HIV Prevention Integration with Monkeypox Vaccination Efforts in Gwinnett County, GA

Gwinnett, Newton and Rockdale County Health Departments (GNR Public Health) works to protect and improve the overall health of the population served by the three county public health district in metro Atlanta, GA.  GNR Public Health strives to meet the health related needs of over 1.2 million residents through education, prevention, preparedness, regulation and clinical services.  GNR Public Health envisions a healthy, protected and prepared community, with a mission to protect and improve the health of our community by monitoring and preventing disease, promoting health and well-being and preparing for disasters.

Gwinnett County, the largest county of the district, located in the northeast suburbs of the Atlanta metropolitan area, has seen explosive growth for the past few decades.  The county population has grown from 72,349 in 1970 to 946,546 as of July 1, 2021.  In addition to explosive population growth, the County's population has become increasingly diverse, both racially and ethnically.  According to the most recent U.S. census estimate for 2021, 51.9% of the population was White alone, 30.8% was Black or African American alone, 13.2% was Asian alone, and 22.2% was Hispanic or Latino.  The diversity of the population served presents unique challenges, as well as opportunities, for collaborative prevention models of care to support the overall health of our community. 

Gwinnett County's designation as one of the 57 jurisdictions with the highest rates of new HIV infections has come at a time where focus on infectious diseases has been identified as an area of great concern.  The proportion of Gwinnett County residents living with HIV has more than quadrupled from 96 per 100,000 in 2008, to 413 per 100,000 in 2020.  Among Gwinnett residents, the HIV epidemic has disproportionately impacted the Black and Hispanic communities, specifically among the LGBTQ+ Black and Hispanic populations.  Federal, state and county resources have been leveraged to build community level prevention and disease control programs as GNR Public Health works collaboratively to build capacity and improve infectious disease prevention, specifically among the populations disproportionately affected by HIV.

The global Mpox outbreak in 2022 had a tremendous impact, predominately among the LGBTQ+ population, throughout metropolitan Atlanta including Gwinnett County.  GA reported 1,984 cases of Mpox, with cases being disproportionally reported among the metro Atlanta LGBTQ+ population.  Nationally, 38% of Mpox cases reported having been diagnosed with HIV; among GA residents, 60% reported HIV infection; and among Gwinnett Mpox cases, 26% reported immunosuppression including HIV infection.  The rapid rise in cases, coupled with limited vaccine resources and federal and state vaccine eligibility requirements necessitated a rapid, strategic response to protect the health of the populations served.   The collaborative response practice leveraged existing HIV prevention functionality, paired with extensive mass vaccination and disease control response efforts, to implement holistic Mpox and HIV prevention and control. 

Rapid HIV testing, utilization of take-home HIV test kits, PrEP referrals, enrollment in condom subscription program, and STI/HIV/Mpox/COVID prevention education efforts were prioritized in all GNR Public Health Mpox vaccination efforts.  In an effort to gain the trust of the at-risk population, initial mass vaccination efforts were carried out in collaboration with the primary Gwinnett HIV care organization and advertised through community based organizations involved in local HIV prevention services. From July 10 December 15, 2022, a total of 7,493 Jynneos Mpox vaccines were administered by GNR Public Health. Eighty-five percent of vaccines were administered to residents of Gwinnett, DeKalb, Fulton, and Cobb Counties, all of which are designated as jurisdictions with the highest rates of HIV infection in the Ending the HIV Epidemic initiative.  Fourty-one percent of vaccine recipients were Black and 11% were Hispanic.  Vaccination operations included mass vaccination walk-in and drive-thru clinics, as well as integration of Jynneos administration into general Public Health clinical services.  Among all Mpox vaccination operations, HIV prevention efforts, including rapid HIV testing, were incorporated.  This included HIV testing utilizing drive-thru tents during a mass Mpox drive-thru vaccination event where 2,309 individuals were immunized ahead of Atlanta Black Pride in September, 2022.  All vaccine recipients were also provide free home COVID-19 test kits and prevention education.  Among Mpox vaccination recipients, 10 individuals were identified to be HIV positive; all were linked to care within 48 hours. 

