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How can we advance the integration of prevention services in public health programs for adults at risk for human immunodeficiency virus (HIV), sexually transmitted diseases (STDs), and viral hepatitis? From the perspective of the state acquired immunodeficiency syndrome (AIDS) directors from the Florida and Hawaii Departments of Health (DOH), we describe principles of integration, identify potential benefits of and key barriers to integration, and recommend changes to advance integration.
Integration is based on the understanding that a risk behavior, such as injecting drugs or having unprotected sex, can put an individual at risk for multiple infections, and that the prevention and treatment of these multiple infections can be addressed in a single intervention or service visit.1 Ideally, integrated services should give clients, regardless of the initial reason for seeking care, seamless access to comprehensive services for HIV, STDs, and viral hepatitis that are tailored to each client's specific risk(s) and prevention needs.2 Reaching at-risk clients will help prevent infection and illness among the clients' at-risk sex and needle-sharing partners.
Integration should maximize clients' access to services and reduce missed opportunities to serve clients' varied needs. To achieve integrated service delivery for clients, service providers must focus on the client and his/her risk behaviors and not on separate, disease-based program funding and reporting requirements.3 We believe that clients should be offered integrated services no matter how HIV, STD, and hepatitis programs and agencies are structured. In state health programs, integrated HIV, STD, and viral hepatitis prevention services usually include (1) hepatitis A and B vaccination and (2) HIV, STD, and hepatitis B and C counseling and testing, partner services, and referral to additional prevention and health-care services.4
In many states and large cities, public health services are increasingly provided to hard-to-reach, at-risk adults in nontraditional settings (e.g., community outreach, syringe exchange). Important lessons have been learned in providing HIV testing in nonclinical settings and using nonphysician health-care providers to reach people at high risk.5 With appropriate protocols, training, support, and supervision, HIV, STD, and hepatitis B and C testing, as well as hepatitis vaccinations, are increasingly being provided in outreach settings.6,7
In Hawaii, guided by DOH standing orders, DOH HIV counselors conduct HIV counseling and testing, draw blood for syphilis and hepatitis C testing, and provide hepatitis A and B vaccinations. Staff must be fully trained in approved medical practices, particularly for adverse reactions.
Organizationally, states and large cities may have to develop new job descriptions for their public health/clinical staff that include the additional responsibilities and skills needed to provide integrated services. Given that most HIV and STD prevention staff have embraced adding viral hepatitis services because of the benefits for clients, this expansion of responsibilities is likely to be accepted by staff. Even so, the expanded roles and integration will demand more of staff and will result in some new stresses; for example, the substantial increase in post-test counseling for positive tests because of the high prevalence of hepatitis C virus5 and the additional time needed for hepatitis A and B vaccinations.8,9
Because federal and state HIV, STD, and viral hepatitis funding is flat or declining in most states, there is a pressing need to maximize new, ideally cost-saving efficiencies through service integration. Such efficiencies can be achieved by integrating program data systems, improving collaborations with immunization programs, and removing restrictions on using federal funding to support service integration.10
In most states, client data are obtained separately by each disease program. Sometimes staff from different programs collect similar data from each client. The Centers for Disease Control and Prevention (CDC) requirements for risk assessments and data reporting for HIV and STD are not compatible, and many of the service components are disparate, making integrated assessments and data collection almost impossible. CDC's HIV, STD, and Viral Hepatitis Divisions and National Immunization Program already have developed or are developing new data collection and reporting systems. However, these systems that have been developed in isolation are incompatible with each other, inhibiting provision of integrated services. For example, although Hawaii and Florida are working on an integrated risk assessment form, the CDC Program Evaluation and Monitoring System11 HIV counseling and testing form does not allow capture of data necessary for STD and hepatitis services. The collection of client demographic and risk assessment data for HIV, STD, and viral hepatitis can and should be integrated.3
Immunization programs traditionally focus on vaccinating children aged 18 or younger seen mainly in traditional health-care settings, such as physician offices or public health clinics. Immunization programs work primarily with health-care providers and not directly with clients, whereas HIV, STD, and viral hepatitis program staff often work directly with clients. Also, clients served by HIV, STD, and adult viral hepatitis programs are generally defined by risk behaviors (e.g., men who have sex with men [MSM], injection drug users).12 Because of the stigma associated with these behaviors, these clients can be difficult to identify and serve.13 These factors and increasingly tight immunization budgets limit the priority given to vaccinating at-risk adults. As a result, many programs cannot comply with CDC recommendations to provide hepatitis A and B vaccination to adults at risk.9 CDC needs to identify funding to support implementation of its own immunization guidelines for adults at risk and, in the near term, strongly encourage states to support these services with available funding. Increased collaboration with immunization programs is needed at the federal and state levels to increase hepatitis A and B vaccinations of at-risk adults seen in public health programs.14–16
Although many states contribute general revenue funds for services for at-risk adults, such funding is often insufficient and can be subject to rapidly changing priorities.9,16–18 Four CDC programs—HIV, STD, Viral Hepatitis, and Immunization—provide most of the funding for corresponding services at the state level. Each of these programs has a separate cooperative agreement (“silo”) with state and some city health departments to support its program activities.19–21 These separate cooperative agreements include multiple restrictions that make integrating program activities difficult. For example, HIV program guidance specifically prohibits purchasing vaccines19 and STD program guidance prohibits funding any HIV services.20 Only limited HIV funding can be used for STD prevention as an HIV intervention.19 Even so, CDC is to be commended for allowing states to use HIV funding for hepatitis C testing.17,19 Overall, increased flexibility in using program funds would allow states to support programs in ways that best serve clients at risk for multiple infections.3 Most states would support increased flexibility in the use of program funding that respects restrictions that come directly from Congress. New cooperative agreement guidance should encourage and reward programs that integrate HIV, STD, and viral hepatitis services.
