Coleman Terrell of the Philadelphia Department of Public Health presented on the PDPH's HIV Prevention Activities at the Philadelphia HIV Prevention Planning Group's December 2014 meeting.

1. HIV Prevention Update – PDPH
Activities
HPG
December 3, 2014

2. Health Department FOA PS 12-1201
Required (75%)
• HIV testing in healthcare
and non-healthcare
settings
• Prevention with positives
• Partner services
• Continuum of care
• EBIs
• Perinatal
• Condom distribution
• Policy strategies
Recommended (25%)
• EBIs for high risk
individuals
• Social marketing, media,
and mobilization
• PrEP and nPEP

3. Year 2 Rapid Feedback Report -
2013

4. Feedback report structure
• Parts A & B
• Annual testing objective
• Missing records
• HIV positivity
• Linkage to care and Partner Services
• Part A only
• Annual condom distribution objective
• Policy activity areas

5. PDPH Strategic Plan – Sexual Health

6. Objective: Reduce new HIV infections and
improve linkage to timely, high-quality HIV
care
Key Measures 2011 2013
New HIV diagnoses per
10,000 residents
4.5 4.4
HIV incidence in adults
and adolescents
872 761 (2012)
Linkage to HIV care
within 90 days
82% 78%
Retention in HIV care
within last year
44% 45%
Viral suppression 42% 45%

7. Estimated HIV Incidence Rates - 2012
Population Population in
2010 (13 +)
ESTIMATED
Incidence
Estimate,
2012
Estimated
Case Rate
per
100,000
95% CI
lower
bound
95% CI
upper
bound
MSM 29,737 357 1,200 652 1,749
IDU 37,378 58 139 0 318
HET 294,682* 346 117 51 185
*Includes persons >13 living in poverty
Data Source: PDPH/AACO HIV Incidence Surveillance Program

8. HIV in MSM in Philadelphia
HIV Incidence Estimates
• Estimated that 1.2% of MSM in
Philadelphia became infected
with HIV in 2012.
– 54.5% estimated increase in HIV
incidence in MSM between 2006
and 2012 (driven by new
infections in 13-24 AA MSM).
– 19.0% increase in the number of
MSM newly diagnosed with HIV
between 2006 and 2012.
– Suggests an increasing number of
MSM are unaware they are
infected.
HIV Prevalence (aware) among MSM,
12/31/2013
Pop size
>age 13
MSM
estimate
MSM
LWHA
% HIV
infected
Black 229,698 11,485 3,706 32.3%
White 244,551 12,228 2,094 17.1%
Latino 69,252 3,463 680 19.6%
Data Source: PDPH/AACO HIV Incidence Surveillance Program and
Philadelphia eHARS data

9. Philadelphia Engagementin Care,2011-2013
SurveillanceMethod
100%
42% 40%
100%
44% 44%
100%
45% 45%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
HIV-Diagnosed In Care Suppressed viral
load
2011
2012
2013

10. Strategies
1. Policy – promote routine HIV screening in healthcare settings
2. Health promotion – offer community-based HIV screening
and education
3. Health promotion – offer prison-based HIV screening and
education
4. Health promotion – support syringe access services
5. Clinical care – improve linkage to care
6. Clinical care – improve retention in care and quality of care
7. Clinical care – offer timely screening and linkage to care for
sexual partners
8. Clinical care – coordinate citywide provision of PrEP

11. Promote routine HIV screening in healthcare
settings
• In 2013 95,817 tests were funded in clinical settings
• Transition from a parallel system that employs HIV testers to
funding HIV coordinators – integration into medical care
• Move from point-of-care rapid tests to laboratory based testing
- early diagnosis
• Develop capacity for third party billing – sustainability
• Develop model programs and tools for implementation –
replication
• Implement performance measure for routine testing –
evaluation

12. Offer community-based HIV screening
• Use of new testing technology for earlier diagnosis –
phlebotomy training for community providers
• Revue of all venues for community-based testing based on part
performance at site, coordination with other providers, and
demographics/ethnography
• Capacity building for quality management/continuous quality
improvement
• Capacity building for MSM-focused and minority-focused CBOs

13. Testing in Non-Healthcare Settings
Tests All
Positive
Self
Report
New
% New Case
to
Surveillan
ce
%
All 11,546 202 181 1.57% 46 0.40%
MSM 3,519 117 108 3.07% 30 0.85%
HET 5,862 44 38 0.65% 8 0.14%
IDU 990 35 30 3.03% 5 0.51%
January – June 2014 HIV Testing Data

14. Offer prison-based HIV screening and
education
• Routine screening implemented in Philadelphia Prison System:
92.5% of persons admitted Jan – Jun 2014 screened for HIV
• Ongoing education
• Linkage programs
• Condom distribution at discharge