The Mpox response, integrated with HIV Prevention functionality, resulted in a successful, community driven, collaborative response.  Leveraging relationships and trust developed through HIV efforts, GNR Public Health was able to rapidly and strategically implement Mpox prevention including mass vaccination clinics serving the LGBTQ+ populations.  The relationships and efforts implemented through the ongoing HIV prevention efforts allowed for a rapid, strategic, community driven Mpox response, incorporating wrap around HIV prevention functionality. 

www.gnrhealth.com   www.SURGEGNR.com

In 2022, the HIV epidemic and Mpox outbreak collided, causing GNR Public Health to quickly coordinate and implement vaccination response efforts, including redirecting programmatic staff and organizational efforts, efforts already stretched to capacity as a result of the COVID-19 pandemic.  While already faced with capacity challenges in addressing the HIV epidemic, and while recovering from an extensive COVID-19 response, the Mpox outbreak further magnified response and community protection challenges.  In light of those challenges, as GNR Public Health mobilized our response, a strategic and innovative approach was required to maximize efforts, and greatly impact communities served by GNR Public Health.  Strategies to address both public health emergency and ongoing HIV prevention priorities were vitally necessary.  Practices were developed to ensure a collaborative and coordinated response effort and to ensure our response prioritized equitable access to both Mpox vaccine and prevention services, all with a very short response window and a high demand for vaccine.  With both public health concerns at the forefront, a collaborative plan to tackle both issues was a dire necessity. 

To understand the significance of GNR Public Health's (GNR) approach, it is first important to understand the observed impact of the Mpox outbreak and HIV epidemic.  In May of 2022, Mpox cases hit the U.S., with a significant increase in cases being observed, causing concern both globally and domestically.  Currently, as of December 2022, there have been 29,630 Mpox cases in the U.S, and similar to what's been seen with the HIV epidemic, the Mpox outbreak has disproportionately affected certain subpopulations.  Among U.S. Mpox cases, 99% have occurred in men, with 94% of whom reported engagement in recent male to male sexual or close intimate contact.  According to the Centers of Disease Control and Prevention (CDC), as of November 30, 2022, it reported that 41% of reported Mpox cases are Black or African American, 31% are White and 10% are Hispanic. The racial/ethnic disparities observed nationally have also been observed in the state of Georgia, and according to the December 28, 2022, Georgia Mpox Situational Report, males accounted for 97% of positive probable and confirmed Mpox cases, and Black/African Americans accounted for 77% on new cases, with a significant number of cases identifying as men who have sex with men (MSM), and as HIV positive.  In addition to the observed Mpox disparities by gender and race/ethnicity, Georgia was identified as one of the top five states with the highest Mpox cases.   

Evaluating the populations being disproportionately affected by the Mpox outbreak, GNR Public Health identified major similarities between the populations being disproportionately impacted by the HIV epidemic.  Despite continued efforts and progress made in combatting the HIV epidemic, the epidemic has continued to have a drastic toll in the U.S.  Despite the infusion of significant financial resources across the nation, there has not been a significant decline in the number of newly diagnosed cases.  From 2016 to 2019, HIV diagnosis decreased 8% overall in the US and dependent areas (cdc.gov/hiv/statistics/overview/ataglance.html).  In 2020, 30,635 people received an HIV diagnosis in the United States and dependent areas.  Of the 30,635 newly diagnosed HIV cases, Black/African Americans accounted for 12,827 of the cases, Hispanic/Latino accounted for 7,999 cases, and White individuals accounted for 7,831 cases, with male to male sexual contact accounted for 20,758 of cases.  (cdc.gov/hiv/statistics/overview/ataglance.html).  In Georgia, according to 2019 DPH HIV surveillance data, 79% of those diagnosed with HIV infection were male, and among males, 83% were attributed to male to male (MSM) sexual contact, and 71% of cases were among Blacks, and the rate of diagnosis was highest among Blacks.

