Lunch Abstracts - 2002 Nat'l STD Prevention Conference

Lunch Sessions' Abstracts

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California Chlamydia Action Coalition (CCAC) – Lessons Learned

J Nagra^1,2, G Bolan¹, R Neiman¹, H Bauer¹, D Wohlfeiler¹, GW Rutherford²

1California Department of Health Services STD Control Branch; 2University of California, San Francisco

Background: CCAC is a public-private partnership led by the California Department of Health Services, the California HealthCare Foundation, and the University of California, San Francisco. The Coalition is comprised of representatives from commercial and Medicaid managed care organizations, public health agencies, community-based organizations, and universities. The goal of CCAC is to reduce the incidence of chlamydia infection in California by 75% by 2005. The Coalition takes action in three areas: science, policy, and awareness.

Objective: To describe the lessons learned from CCAC and to give specific examples of public-private collaborative activities.

Content: After a brief overview of the epidemiology of chlamydia in California, the organizational structure and governance of the CCAC will be presented. Presenters will then highlight four major activities undertaken by the CCAC: 1) the Chlamydia Quality Improvement Initiative with Medicaid managed care and commercial health plans, 2) provider education including an interactive web-based training program, 3) passage and implementation of partner-delivered therapy legislation, and 4) planning and development of a chlamydia data warehouse that will receive chlamydia test results from laboratories and provide data to managed care organizations for HEDIS reporting and prevalence monitoring and to public health agencies for disease reporting purposes.

Implications for Programs/Policy: Comprehensive chlamydia prevention and control programs must mobilize stakeholders from both the public and private sectors and utilize multifaceted approaches that include providers, insurers, researchers, patients, and policymakers.

Implications for Research: Future research and evaluation will monitor the effectiveness of our comprehensive and collaborative approach and will focus on chlamydia incidence, chlamydia prevalence, rates of complications of chlamydia infections, and provider screening and prescribing practices.

Learning Objectives: By the end of this symposium, participants will be able to:

1. Discuss the benefits of a collaborative approach to chlamydia control.

2. Explain the importance of policy in a comprehensive approach to chlamydia control.

Contact Information: Jas Nagra / Phone 510-540-2758 / jnagra@dhs.ca.gov

Program Operations Guidelines for STD Prevention

D Byrum

Centers for Disease Control and Prevention, Atlanta, GA

This roundtable will consist of a discussion of the new Program Operations Guidelines and how they can best be used by STD programs. A short history of the development of the guidelines will be presented and a discussion will follow. The discussion will focus on programs that have successfully used the guidelines to improve their local STD program.

This roundtable will result in a dissemination of knowledge about how to use the Program Operation Guidelines to improve local program operations.

Problem or Solution? California’s Experience with Bathhouses

D Wohlfeiler¹, M Samuel¹, L Klosinski², B Bense³

1STD Control Branch, CA Dept. of Health Services; 2AIDS Project Los Angeles; 3Club EROS, San Francisco

Background and Rationale: Bathhouses and sex clubs facilitate sexual mixing and multiple partners in a short period of time, and thus may amplify STD epidemics. As a result, interventions aimed at reducing risky behavior in bathhouses have potential for HIV and other STD prevention.

Objectives: 1. Participants will become familiar with data about bathhouses and sex clubs’ role in HIV and other STD transmission; 2. Participants will learn how to maximize the role of bathhouse owners, community-based organizations (CBOs), and health departments in designing and implementing interventions, as well as strategies for dealing with a highly politicized debate.

Content: The debate between those who demand bathhouse closure, and those who advocate for no government or outside intervention, has resulted in many health departments and CBOs doing little to take any steps to reduce the risk of HIV/STD transmission in bathhouses. This symposium will examine this issue through epidemiological, policy, health promotion and management perspectives. Twnety-one percent (95/462) of California MSM diagnosed with early syphilis between January 1, 2000 and September 30, 2001, reported meeting partners in bathhouses. During the interview period they reported a mean of 19.5 partners, compared to 7.4 for MSM with early syphilis that did not report meeting partners in bathhouses. Different cities, even within California, have taken different approaches. Interventions include a) HIV/STD testing b) distributing educational materials c) condom distribution d) outreach by staff or volunteers; e) rules being posted; f) public service announcements g) eliminating private rooms or public rooms h) monitoring i) shutting down bathhouses and j) licensing bathhouses. There is a lack of consensus regarding optimal roles for bathhouse owners, CBOs and health departments in risk-reduction efforts. This symposium will clarify pros and cons of different interventions. Speakers will emphaize incentives and barriers to prevention for bathhouse owners, the importance of community buy-in, and the need to develop long-term strategies which assure prevention within the highly-politicized environment.

