A randomized controlled trial to evaluate a structural intervention to promote the female condom in New York state.

We conducted a structural intervention to promote the female condom (FC), comparing 44 agencies randomized to a Minimal Intervention (MI) [developing action plans for promotion and free access] or an Enhanced Intervention (EI) [with the addition of counselor training]. Intervention effects were evaluated via surveys with agency directors, counselors and clients at baseline and 12 months. Agency-level outcomes of the FC did not differ between the two interventions at follow-up. Counselors in the EI showed significantly greater gains in FC knowledge and positive attitudes, although there was no difference in the proportion of clients counseled on the FC, which significantly increased in both conditions. There was a greater increase in intention to use the FC among clients in EI agencies. Intervention effects were stronger in medical agencies. Findings suggest that making subsidized FCs available and assisting agencies to formulate action plans led to increased FC promotion. Limitations and implications for future research and intervention efforts are discussed.

Program and policy interventions for preventing mother-to-child transmission of HIV in New York State.

Mother-to-child transmission (MTCT) of human immunodeficiency virus has been virtually eliminated in New York State (NYS) in a relatively short time. The dramatic reduction in MTCT was achieved through a comprehensive public health program that maximized the benefits of advances in both diagnosis and treatment of HIV infection. The multifaceted program encompassed interventions at multiple levels. It mobilized and engaged medical providers, and it changed clinical practice and the health care delivery system in NYS. Specific approaches were developed and modified over time by using data from multiple sources and in response to medical and scientific advances. This article describes factors associated with MTCT in NYS, the framework for program development, the evolution of NYS's public health program to prevent MTCT, remaining issues, and recommendations.

Progress in prevention of mother-to-child transmission of HIV in New York State: 1988-2008.

OBJECTIVES: To assess the outcomes of efforts to prevent mother-to-child transmission (MTCT) of human immunodeficiency virus (HIV) made over the last 2 decades in New York State (NYS), through review of data from multiple sources. METHODS: Using available surveillance, laboratory, and program monitoring data, the following were examined for NYS: (1) the rate of prenatal HIV testing, (2) HIV prevalence among childbearing women, (3) maternal prenatal and delivery care, (4) care of HIV-exposed infants, and (5) the rate of MTCT. Trends over time and comparisons among groups were assessed. RESULTS: In NYS, HIV prevalence in childbearing women has declined 70% since its peak in 1989. Rates of prenatal HIV testing have been more than 95% in recent years. Rates of MTCT have decreased significantly; since 2003, transmission in HIV-exposed births has ranged from 1.2% to 2.6% annually. On bivariate analysis, MTCT is more likely to occur with breastfeeding or absence of antiretroviral administration in the prenatal, labor/delivery, and newborn periods. CONCLUSIONS: Mother-to-child HIV transmission has declined dramatically in all groups in NYS. Universal newborn screening data have provided the foundation for identifying HIV-exposed births and for initiating follow-up to track all aspects of MTCT in NYS. Remaining challenges include universal prenatal care, prevention of acquisition of HIV infection during pregnancy, and adherence to antiretroviral therapy.

Who purchases nonprescription syringes? Characterizing customers of the Expanded Syringe Access Program (ESAP).

This study represents the first attempt in the USA to survey pharmacy nonprescription syringe customers at their point of purchase. We surveyed 62 individuals purchasing nonprescription syringes in seven pharmacies located in NYC and Albany, NY, USA. Three quarters of respondents purchased for illicit use, and 36% purchased for medical use, with differences found by race and gender. Half got their syringes from pharmacies "most of the time." Half had ever been refused a syringe purchase in a NYS pharmacy, with men, Blacks, and Hispanics reporting higher levels of refusals than women or whites. Two thirds reported syringe reuse but very few reported sharing. While approximately one quarter safely obtained and disposed of syringes "most of the time," two thirds used both safe and unsafe methods. Pharmacy-based syringe access programs are essential in areas not served by syringe exchanges.

Expanding access to sterile syringes through pharmacies: assessment of New York's Expanded Syringe Access Program.