In 2019, an effort to more strategically address the HIV epidemic, the U.S Department of Health and Human Services (HHS) launched the Ending the HIV Epidemic in the U.S. (EHE) initiative, which aims to reduce new HIV infections in the U.S. by 90% by 2030, by scaling up key HIV prevention and treatment strategies.  At the heart of the initiative, is the determination of leveraging innovative HIV prevention tools, and implementing a community driven approach that focuses on diagnosis, prevention, treatment and outbreak response. This strategic focus  ensures increased testing accessibility and availability, leading in an increase in individuals knowing their HIV status, while also ensuring individuals with a negative HIV status are provided HIV prevention education, assessed for PrEP eligibility, and appropriately linked to PrEP services.  In addition, testing ensures HIV positive identified individuals are rapidly linked to HIV care services.  The initial phase of the initiative focuses on 57 priority jurisdictions that account for more than half of new HIV diagnoses, with Gwinnett County being designated as one of those jurisdictions.  This designation has afforded GNR Public Health the opportunity to receive additional funding to address the growing HIV epidemic, working collaboratively with other EHE jurisdictions throughout metropolitan Atlanta.

Therefore, recognizing observed commonalities in the communities being disproportionately impacted by the Mpox outbreak and the HIV epidemic, GNR Public Health's goal was to continue the task of meeting people where they are, while also ensuring that those most impacted, and marginalized communities have equitable access to Mpox vaccine and HIV prevention services.  Working collaboratively with trusted HIV Care providers, community partners and community advocates, GNR Public Health strive to accomplish this goal, while also working diligently to ensure that GNR Public Health break the chain of transmission in all vulnerable populations.  This practice has been accomplished through strategic planning and collaboration, and taking the opportunity to integrate HIV prevention wrap around services into Mpox vaccination response efforts.  Integration of HIV Prevention wrap around services with Mpox vaccination efforts enhance ongoing Ending the HIV Epidemic initiatives in Gwinnett County, GA. 

Initially, Mpox vaccine demand far surpassed vaccine availability in Gwinnett and surrounding metro Atlanta counties.  Due to limitations in vaccine supply, and to ensure care was provided in an environment trusted by the identified at-risk population, initial appointment only events were facilitated in partnership with a trusted HIV care organization in Gwinnett County.  In the initial phase of Mpox vaccine rollout, GNR Public Health observed that many of the individuals arriving for appointments did not mirror the populations being disproportionately affected by the outbreak.  Even though GNR Public Health desired to ensure vaccine availability to all vulnerable populations, we were cognizant of the need to engage disparate communities.  Therefore, in an effort to ensure vaccine equity, GNR Public Health partnered with community based organizations, and funded EHE partners that serve high risk, minority populations, to ensure vaccine appointment availability was prioritized for these communities.  In addition, GNR Public Health collaborated with minority community advocates who were able to more efficiently communicate within their social networks, encouraging the Mpox vaccine, and sharing vaccine appointment availabilities.  Some advocates even took the initiative to assist their community with registering for available appointments.  These efforts assisted with ensuring equitable vaccine distribution, so GNR Public Health could get the vaccine into the arm of the most impacted communities. 

As a result of our efforts to ensure vaccine equity, during our initial response in July 2022, 64% of Mpox vaccine recipients among White and 27% among Black populations, compared to 48% among White and 43% among Black populations in September 2022; 41% of overall vaccine recipients in 2022 were Black. In addition to ensuring equitable vaccine administration, GNR Public Health ensured that vaccine education was offered in multiple languages and ensured translators were present at all vaccine events. GNR Public Health also ensured media messaging targeted at-risk audiences. As vaccine availability increased, strategies were implemented to increase availability, including daily appointments in multiple locations, including GNR District Health Office, Health Department clinics, and utilization of large-scale drive thru/walk-in events. GNR Public Health also ensured all clients had access to wrap around HIV prevention services.

