1. WI State Report RVIPP Meeting Chicago: February 2-3, 2011

2. Wisconsin State Report RVIPP Meeting Chicago: February 2-3, 2011 Timeliness to Treatment Update:  STD Treatment Audit in FP PPW  STD Treatment Audit in FP non-PPW New Initiatives & Updates:  Rural Prevalence Project  Milwaukee School Based Testing Trends 2009-2010  Milwaukee Jail Screening Project  Condom Survey  EPT

3. Timeliness to Treatment STD Treatment Audit in PPW  Audit provided an opportunity to examine Quality Assurance measures in FP Treatment rates for chlamydia and gonorrhea  Compare treatment rates generated from Treatment Audit to treatment rates generated from WEDSS reported morbidity data Re-testing rates for chlamydia and gonorrhea  Included in STD Treatment Audit  STD Treatment Audit in PPW conducted in June 2010  STD Treatment Audit in non-PPW to be rolled March 2011  The results of this first audit effort will provide baseline measures for standard of care expectations in FP statewide

4. Timeliness to Treatment STD Treatment Audit: PPW Summary of Treatment Audit in 25 PPW Clinics  Maximum of 25 charts reviewed per clinic: (20 females, 5 males)  Positive CT and/or GC test results for males and females High volume clinics: randomly select maximum of 25 positives from 4 th quarter 2009 Medium volume clinics: randomly select maximum of 25 positives from 4 th quarter 2009 Low volume clinics: select positives from 2009 up to a maximum of 25 positives

5. STD Treatment Audit: PPW  Electronic Excel Spreadsheet Electronic Each clinic entered data from chart review electronically Grand total site summary of results  PPW Females Positive for Ct Rx rates Re-test Rates

6. STD Treatment Audit: PPW Treatment Rate for Females Positive for CT Overall CT Treatment Rate in Females: 431 Females + for CT 367/431 treated (85%) Treated women (n=367):  18% ( 67) patients >=25  26% ( 97) patients <19  55% (203) patients >=19 <25 Days to Treatment (N=367)  98% (359/367) Rx <=30 days; 92% (338/367)% Rx <=14days  83% (359/431) Rx <=30 days; 78% (338/431)% Rx <=14days Range: 0-133 days Average:7 days Same day RX:30% (109) patients > 14 days 8% ( 29) patients > 30 days 2% ( 8) patients

7. STD Treatment Audit: PPW Treatment Rate for Females Positive for CT Overall CT Non-treatment Rate in Females: 431 Females + for CT 64/431 not treated (15%) Non-treated women (n=64):  17% (11) patients >=25  25% (16) patients <19  58% (37) patients >=19 <25

8. PPW Audit Rx Rate Compared to WEDSS Reported Morbidity Rx Rate Females Positive for Chlamydia 2009 Data Data Source 2009 Overall Rx Rate Rx Rate <=14 Days Rx Rate <=30 Days Audit PPW (N=431) 85% 78% 83% WEDSS PPW (N=1576) 75% 72% 75% WEDSS All FP (N=2594) 78% 76% 78%

9. STD Treatment Audit: PPW Re-testing Rate among CT Positive Females 2010 PPW Audit Results for Re-testing 42% PPW Females Re-tested (153/367)  Positive at Re-test: 12% (19 patients/153)  Days to Re-test Range: 0-329 days Average: 107 days Re-tested <30 days: 13% (20) Re-tested <90 days: 48% (73) Re-tested >=90 days*: 52% (80) * Recommended time frame

10. STD Treatment Audit: PPW Re-testing Rate among CT Positive Females  Plan to evaluate rates of re-testing in FP as a quality assurance measure in FP clinics Plan to include ‘Re-tested?’ field in PPW STD Tx Audit Tool in July 2010  PPW will add a required field for ‘Re-tested?’ to Electronic Medical Record when ready in July 2011  Recommendations to re-test in FP Program Guidelines will include males and females  When have SSC changes from prevalence evaluations finalized, will add these changes and ‘Re-screened?’ field to laboratory request form at SLH

11. STD Treatment Audit Next Steps  Will improve electronic spreadsheet before rolling out non-PPW Audit based on PPW Audit experience Facilitate consistency in data collection Facilitate analysis  Lots of data to sort through Adherence to SSC GC Rx rates and timeliness Males Demographics (age/race, etc.)  Individual Report Cards for each of 25 clinics

12. Rural Screening Project: non-PPW FP Clinics  Low Prevalence of CT (<3%) When prevalence is low, how do we improve our ability to find those chlamydia positives we KNOW are in the haystack of negatives?

