Please login to view this application
LoginJefferson County Department of Health
Sexual Health Clinic
Brittany C. Sanders
Lead Nurse Practitioner - Specialty Clinic
brittany.sanders@jcdh.org
205-930-5557
Birmingham
Alabama
35233
Your summary must address all the questions below:
The Jefferson County Department of Health (JCDH) has provided services to the residents of Jefferson County, Alabama for 102 years. JCDH is located in central Alabama and serves the residents of the most populated county within the state. Jefferson County, Alabama has an estimated 659,546 residents with a growth rate of -0.12% in the past year according to the most recent United States Census data. Jefferson County’s residents are 52.09% Caucasian, 42.58% African American, 1.54% Asian, .24% American Indian/Alaska Native, 0.03% Native Hawaiian/Other Pacific Islander, and 1.57% who are 2 or more races, 1.96% other race per the 2019 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 it is still 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 the Sexual Health Clinic and expanded testing services for Hepatitis C from the AH and STD clinics in 2017. 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. JCDH has continued to provide PrEP and Hepatitis C testing/treatment in the Adult Health and Specialty Clinics since 2017 and recently organized a PrEP coalition for Jefferson County, AL. JCDH has continued to educate the community about PrEP and Hepatitis C using social media, radio ads, club promotion(s), 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). During our education, we have discussed the following information: what PrEP is, people who may benefit from PrEP, risk factors for HIV and Hepatitis C, Hepatitis C testing, Hepatitis C treatment, and our ability to offer services to insured and uninsured individuals using a sliding scale. Patients are screened for Hepatitis C during visits in the Sexual Health and Adult Health Clinics using USPTF guidelines. Persons who have a positive Hepatitis C antibody test are informed of their results by clinic staff. During the notification of results they also receive counseling about Hepatitis C and the need for additional testing to determine whether they are chronically infected. Potential PrEP candidates are identified and referred by community partners and internal referrals (Family Planning Clinic staff, Adult Health staff, or Disease Intervention Specialist). JCDH has met our goals to continue Hepatitis C testing, provide Hepatitis C treatment to patients who would have been referred to an external clinic for evaluation and treatment, increase the awareness of PrEP within the community, increase the uptake of PrEP among persons at high risk for HIV acquisition, and increase awareness of these services for insured and uninsured residents of Jefferson County, Alabama. There have been no new HIV infections among persons who are taking PrEP. JCDH has been successful with meeting our goals because management is supportive of the work that is being done, staff are passionate about services they provide, and our staff are continuously working to improve the services that are offered. JCDH has worked with CBOs, ASOs, and other community partners at community events to promote awareness of HIV and Hepatitis C prior to offering these services so we already had a presence in the community. JCDH's continued offering of PrEP and Hepatitis C treatment 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
A Model Practice must be responsive to a particular local public health problem or concern. An innovative practice must be -
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. Healthy People 2020 was used 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. JCDH utilized information from the CDC’s High Impact Prevention strategy to increase community awareness and uptake of biomedical interventions (PrEP) to prevent HIV, used 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 primarily individuals who were being evaluated or treated for STIs in the Sexual Health Clinic. PrEP handouts and posters were available in clinic areas. Several patients initiated conversations about PrEP after seeing a poster in an exam room or because they knew someone who takes PrEP. Other conversations were initiated by the referring employee. We have had success with initiating PrEP in a population that has been identified as high risk, but who have underutilized PrEP services since its approval in 2012. Prior to the initiation of PrEP services at JCDH any patient who was identified as high risk for HIV acquisition was referred to an external partner that offered PrEP once a week. Offering PrEP at JCDH is better for our patients and the community at large because JCDH offers PrEP appointments every day 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 and has served as a resource for the Alabama Department of Health when they have questions about PrEP. The PrEP providers at JCDH expressed interest in prescribing PrEP and wanting to be proactive about decreasing HIV in our community. Since JCDH began PrEP services in 2017, additional providers have been trained in the Sexual Health Clinic. Additional providers in the Sexual Health Clinic are working with current PrEP providers at JCDH and will begin seeing newly referred PrEP patients in the upcoming months.
