NACCHO Award

Model Practice Title

Please provide the name or title of your practice

Integrating PrEP into a LHD STI Clinic

Practice Categories

Model and Promising Practices are stored in an online searchable database. Applications may align with more than one practice category. Please select all the practice areas that apply.
- Access to Care
- Advocacy and Policy Making
- Animal Control
- Coalitions and Partnerships
- Communications/Public Relations
- Community Involvement
- Cultural Competence
- Emergency Preparedness
- Environmental Health
- Food Safety
- Global Climate Change
- Health Equity
- HIV/STI
- Immunization
- Infectious Disease
- Informatics
- Information Technology
- Injury and Violence Prevention
- Marketing and Promotion
- Maternal-Child and Adolescent Health
- Organizational Practices
- Other Infrastructure and Systems
- Organizational Practices
- Primary Care
- Quality Improvement
- Research and Evaluation
- Tobacco
- Vector Control
- Water Quality
- Workforce
- Conference Theme: Bridging Clinical Medicine and Population Health
Other:
Is this practice evidence based, if so please explain.

Winnable Battles

To keep pace with emerging public health challenges and to address the leading causes of death and disability, CDC initiated an effort called Winnable Battles to achieve measurable impact quickly.Winnable Battles are public health priorities with large-scale impact on health and known effective strategies to address them. Does this practice address any CDC's seven Winnable Battles? If so, please choose from the following:
- Food Safety
- HIV in the U.S.
- Nutrition, Physical Activity, and Obesity
- Tobacco
- Healthcare-associated Infections
- Motor Vehicle Injuries
- Teen Pregnancy
- None

Overview: Provide a brief summary of the practice in this section (750 Word Maximum)

Your summary must address all the questions below:

Brief description of LHD- location, demographics of population served in your community
Describe public health issue
Goals and objectives of the proposed practice
How was the practice implemented/activities
Results/Outcomes (list process milestones and intended/actual outcomes and impacts.
- Were all of the objectives met?
- What specific factors led to the success of this practice?
Public Health impact of practice
Website for your program, or LHD.

750 Word Maximum

Please use this portion to respond to the questions in the overview section.
Champaign-Urbana Public Health District (CUPHD), accredited by the Public Health Accreditation Board (PHAB) in 2014, is the local public health authority for the Cities of Champaign and Urbana and Champaign County, Illinois. Champaign County is located in east central Illinois and is 998.39 square miles with a population density of 201.8 people per square mile. Champaign County is an exemplar micro-urban community and a statewide leader in progressive education, health care, government, high technology, light industry and agriculture. In 2015, the US Census Bureau estimated the population to be 208,861 residents. The current population of Champaign County is composed of 74.5% Caucasian, 12.8% African American and 9.6% Asian (2013 U.S. Census Bureau estimate). The percentage of Hispanic residents in Champaign County in 2013 was 5.1%. Public Health Issue: HIV/AIDS is a significant public health issue in the United States. The Centers for Disease Control and Prevention (CDC) estimates that 1.2 million people aged 13 years old and older are now living with HIV infection, and an additional 40,000 new HIV infections occur every year. One out of eight people with HIV are unaware of their infection. Pre-Exposure Prophylaxis (PrEP) is a very effective tool in preventing new HIV infections. PrEP is a biomedical intervention that allows an HIV negative person to take a daily medication (Truvada) which is over 92% effective in preventing a new HIV infection. When a person on PrEP is exposed to HIV through sex or injection drug use, the medication keeps the virus from establishing an infection in that person. CUPHD has implemented a PrEP program to engage clients at increased risk of HIV in this intervention. The program has been integrated into the existing CUPHD STI Clinic. PrEP is an important addition to the existing HIV prevention activities provided at CUPHD. Goal: Zero New HIV infections in Champaign County Objective: All clients accessing STI or HIV services at CUPHD should have timely access to PrEP while they are at the CUPHD. Objective: Increase local provider network of PrEP prescribers Objective: Increase community awareness of PrEP as a tool to prevent HIV infection. Practice Implementation: In June 2015, CUPHD implemented a PrEP Program into the existing HIV and STI structure. Clients who attend the STI clinic and report an increased risk for HIV transmission (MSM, IDU, and persons with HIV positive partners) receive education on the benefits of PrEP. Clients who are interested in this biomedical intervention have the opportunity to receive a prescription for Truvada that same day. An HIV services staff member is assigned to assist this client in accessing this medication, engaging medication and co-pay assistance programs, and completing the required follow up services. Outcomes: Between June 2015 and October 2016, a CUPHD provider has given 92 Truvada prescriptions for PrEP. 73% have adhered and have attended their last required appointment at CUPHD for PrEP management. 12% of clients have relocated to a new city, most with a referral to another clinic for PrEP continuation. 27% clients are “lost to follow up” and have not completed their last required appointments for PrEP. PrEP case managers attempt to make contact with all clients who discontinue PrEP without explanation to re-engage them in the program. Were Objectives Met? Yes. 73% of all clients prescribed PrEP have continued on the regimen. This is a great success rate in the first year of program implementation. What led to success? Integration and Accessibility. Partnership with Collaborators like Walgreens for Drugs. Public Health Impact: The “National HIV/AIDS Strategy for the United States: Updated to 2020” included a new developmental indicator to “increase use of pre-exposure prophylaxis (PrEP) by 500 percent” to further strengthen the response to HIV in the 2016 Progress Report. The CUPHD intervention is on target to meet this goal. Website : www.c-uphd.org Facebook @CUatZERO