HIV prevention wrap around services include, providing rapid point of care HIV testing, distributing at home HIV test kits, PrEP referrals and linkage, linkage to HIV Care, enrollment in condom subscription program, connecting clients with their local health departments, if needed, and providing STI/HIV/Mpox prevention education.  These efforts were prioritized in all GNR Public Health Mpox vaccination efforts.  Our goal was to ensure all individuals were aware of their HIV status prior to leaving vaccination event, therefore, rapid point of care HIV testing was offered to all clients.  All testing and prevention education was implemented by HIV and STD prevention program staff.  Clients with negative test results were provided prevention education, including PrEP education, and clients with positive results were rapidly linked to HIV care services. Clients voluntarily disclosing their HIV positive status were linked and reengaged if reported to be out of care.   Home HIV test kits were also offered to clients for self-utilization and/or to distribute among their social network.  Clients interested in home test kits were encouraged to access a QR code and complete a short survey. The QR code also linked individuals to GNR's HIV Prevention website, www.SURGEGNR.com.  In an effort to provide ongoing support, clients utilizing at-home test kits were encouraged to contact the HIV Prevention team for assistance if they had any testing questions or concerns.  PrEP referrals and direct linkage to PrEP services were also provided, with some clients being linked to same day services.  Lastly, interested clients were enrolled in our free mail order condom subscription program, which provided access to 30 free condoms every three months.

In taking this strategic approach to provide equitable vaccine and HIV prevention wrap around services, from July 10, 2022 to December 15, 2022, 7,493 Jynneos vaccines were administered, 732 rapid HIV tests were administered, 633 home HIV test kits were distributed, and 118 patients were enrolled in PrEP; 10 individuals were diagnosed and linked to care. This innovative approach was vital and instrumental in combatting both the Mpox outbreak and HIV epidemic, and provided a needed opportunity to engage with communities that historically have been challenging to engage, especially recognizing that many vulnerable populations may fail to utilize traditional route of accessing the healthcare system, due to stigma and structural barriers to care.  This innovative approach allowed GNR Public Health the opportunity to coordinate, mobilize and deploy staff across multiple GNR Public Health programs, staff that worked closely and collaboratively, thereby, increasing our capacity to response to multiple public health emergencies simultaneously, including COVID 19, HIV and Mpox.

Looking forward, GNR Public Health will continue working diligently to integrate HIV prevention services into programmatic functionality, ensuring increased HIV testing access and availability in the community, increased prevention education, and provide linkage to PrEP and HIV care services.  In addition, as GNR Public Health strives to continue providing the aforementioned, GNR Public Health will continue developing and strengthening community partnership, and working collaboratively with other EHE jurisdictions, in an effort to blur jurisdictional line, as GNR Public Health understand infectious diseases knows no boundary, including HIV.  GNR Public Health will continue to prioritize this practice as GNR Public Health strive to greatly impact the community GNR Public Health serve and End the HIV Epidemic.  The integration of HIV prevention activities into emergency response activities presents a model of integrated functionality where silos associated with traditional Public Health response and finding are broken down to ensure that GNR Public Health are serving the population with a more holistic prevention and care model. 

https://www.cdc.gov/poxvirus/Mpox/response/2022/demographics.html

https://www.cdc.gov/poxvirus/Mpox/response/2022/Mpox-trends.html

https://dph.georgia.gov/search?search=Mpox&sm_site_name=dph

https://www.cdc.gov/poxvirus/Mpox/response/2022/us-map.html

https://www.cdc.gov/endhiv/about.html

https://www.cdc.gov/hiv/statistics/overview/index.html

https://www.cdc.gov/poxvirus/Mpox/response/2022/index.html

https://www.cdc.gov/mmwr/volumes/71/wr/mm7132e3.htm

Goals:

The goal of practice was to provide comprehensive HIV wrap around services in association with Jynneos Mpox mass vaccination effort for federally identified priority populations, and to enhance the ongoing HIV prevention functionality initiatives in Gwinnett, Newton and Rockdale Counties.  As Jynneos vaccine was initially only available through Public Health emergency response, activation of the local health Department's Incident Command structure (ICS) was key in ensuring response activities were planned in accordance with available resources and local expertise as establishing mass vaccination efforts.  While response efforts were supported by local emergency management, hospital and community based organization partners, as with all health related emergency response functionality, GNR Health was the lead agency and response functionality was lead through incident command. Objectives for the integrated response were developed, evaluated and reviewed through ongoing Incident Command functionality.

