Strengthening Sexually Transmitted Disease Services in Detroit, Michigan (2015)

Sexually transmitted diseases (STDs) remain a significant cause of morbidity in the United States. In 2013, 1.4 million cases of chlamydia were reported to the Centers for Disease Control and Prevention (CDC), making it the most commonly reported notifiable disease in the United States.1 With such high case numbers, it is unreasonable to expect state and locally funded STD clinics to care for all patients with STDs. However, dedicated STD clinics often serve as a safety net for uninsured or underinsured individuals and provide higher-quality STD services than general medical/primary care clinics.2 Sexually transmitted disease clinics often provide additional services for free or with sliding scale fees, such as walk in or express visits, onsite diagnostics, and partner services, where clinic staff offer testing and treatment to the partner(s) of the patient.3 Sexually transmitted disease clinics are seen as an important place to receive confidential services.3 Recently, this service model has faced numerous challenges with local STD clinics experiencing budget cutbacks or closing.4 Furthermore, the landscape of healthcare provision in the United States is changing as a result of legislation and is causing a shift in the places where individuals seek care and who pays for it. Large municipalities with significant disease burden have been challenged to find the right balance between state and locally funded STD clinics and other models of STD service provision. Because of budget constraints, high disease burden, and a syphilis outbreak, perhaps nowhere has this struggle been more pronounced than in Detroit, Michigan. DETROIT BACKGROUND In July of 2013, the city of Detroit became the largest municipality to file for bankruptcy in US history.5 Before the bankruptcy, the city eliminated funding for the local health department and state and local public health officials contracted with a new nonprofit organization to continue to offer public health services out of the Herman Kiefer Health Complex (HKHC), where Detroit's public health activities had been headquartered.6,7 Unfortunately, in October 2013, the HKHC closed its doors due to costs associated with maintaining the building. This facility had served as the cornerstone of STD prevention and public health activities in Detroit since it opened in 1928, and as the City's sole dedicated STD clinic, served approximately 11,000 STD patients annually between 1999 and 2013.8 Although interim STD services were partially established at a temporary location, timing of the transfer of the STD clinic from HKHC could not have been worse. In 2012, Wayne County, where Detroit is located, ranked seventh nationally in total number of chlamydia cases diagnosed (17,532) and fourth for total number of gonorrhea cases diagnosed (6609) despite a dwindling population.9 From 2010 to 2013, the number of primary and secondary syphilis cases in Detroit increased 173% from 73 cases in 2010 to 199 cases in 2013.10 This syphilis outbreak was concentrated primarily among young black men who have sex with men under the age of 35 years, with 56% of cases occurring in this hard to reach group. ACTION PHASE Just days before the scheduled transfer of services from HKHC in 2013, an internal CDC team comprising clinical, scientific, and programmatic STD experts visited Detroit to evaluate the increase in syphilis cases and the current state of STD clinical infrastructure, and to conduct a patient survey of HKHC STD clinic patients. After a tour of the facilities and meeting with key state and local staff, we concluded that transfer of the STD clinic could have serious implications for STD prevention in the city. As a well-established and known site of free or reduced price STD services, the transfer of this clinic could result in fewer patients seeking sexual health services such as STD and HIV screening, delayed and costly treatment for symptomatic patients, and ultimately increased STD transmission particularly for syphilis where a substantial portion of new cases were diagnosed and treated at HKHC. Aware of shrinking city finances, we suggested that a strategy to reestablish STD clinical infrastructure would require innovative partnerships and collaborations across sectors. In January 2014, the Michigan Department of Health and Human Services (MDHHS) contacted CDC's Division of STD Prevention and formally requested technical assistance to address the instability of Detroit's STD clinical infrastructure and ongoing syphilis outbreak. Our core team enlisted additional CDC staff including experts from policy, surveillance, social marketing, program consultants, and partners from the Division of HIV/AIDS Prevention to support a technical assistance response. To establish external partnerships, our expanded group convened a steering committee with the MDHHS, the Michigan Primary Care Association, the Detroit Department of Health and Wellness Promotion, and national partner organizations (National Coalition of STD Directors, National Association of City and County Health Officials, and the National Association of Community Health Centers). The steering committee planned a consultation to bring in a diverse group of stakeholders to develop a strategy for Detroit. The consultation meeting held on April 9, 2014, was a day-long intensive working meeting at Wayne State University School of Medicine. In attendance were more than 50 participants