1. Program Collaboration and Service Integration:
Kevin O’Connor, PTB, DSTDP
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Centers for Disease Control and Prevention
March, 2008

2. CDC NCHHSTP Organizational Chart
Global AIDS Program
Division of Sexually Transmitted Diseases
Division of Viral Hepatitis
Division of HIV/AIDS Prevention
Division of TB Elimination

4. Overview Rationale for PCSI PCSI Definition/Vision
External Consultation – Brief Summary
Next Steps

5. Modeling/ Health Results Measures
Maximizing
Global Synergies
CDC Goals and Strategic Imperatives
Drug Users
Surveillance/
Strategic
Information
National Center for
Program Integration
HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
MSM
Health Disparities
Associate Director
Director
for Communications
Kevin Fenton
Associate Director
for Program Integration
Susan Robinson r
Deputy Director
Susan DeLisle
Associate Director
(Acting)
Associate Director
for Health Disparities
Reducing
Health Disparities
Hazel D. Dean
for Science
(Acting)
Raul Romaguera
Terry Chorba
Corrections
Program
Integration
Associate Director
Associate Director
for Planning & Policy
Management Official
for Laboratory Sciences
Coordination
Sal Butera
Eva
Margolies
Michael Melneck
Divisions
Dr. Kevin Fenton, Center Director, has established 3 programmatic priorities and PCSI is one of 2 domestic program priorities.
The boxes on the sides represent 8 Cross-Center working groups
Global Antenatal
HIV/AIDS Prevention
HIV/AIDS Prevention
Viral Hepatitis
STD
Tuberculosis
Global AIDS
Modeling/ Health Results Measures
Intervention Research
Surveillance &
Prevention
Prevention
Elimination
Program
& Support
Epidemiology
Director
Director
Director
Director
Director
Director
Robert Janssen
Robert Janssen
John Ward
John Douglas
Kenneth G. Castro
Deborah Birx

6. HIV/AIDS, Hepatitis, STD and TB Common determinants
Similar or overlapping at-risk populations
Disease interactions
Common transmission for HIV, hepatitis and STDs
STDs increase risk of HIV infection
Clinical course and outcomes influenced by concurrent disease
Social determinants
Poor access to, and quality of, health care
Stigma, discrimination, homophobia
Socioeconomic factors, such as poverty
Some commonalities for the center’s diseases:
--Similar or overlapping at-risk populations
--Disease interactions
Common transmission for HIV, hepatitis and STDs, e.g., sexual risk behaviors
STDs increase risk of HIV infection
Clinical course and outcomes influenced by concurrent disease
Social determinants
Poor access to, and quality of, health care
Stigma, discrimination, homophobia
Socioeconomic factors, such as poverty
Prevention and control
Effective interventions exist to reduce the burden of TB, viral hepatitis, most STDs, and HIV
Challenges in funding, delivery, monitoring and quality of prevention services 6

7. Program Collaboration and Service Integration (PCSI)
Operating Definition:
A mechanism of organizing and blending inter-related health issues, separate activities, and services in order to maximize public health impact through new and established linkages between programs to facilitate the delivery of services 7

8. Program Collaboration and Service Integration (PCSI)
Integration should be focused at the field or client level where the interface between the system and the consumer takes place.
Integration results in more holistic services for clients, regardless of the agency structure. 8

9. Program Collaboration and Service Integration (PCSI)
Goal:
Provide prevention services that are holistic, science
based, comprehensive, and high quality to appropriate
populations at every interaction with the health care
system.
Vision:
Remove barriers to and facilitate adoption of service
delivery integration at the client level by aligning
NCHHSTP activities, systems, and policies with this
goal.

10. Principles of Effective PCSI
Appropriateness
Effectiveness
Flexibility
Accountability
Acceptability

11. Barriers to Service Delivery Integration (Summarized from reports, briefs, literature)
Restrictive and inflexible use of categorical funds
Prescriptive program announcements and discordant reporting requirements
Burdensome and inefficient “administrivia”
Lack of harmony, consistency, synchronization of data collection and surveillance
Lack of integrated prevention guidelines
Insufficient translation, integration of science and program
Insufficient support, both technical and financial, for cross training, evaluation and dissemination of best practices

