Jefferson County Department of Health
Implementing PrEP and Hepatitis C Evaluation/Treatment in an Adult Health and STD Clinic
The Jefferson County Department of Health (JCDH) celebrated 100 years of caring for the residents of Jefferson County, Alabama in 2017. JCDH is located in central Alabama and serves the residents of the most populated county within the state. JCDH earned accreditation from the Public Health Accreditation Board in November 2015. Jefferson County, Alabama has an estimated 659, 521 residents. Jefferson County's residents are 50.2% Caucasian, 43.4% African American, 1.7% Asian, 3.7% Asian, 0.3% American Indian, 0.1% Native Hawaiian/Pacific Islander, and 1.2% who are 2 or more races per the U.S. Census Bureau. JCDH has 3 locations within the Jefferson County, Alabama that has clinics to provide Adult Health, Pediatric, Family Planning, International Travel, Tuberculosis, Adult Immunization, and STI/STD services to the community. JCDH provides services to the community regardless of insurance status, uninsured patients receive services using a sliding scale which is based on income. Hepatitis C affects millions of individuals in the United States, but uninsured persons within our community have limited access to testing and treatment in facilities without a sliding scale. Chronic Hepatitis C is the leading cause of Hepatocellular carcinoma and can be largely prevented with the available treatments. HIV disproportionately affects minorities, especially men who have sex with men (MSM) in the South. PrEP has been available since 2012, but is often underutilized by individuals who have the highest risk. In order to decrease the disparity of healthcare for HIV prevention, newly diagnosed HIV among minorities, and Chronic Hepatitis C (testing/treatment) within our community JCDH began offering PrEP in Adult Health (AH) and STD clinics and expanded testing services for Hepatitis C from the AH and STD clinics. Prior to expanding our services, all clinic staff and other interested persons were invited to attend informational sessions about PrEP and Hepatitis C so they would understand the importance of offering these services and be able to provide accurate information to the public if asked about it. The STD clinic began a 90 day opt out testing period of all patients regardless of risk factors in order to determine how to direct our testing efforts. Our goal was to determine if patients without traditional risk factors for Hepatitis C would benefit from Hepatitis C antibody testing. During the opt-out period, all patients at high risk for Hepatitis C were tested based on USPTF guidelines. Patients with a positive Hepatitis C antibody test were referred to the Hepatitis C coordinator who scheduled a follow-up appointment with a provider in the STD clinic for further evaluation and treatment, as needed. Initially, PrEP referrals were only accepted from internal JCDH patients to allow PrEP staff time to work out kinks with the application and appointment process. After several months of hard work the providers became comfortable with prescribing PrEP and were able to assist patients with medication assistance program applications more effectively. Since the initiation of PrEP and Hepatitis C services we began to educate the community about PrEP and Hepatitis C testing/treatment and the availability of these services at JCDH even for uninsured individuals. Our education of the community included radio ads, club promotion, promotion at community events such as the Magic City Classic, presentations on local news, presentations on morning radio shows, and presentations to community based organizations (CBO) and AIDS Service Organizations (ASO). We have met our goals because we were able to expand our testing for Hepatitis C beyond the AH clinic, have initiated treatment for Hepatitis C (previously patients were referred to external organizations for evaluation and treatment), we have increased the awareness of PrEP within the community, and increased the uptake of PrEP among persons at high risk for HIV acquisition. There have been no new HIV infections among persons who are taking PrEP. JCDH has been successful with meeting our goals because our staff members have been willing to serve several roles (provider, coordinator of project, ad-hoc social worker, and community resource person) while we developed our program. JCDH has worked with several CBO/ASOs and at several community events to promote awareness of HIV Hepatitis C prior to starting these service lines so we already had a presence in the community. When we began offering Hepatitis C and PrEP services, there were many people who already had a good relationship with JCDH and were willing to listen to and allow us to share our message at their event(s). JCDH's new programs of service will impact public health by decreasing Hepatitis C transmission (through education/treatment), decrease the incidence of Hepatocellular carcinoma from untreated Hepatitis C, and decrease the number of HIV infections by increasing PrEP uptake. Website: www.jcdh.org
