Integrating Hepatitis, STD, and HIV Services into a Drug Rehabilitation Program

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1 Integrating Hepatitis, STD, and HIV Services into a Drug Rehabilitation Program Robert A. Gunn, MD, MPH, Marjorie A. Lee, MPH, David B. Callahan, MD, Patricia Gonzales, Paula J. Murray, MPH, Harold S. Margolis, MD Background: Methods: Results: Conclusions: Considering the difficulties in providing screening and vaccination services for inmates in short-stay incarceration facilities, an evaluation was conducted of the integration of prevention services in an alternative sentencing drug rehabilitation program (alternative to incarceration) in San Diego CA. During the period April 1999 to December 2002, clients were asked to complete a brief risk-assessment questionnaire, and were offered hepatitis B virus () vaccination, and hepatitis C virus () serologic testing, STD screening, and HIV counseling and testing. Of the estimated 1125 rehabilitation program enrollees, 930 (83%) participated in the integration program services. Most clients were male (64%), were aged 30 years (64%), and few (7%) reported previous vaccination. Of the 854 clients eligible for hepatitis B vaccination, 98% received the first dose, 69% the second dose, and 42% completed the series. Eleven percent of clients had prior infection, and 14.7% had infection, with positivity rates being highest among those with a history of injection drug use, 19%, and, 36%. HIV infection was rare (prevalence, 0.3%), and STDs were uncommon (chlamydia prevalence, 2%, and gonorrhea prevalence, 0.6%). Total annual cost of integration services (excluding HIV testing) was $31,994 equating to $122 per client served. Alternative sentencing drug rehabilitation programs provide a venue to efficiently deliver integrated hepatitis and other prevention services. Considering the vast number of high-risk persons in drug rehabilitation, probation, parole, and inmate release programs, an opportunity exists to greatly expand hepatitis services. (Am J Prev Med 2005;29(1):27 33) 2005 American Journal of Preventive Medicine Introduction Numerous studies have shown that people who have been previously incarcerated are often at an increased risk of acquiring sexually transmitted diseases (STDs), viral hepatitis, and human immunodeficiency virus (HIV) infection, and many have a history of substance abuse. 1 The prevalence of syphilis, hepatitis B virus (), hepatitis C virus (), and HIV infections among inmates of detention facilities are often substantially higher compared to the general population. 2 4 infection is very common among inmates in state prisons, with prevalence rates of 30% to From the Division of STD Prevention, National Center for HIV, STD and TB Prevention (Gunn), Division of Applied Public Health Training, Epidemiology Program Office (Callahan), and Division of Viral Hepatitis, National Center of Infectious Disease (Margolis), Centers for Disease Control and Prevention, Atlanta, Georgia; and STD and Hepatitis Prevention Program, Public Health Services (Gonzales, Lee, Murray, Callahan, Gunn), Health and Human Services, San Diego County, San Diego, California Address correspondence and reprint requests to: Robert A. Gunn, MD, MPH, U.S. Public Health Service, STD and Hepatitis Prevention Program, 3851 Rosecrans St (P511B), San Diego CA %. 5 7 Among people with acute infection, almost 30% report a lifetime history of prior incarceration 8 a missed opportunity for hepatitis B vaccination. However, providing screening services to identify, or vaccination to prevent, these infections, especially for inmates of short-stay detention facilities such as jails, has been problematic in most communities. 1,9 Issues related to security and inmate movement within the detention facility, the short length of stay of many inmates, and the cost of delivering prevention and treatment services are the major obstacles faced by correctional health programs. Alternatively, access to these high-risk populations may be available through inmate release programs, probation services, or programs such as alternative sentencing programs for drug offenders that provide drug abuse rehabilitation services in lieu of incarceration. In San Diego CA, the integration of hepatitis, STD, and HIV prevention services at a nonresidential alternative sentencing drug rehabilitation program was evaluated. The integration program began in April 1999, and data through December 2002 are reported. Am J Prev Med 2005;29(1) /05/$ see front matter 2005 American Journal of Preventive Medicine Published by Elsevier Inc. doi: /j.amepre

