This document summarizes lessons learned from implementing HIV screening and treatment programs that could be applied to improving chlamydia screening and treatment efforts. Some key points discussed include the need to remove barriers to testing, improve linkage between testing and treatment, address disparities in screening and treatment rates, and work with private healthcare systems by understanding their unique contexts and incentives. Expanding recommendations and performance metrics could help drive improved chlamydia screening and treatment practices.

1. HIVI HIV Initiative of Kaiser Permanente and Care Management Institute
Making Chlamydia Screening a
Priority in Medical Groups:
Lessons Learned from HIV
Michael Horberg, MD MAS FACP FIDSA
Executive Director Research, Mid-Atlantic Permanente
Medical Group
Director, HIV/AIDS Kaiser Permanente
Clinical Lead HIV/AIDS, Care Management Institute
Chair-Elect, HIV Medicine Association

2. Speaker Disclosures
• Financial
• Employee of Mid-Atlantic Permanente Medical
Group, PC
• Research grants from Merck, Inc. and Pfizer
Pharmaceuticals
• Organizational
• Chair-Elect, HIV Medicine Association
• Member and committee chair, Presidential Advisory
Council on HIV/AIDS
Please note that the opinions expressed in this
presentation represent those of the presenter and do not
necessarily reflect the view of Mid-Atlantic Permanente
Medical Group or Kaiser Permanente.

3. First, the Private Healthcare World
• Mainly smaller medical groups or individuals in
practice
• Many with a hospital affiliation but not all
• Usually multiple contracts with multiple insurance plans
• Can be through a hospital, IPA, or as an individual
• Each insurance plan has its own
rules, reimbursement policies, and emphases
• Many say emphasis on “prevention” but that can be
highly variable
• Few doctors have a national focus
• Or need to…

4. Private Healthcare World
• More correctly, few doctors can reasonably have a
focus beyond their immediate patients
• Hard enough to manage your own panel of patients
• But deal with others?
• Most insurance plans are not worried about people
outside of their covered patients
• No incentive to do so; likely dis-incentives to do so.
• Same applies to hospital (systems) and larger
group practices.
• Exceptions are usually non-profit health systems*
*--Examples are Health Partners, Group Health

5. Kaiser Permanente (KP)
•Integrated delivery system
(hospitals, clinicians, pharmacies, lab
and x-ray, etc.) and financing scheme
•Operates like a mini-“national health Permanente
system” Medical
 Single funding stream with global
budget Groups
 Accountable for total health of a
population
Health Plan
•Compete in the market for employer
groups, members, physicians Members—Our Patients
•KP defines the integrated model of Kaiser
health care financing and delivery Kaiser Foundation
through its unique partnership among Foundation Health Plan
three entities – contractual and Hospitals
exclusive

6. Kaiser Permanente - Where We Are

7. HIV Demographics Vary:
Comparison between US, VA, and KP—For Context
Kaiser
Permanente (KP)
United States VA + Group Health
Year 2006 2008 2010
Number HIV+ 1,100,000 (est.) 23,463 20,180
% Female 25% 3% *16%
% Black 50% 50% *18%
% Latino 20% 7% *15-25%
% >50 years of age 27% 64% 42%
*--Varies significantly by state
KP and GHC operate in 9 states plus DC.
KP HIV population rising annually; VA remains steady.
Sources: CDC, KFF, VA, KP
Slide 7

8. National HIV/AIDS Strategy (NHAS)
First domestic HIV strategic plan
 Akin to PEPFAR and US Global AIDS Strategy
Goals based on the President’s principles for HIV
care in US
Implementation will be key
 Coordination of federal agencies (including VA)
 Coordination of Public and Private
 PACHA will have role (citizens’ representation)
 Establishment of national metrics to gauge success
Slide 8

9. National HIV/AIDS Strategy Goals…By 2015
Reduce New Infections
 ↓New Infections by 25%
 ↑to 90% Americans who know their HIV Status
 ↓Transmission by 30%
Improve Access and Outcomes
 ↑to 85% HIV+ in care within 3 months of Diagnosis
 Seamless system of testing and linkage to care
 Increase HIV providers
 Set quality standards and monitor
Reduce HIV-Related Health Disparities
 ↑ by 20% HIV+ MSM*, Blacks, Latinos with HIV RNA BLQ*
*--MSM: Men having sex with men; BLQ: Below limits of quantification

10. Health Care Coverage HIV+--National
This should
decrease
with HCR
SOURCE: Kaiser Family Foundation based on Fleishman JA et al., “Hospital and Outpatient Health Services Utilization Among HIV-Infected
Adults in Care 2000-2002, Medical Care, Vol 43 No 9, Supplement, September 2005.; Fleishman JA, Personal Communication, July 2006 Slide 10

