San Francisco Department Of Public Health Research Articles

The San Francisco Health Systems Collaborative: Public Health and Health Care Delivery Systems’ Response to the Covid-19 Pandemic

The Covid-19 pandemic challenged health care delivery systems worldwide. Many acute care hospitals in communities that experienced surges in cases and hospitalizations had to make decisions such as rationing scarce resources. Hospitals serving low-income communities, communities of color, and those in other historically marginalized or vulnerable groups reported the greatest operational impacts of surges. However, cross-institutional collaborations within jurisdictions offer unique opportunities to prevent or mitigate health disparities in resource utilization and access to care. In January 2020, in response to the emerging coronavirus epidemic, the San Francisco Department of Public Health (SFDPH) and local hospital and health systems partners convened to align and coordinate medical surge planning and response. Adopting a governance structure of mutual accountability and transparency, the San Francisco Health Systems Collaborative guided local medical and public health response in the areas of medical surge, vaccination administration, testing, and therapeutics. Four principles guided the collaborative response: (1) shared priorities, (2) clear governance and accountability, (3) data transparency, and (4) operational coordination. High-level priorities established included protecting vulnerable people, protecting health care workers, and maintaining health system capacity. The governance structure consisted of three layers: local hospital and health systems’ CEOs coordinating with SFDPH executives; hospital chief medical and nursing officers coordinating high-level surge capacity assessments and mitigation plans; and local clinical operational managers working with public health response operational leaders to coordinate scarce resource utilization. Fluctuating with the tempo of the disease indicators and medical surge, governance and coordination were maintained through a tiered meeting and reporting system. Data visibility and transparency were key principles facilitating operational decision-making and executive-level coordination of resources, including identifying additional surge bed capacity for use systemwide, as well as ensuring efficient and equitable vaccine distribution through implementation of five mass-vaccination sites with prioritized access for vulnerable communities. Applying these four principles of shared priorities, accountability, transparency, and operational coordination and pragmatism helped the public health and individual hospital systems make contributions to the overall response that were aligned with their unique strengths and resources. Publication here represents the first official public use of the name San Francisco Health Systems Collaborative (which had served as the term used internally to refer to the group) and the first time codifying this structure. Through this coordination, San Francisco achieved one of the lowest Covid-19 death rates and had one of the highest vaccination and booster rates, compared with rates across California or the United States. Similar principles and implementation methods can be adopted by other health jurisdictions for future emergency outbreak response.

Rapid and sustained contact tracing training for COVID-19 in San Francisco: a training model for developing an emergency public health workforce.

The City and County of San Francisco was the first municipality in the United States to institute a COVID-19 contact tracing program. The San Francisco Department of Public Health (SFDPH) and the University of California, San Francisco (UCSF) created an outcome-based fully remote contact tracing curriculum using participatory learning methods to train non-public health emergency workers as contact tracers. Between April and December 2020, we trained over 300 individuals in contact tracing skills and procedures over three training phases. Using iterative curriculum design and Kirkpatrick's evaluation methodology, we aimed to ensure high quality and successful person-centered contact tracing. The resulting curriculum consisted of 24 learning outcomes taught with six participatory skills development activities, asynchronous materials, and one-on-one contact tracer support. We collected more than 700 responses from trainees using various evaluation tools across the training phases, and contact tracers interviewed more than 24,000 contacts after training in our program. Our evaluations showed that knowledge and skills improved for most trainees and demonstrated the utility of the training program in preparing trainees to perform person-centered contact tracing in San Francisco. Local health jurisdictions and state health agencies can use this model of curriculum development and evaluation to rapidly train a non-public health workforce to respond to future public health emergencies.

Effect of Social Determinants of Health on Uncontrolled Human Immunodeficiency Virus (HIV) Infection Among Persons With HIV in San Francisco, California.