2 Methods The participating program enrolled approximately 300 clients per year for a period of 12 to 16 months. Many of the clients enrolled after July 1, 2001 were diverted from the correctional system under the mandates of the California Substance Abuse and Crime Prevention Act of 2000 (Proposition 36), 10 which covered people arrested for possession of controlled substances or those who violated conditions of probation or parole by using controlled substances. Other clients were sent to the program by direct orders of a judge or as a condition of probation. The clients attended rehabilitation services 5 days/evenings per week while working in the community and living in their own residence. Some clients continued to use drugs and were transferred to residential treatment facilities; others who failed the requirements of the program ( 10%) were sent to a detention facility to carry out the terms of their sentence. A nurse and program assistant from the San Diego County STD and Hepatitis Prevention Program visited participating sites quarterly to enroll participants and deliver services. Following a health education presentation about the prevention of viral hepatitis and STDs, each participant was asked to complete a brief risk assessment questionnaire. Initially, hepatitis B vaccination was the only service offered, and interested participants were considered eligible for vaccination if they had not reported a history of previous vaccination or infection. In December 1999, serologic testing for and was introduced, and urine-based STD screening was introduced in September A separate HIV counseling and oral fluid testing program was provided by a communitybased organization contractor every 3 months and had been ongoing since 1996, but data from 2002 only were available. Information about clients not participating in integration program services was not available because a roster of all clients was not easily accessible, and drug rehabilitation classes and programs varied considerably throughout each month. Serologic testing for hepatitis B core antibody (anti-hbc) and hepatitis B surface antigen (HBsAg) was done using commercially available enzyme immunoassays. For infection, the antibody to (anti-) was detected by first testing with a screening enzyme immunoassay (EIA, 3.0, Ortho Diagnostic Systems, Inc, Raritan NJ), and, if repeatedly positive, confirmation was done by recombinant immunoblot assay (RIBA 3.0, Chiron Corp., Emeryville CA). However, beginning July 1, 2001, the RIBA confirmatory test was not performed for clients with a history of injecting drugs because it had been determined that the positive predictive value of a screening EIA alone was 97%. 11 Urine testing for chlamydia (Chlamydia trachomatis) and gonorrhea (Neisseria gonorrhoeae) was conducted using a nucleic acid, amplified ligase, chain reaction based assay (LCR, Abbott Laboratories, Abbott Park IL). All tests were done at the San Diego County Public Health Laboratory, except for RIBA testing, which was done at the Centers for Disease Control and Prevention (CDC) initially, and since July 2002 at a commercial laboratory. Questionnaire, vaccination, and serologic test data were analyzed in 2003 using Epi-Info 6.0 and 95% confidence intervals for and seroprevalence were obtained from the Fleiss quadratic method. Project staff returned to each site to provide the second and third doses of the Hepatitis B vaccine series. Hepatitis B vaccination completion rates were determined only for clients who started the series in this program, were eligible for subsequent doses (did not have a positive anti-hbc test indicating prior infection), and had at least 1 year of follow-up time (started series before December 31, 2001). Written hepatitis and STD test results were delivered (1 week for STD, 4 to 6 weeks for hepatitis results) in a sealed envelope to each client by rehabilitation counselors. Approximately 10% of clients did not receive their hepatitis results because they had left the program before the results were available, and the client was lost to follow-up. For clients infected with chlamydia or gonorrhea, STD program staff assisted in ensuring treatment. Clients with a positive or HBsAg test received written