This issue of Public Health Reports highlights approaches employed by state and local health programs to integrate viral hepatitis prevention services in correctional facilities, sexually transmitted disease (STD) and human immunodeficiency virus (HIV) prevention and treatment programs, and other settings serving high-risk clients. The reports presented in this issue demonstrate the feasibility of integrating viral hepatitis prevention services into a variety of settings; the ready acceptance of new interventions, such as hepatitis B vaccination and hepatitis C counseling and testing, by both providers and clients; and the positive impact the introduction of viral hepatitis prevention services can have on client willingness to consent to other interventions, such as HIV testing. These reports also illustrate the initiative of state and local health officials to craft integrated programs tailored to meet local needs.1–3 Although not representing formal evaluations, the data from these demonstration projects add to a body of evidence indicating that, given adequate guidance and resources, state and local health agencies can integrate services to enhance the prevention of HIV, STDs, and viral hepatitis.
EARLY CDC EFFORTS TO INTEGRATE HIV/AIDS, STD, AND VIRAL HEPATITIS PREVENTION
The projects reported here, some of which were funded by the Centers for Disease Control and Prevention (CDC),3–5 reflect the agency's increasing support for integrated delivery of HIV, STD, and viral hepatitis prevention services. CDC support for program integration began in earnest with the recognition of STDs as co-factors for HIV transmission6 and the subsequent formation in 1995 of a National Center for HIV, STD, and TB Prevention. That organizational change promoted collaboration across the realigned programs at CDC, resulting in the release of STD treatment guidelines with a new emphasis on HIV infection and hepatitis B vaccination,7 the creation of STD/HIV prevention training centers (http://depts.washington.edu/nnptc/) augmented by a national prevention information network (http://www.cdcnpin.org), and support of special projects to match surveillance registries8 and promote hepatitis B vaccination and hepatitis virus (HCV) counseling and testing.9,10
HOW CDC CAN REMOVE BARRIERS IDENTIFIED BY STATE AND LOCAL PROGRAMS
State and local health departments seeking to improve preventive care for their clients welcomed the federal support 11 and encouraged CDC to “demonstrate concerted and focused leadership in the development of integrated service delivery”12 and “remove the lack of integration as one of the barriers to more effective programs.”13 Specific barriers identified by health departments include categorical funding that limits local flexibility, the lack of guidance for program integration based on best practices, inadequate training for staff, and difficulties in merging surveillance and evaluation data.12,13
Change the agency's organization and priorities
Recent changes at CDC bring new opportunities to reduce barriers to the integration of CDC-supported programs. To promote collaboration within the agency and with external partners, CDC adopted new overarching health protection goals and revised the agency's organization to create Coordinating Centers and Offices, including the Coordinating Center for Infectious Diseases (CCID), bringing together related prevention programs. Within CCID, the Division of Viral Hepatitis was incorporated into the proposed National Center for HIV, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), with the explicit intent to promote integration among divisions with complementary expertise, mutual support of state and local prevention programs, and shared target populations.
Promotion of a comprehensive approach to prevention of HIV, STD, and viral hepatitis is a key focus of NCHHSTP, and the center has adopted short-term goals for ongoing integration projects while building a plan to guide future integration of compatible programs. As a first priority, NCHHSTP is supporting the implementation of new adult hepatitis B vaccination guidelines in STD and HIV evaluation and care settings. As a foundation for future planning, the center is developing strategies to strengthen partnerships with governmental and community organizations and build collaborations across the center's HIV, STD, and viral hepatitis prevention and surveillance programs.
Promote the development of integrated prevention programs
NCHHSTP is also identifying programs that have made substantial progress in integrating services (including the program reports in this issue) and targeting promising strategies for further evaluation and development. For example, ideally, comprehensive STD prevention includes provision of hepatitis A and B vaccination, STD screening and treatment, and HIV and selective HCV counseling, testing, and referral. Similarly, integrated services for injection drug users (IDUs) ideally include provision of hepatitis A and hepatitis B vaccination as well as counseling, testing, and referral services for HIV, HCV and, in some settings, hepatitis B virus (HBV) infection. Identifying the best practices for program integration will help public health program managers prioritize which services are feasible and most appropriate for their settings. This is especially important during a period of level or declining resources.