from federal, state, and local governments, Detroit area community-based organizations, local federally qualified health centers (FQHC), primary care providers, hospital systems (Henry Ford Hospital, Detroit Medical Center), and academics and clinicians from Wayne State University, the University of Michigan, and the University of Washington. The consultation accomplished several goals: (1) raised participants awareness about the problems with syphilis and the clinical STD infrastructure in Detroit; (2) defined the ideal STD clinical infrastructure for a large urban municipality; (3) defined roles and responsibilities of public health, primary care, academia, and community-based organizations; (4) established community buy-in and working relationships between federal, state, and local partners in attendance; and, most importantly, (5) reached consensus on an overall strategy to improve STD infrastructure in Detroit. This strategy established a leadership group to coordinate this initiative within the city and in partnership with the state. Our primary goal was to reestablish STD safety net services in Detroit, anticipating the need for a specialty STD clinic. Secondary strategic goals which were addressed during the meeting were to expand syphilis/HIV outreach testing, strengthening emergency department STD screening programs, increase STD testing (especially for chlamydia) within existing primary care clinics, increase the availability of STD provider trainings, support social marketing campaigns, establish community engagement strategies to alert the public about the STD problem and direct individuals to the new service locations, and model the cost-effectiveness of different STD service provision models to inform the best mix of services and allocation of resources. STD CLINIC REOPENS AND OTHER PROJECTS After the consultation meeting, the leadership group headed by MDHHS and Detroit Department of Health and Wellness Promotion secured funding through MDHHS to reestablish a dedicated STD clinic in the city. This walk-in clinic was designed to serve as the STD safety net provider, STD referral center, and training center for the city of Detroit. Six months after the April consultation, the walk in clinic opened at Wayne State University School of Medicine. At present, the clinic has seven full-time staff, a part-time medical director, one imbedded Disease Intervention Specialist, and several part-time nurse practitioners and infectious disease attending physicians. It serves on average 15 STD patients per day, with plans to expand capacity and hire a permanent medical director in the next few months. The clinic has also joined the Sexually Transmitted Infection Clinical Trials Group, with plans to participate in research in the near future. In addition to this success, a project to increase chlamydia screening has been adopted by several FQHCs throughout Detroit, with the goal of reducing chlamydia burden among young women. In 2015, Henry Ford Hospital began the first ever domestic evaluation of a rapid point of care syphilis test in an emergency department. Additional efforts including a new social marketing campaign, increased community engagement, provider training and outreach testing, and cost-effectiveness modeling are currently underway. Importantly, the public health and primary care communities in Detroit and the State of Michigan are now engaged and working together with each other and with national and state partners to maintain a system of care to improve STD prevention and control and reduce disease burden in the City. CONCLUSIONS In the future, STD clinical services in Detroit will be structured as a hub-and-spokes, with the dedicated STD clinic at Wayne State serving as the hub surrounded by a network of providers (spokes) at primary care sites such as FQHCs, local EDs, and private providers. These spokes will be able to refer patients, request technical assistance, and collaborate with the hub. Partnering between DHWP, an integral partner in this model, and academia to locate the new STD clinic at Wayne State University Medical School has several distinct advantages. First, MDHHS is able to provide funding for the clinic with state dollars while saving the cost of operating a separate clinical site. Wayne State is able to staff the clinic with academic infectious disease specialists with expertise in STD clinical management. There are important opportunities for enhancing STD expertise among residents and medical students as they rotate through the clinic during their training. The academic affiliation allows for participation in STD research and clinical trials furthering the field of STD prevention. It is too early to tell what impact this collaboration will have on STD rates in the city of Detroit. Because of increased public awareness and access, we expect that more patients will seek care compared with previous years. With enhanced awareness and clinical capacity among providers, screening for STDs will likely increase compared with previous years. Thus, we expect that STD case reports will increase compared with previous years before they begin to decline. Despite the challenges of measuring impact based on reported case numbers, we believe that this model of community engagement and partnership will prove successful in addressing the challenge of maintaining and supporting STD clinical infrastructure, and ultimately decreasing STD transmission, in high-burden urban municipalities such as Detroit.