In the United States, HIV disproportionately affects minorities, especially men who have sex with men (MSM). Each year, approximately 10,000 African American gay and bisexual men are diagnosed with HIV. Approximately 44% of all persons living with HIV live in the southern states of the U.S., in which JCDH is located. HIV transmission may be decreased by using safer sexual practices, having an undetectable viral load (for serodiscordant couples), identification of persons with HIV and initiation of antiretroviral therapy, and increased utilization of PrEP among persons who are at risk. JCDH utilized information from the CDC's High Impact Prevention strategy to increase community awareness and uptake of biomedical interventions (PrEP) to prevent HIV, use social media to promote community events where PrEP was discussed, and to target discussions with at-risk persons who may benefit from PrEP. The target population in which PrEP was discussed was 15,000 persons because all were at risk for STIs including HIV. PrEP handouts and posters were available in clinic areas. Several patients initiated conversations about PrEP and other conversations were initiated by the referring employee. Of the persons with whom PrEP was discussed, 92 were interested in further discussion about PrEP and possible initiation of treatment. Referrals were received from Adult Health, Family Planning, and STD clinic providers. Most of the 92 referrals and those who began taking Truvada for PrEP were MSM of color. We have had success with initiating PrEP in a population that has been identified as high risk, but who have underutilized PRP services since its approval in 2012. Prior to the initiation of PrEP services at JCDH any patient who was a candidate was referred to an external partner that offered services once a week and was becoming increasingly overwhelmed with patients. Offering PrEP at JCDH is better for our patients and the community at large because PrEP is available every day in multiple clinics which increases the number of patients who may be seen, decreases the number of patients who do not receive services because they are uninsured, and may decrease the number of patients who elect not to receive services due to long wait times for appointments. PrEP is relatively new to healthcare (2012) and still has limited uptake among many providers. JCDH was the first health department in Alabama to offer PrEP services on-site. Implementing PrEP services at JCDH has been innovative because providers were educated about PrEP and have not been forced to prescribe it. Each PrEP provider at JCDH expressed interest in prescribing PrEP and wanting to be proactive about decreasing HIV in our community. Helathy People 2020 was utilized to guide our efforts to decrease health disparities among uninsured, minorities who were previously unable to access PrEP and have the highest rates of infection.
The USPTF guidelines were utilized to increase Hepatitis C testing and initiation of Hepatitis C treatment at JCDH. USPTF recommends testing all persons at high risk for Hepatitis C. JCDH implemented a 90 day opt-out testing period for all STD clinic patients to determine whether additional infections would be detected from persons who were not high risk. JCDH decided to test all patients based on results from other opt-out testing that had been done at medical facilities within Jefferson County that revealed a 15% rate of infection. During JCDH's opt out testing period, 3,261 Hepatitis C antibody tests were done, of those there were 58 positives. All persons with a positive antibody test were contacted by the Hepatitis C coordinator to identify previous positives, persons already receiving treatment, to inform newly positive patients (or those who had not previously received follow up care) of the need for additional treatment to determine Chronic HCV infection, and to discuss the availability of a cure for Chronic HCV. Prior to JCDH's expanded Hepatitis C services, all patients with a positive test were referred to a local hospital that accepted uninsured patients (those with insurance were referred elsewhere). The wait time between referral and an appointment was often 6 months. JCDH's decision to become more involved with Hepatitis C testing/treatment is better than our previous practice because uncomplicated patients are able to be treated sooner, persons without Chronic HCV are not referred to a specialist which may decrease their patient load, and the providers at JCDH are able to increase the services rendered in our facility especially for uninsured and underinsured individuals who may otherwise be unable to access care. Providing Hepatitis C treatment and testing in the STD clinic is a creative use of practice because Hepatitis C is often a scary undertaking for primary care providers. The providers in the STD clinic are already comfortable providing care to patients with an infectious disease, asking questions that may be uncomfortable (including history of drug use, sexual preferences, history of tattoos in an unregulated facility). As the number of patients with Chronic Hepatitis C increase and patients are cured in the STD clinic, additional providers in Adult Health/Family planning may initiate treatment because they will have internal clinicians to discuss patients with.
