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Institute for Population Health IMPLEMENTING ROUTINE HIV AND HEPATITIS C SCREENING IN DETROIT TOOLKIT DRAFT

Using the Learning Collaborative Method to implement routine HIV and Hepatitis C in Detroit The purpose of this toolkit is to get a better understanding of the HIV and Hepatitis C burden in Detroit and model the strategies and best practices used in Detroit to address HIV and Hepatitis C in other urban areas.

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EXECUTIVE SUMMARY In 2010 and 2011 President Barak Obama and the Centers for Disease Control and Prevention (CDC) released reports on how our nation should address HIV and Hepatitis C. The report recommendations highlighted strategies to increase screening, testing and treatment. In compliance with the national strategies in 2015, Institute for Population Health partnered with Gilead through FOCUS (Frontlines of Communities in the United States) to implement routine HIV and Hepatitis C screening in the City of Detroit. We started operationalizing the initiative with 3 clinics in 2015 and as we reached our screening, testing, and identifying positive patient goals, we expanded to 4 more clinics in 2016. Our partnership included Detroit Federally Qualified Health Centers (FQHC), FQHC look-a-likes, and substance abuse facilities. The six clinics are Covenant Community Care, Western Wayne, Self-Help Addiction Rehab (SHAR Main), Health Center Detroit Foundation, Advantage Health Centers, Wayne County Healthy Communities FQHC (Hamtramck), and our two IPH clinics. IPH’s responsibilities are to oversee the day-to-day screening, testing, and linkage-to-care at all 6 partnering sites and our own clinic. IPH completed these responsibilities using five best implementation practices: learning collaborative, integrating screening into the clinic flow/systems and policy, EMR modification, linkage to care, and continuous quality improvement. The first best practice is the learning collaborative. The learning collaborative is a meeting which includes key personnel of each clinic, meeting throughout the grant year, sharing their experiences, barriers, and breakthroughs. The second best practice is the testing being integrated into normal clinic or work flow. This includes identifying barriers in the clinic flow to identify the process for routine HIV testing, how to populate the lab order, and identifying who is eligible for screening using the EMR. Another part of the second best practice is systemic policy change. This includes establishing routine HIV/HCV screening policy. It also includes a multilevel, organization-wide commitment to implement routine HIV and/or HCV testing and linkage to care. The third best practice is EMR modification. EMR modification includes the designing of smart EMR algorithms to automate the screening process, including the automation of eligibility criteria for testing, and auto-population of lab order forms to reduce error; which increases testing. The fourth best practice is linkage-to-care. For patients that cannot be treated in-house, IPH built relationships with HIV and Hepatitis C specialists throughout the community which treat our patients who test positive. The fifth best practice is Continuous Quality Improvement. Continuous Quality Improvement has been a method to identify and reinforce best practices, motivate staff, and monitor testing techniques and outcomes. Collaborating with community agencies allowed IPH to operationalize the initiative. We worked with Midwest Aids Training and Education Center, Michigan Department of Health and Human Services, and Quest Diagnostic Lab. As a result of using the five highlighted best practices above and the support from our partners to implement routine HIV and HCV screening and testing the collaborative as a whole has seen significant increases in testing and identifying positive cases. There has been a 59% increase in HIV testing and a 37% increase in Hepatitis C testing since 2015-2016 (precollaborative) and 2016-2017 (post- learning collaborative). We have been able to locate new positive patients and link them to care. The initiative also identified patients that were previously diagnosed but not adhering to treatment regimens, and was able to link them to care. DRAFT

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TABLE OF CONTENTS PART I: BACKGROUND Leadership Team

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Detroit Learning Collaborative

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PART II: INTRODUCTION 8 HIV National Strategy HIV Statistics

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HCV Statistics

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PART III: METHODS: 5 BEST PRACTICES Learning Collaborative #1

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Michigan Consent Laws

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Treatment Coverage

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Pre-Exposure Prophylaxis (PrEP) 21-22

22-26

Integrating in Clinic Flow/Systems and Policy #2 Cultural Competency

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Substance Abuse and Re-entry Clinics Provider Meeting Tour

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EMR Modification #3 26-28 Linkage to Care #4

28-29

Continuous Quality Improvement #5 Coding Culture

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Data Collection and Reporting

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PART IV: PARTNERSHIPS: THE ART OF COLLABORATION

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Gilead 30 Michigan Department of Health and Human Services (MDHHS) Midwest AIDS Training + Education Center (MATEC) Quest Diagnostics

PART V: RESULTS HIV Outcomes

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32-34 33

HCV Outcomes 34

PART V: DISCUSSION REFERENCES

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APPENDIX 1: OPERATIONALIZING HIV AND HEPATITIS C TESTING IN YOUR CLINIC 36 APPENDIX 2: LINKAGE TO CARE FOR HIV/HEPATITIS C NETWORK DRAFT

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PART I: BACKGROUND ORGANIZATION Founded in October 2012, the Institute for Population Health (IPH) is a 501(c)(3) non-profit organization with the mission of maximizing positive health conditions in populations and communities through collaboration, clinic services, and the application of scientific health practices. In order to achieve this goal, IPH is expanding its capacity to conduct Learning Collaboratives and dissemination of findings to the community at-large, policy makers, and other health institutions. To that end, the resources provided by this initiative would allow IPH to establish a precedent of Learning Collaborative inclusion in the way public health is done. LEADERSHIP TEAM Dr. Gwendolyn Daniels, Principle Investigator and CEO of Institute for Population Health Dr. Gwendolyn Daniels’ provides executive leadership in the development, implementation, and evaluation of population health services in the Detroit area valued by funders, educators, and policy makers. Her 38 year nursing career has intersected acute care, community, and public health. Dedicated to professional development, Gwen has assured a competent workforce in population health to sustain direct services to high risk populations in need of quality care in the community. She has provided executive leadership in the role of Principal Investigator (PI) for the Gilead Focus Grant and the HRSA Healthy Start Grant to eliminate health disparities and improve the health of thousands of individuals and their families in the Detroit area. Her leadership as the Interim CEO of the Institute for Population Health, Inc. (IPH) has sustained the vision of the Non-Profit as quality services are provided to families in the newly HRSA Designated Federally Qualified Health Center-Look A Like. DRAFT