11. Issue 1: Identify Undiagnosed and
Prevent New Infections
These two points cannot be separated
 Similar issue for chlamydia
Test patients for HIV
 Remove testing barriers
 Routinize testing
“Sexual health as a vital sign”?
Can’t treat HIV (or chlamydia) if you haven’t diagnosed it
 Repeat regularly if risk behavior present
CDC, MMWR, September 22, 2006 / 55(RR14);1-17
Slide 11

12. Why Don’t We Test More:
Barriers to HIV Testing
Guidelines Conflict
 CDC and USPSTF Guidelines differ
CDC: Routine testing of all Americans aged 13-64
USPSTF: No recommendation for routine testing (C Level)
Recommend at-risk testing and pregnant women (A Level)
No nationally accepted metric on HIV testing
Written informed consent used to be a barrier
 Not for other sexually transmitted infections or routine blood tests
 46 states, DC, and the VA no longer require written consent
Only California, DC mandate coverage of cost of test
 Medicare now covering targeted HIV testing
 Preventive services included in healthcare reform— only with USPSTF
A/B
STIGMA
Slide 12

13. How HIV Testing Issues Relate to Chlamydia
USPSTF Recommendations limit perceived need of testing:

14. HEDIS (NCQA) Doesn’t Help Either
HEDIS Measure: Chlamydia screening: percentage of
women 16 to 24 years of age who were identified as
sexually active and who had at least one test for
chlamydia during the measurement year.
• Most clinicians will not be concerned with others
• Most health plans will not be concerned with other
patients
• Need to get HEDIS and USPSTF to expand definitions and
recommendations
• Note: CDC is “lukewarm” to more general testing
also.

15. KP Performance on Chlamydia Testing
• Committed to it
• (KP Georgia #1 nationally—not just within KP)
• US 90th Percentile performance: 53.4% (age 16-24)
• KP Program wide performance: 65.8%*
• All KP regions are above US 90th percentile
• Also, all regions and KP nationally above US 90th
percentile for ages 16-20 or 21-24 age groups
• KP performance demonstrates that with
commitment at multiple levels this is achievable
• But even we can improve
*--Commercial plans; similar results for Medicaid only patients

16. But Even Bigger Barrier…
Provider discomfort about talking to their patients
about sex maybe biggest barrier of all.
• Especially if the patient is older than the doctor
• And may be “preachy” rather than frank and open with
younger patients
Also, many doctors do not perceive their patients at
risk
• This is true even among doctors in adolescent clinics
and other “high risk” clinics.
• We see this a lot in HIV—adolescent doctors don’t think
their sexually active patients are at risk

17. Issue 2: Testing is NOT Treatment
I know I’m stating the obvious and “preaching to the
choir”.
• Of course, you cannot treat if patients are
not diagnosed
• And you cannot treat if patients are not in
care
• Or seeking care
• And there is often a disconnect between
testing and treatment
• Including linkage to care

18. Linking patients to HIV care
(and helping patients access care)
42-59% HIV+ in US are not in care
 Includes undiagnosed and lost to follow-up
 Greater risk of late entry for older Americans and males
Testing and then Link to Care
 Critical step that has many potential and REAL gaps
 Including those lost from care
 Care means evaluation for ART and earlier use of ART
 Requires increased ART adherence efforts
Unlike integrated care systems, testing is often
uncoupled with care systems
Potentially, the biggest challenge in HIV care
Van Gorder, 2010; Klein, et.al., JAIDS, 2003; Althoff, et.al., CID, 2010;
Hogg, et. al., The Lancet, 2008; 372: 293-299 Slide 18

19. KP Non-NQF HIV Quality Measures
non-NQF Measures: All Sites Combined: 2007, 2008, 2009
Linkage to care KPCO and KPHI data not available for 2007
100 93.8 94.0 94.3
88.6 88.8 87.5
90
80
70 61.7 61.8 60.5 62.4
55.4 59.3
Percent
60
50
40 27.1 25.7 25.6
30
20
10
0
HIV Testing CD4 Measured CD4 < 200 Adherence Median ART
Among STI in 90 days of Among Newly to ART ≥90% Adherence
Positives Identified HIV+ Diagnosed
(3 STI) HIV+
2007 2008 2009

20. Our NQF/NCQA HIV Quality Performance
NQF Endorsed Measures--KP Performance
Reflects multidisciplinary team effort
100.0 92.9 94.4 94.5
86.3 85.8 85.5 86.8 89.2 90.5
90.0
76.8 79.3 77.8
80.0
Percent Success
68.0 65.6 65.9
70.0
60.0 2007
50.0 2008
40.0
2009
30.0
20.0
10.0
0.0
Retention CD4 PCP On HIV HIV RNA <75/mL
In Care Measured Prophylaxis Treatment
Metric

21. VA HIV Care Quality Measures
(2008 data)
79% with VL/CD4 in last 6 months
31% met AIDS criteria at entry into registry*
 14% met AIDS criteria—all HIV+
86% appropriate PCP prophylaxis
72% ever pneumococcal vaccination
77% Hepatitis B immune or vaccinated
96% Hepatitis C screened
83% HIV+ on ART with maximal viral control
*--Either newly diagnosed or transferred into VA
Slide 21
The State of Care for Veterans with HIV/AIDS, December 2009; www.hiv.va.gov