Responsiveness and Innovation

A Model Practice must be responsive to a particular local public health problem or concern. An innovative practice must be (1) new to the field of public health (and not just new to your health department) OR (2) a creative use of an existing tool or practice, including but not limited to use of an Advanced Practice Centers (APC) development tool, The Guide to Community Preventive Services, Healthy People 2020 (HP 2020), Mobilizing for Action through Planning and Partnerships (MAPP), Protocol for Assessing Community Excellence in Environmental Health (PACE EH). Examples of an inventive use of an existing tool or practice are: tailoring to meet the needs of a specific population, adapting from a different discipline, or improving the content.

Statement of the problem/public health issue
What target population is affected by problem (please include relevant demographics)
- What is the target population size?
- What percentage did you reach?
What has been done in the past to address the problem?
Why is the current/proposed practice better?
Is current practice innovative? How so/explain?
- Is it new to the field of public health
  OR
- Is it a creative use of existing tool or practice:
  What tool or practice did you use in an original way to create your practice? (e.g., APC development tool, The Guide to Community Preventive Services, HP 2020, MAPP, PACE EH, a tool from NACCHO’s Toolbox etc.)
Is the current practice evidence-based? If yes, provide references (Examples of evidence-based guidelines include the Guide to Community Preventive Services, MMWR Recommendations and Reports, National Guideline Clearinghouses, and the USPSTF Recommendations.)