BackgroundIn 2010–2014, the San Francisco Department of Public Health (SFDPH) established programs to rapidly link people with human immunodeficiency virus (PWH) to care and offer antiretroviral therapy (ART) at human immunodeficiency virus (HIV) diagnosis. Such programs reduced the number of PWH out of care or with detectable HIV viral load (ie, uncontrolled HIV infection). We investigated the role of social determinants of health (SDH) on uncontrolled HIV.MethodsCross-sectional data from adult PWH diagnosed and reported to the SFDPH as of December 31, 2019, prescribed ART, and with confirmed San Francisco residency during 2017–2019 were analyzed in conjunction with SDH metrics derived from the American Community Survey 2015–2019. We focused on 5 census tract-level SDH metrics: percentage of residents below the federal poverty level, with less than a high school diploma, or uninsured; median household income; and Gini index. We compared uncontrolled HIV prevalence odds ratios (PORs) across quartiles of each metric independently using logistic regression models.ResultsThe analysis included 7486 PWH (6889 controlled HIV; 597 uncontrolled HIV). Unadjusted PORs of uncontrolled HIV rose with increasingly marginalized quartiles, compared to the least marginalized quartile for each metric. Adjusting for demographics and transmission category, the POR for uncontrolled HIV for PWH in the most marginalized quartile remained significant across metrics for poverty (POR = 2.0; confidence interval [CI] = 1.5–2.6), education (POR = 2.4; CI = 1.8–3.2), insurance (POR = 1.8; CI = 1.3–2.5), income (POR = 1.8; CI = 1.4–2.3), and income inequality (POR = 1.5; CI = 1.1–2.0).ConclusionsBeyond demographics, SDH differentially affected the ability of PWH to control HIV. Despite established care programs, PWH experiencing socioeconomic marginalization require additional support to achieve health outcome goals.

COVID-19: A catalyst for change in telehealth service delivery for opioid use disorder management

Background COVID-19 has exacerbated income inequality, structural racism, and social isolation—issues that drive addiction and have previously manifested in the epidemic of opioid-associated overdose. The co-existence of these epidemics has necessitated care practice changes, including the use of telehealth-based encounters for the diagnosis and management of opioid use disorder (OUD). Methods We describe the development of the “Addiction Telehealth Program” (ATP), a telephone-based program to reduce treatment access barriers for people with substance use disorders staying at San Francisco’s COVID-19 Isolation and Quarantine (I&Q) sites. Telehealth encounters were documented in the electronic medical record and an internal tracking system for the San Francisco Department of Public Health (SFDPH) COVID-19 Containment Response. Descriptive statistics were collected on a case series of patients initiated on buprenorphine at I&Q sites and indicators of feasibility were measured. Results Between April 10 and May 25, 2020, ATP consulted on the management of opioid, alcohol, GHB, marijuana, and stimulant use for 59 I&Q site guests. Twelve patients were identified with untreated OUD and newly prescribed buprenorphine. Of these, all were marginally housed, 67% were Black, and 58% had never previously been prescribed medications for OUD. Four self-directed early discharge from I&Q—1 prior to and 3 after initiating buprenorphine. Of the remaining 8 patients, 7 reported continuing to take buprenorphine at the time of I&Q discharge and 1 discontinued. No patients started on buprenorphine sustained significant adverse effects, required emergency care, or experienced overdose. Conclusions ATP demonstrates the feasibility of telephone-based management of OUD among a highly marginalized patient population in San Francisco and supports the implementation of similar programs in areas of the U.S. where access to addiction treatment is limited. Legal changes permitting the prescribing of buprenorphine via telehealth without the requirement of an in-person visit should persist beyond the COVID-19 public health emergency.