information about the meaning of the test and referral resources for a medical follow-up. HIV test results and post-test counseling were provided in person by HIV program counselors. During the period November 2002 to June 2003, an attempt was made to contact all clients who received a positive test result (at least 6 months ago) to determine if they had obtained a medical evaluation. The estimated costs of the prevention services program included nurse and program assistant salary and benefits, travel mileage, hepatitis B vaccine, serologic testing for markers of infection with hepatitis viruses, and STD testing and treatment. HIV counseling and testing costs were not included since this service was provided through a state-funded program, nor were the costs of rehabilitation program staff related to the minimal time expended to help provide the services and distribute the screening test results. Results During the almost 4 years (45 months) that these services were evaluated, approximately 1125 clients were enrolled in the drug rehabilitation program, and 930 (83%) participated in the integrated prevention program. Most were male (64%), were 30 years of age (64%), and the majority were white (58%), followed by Hispanic (21%), African American (7%), and Asian/ Pacific Islanders (4%). Of the 930 participants, 698 (75%) completed a risk assessment questionnaire, with little variation in completion rates by age, gender, or race/ethnicity. Of the 698 persons who completed the questionnaire, 31% reported a history of injection drug use 32% were sex partners of an injecting drug user (IDU), 5% reported commercial sex work, and only 3% were men who have sex with men. Some clients had multiple risk factors. Of the 930 participants, 854 (92%) were eligible to start hepatitis B vaccination; 7% had completed or partially completed the hepatitis B vaccination series, and 1% reported previous infection. Of the 854 eligible clients, 835 (98%) started the vaccination series and 639 received the first dose before December 31, 2001, which allowed at least 1 year of follow-up time to assess vaccine series completion. Among this latter group, 43 (7%) had serologic markers of previous 28 American Journal of Preventive Medicine, Volume 29, Number 1

3 Table 1. and infection by demographic characteristics by drug rehabilitation program, December 1, 1999 to December 31, 2002 Total Positive a % 95% CI b Positive c % 95% CI Gender d Male Female Age (years) e Race/ethnicity White Hispanic African American Other/unknown f Total a Positive anti- core. b 95% confidence interval obtained by the Fliess quadratic method. c For 27 IDU clients, EIA positive, RIBA not done; for 37 IDU clients and 17 non-idu clients, EIA positive and RIBA confirmed. d Gender unknown for three cases. e Age unknown for four cases. f Race/ethnicity unknown for 56 cases. CI, confidence interval; EIA, enzyme immunoassay;, hepatitis B virus;, hepatitis C virus; IDU, injection drug use; RIBA, recombinant immunoblot assay. infection and did not need additional vaccine, leaving 596 clients eligible to receive additional vaccine and complete the series. Of these, 69% received the second dose, and 42% completed the 3-dose series. The vaccination completion rates were similar by demographic characteristics and risk group. Serologic testing for and infection was available to 808 clients over a 37-month period (December 1, 1999 to December 31, 2002), and slightly more than 65% were screened for either or markers. Overall, 11.1% (60/539) were anti-hbc positive (0.4% [2/539] were HBsAg positive), and 14.7% (81/550) were infected (EIA positive without confirmation being done for 27 IDUs, and RIBA confirmed for 37 IDUs and for 17 non-idu clients). An additional four clients had a positive EIA that was not confirmed by RIBA two were indeterminate and two negative. Prevalence of past infection was similar by gender and race/ethnicity (Table 1), but was higher among clients 30 years of age compared to younger clients (15.6% [55/352] vs 2.7% [5/187]; prevalence ratio [PR] 5.8, 95% confidence interval [CI] ). Among risk groups, past infection was highest among IDUs (18.8%) (Table 2), and infection was higher among IDUs 30 years of age compared to younger IDUs (Table 3). Prevalence of infection was also similar by gender and race/ethnicity (Table 1), and was also higher in clients aged 30 years compared to younger clients (20.1% [72/358] vs 