam % Cases Counseled with ≥ 1 Sex Partner Infected Brought to Treatment %

Targeted GC Counseling and Sex Partner Services Outcomes By Sex: February – December 2009 Sex of Case Cx # Cases Cx N=754 % Cases Cx % Cases Cx in Clinic # CP SP Per Case Cx # CP SP Exams Per Case Cx # Infected SP Newly Rx Per Case Counseled % Cases Cx With ≥ 1 Infected Newly Rx SP Male32944%64% % Female42556%37% % Rpt= Reported, Cx = Counseled, SP = Sex Partners, Tx/Rx = Test/Treatment, Init = Initiated CP = Critical Period (60 Days Prior to Positive GC Test)

Targeted GC Counseling and Sex Partner Services Outcomes By Race/Ethnicity: February – December 2009 Race and Ethnicity of Case Cx # Cases Cx N=754 % Cases Cx # CP SP Per Case Cx # CP SP Exams Per Case Cx # Infected SP Newly Rx Per Case CX % Cases Cx With ≥ 1 Infected Newly Rx SP Race Black60480% % White9613% % Ethnicity Hispanic223% % Non-Hispanic66388% % Rpt= Reported, Cx = Counseled, SP = Sex Partners, Tx/Rx = Test/Treatment, Init = Initiated CP = Critical Period (60 Days Prior to Positive GC Test)

Targeted GC Counseling and Sex Partner Services Outcomes By Age Group: February – December 2009 Age Group of Case Cx # Cases Cx N=754 % Cases Cx # CP SP Per Case Cx # CP SP Exams Per Case Cx # Infected SP Newly Rx Per Case CX % Cases Cx With ≥ 1 Infected Newly Rx SP % % % % % % % % Rpt= Reported, Cx = Counseled, SP = Sex Partners, Tx/Rx = Test/Treatment, Init = Initiated CP = Critical Period (60 Days Prior to Positive GC Test)

Targeted GC Counseling and Sex Partner Services Outcomes By Cx Setting: February – December 2009 Setting Where Case Cx # Cases Cx N=754 % Cases Cx # CP SP Per Case Cx # CP SP Exams Per Case Cx # Infected SP Newly Rx Per Case Cx % Cases Cx With ≥ 1 Infected Newly Rx SP Clinic36749% % Telephone35246% % Field354% % Rpt= Reported, Cx = Counseled, SP = Sex Partners, Tx/Rx = Test/Treatment, Init = Initiated CP = Critical Period (60 Days Prior to Positive GC Test)

Targeted GC Counseling and Sex Partner Services Outcomes By Quarter: February – December 2009 Time Period of Case Cx # Cases Cx N=754 % Cases Cx # CP SP Per Case Cx # CP SP Exams Per Case Cx # Infected SP Newly Rx Per Case CX % Cases Cx With ≥ 1 Infected Newly Rx SP 1 st Quarter19326% % 2 nd Quarter25534% % 3 rd Quarter23130% % 4 th Quarter7510% % Rpt= Reported, Cx = Counseled, SP = Sex Partners, Tx/Rx = Test/Treatment, Init = Initiated CP = Critical Period (60 Days Prior to Positive GC Test)

Targeted GC Counseling and Sex Partner Services Outcomes – 1 By LHD: February – December 2009 Project Cities # Rpt Cases In Target Zip Code % Rpt Cases Cx # Cases With Cx Record % Cases With Cx Record Counseled % Cases Cx in Clinic % Cases Cx By Phone % Cases Cx in Field Champaign27354%22067%35%55%10% East St. Louis34716%7771%73%15%12% Carbondale9872%8287%17%79%4% Peoria50327%23159%58%41%1% Rockford52064%43377%53%45%2% Danville1228%1283%100%0% Total1,86340%1,05572%49%47%4% Rpt= Reported, Cx = Counseled, SP = Sex Partners CP = Critical Period (60 Days Prior to Positive GC Test)

Targeted GC Counseling and Sex Partner Services Outcomes - 2 By LHD: February – December 2009 Project Cities # Cases Cx With Cx Record # SP Within CP # SP Per Case Cx # SP Init For Tx and Rx # Init SP Per Case Cx # SP Exam Per Case Cx % SP Infected Newly Rx # SP Newly Infected Per Case Cx Champaign %0.25 East St. Louis %0.76 Carbondale %0.13 Peoria %0.31 Rockford %0.18 Danville %0.20 Total7541, %0.25 Rpt= Reported, Cx = Counseled, SP = Sex Partners, Tx/Rx = Test/Treatment, Init = Initiated CP = Critical Period (60 Days Prior to Positive GC Test)