The COVID-19 Global Pandemic

INTRODUCTIONThe recent outbreak of a novel coronavirus illness (COVID-19) has grown into a global pandemic. As a response, there have been several treatment recommendations published by international, federal, state, and local governing bodies.METHODSWe performed a comprehensive review of COVID-19 policies and aggregated multi-disciplinary expertise at our quaternary care academic facility to formulate objective criteria for scheduling surgery, providing neurosurgical coverage, and engaging in neurosurgical research during the COVID-19 outbreak. Recommendations from the CDC, WHO, California State Department of Public Health (CDPH), San Francisco Department of Public Health (SFDPH), and the UCSF School of Medicine were collected and reviewed by the expert panel. Treatment algorithms regarding the following issues were drafted: (1) neurosurgical case scheduling, (2) neurosurgical clinic scheduling, (3) contingency plans for neurosurgical staffing and ICU utilization, and (4) staffing neurosurgical research directives.RESULTSHere, we present a neurosurgical treatment algorithm for varying levels of COVID-19 community infection. This algorithm (with an accompanying checklist) is centered around a three-tiered system of viral ‘surge’ quantification, which we use to triage case scheduling, and a paired coverage model for inpatient services.CONCLUSIONCOVID-19 represents a challenge to ongoing practice, however with clear algorithms, checklists, and contingency planning, it is possible to provide focused neurosurgical care during this pandemic.

Systematic Collection of Sexual Orientation and Gender Identity in a Public Health System: The San Francisco Health Network SO/GI Systems-Change Initiative

Lesbian, gay, bisexual, transgender, and queer (LGBTQ+) individuals experience disparate outcomes within health care that are often unacknowledged by health systems due to lack of systematic collection of sexual orientation/gender identity (SO/GI) data. This article describes a San Francisco Department of Public Health (SFDPH) initiative to standardize SO/GI data collection for every patient/client utilizing SFDPH services, as well as the training development and implementation around this initiative. This initiative incorporated community engagement throughout and had an aim of meeting new regulatory requirements, improving patient experience and, ultimately, equipping staff with the needed data to uncover and reduce health disparities. Upon completion of the first wave of training (May 2019), a total of 5618 (69.1%) staff completed the online training and 2189 (26.7%) staff completed the optional in-person training. As of June 2020, SO/GI was collected in 35.0 percent of empanelled primary care patients and in 26.8 percent of the unique patient encounters overall throughout the health network. This initiative demonstrated the feasibility of implementing SO/GI data collection as an inclusive and community-driven culture change initiative, fully integrated with the complexities of operational change in a diverse public health network. Next steps include providing ongoing training and support for clinicians, staff, and patients, implementing SO/GI data collection for pediatric patients/clients, and identifying health disparities within the network to create targeted interventions and improve the care experience for our LGBTQ+ patients/clients.

Implementation of pre-exposure prophylaxis at a community pharmacy through a collaborative practice agreement with San Francisco Department of Public Health

ObjectiveTo discuss the design and implementation of a community pharmacy–initiated HIV pre-exposure prophylaxis (PrEP) and postexposure prophylaxis (PEP) program developed in collaboration with the San Francisco Department of Public Health (SFDPH). SettingA community pharmacy in San Francisco and the SFDPH developed a collaborative practice agreement (CPA) that allowed community pharmacists to initiate PrEP and PEP to prevent HIV acquisition and increase uptake in vulnerable populations. Practice descriptionA community pharmacy in San Francisco’s Mission District, an urban, historically Hispanic/Latino/Latinx neighborhood. The primary collaborative practice team consisted of 1 community pharmacy technician, 4 community pharmacists, and 1 designated overseeing physician at SFDPH. Practice innovationThe pharmacy and the SFDPH collaborated together for 20 months from start to implementation of the CPA and the PrEP program. An interdisciplinary team of pharmacists, pharmacy personnel, public health physicians, and health department staff members worked together to design, launch, and maintain the program. Pharmacists were trained by SFDPH staff members on HIV testing and counseling and implementation of the PrEP protocol, including PEP initiation and sexually transmitted disease testing. A Department of Public Health secure portal was used to share patient information. An SFDPH physician reviewed patients’ charts regularly and communicated with PrEP pharmacists as needed. ResultsBetween April 2018 and the end of March 2019, 6 patients received PEP and 53 patients completed a PrEP initiation visit, of whom 96% (n = 51) filled their prescription. Approximately 47% (n = 24) of clients who started PrEP self-identified as Hispanic or Latino, 10% (n = 5) were black or African American, and 82% (n = 42) identified as men who have sex with men. ConclusionImplementation of a CPA between a community pharmacy and a local health department enabled the launch of pharmacist-delivered PrEP, further expanding the landscape of access points to vulnerable populations in San Francisco.