4.7% [9/192]; PR 4.3, 95% CI ). Among risk groups, the -positive rate was highest among IDUs (35.8%) and among non-idus with a history of a blood transfusion received before 1992 (18.8%) (Table 2). Similar to infection among IDUs, infection was higher among IDUs 30 years compared to younger IDUs (Table 3). Overall, only 35% (28/81) of -infected clients could be contacted during the follow-up period, with follow-up more successful among clients testing positive more recently compared to earlier years. Among those 28 clients with follow-up information, 19 (68%) had obtained a medical evaluation, but only one had started antiviral treatment. A medical evaluation was more commonly performed among those who had health insurance (85.7% [12/14]) compared to those without insurance (50% [7/14]; rate ratio [RR] 1.7, 95% CI ). In addition, 78.3% (18/23) of clients responded that they would have been interested in having case management assistance to help them obtain a medical evaluation. Urine-based testing for chlamydia and gonorrhea was available to approximately 600 clients during a 28- month period (September 1, 2000 to December 31, 2002), and 25% were tested. Overall, the rate for positive chlamydia tests was only 2.0% (3/150, 2.2% among males and 1.8% among females) and for positive gonorrhea results was 0.7% (1/150, 0% among males and 1.8% among females). All four infected Am J Prev Med 2005;29(1) 29

4 Table 2. and infection by risk group by drug rehabilitation program, December 1, 1999 to December 31, 2002 Risk group a Positive b % 95% CI Positive c % 95% CI IDU Blood transfusion before 1992 NA d Sex partner IDU MSM Three or more sex partners No other risk No risk information Total a Risk groups hierarchical and mutually exclusive. b Positive anti- core. c For 27 IDU clients, EIA positive, RIBA not done; for 37 IDU clients and 17 non-idu clients, EIA positive and RIBA confirmed. d Not applicable (not a risk factor for infection). CI, confidence interval; EIA, enzyme immunoassay;, hepatitis B virus;, hepatitis C virus; IDU, injection drug use; MSM, men who have sex with men; RIBA, recombinant immunoblot assay. clients received treatment. In 2002, 317 oral-fluid HIV tests were done, and only one (0.3%) was positive. The estimated annual cost of delivering hepatitis and STD services at this drug rehabilitation program was $31,994 (Table 4). Total cost was as follows: staff costs,47%; vaccine, 34%; and hepatitis serologic testing, STD screening, and supplies/std treatment, 19%. Using the 37-month period (December 1,1999 to December 31, 2002) when all hepatitis services were available to the 808 clients participating, the cost per person served was $122 ($31,994/262 persons served per year), which includes the cost of vaccine, screening, and STD treatment. Discussion This project showed that viral hepatitis and STD prevention services, and HIV testing could be integrated into an alternative-sentencing, nonresidential drug rehabilitation program that served clients at increased risk for and infection. More than 90% of clients were eligible for hepatitis B vaccination, and the 95% first-dose acceptance and completion rate for subsequent doses (second dose 69% and series completion 42%) were higher than previously reported from STD clinics, 9,12 and much higher than those reported in jails 9 and prisons. 1 However, the vaccination eligibility and first-dose acceptance rates may have been slightly over-estimated because not all clients chose to participate in the immunization program, and the true number of eligible clients was not known. Even if all those who did not participate were eligible for vaccination, the minimum estimated first-dose acceptance rate would be 80% (835/1049 [ ]). In this evaluation, the relatively high rates of success in providing hepatitis prevention services indicate the importance of drug rehabilitation venues. In San Diego County, although the number of people under jurisdiction of the courts and correctional systems and served by alternative sentencing programs is not great compared to the number of people incarcerated, the rate of service delivery is much higher than what might be expected in most correctional facilities. In California, it is estimated that 36,000 persons are enrolled annually in alternative-sentencing drug rehabilitation programs mandated by Proposition 36. These and other rehabilitation programs could markedly increase the number of high-risk persons receiving hepatitis B vaccination, Table 3. and infection among IDUs by age by drug rehabilitation program, December 1, 1999 to December 31, 2002 Injection a drug user age group b positive Prevalence positive Prevalence n % Ratio 95% CI n % Ratio 95% CI 30 years Referent Referent 30 years Total a History of injecting drugs. b Age unknown for four IDU cases testing for. CI, confidence interval;, hepatitis B virus;, hepatitis C virus; IDU, injection drug user. 30 American Journal of Preventive Medicine, Volume 29, Number 1