Chinwe Obianwu, Project Director Institute for Population Health Chinwe Obianwu began her career in 2010 as a Clinical Epidemiologist at the Department of Defense, where she developed metrics to measure the efficiency, effectiveness, and benefits of Department of Defense funded health initiatives such as the pay-for-performance tobacco cessation initiative, access to care for mental health patients, and case management transition of care. She relocated to Detroit in 2013 and worked as a Maternal Child Health Epidemiologist, Environmental Epidemiologist, and Tuberculosis Epidemiologist. She is a passionate public health practitioner that enjoys disseminating public health information to underserved populations. She is currently the Project Director of this FOCUS grant. Anthony Harris, Linkage to Care Coordinator Institute for Population Health Anthony Harris began his career in Public Health in 1993 with Detroit Health Care for the Homeless in Detroit, Michigan. His responsibilities included HIV Respite Care as well as overseeing temporary housing for HIV/AIDS clients in the city of Detroit. His management experience with the AIDS Consortium of Southeast Michigan, included developing contacts among area property owners for placement of HIV infected clients and providing pre and post HIV test counseling. Under MDCH, as a Disease Intervention Specialist, he conducted HIV and STD interviews and performed screening activities for clients. As part of this city wide initiative, 5


patients were assessed as to their risk factors and were investigated as to risks posed by their possible exposure to the population at large. Presently, his duties as HIV Prevention Manager and Linkage to Care Coordinator with Institute for Population Health include overseeing clinical services for the citizens of Detroit and surrounding counties, addressing HIV/STD and TB services. DETROIT LEARNING COLLABORATIVE The Detroit Learning Collaborative includes: Institute for Population Health, Advantage, Covenant Community Care, Hamtramck Wayne County, Health Center Detroit Foundation, Western Wayne, and SHAR Main (substance abuse clinic). These clinics were selected because there is an unmet need for routine screening for routine HIV and HCV screening in their clinics for adults and adolescents and in the geographic area surrounding the clinics. The goal of the collaborative is to build the capacity for these clinics to routinely screen patients with lab-based HIV and HCV testing, linkage to care, and early detection.

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Special thanks to the participants of the Detroit Learning Collaborative:                

Dr. Anthony Clarke, Health Center Detroit Foundation Kimberly Hayes, Health Center Detroit Foundation Michelle McGarrity, Health Center Detroit Foundation Shameekqua Tripplett, Advantage Health Center Gyona Crawford, Advantage Health Center LeNetia Norris, Self Help Addiction and Rehabilitation (SHAR) Main Amie Lewis, Self Help Addiction and Rehabilitation (SHAR) Main Dwight Vaughter, Self Help Addiction and Rehabilitation (SHAR) Main Anthony Moses, Self Help Addiction and Rehabilitation (SHAR) Main Ashley Fitzpatrick, Covenant Community Care Dr. Jack Ebright, Covenant Community Care Tracie Cox, Western Wayne Family Health Centers Randy Lynn, Western Wayne Family Health Centers Monica Geldres, Western Wayne Family Health Centers Jennifer Mahn, Wayne County Healthy Communities in Hamtramck Marva Hairston, Wayne County Healthy Communities in Hamtramck DRAFT

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PART II: INTRODUCTION HIV NATIONAL STRATEGY In 2010, President Obama released a set of strategic action steps to address the domestic HIV epidemic. There were 4 main strategies: Reduce new infections; Increase access to care and improve health outcomes for people living with HIV; Reduce HIV-related health disparities and health inequities; Achieve a more coordinated national response to the HIV epidemic. In 2015, the United Nations program on HIV/AIDS developed the 90-90-90 initiative an ambitious treatment target to help end the AIDS epidemic. The initiatives’ goals are to diagnosis 90% of the HIV population, 90% of persons living with HIV are on treatment, and 90% of persons on treatment are virally suppressed. To align with the national and international mandate the Institute for Population Health partnered with Gilead Sciences to address HIV in Detroit. HIV STATISTICS The graphs which follow are based on Detroit specific data. Detroit has an HIV prevalence of approximately 5,620 persons living with HIV. With a rate of 671.8 per 100,000 people. The Detroit male population accounts for 74% of the HIV cases. Females make up 24% of the Detroit HIV cases. The transmission risk is mainly with the men who have sex with men population. Men who have sex with men are 48% of the HIV population, heterosexuals are 19% of the HIV population, persons who inject drugs are 7%, and 21% of the risks are undetermined. The Institute for Population Health’s HIV and HCV initiative has put a huge emphasis on linkage to care. We have hired a Linkage To Care Coordinator to support each of our partners in linkage to care efforts. We know that being linked to care improves the patients condition and decreases transmission. To align with the nations strategic steps to address HIV and the WHO 90-90-90 initiative we need to make sure that all of the positive patients that are found under our initiative are linked to care under 30 days. Currently, Detroit’s percentage of linkage to care is around 35% within 1 month of diagnosis, and around 60% linked, 1-3 months after diagnosis. We have strategically placed support systems in this partnership to increase the amount of patients that are linked to care in a timely fashion after diagnosis. DRAFT

Timely linkage to care will lead to viral supression. The WHO goal is that 90% of the people living with HIV will be virally suppressed. Detroit’s viral supression is rising. As of 2015, 57% of people living with HIV in Detroit are virally suppressed. Unfortunately there is still a large percentage of people living with HIV that are not virally suppressed. This is due to a number of reasons. Some are not adhering to their antiretroviral therapy, some may be unaware of their HIV status, and others have not been linked to a health care provider for treatment. There are other social and economic factors that may keep people living with HIV from completing their HIV care continuum. As we screen and test people through our partnership we will locate HIV patients who have not achieved viral suppression. The clinicians in our initiative use this as an opportunity to reengage with patients and bring them back to the HIV care continuum.

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Michigan Department of Health and Human Services, Annual Detroit HIV Surveillance Report, 2015.

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ichigan Department of Health and Human Services, Annual Detroit HIV Surveillance Report, 2015. 10


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Michigan Department of Health and Human Services, Annual Detroit HIV Surveillance Report, 2015.

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HCV NATIONAL STRATEGY Hepatitis C Virus (HCV) is a blood-borne pathogen that can cause a chronic infection that affects the liver. Chronic infection with HCV can lead to liver disease, liver cancer, and death. In 2011, the CDC released the Combating the Silent Epidemic of Viral Hepatitis: Action Plan for the Prevention, Care, & Treatment of Viral Hepatitis report. The report has 4 sections outlining strategies to address the HCV epidemic. They include surveillance, knowledge and awareness about chronic Hepatitis B and Hepatitis C, viral hepatitis services, and eliminating the health disparity of hepatitis C among racial groups. The IPH and Gilead partnership have adopted and implemented these strategies outlined in the report to address Hepatitis C in Detroit. The report recommendations are to:  Expand community-based programs that provide hepatitis C screening and testing services.  Expand programs to reduce the risk of Hepatitis C virus infection through injection-drug use.  Provide comprehensive Hepatitis C virus prevention programs.  Provide adequate resources to federally funded community health facilities for provision of comprehensive viral hepatitis services.  Provide resources and guidance to integrate comprehensive viral hepatitis services into settings that serve high-risk populations such as STD clinics, sites for HIV services and care, homeless shelters, and mobile health units. A 2011 analysis of the National Health and Nutrition Examination Survey (NHANES) data revealed that individuals infected with Hepatitis C are less likely to be covered by private insurance compared with the overall population, and only half had any health insurance coverage. The recent Affordable Care Act (ACA) Medicaid expansion program requires coverage for preventive services including Hepatitis C screening. One-time HCV screening for baby boomers and persons at high risk of infection are now covered at no cost to the individual. ACAassociated expansion expands opportunities to increase diagnosis rates and entry to care. The Medicaid expansion helped this initiative in screening and testing eligible patients in Detroit. With preventive screening available without cost-sharing under the ACA, now is a critical time to scale-up HCV testing, linkage to care, and treatment in the African American community. DRAFT