Mpox HIV Prevention Objectives:

·        To integrate HIV Prevention into emergency response activities related to the ongoing Mpox global outbreak ensuring  HIV wrap services were available for Mpox vaccination recipients

·        To utilize strategies to address the initial vaccine demand compared with Jynneos vaccine availability and ensure efforts incorporate initiatives to ensure health equity among vaccine recipients

·        To incorporate trained HIV and STI Prevention program Communicable Disease Specialists (CDS) into emerging pathogen outbreak response, case management, and disease mitigation efforts

·        To engage and serve clients who may not access traditional healthcare facilities

·        To continue to develop trust and partnerships among the community most impacted by both Mpox and the ongoing HIV Epidemic. 

At the start of the Mpox outbreak, the Centers for Disease Control and Prevention (CDC) identified priority groups for Mpox vaccination.  As a result, all vaccination strategies required screening and validation efforts to ensure vaccine recipients were among the approved populations.  As the vaccine was allocated through federal assets, verification and maintenance of eligibility criteria was required.  As strategies were put in place to ensure vaccine access and equity, HIV prevention integration was embedded in the local emergency response.  The Mpox outbreak presented a unique opportunity to extend the reach of public health emergency response and continue to develop and foster relationships with the population most impacted by the ongoing HIV epidemic.   

An Incident Command Structure (ICS) was established and activated, comprising staff from all program areas of the health department including the communications team. The EHE and HIV Prevention programs were represented by the the Clinical Infectious Disease Program Director and HIV program managers. Support from local community based HIV support services was also established to increase response capacity and ensure HIV Prevention wrap around services were fully integrated with Mpox vaccination efforts and to enhance the ongoing HIV prevention functionality. 

Initial Mpox vaccine demand far surpassed the availability of Jynneos vaccine in Gwinnett and the surrounding counties in metro Atlanta. As agreed by the ICS, to ensure clinical care was provided in a trusted environment and accessed by the population eligible for vaccine, initial appointment only events were facilitated in partnership with a trusted HIV care organization in Gwinnett County. Events were advertised on the GNR Public Health and partner websites and social media, and appointment slots were filled through an online application.  Given initial vaccine allocations were only provided through Public Health, innovative strategies were needed to ensure vaccine reached the population most impacted by the Mpox outbreak. To meet the vaccine demand and to widen access to HIV prevention efforts, GNR Public Health worked collaboratively with four neighboring EHE jurisdictions to ensure that residents from any area could access vaccinations regardless of residence, and to link clients to prevention services in their residential counties, if requested.

Following initial vaccination events, of the individuals receiving Mpox vaccines, GNR Public Health observed that 64% were White, 27% Black.  Vaccine equity was evaluated and reported on a weekly basis to ensure vaccination efforts reached the populations disproportionately impacted by the Mpox outbreak. GNR Public Health collaborated with community partners serving those communities, and as a result, increased vaccine uptake in the Black community.  To ensure maximum availability, wait lists were established to fill no-show and cancellation slots. Initial vaccination enrollment efforts resulted in a waiting list of over 2,400 individuals.

Ahead of Atlanta Black Pride festivities, a large drive-thru vaccination event with 3,000 vaccination appointments over two days was operationalized. As all vaccination recipients remained in their vehicle throughout the process. HIV testing and wrap around services were provided in drive thru tents established in the patient Mpox vaccination flow. In cases of a confirmatory HIV test being required, recipients were accompanied indoors for confidential confirmatory testing and linkage to care services. Second doses vaccines were administered in a walk-in format due to implementation of the vaccine-sparing intradermal administration technique.  As availability of vaccine increased, Jynneos vaccination, including HIV wrap around services, was integrated into health department clinic sites. In addition to offering free HIV testing, branded take home kits containing a HIV home test kit, condoms, HIV prevention and HIV PrEP enrollment literature were provide for all vaccine recipients, increasing access in more rural Newton and Rockdale Counties.