13. Rural Screening Project  4 sites in Northern Wisconsin participated in Universal screening for the months of April and May Objective: to estimate CT prevalence in rural non-PPW clinic populations Determine if there are risk criteria outside of the evidence based SSC currently in use in WI FP which add greater sensitivity to the risk assessment for CT and GC infection in men and women attending these clinics

14. Rural Screening Project  Preliminary Findings Nuances of interviewing patients important  Consider the consistency and how questions are asked and perceived by the patient Numbers are small, but prevalence appears to be under 3% threshold

15. Rural Screening Project ‘North of HWY 29’  Four Agencies to be commended for their efforts Oneida Pierce Polk St. Croix  Universal Screening in April-May 2010 included risk assessment for: Current SSC for chlamydia (12 criteria) Non-SSC Reasons for Testing SSC’ (11 criteria compiled by participating agencies) If no SSC or OC, would you have tested OC?

16. North of HWY 29  770 total patients (Females and Males)  Females 729 total female patients  640 tested; 18 + (2.8%)  Males 41 total male patients 40 tested  12+ (30%) (11/12 met SSC; the one who did not, met OC  28 –  12/28 (43%) of negatives met an SSC  24/40 (60%) would have been tested if not universally screening

17. North of HWY 29  SSC met among 18 Positive Females ? 8/18 met SSC (44%) 10/18 did not meet SSC  Off Criteria met among same 18 Positive Females? 16/18 met OC (89%); majority of these met the >90 day OC 2/18 no OC  BUTTTTT……!!!

18. BUTTTT…!!!  622/640 (97%) females tested were NEG 344/622 (55%) negative females met SSC 278/622 (45%) no SSC 514/622 (83%) met OC 108/622 (17%) no OC

19. Positivity* in 4 Rural Clinics 2009 vs. 2005 Clinic Females 2009 Males Females 2005 Males Oneida4.9% (14/286)23.1% (9/39)5.8% (21/362)14.3% (8/56) Pierce5.4%(41/761)13.9% (10/72)5% (34/680)20.2% (17/84) Polk4.5% (10/221)33% (5/15)6.5% (22/338)28.6% (10/35) St. Croix5.5% (24/433)20.8% (5/24)6.6% (14/211)33.3% (7/21) * Positivity represents selectively screened individuals (not prevalence) Positivity fluctuates over the period of 2005-2009

20. Rural Screening Project Positivity in Females in 4 non-PPW Rural Clinics 2005-2009 %Positive

21. Preliminary Conclusions: Lessons Learned…  Further multivariate analysis needed…but numbers are very small….  Patients in low prevalence areas may benefit from clinician directed enhancement of discussions with patients to ensure patients are understanding context of questions so their risk for infection is identified more accurately

22. Preliminary Conclusions: Lessons Learned… Rural clinician group will summarize their experience and lessons learned regarding more precise interviewing techniques to increase sensitivity of current SSC  How to better define the 90 day time period of risk assessment for patients to improve accuracy of sexual history  Best methods to elicit a thorough and accurate sexual history  Provide Statewide training on these issues through Webinar/WRPHFP meeting

23. Preliminary Conclusions: Lessons Learned…  Why do we care about digging deeper for positives in low prevalence settings, when we have plenty of them in more urban settings? Must address clinician trust in SSC as appropriate standard of care for patients in order for them to continue to adhere to using SSC as an accurate screening tool  Fertile ground for further examination? = 25 years of age groups in patients meeting the “Off Criteria” for:  “Lifetime never tested females with Hx of multiple partners” (and <25 years of age)  Cap testing in females >=25 years of age unless symptomatic and/or contact?