The disproportionate burden of chronic Hepatitis C among African Americans is a health disparity experienced by this population. Increasing the number of African Americans who are aware of their chronic hepatitis C infection requires relevant, timely and impactful educational efforts to encourage the public to get screened for hepatitis C and motivate providers to recommend screening. The learning collaborative discusses the disparities of Hepatitis C among the African American population and how our initiative is critical for the heavily segregated African American Detroit population. HCV STATISTICS Since the CDC’s 2011, Hepatitis C report, according to Detroit health data the cases of Hepatitis C have gone down in Detroit. This decrease could be attributed to Medicaid expansion and the 12


implementation of the recommendations in the report such as increase in screening and testing efforts and the Institute for Population Health partnership with multiple key heavy traffic health agencies. We have been implementing the 5 best practice strategies and are continuously seeing the collective impact in the number of increased testing and decrease in cases of Hepatitis C. The chart below illustrates the decline in HCV cases and rates in Detroit.

Hepatitis C is nearly 4 times as prevalent as HIV and Hepatitis B in the United States. Offering routine testing provides opportunities to further educate people that individuals can be cured of Hepatitis C infection. Currently available Hepatitis C treatment options can reduce treatment time to 8-12 weeks, are injection-free, have minimal side effects, and cure over 90 percent of patients. Curing Hepatitis C prevents the risk of subsequent transmission. DRAFT

Michigan Department of Health and Human Services, Hepatitis C annual Surveillance Report, 2015. 13


HCV kills more people in the U.S. than all other infectious diseases combined. Approximately, 4 million Americans are infected with HCV and 50-75% do not know it. The main objective from IPH’s HIV and HCV screening initiative is to increase the routine screening that is done in clinics and substance abuse facilities in Detroit. Part of the initiative’s policy is to ensure clinics use reflex RNA testing for HCV patients. The RNA test is a confirmatory test that is automatically done when a positive antibody patient is identified. The automated reflex RNA produces timely and more accurate results and is needed to confirm HCV diagnosis. Unfortunately, Medicaid does not pay for treatment of Hepatitis C stage 0-2 of fibrosis. Private insurance offers treatment coverage, however, waiting until patients are stage 3-4 of fibrosis which usually leads to cirrhosis is when Medicaid can cover Hepatitis C. The below graph depicts the United States cascade of HCV care.

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Michigan Department of Health and Human Services, Hepatitis C annual Surveillance Report, 2015.

HCV at risk populations are primarily people who were born in the baby boomer birth cohort between 1945-1965 and persons who inject illegal drugs, including those who injected only once many years ago. Currently we are seeing an increase of Hepatitis C cases among people who are between the ages of 18-29 which is related to increases in intravenous drug abuse, particularly heroin; 94% of HCV positive young adults reported using intravenous drugs; heroin being the most common 92%. Young adults with HCV diagnoses tend to be: Caucasian (over 90%), live in suburban or rural areas, and equally male and female.

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As the amount of Michigan’s heroin substance abuse treatment increases, the amount of Michigan young adult cases of Hepatitis C increases. Screening baby boomer birth cohort was a simple way to screen for Hepatitis C without patients having a risk assessment done and is consistent with the CDC’s recommendations. Now that there is a new birth cohort at risk, doing risk assessments and determining the injectable drug users is now important in identifying Hepatitis C cases.

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Michigan Department of Health and Human Services, Hepatitis C annual Surveillance Report, 2015.

Michigan Department of Health and Human Services, Hepatitis C annual Surveillance Report, 2015. 15


Michigan Department of Health and Human Services, Hepatitis C annual Surveillance Report, 2015.

The rate of liver cancer incidence is 2.2 times higher in African Americans than Caucasians. Factors that increase the risk of primary liver cancer include untreated chronic infection of Hepatitis. Untreated chronic infection of hepatitis causes fibrosis and then cirrhosis which is irreversible and increases risk of liver cancer. The NHANES study revealed individuals infected with Hepatitis C are less likely to be covered by private insurance, and only half had any health insurance coverage. Medicaid does not pay for stage 0-2 of fibrosis treatment, which leaves half of the Hepatitis C patient population at risk for untreated chronic Hepatitis C. DRAFT

Michigan Department of Health and Human Services, Vital Records 2014.

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The Detroit Learning Collaborative serves a majority African American population. There are disparities in HCV testing among the African American population. Our collaborative has ensured that all HCV positive antibodies automatically reflex to HCV RNA confirmatory tests. Once the HCV RNA confirmatory tests are confirmed as positive, the patients are then linked to care.

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Michigan Department of Health and Human Services, Vital Records 2014.

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PART III: METHODS: 5 BEST PRACTICES For the past two years, IPH in partnership with Gilead Sciences has worked together to implement routine HIV and Hepatitis C screening and testing in metro-Detroit. Our first year was primarily focused on HIV outreach with two metro-Detroit clinics. By the end of year one we had developed skills to screen, test, and track testing data efficiently. Thus, we decided to expand and implement our screening and testing practices to six more metro-Detroit clinics for our 2 nd grant year. Our partnership included Detroit Federally Qualified Health Centers (FQHC), FQHC look-a-likes, and substance abuse facilities. The six clinics include Covenant Community Care, Western Wayne, Self-Help Addiction Rehab (SHAR Main), Health Center Detroit Foundation, Advantage Health Centers, Wayne County Healthy Communities FQHC (Hamtramck), and our two IPH clinics. We selected these clinics based on patient population and zip code level data with high prevalence of persons living with HIV and interest in implementing routine screening. BEST PRACTICE #1 - LEARNING COLLABORATIVE We have had seven learning collaborative meetings since the beginning of the grant. Each learning collaborative was geared towards operationalizing routine screening and testing. The purpose of the learning collaborative is to get feedback from each of the clinics, share each other’s barriers, challenges, and wins. They also allow each of the clinics to share best practices. The first learning collaborative was to introduce the grant to each of the partnering clinics. Initial grant engagement is usually between CEO of the leading agency and CEO of the partnering agencies. This first meeting establishes the clinic contact person(s). This is usually the clinic’s Quality Assurance Manager and/or Office Manager. This is the person who the Project Director engages with for the majority of the grant cycle. However, this person may change, and more than likely more people will become the point person and or have major roles in the completion of the initiative. Each of the clinics point persons are introduced to each other and understand the populations which each of the clinics serve. DRAFT