5 Table 4. Estimated annual costs for hepatitis and STD services, drug rehabilitation program, San Diego CA, Staff Unit rates Total % Nurses $26/hr 345 hr 8,970 Support $20/hr 240 hr 4,800 Clerical $13/hr 25 hr 325 Mileage 3000 mi 0.34/mi 1,020 Subtotal $15,115 (47) Vaccine Hepatitis B $24.23/dose 450 $10,903 (34) Hepatitis tests Hepatitis B $16.53/test a 175 2,892 Hepatitis C EIA $11.17/test b 175 1,954 RIBA c $76/test STD tests d $10/test Supplies/STD treatment 250 Subtotal $ 5,976 (19) Total $31,994 (100) a Includes cost of repeating a positive anti-hbc test and HBsAg testing of these repeatedly positive anti-hbc tests. b Includes cost of repeating EIA positive tests 3. c Only done on persons without an IDU history. d Combined chlamydia and gonorrhea amplified urine test. EIA, enzyme immunoassay;, hepatitis C virus; IDU, injection drug use; RIBA, recombinant immunoblot assay. hepatitis C screening, and other integrated prevention services. In San Diego alone, an estimated 15,000 people are in drug rehabilitation programs (69% nonresidential), and another 2000 are in methadone maintenance programs. However, very few programs provide any hepatitis or STD services. In 2000, a nationwide random survey of drug treatment programs showed that education and screening services were limited only 7% screened all clients, and 22% did not screen any clients. 13,14 Other studies have shown similarly poor utilization of prevention services including hepatitis serologic screening or hepatitis B vaccination. 15,16 In addition to expanding services in drug rehabilitation programs, the development of new programs for inmates upon release from jails and prisons, the integration of hepatitis and STD services into existing HIV/AIDS and other programs for released inmates, and working collaboratively with probation and parole departments, could provide more access to high-risk clients in need of these prevention services. The prevalence of infection among clients in this program was higher than in the general population, since 20% had a history of injecting drug use. The prevalence of infection among IDUs ( 35%), which was substantially higher among IDUs aged 30 years, was very similar to infection rates seen in the San Diego County STD clinic, 11 HIV testing sites, 20,21 and in other STD clinics. 22 Although limiting testing to IDUs at the project site would have identified 79% of all -infected persons, while testing only 35% of all clients, universal testing among clients in drug rehabilitation programs is usually easier to implement, protects confidentiality of risk behaviors, and will identify all those infected. 21 Hepatitis C virus infection screening can be efficiently accomplished in a program with a high proportion of people with an IDU history by using only the EIA screening test. It has been shown that the EIA positive predictive value among people with a history of injecting drugs is 97%. 11 In addition, recent data have shown a 97% positive predictive value when the EIA signal-to-cutoff ratio is The CDC now recommends that the EIA signal-to-cutoff ratio be reported by laboratories, and be used to more efficiently conduct screening programs. 23 For clients with an EIA positive signal-to-cutoff ratio of 3.8, or for clients without an IDU history and no signal-to-cutoff data, confirmatory testing with an RIBA or an viral RNA test can be done to determine if circulating virus is present. In San Diego and other West Coast cities, most HIV infections are among MSM, with HIV prevalence among IDUs usually 2%. 