1. 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

2. 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?

3. 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

4. HBV Infection and Immunization Coverage, by Site (YMS Phase I)27
HBV Infection (%)
Immunization coverage (%) 6 16
Seattle, 13 12 12 11 6
San Francisco,
New York, 11
Baltimore, 5 11
Los Angeles, 3 9
Dallas, 5
Miami,

5. 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

6. 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
– 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???

8. 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

9. 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)

10. 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

11. 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

12. 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?

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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)

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

22. 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

23. 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.