The first learning collaborative lays the foundation of the initiative. We discuss the grant objectives, review clinics nationally who have implemented routine screening, and the best practices in operationalizing routine screening. We discussed the epidemiology and disease burden of HIV and Hepatitis C in Detroit statistically and geographically using the AIDSVu. We also review the purpose of the collaboration in relation to national strategies in addressing HIV and HCV. By the end of the learning collaboration, everyone should have a good idea of what is expected of them and what our end goal should look like. The Project Director does an on-site meeting with each of the partnering clinics between the first collaborative and second to get a face-to-face and understand of each clinic flow. At each of the on-site meetings the Operationalizing HIV and Hepatitis C testing in the clinic document was reviewed (See Appendix 1). This document asks questions such as: Does your clinic have a policy for HIV and/or Hepatitis screening? If not, what is the process for approving a written 18


policy? How are confirmation laboratory tests for HIV and Hepatitis processed? Internally or externally? Who are the HIV, HCV, HBV linkages to care in the City of Detroit and specifically in the area surrounding your clinics or where your patients live? The face-to-face meetings set the platform for learning collaborative #2. The second learning collaborative allowed for each of the clinics to discuss their clinic flow, the EMR and labs they use. During this time we realized 2 of our partnering clinics used the same EMR, and our partnering substance abuse facility did not have an EMR system and were doing all of their medical examinations in paper files. From the discussions at our learning collaborative, clinic feedback, and through partnership support, the substance abuse facility purchased an EMR system that one of the other partners was already using. They went from paperless to electronic which made their clinic more efficient in all areas not just HIV and HCV. They were also able to get feedback and help from the clinic that was already using that EMR. We also noticed several of our clinics used the lab, Quest Diagnostics, to read their blood work. This presented an opportunity to negotiate the cost for testing. One of the clinics was using a different lab and paying a lot more than the clinics using Quest Diagnostics. They switched over to Quest Diagnostics, have been able to include more routine testing which they were not doing before, and it has saved their clinic a lot of money. To build our community partnership we had a guest speaker from Midwest AIDS Training and Education Center at our second learning collaborative. The have become great partners throughout the grant duration. They discussed a lot of the work they have been doing in the community and the partnerships they have built. They are a great HIV resource and always invite us to any HIV events that they know of in the community. We also discussed monthly data collection and how we are going to monitor our efforts to see the impact they have on our screening and testing efforts. DRAFT

MICHIGAN HIV CONSENT LAW By the third learning collaborative could discuss the monthly numbers and trends. We looked at where we were in regards to testing before the learning collaborative started and what strides we had made, via data. We also discussed the Michigan HIV testing consent law. Currently the Michigan HIV testing law is opt-in. Opt-in testing requires that the patient provide additional and separate written or verbal “informed consent� for the HIV test, and is a barrier to screening. Separate consent for HIV testing compromises the goal of routine screening. The providers shared at the learning collaborative that the opt-in consent deters patients from testing due to stigmatization. The collaborative became eager to learn about HIV consent laws in other states and learn strategies we could collectively work to change the Michigan HIV consent law and become an opt-out state. Opt-out testing, which is recommended by the CDC, indicates that the general consent is sufficient to notify patients that HIV testing may occur. We had a policy analyst guest speaker talk about the Michigan opt-in consent law in comparison to other states opt-out consent law and strategies the learning collaborative can incorporate in our initiative to make this possible. 19


HEPATITIS C TREATMENT AND MEDICAID COVERAGE During the fourth learning collaborative we reviewed our quarterly report and discussed the process of collecting the data. It gave us an opportunity to take a closer look at our linkage to care from a 3 month snap shot. We discussed some of the barriers that are keeping us from following up with some of the HCV population. We realized that a lot of the Hepatitis C positive patients have Medicaid. Unfortunately Medicaid does not pay for Hepatitis C treatment or stage 0-2 of fibrosis. Medicaid only pays for stage 3-4 when the liver has reached cirrhosis. A lot of these patients and practitioners know their patients have Hepatitis C but have no way of treating them until they are really sick and have stage 3-4 fibrosis/cirrhosis. Waiting until the patient is sick has made a lot of our doctors feel as though their hands are tied, they diagnose patients but cannot treat them due to minimal health coverage and/or expensive medication. This lack of access to care, puts linkage to care for Hepatitis C in perspective; Some of our patients can be linked but may not receive care. We had a policy analyst talk about Medicaid expanding treatment of fibrosis. The learning collaborative is advocating to Michigan’s Medicaid Director and Pharmacy and Therapeutic Committee for more Medicaid coverage on the lesser stages of fibrosis.

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HIV AND PRE-EXPOSURE PROPHYLAXIS The other guest speaker at the fourth learning collaborative was a Pharmacist who presented on Truvada and PrEP. She presented on the PrEP guidelines and recommendations, identifying candidates for PrEP, PrEP implementation, and Accessing PrEP.

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Truvada is indicated in combination with safer sex practices for PrEP to reduce the risk of sexually acquired HIV-1 in adults at high risk. Truvada taken once a day has been recommended as an HIV prevention therapy. Identifying candidates for PrEP was really interesting, there was a survey done in Philadelphia with around 3,500 people to determine their self-perception of being at high risk for HIV infection. Only 9.5% of the people in the survey perceived themselves as being high risk, however the testers at the clinic identified 68.5% of the patients in the survey as being high risk for HIV infection. The presentation taught the learning collaborative that a large proportion of patients at high-risk for HIV infection do not perceive themselves at high risk. Providers having risk category discussions with their patient population educate their patients and equip them with the proper information to make informed decisions in regard to their sexual health. The learning collaborative learned that through routine screening, patients at high risk for 21


HIV could be identified upon receipt of a negative test result and ascertainment of risk level for HIV acquisition. PrEP implementation was also discussed. Many of the providers needed to know how to implement PrEP if they identify patients who are at high risk for HIV. The PrEP implementations for providers are: Identification of high risk, make medical appointment or referral, prescribe Truvada prescription, and follow-up every 3 months with the patients.

