Program Collaboration and Service Integration in the Prevention and Control of HIV Infection, Viral Hepatitis, STDs, and Tuberculosis in the U.S.: Lessons Learned from the Field

This supplemental issue of Public Health Reports (PHR) presents a selection of innovative approaches, studies, and lessons learned from efforts to implement program collaboration and service integration (PCSI) in the prevention and control of human immunodeficiency virus (HIV) infection, viral hepatitis, sexually transmitted diseases (STDs), and tuberculosis (TB) in the United States. Promotion of a comprehensive approach for these diseases is an important cross-cutting goal for the Centers for Disease Control and Prevention's (CDC's) National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP).¹

NCHHSTP's PCSI efforts are intended to strengthen collaborative work across disease areas and to integrate services that are provided by related programs at the client level. The catalyst for this systems change stems from the enhanced understanding of how these diseases synergistically relate with one another.² With the rise of infectious disease syndemics (e.g., HIV and TB³) and the resultant increase in burden of disease,⁴ guidance has been produced to help state and local health departments better integrate service delivery.^2,5–7 PCSI aims to organize and blend interrelated prevention strategies in an effort to provide more comprehensive delivery of services.²

Current disease-specific services provided to people with multiple related risks may represent significant missed opportunities to diagnose, treat, and prevent other diseases. Integration of prevention services can extend the reach of population-based services; it may also support improvement in the efficiency of service delivery, increase programmatic cost-effectiveness, and improve health outcomes.² For example, in publicly funded STD clinics in Illinois, service integration resulted in increased hepatitis A and B vaccinations and hepatitis C counseling from essentially no activity in 1999 to substantial levels of service in 2005.⁸ Despite myriad examples of service integration in publications and the peer-reviewed literature,^2,9–11 however, there are still many challenges for successful integration.

The articles in this supplement describe approaches to service integration, provision of integrated services to groups at high risk for acquisition of these diseases, and implementation of PCSI through the harmonization of multiple surveillance data and disease registry matching. Data harmonization is the process of comparing two or more data component definitions and identifying commonalities among them that warrant their being combined, or harmonized, into a single data component.¹² Many of the articles detail innovative approaches to collaborative program design and integration of testing and screening services at the client level. These issues are especially timely given the implementation of the Affordable Care Act, which can result in an expansion of health-care coverage for previously uninsured Americans, and may likely lead to an increased volume of health data. Increased provision of care, coupled with the growing use of electronic medical records, means that it is more important than ever that prevention programs within health departments share data, match client information across databases, and harmonize data collection and reporting protocols.^6,13 This supplement demonstrates the benefits gained through data harmonization—particularly through registry and database matching—at the local, state, and federal level.

SERVICE INTEGRATION

Advances in testing and screening for HIV, viral hepatitis, STDs, and TB now allow clients to receive laboratory results with less delay and, potentially, more infectious disease testing to be conducted with the client at the point of care. A variety of approaches to integrated testing are described in this supplement (e.g., testing in correctional facilities and emergency departments [EDs]). Using new diagnostic technology allows for a single blood draw for multiple diagnostic tests, and integrated screening and reproductive health care in the context of syringe access programs, all of which permit greater convenience for clients. These articles provide further evidence that, at the state and local level, integrated testing and screening for infectious diseases can be done, but testing for at-risk populations may remain low.

There are many opportunities for service integration in correctional and ED settings. Cocoros et al. discuss the Massachusetts-based Screening for Hepatitis C as Prevention Enhancement (SHAPE) program for HIV, which provides integrated hepatitis C and HIV testing to inmates in a correctional facility.¹⁴ The SHAPE program reveals high rates of HCV infection and demonstrates that integrating HCV education and testing into correctional facilities is feasible. Because the HCV testing was an add-on to a functional HIV program, the costs of this initiative were low. Most importantly, this program prepares inmates for release and makes referrals for outside care and treatment as part of the inmates' transition planning. The program continues following inmates' release.

Klein et al. evaluated provider adherence to guidelines for concurrent HIV-STD testing in an ED setting.¹⁵ They found that despite the presence of CDC recommendations for routine HIV screening and a targeted HIV testing program, concurrent HIV-STD testing in the ED remains inadequately low. To improve HIV testing of people with an STD, they will remove provider barriers to concurrent HIV-STD testing by focusing on systematic changes that lessen the decision-making burden on ED providers. Automatic HIV testing of all patients in the ED who are tested for syphilis, gonorrhea, or chlamydia will be introduced to increase concurrent HIV-STD testing in this high-risk population.

HIV testing of TB contacts is inexpensive and feasible but infrequently done.¹⁶ In North Carolina, Stout et al. describe their experience for integrated testing for TB and HIV in the setting of TB contact investigations. In their study, a new diagnostic tool—the interferon gamma release assay—was combined with opt-out HIV testing to facilitate simultaneous, integrated, blood-based testing for both infections.¹⁷ HIV testing in the setting of TB contact investigations provides a unique opportunity to test people who may not otherwise be tested. At times, there are unexpected benefits to integrated testing. In North Carolina, there were no previously undiagnosed people with HIV found when testing TB contacts for HIV. However, people who were previously diagnosed with HIV but fell out of HIV care were reengaged in care and also discretely identified and prioritized for latent TB treatment.

Burr et al. describe the Access to Reproductive Care and HIV Services (ARCH) program, which targets male and female intravenous drug users (IDUs) through stationary and mobile STD testing clinics in New Jersey.¹⁸ They reach populations at high risk for a variety of syndemic, infectious diseases who would otherwise avoid testing and care. The findings from the ARCH program add to the evidence that clients are receptive to integrated services that are beneficial to their health and well-being. ARCH is an example of how to extend the reach of state health department programs to a vulnerable population who would otherwise be unlikely to seek out services at multiple venues. It demonstrates that service integration for IDUs is feasible and acceptable in these settings.

