Baltimore City STD Clinics Assessment STI Testing Guidelines Adolescent-specific Considerations How to Access PrEP in Baltimore References Acknowledgments Free con dential HIV counseling and testing 515 W. North Ave All services are free, no insurance STD services for patients Baltimore, MD 21217 necessary presenting symptoms or at risk Adolescents do not need parental of exposure, HIV counseling (410) 396-0176 consent for examination and and rapid testing, pap smears, treatment tests Penn-North Station Proof of citizenship or immigration status not required Rapid HIV testing, hepatitis B No.13 (Pennsylvania & North Ave) vaccines, and emergency contraception are available Wednesday and Friday at both sites 9:00AM - 5:00PM

620 North Caroline St STD services for patients Baltimore, MD 21205 presenting symptoms or at risk of exposure, HIV counseling and rapid testing, pap smears, (410) 396-9410 pregnancy tests Johns Hopkins Hospital

No. 5 (Monument & Central Ave) No. 21 (Caroline & Biddle Street)

Monday, Tuesday & Thursday 9:00AM - 5:00PM

Protect Baltimore Have you ever been emotionally or physically abused by a partner? Yes No If so, by whom?

Within the past year, have you been hit, slapped or otherwise physically hurt? Yes No If so, by whom?

Within the past year, have you been forced to have sex against your will? Yes No If so, by whom?

Are you afraid of your partner? Yes No

Protect Baltimore Individuals infected with a sexually transmitted infection (STI) are more All females with symptoms of a sexually transmitted infection likely than uninfected individuals to (STI) like cervicitis; or a discharge from the genital area, the throat acquire HIV infection. and/or the rectum; lesions; rashes; urethritis; vaginitis; painless, The terms STI and STD (sexually round lesion in the genital area or mouth should be tested for transmitted disease) are used chlamydia, gonorrhea, syphilis and trichomonas. interchangeably. All sexually active females, 25 years or younger, should have an Chlamydia, gonorrhea, and syphilis annual screening for chlamydia, because of the high prevalence of can be treated and cured if they are the disease in this population and because asymptomatic infection treated early. is common. If these STIs aren’t treated, they All sexually active females, should be screened for chlamydia, can cause serious health problems, gonorrhea and syphilis if they have another STI, a such as infertility. who has an STI, new or multiple sex partners, use drugs, and/or have ever had an STI. If your patient is positive for any one of these STIs, it is important to All pregnant women should be screened for chlamydia, provide treatment right away. gonorrhea and syphilis at the rst prenatal visit, in the third trimester and at delivery. All females, 11 12 years of age, should be vaccinated with the HPV vaccine. All females, 13 26 years of age, who are not sexually active and have not received the HPV vaccine are eligible to be vaccinated.

Protect Baltimore All males with symptoms of a sexually transmitted infection (STI) like urethritis; or a discharge from the genital area, the throat and/or the rectum; lesions; rashes; urethritis; vaginitis; etc. should be tested for chlamydia, gonorrhea, syphilis and trichomonas. All sexually active males, should be screened for chlamydia, gonorrhea and syphilis if they have another STI, a sexual partner who has an STI, new or multiple sex partners, use drugs, and/or have ever had an STI. Men who have sex with men should be screened for syphilis if they(or their partner(s)) have sex with anyone else All males, 11-12 years of age, should be vaccinated with the HPV vaccine. All males, 13 to 21 years of age, who are not sexually active and have not received the HPV vaccine are eligible to be vaccinated.

…chlamydia is urine-based or via a vaginal or penile swab. The test is easy and painless. …gonorrhea is urine-based or via a vaginal or penile swab. The test is easy and painless. …syphilis is conducted by a serum blood test. Sometimes uid from a syphilitic sore is also taken to see if it is caused by syphilis.

Protect Baltimore A minor (i.e., a person under the age of 18) has the same capacity as an adult to consent to treatment for or advice about venereal disease. A provider does not need to provide information to the minor’s parent, guardian or custodian or to the spouse of the minor’s parent about treatment needed or provided. However, a provider may provide this Adolescents list con dentiality concerns as information to those parties without the consent of or the number one reason for delaying or forgoing over the express objection of a minor. (See Types of medical care. HIV tests in section 2) During a visit, teens are more likely to disclose sensitive information if consent and con dentiality is explained to them and they have time alone with a Begin by discussing con dentiality and its limits. provider (see guidance below on discussing consent). This helps build trust and explains the basis for mandated reporting. Explain that mandated reporting exists. Though it can cause confusion at times, it is ultimately for their Do not make any assumptions, particularly about protection. initiation of sexual activity, type of activity, gender identity, and . Avoid jargon or complex medical terminology. A Disease Intervention Specialist (DIS) may be Teens are often hesitant to ask for clari cation. contacting an HIV positive patient to discuss notifying Simple, straightforward language ensures effective the patient’s partners. The DIS cannot disclose the communication of important information. patient’s identity to any partners and cannot discuss test information with a parent/caregiver. Use inclusive language. Language that includes LGBTQ or gender variant youth builds trust and indicates acceptance. Instead of ‘do you have a boyfriend/girlfriend?’ try saying ‘are you seeing anyone?” or ‘are you in a relationship?’