2000 Word Maximum

Please state the Responsiveness and Innovation of your practice (2000 Word Maximum)
CUPHD shares the CDC's goal of creating a future free of HIV. There are tremendous disparities in HIV prevalence. Men who have sex with men bear a greater burden of HIV, accounting for about 63% of all new infections. The estimated number of new HIV infections was greatest among young MSM, specifically young African American MSM. Public health nurses and HIV services staff are trained to provide STI, HIV, and family planning services for all clients at each visit. The guiding principle is to provide needed services during the client’s visit rather than referring a client to return for another service at CUPHD. The CDC developed “High-Impact HIV Prevention: CDC’s Approach to Reducing HIV Infections in the United States” as a roadmap to eliminate HIV. This guidance documents the plan that CUPHD has adopted for its HIV prevention program. CUPHD has employed the following HIV prevention activities: Biomedical Interventions; Public Health Strategies; Behavioral Interventions; Structural Interventions; and Social Marketing. Biomedical interventions include access to Pre-Exposure Prophylaxis (PrEP) to clients most at risk for HIV infection. This is a powerful tool in HIV prevention and even more effective when combined with other prevention strategies. PrEP was approved for use to prevent HIV infections in 2012. In 2014, the CDC released the PrEP Clinical Practice Guidelines to describe what providers need to know to implement PrEP. Other biomedical interventions focus on treatment adherence strategies for persons living with HIV. CUPHD staff and peers work closely with clients to ensure that they attend medical appointments and in assessing potential barriers to medication adherence. STI testing is promoted for all persons at risk including people living with HIV. CUPHD provides STI services onsite all day each weekday. In addition, CUPHD has an offsite evening clinic one night a week for clients who cannot access services at the main clinic. STI testing is offered in all mobile outreach and during gay bar outreach. STI testing is normalized during routine visits for HIV care services. CUPHD provides public health strategies which include HIV testing and linkage to care for persons that are HIV positive. Staff has received intensive, focused training to conduct HIV Counseling and Testing with those at risk for HIV. Staff is practiced at delivering an HIV positive test result and conducting partner services. Linkage to Care interventions are highlighted with the engagement of HIV persons in medical care and supportive services. Behavioral Interventions at CUPHD include a long-standing Mpowerment project for African American MSM. This group follows the CDC Effective Behavioral Intervention model and is managed by two peers who are employed by CUPHD. The peers are IDPH trained to conduct HIV Counseling and Testing. The project uses an offsite location for project activities. The peers have been trained in PrEP promotion and market the CUPHD PrEP clinic through their gay bar outreach and small group activities. Peers are integrated into the CUPHD HIV services programming Another behavioral intervention that is important to the program is peer support for persons living with HIV. CUPHD employs four HIV positive peers that provide treatment adherence strategies to clients accessing care services. Peers engage members of their social networks to reach “harder-to-reach” clients and connect them to medical care. The peers assist HIV positive persons with accessing medical appointments, laboratory testing and other health services that are needed to manage HIV disease. Peers engage these members in AIDS Drug Assistance Program (ADAP) enrollment to ensure medication adherence. Other barriers to medical care are assessed though one on one meetings and in support groups. These peers are a vital piece of the care continuum and reach HIV positive persons in ways that local health department staff cannot. CUPHD operates with the understanding that all HIV programming must be supported by structural interventions including syringe exchange and condom distribution. CUPHD has provided syringe exchange services since 2001. CUPHD offers comprehensive harm reduction services to participants. Sharps containers are offered to all participating clients. Participants who are hesitant to take a sharps container are offered a hard plastic container, often bleach or laundry detergent bottle, for collecting syringes. In addition, CUPHD provides overdose prevention services. Participants are trained in the signs and symptoms of opiate overdose and in rescue breathing. The overdose training includes Naloxone administration, how to continually monitor the overdosing person, and how to contact emergency services. Condoms are distributed throughout the agency, through mobile outreach, and at the gay bar. Access to condoms is vital in reducing new HIV infections. CUPHD works to ensure that people living with HIV or who have an increased risk for HIV infection have easy access to condoms as a prevention tool. Efforts to identify HIV positive individuals who are aware of their status but not engaged in HIV medical care has become a priority. Research has shown that engaging HIV positive persons in medical care reduces HIV transmission potential through HIV viral suppression. This staff conducts surveillance activities for persons who are previously diagnosed with HIV but are not active in HIV medical care. The Illinois Department of Public Health (IDPH) generates a roster of persons who are HIV positive but have not had viral load testing in the past six months or have been recently diagnosed with an STI. CUPHD staff conducts DIS investigations to locate these individuals and assist them in addressing their barriers to accessing HIV medical care. This surveillance model has been implemented in the local HIV clinic. The HIV clinic now releases a roster of clients that are not medically-adherent for the same surveillance activities. Staff has discovered that it is easier to locate a client who missed a recent HIV related medical appointment rather than wait until the client is reported by IDPH months later. This collaboration has enhanced the quality of care that clients receive. CUPHD has adopted the national social marketing campaign, “Getting to Zero” by putting a local spin on it with “CU at Zero”. The campaign has three tenets: Zero new HIV infections; Zero HIV related deaths; and Zero HIV-related stigma. The campaign is particularly useful because it fits well with CUPHD’s integrated services model, as it engages both HIV positive and negative individuals. “CU at Zero” incorporates all of the interventions that are employed at CUPHD to end HIV in our community. Messaging under the “CU at Zero” brand can range from promoting condom use, to PrEP and HIV testing, to treatment adherence, and STI testing for HIV+ people. The campaign differs from traditional “use a condom every time” campaigns, and parallels efforts happening in larger cities.

LHD and Community Collaboration

The LHD should have a role in the practice’s development and/or implementation. Additionally, the practice should demonstrate broad-based involvement and participation of community partners (e.g., government, local residents, business, healthcare, and academia). If the practice is internal to the LHD, it should demonstrate cooperation and participation within the agency (i.e., other LHD staff) and other outside entities, if relevant. An effective implementation strategy includes outlined, actionable steps that are taken to complete the goals and objectives and put the practice into action within the community.

Goal(s) and objectives of practice
What did you do to achieve the goals and objectives?
- Steps taken to implement the program
Any criteria for who was selected to receive the practice (if applicable)?
What was the timeframe for the practice
Were other stakeholders involved? What was their role in the planning and implementation process?
- What does the LHD do to foster collaboration with community stakeholders? Describe the relationship(s) and how it furthers the practice goal(s)
Any start up or in-kind costs and funding services associated with this practice? Please provide actual data, if possible. Otherwise, provide an estimate of start-up costs/ budget breakdown.