GNR Public Health emergency response is a core function of all program and clinical staff.  As COVID mitigation was included in all response activities, general Mpox response costs, including staffing, were funded through ongoing state approved COVID emergency response funding.  These funds covered all associated staffing and operational costs.   Costs associated with the integration of HIV wrap around services, the model practice being presented, were absorbed primarily through GNR Public Health's Ending the HIV Epidemic (EHE) funding.  Utilization of state and federal STI and HIV funding was approved to support overall local level Mpox response and control activities, including utilization of STI and HIV CDS staffing.  Additional funding was allocated for the provision of take-home bags with home HIV test kits, condoms, PrEP and STI prevention education, and literature linking patients being vaccinated with local HIV prevention functionality.  In addition, a COVID home test kit labeled with a QR code linking individuals to HIV and Mpox prevention education was provided to all Jynneos vaccine recipients.  The overall cost associated with these take home” HIV/STI prevention kits was $49,728. 

Activities associated with this model practice initiated on June 30, 2022 when GNR Public Health's Incident Command Structure for Mpox response was activated.  Mpox vaccination events were initiated on July 16, 2022 and are ongoing.  These events included initial, by appointment only, mass vaccination events held in partnership with a local HIV care organization, walk in and drive-thru mass vaccination clinics held at the GNR Public Health sites, and a large scale mass vaccination drive thru/walk-in site established during the local COVID response.  Although the demand remains low, Mpox response, with wrap around HIV Prevention integration, is ongoing in all GNR Public Health clinical sites. 

Section 3: Evaluation GNR MPOX and HIV Wrap around services

Findings

Utilization of emergency response strategies provided an opportunity to implement Mpox outbreak prevention strategies in tandem with ongoing HIV Prevention, including vaccinating populations determined to be most at risk for Mpox infection. Early utilization of mass-vaccination operations allowed for prioritized prevention strategies, limited wait time for vaccine recipients, and incorporation of wrap around HIV prevention services. The community driven response also proved to be a valuable opportunity to reach priority populations, community based partners serving these populations, and resulted in ongoing engagement with sections of the community reluctant to access traditional Public Health clinical services.

HIV prevention services including HIV prevention education, HIV testing, PrEP referrals, linkage to care for confirmed HIV positive cases or for those out of care, and free condom by mail subscription program were available in conjunction with all Mpox vaccination efforts. In addition to the provision of opt-out HIV testing, HIV Prevention services were also incorporated into the general Public Health clinics as part of the daily services provided to all patients receiving Mpox vaccine.  HIV/STD CDS staff were also trained on contact tracing, case management and follow-up for Mpox patients based on CDC provided guidance.  The CDS staff had unique training and skills to assist in the elicitation of partners, ability to provide risk reduction education about STIs/HIV, and overall disease mitigation management. 

Throughout this strategic approach to provide equitable vaccine and HIV prevention wrap around services, from July 10, 2022 to December 15, 2022, 7,493 Jynneos vaccines were administered, 732 rapid HIV tests were administered, 633 home HIV test kits were distributed, and 118 patients were enrolled in PrEP; 10 individuals were diagnosed and linked to care. Free condoms were also distributed at least 10 condoms per patient based on patients request to all those getting point of care HIV test or at home test kits.

As a result of our efforts to ensure vaccine equity, during our initial response in July 2022, 64% of Mpox vaccine recipients were among White and 27% among Black populations, compared to 48% among White and 43% among Black populations in September 2022; 41% of overall vaccine recipients in 2022 were Black. Other racial categories included Asian, American Indian/Alaskan Native, Multicultural, Hawaiian /Polynesian, multicultural and unknown.  Overall, 11% of vaccine recipients self reported as Hispanic. Thirty-four percent of vaccine recipients were between the age of 31-40, with 21% in both the 21-30 and 41-50 years of age categories. 