HIV in the U.S.
JCDH has worked with community partners to decrease morbidity/ mortality related to illness, inadequate access to healthcare, poor sanitation, and environmental concerns during the last 100 years. We collaborate with numerous organizations within Jefferson County and the state of Alabama to support their efforts to improve the health of residents in Jefferson County. Two recent partnerships that have enhanced JCDH's capacity to provide PrEP and Hepatitis C services are THRIVE (PrEP) and ACTIVE-C (Hepatitis C). THRIVE is a CDC funded grant which was designed to increase the utilization of PrEP among African American MSM. JCDH has been an unfunded partner for THRIVE for years and provided referrals to local PrEP providers, confirmatory testing of preliminary positive HIV test, and treatment of positive STDs. In 2017, we began prescribing PrEP to internal patients based on conversations between patients and provider that they were interested in PrEP, but unable to access it due to cost or availability of appointments. After hearing of several interested patients, JCDH management/providers decided to learn more about PrEP and offer it to patients. Our primary goal when initiating PrEP at JCDH was to remove the barriers associated with PrEP access (i.e. cost of labs, cost of provider time, and need for referral for service). In order to achieve our goal, the following tasks had to be completed: review CDC's guidelines for PrEP, review Truvada website for guidelines and information about PrEP, negotiation of lab costs with our lab vendor, develop and implement a protocol for PrEP visits and referrals, organize staff training about PrEP, design an EMR template for PrEP visits and referrals, provide general training about PrEP for all staff and providers, and promote PrEP awareness (general) and availability of services at JCDH. The Deputy Health Officer, Medical Director of Disease Control, and the Lead Nurse Practitioner of the Specialty Clinic collaborated to create the protocols for PrEP visits and referrals. Once the protocols were completed, the Laboratory Supervisor was given a list of CPT codes for lab tests in order to negotiate the best price for our patients. Having a decreased price for labs allowed us to provide PrEP at a lower out-of â€“pocket cost for uninsured patients. The templates for PrEP visits and PrEP correspondence were developed by the Lead Nurse Practitioner and Nurse Coordinator for the EMR. After the protocols and EMR templates were finalized, providers who expressed interest in prescribing PrEP were given time to review/discuss the protocol and were able to work together while seeing initial patients who presented for PrEP visits. Having a partner during the initial visits ensured providers did not omit any pertinent patient education or components of the application that was used for the copay/medication assistance program. The first PrEP patient was seen at JCDH in January 2017 by our Deputy Health Officer, prior to the development of a template or protocol, because the patient presented to the STD clinic and was unable to access PrEP in another facility. We did not want to delay an initial visit for evaluation, testing, and discussing PrEP because the patient's risk of becoming HIV positive while waiting was high. EMR template and protocols for visits were developed within the next few months. While the protocol and templates were being developed, a medical scientist from Gilead was contacted to discuss PrEP at all 3 clinic locations. The Lead Nurse Practitioner also made presentations to small groups of staff (interpreters, clinic managers, and social workers) to further promote understanding and engagement of non-clinical staff. Once all staff was aware of what PrEP was and how effective it could be, posters and handouts about PrEP were distributed to clinic staff. All patients in the STD clinic were eligible for PrEP discussions due to their high risk of STDs including HIV. Other patients received targeted information if they met eligibility criteria which was documented in the PrEP referral protocol. In May 2017, JCDH presented data to THRIVE to update them on the status of PrEP services that we offered. At that time, we had only received 17 referrals and had 3-4 patients who had initiated treatment. In October 2017, JCDH became a funded partner of the THRIVE project and began accepting referrals from our external partners. The Lead Nurse Practitioner and Program Manager of the STD Clinic collaborated with the organizations involved with THRIVE and other CBO/ASO to promote awareness of PrEP services that are being offered in our facility. The STD program manager and other Disease Intervention Specialists attend meetings with community stakeholders, serve on HIV coalitions, and work with elected officials to foster collaboration between organizations and share successes/ items for improvement in our county's effort to decrease HIV transmission and new infections. Now, we have had 92 referrals and have 18 people who are currently taking Truvada for PrEP. There have been several other patients who have initiated treatment but chose to discontinue therapy for various reasons (side effects, no longer at risk, unwilling to take daily medication).