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. Most of the patients who have been treated for Hepatitis C were tested in the Sexual Health Clinic during a routine STI exam. All persons with a positive antibody test were contacted by a nurse practitioner 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 approximately 6 months. Since JCDH began Hepatitis C treatment most patients with Chronic Hepatitis C begin treatment within 6 weeks (includes time for ultrasound to be scheduled and read and application time for medication assistance programs).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 Sexual Health Clinic is a creative use of practice and staff because the providers 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 Sexual Health Clinic and providers discussed the ease of treatment, two additional providers in Adult Health providers began offering Hepatitis C treatment for their uncomplicated patients.
JCDH wanted to increase access to PrEP services among persons at high risk for HIV acquisition (especially MSM), increase Hepatitis C testing at JCDH, and increase access to Hepatitis C treatment and testing to Jefferson County residents. Since we began Hepatitis C treatment and PrEP we have increased community awareness about PrEP and Hepatitis C among the general population and providers. We have provided education using multiple mediums: in person, internet, radio, and television and have many patients who present to our clinic with questions about PrEP and for Hepatitis C testing/treatment because they saw information online or were referred from a community partner who was aware of our services.
JCDH has met all goals that were set when we began providing PrEP and Hepatitis C services. We have continued to offer Hepatitis C testing to high risk persons, continued testing patients to determine Chronic HCV infection, and continued to offer treatment for patients with uncomplicated Chronic Hepatitis C. JCDH has continued to provide PrEP for patients who are high risk for HIV acquisition. Most of the PrEP patients at JCDH 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. JCDH has started PrEP for more than 90 patients and began Hepatitis C treatment for more than 20 patients. There are a few patients who began taking PrEP in 2017, when our program began, who have remained in care and referred additional patients for PrEP.
A social worker was hired in 2018 to track Hepatitis C and PrEP patients in addition to providing social services needs for other clinic patients. The social worker maintains a spreadsheet of active patients, schedules appointments, and completes medication assistance applications. The need for a social worker was identified shortly after the PrEP and Hepatitis C programs began to grow because there was too much follow up needed for a nurse practitioner to adequately provide case management for the volume of patients who needed Hepatitis C or PrEP services.
The LHD should have a role in the practice’s development and/or implementation. Additionally, the practice should demonstrate broadbased 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.
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 102 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.
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). JCDH has worked with the Alabama Department of Health (ADPH) to obtain free Hepatitis A and B vaccines for uninsured patients which decreases out of pocket costs. EMR templates for PrEP and Hepatitis C visits (initial and follow up) were created to improve the flow of clinic visits. The EMR templates were developed with input from the clinic staff, Medical Director of Disease Control, and the EMR team.
All patients in the Sexual Health Clinic were eligible for PrEP discussions due to their high risk of STIs including HIV. Other patients received targeted information if they met eligibility criteria which was documented in the PrEP referral protocol. JCDH has worked with Community Based Organizations (CBO) and AIDS Service Organizations (ASO) to accept PrEP and Hepatitis C referrals, primarily uninsured persons. JCDH also works with community partners (CBO and ASO) and other local governmental entities during community evets to provide education about PrEP and Hepatitis C. The Medical Director of Disease Control recently spoke to employees of Birmingham, AL about PrEP during World AIDS Day and organized a PrEP coalition for Jefferson County, AL to engage all PrEP stakeholders and develop a toolkit that will be used to train/engage new providers.
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 are unable to be served by have overwhelmed the specialists who were primarily responsible for providing Hepatitis C treatment. JCDH worked with a large local university 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 partnership with the university, the providers in Adult Health tested high risk adults for Hepatitis C based on USPTF guidelines. JCDH continued to work with the university partner for treatment guidance related to Hepatitis C until staff had the capacity to treat uncomplicated patients on their own. JCDH staff is now comfortable treating uncomplicated Chronic Hepatitis C. JCDH has received referrals for Hepatitis C testing and treatment from local drug treatment centers and providers who suspect Hepatitis C infection in a patient.
JCDH has fostered collaboration with drug rehabilitation facilities who refer patients with positive Hepatitis C tests, ASO, CBO, the local university, 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 services.