Increase sources of funding
The categorical nature of federal funding for HIV, STD, and viral hepatitis prevention limits the shifting of funds across program lines. Level or decreased funding of the categorical programs in recent years, as well as increased demands to support new vaccinations for children, have further limited funding for hepatitis A and hepatitis B vaccination of at-risk adults and other integration priorities. Thus, a commitment to service integration will require NCHHSTP to assess ways to better support integrated services within current budget authority, demonstrate the value of integrated services, and seek new funding for integrated programs. The center will also help state and local agencies adapt their current infrastructure to provide new services (e.g., hepatitis A and B vaccination in STD clinics). For additional support, the center must leverage resources from other sources within the agency and from external sources, such as other federal agencies and public/private partnerships.
CDC's grants and cooperative agreements are the main mechanisms for funding HIV, STD, and viral hepatitis prevention activities. Therefore, future support for program integration will require modifications to the nature and form of these funding agreements to reflect new priorities. Potential modifications include: (1) ensuring that funding agreements contain standard elements for integration and indicators to monitor program outcomes, with a clear intent to prioritize funding for programs that implement or follow these practices; (2) cross-training CDC project officers and program consultants to monitor program performance; (3) encouraging project officers to conduct joint site visits; and (4) sharing models of promising practices within CDC and with partners.
Provide training for public health providers to deliver new services
Successful integration of prevention services will require specialized training to build capacity at federal, state, and local levels. At a minimum, integrated training provided at STD/HIV training centers and other venues should inform participants of the benefits (individual, social, and economic) of program collaboration and service integration, build skills to deliver new services such as viral hepatitis immunization and screening, and provide best practices regarding the management of integrated prevention programs guided by standards of integrated care.
Collect strategic information to direct and evaluate programs
The integration of HIV, STD, and viral hepatitis prevention is a dynamic process requiring interactive information networks that supply reliable and timely information regarding surveillance, evaluation, and research data. As data needs evolve with changing disease patterns and the introduction of new interventions, the center is exploring opportunities to integrate surveillance activities for HIV/AIDS, STDs, and viral hepatitis. These opportunities might take the form of joint planning to coordinate data collection and dissemination and to ensure that surveillance systems “speak to each other” by adopting compatible technology and data items. To gather evidence needed to monitor performance, NCHHSTP will bring together federal, state, and local partners to draft a common framework for program evaluation based on a shared vision and selected performance measures. Two CDC-supported systems, the Program Evaluation Monitoring System (PEMS), designed to monitor performance of HIV prevention programs, and STD Data Management Information System, which supports case management and is available to STD clinics, provide templates to build an integrated system for evaluation of HIV, STD, and viral hepatitis prevention programs. From a national perspective, it will be worthwhile to collect evaluation data in a manner applicable to CDC health protection goals and Healthy People 2010/20.14
Public health research is needed to strengthen the evidence base regarding the best practices for integrated service delivery. Key research questions remain: What are the best practices for program integration to benefit individual clients as well as communities (venues, types of services, cost-effectiveness)? What are the opportunities for better integration within the context of existing service provision? How can new technologies (e.g., rapid testing) promote program integration? Strengthening research partnerships and enhancing program integration research capacity within the agency remain important CDC goals.
CONCLUSION
As we look to the future, program collaboration and service integration are essential steps toward providing comprehensive care for clients at risk for multiple sexual and blood-borne infections. Although program collaboration and service integration will not meet all the needs of component prevention programs, this effort offers a compelling and powerful approach to prevention, especially in reaching populations at highest risk for disease transmission and acquisition. Together with federal, state, and local partners, NCHHSTP is committed to completing the task of integrating related HIV, STD, and viral hepatitis prevention activities and achieving a comprehensive approach to health protection and disease prevention.
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