Implications for Programs/Policy: This symposium will highlight the need for shared responsibility in preventing new infections by management, the public sector, and individuals.

Implications for Research: We know a lot about who goes to bathhouses, but nothing about the level of risk which takes place in them. Research into different interventions will make a significant contribution toward minimizing transmission of STDs in bathhouses, and advance the field of evaluating structural interventions.

STD*MIS and CDC’s NEDSS Base System: Progress Made and Future Plans

CS Danos¹, M Cicchinelli²

Statistics & Data Management Branch, Division of STD Prevention, Centers for Disease Control & Prevention, Atlanta, Georgia

Background: In the last two years CDC has awarded over $30 million to states and major metropolitan areas that wish to develop software surveillance systems that adhere to CDC’s standards for system integration. In addition, this CDC National Electronic Disease Surveillance System (NEDSS) project includes the design and development of current and future CDC surveillance systems. The STD program has been an active participant in this project from its inception. Efforts are now underway for the development of a NEDSS-based STD surveillance system that will be a successor to STD*MIS.

Purpose: To describe the wide-ranging work now underway to design, develop, and distribute the CDC NEDSS Base System and the STD program area module (PAM) that will replace the current STD*MIS application. To better prepare STD project staff for the changes they will face with this new surveillance system and the burden these changes may place on staff and other program resources.

Methods: The presenter will use PowerPoint presentations with handouts. Following the formal presentation a question and answer session will be held.

Learning Objectives: By the end of this session:

1. Participants will be able to identify the features of the CDC NEDSS Base System

2. Participants will understand the process now underway to develop the new NEDSS-based STD surveillance system 3. Participants will be better prepared to evaluate their existing resources (staff, hardware, etc.) in advance of deployment of the new NEDSS-based STD surveillance system

Contact Information: C. Scott Danos / Phone no. 404-639-8355 / csd3@cdc.gov

Screening for Syphilis in Jails: Lessons Learned from the Three Syphilis Elimination Demonstration Sites

PA Leone¹, CP Seigenthaler², D Wilmot³, RH Kahn⁴

1North Carolina Department of Health, Raliegh, NC; 2Metropolian Health Department of Nashville and Davidson County, Nashville, TN; 3Marion County Health Department, Indianapolis, IN; 4Centers for Disease Control and Prevention, Atlanta, GA

Background: In 1999 the Centers for Disease Control and Prevention (CDC) announced the National Plan to Eliminate Syphilis from the U.S. Thirty-two sites were funded for syphilis elimination activities; of these sites 24 (75%) included plans for jail syphilis screening as an important elimination intervention strategy. Three sites were funded as demonstration sites (Marion County, IN; Davidson County, TN; and Wake County, NC). Previous studies and surveillance projects have demonstrated a high prevalence of STDs in persons entering jails and corrections.

Purpose: To describe factors associated with successful implementation of jail syphilis screening programs in the three syphilis elimination demonstration sites and to describe the syphilis prevalence in these facilities.

Nature: Investigators from each demonstration site will describe: obstacles and challenges in implementing jail screening (e.g., intake screening, informed consent, space limitations, staffing, specimen storage and transportation, STAT testing), screening rates, syphilis prevalence, treatment rates, follow-up success, data systems, and sustainability.

Implications for Programs: These presentations will discuss the main obstacles STD programs may face when implementing a jail screening program and present options for resolving these issues. Program staff that implemented these programs will discuss the “nuts and bolts” of jail screening from the local perspective, and describe the programmatic contribution this activity makes.