12. CDC Consultation on PCSI Overall meeting objectives
To advise NCHHSTP on the development of Program Collaboration and Service Integration (PCSI) activities over the next five years
Assist in establishing priorities for PCSI; short term and longer term
Identify what CDC can do to assist local PCSI efforts
Identify what CDC can do to improve its own efforts toward PCSI

13. CDC Consultation on PCSI Process for Identifying PCSI Participants
Planning Committee of national organizations
NCSD, NASTAD, NTCA, Hep. C Coord., UCHAPS, CSTE, NNPTC
Peer selection process for Non-CDC members, obtained diversity using selection criteria:
Large and small size programs (both in funding and population)
Integrated and non-integrated programs (structurally and service delivery)
Urban and rural states; High morbidity and lower morbidity states/cities
Equity across diseases (HIV, TB, STD, viral hepatitis)
NCHHSTP Divisions nominated surveillance breakout session participants, DHAP nominated 5 CBOs for consultation

14. CDC Consultation on PCSI Attendees
Broad range of external and internal stakeholders (approx.125)
Grantees – 7 from each program, 5 CBO’s (LGBT, corrections, substance abuse, AF/AM women)
NNPTC, RTMCC, AETC
CSTE and 3-4 state surveillance coordinators from each program
CHAC, ACET representation
Representatives from each NCHHSTP Division
Other federal agencies (e.g. HHS,HRSA, SAMSHA, OPA, )
Non federal partners (e.g. ASTHO, NACCHO, ASHA)
40 Project areas/jursidictions represented

15. External Consultation Charge
Obtain top three priorities in…..
Opportunities for PCSI implementation
Policy improvements related to opportunities
Performance measures for levels of service integration
Workforce development and training needs 15

16. Priority Opportunities
Integrated surveillance and data efforts
Integrated training efforts
Integrated funding 16

17. 1. Integrated Surveillance and Data
Integrated surveillance reports
Standards for sharing of data
Guidelines for integrated data with common demographics, variables, and definitions
Address confidentiality issues – create a gold standard
Surveillance systems that work with and across programs

18. 2. Integrated Training efforts
Flexible funding for training
Integrated and comprehensive guidelines
Program announcements that include common language and objectives to address Center’s diseases
Training centers required to have integrated training curricula

19. 3. Integrated funding
Integrative program announcements (PA’s) (leverage integration through PA’s)
Collaboration on program announcements and post award management
Incentives for state and federal funding to support integration
Incentives for “in-kind funds” and/or require matching funds
Reprioritization of funds at CDC level
Reporting and evaluation components
Fund pilots or demonstrations

20. Addressing Barriers to PCSI
Meeting Report, presentations on web
Develop a national policy framework for PCSI
Green paper è White paper èSpring, 2008
Stakeholder input è Ongoing
Explore funding for program collaboration and service integration
Analyze budget authorities è Initiated
Explore opportunities for seed money
Realignment of funds to support PCSI demos/ evaluation

21. Addressing Barriers to PCSI (continued)
Harmonize and synchronize data collection and surveillance
Establish cross center work group èCompleted
Publish integrated annual surveillance reports è 2008
Develop common standard for confidentiality and sharing of surveillance and program data èInitiated
Publish STD/HIV integrated interview record èCompleted
Harmonize Partner Services Guidelines
STD/HIV Partner Services guidelines èJune, 2008

22. Addressing Barriers to PCSI (continued)
Develop integrated prevention guidelines
Commission workgroups to develop guidelines
Cross-Center workgroups established on: Program integration, Corrections, MSM, Drug users, Surveillance
Coordinate CDC program announcements and reporting requirements
Ensure new program announcements promote program integration èGoals architecture; consistent language
Review PAs to ensure PCSI includedè New SOP’s in place (2 completed)

23. Addressing Barriers to PCSI (continued)
Provide support, both technical and financial, for cross training, evaluation and dissemination of best practices
Collaborate with National Training Centers
Meeting scheduled June, 2008

24. Areas for future work Widening circle of engagement on PCSI
Involving community prevention services
Summarize wealth of evidence and experience
Working with specialist partners
CDC level activities
Develop implementation plan
Develop research, monitoring, and evaluation strategy
State, city and local partner activities
Conversations, mobilization, support and engagement
Create opportunities for sharing promising practices

25. Next Steps Meeting Report, presentations on web Winter 2008
Winter 2008
Publication of NCHHSTP Action Plan for PCSI
Spring 2008
Publication of NCHHSTP white paper on PCSI
Ongoing
Engagement with partners
Integration “tracks” at national meetings