5000 words maximum

Enter the LHD and Community Collaboration related to your practice (5000 words maximum)
CUPHD has a long standing history of collaborating with traditional and non-traditional partners for new and existing program implementation. In order to assess the need for PrEP interventions in Champaign-Urbana, CUPHD gathered stakeholders including consumers and representatives from the University of Illinois, the local AIDS Service Organization, Walgreens HIV Specialty Pharmacy, and the local medical group in June 2014. This group met to discuss PrEP and local options for engaging clients in PrEP interventions. The group developed plans to engage medical provider in PrEP promotion with patients and intervention delivery. A client survey was also developed to determine client awareness and interest in PrEP promotion. In the summer and fall of 2014, CUPHD HIV services staff was focused on PrEP promotion and working with local providers to build PrEP prescribing capacity. The plan from the stakeholder’s meeting was to refer CUPHD clients to local providers for PrEP prescription. In October 2014, the local medical group decided to refer all PrEP requests to their infectious disease physicians. This created a significant barrier to PrEP delivery for clients, thus creating a need for a new model of PrEP delivery in Champaign-Urbana. Client requests made to CUPHD staff for PrEP resources increased over the next several months. It was at this point that the CUPHD management team agreed to pursue the creation of a PrEP clinic through existing HIV and STI services. In June 2015, CUPHD’s HIV services staff received extensive training on PrEP from the AIDS Foundation of Chicago and the Illinois Department of Public Health. After this training, CUPHD implemented PrEP services into the existing HIV/STI comprehensive clinic. A PrEP client receives comprehensive STI services, including site-specific testing for gonorrhea and Chlamydia, syphilis and fourth generation HIV testing. During the initial PrEP visit, each client receives a personalized risk assessment, counseling on the importance of medication adherence, and education on the potential side effects of Truvada. Laboratory screening for Hepatitis B and creatinine clearance for kidney function is completed. The CUPHD provider completes an acute HIV signs and symptoms review and a provider/client agreement to initiate a prescription for Truvada. HIV services staff works with clients to ensure that they have the ability to pay for medication, through health insurance, Medicaid, or the pharmaceutical medication assistance programs. The client leaves the visit with a prescription for Truvada, a plan to pay for the medication, and an appointment for a follow up visit with their assigned PrEP case manager. CUPHD staff works closely with the Walgreens pharmacist. The pharmacist assists CUPHD in completing medication assistance forms for clients, when needed. He contacts CUPHD when a client is due to pick up their medication but have not made contact. The pharmacist also works with local providers to ensure that all required PrEP related testing is completed and will refer providers to CUPHD for support. Start-up cost Minimal start-up costs were associated with the addition of this intervention. Staff time was the main resource needed to start this clinic. Existing staff was incorporated into this new model of care. Existing grant funds were used to develop the staff skills needed for this program. Staff spent approximately 20 hours in onsite training to provide PrEP services. The CUPHD HIV services manager spent close to 100 hours preparing for the clinic by completing PrEP paperwork, clinic flow plan, getting CUPHD management and provider buy-in, collaborating with Walgreens, working with laboratory personnel to add new testing options, and in preparing marketing materials for PrEP. HIV services staff already had the skill set needed to effectively deliver this intervention: HIV risk assessment; HIV Test Counseling; medication adherence counseling; financial assistance navigation; and expanded Medicaid and insurance enrollment. HIV services staff was already integrated into the STI clinic and have provided client-based HIV services to STI clinic clients for the past four years. All STI and HIV staff are crossed trained to deliver PrEP interventions. Staff time spent on PrEP related activities is charged to the HIV prevention grant that is managed by IDPH. Laboratory services were added for PrEP implantation. CUPHD obtained lab support from a private lab to conduct PrEP specific testing. The costs for these tests are covered by the client’s insurance and the HIV prevention grant as a payer of last resort. The intention was to keep this intervention at a low cost and sustainable to be able to replicate it to other communities. We do not anticipate any additional on-going cost to this program. There were no indirect costs associated with the implementation of the PrEP program.

Evaluation

Evaluation assesses the value of the practice and the potential worth it has to other LHDs and the populations they serve. It is also an effective means to assess the credibility of the practice. Evaluation helps public health practice maintain standards and improve practice. Two types of evaluation are process and outcome. Process evaluation assesses the effectiveness of the steps taken to achieve the desired practice outcomes. Outcome evaluation summarizes the results of the practice efforts. Results may be long-term, such as an improvement in health status, or short-term, such as an improvement in knowledge/awareness, a policy change, an increase in numbers reached, etc. Results may be quantitative (empirical data such as percentages or numerical counts) and/or qualitative (e.g., focus group results, in-depth interviews, or anecdotal evidence).

