813 wake county
DESCRIPTION
813 Wake County. Lessons Learned and What’s to Come. 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 - PowerPoint PPT PresentationTRANSCRIPT
813 Wake County
Lessons Learned
and
What’s to Come
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
Gaining Access to the Community
Managers
Outreach CommunityLeaders
Community
Access
Areas of Attention
• Geographic clustering
• Heterogeneity of community
• Institutional barriers
• Screening to diagnose asymptomatic disease • STD/HIV co-infection
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
Community Focus GroupsOBJECTIVES
– 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
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
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?
KEY BARRIERS• Rude staff
• Cost
• Intrapersonal barriers
• Confidentiality Concerns
Key Barriers by Gender
Women
• Rude staff• Cost• Confidentiality• Long wait
Men
• Intrapersonal factors• Confidentiality
concerns• Cost• Addiction• The SWAB!
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?
RECOMMENDATIONS• Convenient location
• Integrate into other services
• Staff who are trained in sensitivity
• Ensure confidentiality
• Increase outreach efforts
• Welcoming clinic environment
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
Phase IIExpanded 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
HIV INFECTION AND PREVALENT STDs AT TIME OF
HIV TESTINGEstimate 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)
Infection Rates HIV Test Study in STD Clinic
N GC CT HSV Syph HIV
Male 119 16 (13%)
23 (19%)
41 (34%)
2 (2%)
1 (<1%)
Female 102 9 (9%)
14 (14%)
42 (41%)
0 (0%)
1 (<1%)
Total 221 25 (11%)
37 (17%)
83 (38%)
2 (<1%)
2 (<1%)
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.
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
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
HIV Care Study
N GC (%) Ct (%) TV (%) HSV(%) Syph. (%)
Total 67 4 (6%) 1 (1%) 8 (12%) 48 (72%) 10 (15%)
Female 20 0 0 6 (30%) 18 (90%) 0
Male 44 4 (9%) 1 (2%) 2 (5%) 30 (68%) 10 (23%)
HIV/STD Co-Infection Females
N GC Ct TV HSV Syph.
6 X X
12 X
2
HIV/STD Co-Infections Males
N GC Ct TV HSV Syph1 X X X1 X X3 X1 X X6 X X21 X2 X
none 9
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
813UNC• Bill Miller• Marlene Smurzynski• Trang Nguyen• Dionne Law• Chandra Ford• Betsey TilsonCDC• Kim Fox• Katie Irwin• Rheta Barnes
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
BARRIERSCost
“…’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 riskfear
embarrassment,
shame
denial
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
BARRIER:ConfidentialityVisibility
“…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
Community Identified Priorities
• Cardiovascular disease
• Violence
• HIV infection
HIV Test Study in STD Clinic
N % Eligible % Offered
559 100 # HIV tests
386 70 100 Offered
148 26 38 Declined
6 1 2 Withdrawn,
232 41 60 Total Participants