Dr. Stacey Trooskin's presentation on the Do 1 Thing HIV & HCV testing initiative, as seen at the April 2013 RWPC meeting.

1. Stacey B. Trooskin, MD PhD
Assistant Professor
Drexel University College of Medicine
Using Community-Engaged Research toUsing Community-Engaged Research to
Address Racial and GeographicAddress Racial and Geographic
Disparities in HIV and HCV InfectionDisparities in HIV and HCV Infection

2. Racial Disparities in HIV InfectionRacial Disparities in HIV Infection
• African Americans represent 14% of the
population and 45% of HIV infections
• African Americans are more likely to present
later in the course of their infection and have
higher rates of AIDS-related mortality
• Traditional behavioral risk factors don’t explain
disparities
– More limited access to HIV testing, lower insurance
rates
– Structural and social factors
– Complex sexual networks

3. Geographic DisparitiesGeographic Disparities
• In many urban areas, a few
neighborhoods account for a
large share of HIV infections
• HIV infections cluster
• Some neighborhoods have
HIV infection rates similar to
sub-Saharan Africa
• Maps tell us where to focus
intensive prevention and
treatment efforts Source: AIDSVu

4. • Philadelphia has infection rates 5 times the national average
• Heterosexual epidemic
• Zipcode 19143 (in Southwest Philadelphia) is the second most
populous zipcode in the city (60,000 people)
– 86% African American, 30% people < poverty line
• Zipcode 19143 has the 2nd
highest number of people living
with HIV/AIDS (1,014 individuals in 2010)
– Approximately 1.8% seropositivity
• Rates of Hepatitis C (HCV) in 19143 unknown, but likely high
• 19143 has few medical and health resources
HIV & HCV in SouthwestHIV & HCV in Southwest
PhiladelphiaPhiladelphia

5. Rates of Persons Living with HIV/AIDS by Zip
Code and Census Tract, 2009
Source: AIDSVu

6. Do One Thing OverviewDo One Thing Overview
• Southwest Philadelphia, PA is a medically underserved area with high
rates of HIV and HCV infection & few HIV and HCV testing & treatment
services
• Do One Thing is a testing, linkage to care and treatment campaign that
stimulates demand for and provides HIV and HCV testing and treatment
across an entire zipcode
• Do One Thing includes:
• A large-scale social marketing and media campaign
• Community outreach and mobilization
• Partnerships with business, community organizations, and faith institutions
• A partnership with a federally qualified health center in Southwest
Philadelphia to routinely offer HIV testing to all patients over age 13
• Rapid HIV and HCV testing in a mobile unit, door-to-door testing in 4 census
tracts
• Community service and volunteerism
• Monitoring and evaluation

7. Location, location, location!Location, location, location!
Do One Thing in Southwest PhiladelphiaDo One Thing in Southwest Philadelphia

8. Social Marketing CampaignSocial Marketing Campaign

9. Social Marketing CampaignSocial Marketing Campaign
• Website: 1nething.com
• Texting service
• Yard signs, door knockers, door to door
outreach
• Palm cards
• Street outreach
• Twitter feed with map of mobile
unit of of mobile unit
locations

10. Community Mobilization:Community Mobilization:
BusinessesBusinesses

11. Community Mobilization:Community Mobilization:
BusinessesBusinesses
Community Pharmacy Corner Market Cafe

12. Routine HIV Testing at theRoutine HIV Testing at the
Health Annex, a FQHCHealth Annex, a FQHC

13. Victories and Challenges withVictories and Challenges with
Routine Testing in Clinical SettingRoutine Testing in Clinical Setting
Clinical Challenges and Lessons learned
• Policy Change: Leadership is most important factor
• Integrated Model: Know your patient flow and model
– NP clinical model with MAs testing model
• EMR Enhancement
• Staff and Provider Training
• Financial incentives

14. Victories and Challenges withVictories and Challenges with
Routine Testing in Clinical SettingRoutine Testing in Clinical Setting
Clinical Challenges and Lessons learned
• Offer rate has plateaued at 70%
– Next step: incentivize acceptance rate
improvements
• High decline rate: most commonly cited reasons
are “recently tested” and “wasn’t expecting an
HIV test”
• Behavioral risk profiles: most new positives have
“no identified risk;” most are young, African
American women
• Lower seropositivity than expected: 0.4%
• 95% linkage and retention in care rate; has been
sustained over time

15. Community Service: Our VolunteersCommunity Service: Our Volunteers

16. Do One Thing Door To DoorDo One Thing Door To Door
HIV/HCV Testing CampaignHIV/HCV Testing Campaign

17. Non-Clinical Testing on MobileNon-Clinical Testing on Mobile
Medical UnitMedical Unit

18. Demographic Percentage
Gender Female 45%
Male 54.4%
Transgender .6%
Race African American 90%
African 3%
Other 7%
Education Less than high school 20%
High School 50%
Some college/AA 21%
4 year college 8%
Household Income <$10,000/yr 43%
$10,000-15,000/yr 15%
$15,000-20,000/yr 12%
>$20,000/yr 30%
Employment Unemployed 37%
Part-time 15%
Disabled 11%
Full-time 31%
Other 6%
Demographi
c
Percentage
Health Insurance
Status
None 37%
Medicaid 36%
Private 18%
Other (Medicare,
Veterans, etc)
9%
Sexual Orientation
(self-report)
Heterosexual 89%
Gay/Lesbian 6%
Bisexual 5%