26. Dr. Kevin Fenton NCHHSTP Director (Fantastic!)

29. CDC NCHHSTP Organizational Chart
Global AIDS Program
Division of Sexually Transmitted Diseases
Division of Viral Hepatitis
Division of HIV/AIDS Prevention
Division of TB Elimination

30. NCHHSTP Programmatic Imperatives Program Collaboration and Service Integration
Definition: Integration - A mechanism of organizing and blending inter-related health issues, separate activities, and services in order to maximize public health impact through new and established linkages to facilitate the delivery of services
Integration should be focused at the field or client level where the interface between the system and the consumer takes place.
Integration results in more holistic services for clients, regardless of the agency structure.

32. PCSI Current issues: Adult Hepatitis B Vaccination Initiative
Joint PS guidelines
Access to surveillance data
STDs among HIV+
Addressing health disparities comprehensively

33. Often Cited Barriers to Program Integration
Restrictive and inflexible use of categorical funds
Prescriptive program announcements and discordant reporting requirements
Burdensome and inefficient “administrivia”
Lack of harmony, consistency, and synchronization of data collection and surveillance
Lack of integrated prevention guidelines
Insufficient translation and integration of science and program
Insufficient support, both technical and financial, for cross training, evaluation and dissemination of best practices

34. NCHHSTP Integration Activities Already Underway
Joint Project Officer Meetings – quarterly
Program Integration Meetings – bi-weekly
Joint Branch Chiefs Meetings –quarterly
Branch Seminars - weekly
Hepatitis B integration letter and Division commitments (Fenton/Schuchat letter)
Joint site visits – listening tours
NY, Chicago, CA
External Consultation on Program Integration

35. Collaboration within NCHHSTP
HIV testing guidelines – Roxanne Barrow and Franklin Fletcher
New HIV testing PA – STD clinics – Chris Lupoi and Ron Turski
Adult hepatitis B immunization action plans
Partner services guide
Prevention Training Centers (PTCs)
Joint Project Officer workgroup
Meth workgroup – Susan Arrowsmith

36. STD/HIV Program Collaboration and Integration
Revised HIV testing guidelines
Routinize testing in a variety of clinical care settings
Consent advised to be part of general consent for clinical services
Risk reduction counseling encouraged but not a requirement
Data systems
STD interview record
Attempts to enhance linkages between data systems for STD (STD-MIS, STD-PAM) and HIV (PEMS)
Partner services
Harmonize guidance

37. Enhanced STD (inc. HIV) interview form
STD case reports to CDC lack standardized behavioral variables
(e.g., gender of sex partner, drug use, exchanging money/drugs for sex)
Needs:
add new variables but limit number to avoid burden on field staff
harmonize STD and HIV interview forms to decrease duplication
Key new components:
gender of sex partner
recreational drug use (e.g., methamphetamine, Viagra)
venues used to meet and have sex with partners
Next steps:
integrate variables with DHAP activities (i.e., PEMS)
finalize form and methods for training/implementation

38. HIV PCRS and STD PN integration
Principles for STD partner notification and HIV PCRS are almost identical.
Same 11 common principles (plus two extra for PCRS).
But differences in HIV vs. STD training and application have led to practical approaches that have different emphases.
This has created tension for combined HIV/STD PN/PCRS programs and when programs see persons co-infected with HIV and STD.
A CDC working group is integrating the 1998 HIV PCRS guide with the 2000 STD Program Operations Guidelines (POG) Partner Services Chapter.
The POG becomes the base document.
What is common to HIV and STD partner management remains in the POG.
What is unique to HIV is placed in a separate module.
The module contains HIV-specific elements from the 1998 PCRS guide.
The module contains updated information relevant to HIV PCRS (e.g., case-finding through network-based approaches).
The POG Partner Services chapter will be revised concurrently.