Implementing a Trauma-Informed Public Health System in San Francisco, California.

Trauma is a ubiquitous and harmful public health concern. Much like individuals, organizations experience trauma and can embed it within their culture. Left unaddressed, trauma inhibits staff from confronting problems, communicating effectively, and generating solutions, factors that undermine organizational functioning. In response to trauma's far-reaching impact, recent efforts have focused on creating "trauma-informed" systems that emphasize safety and avoid retraumatization. Trauma-informed systems are uniquely connected to relationships, as the impact of trauma both impairs relationships and is heightened in the absence of quality relationships. Developing trauma-informed relationships is therefore critical to creating a healing organizational culture. The objective of this article is to describe the process through which the San Francisco Department of Public Health (SFDPH) developed and implemented their Trauma-Informed Systems (TIS) Initiative, an organizational model to address trauma at the systems level. The article highlights the centrality of trauma-informed relationships to the initiative's guiding principles, activities, and implementation process. Six core principles underlie the work of the SFDPH's TIS Initiative: (1) Understanding Trauma & Stress, (2) Compassion & Dependability, (3) Safety & Stability, (4) Collaboration & Empowerment, (5) Cultural Humility & Responsiveness, (6) Resilience & Recovery. Initiative components focus on creating and sustaining trauma-informed knowledge (i.e., foundational training, train-the-trainer program) and organizational practices (i.e., aligned efforts, leadership, and champion engagement). Trauma-informed systems represent an emergent organization-level intervention designed to address trauma and its sequelae. SFDPH's TIS Initiative is creating a healing organization through its innovative response to the impact of trauma.

Historical and Current Trends in the Epidemiology of Early Syphilis in San Francisco, 1955 to 2016.

Seventeen years into a sustained epidemic, early syphilis (ES) rates in San Francisco (SF) are continuing to increase and the demographics of the affected population are changing. We provide a historical overview of ES in SF among men who have sex with men (MSM) and describe trends in the epidemiology and disease investigation outcomes. We examined data from the SF Department of Public Health's patient-based registry of integrated STD surveillance, clinical, and field investigation data to describe demographic and behavioral characteristics of ES cases, as well as outcomes of syphilis partner services (PS). χ Tests were performed to examine categorical differences across periods. Analysis of variance was used to examine differences in continuous variables. In 2016, 1095 ES cases were reported among males in SF, a 219% increase from the 343 cases identified 10 years ago. Between 1996-1999 and 2010-2016, an increasing proportion of ES cases were among MSM younger than 25 years, nonwhite, and HIV negative (P < 0.05). A decreasing proportion of ES cases were assigned for PS, among whom a smaller proportion of reported sex partners were identified by name, resulting in an overall decline in the proportion of cases who had at least one named partner treated as a result of PS (Disease Intervention Rate) from 30.5 in 2000-2004 to 14.8 in 2010-2016. Syphilis case rates continue to increase in SF and the epidemic is expanding beyond a core population. Additional resources and innovative prevention approaches are needed to reduce the burden of syphilis among MSM.

Integrating Oral Health into Social Marketing Campaigns: Program Development and Description for San Francisco Children’s Oral Health Strategic Plan

Integrating oral health into an existing San Francisco Department of Public Health (SFDPH) social marketing campaign was a specific goal of the San Francisco Children’s Oral Health Strategic Plan 2014-2017 with the purpose to more fully integrate oral health promotion into the City’s overall health promotion efforts. In the winter of 2015, utilizing a collaborative approach, oral health was successfully integrated in the Open Truth campaign, promoting decreased consumption of sugar sweetened beverages in order to improve health outcomes, including decreasing tooth decay.