22. HIV Lessons for Chlamydia and Access to Care
• Performance metrics are for testing and not
treatment
• Again, these are often disassociated
• Testing may be by one department but treatment by
another
• Or more likely, sexual health treatment outside of
system but rest of care is not
• Primary care may not be the ones doing follow-up or
gynecology may test but not be the ones to get test results
• This is potentially less of an issue with the greater
deployment of electronic health records

23. New Pap Guidelines Don’t Help Either
• For women, gynecologist is often the primary
care doctor
• Historically, it’s why women see primary care more
often than men when looking at folks <50 years old
• New pap guidelines (gee thanks ACOG…) are to
start 3 years after first sexual activity or 21yo and
then q 3 years
• Likely won’t get women in annually
• Also, with increased HPV vaccination, there may
be even less returns in the future.

24. HIV Lessons for Chlamydia and Treatment
• Treatment has costs
• Don’t forget co-pays
• For students and poorer folk this is real issue
• Fortunately, azithromycin is generic
• As is doxycycline, erythromycin, ofloxacin
• Not levofloxacin yet
• Follow-up testing for cure is rare
• Not advised by CDC for initial treatment
• Recommended if repeat treatments required
• Especially if treatment was not in healthcare system
• Example: gets tested/treated at Planned Parenthood
but usual care is with private doctor

25. Issue 3: Treatment for Partners
• Rarely, treatment for partner happens
• Not covered by insurance usually
• And no real incentive to do so
• Not covered by Medicare or Medicaid
• You cannot write a double dose prescription if not
for the patient to take himself/herself
• And no “wink wink”!
• Potential medical, safety, and bacteriologic issues
with empiric treatment for partners
• Need to know drug allergies of partner
• Could widespread use lead to resistance?

26. Issue 4: Remove Disparities—
The Application to Chlamydia is Obvious
Stigma is rampant in HIV
 Both at testing and at accessing care
 And racial discrimination
Patients must feel valued, at ease, and have faith in healthcare providers
Community must support HIV+ patients and those at risk
 Public-private partnerships likely of use
Need to improve outreach to youth and older Americans
 Consider newer technologies (do you tweet?)
 Go to where they are; not where you are
Remove language barriers and health illiteracy
Consider gender issues
STOP HOMOPHOBIA AND RACISM!!
Slide 26

27. Issue 4b: Adolescents and Their Parents
• Minors can consent for STI screen and treatment
without parental consent or notification
• All 50 states plus DC
• However, “explanation of benefits” (EOB) may go
to parent
• This is a breach of confidentiality but very grey area in
the law
• It’s who pays for the insurance…
• Some health systems, like KP, don’t have EOB so not
an issue
• Potential solution: No co-pays and fees for STI care
• Title X clinics are exempt

28. Making the Case in a Private Health System
What will work: What will not work:
1. Engage partners 1. Telling them what to do
2. Be open to their ideas 2. No consideration of
 Each system is VERY financial issues
different.  I’d recommend
 It’s not one size fits all abandoning partner
3. Understand their context treatment for now
 They may not want 3. No consideration of
chlamydia as its own USPSTF or HEDIS
issue limitations
4. Work to reduce stigma on 4. Not recognizing that ACA
a more public basis will have great impact

29. Potential Solutions
1. Think about joining all STI under “sexual health”
 KP did this with our latest HIV and STI testing and
prevention guidelines
 “Ask, Screen, Intervene” is applicable to all STI, even
if USPSTF and NCQA don’t think so
 Widen the scope of Why Screen for Chlamydia
2. Work to have USPSTF expand recommendations
 Insurers, Medicare, and health care reform work off of
USPSTF levels A and B recommendations
3. Get HEDIS criteria expanded
 Health plans respond to HEDIS!!
 Consider reporting results on your website

30. Potential Solutions (2)
4. Recognize health systems that succeed
 It becomes a matter of pride
 And let’s them know someone is paying attention
5. Work to fully implement ACA (Health Care
Reform)
 Strong emphasis on preventive medicine
 More Americans in care
 With (hopefully) greater “essential benefits” many
states will expand sexual health and treatment for
conditions

31. Potential Solutions (3)
6. Find champions at medical centers and health
systems
 The more local the better, but respect the rules of the
health systems
 Probably better if they are the peers of the target
audience
 So, if target audience is pediatricians, make sure
champion is a pediatrician
 May require multiple champions at a single medical
center/system
 This may require grants, $$, and training
 CME credit?

32. “Working together, I am confident that we
can stop the spread of HIV and ensure that
those affected get the care and support they
need.”
--President Barack Obama
The same applies to chlamydia.
The great work continues. Thank you.
Slide 32