1. Public/Private Sector Collaboration Why Does it Always Seem Like a Square Peg in a Round Hole? Michael Allerton MS Daniel Klein MD Sonja vonColl MA Kaiser Permanente Medical Care Program Public/Private Sector Collaboration Why Does it Always Seem Like a Square Peg in a Round Hole? Michael Allerton MS Daniel Klein MD Sonja vonColl MA Kaiser Permanente Medical Care Program

2. What are the Legal, Operational, and Cultural Differences That Make Collaboration Difficult? Some Examples: What are the Legal, Operational, and Cultural Differences That Make Collaboration Difficult? Some Examples:

3. Rapid Testing Prenatal Testing HIV Reporting Risk Assessment Condom Education Rapid Testing Prenatal Testing HIV Reporting Risk Assessment Condom Education

4. BACKGROUND: The Kaiser Permanente Medical Care Program

5. 9 Regions Nationally 8,434,930 Members 14,581 HIV Positive Members 9 Regions Nationally 8,434,930 Members 14,581 HIV Positive Members

6. Total California HIV Positive Members Northern California Region 4833 Northern California Region 4833 Southern Californian Region 5063 Southern Californian Region 5063 9,896 =.16%

7. RAPID TESTING: 3 MAIN ISSUES:

8. RAPID TESTING: 3 MAIN ISSUES: Different Goals/Cross Purpose 3 MAIN ISSUES: Different Goals/Cross Purpose

9. RAPID TESTING: 3 MAIN ISSUES: Different Goals/Cross Purpose Competitive Disadvantage 3 MAIN ISSUES: Different Goals/Cross Purpose Competitive Disadvantage

10. RAPID TESTING: b Nearly half (43%) of newly diagnosed pts. had AIDS-defining immune deficiency at time of HIV dx. HIV Early Detection Study of Unrecognized Positives - HEDS UP -

11. RAPID TESTING: 3 MAIN ISSUES: Different Goals/Cross Purpose Competitive Disadvantage 3 MAIN ISSUES: Different Goals/Cross Purpose Competitive Disadvantage

12. RAPID TESTING: 3 MAIN ISSUES: Different Goals/Cross Purpose Competitive Disadvantage Assured Referral 3 MAIN ISSUES: Different Goals/Cross Purpose Competitive Disadvantage Assured Referral

13. PRENATAL TESTING:

14. 85-95% Of Prenatal Patients Are Tested for HIV at First Prenatal Visit 85-95% Of Prenatal Patients Are Tested for HIV at First Prenatal Visit

15. PRENATAL TESTING: 85-95% Of Prenatal Patients Are Tested for HIV at First Prenatal Visit SYSTEMIC APPROACH 85-95% Of Prenatal Patients Are Tested for HIV at First Prenatal Visit SYSTEMIC APPROACH

16. PRENATAL TESTING: 85-95% Of Prenatal Patients Are Tested for HIV at First Prenatal Visit SYSTEMIC APPROACH STRATAGIES FOR NEXT PREGNANCY 85-95% Of Prenatal Patients Are Tested for HIV at First Prenatal Visit SYSTEMIC APPROACH STRATAGIES FOR NEXT PREGNANCY

17. PRENATAL TESTING: 85-95% Of Prenatal Patients Are Tested for HIV at First Prenatal Visit SYSTEMIC APPROACH STRATAGIES FOR NEXT PREGNANCY LEGISLATIVE CHALLENGES 85-95% Of Prenatal Patients Are Tested for HIV at First Prenatal Visit SYSTEMIC APPROACH STRATAGIES FOR NEXT PREGNANCY LEGISLATIVE CHALLENGES

18. HIV REPORTING:

19. Legislative Requirements VS. Operational Efficiencies Legislative Requirements VS. Operational Efficiencies

20. HIV REPORTING: Legislative Requirements VS. Operational Efficiencies “DUAL” REPORTING Legislative Requirements VS. Operational Efficiencies “DUAL” REPORTING

21. HIV REPORTING: Legislative Requirements VS. Operational Efficiencies “DUAL” REPORTING SS NUMBER Legislative Requirements VS. Operational Efficiencies “DUAL” REPORTING SS NUMBER

22. HIV REPORTING: Legislative Requirements VS. Operational Efficiencies “DUAL” REPORTING SS NUMBER ACTIVE SURVEILLANCE Legislative Requirements VS. Operational Efficiencies “DUAL” REPORTING SS NUMBER ACTIVE SURVEILLANCE

