1. Implementing a Novel Public Health Intervention at a Local Health Department Valerie D. Bampoe, MPH Public Health Prevention Service Fellow Office for State, Tribal, Local and Territorial Support Centers for Disease Control and Prevention PHAP/PHPS Summer Seminar June 2, 2014 Centers for Disease Control and Prevention Office for State, Tribal, Local and Territorial Support

2. OVERVIEW

3. Presentation Overview  Background  HIV/AIDS Snapshot  Pre-Exposure Prophylaxis (PrEP) 101  PrEP Westchester  Planning and Pre-Implementation  Planning  Stakeholder Engagement  Implementation Tools  Implementation  Conclusion  Challenges  Findings  Public Health Implications  Next Steps

4. BACKGROUND

5. HIV/AIDS Snapshot New York State & Westchester County  HIV/AIDS in New York State  Approximately 130,000 People Living with AIDS  Approximately 10% of the nation’s newly diagnosed HIV cases  NYS Ending the AIDS Epidemic Initiative (ETE) Identify HIV positive undiagnosed persons & link them to care Link to and retain HIV positive persons in care; initiate antiretroviral therapy (ART) to maximize viral suppression and decrease transmission Provide access to PrEP for high-risk persons to keep them HIV Negative  Westchester County  1.9 million residents  Highest HIV/AIDS rates outside New York City  Approximately 3,500 STD/HIV case investigations annually  Approximately 3,000 STD clinic visits annually New York State HIV/AIDS, STD, HCV Epidemiologic Profile-2012 Cuomo, Andrew M. June 29 th 2014. Governor Cuomo Announces Plan to End the AIDS Epidemic in New York State.

6. HIV Pre-Exposure Prophylaxis (PrEP) 101  What is PrEP?  New HIV prevention tool  Once-a-day pill [Truvada: Tenofovir (TDF) + Emtricitabine (FTC)]  How Does it Work?  Once-a-day pill  Inhibits penetration of the HIV virus into T4 Cells * PreExposure Prophylaxis for the Prevention of HIV Infection in the United States-2014 A Clinical Practice Guideline

7. HIV Pre-Exposure Prophylaxis (PrEP) 101  How Effective is It?  8 published trials [2 MSM; 5 heterosexual; 1 IDU]  Up to 92% effective at lowering risk of HIV acquisition  Target Population:  Men who have Sex with Men (MSM); Injection Drug Users (IDU)  Heterosexuals at substantial risk of HIV acquisition  HIV-discordant couples; HIV-discordant couples seeking to conceive  Additional New York State DOH Target Populations:  Transgender individuals  Commercial sex workers  Methamphetamines and “Speed” users  Individuals diagnosed with more than one STD in the last year  PEP prescription within the last 6 months PreExposure Prophylaxis for the Prevention of HIV Infection in the United States-2014 A Clinical Practice Guideline What Support Services Providers Should Know about HIV Clinical Guidelines: Improving Health Outcomes Series-NYSDOH AIDS Institute

8. PrEP Westchester  Grant Award  $40,000  1 of 3 counties selected  Service Locations  WCDH STD clinics White Plains (2 days a week) Yonkers (2 days a week)  Disease Intervention Specialists (DIS)  Services to be provided:  Eligibility screening  Counseling  Referral to prescribing physician  Monitoring and Evaluation

9. PLANNING & PRE-IMPLEMENTATION

10.  PrEP Literature Review  CDC, NACCHO, WHO, NYSDOH, NYCDOHMH  Examined other DOH PrEP Models  Chicago, Denver, Hennepin County, New York City  Identified Key WCDH Stakeholder Groups  Clinical Team (PHNs, RNs, NPs, MDs)  DIS Team  Clerical Team  Planning and Evaluation Team  Developed a Project Logic Model  Develop performance measures  Create project management tracking tool Planning Steps Taken

11.  Developed Eligibility Screening Questions  Nursing Screening  DIS Screening  Identified Systems to be Modified  Electronic Medical Records (EMR) STD charts  DIS Forms  Clinical Workflow  Developed Referral Algorithms  Identified communication Materials Implementation Tools Developed

12. City of New York, Department of Health and Mental Hygiene. All Rights Reserved. Communication Materials

13.  Held a PrEP Forum  Introduced ETE and PrEP Tri-County Representation Sought stakeholder buy-in and engagement  Identified PrEP Champions  Westchester AIDS Council  Community Based Organizations  WCDH Staff  Convene a WCDH PrEP Workgroup  Discussed ways to get WCDH buy-in  Explored ways to integrate PrEP seamlessly  Brainstormed implementation Stakeholder Engagement Efforts

14.  Developed PrEP Protocols and Guidelines  “Secret-Shopped” Clinic Services  Expanded Referral Network  Recruited physicians who prescribe PrEP  Executed MOUs with recruited physicians  Facilitated PrEP Trainings  Clinical Team: Nurses, Nurse Practitioners, and Physicians  DIS  Outreach Workers  Established a Process to Close Referral Loop  Identified contact persons in each physician office to facilitate follow-up Sustainability Efforts

15. IMPLEMENTATION

16.  Held an Implementation Workshop  Required for all key staff  Created a Tracking Mechanism  Provided Communication & Administrative Materials  Brochures for dissemination  Algorithms for display  Publish physician prescribers list Implementation

17. RESULTS

18. FINDINGS  A Shared Vision is Critical  Adequate Staffing is a necessity  Seamless Integration is Key to Program Longevity and Success  Invest in the front end to make sure systems are self sustaining  Leverage Available Resources  Make processes as automated as possible  Use materials already produced by other DOHs  Invest Time in Obtaining Stakeholder Buy-in Image source: Google Images

19. Public Health Implications  HIV Prevention  Increased HIV Testing & Screening  Primary Health Care Access for Identified Populations  Routine HIV testing & other testing  Increased awareness of overall health

20. Challenges  Internal Stakeholder Buy-in  No Leadership Mandate  Competing Priorities  Inadequate Staffing  Limited Funding

21. Next Steps  Expand PrEP Provider Directory  Engage Community Based Organizations  Create a PrEP Webpage for DOH Website  Evaluate PrEP Westchester Implementation

22. For more information, please contact CDC’s Office for State, Tribal, Local and Territorial Support 4770 Buford Highway NE, Mailstop E-70, Atlanta, GA 30341 Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348 E-mail: OSTLTSfeedback@cdc.govWeb: http://www.cdc.gov/stltpublichealthOSTLTSfeedback@cdc.govhttp://www.cdc.gov/stltpublichealth The findings and conclusions in this presentation are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. KEYS TO SUCCESS: A Shared Vision Adequate Staffing Stakeholder Collaboration Effective Communication Tools A PrEP Coordinator Valerie D. Bampoe wvh5@cdc.gov vqba@westchestergov.com Centers for Disease Control and Prevention Office for State, Tribal, Local and Territorial Support