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The fifth learning collaborative focus was on EMR modification (See EMR modification section). The sixth learning collaborative was a continuous quality improvement meeting. BEST PRACTICE #2 - INTEGRATING IN CLINIC FLOW & SYSTEMS AND POLICY The CDC guidelines recommend that all Americans adolescents and adults (ages 13-64) be tested for HIV as part of their routine medical care. An integrated testing model is one that is not dependent on dedicated testers and is fully integrated into regular patient flow. 22


Institute for Population Health (IPH) - Patients that come into the Institute for Population Health clinics are usually serviced with routine STD testing and Primary Care check-ups. The majority of our patient population is eligible for routine HIV and HCV tests. However, not everyone that is eligible is receiving routine testing. To integrate routine HIV and HCV testing into clinic flow at IPH we had to engage our laboratory, Quest Diagnostics. We have standard blood panels which we administer to all of our STD and primary care patients. However, HIV is not on the primary care panel and is only on the STD panel. Patients that come in specifically for STD testing automatically receive an HIV test. However, patients that come in for primary care do not. We have met with the providers to make sure that they are administering HIV tests to all patients that are eligible even if they did not come into the clinic for STD testing. The best practice to ensure this practice is being done is via EMR modification. Our testing numbers increased, however we attribute the exponential increase to the implementation of EMR modification. DRAFT

Health Center Advantage – Since the beginning of the initiative, we have seen an increase in the amount of HIV and HCV testing. However, there is a care gap between the number of people coming into Advantage and the number of people screened and tested for HIV and HCV. Advantage is located in an area with a high prevalence of HIV. Implementing routine HIV and HCV is most important at this site. One-quarter of the estimated 1.1 million people living with HIV in the United States- 180,000 to 280,000 individuals– are unaware of their HIV status and may transmit HIV without knowing they are putting partners at risk (Fullilove, ED.D 2006). The 23


initiative is addressing Advantage’s gap of care, in two ways: By implementing EMR modification and screening during the clinic flow Chief of Compliant area. Advantage’s Chief of Compliant area is where the patient receives their risk assessment and the medical assistant reviews the patient’s Chief of Compliance. This triage area is a good opportunity to screen patients and determine if they are eligible for routine screening. 80% of the patient population has their blood drawn. The opportunity to ensure HIV and HCV is done routinely is through engaging Quest Diagnostics. Covenant Community Care – Covenant Community Care has a large uninsured population, they absorb medical costs for patients who can’t afford to pay for their tests. The have limited resources to implement routine screening. They try to screen as many people as possible but for the purposes of cost, they will be paying for all of their uninsured patient population. Health Center Detroit Foundation (HCDF) – The initiative integrated HIV and HCV screening into the HCDF workflow by supporting them in becoming a paperless clinic. We helped them pay for tablets which each of the providers now bring into the examination room. The EMR modification will screen the patients for HIV and HCV testing eligibility for the provider and alert them if the patient is eligible for testing at each examination. Western Wayne – Western Wayne has a quality improvement evaluation tool called MediQuire that has tracked the screening and testing of HIV and HCV. Every month at the clinic’s providers meeting, providers are able to see their monthly performance. This tool has encouraged the providers to screen and test eligible patients. It keeps the provider accountable for their performance and helps adherence to recommended quality of care practices. DRAFT

CULTURAL COMPETENCEY Wayne County Healthy Communities in Hamtramck – Hamtramck has a high population of immigrants (over 40% Asian and Middle Eastern population) which supports the need for HBV screening. The clinic staff indicated the tremendous challenges in implementing HIV screening, but HBV screening may be used as a gateway test for HIV and HCV screening. At the beginning of the initiative the LC knew implementing routine screening at Hamtramck was going to be a challenge. The Hamtramck clinic services a large Muslim population which requires the initiative to be culturally competent. Cultural competence requires that organizations have a defined set of values and principles, and demonstrate behaviors, attitudes, policies, and structures that enable them to work effectively cross-culturally. In general cases, if there is even a suspicion of illicit sexual conduct or any HIV/AIDS infection, the affected person(s) is discriminated against and shunned by the family as well as by the community (Hasnain, 2005). To that end, HIV prevention, screening, and testing come with stigma from the Hamtramck community. In the beginning of the initiative HIV testing was not being done at the Hamtramck clinic. Halfway through the grant year our implementation increased to approximately 11 tests a month. We collectively decided that the grant funding would be better utilized at a clinic which would screen and test their patient population routinely without insurmountable cultural barriers. This 24


allowed our collaborative to learn about the challenge of cultural competency and public health. As public health practitioners the LC want to implement routine HIV screening in an area that could be at risk, however we had to understand our population and how they receive education regarding a predominantly sexual transmitted disease. There are clinics in predominantly Muslim areas that do HIV testing, however those clinics have been in the area for a very long time and have built trust with their patient population. However, Hamtramck is a new clinic, the staff at this clinic recommended that routine HIV and HCV testing had to be slowly introduced. There are other clinics in the City of Detroit that can utilize the capacity this grant offers in operationalizing routine HIV and HCV. For this grant cycle we decided to give the funding to our clinics that could use the money towards the initiative. Next year we will replace Hamtramck with a clinic that will screen and test more and get Detroit closer to 90% of its population knowing it status. SUBSTANCE USE AND RE-ENTRY CLINICS Self Help Addiction and Rehabilitation (SHAR) Main – One of our partnering clinics is a substance abuse and re-entry residential facility located in Detroit. Detroit’s population is 80% African-Americans (Fact Finder, Census, 2015). Drug use is an important risk factor for HIV and HCV among African Americans and Hispanics. Injection drug using is also associated with high rates of hospitalization for HIV disease as well as poor treatment outcomes. As of 2016, 10% of people living with HIV in Detroit became infected via injection drug use. SHAR Main is also a re-entry program; many of the men are coming back from prison and re-entering into the general population. There are currently 2.2 million people in jail or prison in the U.S. According to the Bureau of Justice Statistics (BJS), about 1.5% of all inmates in state and federal prisons have HIV or AIDS (21,987 persons).1 This is 4 times the prevalence rate of HIV in the general population. As inmates are released back into their communities, they stand to impact the overall health and well-being of entire communities. As more and more inmates are susceptible to HIV infection in prisons, the communities into which they return are also placed at risk. Promoting the normalization and sustainability of routine testing at substance abuse and re-entry clinics is a priority for the Detroit LC. Our initiative has trained clinic nurses at SHAR with HIV test counselor certifications. The HIV test counselor certification is designed to prepare providers in a variety of settings to support individuals in conducting HIV testing, provide participants with the core elements necessary for delivering a positive test result, and teach participants how to understand delivering a reactive test result, linking a client to medical, and holding the initial partner services (PS) conversation (linkage-to care).We have also implemented policy and systematic changes at SHAR Main. We implemented a policy that everyone who enrolls into SHAR Main will have an HIV test included in their routine test. They went from not testing anyone to testing all of their clients. The initiative also implemented HCV RNA test. Before SHAR Main was only doing HCV antibody tests, they are now doing HCV RNA testing which is a CDC best practice to determine if a patient is a true positive. DRAFT