Evaluation of Practice

GNR Public Health operated under the Incident Command System during all mass Mpox vaccination operations. This structure allowed for ongoing evaluation and quality improvement of vaccination efforts to ensure efforts were meeting the incident objectives and overall community needs.  Incident Command staff routinely evaluated all operations including appointment availability and utilization, mass vaccination operations, patient education, general communications and marketing, community engagement, and client satisfaction.  Epidemiology, operating under Operations, also evaluated ongoing demographics of vaccine recipients to ensure response activities were reaching our population in an equitable manner.  When inequities were identified, initiatives were put in place to address the inequities. Overall incident command objectives were reviewed weekly and alterations needed based on the community needs, resources, staffing, etc. were implemented in the following operation period.  Technology solutions including an online appointment based system, electronic consenting and check in process, vaccine inventory management, and patient education were utilized to streamline operations.    

Vaccine administration numbers were monitored on a weekly bases to assess staffing and operational needs.  Staffing was assigned following ICS update meetings where ongoing planning operational, logistical, and finance/administration objectives were evaluated.  Once vaccine demand dropped to a level that the patients could be incorporated into daily functionality on general Public Health clinics, mass vaccination sites were closed and staff dedicated to the Mpox response were reallocated to support vaccines in the clinic setting.  At this point, the HIV prevention team worked with the clinical administrators to put in place processesto ensure that all vaccine recipients were offered in house HIV testing as well as a take home kit with home test kits, condoms, education, and information regarding linkage to available prevention services.  The number of kits distributed and pertinent demographic data were collected at the centers and provided to the HIV Prevention team for tracking purposes. 

Data was collected directly from Mpox patients using standard CDC Case Report Forms (CRF) and state approved HIV test forms for HIV testing and linkage services. All Mpox and HIV data was entered into the GA Notifiable disease reporting system.  A QR code for at home HIV test kits survey was also provided, allowing for data capture and follow-up as necessary to implement effective HIV prevention and linkage activities.  Appointment and vaccine recipient demographic and clinical data were entered into the GNR Public Health Electronic Health Record (HER). All vaccine administration data was directly uploaded to the GA statewide immunization tracking system. 

Monitoring of health equity impact was conducted through assessing demographic profile data (race, ethnicity, age, and county of residence) for vaccine recipients utilizing local EHR data and reports were generated utilizing Microsoft excel.  GNR Public Health epidemiologists assessed patient demographics for both Mpox cases and vaccine recipients and reported this data to the Incident Command team on a weekly basis.  This allowed Command staff to alter operations, including communications and marketing, to ensure response and prevention efforts were reaching the populations disproportionately impacted by the ongoing outbreak.  As the populations being disproportionately impacted by Mpox mirrored those disproportionately impacted by the ongoing HIV epidemic, linking prevention and control services allowed for strategic public health intervention efforts. 

As Mpox vaccine demand decreases, GNR Health altered operations, integrating HIV prevention wrap around services into our standard Public Health clinic and outreach functionality.  For clients presenting in our clinics for Mpox immunization and/or adult health services, including STD and contraceptive services, a nurse provides vaccine and HIV prevention education, performs a sexual risk assessment, and evaluates the clients PrEP eligibility. All clients seeking clinical services for Mpox vaccinations are offered a rapid POC HIV test and all clients are offered a take away kit with an at home HIV test kit, condoms, HIV prevention education and information linking to STI/HIV/PrEP resources.  This functionality ensures sustainability of HIV prevention services to vulnerable populations who otherwise may not access HIV prevention services.  Recognizing that many clients accessing our clinical services, specifically immunization services, may not have otherwise engaged with HIV/STI Prevention efforts, prioritizing ongoing prevention services is key to ensuring GNR Public Health are maximizing our efforts and reaching vulnerable, at-risk populations, and ultimately continuing the work of Ending the HIV Epidemic.  In addition to integrating HIV prevention services into clinical functionality, GNR Public Health have been able to integrate HIV prevention, including education, testing, and linkage, into other GNR program functionality, including Mobile Outreach team activities and Opioid Prevention response efforts.  For Mpox case management, GNR Public Health integrate HIV prevention education and guidance, including evaluating clients for last HIV test, ensuring STD and HIV testing was completed by Mpox testing provider and ensuring results were obtained, and if testing was not completed, GNR Public Health assist the client with testing services.  GNR Public Health also assess the clients PrEP awareness, determine PrEP eligibility and link as needed, and provide HIV Care linkage for newly diagnosed individuals and previously diagnosed individuals who are determined to be out of care.

