1. Putting It All Together:
Massachusetts Integrated Counseling, Testing and Referral Program (ICTR)
Sheila Nelson, MPH, MSW
Daniel Church, MPH; Brenda Cole; H. Dawn Fukuda, Sc.M; David Novak, MSW; Clare O’Donoghue
Massachusetts Department of Public Health
Hello everyone. My name is Sheila Nelson, and I’m going to be speaking about the Massachusetts Integrated Counseling, Testing, and Referral program

2. Massachusetts Prior to 2003
HIV Testing
~40 DPH-funded HIV Counseling and Testing Programs
Referral
STI Testing
9 DPH-funded STD Clinics
To give some history to the project, prior to 2003, the Massachusetts Department of Public Health HIV/AIDS Bureau funded over 40 HIV counseling and testing sites throughout the state.
Depending on need, HIV counseling and testing clients could be referred out to STD clinics supported by the Division of STD Prevention, or hepatitis C testing through community health centers or private primary care.
Referral
Hepatitis Testing
No DPH-funded testing programs

3. Connects 3 disease entities with similar associated risk indicators
Rationale for ICTR
HIV
Hepatitis
STIs
However, there was growing awareness that HIV, STIs, and viral hepatitis share not only common transmission routes and challenges with co-infection, but also common populations at risk, social stigma and discrimination, and issues of complex access to care and treatment.
Connects 3 disease entities with similar associated risk indicators

4. ICTR Service Delivery HIV Testing STI Testing Hepatitis Testing
The integrated counseling and testing model recognizes overlapping behavioral risks, and the potential for clients to “fall through the cracks” when referred to other programs for STI testing and viral hepatitis services.
With this model, an individual can present for any one of three testing needs, and be offered
HIV testing, using oral-mucosal, serologic, or finger-stick rapid testing;
testing for chlamydia and gonorrhea using urine-based NAATs;
syphilis by RPR serology;
hepatitis C testing by serology,
and hep A and B vaccine.
Supported referrals as needed

5. ICTR Collaborations Department of Public Health Across Provider System
HIV/AIDS Bureau
Bureau of Communicable Disease Control
STD Prevention
Viral Hepatitis
HIV/Hepatitis Laboratory
STD Laboratory
Across Provider System
Clinic-based Programs
Community-based Programs
HIV Medical Management
Primary Care
What became the Integrated Counseling, Testing, and Referral (or ICTR) program began in 2003, although the process of integrating STI testing has really happened in the past two years.
Integration began at the departmental level. The Integrated Counseling and Testing Workgroup, including staff from the HIV/AIDS Bureau, the Division of STD Prevention, and the Viral Hepatitis Program, has been meeting weekly or bi-weekly since early 2006.
Integration also required new relationships between DPH and the funded sites, as well as new relationships within programs themselves.

6. ICTR Site Locations Lawrence Lynn Cambridge Boston Fall River
New Bedford
Hyannis
Provincetown
Worcester
Springfield
Holyoke
In an effort to make these services available to as much of the population as possible, ICTR sites are distributed across the state

7. ICTR sites are also located in areas with high morbidity for HIV, STIs, and viral hepatitis. This is a map of Massachusetts, where the dark blue areas represent cities and towns reporting more than 250 cases of chlamydia in 2006.
(animation) These are the ICTR clinics.

8. ICTR Performance Measures
Target populations at risk
70% ICTR clients will be members of priority populations (MSM, IDU, partner of IDU/HIV+)
Promote enhanced screening
50% of clients at risk for STIs will be screened for chlamydia, gonorrhea, and/or syphilis
50% of clients at risk for HCV will be screened for HCV
Provide results
85% of clients tested for HIV, HCV, and/or STI will receive their results and post-test counseling
Vaccinate
85% of HIV+ or HCV+ clients will receive at least 1 dose of HAV and/or HBV vaccine
Connect to care
100% of clients positive for HIV, HCV, or STI will be referred for treatment, follow-up care, and partner services
At the program level, ICTR sites are expected to target populations at high risk, promote enhanced testing based on risk assessment, inform clients of their results, and vaccinate as appropriate.
Additionally, clients testing positive for STIs, HIV, or hepatitis C should be linked to treatment or ongoing care.
One of the major outcomes of the ICTR workgroup was a set of very specific performance measures that incorporated service delivery targets for HIV, STIs, and viral hepatitis. For example, 70% of clients seen at ICTR sites should be members of priority populations.

