No easy task: Finding clients post-hurricane

Many still have not returned to Louisiana

Nine months after one of the deadliest and costliest hurricane disasters hit the United States, the Louisiana HIV/AIDS program still is looking for hundreds of clients who had been on medication lists prior to the New Orleans' flooding destruction.

In August 2005, the AIDS Drug Assistance Program (ADAP) served 1,720 people, and in September 2005, that number dropped to 1,139 people, says Beth Scalco, LCSW, MPA, administrative director for the Louisiana Office of Public Health HIV/AIDS program in New Orleans.

As of March, 2006, the program had 1,350 clients. "So we're heading in the right direction, but obviously we're missing 300 to 400 people," Scalco says. "Texas had hundreds of our clients on ADAP, so we're hoping a lot of the missing people are still on other state's ADAPs, with the primary one being in Texas."

Another problem for HIV clients was that the main HIV clinic in New Orleans was closed for months. Prior to the disaster, it served 3,000 HIV clients, and now it serves about 1,400, Scalco says.

The state's HIV/AIDS program staff worries about the long-term impact from the disaster.

"This disaster, no doubt, impacted adherence to medication," Scalco says. "If you don't have a house and you don't have a job, and you might be far from your family, then your medication is not the top priority on your list."

There likely are HIV clients who have fallen out of care, and the HIV care providers and state program might not see them again until their lives have become stable, or, in a worst case scenario, they become ill, Scalco adds.

"One of the things we're going to do better now is to prepare our AIDS Drug Assistance Program (ADAP) clients for a hurricane," Scalco says.

"What we're planning to do when clients pick up their medication from the pharmacy in June is to give them an information sheet that says, 'In the event of a hurricane, these are the other distribution sites where you can get your medicine if your site is closed,'" Scalco says.

If someone is evacuated to another state, they will be instructed to call that state's health department and ask or the AIDS Drug Assistance Program, supplying that state with a list of their medications that will be kept on a little wallet card, she adds.

The STD program at the Louisiana Office of Public Health in New Orleans has a syphilis registry in its computer database, and this was impacted by the hurricane disaster, says Lisa Longfellow, MPH, STD director.

In 2004, New Orleans was first in the country in its rate for syphilis, so when hundreds of thousands of people from the area were relocated after the hurricane, the STD office needed quick access to its database, Longfellow says.

Since people who have had syphilis will test positive even if they're not infectious and do not need to be treated, the database was the only way to verify who needed treatment and who did not, she says.

STD officials from states that welcomed Louisiana evacuees began to call two weeks after the hurricane to find out if patients were on the database or if they needed treatment, Longfellow says. "So it was crucial we get that database up and running."

Another problem for the STD program was the closing of STD clinics and services in the hurricane-impacted areas. Of seven clinics that were closed as a result of the disaster, only two had re-opened by May 2006, Longfellow says.

"The good and bad news is the STD reports are down significantly in the New Orleans area, and so we haven't seen a tremendous increase in traffic in the two parish clinics that are open," Longfellow notes. "One thing our staff is doing now as far as a surveillance program is working closely with other providers to ensure STD cases are reported, and we're collaborating with the people who are providing the services."

Each HIV clinic in Louisiana receives contract funding based on how many clients they are expected to serve in a year's time. Since the hurricane shifted some of New Orleans' HIV clients to areas that typically might serve only a small number of HIV clients, then adjustments in contract amounts needed to be made, but it wasn't possible for the HIV/AIDS program to make these changes immediately.

"We worked with the clinics to help them receive evacuees and then worked out the reimbursement," Scalco says.

The clinics and other contractors also were forced to be patient with receiving their checks.

Louisiana's contract payment system involved sending invoices through an internal approval process and then through the state system for payment, Scalco says. "One of the problems was we had this huge amount of invoices located in New Orleans, and we couldn't get into the building to get those invoices, so we had to work with contractors and say, 'Do you have a copy of the invoice, or can you recreate this so we can move it along through Baton Rouge to get your payment,'" Scalco explains.

State officials now are discussing a way to handle this process electronically, so it wouldn't matter where the physical invoices are stored, she notes.

Another big issue tackled after the storm was finding ADAP clients. The Centers for Disease Control and Prevention (CDC), the American Red Cross, and FEMA provided some assistance by giving some names of evacuees and their locations, which the HIV/AIDS program staff could then match to its own list of clients, Scalco says.

Many New Orleans people infected with HIV had moved to other states, so the HIV/AIDS program staff also worked with other states' ADAPs to make certain they were willing to provide help to Louisiana ADAP clients, Scalco says.

They had a national conference call in the first week after the storm, hosted by the National Alliance for State and Territorial AIDS Directors and the Health Resources and Services Administration.

"That was to get all of the medication assistance coordinators on the telephone and talk through what was going on and how they were going to respond to it," Scalco says.

Texas ADAP officials did an excellent job of getting hurricane evacuees medication and assistance, she notes.

This wasn't easy because many of the HIV clients would arrive in another city or state and not know what medications they were taking or even whether they received drugs through ADAP or some other program, Scalco says.

Several other unexpected challenges occurred, including the loss of rapid HIV testing kits and hepatitis B vaccine kits, which needed to be refrigerated.

Although the facility had generators, these were useless if they were flooded or the gasoline fuel ran out, Scalco notes.

"The other big impact that we didn't expect was that we process our HIV tests at the Office of Public Health laboratory in New Orleans, and the lab was in a building that lost electricity," Scalco says. "We had a lot of specimens that were in a controlled temperature environment that we lost because the generators ran out of gasoline."

So all of the HIV clients who had samples pending in the laboratory would need to be retested, she says.

"It took us about four weeks to figure out an alternate mechanism to process laboratory tests," Scalco says. "We went to the CDC and asked them if they could process our test with new specimens coming in, but, unfortunately, that's a very slow process." Ultimately, while the issue was being resolved, the state lost four weeks of HIV testing and had to suspend all testing activities statewide, Scalco says.