Does integrating viral hepatitis services into a public STD clinic attract injection drug users for care

Injection drug users (IDUs) are at high risk for multiple health problems, such as human immunodeficiency virus (HIV) and viral hepatitis. In 2004, 19% of all newly reported HIV infections in the United States were attributed to injection drug use.1 Additionally, in 2004, 16% of all acute hepatitis B virus (HBV) infections and 42% of all acute hepatitis C virus (HCV) infections were attributed to injection drug use.2 Studies have found that women IDUs have high rates of exchanging sex for drugs and/or money, often without condoms, placing them at high risk for sexually transmitted diseases (STDs).3–6 Additional studies of IDUs have shown high rates (48% to 56%) of self-reported, lifetime history of at least one STD.5,7,8 Studies of IDUs that included STD testing found high rates of current infection, ranging from 8% for chlamydia, gonorrhea, or trichomoniasis to 48% for genital herpes.3,6 Although IDUs are burdened with many health-related problems, studies of preventive health services and vaccinations in syringe exchange programs show that only half of the clients received any of the health services offered, and acceptance of vaccinations was low.9,10 A project that offered HIV-infected clients an array of social and health referrals found that IDUs were more likely to accept referrals for immediate needs such as housing; but less than half of HIV-infected IDUs who accepted health-care referrals actually received any services.11 Public health experts have recommended that health programs serving clients at risk for multiple health problems integrate relevant services to more efficiently meet client needs.12 Arguments have been made that integrating services can be cost-saving and decrease barriers for clients who might otherwise need to go to several locations for services.13 Program integration is one step toward making a range of important preventive services more accessible to clients.14 The New York City Department of Health and Mental Hygiene (NYC DOHMH) Bureau of STD Control (BSTDC) is experienced with service integration. Pap smears have been offered at BSTDC clinics since the 1970s. In 1997, traditional HIV counseling and testing sites were merged into BSTDC clinics, where roughly 50,000 anonymous and confidential HIV tests were performed in 2005. Additionally, in 2003, a NYC law mandated that all STD clinics offer emergency contraception to women at risk of unintended pregnancy. In May 2000, with funding from the Centers for Disease Control and Prevention (CDC), NYC DOHMH began offering integrated viral hepatitis services (hepatitis A and B vaccinations and HCV counseling, testing, and referral [CTR]) at the Riverside STD clinic, one of 10 BSTDC clinics. The clinic offers free exams, testing, and treatment for STDs (e.g., syphilis, chlamydia, gonorrhea, cervical cancer screening), as well as confidential and anonymous HIV CTR. Prior research on program integration demonstrates the need for integrated services, as well as high acceptability of such services by clients utilizing them and staff providing them.8,15 Research on integrated services also demonstrates no decrease in productivity of the original service (i.e., integrated services do not overburden staff and do not require excessive financial or personnel resources).16 Further reports demonstrate that clients who access the original program take advantage of new services being added.13,14 However, data documenting that newly integrated services can draw in new clients, who then take advantage of all services, have not been reported. Our research focused on IDUs, an important segment of clinic clientele that may benefit from the clinic's range of health services. We examined integrated hepatitis/STD/HIV service delivery for IDUs who attend the Riverside STD clinic and discuss how this program may have benefited them. We also looked at whether integrating services had an impact on the number of clinic visits.