Protect Baltimore How to Access PrEP in Baltimore

______Access In order to access HIV Pre-Exposure Prophylaxis (PrEP), you need a prescription for Truvada written by a health care provider and a means to cover the cost of the drug as well as the cost of medical visits and lab work that are part of a comprehensive PrEP program. Types of Insurance Coverage Privat e Insurance via t he Market place: Maryland Health Connection is Maryland’s official health insurance marketplace, offering a range of health coverage options from health insurance carriers and public health care programs. You can get the coverage you need online, over the phone, or in person. Go to: https:/ / www.marylandhealthconnection.gov for more information. Financial assistance is available to help reduce the cost of health care for individuals and families who enroll in a marketplace health insurance plan and meet certain income requirements. o For premium assistance, an individual’s annual household income must be below 400% of the federal poverty level (FPL), or $47,080 for a single person. Consumers may use their premium assistance for any plan under any metal tier in the Marketplace (Bronze, Silver, Gold or Platinum) and may choose to receive it in advance each month or at the end of the year when they file their taxes. For cost-sharing subsidies, an individual’s annual household income must be 250% of the federal poverty level (or $29,425 for a single person) or less. Individuals may only receive cost-sharing subsidies if they choose to enroll in a Silver-level plan. You can stay on your parent’s health insurance until you turn 26. Open enrollment for 2016 coverage began on November 1, 2015 and ends January 31, 2016. You may be able to buy a health plan outside of open enrollment only if you’ve had special circumstances like having a baby or losing other health coverage. The amount you pay to access PrEP will vary depending on the metal level you choose and the corresponding premium, deductible, copay and coinsurance amount.

Medicaid: Maryland has chosen to implement the Affordable Care Act's Medicaid expansion. To find out if you are eligible for Medicaid or the Maryland Children’s Health Program (MCHP), and for information on how to apply, go to https:/ / www.marylandhealthconnection.gov/ medicaid-basics-benefits. Enrollment in Medicaid and MCHP is year- round. If eligible, coverage will be effective back to the first day of the month in which you applied.

If You Are Insured Medicaid and most private insurance covers PrEP, however, several barriers can still make accessing PrEP difficult. These barriers may include high out of pocket costs (e.g. premiums, co-pays, etc.); prior authorization (when the pharmacy and doctor need to submit documentation to the insurance company to get the drug approved), and quantity limits (when the plan will only pay for a few pills instead of a full month supply). The CDC publishes a helpful brochure (http:/ / www.cdc.gov/ hiv/ pdf/ risk_PrEP_TalkingtoDr.pdf) on how to talk to your doctor about PrEP.

PrEP-Related Resources in Baltimore (partial list) Chase Brexton – Mount Vernon 1111 North Charles Street Balt i mor e, M D 21201 Telephone: 410-837-2050; http:/ / chasebrexton.org

Protect Baltimore Johns Hopkins Moore Clinic for HIV Care 1800 Orleans Street Carnegie 346 Baltimore, MD 21287 Telephone: 410-955-1725; http:/ / www.hopkinsmedicine.org/ moore_clinic.html

JACQUES Initiative- Institute of Human Virology - University MD School of Medicine 821 N. Eutaw St., Suite 209 Balt i mor e, M D 21201 Telephone: 443-552-2933; http://www.jacques.ihv.org

Star Track - University of Maryland Adolescent Clinic (28 and younger) * Program should be up and running by Dec. 1st 120 Penn St Baltimore, MD 21201 Telephone: (410) 328-TEEN (8336); http://umm.edu/programs/childrens/services/adolescent-and-young-adult

Fr e e an d Lo w Co st Cl i n i cs Free and low cost clinics in Baltimore, including community clinics and federally qualified health centers, generally accept most t ypes of healt h insurance and provide services f or people who don’ t have insurance at a sliding scale payment rate (including, possibly free). These clinics generally serve individuals from the county where the clinic is located and surrounding areas. To find a list of clinics in your area visit: http:/ / findahealthcenter.hrsa.gov/ Search_HCC.aspx