24 This distribution of HIV infection explains the very low (0.3%) HIV prevalence seen in the current study population. Similarly, the older age of clients in this program and the predominance of men probably explains the low chlamydia and gonorrhea screening prevalence rates. Even with low HIV/STD prevalence rates, there is value in providing prevention information and counseling to all clients, and in some communities, especially in the East and Southeast regions of the United States, HIV and STD prevalence rates may be considerably higher. Providing adult immunizations, such as hepatitis B and selected infectious disease screening services, to high-risk disadvantaged persons, especially for men who have limited options for prevention services, usually engenders a direct local health department cost. These services cost $32,000 per year, but 220 clients started the hepatitis B vaccine series each year, and an estimated 40% complete the series. In addition, approximately 25 -infected clients, many in need of treatment, were identified each year. The estimated cost per client ($122) is comparable to the cost of an office visit at a clinic or physician s office ($75 to $125), and may be even less, since the cost estimated in this study includes hepatitis B vaccination for almost all clients (on average each client received 1.8 doses of vaccine costing $43.74) and about 67% received a hepatitis screening tests (averaging $18.68 per client). In the period, a chlamydia outreach in-field screening program was shown to cost $25,308 per year, which equated to $103 per specimen obtained, and at the same time the estimated cost of an STD clinic visit was $72, not including laboratory testing. 25 Even though outreach programs may cost about the same or slightly more than providing services at a fixed location, Am J Prev Med 2005;29(1) 31

6 What This Study Adds... Screening and follow-up services are difficult to provide for inmates in short-term facilities. This study showed one way in which hepatitis B vaccination, hepatitis serologic screening, STD screening, and HIV counseling and testing were effectively integrated into an alternative-sentencing, drug rehabilitation program serving high-risk clients. Health departments should consider developing collaborative partnerships with drug rehabilitation programs to provide prevention services. Health department costs, including vaccine, testing, treatment, and nursing staff, were estimated at $122 per client served. the high proportion of high-risk clients served and the increased yield of screening tests suggest that providing these services using an outreach approach is an efficient use of limited resources. This evaluation showed that testing identified people with infection. However, using the information to prevent long-term sequelae and reduce transmission is problematic. It is evident from this evaluation and those of others 26 that -infected adults without medical insurance will have difficulty in obtaining a medical evaluation, and, overall, only a very small percentage of -infected people identified through high-risk screening programs will start and complete medical treatment. Programs to reduce alcohol consumption and drug use should be encouraged. However, the effectiveness of these approaches in this population is unknown. As the proportion of people with infection acquired from blood and blood product exposure decreases, those who acquired through injecting drug use will constitute the vast majority of infected people needing medical care. The clients in this program and those receiving services in STD and HIV sites in San Diego want case management assistance. 11,26 The complexity of evaluating and treating is similar to that involved with HIV/AIDS care, and argues for a case management system similar to that provided for people with HIV/AIDS. This study was partially supported by funding from the Viral Hepatitis Integration Project cooperative agreement U50/ CCU , Centers for Disease Control and Prevention. We are grateful to field nurses Blanca Ramirez-Brown, RN, and Vanessa Ramirez, RN, for their assitance, and to Jody Thomas for manuscript preparation. No financial conflict of interest was reported by the authors of this paper. References 1. Centers for Disease Control and Prevention. Prevention and control of infections with hepatitis viruses in correctional settings. MMWR Recomm Rep 2003;52: National Commission on Correctional Health Care. Public health and corrections. Health status of inmates: Congress calls for the facts. July Adapted from: The heath status of soon-to-be-released inmates: a report to Congress. Chicago IL: National Commission on Correctional Health Care, Available at: Accessed August Mertz KJ, Voight RA, Hutchins K, Levine WC, Jail