English

Executive Summary: The American Public Health Association (APHA) recently recommended that health professionals partner with park agencies in order to use nature for health promotion. We aimed to 1) determine the capacity of a local public health system to implement the APHA recommendations, 2) test the hypothesis that the likelihood of implementation is associated with health professional knowledge and beliefs, and 3) identify a framework for facilitating implementation. We surveyed all staff members at the San Francisco Department of Public Health (SFDPH) Maternal, Child and Adolescent Health Branch. SFDPH, like many health departments, provides services for underserved and marginalized populations. The results of 108 quantitative surveys and the qualitative analysis from small group discussions with 120 public health professionals are presented in this paper. The majority of those surveyed (81%) agreed that patient health would improve if they spent time in nature. However, few health professionals believed that patients regularly visit parks (11%) or would follow a practitioner’s recommendation to visit a park (16%) in order to experience nature. We found that if public health professionals knew of a specific location and activity to do in nature, and if they were confident that their low income patients would be welcome at parks, they were more likely to recommend a park visit. In group discussions, health professionals showed enthusiasm for collaboration with park agencies, pragmatism that their patients will need multiple supports in order to sustain outdoor behaviors, and a perspective that time in nature for underserved communities is the product of a socioecological system. This socioecological system includes factors to be considered at the individual, interpersonal, community, and societal levels. Participants engaged in a rich discussion on how health departments can partner with park agencies and community-based organizations to encourage nature for health at each of these levels.We turned to public health professionals for suggestions about how nature can be integrated into public health systems. The resulting discussions came together in the form of a framework that provides insight on public health priorities, a roadmap for those who seek to initiate interdisciplinary alliances, and suggestions for future research.

Disparities and Trends in Viral Suppression During a Transition to a "Test and Treat" Approach to the HIV Epidemic, San Francisco, 2008-2012.

In 2010, 2 years before national recommendations to provide antiretroviral therapy for HIV-infected persons regardless of CD4 count, the San Francisco Department of Public Health (SFDPH) implemented a "test and treat" strategy that expanded HIV testing and offered antiretroviral therapy to persons at all publicly funded HIV clinics. We used the SFDPH registry of HIV-infected persons to measure trends in the time to viral suppression of persons suppressed. The Kaplan-Meier product limit method was used to assess trends in time from HIV diagnosis to viral suppression (HIV RNA <200 copies/mL) among persons diagnosed from 2008 to 2012. The annual proportion of persons living with HIV who were virally suppressed was measured for the years 2008 to 2012. Independent predictors of viral suppression were determined using proportional hazards regression for newly diagnosed cases and Poisson regression for living cases. Of the 2349 persons newly diagnosed, the median time from diagnosis to suppression decreased from 13 months in 2008 to 5 months in 2012 (P < 0.0001). Among the 11,787 persons living with HIV, the annual proportion suppressed increased from 69% in 2008 to 78% in 2012. African Americans, persons who inject drugs, persons without private insurance, and persons with nadir CD4 counts above 350 cells per cubic millimeter, were less likely to be virally suppressed. We found a decrease in time and overall population-level increases in viral suppression under a test and treat strategy and highlight sociodemographic disparities that may hamper the full benefit of this approach.

Using HIV surveillance registry data to re-link persons to care: the RSVP Project in San Francisco.

BackgroundPersons with unsuppressed HIV viral load (VL) who disengage from care may experience poor clinical outcomes and potentially transmit HIV. We assessed the feasibility and yield of using the San Francisco Department of Public Health (SFDPH) enhanced HIV surveillance system (eHARS) to identify and re-engage such persons in care.MethodsUsing SFDPH eHARS data as of 4/20/2012 (index date), we selected HIV-infected adults who were alive, had no reported VL or CD4 cell count results in the past nine months (proxy for “out-of-care”) and a VL >200 copies/mL drawn nine to 15 months earlier. We prioritized cases residing locally for investigation, and used information from eHARS and medical and public health databases to contact them for interview and referral to the SFDPH linkage services (LINCS). Twelve months later, we matched-back to eHARS data to assess how HIV laboratory reporting delays affected original eligibility, and if persons had any HIV laboratory results performed and reported within 12 months after index date (‘new labs’).ResultsAmong 434 eligible persons, 282 were prioritized for investigation, of whom 75 (27%) were interviewed, 79 (28%) could not be located, and 48 (17%) were located out of the area. Among the interviewed, 54 (72%) persons accepted referral to LINCS. Upon match-back to eHARS data, 324 (75%) in total were confirmed as eligible, including 221 (78%) of the investigated; most had new labs.ConclusionsAmong the investigated persons presumed out-of-care, we interviewed and offered LINCS referral to about one-quarter, demonstrating the feasibility but limited yield of our project. Matching to updated surveillance data revealed that a substantial minority did not disengage from care and that most re-engaged in HIV care. Verifying persons’ HIV care status with medical providers and improving timeliness of transfer and cross-jurisdictional sharing of HIV laboratory data may aid future efforts.