OBJECTIVES: To investigate the evolution of pharmacist practices, attitudes, and experiences with the Expanded Syringe Access Program (ESAP), which permits over-the-counter sale of syringes by registered pharmacies in New York State. DESIGN: Longitudinal study. SETTING: New York State in 2002 and 2006. PARTICIPANTS: 506 (2002) and 682 (2006) managing pharmacists (response rates approximately 70%) at ESAP-registered pharmacies (n = 346 in both years). INTERVENTION: Mailed surveys (2002 and 2006). MAIN OUTCOME MEASURES: Pharmacist practices, attitudes, and experiences with ESAP over time. RESULTS: Approximately 75% of pharmacists reported that ESAP had facilitated timely/emergency access to syringes, and more than 90% in each year reported no problems or very few problems administering ESAP. The practice of placing additional requirements on the sale of syringes decreased from 2002 (51.4%) to 2006 (45.1%), while a 55% increase in syringe sales was reported between 2002 (43.3/month) and 2006 (67.1/month). The sale of sharps containers also increased between 2002 (85.2%) and 2006 (92.8%). Community independent pharmacies and those located outside New York City generally expressed more favorable attitudes and experiences with ESAP, although these differences decreased over time. CONCLUSION: Pharmacy-based syringe access is a viable harm-reduction alternative in the fight against blood-borne diseases, with ESAP now equaling the number of syringes being distributed by syringe exchange programs in New York State. Continued education/training is necessary to increase participation in ESAP and to further reduce barriers to ESAP use.

Increasing safe syringe collection sites in New York State.

This article describes expansion of options for safe syringe collection in New York State (NYS) in conjunction with efforts to enhance and expand access to hypodermic needles and syringes. Together with activities to educate the public and providers about the dangers of improperly disposed of syringes, the goals were to (1) develop community-based collection sites for individuals to safely dispose of used syringes and (2) improve accessibility of existing health-care facility-based collection sites. During the period of 2002 to 2006, 79 community-based collection sites were created. These sites collected an estimated 2.6 million used syringes during 2006. Significant increases in availability and use of health-care facility-based collection sites was also documented. Efforts to promote safe disposal in NYS are ongoing, informed by these findings.

Bill Kane passionate practitioner.

William "Bill" M. Kane, PhD, CHES. William "Bill" M. Kane, PhD, CHES, was a man with public health credentials that could impress just about anyone. He served as executive director of both the American College of Preventive Medicine and the Association for the Advancement of Health Education. He was a professor of health education at the University of New Mexico, and taught at several other colleges and universities over the course of his career. He spent time as director of school health programs at ETR Associates, and served on the boards of several nonprofit organizations devoted to public health and health education. He received many honors, and wrote or coauthored over 50 books and curricula focused on health. Bill Kane was undoubtedly a man who got a lot done. But, even more important for those of us who work in public health, he remains a consummate model of how to do this work with passion.

Screening persons newly diagnosed with HIV/AIDS for risk of intimate partner violence: early progress in changing practice.

Interventions to prevent intimate partner violence (IPV), including among those at risk for or living with HIV/AIDS, are needed. In 2001, screening persons who test positive for HIV for risk of IPV was required in New York State, launching the first large-scale program to screen for IPV risk in conjunction with HIV counseling and testing (HCT). Written surveys of counselors, physicians, and agency supervisors explored attitudes, practices, knowledge, and training needs surrounding screening for risk of IPV during HCT. Most HCT providers were aware of screening requirements, but practice varied. Counselors were more likely to screen than were physicians and asked more screening questions. Despite guidelines, screening was generally not standardized and sporadic. IPV screening in conjunction with HCT is possible. Building capacity and commitment of local HCT providers through provision of training and by fostering partnerships with public health partner services staff can help overcome identified barriers to preventing IPV in a high-risk population.

Early results of a statewide initiative to involve faith communities in HIV prevention.

In the United States, racial/ethnic health disparities persist across all leading health indicators. In 2005, African Americans accounted for half of all HIV/AIDS cases, but only 12 percent of the US population was African American. Since the beginning of the HIV/AIDS epidemic, the New York State Department of Health, AIDS Institute recognized the importance of faith communities' involvement in HIV prevention. A survey assessed faith community involvement in HIV prevention, identified barriers to involvement, and determined willingness to partner with HIV prevention programs. Although less than 25 percent of respondents reported involvement in HIV prevention, 50 percent were willing to meet with service providers. Those willing to meet included 74 percent of faith leaders with primarily African American congregants. On the basis of the survey and subsequent forums, a statewide initiative was created to involve faith communities in HIV prevention. An assessment of the statewide initiative showed that it has been highly effective in engaging faith community involvement, including a large number of African American faith communities. These findings have implications for future programming and can aid to further strengthen the statewide initiative.

