# Presentation: 130786

## 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**

**Community**
**Leaders**

**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 GroupsOBJECTIVES

- 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 IIExpanded 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 TESTING

- Estimate 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

## HIV/STD Co-Infection Females

## HIV/STD Co-Infections Males

## 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

## 813

_**UNC**_
- Bill Miller
- Marlene Smurzynski
- Trang Nguyen
- Dionne Law
- Chandra Ford
- Betsey Tilson
_**CDC**_
- Kim Fox
- Katie Irwin
- Rheta Barnes

## Slide 25

## 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

## BARRIERS

_**Cost**_
**“...’****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 risk
- fear
- 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:Confidentiality

_**Visibility**_
- “...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