Preparing for the Release of CDC's Recommendations for Partner Services Programs for HIV, Syphilis, Gonorrhea, and Chlamydial Infection
This podcast provides information useful to state and local leadership as they prepare for the release of CDC's Recommendations for Partner Services Programs for HIV, Syphilis, Gonorrhea, and Chlamydial Infection. Dr. John Douglas, Director of CDC's Division of STD Prevention and Dr. Rich Wolitski, Acting Director of CDC's Division of HIV/AIDS Prevention, provide some background information on the development of the Recommendations, summarize the key information and features, and describe what plans are underway to support implementation. Created: 10/29/2008 by National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP).
Date Released: 10/29/2008. Series Name: CDC Featured Podcasts.
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[Dr. John Douglas] Good afternoon, everyone. Welcome to CDC’s telebriefing on Recommendations for Partner Services Program for HIV and Other Sexually Transmitted Diseases. In the spirit of the joint recommendations, both Dr. Rich Wolitski who is the Acting Director of the Division of HIV and AIDS Prevention and I will be conducting this briefing. For those of you who don’t know me, I’m John Douglas, Director of the CDC's Division of STD Prevention. Rich and I would like to welcome you to this telebriefing.
These recommendations represent an important milestone for CDC. For the first time since the onset of the HIV epidemic, Partner Services Recommendations for HIV and STD have been integrated. These recommendations replace two previous separate sets of guidelines that governed Partner Services for HIV and Other STDs - the 2001 Program Operations Guidelines for STD Prevention and the 1998 HIV Partner Counseling and Referral Services Guidance.
CDC strongly believes this integration of prevention efforts at the client level will reduce missed opportunities to offer clients needed services when they access care, help eliminate duplication and other structural inefficiencies, and potentially create cost savings while simultaneously realizing public health benefits. The process of developing the recommendations has been highly collaborative and involved many, many partners and end users of the recommendations, including national organizations such as the National Association of People with AIDS and the National Coalition of STD Directors; federal agencies, such as HRSA and SAMHSA; state STD and HIV prevention program and surveillance staff; subject matter experts in relevant areas, such as law and ethics, including Lambda Legal and the American Bar Association; and community-based organizations.
We at CDC extend our thanks to those of you who devoted countless hours to this process. I would like to emphasize that the recommendations were developed to assist jurisdictions with planning, implementing, and evaluating Partner Services. Toward that end, they provide a wealth of policy suggestions and key contextual information intended to indicate what Partner Services programs should do and why. They are not, however, meant to serve either as an instructional manual for day-to-day operations or as a detailed training curriculum for Partner Services. How recommended Partner Services practices are implemented in a particular jurisdiction is left to local discretion. However, CDC does plan to provide programs with technical assistance and supporting materials.
The topics we will cover in this telebriefing today include the genesis of the recommendations, a summary of the highlights of the recommendations, CDC’s expectations regarding implementation, a summary of support CDC will offer for implementation, and implementation challenges. To get started, I’d like to hand this off to my colleague, Rich Wolitski, to briefly explain the genesis of the recommendations.
[Dr. Rich Wolitski] Thank you, John. Hello everyone. As John said I’m Rich Wolitski and I’m the Acting Director of CDC’s Division of HIV/AIDS Prevention. And it really is my pleasure to be here today to participate in this briefing on these new recommendations. The development of these integrated recommendations came about because of a number of factors. And I think first and foremost, you, our partners, noticed inconsistencies between the two sets of guidelines that previously governed Partner Services for STDs and HIV.
Then there were the increasing rates of syphilis and HIV coinfection in many areas that highlighted the discrepancies in approaches and the resulting difficulties in insuring appropriate services. These inconsistencies created confusion for providers of Partner Services for HIV and STDs. And at the same time, new technologies, such as rapid HIV tests, and new concerns, such as the increasing use of the Internet to find sex partners, have required updated recommendations. The integration of these recommendations also falls under a CDC priority of program collaboration and integration. So it was all of these factors that drove the development of these recommendations.
The process of developing these recommendations followed a scientifically sound and rigorous path. This was a process that began in 2005, when CDC led a workgroup that planned and coordinated the revision process beginning with a review and a comparison of the two existing guideline documents and an extensive literature search to identify relevant research. At the same time, about 70 organizations and persons with potential interest in Partner Services were notified of the revision and invited to provide input.
During 2005 and 2006, CDC sought input from attendees at national conferences, conducted reviews of Partner Services and health department jurisdictions, conducted focus groups with potential recipients of Partner Services and private clinicians, and conducted a detailed review of state laws and regulations related to Partner Services. All of this accumulated in the development of a draft of the recommendations. In November 2006, CDC convened a meeting to obtain input into the draft, which approximately 70 participants from 23 states and the District of Columbia attended.