39. ‘Dear Colleague’ Letter

40. Integration Strategies
for MSM Services
Use the 2006 STD Treatment Guidelines
Use media materials at
Inform MSM about these recommendations
Get the word out to public and private
practitioners
Get the word to your clinicians, counselors
Link behavioral interventions to clinical services
Prevention activities targeting MSM should
include the message from the ‘Dear Colleague’ letter

41. HIV/STD Integration Strategies
HIV CPGs ?? Prevention Plans ¨¨ CBOs
¨¨ community members
HIV ¨¨ DEBI ¨ CBOs, HD, community
STD ¨¨¨ practitioners: private & others
Offer comprehensive clinical services and integrated PN
Promote common, comprehensive
messages and services

44. HIVP Program Structure
CDC
CPG
DoH
Health Ed/
Risk Reduction
Counseling &
Testing
Lets take a look at HIV prevention programs…….
This is a simplified view, it doesn’t include community planning, evaluation, and lots of other things, but it does show how HIV prevention programs can be divided into Behavioral based Health Education/Risk Reduction (HERR) and Counseling/Testing/Referral (CTR). HERR is largely driven by community planning and implemented in Community Based Organizations (CBO), while CTR is largely Health Department based and staffed by public health professionals.
These programs are so far apart, you could drive a BUS through them!

45. HIVP Program Structure
CDC
DoH
Behavioral
Intervention
HIV
Test
Now think for a moment about your HE/RR programs.
You’re probably reaching a lot of your priority population, (probably MSM and IDUs) from the Comprehensive HIV Prevention Plan – developed by your local Community Planning Group (CPG) in those HE/RR programs. But let me ask you – how many of your HE/RR clients actually get from the HERR over here to the CT sites to get an HIV test??
[standard answer: not many] well, if we’re not getting HIV clients an HIV test, how can we ever hope to integrate STD or hepatitis into these programs?? ?
STD Screening?
A & B Vaccinations?

46. Suggested Program Structure
CDC
DoH
HE/RR
HE/RR
HE/RR
HE/RR
Another way to think about this would be to build these more medical interventions into our CBO-based behavioral interventions. Let’s say you fund a peer-based 6-step behavioral intervention in these CBOs. Well, how about if we add a bullet and created a 7 step program where the additional session includes CTR, STD screen and appropriate hepatitis immunization, testing, and counseling. This might be achieved by bringing in a public health nurse, or meeting at a clinic facility. Ask the group if they may have suggestions on how to do this..
= CTR/STD/Hepatitis services

47. Comprehensive Approach to Fighting EVERYTHING!
High- Risk Individuals
Test - HIV/STD/HCV
Immunize - HAV HBV
Medical
Evaluation/Treatment; Partner Services
HIV +
STD +
HCV +
Status Appropriate Prevention Counseling
&
Social Services
If negative
If we can do all that, then we’ve adopted the ‘Comprehensive Approach to Fighting EVERYTHING’ or ‘CAFÉ’.
[Walk through chart (modified from SAFE) integrating HIV, STD, and hepatitis services].
Since this approach is so big, we can call it ‘CAFÉ’ Grande”.
[Note that actual services would differ for different risk groups like MSM or IDU.
CAFÉ Grande

48. CAFÉ Grande Benefits: Clients learn HIV sero-status
At risk get HAV & HBV immunized
STDs identified and treated
Overlapping epidemics are addressed
Clients get better services/counseling
Reinforces positive behavior change
Address scrutiny by documenting services
Increases efficiency, improves services, reduces redundancy…
[Read all the benefits of CAFÉ Grande].
Speaker might want to discuss benefits for both MSM and IDU.
MSM - overlapping HIV, Syphilis, HAV and HBV epidemics addressed. Counseling more appropriately based on a more complete medical assessment.
IDU -IDU are 10x more likely to have HCV than HIV. Wouldn’t it make more sense to counsel and refer them for the disease they do have?
-Do you think their HIV risk behaviors would change if they learned HCV status?

49. Reasons to Combine Viral Hepatitis, HIV/AIDS and STD Prevention
Routes of transmission & at risk populations overlap
Major public health problems
Effective prevention tools
Referral is inherently inefficient
Lack of integrated prevention activities leads to transmission of viral hepatitis, syphilis, gonorrhea, chlamydia, and HIV
Counseling will be based on a more comprehensive medical & risk assessment

50. Conclusions
Offer comprehensive ‘one stop’ service to clients who are being reached but not fully served
Learn to say: ‘HIV/STD/hepatitis’ like its one word!!!

51. Strategies and Tools for Program Integration
Dear Colleague Letter on comprehensive STD prevention services for MSM
HIV Funding for HCV C&T
Vaccination (using VFC and 317)
SAMHSA, correctional based services
‘Comprehensive approach’ for IDU
Integrate programs targeting at-risk populations