23. RISK ASSESSMENT:

24. Klein 10-12-0224 Case Presentation b 37 y.o. Hispanic woman b Diagnosed with sero-neg SLE on prednisone b Past medical history: Jan 2002 - thrushJan 2002 - thrush May 2002 – skin ulcersMay 2002 – skin ulcers Jun 2002 – zosterJun 2002 – zoster Jul 2002 – candida esophagitisJul 2002 – candida esophagitis Aug 2002 – retinal hemor/occlusionAug 2002 – retinal hemor/occlusion Aug 2002 – CMV, CD4: 5Aug 2002 – CMV, CD4: 5 Background:

25. Klein 10-12-0225 Background: Case Presentation b 38 y.o. single Caucasian woman b Past medical history: headaches, obesityheadaches, obesity year of recurrent sinus infectionsyear of recurrent sinus infections ER visit for asthma/CXR=atelectasisER visit for asthma/CXR=atelectasis admitted "asthma/pneumonia"admitted "asthma/pneumonia" CD4: 4CD4: 4 PCP: +PCP: +

26. Klein 10-12-0226 Background: Benefits of Early Detection b Preserve immune function b Increase disease-free survival b Prevent further transmission b Prevent OIs

27. Klein 10-12-0227 Barriers to Effective Risk Assessment b Embarrassment b Lack of Training b Married Patients b NOT Lack of Opportunity

28. Klein 10-12-0228 Conspiracy of Vagueness b Vague questions or statements that are never clarified: b Changing the topic without pursuing further HIV risk b Leading questions

29. Klein 10-12-0229 Examples of Vagueness Clarification needed Examples of Vagueness Clarification needed b “I consider myself pretty safe in that area…” b “I’ve slowed down in recent years.”

30. Klein 10-12-0230 b Doctor: “Does he use condoms every time?” b Patient: “No,not every time” b Doctor: “Not every time?” b Patient: “ Uh huh” b Doctor: “And you said you’re a smoker, right?” Changing the Topic Changing the Topic

31. Klein 10-12-0231 Leading Questions Leading Questions b Doctor: “OK, sounds like you have acid reflux…so--you’ve never done any IV drugs or anything?” b Doctor: “ and you’ve never traded sex for drugs or anything like that, have you?”

32. Klein 10-12-0232 Sexual History Taking Sexual History Taking b “I would like to ask you some questions related to your sexual health that I ask all my patients.” b “Are you sexually active?--if no, have you ever had sex?”

33. Klein 10-12-0233 Sexual History Sexual History b “Are/were your sexual partners men, women, or both?” b “How many sexual partners have you had in the past 6 months? Before that?” b “Did/do you have vaginal, anal, and/or oral sex”

34. Klein 10-12-0234 Sexual History Sexual History b “Have you ever been diagnosed with an STD or thought you might have one? Has your partner?” b “Have you or your partner ever been tested for HIV or advised to be tested?” b “How do you protect yourself from STDs and HIV?”

35. Klein 10-12-0235 FAQ What if my patient is married? b “I’d like to ask you a few questions related to your sexual health. These are questions that I ask all my patients regardless of the type of relationship they are in.” b “How long have you been together? b “Before you were a couple did either of you have sex with other people?”

36. Klein 10-12-0236 Recommend Testing Recommend Testing b “I think it would be a good idea for you to have an HIV test. Sometimes people can have HIV and be unaware of it.” b Refer patients to receive their results from your CHE or HIV Test Counselor in Health Education. b “We will schedule an appt for you with our CHE/ HIV Test counselor to discuss your test results, prevention strategies, and answer any questions you may have.”

37. Klein 10-12-0237 Post Test Counseling b Negative post test counseling is primary prevention! b CHE’s and HIV test counselors help patients: b Evaluate 6 month window b Plan for follow-up and partner testing b Learn strategies to reduce risk

38. CONDOM EDUCATION: THE DEBATE CONTINUES:

39. The Appropriate Role of Condoms in HIV Prevention – The “ABC…Z” Approach Willard Cates, Jr., MD, MPH Family Health International Infectious Disease Society of America San Diego, CA October 9, 2003

40. Estimated Risks from 2 Acts of Unprotected Intercourse Per Week Jan. April JulyOct.Dec. SyphilisGonorrhea Chlamydia Pregnancy HIV (if cofactors) MONTHS

41. But If Protected by Condoms 05102550Pregnancy HIV (if cofactors) SyphilisGonorrhea Chlamydia YEARS Source: Cates, STD, 2002;29:350-52

42. CONDOM EDUCATION: THE DEBATE CONTINUES: PRIVATE SECTOR ROLE THE DEBATE CONTINUES: PRIVATE SECTOR ROLE

43. CONTACT INFORMATION: MICHAEL ALLERTON HIV OPERATIONS POLICY LEADER EMAIL: Michael.Allerton@KP.org