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PROVIDER MEETING TOUR The success of the initiative is contingent on the multi-level organization-wide commitment to implement routine HIV and HCV testing and linkage to care. All of the staff at each site, including the CEO, providers, medical assistants, information technology team, and quality improvement specialists have to be invested in the initiative. Each personnel has their role to play in the success of routine testing. Site visits in between each LC allowed are essential to make people accountable to the tasks which were decided at the last LC. The site visits are a constant reminder for the site to stay in compliance with the timeline and goals. Another strategy we implemented to foster multi-level organization-wide commitment to the initiative, is the provider meeting tour. The provider meeting tour is the project director presenting the initiative at each of the partnering clinics at their provider meeting. Engaging the provider is one of the most important measures of success of the initiative. The provider-patient exam is the point of care where consent and ordering of tests are done. Getting provider support is needed to complete the screening, testing, and start the cascade of care. The provider meeting tour occurred in the 3rd Phase of the grant cycle. By the time the provider meeting occurs, all of the clinics should have an in-depth understanding of the initiative’s objectives and the 5 best practices. This is an evaluation strategy that allows the providers to see the progress they are making since the beginning of the grant cycle and make any corrective actions to align with the CDC routine testing guidelines. BEST PRACTICE #3 – ELECTRONIC MEDICAL RECORDS (EMR) MODIFICATION DRAFT

The purpose of EMR modification is to prompt testing, automate processes, populate lab orders, and track performance. The smart EMR algorithms automate the screening process by automation of eligibility criteria for testing and lab EMR interface which automatically orders HIV and HCV testing. EMR technologies (e.g. electronic alerts, checklists, and decision support systems) are increasingly promoted as innovative platforms to streamline preventive health programs and improve compliance with clinical guidelines. To leverage the full potential of EMR tools they must be user-friendly, efficient (i.e., limited to a few clicks), and fit seamlessly into the clinic workflow (Lin et el 2016). Each partnering site received funding to purchase professional services, customizations, and end user training. We engaged the chief information officers, information technology personnel, and the EMR service representatives to help drive the integration of EMR modification. The flow chart below gives a model for how EMR’s can be modified to support routine screening.

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One of our Detroit LC participants is an infectious disease physician who developed eligibility criteria for screening HIV and HCV. The guidelines for screening are based on CDC recommendations and Detroit’s prevalence areas: HIV 1. All patients, age 18 or older, once in their lives 2. Patients who are between ages 13-17, if they have been sexually active or have snorted cocaine or injected drugs (IDU). These patients should be tested at least once, and possibly yearly if they remain active in these practices. 3. All patients found to have a new STD, even if they have tested at an earlier date 4. Yearly testing (or more frequently on case-by-case basis) if high risk sexual practices or IDU. High risk practice not well defined, but suggest more than one sexual partner per year, especially if inconsistent condom use. Hepatitis C 1. All patients born between 1945 and 1965 2. Patients who received blood or blood product transfusion prior to 1992 3. Gay males with HIV (yearly) 4. Persons with history of injecting drugs (IDU), yearly while continuing to inject drugs.

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When patients check in at the front desk at their provider visit, EMR algorithms identify patients who meet the eligibility criteria for routine HIV (process with HCV is automatic and is already routine in most clinics) screening guidelines. One algorithm identifies patients eligible for the once in a lifetime screening based on age (13-64 years) and no prior HIV diagnosis or test documented in the EMR. CDC guidelines do not specify an optimal interval for repeat screening of the general population but recommend at least annual screening for individuals at high risk for HIV infection. To ensure that high-risk patients are screened more regularly than once in a lifetime, a second risk based EMR algorithm is developed that searches the patient’s medical record for any of the following proxies for high risk: residence in a zip code with more than 1% HIV prevalence, men who have sex with men (MSM), intravenous drug use, homelessness, or unsafe sex. Patients who have any of these risk factors documented in a searchable EMR field (patient information, diagnosis list, problem list, social history) are eligible for routine screening if they have not had an HIV test documented in the past 365 days. For eligible patients, the EMR generates a patient care order, titled “Consent patient for routine HIV screening,” in the patient’s order set. To complete the order, the provider discloses the routine HIV screening policy using Michigan’s opt-in language (“As part of our public health clinic policy, we recommend an HIV test to be included as part of your blood work. Do you have any questions?”). If the patient consents and does not refuse the test, the provider clicks “Yes, order test” for patients who consent, which automatically generates an order for a fourth generation in the laboratory. If the patient opts out, the option “No, patient refused (indicate reasons why below)” is clicked and a drop-down menu allows the provider an option to select the patient’s reason for opting out. When the clinic’s lab receives an HIV-positive result the lab sends results to clinic and patients are notified of test results via an HIV test counselor or designated outreach worker who delivers the positive test result in person and facilitates linkage to care within an existing HIV clinical service network affiliated with the Detroit LC. Information about patients’ linkage to care status is documented in the EMR by the outreach worker to ensure data quality and accessibility to providers. DRAFT

BEST PRACTICE #4 - LINKAGE TO CARE The Institute for Population Health Linkage to Care program has had much success with its clients providing services for HIV and HCV. Our program provides client centered services for all clients newly infected or clients who have been out of care and looking for services. IPH is a non-judgmental and open stance, and flexibility in counseling approach: Respect is demonstrated for the choices a client has made and will make. We provide comfort with discussing explicit risk behaviors (sexual and drug using behaviors) with terminology that is comfortable for the client. Linkage HIV and HCV testing to care normally occurs within a month of confirmatory result if not sooner. The Care Coordinator determines the readiness of the client for care before locating care. This is a very important part of linkage to care, if a client has other issues that may prevent him/her from receiving treatment these issues should be addressed. The Detroit LC has identified several infectious disease physicians throughout the city that have experience with HIV and HVC client. This allows the care coordinator to give a warm hand-off to the referring doctor for identified clients. Once an appointment is set for the client; the care coordinator will discuss the 28