So based on the outcomes of that meeting, CDC then convened seven workgroups to revise the draft recommendations. In January of this year  the revised draft was distributed for review to a wide range of persons who represented all facets of interested parties, including non-federal subject matter experts. The document was finalized after revisions based on those reviewer comments.
Important concepts that were key in the development of these recommendations were the respect for the value of local innovation and the variety of context within which our partners operate. Therefore, even though the recommendations indicate what an effective Partner Services program should include and why, they do not include specific instructions about how Partner Services programs should operate or implement recommended practices.
Now I’d like to talk about a few of the highlights of the new recommendations. As I mentioned, these new recommendations sought a balance between direct guidance and respect for local flexibility and program innovation. With that balance in mind, here are some of the most important points in the recommendations.
• All persons who are newly diagnosed or reported with early syphilis or HIV/AIDS infection should be offered Partner Services, typically at or as soon as possible after diagnosis.
• Partner Services programs should use surveillance and disease reporting systems to assist them with identifying persons with newly diagnosed or reported STDs, including HIV, for potential candidates for Partner Services.
• At a minimum, health departments should use provider and aggregate level data from the surveillance systems to support Partner Services.
• Health departments should insure that appropriate data security and confidentiality procedures are in place and should strongly consider using individual level data to maximize number of persons offered Partner Services.
Whatever the particular approach used to notify partners of their exposure, the health department should be directly involved. Programs should create strong referral linkages with care and prevention service providers to insure that the needs of patients and their partners are addressed. Moreover, in the case of HIV infected individuals, follow-up should be conducted to verify that they have accessed medical care or HIV case management at least once. Partner Services program managers should assess and eliminate barriers to programmatic collaboration and service integration within their jurisdictions with the specific goal that clients receive comprehensive STD/HIV prevention services regardless of how or where they entered the system.
Partner Services programs should have systems in place to monitor and evaluate program performance and to identify areas that need improvement. Now John is going to explain CDC’s expectations regarding implementation of the recommendations and he’s going to summarize how CDC will support those efforts.
[Dr. John Douglas] Thanks very much, Rich. So it’s clear that these recommendations make a case for the importance and effectiveness of Partner Services. Further, Partner Services offer STD, HIV, and other public health programs an excellent opportunity for collaborating to deliver comprehensive services to clients, improve program efficacy, and maximize the positive effects on public health.
Because CDC values Partner Services so highly, it expects jurisdictions that receive CDC funding for Partner Services to move toward having programs that are consistent with the recommendations. HIV and STD program managers should look to the program requirements in their cooperative agreements and to their project officer and program consultant for specific technical direction and assistance. CDC will continue to monitor HIV and STD Partner Services through the collection of program performance measures; information provided by grantees in their progress reports; information obtained through CDC site visits; and for HIV – data collected through the program monitoring and evaluations system, otherwise knows as PMES.
Grantees should also regularly review their local Partner Services implementation and outcomes data. CDC recognizes that implementing integrative Partner Services programs will cause varying shifts in programs, depending on the jurisdiction. Therefore, we are developing a number of new products and strategies to assist jurisdiction with the implementation of the recommendations.
Training is one key element of the implementation strategy. CDC is working with the STD/HIV Prevention Training Centers to revise the current STD and HIV Partner Services training materials to create one, integrated Partner Services training. CDC anticipates incorporating a variety of teaching methodologies into the training materials. For example, some materials may involve computer technology, such as e-learning, while other materials may involve instructor-led sessions. CDC also plans to offer a series of Train the Trainer sessions, in addition to other technical assistance to local instructors.
Finally, we intend to cross-train Division of STD Prevention and Division of HIV/AIDS Prevention instructors in the materials, so both divisions can work effectively with local programs. CDC may also develop or revise other training products, as needed, based on grantee needs.
Technical assistance is another element of the implementation strategy. Currently, CDC grantees can access individual and programmatic TA through the following means or individuals: HIV project officers, STD program consultants, and/or surveillance project officers assigned to their jurisdiction; CDC staff with technical expertise in Partner Services; STD/HIV Prevention Training Centers; and other national partners, such as the National Alliance of State and Territorial AIDS Directors, or NASTAD, and the National Coalition of STD Directors, or NCSD. CDC is presently working with national partners to develop a Partners Services technical assistance system that will focus on providing TA to individuals and organizations implementing the recommendations.
Finally, CDC will maintain a Web site that will house the recommendations and related materials, such as questions and answers. Now I’ll turn the briefing back over to Rich to conclude the discussion by summarizing potential challenges to implementation.
[Dr. Rich Wolitski] Thank you, John. CDC believes that there are two main challenges to implementing these recommendations. And these challenges are the sharing of surveillance data between the surveillance and Partner Services programs and the current lack of additional resources. So let’s begin by discussing the sharing of surveillance data.