24. Milwaukee School Based Clinics Update 2010  Testing in 15 SBC began Jan 2009 Low volume of testing/positivity at first Volume and positivity picking up Tested 23% more students in 2010 Saw nearly 50% increase in CT positivity and 14% increase in GC positivity Higher-risk kids more comfortable with health center presence? Staff efforts? Year# Tested#/% Pos CT#/% Pos GC 2009 27634/12.3%10/3.6% 2010 33962/18.3%14/4.1%

25. Milwaukee School Based Clinics Update 2010 Positivity Rates by Gender 2009-2010: Increase in CT both females and males GC rate in females exceeds GC rate in males in 2010 Year CT % PositiveGC % Positive Female MaleFemale Male 2009 12.5%11.9%2.7%4.8% 2010 21%15.6%5.7%2.2%

26. Milwaukee County Jail Screening Project  CDC Funded Pilot Project (~ $25,000) 2010 Determine CT and GC positivity among women <=39 years of age in Wisconsin jail population Provide testing, treatment and STD education session for first 400 females at time of jail booking for CT and GC  “Opt out” medical consent for testing  Urine sample collected at booking for pregnancy test to be tested for CT and GC  If not treated in facility, City Health Department to provide f/u for notification of results, treatment and f/u of partners Organizational and personnel difficulties after Medical Director departed  One month of data available for October 2010

27. Milwaukee County Jail Screening Project Women Booked & Tested for CT and GC During the Month of October 2010 (N= 131) Chlamydia (26 +) +/Tests % Gonorrhea (10 +) +/Tests % Total 26/130 20%10/131 7.6% Black 21/83 25% 7/82 8.5% White 4/45 8.9% 3/47 6.4% <18 yrs 4/944.0% 3/10 33.0% 18-24 yrs 11/4325.6% 3/42 7.1% 25-34 yrs 9/4022.5% 3/40 7.5% Sex Charges <=30 22/4845.8% 8/49 16.3% Sex Charges >30 2/79 2.5% 2/78 2.6% Total Rx11/2642.3% 4/10 40.0% Rx In: Rx Out: 4/2615.4% 3/10 30.0% 7/2626.9% 1/10 10.0%

28. Condom Survey  Brand sensitivity in FP clinics in Wisconsin Do we provide a variety of desirable brands and sizes in WI FP clinics? Survey was distributed at the DPH/WFPRHA meeting in Wausau in September 2010 17 responses

29. Condom Survey Results  Types & Sizes Good variety and sizes  Suppliers Global Protection Four Seasons Total Access Trojan Access FPHS IBI Synergy, Inc

30. Condom Survey Results  Female Condoms: Yes; 11/17  Non-latex Condoms: Yes; 16/17  Colored: Yes; 15/17  Flavored: Yes; 12/17  Other Specialty Condoms: Yes; 10/17  Provide Prescription for Condoms: No; 15/17

31. Condom Survey Conclusions & Lessons Learned…  Among FP clinics responding: Good variety and specialty condoms available Non-latex available Female condoms less available Most condoms are provided on site  Future Goals: (Goals met in 2011) Utilize FPOS to cover cost of condoms through prescriptions or FPOS reimbursement for condoms on site Conduct patient survey (no interest/need)  Desired brands?  Use female condoms if available (now more available through Dual Protection in 2011)

32. EPT Update  EPT signed into Wisconsin Law May 11, 2010  Became effective May 26, 2010  EPT allowed for one dose therapy for CT, GC, Trichomoniasis No name prescription allowed if partner name not obtainable, in which case, ‘EPT’ required to be written on prescription  Information sheets for patient/partner required by the new law and on WEB site; provider guidance soon to be on WEB site  Preliminary training for Family Planning Providers provided in July, September and November 2010  Plans for evaluation under development; WEDSS  Promotion of EPT and FPOS awareness among clinical providers and pharmacists (i.e. males added to waiver, condoms covered by waiver, etc)  Partner referral card for use in FP under development emphasizing partner test and treat gold standard; FPOS enrollment and EPT last resort