The expansion of Hepatitis C services at JCDH was developed similarly to PrEP services. There has been an increase in opioid use (predominantly injection drug use) in our county during the past several years. Injection drug users and baby boomers comprise a large percentage of persons infected with Hepatitis C. The increased number of persons infected have overwhelmed the specialists who were primarily responsible for providing Hepatitis C treatment. JCDH began a partnership with the ACTIVE-C program to enhance our capacity with evaluation for Chronic Hepatitis C and treatment. JCDH's goal for Hepatitis C was to increase testing at JCDH and increase the community's access to testing/treatment. Prior to our involvement with ACTIVE-C, the providers in Adult Health tested high risk adults for Hepatitis C based on USPTF guidelines. Several staff members from JCDH and the research review committee had meetings with ACTIVE-C staff to determine the guide our expanded Hepatitis C efforts. After these meetings, the Lead Nurse Practitioner of the Specialty Clinic and Medical Director of Disease Control developed protocols for the 90 day opt-out testing period, evaluation of patients with positive antibody test, and treatment of patients Chronic Hepatitis C. EMR templates for Hepatitis C visits and correspondence were developed by the Lead Nurse Practitioner and EMR nurse coordinator. The Laboratory Supervisor was given a list of CPT codes for labs that would be used during each visit in order to negotiate the price. The negotiation of lab prices took approximately 1 month of daily communication between JCDH and our lab vendor. Staff members at JCDH were trained about Hepatitis C by a Medical Scientist from Gilead who presented at all 3 clinic locations and a treating physician from ACTIVE-C. Prospective providers received additional training from the treating physician from ACTIVE-C and participate in patient discussions via telephone. JCDH expanded testing to all STD patients from July-October 2017 in order to determine whether other patients who did not have traditional risk factors would have a positive Hepatitis C antibody result. More than 3,000 Hepatitis C antibody tests were done during the opt-out testing period and most of the positive results had traditional risk factors. The Lead Nurse Practitioner has contacted all patients with a positive antibody test, provided information about Hepatitis C, and scheduled follow up visits for persons who were not currently being treated and who were interested in further evaluation. As of December 2017, 1 patient has begun treatment for Chronic Hepatitis C and several others are awaiting approval to begin treatment from payors. JCDH has fostered collaboration with participating organizations in ACTIVE-C, drug rehabilitation facilities who refer patients with positive Hepatitis C tests, and community members by keeping them abreast of our successes and willingness to accept their referrals. JCDH has collaborated with local news and radio stations, Magic City Classic, and other event promoters to increase awareness about Hepatitis C and the availability of a cure, even if community members choose to access care outside JCDH. The start-up costs for Hepatitis C and PrEP included training time of current staff, printing costs of fliers and posters, and staff time promoting awareness within community members and community collaborators of these new service lines.