In addition to the integration of HIV prevention services into Mpox emergency response activities, through these efforts, ongoing prioritization of internal and external collaboration and partnerships is critical to ensure ongoing collaborative community health.  The COVID 19 pandemic response taught us valuable lessons regarding maximizing our efforts and impact, in times when a prompt and magnified response is required.  GNR Public Health recognizes the value of working collaboratively across internal program areas to reach a common goal, as well as the importance of external collaboration and partnership development, as we develop and operationalize initiatives to meet the needs of the community, especially when it comes to providing HIV prevention services to hard to reach, high-risk populations, many of which are disproportionately impacted by ongoing health issues and not linked to services through normal public health program operations.  In addition, community partnerships play a vital role in increasing our response capacity, and ensuring GNR Public Health is meeting response needs, while also ensuring equitable access of services to risk high communities. 

The COVID-19 pandemic played a vital role in paving the way to establish new community partnerships, but also signified the importance of maintaining and strengthening existing partnerships.  Working collaboratively with community partners, including the healthcare community, allowed GNR Public Health the opportunity to build a stronger rapport and larger reach, which allowed greater access to vulnerable communities, and ultimately the opportunity to have an even greater impact through the Mpox response and beyond.  For instance, as the Mpox response was operationalized, collaboration with a trusted HIV Care organization and community HIV advocates allowed for rapid establishment of a mass vaccination clinic, prioritizing HIV positive individuals and populations identified to be at increased risk for Mpox, including the LGBTQ+ community.  This partnership afforded the opportunity to establish a rapport and build trust with individuals in the community, individuals who were once distantly disengaged from public health, reluctant to access services, and skeptical of intentions as a governmental agency.  Integrating HIV Prevention practice into our Mpox response signified the importance of utilizing innovative approaches to engaging vulnerable communities.  Traditional Public Health partnerships, including those with first responder agencies and the healthcare community are vital, but also having the ability to establish and enrich relationships with non-traditional community members, such as grass root organizations serving the LGBTQ+ population was also imperative.  GNR Public Health found as these partners encountered our quality services, as a result of their experience, by word of mouth, they were willing to communicate their positive experience through their social network, increasing our reach and impact among the at-risk populations.

Lastly, through the Mpox response, GNR Public Health was able to utilize existing EHE funding and COVID response funding approved for Mpox response efforts to expand HIV prevention outreach functionality, not only through mass vaccination events, but also in general public health clinics and through community partners.  Moving forward GNR Public Health will continue providing ongoing integrative HIV prevention services into its organizational and programmatic functionality, ensuring efforts are focusing on vulnerable communities, equity, and taking advantage of newly established relationships and partnerships to engage our community and extend the reach of prevention, education, and community health efforts through our communities.   

Through integration of HIV Prevention with emergency response efforts, GNR Public Health was able to engage nearly 8,000 individuals with HIV prevention information and education that we otherwise may not have had the opportunity to reach.  While roughly only 10% of these individuals actively  engaged in testing and other HIV prevention efforts, 100% received education related to HIV/STI, Mpox and COVID prevention education.  The community level impact of these prevention and education may be impossible to measure, but the surge of disease prevention education in our communities will undoubtedly increase awareness and knowledge, and as importantly, link and educate these individuals to critical public health services.  Knowing we may only have one opportunity to make the biggest impact in the lives of individuals and the community we serve, GNR Public Health strives to work collaboratively, breaking down traditional response silos, to ensure we do not miss vital opportunities to educate and protect our community.  As GNR Public Health strives to enhance our efforts, this innovative, strategic approach of integrating HIV prevention services into our Mpox vaccine response, clinical and outreach functionality has allowed the opportunity to engage a larger audience, providing the opportunity to address overlapping public health concerns and priorities like never before. This model of integration of public health efforts, breaking down response and funding silos, has far-reaching implications and provides never-ending opportunities to provide a higher level of protection, prevention, and education for our communities.