HIV/AIDS case managers and client HIV status disclosure: perceived client needs, practices, and services.

People living with HIV/AIDS often need assistance in deciding whether or how to disclose their HIV status to others, and case managers are in a unique position to offer this assistance. The current study surveyed 223 case managers providing services to people living with HIV/ AIDS in NewYork State. The survey was conducted anonymously, and case managers were sampled at the agency level. Results showed that two-thirds of case managers routinely discuss disclosure issues with their HIV-positive clients. However, case managers often felt that they lacked the resources to provide assistance with disclosure decisions, and 66 percent of those who routinely discuss disclosure issues had not received training in assisting with disclosure to sex and injection drug-sharing partners. HIV disclosure issues were also seen by case managers as only one of many pressing issues facing their HIV-positive clients; other pressing issues were housing, food, medical care, mental health treatment, and preventing HIV transmission. These results indicate a need for training and resources to facilitate HIV status disclosure assistance services offered by case managers.

Integrating multiple programme and policy approaches to hepatitis C prevention and care for injection drug users: a comprehensive approach.

BACKGROUND: New York State is home to an estimated 230,000 individuals chronically infected with hepatitis C virus (HCV) and roughly 171,500 active injection drug users (IDUs). HCV/HIV co-infection is common and models of service delivery that effectively meet IDUs' needs are required. A HCV strategic plan has stressed integration. METHODS: HCV prevention and care are integrated within health and human service settings, including HIV/AIDS organisations and drug treatment programmes. Other measures that support comprehensive HCV services for IDUs include reimbursement, clinical guidelines, training and HCV prevention education. Community and provider collaborations inform programme and policy development. RESULTS: IDUs access 5 million syringes annually through harm reduction/syringe exchange programmes (SEPs) and a statewide syringe access programme. Declines in HCV prevalence amongst IDUs in New York City coincided with improved syringe availability. New models of care successfully link IDUs at SEPs and in drug treatment to health care. Over 7000 Medicaid recipients with HCV/HIV co-infection had health care encounters related to their HCV in a 12-month period and 10,547 claims for HCV-related medications were paid. The success rate of transitional case management referrals to drug treatment is over 90%. Training and clinical guidelines promote provider knowledge about HCV and contribute to quality HCV care for IDUs. Chart reviews of 2570 patients with HIV in 2004 documented HCV status 97.4% of the time, overall, in various settings. New HCV surveillance systems are operational. Despite this progress, significant challenges remain. DISCUSSION: A comprehensive, public health approach, using multiple strategies across systems and mobilizing multiple sectors, can enhance IDUs access to HCV prevention and care. A holisitic approach with integrated services, including for HCV-HIV co-infected IDUs is needed. Leadership, collaboration and resources are essential.

Expansion of adult hepatitis A and B vaccination in STD clinics and other settings in New York State.

Since 1995, the New York State (NYS) Adult Hepatitis Vaccination Program has promoted adult hepatitis B vaccination for those receiving sexually transmitted disease (STD) clinic services. An average of 6,333 doses was administered annually from 1995 to 1999. By 2000, only 15 of 57 county STD programs in NYS outside of New York City participated. From 2000 to 2005, efforts to enroll county health departments and others included outreach, provision of hepatitis A and B vaccine, materials and training, and new collaborations. All 57 counties now participate. From 2000 to 2005, the number of settings offering hepatitis vaccination increased from 57 to 119. Sites include STD clinics; jails; migrant, Indian health, and college health centers; and methadone clinics. More than 125,000 doses of hepatitis A and B vaccine were administered from 1995 through 2005, with annual increases up to a high of 21,025 doses in 2005. Intensive promotion expanded hepatitis vaccination to all county STD clinics and other settings where high-risk adults can be vaccinated.