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).
JCDH wanted to
increase access to PrEP services among persons at high risk for HIV acquisition
(especially MSM), increase Hepatitis C testing at JCDH, and increase access to
Hepatitis C treatment and testing to Jefferson County residents. Since we began
Hepatitis C treatment and PrEP we have increased community awareness about PrEP
and Hepatitis C among the general population and providers. We have provided
education using multiple mediums: in person, internet, radio, and television
and have many patients who present to our clinic with questions about PrEP and
for Hepatitis C testing/treatment because they saw information online or were
referred from a community partner who was aware of our services.
JCDH has met all goals
that were set when we began providing PrEP and Hepatitis C services. We have
continued to offer Hepatitis C testing to high risk persons, continued testing
patients to determine Chronic HCV infection, and continued to offer treatment
for patients with uncomplicated Chronic Hepatitis C. JCDH has continued to
provide PrEP for patients who are high risk for HIV acquisition. Most of
the PrEP patients at JCDH 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.
Eight hundred thirteen Hepatitis C tests were run at JCDH from
1/1/19 to 12/27/19. All patients with a positive Hepatitis C antibody test had
a Hepatitis C RNA and genotype test done.
Patients with a positive RNA and genotype were referred for an
ultrasound, when applicable, and evaluated for signs of advanced liver
disease. Patients with chronic Hepatitis
C and advanced liver disease were referred to a hepatologist. Patients with
chronic Hepatitis C without advanced liver disease had applications completed
for treatment (Medicaid or other insurers) or medication assistance
programs. Since JCDH began Hepatitis C
treatment, sixteen patients have been cured of Hepatitis C, five patients are
currently taking treatment, one patient is awaiting SVR testing after treatment
(to determine whether treatment was effective), four patients are pending the
start of treatment, a few patients have been denied for treatment by the insurer,
and other patients have not started treatment due to other issues (i.e.
awaiting health card for ultrasound, lost to follow up, etc.).
In 2019 there were ninety-three individuals who had a PrEP
appointment at JCDH which included fifty-four initial visits and one hundred
forty follow up visits. There are currently fifty-eight active PrEP patients
(seen in clinic within last the last six months). There are a few patients who began taking
PrEP at JCDH in 2017, when our program began, who have remained in care and
referred additional patients for PrEP. The patients who discontinued PrEP
stopped medication because they did not want take a daily medication, felt they
were no longer at risk for HIV, change in relationship status, and no reason
was given.
A social worker was hired in 2018 for the Specialty Clinic. The
social workers duties include case management for Hepatitis C and PrEP patients
in addition to providing social services needs for other clinic patients.
The social worker maintains a spreadsheet of active patients, schedules
appointments, and completes medication assistance applications. The need
for a social worker was identified shortly after the PrEP and Hepatitis C programs
began to grow because the need for follow up became too great for other
clinical staff to manage.
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.)
JCDH knows the importance of collaboration between internal and external partners. Offering Hepatitis C and PrEP has promoted continued internal collaboration among staff members at JCDH who may routinely interact (Clinical Services and Disease Control staff). Staff from the Adult Health and Sexual Health Clinics work together to treat Hepatitis C and to make referrals to the other clinic when a primary care or sexual health need is identified in the other clinic. 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 continue to develop capacity to treat Hepatitis C), and providing additional training for our staff members. The AIDS Service Organizations, Community Based Organizations, Alabama Department of Public Health, and other community partners have continued to refer patients to JCDH for Hepatitis C testing/treatment and PrEP since we began offering services in 2017. Since 2017, JCDH has decreased the number of patients who have been referred for Hepatitis C treatment and PrEP, unless requested by the patient.
JCDH received a $50,000 grant to support nurse practitioner and social work staff in their provision of PrEP services to patients who were referred from community partners. The grant funding ends in 2020, but JCDH will continue to offer Hepatitis C and PrEP services because the services are important to the residents of Jefferson County. JCDH will continue to offer Hepatitis C and PrEP appointments Monday through Friday to further improve access within Jefferson County.
Promising Practice 2018