Developing two new service lines within one year and offering these services in multiple locations has been a huge project for JCDH staff members. The staff members have had to learn new protocols, provide feedback on EMR templates/protocols, and fill-in for positions that were vacant (especially that of the Social Worker). JCDH wanted to increase access to PrEP services among persons at high risk for HIV acquisition (especially African American MSM), increase Hepatitis C testing at JCDH, and increase access to Hepatitis C treatment and testing to Jefferson County residents. During the last 11 months, we have realized how much education regarding PrEP and Hepatitis C is needed within our community (providers and general population). Although we have been providing education using multiple mediums: in person, internet, radio, and television there are still many people who our staff members encounter that have little knowledge about the effectiveness of Truvada for PrEP or the availability of a cure for Hepatitis C. When community members/patients have been informed of the effectiveness of prevention/treatment for HIV and Hepatitis they have been receptive of additional training, even if they are not ready to get tested or treated at that time. JCDH has met all goals that were set when we began providing PrEP and Hepatitis C services. We tested more than 3,000 people for Hepatitis C in 90 days, began testing patients to determine Chronic HCV infection, and began treating Chronic Hepatitis C. The majority of the patients who are taking Truvada for PrEP are uninsured, MSM, or minorities. Most of the patients who are uninsured would be unable to access PrEP due to financial barriers if it was not offered at JCDH. Finalized qualitative data regarding positive Hepatitis C antibody tests are still pending, but based on the review of labs and charts from the Lead Nurse Practitioner most patients with a positive test had a traditional risk factor. Spreadsheets for referrals for PrEP and patients with positive Hepatitis C tests have been kept by the Lead Nurse Practitioner to track patients who need follow up appointments/labs/additional testing. Based on the amount of time needed to adequately follow-up with PrEP and Hepatitis C patients, a social worker has been hired for the STD clinic to coordinate their care. Modifications have been made to the EMR templates and patient education to improve clinic flow. Patient education folders have been created for the initial PrEP visit and includes handouts about expectations for the visit, information about PrEP, information about the Advancing Access program, and FAQ about PrEP. The PrEP and Hepatitis C templates were amended to include a location for vital signs so the provider wouldn't have to open multiple form types (based on comments from providers) and required patient education was pre-populated as a reminder for providers during the visit. We have also been able to provide a more accurate estimate for the time between the submission of an application for prior authorization, application of copay/medication assistance application, and better manage patient expectations as we have increased our patient load.
JCDH has learned the importance of collaboration between internal and external partners. Developing Hepatitis C and PrEP service lines within the same year has increased the opportunity for internal collaboration among staff members at JCDH who may routinely interact. These services involved laboratory staff, EMR coordinators, clinic staff in order to develop protocols, adjust prices, and develop templates. JCDH has valued the partnerships we have developed within our community for the past 10 years.
The addition of Hepatitis C and PrEP services at JCDH has further increased our appreciation of the partnerships we have with organizations that are currently providing Hepatitis C and PrEP services, providing referrals of patients to JCDH, accepting referrals of difficult cases (as we develop capacity to treat Hepatitis C), and providing additional training for our staff members. The AIDS Service Organizations, Community Based Organizations, ACTIVE-C, THRIVE, and other community partners are committed to refer patients to JCDH for Hepatitis C testing/treatment and PrEP which will allow us to continue to provide these services to residents of Jefferson County, Alabama. ACTIVE-C (Hepatitis C) and THRIVE (PrEP) have both provided funding to JCDH to help us increase our capacity with these services. Hepatitis C and PrEP effectively began evaluating and treating patients this year before funding was awarded using existing staff members. Prior to the development of these service lines, JCDH planned to hire a social worker for the STD clinic, but the duties would have included making referrals for PrEP and Hepatitis C instead of scheduling patients for follow-up visits. If we are not funded in the future, JCDH will continue to offer these services because no additional staff was hired specifically for Hepatitis C. There are no specific days or times of the week for Hepatitis C or PrEP appointments, so providers may continue to evaluate and treat routine Adult Health and STD clinic patients.