Designing a learning health organization for collective impact.

In May 2014, the Public Health Leadership Forum published “The High Achieving Governmental Health Department in 2020 as the Community Chief Health Strategist.”1 This groundbreaking paper started with the following statement: Local and state health departments need to adapt and evolve if governmental public health is to address emerging health demands, minimize current as well as looming pitfalls, and take advantage of new and promising opportunities. To succeed requires a view into the future. In November 2011, the San Francisco Department of Public Health (SFDPH), Population Health Division embarked on this journey to reorganize the public health division into a high-achieving governmental health department for the future. We used public health accreditation as the catalyst to reorganize, and the new organization structure launched on July 1, 2013. For the staff in the SFDPH, public health accreditation is about the humble and passionate pursuit of results, equity, and accountability for improving community health. This inspired us to call our framework for public health accreditation and improvement REACH (Results, Equity and Accountability for Community Health). Staff are focused on achieving results (impacts, goals, and outcomes); integrating equity into quality improvement efforts; designing accountability into our activities, including community-based evidence (local voice, wisdom, and knowledge) with science- and practice-based evidence; and protecting and promoting population health. REACH was developed after the SFDPH leadership embraced the idea that public health accreditation could be used as a vehicle to protect and promote the health of all San Franciscans. The San Francisco Health Commission—the governing health body—passed a resolution declaring public health accreditation a top strategic health priority for San Francisco. With this support, the SFDPH embarked on an extensive reorganization of its public health services into a new Population Health Division. The overarching goal was to design a community-centered, responsive, and agile health organization that could adapt quickly to current and emerging public health challenges and opportunities. Strategic objectives included the following: provide leadership in health protection, health promotion, disease and injury prevention, and disaster preparedness; expand our focus to community wellness, beyond disease events; promote healthy and sustainable environments; integrate health equity into quality improvement efforts; strengthen service excellence to communities, clients, and providers; ensure a culture of trust and innovation; strengthen our culture of finding, translating, and implementing science-based solutions to problems; and achieve and maintain public health accreditation. An organization design team consisting of leaders, managers, and staff was convened. Because there is limited collective knowledge and funding for developing organizational structures in local health departments, a new structure was designed using existing local experience and published resources. The design team members reviewed public health accreditation domains and standards, population health models,2,3 the Baldrige Criteria for Performance Excellence (CPE),4 key public health texts,5,6 and modern organization design books.7,8 The design team actively engaged the staff, the affected community, and other stakeholders to bring in and build connections of trust and understanding. By pulling together all those sources of input, the design team developed a strategic map and then created an organization design framework and staffing chart. With that foundation, the REACH framework evolved after reviewing and testing several quality improvement models.9–16 Finally, the SFDPH was able to leverage funding and technical assistance from the Centers for Disease Control and Prevention and the National Association of County & City Health Officials, which supported preparation for public health accreditation and funding for program collaboration and service integration.17 The purpose of this commentary is to review how the SFDPH used organization design concepts and continuous improvement frameworks to reorganize from autonomous, categorical silos of public health services to an integrated, community-centered Population Health Division. We believe that these concepts and methods can be adapted to many health organizations.

