1. 813 Wake County Lessons Learned and What’s to Come

2. Community Assessment Discussions with Health Department administration and outreach staff Individual interviews with STD clinic staff Meetings with CBOs and Health Task Forces Focus groups with Adolescent community members GIS mapping of STDs

3. Gaining Access to the Community Managers Outreach Community Leaders Community Access

4. Areas of Attention Geographic clustering Heterogeneity of community Institutional barriers Screening to diagnose asymptomatic disease STD/HIV co-infection

5. Community Outreach - Many Lessons Learned Substantial mistrust of "research” - particularly among the managerial and outreach levels - managerial gatekeepers act to “protect” the community Substantial mistrust of "partnerships" between university and county health department - concern over lack of community involvement in grant submission

6. Community Focus Groups OBJECTIVES –To identify those factors that serve as barriers to accessing STD/HIV testing in the target population –To obtain recommendations on how best to facilitate testing and treatment in this population

7. METHODS Sample –N=10 groups –Recruitment Instrument –Based on previous outreach –Validity assessed –4 issues explored Data Collection Analysis –Software: Qsr NVIVO MS Word –Theory informed Pilot tested - In same population

8. INSTRUMENT: Relevant Questions BARRIERS Let’s say you decide that you want to get tested, what kinds of issues might come up? RECOMMENDATIONS …now, think of the ideal, easiest or best way for people to get tested or treated for STDs, what would it be like?

9. KEY BARRIERS Rude staff Cost Intrapersonal barriers Confidentiality Concerns

10. Key Barriers by Gender Women Rude staff Cost Confidentiality Long wait Men Intrapersonal factors Confidentiality concerns Cost Addiction The SWAB!

11. Barriers:Mistrust Substantial mistrust of State and Federal (i.e. CDC) organizations - managerial levels uncertain of benefit for community - STDs are priority of State/Federal organizations, not community?

12. RECOMMENDATIONS Convenient location Integrate into other services Staff who are trained in sensitivity Ensure confidentiality Increase outreach efforts Welcoming clinic environment

13. Recommendations Increased access to general medical services is considered more important than access to STD services Community members want “mainstream” access to care (HMO settings, physician offices, ER), not clinic

14. Phase II Expanded STD Screening Expanded STD screening and Incident HIV infection in clients obtaining HIV testing in STD clinic STD/HIV Testing in County Hospital ED STD Screening in HIV Clinic setting STD screening in HIV C&T site

15. HIV INFECTION AND PREVALENT STDs AT TIME OF HIV TESTING Estimate the point prevalence of : -HSV-2 (serology) -chlamydial infection, gonorrhea (NAAT) -syphilis (serology) in patients undergoing HIV testing at the Wake County Human Services STD clinic. Determine the relationship between concurrent STD diagnosis (symptomatic and asymptomatic) and HIV test result. Determine incidence of HIV by detuned HIV assay and p24 antigen (Primary HIV)

16. Infection Rates HIV Test Study in STD Clinic NGCCTHSVSyphHIV Male 11916 (13%) 23 (19%) 41 (34%) 2 (2%) 1 (<1%) Female 1029 (9%) 14 (14%) 42 (41%) 0 (0%) 1 (<1%) Total 22125 (11%) 37 (17%) 83 (38%) 2 (<1%)

17. HIV Care Purpose: - Determine the incidence/prevalence of GC, CT, syphilis, TV and HSV-2 in people with HIV who attend the Wake County HIV clinic and other sites for routine care - Determine the relationship of STD prevalence and HIV status as indicated by CD4 count and viral load.

18. HIV Care Cohort of individuals will be followed for one year Baseline and ~ every 3 months – Behavioral data –Blood for syphilis and HSV-2 testing – Urine for GC and Ct testing; TV in men –Self-collected vaginal swab from women for TV culture

19. HIV Care Behavioral Data includes: Number and type of sexual partners in the previous three months HIV serostatus of sexual partnerships STD infection in sexual partners Condom use (last time had sex) Self-report of previous STD symptoms or diagnosis Interim STD symptoms and possible diagnosis/treatment elsewhere

20. HIV Care Study

21. HIV/STD Co-Infection Females

22. HIV/STD Co-Infections Males

23. Conclusions STD screening is feasible in HIV care Preliminary results suggests high rates of TV infection in HIV infected High Rate of HSV/HIV co-infection High Rate of + syphilis serology

24. 813 UNC Bill Miller Marlene Smurzynski Trang Nguyen Dionne Law Chandra Ford Betsey Tilson CDC Kim Fox Katie Irwin Rheta Barnes

26. BARRIER: Rude Staff #1 barrier for women Perceived as –Unprofessional –Rude –Prejudicial “I went to get tested at the HD. I had a nurse there, I’ll never forget…she talked to me like I was a speck of dirt on the floor, because I had had …unprotected sex… When I left there, I was walking down the sidewalk crying cause she made me feel that bad …” - Homeless female

27. BARRIERS Cost “…’cause I just went to have a test done, and it cost me $15, and I was like,…A person in my status, homeless, I don’t have that kind of money.” - homeless female Intra-personal Factors perceived risk fear embarrassment, shame denial

28. BARRIER: Confidentiality Concerns Visibility: Being identified by peers Confusion : ‘Confidential’ vs. ‘Anonymous’ Broken Confidentiality: Staff sharing patient information to others in the community Privacy: Indiscrete or careless disclosure by staff during patients’ visit

29. BARRIER:Confidentiality Visibility “…I’m in contact with a lot of women that go to the Women’s Ctr., and if I’m there to do that, that may not be something I want everybody to see.” -Homeless female Confidential vs. Anonymous “The people that are testing it are going to know. Somebody else is going to know, cause they got to send it here to get it tested…” -In-treatment, male SA

30. Community Identified Priorities Cardiovascular disease Violence HIV infection

31. HIV Test Study in STD Clinic