Prevalence Monitoring Group. Findings from STD screening of adolescents and adults entering corrections facilities: implications for STD control strategies. Sex Transm Dis 2002;29: Hammett TM, Harmon MP, Rhodes W. The burden of infectious diseases among inmates of and releasees from US correctional facilities, Am J Public Health 2002;92: Baillargeon J, Wu H, Kelley MJ, Grady J, Linthicum L, Dunn K. Hepatitis C seroprevalence among newly incarcerated inmates in a Texas correctional system. Public Health 2003;117: Spaulding A, Greene C, Davidson K, Schneidermann M, Rich J. Hepatitis C in state correctional facilities. Prev Med 1999;28: Ruiz JD, Molitor F, Sun RK, et al. Prevalence and correlates of hepatitis C virus infection among inmates entering the California correctional system. West J Med 1999;170: Goldstein ST, Alter MJ, Williams IT, et al. Incidence and risk factors for acute hepatitis B in the United States, : implications for vaccination programs. J Infect Dis 2002;185: Centers for Disease Control and Prevention. Hepatitis B vaccination among high-risk adolescents and adults San Diego, CA, MMWR Morb Mortal Wkly Rep 2002;51: Longshore D, Evans E, Urada D, et al. Evaluation of the Substance Abuse and Crime Prevention Act 2002 report. UCLA Integrated Substance Abuse Program and California Department of Alcohol and Drug Programs. Available at: Accessed August Gunn RA, Murray PJ, Brennan CH, Callahan DB, Alter MJ, Margolis HS. Evaluation of screening criteria to identify persons with hepatitis C virus infection among sexually transmitted disease clinic clients: results from the San Diego Viral Hepatitis Integration Project. Sex Transm Dis 2003;30: Weinstock HS, Bolan G, Moran JS, et al. Routine hepatitis B vaccination in a clinic for sexually transmitted disease. Am J Public Health 1995;85: Strauss SM, Falkin GP, Vassilex Z, Des Jarlais DC, Astone J. A nationwide survey of hepatitis C services provided by drug treatment programs. J Subst Abuse Treat 2002;22: Astone J, Strauss SM, Vassilex ZP, Des Jarlais DC. Provision of hepatitis C education in a nationwide sample of drug treatment programs. J Drug Educ 2003;33: Farrell M, Battersby M, Strang J. Screening for hepatitis B and vaccination of injecting drug users in NHS drug treatment services. Br J Addict 1990;85: McGary KA, Stein MD, Clark JG, Friedman PD. Utilization of preventive health services by HIV-seronegative injection drug users. J Addict Dis 2002;21: Arriola KR, Kennedy SS, Coltharp JC, Braithwaite RL, Hammett TM, Tinsley MJ. Development and implementation of the cross site evaluation of the CDC/HRSA corrections demonstration project. AIDS Educ Prev 2000;14: Conklin TJ, Lincoln T, Flanigan TP. A public health model to connect correctional health care with communities. Am J Public Health 1998;88: Glassser JB, Greifinger RB. Correctional health care: a public health opportunity. Ann Intern Med 1993;118: Gunn RA, Murray PJ, Borntrager D, Brennan C. Hepatitis C and syphilis seroprevalence among clients attending anonymous HIV testing and counseling sites, San Diego, CA, In: Abstracts of the 129th annual meeting and exposition. Atlanta GA: American Public Health Association, Centers for Disease Control and Prevention. Prevalence of hepatitis C virus infection among clients of HIV counseling and testing sites: Connecticut, MMWR Morb Mortal Wkly Rep 2001;50: Weinstock HS, Bolan G, Reingold AL, Polish LB. Hepatitis C virus infection among patients attending a clinic for sexually transmitted diseases. JAMA 1993;269: American Journal of Preventive Medicine, Volume 29, Number 1

7 23. Centers for Disease Control and Prevention. Guidelines for laboratory testing and result reporting of antibody to hepatitis C virus. MMWR Recomm Rep 2003;52: Kral AH, Lorvick J, Gee L, et al. Trends in human Immunodeficiency virus seroincidence among street-recruited injected drug users in San Francisco, Am J Epidemiol 2003;157: Gunn RA, Podschun GD, Fitzgerald S, et al. Screening high-risk adolescent males for chlamydia trachomatis infection: obtaining urine specimens in the field. Sex Transm Dis 1998;25: Mark KE, Murray PJ, Callahan DB, Gunn RA. Follow-up on patients diagnosed with hepatitis C through and STD and anonymous HIV test site screening program San Diego, California In: Abstracts: Infectious Disease Society of America, San Diego CA, October Am J Prev Med 2005;29(1) 33

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