Medication Assistance and Copay Programs Gilead’s Medication Assistance Program: provides Truvada for PrEP at no cost for those without health insurance or prescription drug coverage. To be eligible for Gilead’s Medication Assistance Program for Truvada, you must: • Be HIV-negative • Have an income below 500% of the FPL ($58,850 for one person) • Not have any other source for health insurance or prescription coverage (re-evaluated on a regular basis) • Have a prescription for Truvada • Show proof of U.S. residency. In other words, you must live in the US but you don’t have to be a “ legal resident.” • Medication (30 day supply) will be shipped to provider’s office—may take up to two weeks. Gilead will check your status every 90 days and requires that you reapply after 6 months. Contact Gilead: 1-855-330-5479 Gilead’s Co-pay Program provides assistance (up to $300/month) with out-of-pocket costs (including co-pays, co- insurance and deductibles) for people who have insurance, regardless of income. To be eligible for Gilead’s co-pay program for Truvada, you must: ƒ Have private insurance ƒ Reside in t he US or US territ ories ƒ Not have Medicaid or Medicare If eligible, Gilead will issue a co-pay card for use at pharmacies. They will also reimburse when pharmacies don’t accept the card. Need to re-apply every 6 months. Contact Gilead at 1-877-505-6986 (www.gileadcopay.com) Patient Access Network (PAN) Co-pay Program: Through the Patient Access Network, you may receive a grant for up to $4,000 per year, which covers deductibles and co-insurance and is designed for those whose out-of-pocket costs are not fully covered by the Gilead program. Most pharmacies should be able to bill PAN directly. To qualify for co-payment assist ance wit h Pat ient Access Net work, you must : • Have private insurance that covers Truvada • Have income below 500% of FPL • Not be eligible for Medicaid or Medicare • Reside and receive treatment in the US. Co n t act : www.panfoundation.org/fundingapplication/ welcome.php or 1-866-316-PANF

Protect Baltimore 1. Baltimore City HIV/AIDS Epidemiological 6. Code of Maryland Regulations, 10.18.09.05. Pro le Fourth Quarter 2011 Data reported http://dsd.state.md.us/comar/get le. through December 31, 2011. Access: http:// 7. Remien RH, Higgins JA, Correale J, et al. Lack phpa.dhmh.maryland.gov/OIDEOR/CHSE/ of understanding of acute HIV infection among Shared%20Documents/ Baltimore%20City%20 newly-infected persons: Implications for HIV%20AIDS%20Epidemiological%20 prevention and public health: The NIMH Multisite Pro le%2012-2011.pdf Acute HIV Infection Study: II. AIDS Behav 2009; 2. Centers for Disease Control and Prevention. 13:1046-1053. HIV Surveillance-, 1981-2008. 8. Monasterio E, Combs N, Warner L, Larsen- MMWR. 2011;60(21):689-693. http://www. Fleming M, St. Andrews A, (2010). Sexual cdc.gov/mmwr/preview/mmwrhtml/mm6021a2. Health: An Adolescent Provider Toolkit. San htm. Accessed September 28, 2012. Francisco, CA: Adolescent Health Working 3. Practice Advisory for the HIV Testing Group, San Francisco. Process in Maryland. AIDS Administration. 9. Maryland Annotated Code. Health-Gen. II. 20-102. Maryland Department of Health and Mental Hygiene. http://healthymaryland.org/wp-content/ uploads/2011/05/HIVTestingPractice AdvisoryAug2008FINAL_002.pdf.

4. Klein D, Hurley LB, Merrill D, Quesenberry, CP. Review of medical encounters in the 5 years before a diagnosis of HIV-1 infection: implications for early detection. J Acquir Immune De c Syndr. 2003; 32(2):143-152.

5. Branson BM, Hands eld HH, Lampe MA, et al. Revised recommendtions for HIV testing of adults, adolescents, and preganant women in health-care settings. MMW R. 2006; 55(RR- 14):1-17. www.cdc.gov/mmwr/preview/ mmwrhtml/rr5514a1.htm

Protect Baltimore The Protect Baltimore Campaign is a collaborative effort by the Centers for Disease Control and Prevention (CDC), the Baltimore City Health Department (BCHD) and the Center for Child and Community Health Research (CCHR) at the Johns Hopkins School of Medicine. The goal of the collaboration is to reduce HIV transmission by increasing routine HIV screening. This campaign provides informational tools to make HIV screening easier and more familiar for patients and providers. We look forward to working with you to Protect Baltimore. The informational tools include the most current guidelines for HIV screening and counseling in addition to best practices for notifying patients of results, treatment, reporting and coding for reimbursement. Special information is provided for patients who are pregnant and/ or engage in high-risk behaviors, i.e. behaviors that may facilitate transmission.