Integration of viral hepatitis with HIV and STD helps build new strategic partnerships at the national, state, and local levels.2,10,22 The collaboration of individuals and groups concerned with hepatitis has broadened the constituencies advocating for HIV and STD prevention.23 In Hawaii, for example, Asian and Pacific Islander hepatitis B activists, veterans' groups, homeless advocates, the American Liver Foundation, and many others have joined HIV and STD stakeholders in support of strengthened, integrated services. Across the country, HIV community planning groups have become more aware of and involved with hepatitis issues.23 Some states, such as Hawaii, have approved the use of HIV prevention funds for hepatitis C testing. Florida has a statewide Viral Hepatitis Council that is modeled after HIV prevention community planning.24 Community groups and legislators now appear to be more willing to discuss multiple blood-borne diseases rather than HIV alone because a broader cross section of society appears to be affected. Adding viral hepatitis prevention may help reduce the stigma involved with interventions for HIV. In many states, the Hepatitis C Coordinators25 have played an important role in bringing new partners together to better understand the common issues and populations affected by hepatitis, HIV, and STD.
Staff training, particularly as roles are expanded, is vital in supporting program development and delivery of integrated services.3,8,17 Several Viral Hepatitis Education and Training projects funded by CDC have piloted integrated training curricula.26 Cross training is essential to develop the expanded staff roles that will make program integration work.23,27 In Hawaii and Florida, HIV and STD counseling and testing trainings now include viral hepatitis. In Hawaii, providing viral hepatitis and STD training to experienced HIV staff seemed to reduce HIV fatigue. Whenever possible, CDC and its funded technical assistance providers should focus on cross training for HIV, STDs, and viral hepatitis. For example, the CDC course “Fundamentals of HIV Prevention Counseling” should be updated to include STDs and viral hepatitis. In addition, although CDC-funded STD/HIV Prevention Training Centers (PTCs)28 have added a viral hepatitis module, they should also explicitly promote integration of HIV, STD, and viral hepatitis prevention services into all relevant trainings. PTCs are respected institutions that should not only teach integration but also model it in all interactions with state and local health staff.
Continued and expanded collaborations among federal partners (e.g., CDC, Substance Abuse and Mental Health Services Administration,29,30 Health Resources and Services Administration)4 and nongovernmental professional organizations (e.g., the National Alliance of State and Territorial AIDS Directors, the National Coalition of STD Directors, medical associations) are needed to reinforce integrated programs for health providers serving at-risk clients. Currently, major national conferences are held separately for HIV, STD, and viral hepatitis. Although these conferences often include sessions discussing integrated services, they are a missed opportunity to model and encourage integration. Joint integrated meetings should be developed to support integration.
The roles and responsibilities of the CDC-funded Hepatitis C Coordinators working in almost every state need to be clarified and strengthened in terms of hepatitis vaccinations for at-risk adults.25 In many states, Hepatitis C Coordinators work in a broad area of viral hepatitis, including education and training, prevention, hepatitis C testing, and hepatitis A and B vaccination for at-risk adults.31 Some coordinators have encountered resistance to working on hepatitis vaccination either from supervisors who want them to focus exclusively on hepatitis C programs or from their state immunization programs.
Public health programs look to CDC to provide leadership and clear support for integrated services.3 The recent CDC internal reorganization creating a new National Center for HIV, Hepatitis, STD, and TB Prevention (NCHHSTP) is a welcome step that should improve collaboration among these programs.32
We recommend that CDC create a Deputy Director position, reporting directly to the NCHHSTP Director, which would lead integration within NCHHSTP. With the strong support of the NCHHSTP Director, this position would help NCHHSTP divisions identify opportunities to collaborate, develop specific integration objectives, and plan how the objectives will be achieved (e.g., through funding, data and information systems, cross training, and best practices). CDC can direct the HIV, STD, and Viral Hepatitis divisions to designate some of their program support budget to specifically support integration efforts. CDC can increase support for integration by providing cross training to staff, establishing cross-division teams that develop program guidance and reporting requirements, and advocating for joint site visits by project officers from different divisions. CDC, working with state and local health departments, can explore systems that will monitor the success of program integration. Finally, stronger links at all levels are needed between immunization programs and the HIV, STD, and viral hepatitis programs. The 2006 initiative to increase adult hepatitis B vaccination should help strengthen those links.15,22–34
With limited resources and the substantial disease burden of HIV, STD, and viral hepatitis, a bold initiative is needed to establish an explicit objective of integrating services for at-risk adults at the national, state, local, and client service levels. To achieve this goal, we call on CDC to provide strong national leadership. One of the first steps, in collaboration with national- and state-level partners, will be to develop a plan of action. Best integration practices should be identified, modeled, and supported. We do not need new structures, but CDC, state, and local providers will have to let go of traditional disease siloed programs and practices. Integration does not have to look the same in every state, but the focus has to remain on providing clients with seamlessly integrated HIV, STD, and viral hepatitis services.