CDC funds state and local health departments to implement HIV prevention and HIV testing programs in the U.S. Fitz Harris et al. examined data from annual reports from funded grantees in 50 states, the District of Columbia, and six directly funded cities.¹⁹ They describe key PCSI activities conducted by health departments, which include integrated testing, integrated education/outreach, and training. HIV programs report that they primarily collaborate with STD programs, although the level of collaboration and integration merits further assessment.

TARGETING HIGH-RISK GROUPS

Several programs described in this supplement identify barriers to service integration for high-risk groups and demonstrate successful means to deliver integrated, high-impact prevention and care activities. Hunter et al. describe how an innovative outreach approach using social media can reach vulnerable at-risk groups and help to identify sexual partners for contact tracing and delivery of testing services.²⁰ Through targeting those at highest risk for acquiring STDs in the Milwaukee, Wisconsin, area—young black men who have sex with men (MSM)—the health department was able to investigate a syphilis outbreak and catalyze a community conversation around barriers affecting STD testing uptake in black MSM—namely, stigma and homophobia. Bernstein et al. show how the local epidemiologically relevant high-risk group of white MSM in San Francisco, California, was targeted by partner services for both HIV and syphilis to combat the high coinfection rates for HIV and STDs.²¹ This program is an example of how locally relevant outcome measures could be used to identify new HIV cases and that more HIV- and STD-positive clients could be tested and counseled.

Similarly, the program in Baltimore, Maryland, and Denver, Colorado, described by Hutton et al. identified a high-risk group of women who were at risk for both alcohol-exposed pregnancy (AEP) and STD infection due to excessive alcohol consumption and low contraceptive usage.²² Through the use of multimedia (e.g., text messages, appointment reminders, and testing sites), more women could be retained in this study without the need for monetary incentives. Once contacted, these women were met with services where they lived, both with co-location of local substance abuse and STD testing services, as well as with mobile testing offering pregnancy and STD testing to women without regular housing. Due to this innovative use of technology to target these high-risk women, as well as the delivery of testing and counseling services in local communities, the study was able to produce marked decreases in women with AEP as well as decrease alcohol consumption per woman. This program, which uses a targeted, integrated approach to help keep women healthy to ensure they give birth to healthy babies, is a model for collaboration with a public health service agency outside of the traditional partners in infectious disease.

DATA HARMONIZATION AND REGISTRY MATCHING

Comorbidity of disease occurrence among high-risk groups may also be identified through unique uses of disease surveillance data. Harmonizing data across disease conditions allows one to examine synergistic epidemics in the same geographical context. Elmore et al. describe the process used to harmonize HIV, viral hepatitis, STD, and TB surveillance data to develop an online, interactive tool—the NCHHSTP Atlas—which allows users to dynamically query these data and generate comparable maps, charts, and tables at the state level via the same user interface.²³ The overarching goal of the Atlas is to strengthen the capacity to monitor the diseases and to illustrate variation in disease patterns. The first step in accomplishing this goal was to produce a “harmonized” dataset whereby similar data elements were translated into a common format for analysis. The authors state that two key variables—race/ethnicity and age—lacked standardization across disease areas and suggest that continued efforts in harmonization are needed.

Surveillance registry matching is also an important activity when examining the rates of coinfection in a given jurisdiction. Two examples of surveillance registry matching are provided in this supplement. Chu and colleagues describe the process of matching four registries across eight infectious diseases in San Francisco, which allowed the authors to compare these data with previously established screening recommendations and determine whether new recommendations were needed based on local epidemiology.²⁴ In so doing, the authors were able to develop or revise four recommendations. Xia et al. highlighted the importance of increasing the positive predictive value (PPV) of a probabilistic matching algorithm for HIV/acquired immunodeficiency syndrome (AIDS) and STD surveillance registry data in New York City.²⁵ The authors found that PPV varied greatly in subpopulations with different case rates and coinfection rates and, more specifically, that PPV decreases as the case rate increases and the coinfection rate decreases. By applying different cutoff rates in the probabilistic matching algorithm, the authors were able to decrease the number of matches that had to be manually examined.

Implementing the PCSI approach can also help to highlight the epidemiologic dynamics of syndemics, which may not have been detected without such an integrated, collaborative approach. In this issue, the efforts of the Arizona Department of Public Health, as presented by Skinner et al., helped to reveal that “sero-sorting” (i.e., the process of choosing sexual partners of the same HIV status) among MSM helped to explain why coinfection rates for syphilis and gonorrhea were increasing, while rates for HIV infection were not increasing.²⁶ Sanchez et al. used data harmonization efforts and communication between STD and HIV programs in San Francisco to help reveal sexual transmission of hepatitis C among MSM.²⁷

MOVING FORWARD

The articles included in this supplement demonstrate the need to continually rethink prevention in the face of changing epidemics and syndemics. Budget challenges and new technologies present integration opportunities for state and local health departments. Programs that practice PCSI are embracing a sustainable approach, which may reduce barriers to clients accessing care and better enable health department staff to serve their clients with improved data collection and analysis, stronger partnerships, and more complete training. PCSI approaches also address the Institute of Medicine's recent recommendations that integration of public health efforts involve “the sharing and use of data and the development of a workforce capable of functioning in an integrated environment.”²⁸ This bridge-building between programs and levels of service delivery “reduces fragmentation and fosters continuity”²⁸ and also encourages accountability, thereby creating a more nimble health department—one that may better meet the health needs of the communities it serves.