importance of making that initial visit along with other support services. We understand that there may be some barriers in the client’s life circumstances preventing them from following through with appointments. That is why when it is time for the client’s first appointment, the care provider will call to see if client has kept his/her appointment. This will show the client that somebody is taking an interest in his/her treatment and they are not alone. In addition, the care coordinator has been instrumental in helping staff at our partnering agencies to be certified in Counseling, Testing and Referral services through the State of Michigan. The training will give staff the skills need to face those barriers and challenges presented at the clinics. This gives the Detroit LC a better opportunity to provide successful service to our clients. However, with success there have been challenges. Clients have been turned away from treatment due to HCV levels. This is very alarming for clients who have finally gotten the courage to seek treatment and have the door closed in their face. The Detroit LC advocated to the state about Medicaid expanding HCV treatment, we recently learned that coverage for F-2 has been approved, and that doctors are now accepting lower levels of HVC for clients to be treated. With this news we believe this will make it a lot easier for referring clients for HVC care. BEST PRACTICE #5 - CONTINUOUS QUALITY IMPROVEMENT Training, feedback, and quality improvement is done to identify and reinforce best practices and motivate staff. During each of the learning collaboratives site visits, and the provider meeting and tours, the Detroit LC had the opportunity to improve the process and assure that there were adequate resources to correct any identified problems. The monthly data submission allowed us to track our efforts and determine where there was room for improvements. A lot of time is dedicated to meetings with the Project Director, Linkage to Care Coordinator, FOCUS regional lead, and Principle Investigator to evaluate the initiatives progress and goals. Our main performance measure was making sure we closed the gap of care for people eligible for testing and the amount of people actually tested and making sure we linked positive cases to care. DRAFT

DATA COLLECTION AND REPORTING

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The monthly reports were collected the first week of each month. The collaborative also collected data quarterly. The quarterly reports were more detailed and included a lot of refinement to ensure quality and timely care was being given to positive HIV and/or HCV patients in respect to linkage to care. The quarterly reports are done every 3 months. This allowed the Detroit LC to ensure that all linkage to care cases was closed and patients that were found to be positive have had their treatment referred first appointment. CODING CULTURE During the collaborative we learned that the providers were using different procedure (CPT) and diagnosis codes (International Classification of Diseases, 10th revision, Clinical Modification, ICD-10) to document HIV and HCV screening. Medical providers offer a range of vital prevention services—including HIV Pre-exposure Prophylaxis (PrEP) access services, linkage to care services, adherence counseling and HIV testing. Some of these services are performed by physicians, nurse practitioners, or physician assistants or the staff working under the supervision of these medical professionals. As an alternative, some of these same services are provided by community health workers (CHWs) or other non-licensed health professionals and peers. Payment by insurance companies for these services can be problematic, depending upon whether the payer (e.g., Medicare, Medicaid or private insurance plans) recognizes the service, the credentials of the person providing the service, and the setting in which the service is provided. The Detroit Learning Collaborative has recommended using CTP codes 86703 (HIV-1 and HIV2, single result) and 87389 (HIV-1 antigen(s), with HIV-1 and HIV-2 antibodies, single result) for HIV screening and CPT code 86803 (Hepatitis C antibody) for Hepatitis C screening. However, every clinic is set-up differently and uses their own policy based ICD-10 and CPT codes. Many of the codes vary due to insurance companies not reimbursing certain codes. We have found that each clinic’s billers have a lot of trial and error with billing Medicare, Medicaid, and various insurance companies. They have had to submit and resubmit codes to be paid for the providers services when insurance companies did not accept certain codes. DRAFT

PART IV: PARTNERSHIPS: THE ART OF COLLABORATION The Detroit LC was able to build partnerships with many agencies in Detroit. These partnerships are associated with the success of the initiative. Our community support system supported us with epidemiological data, to identify the areas we needed to focus our resources. It also supported us with training to sharpen our skills and service our population more effectively. Most importantly, our community relationships allowed the initiative to be a part of collective impact in addressing the HIV and HCV within Detroit. GILEAD Gilead supported IPH with funding for screening, diagnosis, and linkage to care, under the FOCUS (Frontlines of Communities in the United States) program, and guidance to implement the initiative. Established in 2010, Gilead’s FOCUS program partners with health care 30


organizations, government agencies, community organizations, and others to change the way clinical and community institutions approach HIV and HCV testing. In the years since inception, partners have developed replicable model programs that address systematic and institutional barriers to screening and access to care in health care institutions and communities across the nation. To date, the FOCUS program has established over 230 partnerships, 100 current, in 18 cities across the United States that are heavily impacted by HIV and HCV. Gilead’s FOCUS program has two partnerships in Detroit, the Detroit Learning Collaborative with IPH and our six partners and Detroit Medical Center Detroit Receiving Hospital. The Detroit Learning Collaborative with IPH is in its 2nd year. MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES (MDHHS) The Hepatitis C department at MDHHS has been very helpful in supporting the LC with epidemiological data and resources. MDHHS recently received a grant from the CDC to improve hepatitis C and B care cascades; and focus on increased testing and diagnosis. They have supported IPH and our partnering clinics with lab testing. They also provide a layer of governmental support behind our initiative. The CDC has provided HIV and HCV testing recommendations and has given MMWR endorsement to the initiative, however the Detroit LC has benefited from the presence of the state at our learning collaborative meetings and our provider meeting tour. The state endorsing our efforts gives us governmental support. The HIV Department at MDHHS has also been very supportive. To successfully implement this initiative we had to determine what we were building upon. In order to have collective impact we had to see what other initiatives were already being done in the community and try not replicate but bolster. They gave us a nice summary of the screening databases they have been building as well as the HIV rapid testing they have been providing to clinics. They also support us with HIV specific HIV epidemiology data. DRAFT

MIDWEST AIDS TRAINING + EDUCATION CENTER The Midwest AIDS Training and Education Center (MATEC) provides HIV training and information services. The organization is charged with developing training and information services to meet the needs of their area. MATEC’s goal is to increase the number of health care professionals who provide quality HIV care to underserved and vulnerable populations. They offer programs on the latest scientific knowledge about HIV/AIDS. They also conduct a longitudinal training program (LTP) at work sites. The LTP consists of four or more programs, which are presented over a period of time. The LC used their services at our Hamtramck site. The Hamtramck site is in a predominantly Muslim community and so are the clinic staff. The staff has been at MATEC conducting LTP at the Hamtramck site for six months. QUEST DIAGNOSTICS Building a relationship with the regional executives of the lab where blood work is sent is critical to the success of the initiative. The majority of our partnering clinics use Quest Diagnostics Lab. 31