Promoting HCV treatment completion for prison inmates: New York State's hepatitis C continuity program.

This article describes the development of a statewide program providing continuity of hepatitis C virus (HCV) treatment to prisoners upon release to the community. We discussed length of stay as a barrier to treatment with key collaborators; developed protocols, a referral process, and forms; mobilized staff; recruited heath-care facilities to accept referrals; and provided short-term access to HCV medications for inmates upon release. The Hepatitis C Continuity Program, including 70 prisons and 21 health-care facilities, is a resource for as many as 130 inmates eligible to start treatment annually. Health-care facilities provide fairly convenient access to 87.1% of releasees, and 100% offer integrated HCV-human immunodeficiency virus/acquired immunodeficiency syndrome care. As of March 2006, 24 inmates had been enrolled. The program was replicated in the New York City Rikers Island jail. The program is operational statewide, referrals sometimes require priority attention, and data collection and other details are still being addressed.

Integrating HIV prevention activities into the HIV medical care setting: a report from the NYC HIV Centers Consortium.

With the maturing of the HIV epidemic and availability of potent antiretroviral therapies in the US, priorities for HIV prevention have shifted from general population approaches to case finding, treatment, risk reduction and relapse prevention activities among those at greatest risk for acquiring or transmitting HIV infection. The challenges of this approach include ensuring access and adherence to HIV care and treatment and appropriate prevention activities to ensure adequate and sustained sexual and drug use risk reduction across diverse populations. Experience with approaches to address these issues, particularly in the context of primary care, has been limited. An agenda for future research and practice includes continued development and evaluation of interventions that can address this next generation of health care issues.

HIV/AIDS and Native Americans: the health departments' response.

For some time, state health department HIV/AIDS programs have worked with communities of color to address their unmet needs. Because of the need for a holistic approach to the multiple issues impacting these communities, efforts to address HIV/AIDS in Native American communities are often integrated into programs addressing related issues, such as substance abuse, mental health and other STDs. Building upon a recent report from the National Alliance of State and Territorial AIDS Directors (NASTAD), this article will review the numerous challenges state and local health departments face in supporting HIV/AIDS-focused health and human services in Native American communities and how some health departments have worked with Native American communities to respond to these challenges. A series of recommendations and next steps for health departments seeking to improve services in Native American communities will be offered.

Developing practical "tips" for HIV/AIDS service delivery in local jails.

Numerous national, state, and local public health and correctional organizations and others recognize the important roles that community-based organizations and other agencies play in meeting the needs of persons incarcerated within local correctional facilities. Yet to date, there has been little, if any, guidance offered to community-based organizations about how best to approach local correctional facilities. This article discusses the process and outcomes of a collaborative process. Practical advice was drawn from the actual experiences of corrections staff, community-based organizations, and other agencies, including health departments, that are providing services in local correctional facilities. The product of this collaboration, a booklet entitled "How to Gain Access to County Jails for Delivery of HIV/AIDS Services: A Guide for Community-Based Organizations," outlines strategies for success that can be used to facilitate service delivery to incarcerated individuals with multiple primary and preventive health needs.

A public health approach to "prevention with positives": the New York State HIV/AIDS Service Delivery System.

Prevention of new HIV infections through meeting the prevention needs of HIV-infected persons, known as "prevention with positives," is a national priority. State health departments administer complex HIV/AIDS prevention, health care, and supportive service programs and shape the context for prevention services in their states. This larger context provides opportunities for development and enhancement of HIV prevention interventions. This article presents results of an assessment conducted by the New York State Department of Health of the extent to which the New York State HIV service delivery system, conceptualized as a continuum of services, supports prevention with positives and identifies opportunities for new initiatives. The New York State service continuum offers a comprehensive yet flexible framework into which effective HIV prevention interventions and services are embedded. It is mobilized in support of meeting individuals' HIV prevention needs. The service continuum continues to evolve and requires constant attention on the part of New York State Department of Health to keep pace with the ever-changing HIV epidemic. Additional features of New York State's comprehensive approach to prevention with positives are also discussed. This simple assessment, which can be adapted for use elsewhere, was effective in pinpointing how the current service delivery system supports prevention with positives. Approaches used by state health departments to advance prevention with positives warrant support and recognition.