What did you find out? To what extent were your objectives achieved? Please re-state your objectives.
Did you evaluate your practice?
- List any primary data sources, who collected the data, and how (if applicable)
- List any secondary data sources used (if applicable)
- List performance measures used. Include process and outcome measures as appropriate.
- Describe how results were analyzed
- Were any modifications made to the practice as a result of the data findings?

2000 Words Maximum

Please enter the evaluation results of your practice (2000 Words Maximum)
CUPHD conducted a community survey on knowledge and attitudes toward the PrEP Intervention in September 2014 during the Champaign-Urbana gay pride weekend. Survey results indicated that most clients did not know about PrEP, over half had never heard of it, but nearly 70% of those surveyed said that they would consider the intervention with what they knew of it. We also learned that one quarter of the persons surveyed would not feel comfortable talking to their provider about starting PrEP. Process Evaluation: The CUPHD HIV services program manager reviews PrEP client charts monthly to ensure that all required testing and follow up visits have been conducted. An Excel spreadsheet is maintained to track client engagement and retention in PrEP services. The intervention is now added to the CUPHD EHR. Clients who completed the last scheduled PrEP appointment are considered to be current in the program. The CUPHD nursing staff keeps a log on the clients that have been engaged in PrEP education but do not choose this intervention at the time of the STI clinic visit. Clients are given information sheets with national resources to education themselves on PrEP and are encouraged to return if they decide to discuss the PrEP intervention further. HIV services staff meets weekly to discuss HIV interventions, including PrEP. The PrEP program manager, STI clinic nurse who is the lead on PrEP, providers, and the HIV services program manager meet monthly to discuss program needs and challenges. Client feedback on the CUPHD PrEP intervention is discussed at these meetings and improvements are made based on these suggestions. For instance, clients reported a desire for appointment reminders and CUPHD developed the case management model to address this concern. Outcome Evaluation: Between June 2015 and October 2016, a CUPHD provider has given 92 Truvada prescriptions for PrEP. 73% of these clients have attended their last required appointment at CUPHD for PrEP management. This is a great response to a new program in the first year of its implementation.

Sustainability

Sustainability is determined by the availability of adequate resources. In addition, the practice should be designed so that the stakeholders are invested in its maintenance and to ensure it is sustained after initial development (NACCHO acknowledges that fiscal challenges may limit the feasibility of a practice's continuation.)

Lessons learned in relation to practice
Lessons learned in relation to partner collaboration (if applicable)
Did you do a cost/benefit analysis? If so, describe.
Is there sufficient stakeholder commitment to sustain the practice?
- Describe sustainability plans

1500 Words Maximum

Please enter the sustainability of your practice (2000 Words Maximum)
Many lessons have been learned as this program continues to develop. The need for “prescription on demand” was recognized in the first months of the program. CUPHD committed to training a nurse practitioner who is on site daily to serve as a PrEP provider. This change led to more engagement in the program. STI nurses have been crucial to the success of this program and act as gatekeepers into the PrEP program as they encounter clients at increased risk of HIV infection in STI clinic. If IDPH funding were eliminated, CUPHD will be able to sustain PrEP activities funded through private insurance and Medicaid billing infrastructure that CUPHD has developed and build over the years. CUPHD staff would employ the National Alliance of State and Territorial AIDS Directors (NASTAD) guidance document “Billing Coding Guide for HIV Prevention: PrEP, Screening, and Linkage Services”. It is predicted that these billable services will cover over 75% of the costs associated with PrEP interventions. The additional costs will be supplemented with local agency tax dollars as the benefits outweigh the risk of doing nothing. CUPHD sponsored a PrEP training for providers at a local medical group. The training was well attended with over 75 providers in attendance. CUPHD will continue to build community capacity with medical providers to expand PrEP access.

Additional Information

How did you hear about the Model Practices Program:
- I am a previous Model Practices applicant
- At a Conference
- NACCHO Website
- Public Health Dispatch
- Colleague in my LHD
- Model Practices brochure
- NACCHO Exhibit Booth
- NACCHO Connect
- Colleague from another public health agency
- E-Mail from NACCHO
- NACCHO Exchange

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2017 Model Practices