We have built a relationship with the data analyst and physician and support staff at Quest Diagnostics. The regional executive is a champion of the initiative and introduced us to key supporting Quest Diagnostic staff. The staff at Quest Diagnostic sends IPH, HIV and HCV testing data, which allowed us to establish a quality assurance practice with the clinics data. The LC did a cost benefit analysis with the lab testing prices SHAR Main was paying with their previous lab. From our analysis we realized if the substance abuse clinic switched to Quest Diagnostic they would save a substantial amount of money and include more routine testing (e.g. HIV and the automatic Hepatitis C reflex). SHAR Main recently made the switch to Quest and they are pleased with Quest’s services. COST ANALYSIS Quest has also been very helpful in negotiating prices and understanding what our Detroit population needs in routine screening. They have negotiated test panel prices with us and our partnering clinics. However, each clinic has uninsured populations and each clinic has had to pay for the uninsured patients who have come in to be tested. Through Healthy Michigan the Affordable Care Act initiative to expand Medicaid coverage, we have been able to register a lot of our uninsured patients into Medicaid. There are staff at each clinic to enroll patients into Healthy Michigan. However, we have many patients that are undocumented, patients that earn a little over the Healthy Michigan criteria and are not eligible and/or have not purchased their own health insurance, and we have patients that do not follow-up with their Healthy Michigan enrollment. Whatever the reason, there are patients that do not have insurance. Some clinics have been able to write off the lab bills to bigger medical centers but the majority of the collaborative partners and IPH have had to pay a substantial amount of money for the lab fees of the uninsured population because of the initiatives’ testing goals. Gilead has been able to pay some of our uninsured billing. Since then we have built a relationship with MDHHS lab. We will be sending our HIV and HCV test to MDHHS lab for free testing going forward. DRAFT

PART V: RESULTS HIV AND HEPATITIS C OUTCOMES The HIV and Hepatitis C results differed throughout the year. The fluctuation can be due to seasonal trends in patient visits. However, each partnering site increased their screening significantly from April 2015-March 2016 (pre-learning collaborative) to April 2016-March 2017 (post-learning collaborative). Collectively the collaborative increased HIV screening by 59% and Hepatitis C screening by 37%. We attribute this increase to all of the work highlighted in this report. Our learning collaborative allowed the group share best practices, make our policy and clinic flow more efficient, and modify our electronic health records. We have institutionalized the best practices of routine HIV and Hepatitis C at each one of the clinics. The Institution for Population Health was the only clinic that had a decrease in Hepatitis C testing pre and post the learning collaborative. However, as of March IPH implemented EMR modification, now each individual that is eligible for Hepatitis C is screened via automation and the provider receives 32


and screening alert reminder. Prior to this update, our providers were having a hard time determining patients eligible for Hepatitis C screening. Our EMR modification addresses this barrier, we should be seeing our Hepatitis C numbers begin to increase as soon as April 2017.

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PART V: DISCUSSION Our initiative is an example of how the learning collaborative method can be utilized to address and alleviate the spreading of disease in urban areas. The Learning Collaborative offers an important advantage to Detroit which is collective impact. We have utilized all of the sciences of health in Michigan to support this effort and create a healthier Detroit. By including many health care organizations and community clinics in our initiative we have changed the way Detroit’s public health approaches HIV and HCV testing. In addition, we have created a model that can be applied to other health conditions. As we continue to expand our testing, identifying positive patients, and linkage to care capabilities we will include more health care organizations and community clinics in the Detroit Collaborative. We look forward to continuing the Detroit Collaborative in years to come, and having a city that has implemented routine HIV and HCV into each of our local clinic’s office flow. We hope to meet the United Nations’ goal of 90-90-90 with HIV and our nation’s HCV goal of adhering to the HCV cascade of care with each positive HCV patient.

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REFERENCES 1. 2. 3. 4. 5. 6. 7.

AIDSVu National HIV/AIDS Strategy for the United States: Updated to 2020 In the Clinic, Hepatitis C Virus, American College of Physicians Annual HIV Surveillance Report City of Detroit, July 2015 Annual Detroit HIV Surveillance Report, New Diagnoses and Prevalence, 2015 Annual Detroit HIV Surveillance Report- Tables, New Diagnoses and Prevalence, 2015 Combating the Silent Epidemic of Viral Hepatitis: Action Plan for the Prevention, Care, & Treatment of Viral Hepatitis 8. National Health and Nutrition Examination Survey (NHANES) 9. Recommendations for the Identification of Chronic Hepatitis C Virus Infection Among Persons Born During 1945–1965 (MMWR 2012; 61(RR04); 1-18). 10. Michigan Department of Health and Human Services, Hepatitis C annual Surveillance Report, 2015. 11. CDC Guidelines and Recommendation HIV/AIDS, 2017. https://www.cdc.gov/hiv/guidelines/index.html 12. CDC Guidelines and Recommendation HIV/AIDS, Pre-Exposure Prophylaxis (PrEP) 2017. https://www.cdc.gov/hiv/risk/prep/index.html 13. Harnessing the Power of Electronic Medical Record to Facilitate an Opt-Out HIV Screening Program in an Urban Academic Emergency Department 14. Cultural Approach to HIV/AIDS Harm Reduction in Muslim Countries 15. Aids and the Muslim World: A Challenge 16. African Americans, Health Disparities and HIV/AIDS: Recommendations for Confronting the Epidemic in Black America 17. Billing Coding Guide for HIV Prevention DRAFT

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APPENDIX 1: OPERATIONALIZING HIV AND HEPATITIS C TESTING IN YOUR CLINIC QUESTIONS Does your clinic have a policy for HIV and/or Hepatitis screening? If not, what is the process for approving a written policy?

RESOURCES/IDEAS Existing policies used by other clinics for HIV/HCV

Where in your clinical flow does it make sense to notify a patient they will be screened for HIV and Hepatitis?

Clinical flow documentation Registration Posters/brochures/video

Where in your clinical flow does it make sense to consent a patient for HIV testing? No consent is needed for Hepatitis testing

Michigan Law – permits verbal consent / documentation in EMR is OK Medical Assistant Intake Clinical flow documentation

How will laboratory tests for HIV and Hepatitis occur?

Routine lab orders built into EMR or in hard copy Special HIV and Hepatitis lab orders that are limited to 4th generation technology and reflexed testing

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How are confirmation laboratory tests for HIV and Hepatitis processed? Internally or externally? - HIV Antibody positive tests should be reflexed to HIV viral load - HCV Antibody positive tests should be reflexed (automatically ordered) to an HCV PCR RNA How will patients confirmed with infection be notified and by whom?

Conversation with internal lab Conversation with reference lab (e.g. LabCorps) - Quest reflexes all HCV Ab positive tests to HCV RNA (new policy) What vials need to be collected? Color of vials and quantity Current clinical protocol for disease notification to patients Michigan HIV testing law Tracking sheet for documentation

Who are the HIV, HCV, and HBV linkage to care facilities in the city of Detroit and specifically in the areas surrounding your clinics or where your patients live? Can you set up MOU’s with them?

Existing MOU’s with Infectious Disease clinics that can be updated/modified for other clinics List of clinics from IPH

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APPENDIX 2: LINKAGE TO CARE FOR HIV/HEPATITIS C NETWORK

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Using the learning collaborative method to implement routine HIV and Hepatitis C in Detroit  

This toolkit highlights the best practices, including barriers and strategies in the implementation of routine HIV and Hepatitis C screening...

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