9. ICTR Algorithm This is a busy slide, so let me walk you through it.
STI Testing
Negative result
Informed by
Positive result
Informed by ______
Referral and appt made for medical care
Scheduling done by _________
STOP
Additional supported referrals*
Specimens collected by ___________
Pt. treated per clinical protocol
Report to DPH (yellow card)
Completed by ____
F/u as needed
Pt. cannot be contacted or DNKA
F/u attempted by ____________
Completed by _____________
DPH Disease Intervention Specialists (DIS)
HIV Testing
Specimens collected by__
Plasma ____
OMT ____
Rapid ____
Referral and appt made for primary care
EMMS
Hepatitis Services
Vaccine administered_____
Appt made to complete vacc series_____
HCV testing
Specimens collected _____
Results and post-test counseling
Results and post-test counseling given by
___________
Private care provider
Left state
PCRS**
Data collection and reporting
This is a busy slide, so let me walk you through it.
This algorithm was developed by the Integrated Counseling and Testing Workgroup, and then shared with ICTR sites as a tool for structuring the elements of providing counseling, testing, and care for all three disease entities.
The programs were then asked to tailor the algorithm to reflect the flow of care at their individual site, and to identify members of their staff who would be responsible for each aspect of testing
So for example, sites were asked to identify who would be responsible for collecting STI specimens, as well as who would be responsible for informing clients of their results, scheduling treatment, reporting and documentation, and referring positive clients to partner services.

10. Training and Technical Assistance
Site Visits
Develop clinic-specific protocols for counseling, testing, specimen collection/submission based on algorithm
Training and support
Site-by site training on relationship between HIV, STIs, viral hepatitis
STI training focused on:
Basic information on chlamydia, gonorrhea, and syphilis
STI related counseling and risk reduction messages
Specimen collection and submission (if applicable)
Staff from the HIV/AIDS Bureau, the Division of STD Prevention, and the Viral Hepatitis program then met with each ICTR program, using the performance measures and the individualized testing algorithm as guides for discussing the implementation of integration at that site.
Although some sites had been providing hepatitis vaccination and HCV testing for several years, RPR testing and the use of urine-based NAATs for chlamydia and gonorrhea screening was new to everyone. Additional technical support was provided to all the sites, including trainings with staff on basic STI information, counseling messages, and specimen collection and handling.

11. ICTR: HIV Testing Data For 4/1/07-12/31/07
Total HIV Tests
11,123
Gender
Male
6170 (56%)
Female
4915 (44%)
Missing
38 (<1%)
Mean Age
34.6 years
Total Positives
110 (1%)
This data is from the first 8 months that STI services began to be offered at ICTR sites.
I do want to make it clear that all of this data is encounter level, and does not describe unduplicated clients.
A total of 11,123 HIV tests were provided at ICTR sites. The gender breakdown was 56/44% male/female, with a mean age of 34.6 years. Overall positivity for HIV of about 1%

12. ICTR: HIV Testing Data For 4/1/07-12/31/07
White non-Hispanic
Hispanic/Latino
Black non-Hispanic
Brazilian
Haitian
Asian/Asian American
Cape Verdean
Portuguese
This data is also for HIV testing at ICTR sites during the same time period.
Slightly more than 40% of HIV tests were among non-Hispanic whites, followed by Hispanics at 22.7% and 16.3% among those identifying as black non-Hispanic.
In contrast, the overall population of Massachusetts is 82% white non-Hispanic, 7% Hispanic/Latino, and 5% black non-Hispanic, suggesting that ICTR sites provide a significant amount of testing to communities of color.
American Indian/Aleutian/Eskimo
Other/Unknown
Missing

13. ICTR: HIV Testing Data For 4/1/07-12/31/07
Heterosexual sex
Male sex with male
Injection drug user
STD diagnosis
Sex with IDU
Sex w/ persons w/ AIDS or HIV
Sex with prostitute
The HIV risk behavior most frequently reported was heterosexual sex, followed by men having sex with men, and injection drug use.
Interestingly, the fourth highest HIV risk factor reported was a previous STD diagnosis, suggesting that ICTR sites are reaching populations with an already identified risk for sexually transmitted infections.
No acknowledged risk
No response
*Includes only behaviors reported >1%