Partner Services as Targeted HIV Screening—Changing the Paradigm

The San Francisco Department of Public Health (SFDPH) has the goal of offering HIV partner services (PS) to all individuals newly diagnosed with HIV in San Francisco. However, measuring the potential impact of these services is challenging. Building on an existing syphilis partner notification program, we developed a framework for expanding and monitoring HIV PS in San Francisco. We identified process and outcome measures to evaluate HIV PS in San Francisco, including the number of index patients interviewed, the proportion of named partners who had previously diagnosed HIV infection, the proportion of HIV-uninfected partners who tested through HIV PS, and the positivity rate among the partners tested. Results were recorded in a locally developed electronic surveillance and case-management system at SFDPH. We examined HIV PS data from 2005-2011. In 2011, 426 new HIV diagnoses were reported, and 178 were assigned for HIV PS; of these, 124 (69.7%) patients were successfully interviewed, naming a total of 109 sex partners. Of the named partners, 34 (31.2%) had been previously diagnosed with HIV. Among the remaining named partners not known to be HIV infected, 31 (32.3%) were tested, for a positivity of 22.6% (n=7). The proportion of HIV that was newly diagnosed by a provider who participated in the citywide HIV PS program increased from 15.4% in 2005 to 69.5% in 2011. As HIV PS expand, locally relevant outcome measures are increasingly important. Using these criteria, HIV PS as a targeted screening activity resulted in the identification of newly diagnosed HIV cases.

Access, interest, and attitudes toward electronic communication for health care among patients in the medical safety net.

Electronic and internet-based tools for patient-provider communication are becoming the standard of care, but disparities exist in their adoption among patients. The reasons for these disparities are unclear, and few studies have looked at the potential communication technologies have to benefit vulnerable patient populations. To characterize access to, interest in, and attitudes toward internet-based communication in an ethnically, economically, and linguistically diverse group of patients from a large urban safety net clinic network. Observational, cross-sectional study Adult patients (≥ 18 years) in six resource-limited community clinics in the San Francisco Department of Public Health (SFDPH) MAIN MEASURES: Current email use, interest in communicating electronically with health care professionals, barriers to and facilitators of electronic health-related communication, and demographic data-all self-reported via survey. Sixty percent of patients used email, 71 % were interested in using electronic communication with health care providers, and 19 % reported currently using email informally with these providers for health care. Those already using any email were more likely to express interest in using it for health matters. Most patients agreed electronic communication would improve clinic efficiency and overall communication with clinicians. A significant majority of safety net patients currently use email, text messaging, and the internet, and they expressed an interest in using these tools for electronic communication with their medical providers. This interest is currently unmet within safety net clinics that do not offer a patient portal or secure messaging. Tools such as email encounters and electronic patient portals should be implemented and supported to a greater extent in resource-poor settings, but this will require tailoring these tools to patients' language, literacy level, and experience with communication technology.

Using surveillance data to monitor entry into care of newly diagnosed HIV-infected persons: San Francisco, 2006-2007.

BackgroundLinkage to care after HIV diagnosis is associated with both clinical and public health benefits. However, ensuring and monitoring linkage to care by public health departments has proved to be a difficult task. Here, we report the usefulness of routine monitoring of CD4 T cell counts and plasma HIV viral load as measures of entry into care after HIV diagnosis.MethodsSince July 1, 2006, the San Francisco Department of Public Health (SFDPH) incorporated monitoring initial primary care visit into standard HIV public health investigation for newly diagnosed HIV-infected patients in select clinics. Entry into care was defined as having at least one visit to a primary HIV care provider after the initial diagnosis of HIV infection. Investigators collected reports from patients, medical providers, laboratories and reviewed medical records to determine the date of the initial health care visit after HIV diagnosis. We identified factors associated with increased likelihood of entering care after HIV diagnosis.ResultsOne -hundred and sixty new HIV-infected cases were diagnosed between July 1, 2006 and June 30, 2007. Routine surveillance methods found that 101 of those cases entered HIV medical care and monitoring of CD4 T cell counts and plasma HIV viral load confirmed entry to care of 25 more cases, representing a 25% increase over routine data collection methods. We found that being interviewed by a public health investigator was associated with higher odds of entry into care after HIV diagnosis (OR 18.86 [1.83–194.80], p = .001) compared to cases not interviewed. Also, HIV diagnosis at the San Francisco county hospital versus diagnosis at the county municipal STD clinic was associated with higher odds of entry into care (OR 101.71 [5.29–1952.05], p < .001).ConclusionThe time from HIV diagnosis to initial CD4 T cell count, CD4 T cell value and HIV viral load testing may be appropriate surveillance measures for evaluating entry into care, as well as performance outcomes for local public health departments' HIV testing programs. Case investigation performed by the public health department or case management by clinic staff was associated with increased and shorter time to entry into HIV medical care.