Jurisdiction Percent Change 2007 to 2010 CARBONDALE % CHAMPAIGN % DANVILLE % EAST ST. LOUIS % PEORIA % ROCKFORD % TOTAL DOWNSTATE6,3186,8327,7036,9925,896 4, % TOTAL SIX TARGET CITIES1,7341,8572,2531,8691,604 1, % TOTAL DOWNSTATE EXCLUDING TARGET CITIES4,5844,9755,4505,1234,292 3, % Illinois Reported Gonorrhea Among African Americans, 2005 – 2010* Target Cities Compared to Downstate** * 2010 Projected based on reported cases 1-8/2010 ** Downstate = Illinois Excluding Chicago

Cost Calculations $75,450 = Fee for Service Cost for Counseling 754 Infected Persons Resulting in 192 Newly Rx Infected Sex Partners $393 = Overall Cost per Infected Newly Rx Sex Partner $246 = Cost for Infected Newly Rx Sex Partner Identified by OP Counseled in Clinic/Time of Rx $683 = Cost for Identifying Infected Newly Rx Sex Partner Identified by OP Counseled in Field $645 = Cost for Infected Newly Rx Sex Partner Identified by OP Counseled by Telephone OP = Original Infected Person Counseled

Conclusions and Implications - 1 Number of Critical Period Sex Partners per Case was very Consistent Across Data (~1.4 per case) Counseling Males May Be More Productive Than Females Counseling at Time of Rx is almost 2x as Productive as Counseling in Field or by Telephone; and was 2.7 times less costly to Identify Infected Newly Treated Sex Partners Grants and Contracts Need More Flexibilit y to Enable Fee for Service

Conclusions and Implications - 2 Counseling Productivity Degraded Over Time Indicating Need for Frequent Feedback to Counselors on Performance and Outcomes Counseling year olds is More Productive than year olds Insufficient Evidence of Reduced Incidence Among African Americans in Target Zip Codes Compared to Other Downstate Communities Lessons Learned From Pilot Project Facilitated Project Area Wide Expansion of GC/CT PCPS

Reported Gonorrhea and Chlamydia Cases Documented Counseling/Partner Services Outcomes Illinois Excluding Chicago: May – August 2010 OutcomesGonorrheaChlamydia NumberPercentNumberPercent Reported Cases2,207N/A9,814N/A Cases Counseled28213%5095% Sex Partners in Critical Period (Past 60 Days) *1, * Critical Period Sex Partners Initiated19145%28519% Initiated Sex Partners Newly Examined10656%19870% Initiated Sex Partners Infected Brought to Treatment6232%11942% Initiated Sex Partners Preventively Treated2513%3613% Initiated Sex Partners Treated Not Tested84%176% Sex Partners Infected Previously Treated5931%8229% Sex Partners Initiated Out of Jurisdiction179%3211% Sex Partners Unable to Locate or Refused Exam10756%13848% * Sex Partners Identified in Critical Period per Case Counseled

Acknowledgments Study Co-authors  Steve Holmes  Ed Renier Administrators and staff at Champaign, East Side, Jackson, Peoria, Vermilion and Winnebago Health Departments IDPH STD Program staff Becky Rinozzi Danny Brikshavana Wiley Jenkins

Questions ? Illinois Department Of Public Health Sexually Transmitted Diseases Program Charlie Rabins, MPH

Referenced Items Map of Gonorrhea Rates in Illinois by County for 2007 GC PCRS Algorithm GC PCRS Counseling Record STD Morbidity Record linked to GC PCRS Cx Record Web Data Entry Screen for Summary Data Sample Telephone Scripts Sample Cost Report for LHDs

2007 Illinois Gonorrhea Rates >300 > > Rate per 100,000 Population

Algorithm for Participating LHDs

IDPH GC Counseling and Sex Partner Services Data Collection Tool

Morbidity Report Form Used to Link Patient Demographics with GCPS Counseling Record GC Counseling #

IDPH GCPS Web Data Collection Screen

Sample Telephone Counseling Script - 1

Sample Telephone Counseling Script - 2

GC Counseling and Partner Services Report All 6 LHD February – June 2009