15. Support syringe access services
• Can only be supported with City of Philadelphia funds
• AACO increase allocation in 2014
• Expanded hours
• In 2014 distributes 98,000 syringes to more than 750 clients
each month

16. Improve linkage to care
• Quality improvement projects for all funded HIV testing
programs for improving linkage to care
• Implementation and ongoing support of ARTAS programs
• Focus groups held to develop linkage best practices and
template for clinics to use to develop clinic-specific linkage
protocols
• Very different linkage rates depending on the test setting –
overall 78% linkage in 90 days based on surveillance data
• The publically funded system does not perform as well –
difficulties in linking from ED, community settings, prisons etc

17. Linkage to Care
Setting New
Positive
Linked to Care in 90
days (Test Form)
%
All Testing 363 200 55%
Medical Care 42 28 67%
Inpatient Unit 5 5 100%
Emergency
Department
24 20 83%
STD Clinic 44 22 50%
Correctional Facility 67 37 55%
Non-Healthcare 181 88 49%
January – June 2014 HIV Testing Data

18. Improve retention in care and quality of care
• The biggest drop off in the continuum of care is retention
• Major focus of Ryan White programs
• Anonymous callers to assess barriers to linkage and re-
engagement
• Standard re-engagement protocols developed for use by RW
providers
• Protocols developed and beginning to be implemented for
surveillance assisted re-engagement
• Various demonstration health navigators programs
• AACO funded for CoRECT – a 5-year re-engagement study

19. HIV Treatment as Prevention
• Decreasing community viral load – decreasing
transmission
• QI focus on linkage to medical care for testing programs
• QI focus on retention in care and viral suppression (MSM
of color: 45.4% retained; 46.0% virally suppressed)
• New performance measures related to STD screening for
HIV+ MSM in AACO funded system

20. Ryan White Baseline Performance on Key
Continuum Measures
Performance Measure As of 6/30/14 As of 8/31/14
HAB Core01
HIV Viral Load
Suppression
77% 77%
HAB Core03
HIV Medical Visit
Frequency
(24 months)
70% 66%
HAB Core04
Gap in HIV Medical Visits
(6 months)
17% 17%

21. Offer timely screening and linkage to care for
sexual partners
• In April 2013, AACO and STD Control consolidated all Partner
Services under STD Control; additional resources added in 2014
• AACO and STD Control began matching all reported GC and syphilis
cases to eHARS
• Partner Services initiated for cases found to be coinfected
• Partner services provided to all new HIV morbidity
• QI process in place to improve referrals from HIV test sites

22. HIV Partner Services
2009 2010 2011 2012 2013 2014*
# HIV Cases Referred 78 134 254 509 626 945
# Interviewed 64 124 221 439 553 730
# Contacts Initiated &
Tested 20 76 74 170 177 235
# of Contacts with new
HIV diagnosis 6 13 5 21 24 29
* Data through 3rd Quarter, 2014
17 of the newly positive contacts were named by
newly diagnosed HIV cases!

23. Coordinate citywide provision of PrEP
• Increase numbers of referral sites by training and
supporting medical providers interested in providing PrEP
• Increase understanding of PrEP in Prevention workforce
and increase referrals to PrEP
• Increase community awareness of PrEP
• Develop evaluation plan for PrEP implementation
(uptake,breakthrough infections, resistance, increased
STDs)
• Provide support for PrEP adherence (future)

24. PrEP Referrals
• Aggregate data reports from AACO funded prevention
providers show between January and September 2014:
• 67 MSM were Referred to PrEP
• 29 MSM Initiated PrEP Therapy

25. Condom Distribution
• Included as a required
component of Ryan White
funded services for HIV+
• Adolescent STD/HIV
Prevention Project
(ASHPP)
• Increasing condom
availability citywide
through MSM-focused
service providers
NHBS – MSM:
% of Black MSM who
received free condoms
in past 12 months
increased from 44% to
70% between 2011 and
2014

26. Preventing perinatal HIV transmission
• In 2013 there were no cases of perinatal HIV transmission
• Perinatal case management
• Perinatal marketing project – promotes universal HIV screening
for all of their pregnant patients early in prenatal care as well
as repeat HIV testing during the third trimester and rapid HIV
testing during labor as clinically indicated
• FIMR/HIV
• Case Review Team – reviews transmissions and missed opportunities:
chart review and interviews
• Community Action Team – initiates systems changes based on findings
and recommendations of Casr Review team

27. Emerging issues
• Rapidly changing technology for HIV testing
• Decreased focus on and support of behavior – based EBIs
• Increased focus on continuum services
• Focus on MSM – LEAP project
• Coordination with ACA – billing
• Coordination with HIV care and treatment system

28. Questions?