As you know, the data collected through HIV/AIDS and STD surveillance systems are used for many complimentary public health purposes at the national, state, and local levels. So for example, such data are used to monitor disease, estimate incidents of infection, identify changing trends in transmission, target and evaluate prevention interventions, and allocate funds for HIV care and prevention services. Many states and territories also use case reports to initiate Partner Services for infected individuals and offer referrals for prevention, medical care, and supportive services.
Sharing information between HIV/AIDS and STD surveillance programs and Partner Services programs can be important for comprehensive disease intervention and potentially offers many benefits to both programs. For example, surveillance data can provide a more complete understanding of the population of persons newly diagnosed with HIV or other STDs who are in need of Partner Services. And they can supply valuable information on demographics and risk characteristics. Surveillance data can also identify existing or previous coinfections among Partner Service clients and insure that they are and their partners receive appropriate services.
Surveillance data can help Partner Services programs identify and develop relationships with healthcare providers who diagnose and treat persons with HIV and other STDs. Consequently, Partner Services programs can better target their education and outreach efforts to key service providers. Similarly, the benefits of the surveillance system should not be underestimated. As a result of the collaborative relationships they have established with healthcare providers, Partner Services programs can also improve surveillance reporting by encouraging complete and timely reporting of HIV/AIDS and other STDs.
Similarly, disease intervention specialists can contribute to more complete reporting by surveillance by finding data, such as information about risk, thereby strengthening the surveillance program. These are just a few of the mutual benefits to both surveillance and Partner Services programs that can be derived from linking the two programs. However, CDC recognizes that there may be vulnerabilities associated with using surveillance data for non-epidemiologic purposes.
For one thing, certain states may have laws prohibiting the use of these data for anything other than epidemiological purposes. Also, in implementing name-based HIV reporting, certain jurisdictions may have made informal agreements not to use data collected through surveillance systems for anything other than epidemiological purposes. Additionally, concerns about personal privacy, confidentiality, and security of personal data are increasing across all of society.
These recommendations were crafted with those concerns in mind. CDC recognizes that Partner Services data for STDs and HIV, with or without data obtained from disease reporting systems, are among the most sensitive public health data routinely collected. As such, they merit careful protection. The new recommendations encourage all Partner Services programs - whether they share data with surveillance programs or not – to establish and adhere to strict jurisdiction-specific guidelines, policies, and procedures for information security and confidentiality.
In addition, an appendix to the recommendations outlines a set of guiding principles and standards which must be met and must be in place before Partner Services and surveillance programs share individual-level data. These standards, which were drafted in close collaboration with representatives from the Council of State and Territorial Epidemiologists, or CSTE, closely adhered to your previously published technical guidance from CDC and CSTE describing minimum data security and confidentiality standards that should be met by surveillance programs. As such, the standards included in the recommendations reflect best practices for protecting HIV/AIDS surveillance and Partner Services data.
Now, let’s move on to the challenge of limited resources. At this time, neither DEHAB nor DSTDP anticipate having additional funds to support programs with implementing the new recommendations for HIV/STD Partner Services. We do plan to offer material and technical assistance throughout the implementation process. We’re encouraging partners to identify resources to support the implementation of Partner Services through activities, such as forming strategic partnerships with other service providers, or diverting funds from less effective or lower priority programs, and/or examining current operations to ensure that existing resources are being used efficiently.
As John mentioned, CDC is currently developing a number of products and services that will support implementation of the new recommendations, including an operational guide and monitoring tools, a new modular training curriculum, a formal system for requesting and providing technical assistance, and a supplemental interview form to assist in gathering HIV Partner Services data that are not included in the current STD/HIV interview record form. CDC expects to begin introducing these products by early 2009. In the interim, health departments are strongly encouraged to begin implementing the recommendations and to assess the policy and programatic changes that will be needed to implement any unaddressed recommendations.
In conclusion, Partner Services have proven to be a vital component of disease intervention. They have shown to be not only cost effective, but cost saving. Because of their benefits, CDC strongly recommends that all persons with newly diagnosed or reported HIV infection or early syphilis receive Partner Services with active health department involvement.
CDC also recognizes the importance of Partner Services for those diagnosed gonorrhea or chlamydial infections. However, the reality of resource limitations dictates that health departments might need to limit their direct involvement to high priority cases for these infections. Given these resource constraints and the importance of insuring Partner Services to persons with gonorrhea and/or Chlamydia, program directors and managers should note that expedited partner therapy - whereby patients deliver treatment or prescriptions to their partners directly, without a previous medical evaluation – can be a useful and a cost effective way to offer Partner Services.
These new recommendations highlight the importance of program collaboration and service integration. STD and HIV Partner Services offer STD/HIV and other public health programs an excellent opportunity for collaborating to deliver comprehensive services to clients, improve program efficiency, and to maximize the positive effects on public health.
In closing, I’d like to note that we deeply appreciate our collaboration with many of you during the development of these recommendations and we look forward to working with you in the coming months as you begin implementing them in your jurisdiction.
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