19. Risk Behavior Percentage
Multiple sexual partners 22%
Believe partner has multiple sexual
partners
24%
Ever injected drugs 6.7%
Ever used crack or cocaine Cocaine 15%
Crack 14%
Tattoos 49%
If tattooed, received tattoo at
tattoo
party
24%
Ever tested for HIV? 85%
Ever tested for HCV? 36%
Reported venue for testing for HCV Doctor’s Office 56%
Reported reason for testing for HCV Participant asked for the test 41%
Doctor Recommended 33%
Other 26%

20. Clinical and Non-ClinicalClinical and Non-Clinical
HIV Testing TrendsHIV Testing Trends
• Clinical Settings
– Tested 2,100 people for HIV in clinical settings
– Health Annex (FQHC) seropositivity: 0.4%
– Greatest challenge: 55% decline rate
• Non Clinical Settings
– Tested 900 people for HIV in non-clinical settings
• 1.3% HIV seropositivity
– Tested 350 people for HCV in non-clinical settings since December
2012
• 4.8% HCV seropositivity

21. Linkage to Care Protocol
OraQuick® rapid HCV
antibody test reactive
OraQuick® rapid HCV
antibody test reactive
Confirmatory test is
positive
Confirmatory test is
negative x 2
D1T staff notifies
patient and provides
counseling
D1T staff notifies
patient : counseling +
insurance status
Insured with a
primary care provider
Referral
Insured with no known
primary care provider
PCP visit followed by
referral
Uninsured with no
primary care provider
Social worker works w/
clients to gain
insurance + then refers
OraQuick® rapid HIV
antibody test reactive
D1T staff immediately
links patient to HIV
care within 24-48 hrs
If
uninsur-
able,
refer to
health
center
Repeat test  Blood
draw for confirmatory
Western blot
Repeat test  Blood
draw for confirmatory
HCV PCR quant
Repeat test  Blood
draw for confirmatory
HCV PCR quant

22. Preliminary linkage to HIV carePreliminary linkage to HIV care
trends: Non-clinical Testingtrends: Non-clinical Testing
12 People Tested Preliminary Positive
10 confirmed
positives
2 discordant
confirmatory results
8 known positives 2 new diagnoses
4 currently in care
1 LTFU
6 being linked to
care
1 awaiting
viral load
results

23. Demographic characteristics of HIV-positiveDemographic characteristics of HIV-positive
patients in non-clinical settingpatients in non-clinical setting
• Average age HIV+ = 44 years old
• African American
• Transmission risk factors: MSM (2),
Heterosexual (5), no identified risks (5)
• 2 co-infected with HCV

24. Preliminary Linkage to Care Trends forPreliminary Linkage to Care Trends for
Non-clinical Testing: HCVNon-clinical Testing: HCV
17 People Tested Preliminary Positive
13 chronically infected 2 cleared virus
10 previously known 3 new diagnoses
1 currently in care 2 in process of
linkage
10 linked to care
outreach services
2 uninsured 10 have insurance
2 with insurance
pending
6 referrals
pending
4
awaiting
referrals
2 awaiting results

25. • Average age is 52
• One third are NOT in baby boomer birth cohort
• Mode of transmission: no identified risk (7),
IDU/cocaine use (7), Heterosexual (1)
• 2 co-infected with HIV
• Tattooing in unregulated environments
Demographic Trends of HCV positiveDemographic Trends of HCV positive
Patients in non-clinical SettingPatients in non-clinical Setting

26. • Continuing Quality Improvement (CQI) is critical
• Many are known HIV and HCV positive and not in care
• Comprehensive campaign is a way to raise awareness,
fight stigma and re-engage patients in care
• Biggest challenge in non-clinical setting: retaining HIV
patients in care
• Biggest HCV challenge: payment and linkage
– insurance and referrals for HCV care
Lessons Learned and ImplicationsLessons Learned and Implications

27. • Biggest challenge in clinical setting: high decline rate
• 74% of patients testing for HIV at clinic were women; men
more frequently decline HIV testing in clinical setting
• More new diagnoses in clinical settings than non-clinical
settings
• Offering HIV and HCV testing together may enhance testing
rates
• Street and door to door outreach is effective, especially for
reaching youth and men
• High HCV seropositivity rate; few clients are in care
• Volunteers reduce staff costs and enhance sustainability
Surprising FindingsSurprising Findings

28. WhatWhat is next?is next?
• Enhancing routine testing at FQHC
– Boost our offer rate and reduce our decline rate
• Develop a complete neighborhood-based diagnosis,
treatment and care cascade
• GIS mapping of hotspots for HIV and HCV
• Trial comparing control and treatment neighborhoods
• Cost-effectiveness study
• Complete program evaluation, including improvements
from baseline
• Mapping transmission using HIV sequences at
neighborhood level

29. • Principal Investigator
Amy Nunn, ScD
Brown University
• Gladys Thomas, Project Director
• Gilead Sciences
• Health Annex partners
• 80 Volunteers
• The Southwest Philadelphia community
AcknowledgementsAcknowledgements