14. ICTR: STI Testing Data For 4/1/07-12/31/07
Number Tested
Number Positive (%)
Number Unsatisfactory (%)
Chlamydia
1564
85 (5%)
8 (1%)
Males
1021
57 (6%)
7 (1%)
Females
543
28 (5%)
1 (<1%)
Gonorrhea
1563
14 (1%)
7 (<1%)
542
Syphilis
1440
17 (1%)
3 (<1%)
874
12 (1%)
2 (<1%)
545
5 (1%)
In the first 8 months that STI testing was integrated into ICTR sites, over 1500 combined chlamydia and gonorrhea tests and over 1400 RPR serologies were submitting to the Massachusetts state laboratory institute for testing.
Chlamydia positivity was approximately 5% overall, and GC positivity was about 1%. About 1% of RPRs were reactive.
The reason I included the data on unsatisfactory tests was that many sites actually trained counselors to collect and submit specimens. But the overall rate of unsatisfactory tests was very small, suggesting that non-clinical staff can effectively manage the urine-based chlamyida/GC testing with proper training and support.

15. ICTR: HCV Testing and HAV/HAB Vaccination Data For 4/1/07-12/31/07
Total HCV Tests
2958
Total HCV Positive
293 (10%)
Total doses HAV vaccine
284
Total doses HBV vaccine
344
Of the almost 3000 hepatitis C test specimens submitted, 10% were HCV antibody positive.
284 doses of hep A vaccine and 344 doses of hep B were administered at ICTR sites.

16. ICTR: Challenges Data collection and analysis
Access to clinical staff at ICTR sites for vaccination
Reimbursement for care for STI-positive or HCV-positive clients
Those of us working on this project did encounter some significant challenges.
Massachusetts has separate data collection systems for STIs, HIV, and hepatitis, with different variables reported. HIV and hepatitis C specimens are collected and submitted to the lab using a bar-code system; STD specimens are submitted and reported by name, and the data systems can’t be linked.
In addition, providers had to use new data forms, and there has been a significant lag in providers reporting data for all three testing elements.
Access to nurses and other clinicians for vaccination is an ongoing challenge for some ICTR sites; although counselors and non-clinical staff can do most of the risk assessment and specimen collection, Hep a and B vaccination require a clinical provider
Most of the ICTR programs are part of community based health centers, and although all of them prioritize on-site treatment for individuals testing positive for an STI, covering costs for those individuals who are uninsured has been a challenge.
Programs for hepatitis C medical management are available at a few sites, but aren’t widespread at this point.

17. Future Directions: Revisiting ICTR Performance Measures
Target populations at risk
70% ICTR clients will be members of priority populations (MSM, IDU, partner of IDU/HIV+)
Promote enhanced screening
50% of clients at risk for STIs will be screened for chlamydia, gonorrhea, and/or syphilis
50% of clients at risk for HCV will be screened for HCV
Provide results
85% of clients tested for HIV, HCV, and/or STI will receive their results and post-test counseling
Vaccinate
85% of HIV+ or HCV+ clients will receive at least 1 dose of HAV and/or HBV vaccine
Connect to care
100% of clients positive for HIV, HCV, or STI will be referred for treatment, follow-up care, and partner services
One of our challenges going forward is the need to analyze and integrate our data, to really evaluate how well the program is meeting the performance measures developed at the beginning of the process

18. ICTR: Conclusions
Service integration is a viable way to enhance access to STI, HIV, and viral hepatitis testing, prevention, and care
Successful integration requires:
Coordination and active participation at the level of the Department of Public Health
Training and technical support for ICTR providers
New provider relationships with primary care and medical management
However, overall we found that the integrated counseling testing and referral model was effective in enhancing access to testing and care for STIs, HIV, and viral hepatitis.
Making the program a success required true integration at all levels: among contract managers and program developers at the Department of Public Health, between DPH staff and funded programs, and within the programs themselves.

19. Acknowledgements The MDPH ICTR Workgroup: Additional thanks:
Juliet Berk
Dan Church
Daniel Cohen
Brenda Cole
Joanne DeVries
Lisa Ehle
Dawn Fukuda
Bernadette Green
David Novak
Clare O’Donoghue
David Lessard
Additional thanks:
My name is Sheila Nelson, I’m the Women’s Health Coordinator with the Division of STD Prevention at the Massachusetts Department of Public Health.
Before I go further, I want to acknowledge that I’m describing an incredible amount of work on the part of staff at the HIV/AIDS Bureau, the Division of STD Prevention, the Viral Hepatitis program, and the Massachusetts State Laboratory Institute.
Delete the top move to end add titles
Alan Borne
Katherine Hsu
Debbie Isenberg
Support for this project was provided by the MDPH HIV/AIDS Bureau, the MDPH Division of STD Prevention, and the MDPH Viral Hepatitis Program