Simplifying Consent for HIV Testing Is Associated with an Increase in HIV Testing and Case Detection in Highest Risk Groups, San Francisco January 2003–June 2007

BackgroundPopulations at highest risk for HIV infection face multiple barriers to HIV testing. To facilitate HIV testing procedures, the San Francisco General Hospital Medical Center eliminated required written patient consent for HIV testing in its medical settings in May 2006. To describe the change in HIV testing rates in different hospital settings and populations after the change in HIV testing policy in the SFDH medical center, we performed an observational study using interrupted time series analysis.MethodsData from all patients aged 18 years and older seen from January 2003 through June 2007 at the San Francisco Department of Public Health (SFDPH) medical care system were included in the analysis. The monthly HIV testing rate per 1000 hadpatient-visits was calculated for the overall population and stratified by hospital setting, age, sex, race/ethnicity, homelessness status, insurance status and primary language.ResultsBy June 2007, the average monthly rate of HIV tests per 1000 patient-visits increased 4.38 (CI, 2.17–6.60, p<0.001) over the number predicted if the policy change had not occurred (representing a 44% increase). The monthly average number of new positive HIV tests increased from 8.9 (CI, 6.3–11.5) to 14.9 (CI, 10.6–19.2, p<0.001), representing a 67% increase. Although increases in HIV testing were seen in all populations, populations at highest risk for HIV infection, particularly men, the homeless, and the uninsured experienced the highest increases in monthly HIV testing rates after the policy change.ConclusionsThe elimination of the requirement for written consent in May 2006 was associated with a significant and sustained increase in HIV testing rates and HIV case detection in the SFDPH medical center. Populations facing the higher barriers to HIV testing had the highest increases in HIV testing rates and case detection in response to the policy change.

Characteristics of Persons With Chronic Hepatitis B—San Francisco, California, 2006

Chronic hepatitis B is the most common cause of cirrhosis and liver cancer worldwide. Approximately 45% of the world's population lives in regions where chronic hepatitis B virus (HBV) infection is endemic, including most of Asia and the Pacific Islands, Africa, and the Middle East. Nearly one fourth of the population of San Francisco was born in Asia and the Pacific Islands. In 2006, the San Francisco Department of Public Health (SFDPH) received reports consistent with probable chronic HBV infection for 2,238 persons. To characterize persons with reported confirmed chronic HBV infection in San Francisco in 2006, SFDPH collected additional data on a subset of 567 cases reported to the SFDPH chronic hepatitis B registry. Eighty-four percent of the persons were Asians/Pacific Islanders (A/PIs), 80% of whom were foreign born. Fewer than half had been referred to a gastroenterologist/hepatologist for evaluation at the time of reporting. Persons with chronic HBV infection can benefit from medical care by providers with expertise in viral hepatitis. In addition, close contacts of infected persons should be screened and offered vaccination if found to be susceptible to HBV infection. Culturally appropriate counseling for and follow-up of persons with chronic HBV infection and their contacts could help reduce the transmission of HBV infection.

3: Is text messaging key to improving adolescent sexual health?

Consistent with national trends, San Francisco adolescents have the highest rates of sexually transmitted infections (STIs), a disproportionate number of which occur among African Americans. While STIs most incident to adolescents (chlamydia and gonorrhea) are curable, they are commonly asymptomatic, detectable only through clinical screening. In April 2006, Internet Sexuality Information Services (ISIS) and the San Francisco Department of Public Health (SFDPH) launched a text messaging service, SexInfo, to provide youth with medically accurate information on STIs, HIV, and pregnancy as well as referrals for free sexual health services.