Implications for Research: Future research and evaluation should address the sustainability of jail screening after national funding ceases. In addition, the utility of syphilis prevalence monitoring in low morbidity areas as a surveillance tool should be assessed.

Learning Objectives:

1. Participants will be able to describe the obstacles to implementing syphilis-screening programs in jail settings.

2. Participants will be able to describe successful jail screening models and will have knowledge of appropriate staffing, laboratory methods, data systems and follow-up services.

3. Participants will be able to describe the programmatic benefits that jail screening makes, such as monitoring disease levels and informing other prevention activities.

Enhancing the STD Prevention Infrastructure by Building Social Capital: A Structural Intervention Workshop

FR Bloom, SP Williams

Behavioral Interventions and Research Branch, Centers for Disease Control and Prevention, Atlanta, GA

Background and Rationale: Given the increased recognition of structural interventions in public health care settings, there is a need for public health professionals to effectively develop and implement such strategies. Social capital, a theory of reciprocity and cooperation for mutual benefit, can be critical to successful implementation of structural interventions. Social capital provides a framework for understanding and intervening in a system to promote reciprocity based on shared goals, active participation, and mutual support. The goal of this workshop is to convey a theoretical yet practical understanding of social capital that can be applied to the formation of working groups, task forces, advisory counsels, and to provide a hands-on experience for public health professionals to effectively implement such interventions.

Methods: The first half of this interactive workshop will consist of background information on social capital and structural interventions. The latter half will give participants an opportunity to apply the background information by using the concept of social capital to develop a structural intervention. This intervention will address a selected health problem based on data provided by the presenters. Presentation and discussion will include the following key issues: 1) how to define the group members, 2) the role of the health department as group participant and selection of group, 3) defining goals and promoting action, and 4) group process and sustainability.

Learning Objectives: At the end of this workshop, participants will have: 1) An understanding of the concepts of social capital and structural intervention, 2) An understanding of how to implement a structural intervention based on promoting the building of social capital, and 3) Hands-on experience in developing a framework for an intervention.

Youth/Adult Partnerships in Prevention Programming

J Gilliam, J Augustine

Advocates for Youth, Washington, DC

Background and Rationale: Research suggests that programs for youth that are developed through a partnership of youth and adults may be highly effective in reducing young people’s sexual risk-taking behaviors. Young people involved in prevention programming benefit sexual health organizations by sharing valuable information about the needs and interests of young people. In turn, sexual health organizations benefit young people through involvement by developing leadership skills and reducing risk rates.

Purpose: Too often, the attitudes of well-intentioned adults undermine effective youth involvement. Adults may inadvertently tokenize or even ignore young people in their approaches to working with youth. This workshop will demonstrate how to create effective and lasting youth–adult partnerships.

Methods (instructional approach): In this roundtable, we will discuss the challenges facing youth–adult partnerships, from both the perspective of the young person and the adult. Roundtable participants will strategize how to overcome these challenges, and presenters will introduce several best-practice models for youth–adult partnerships. Participants in the roundtable will then rehearse positive strategies for communication and working between generations.

Learning Objectives: By the end of this roundtable, participants will be able to:

1) Identify challenges and strategize solutions around youth/adult partnerships in prevention programming.

2) Describe best-practice models for youth/adult partnerships.

3) Develop tools for effective communication between generations.

Contact Information: Jessie Gilliam /

Phone 202-347-5700 / jessie@advocatesforyouth.org

Providing Health Care for Patients with External Genital Warts: Treatment Patterns, Cost of Care, and Practice Guidelines in Public and Personal Health Care Settings

GA Richwald¹, RM Rash², PC Langley³

1UCLA School of Public Health, Los Angeles, CA; 2Health Market International, Ann Arbor, MI; 33M Pharmaceuticals and University of Minnesota, St. Paul and Minneapolis, MN

Background and Rationale: Genital HPV is the most frequent cause of new cases of STDs in the United States. Approximately 5.5 million new HPV infections and 500,000 to 1 million new cases of external genital warts (EGWs) occur annually. Genital warts account for almost 250,000 initial visits to private physician’s offices each year and an estimated 100,000 to 200,000 visits for EGW treatment in health department and family planning settings. Despite this health care delivery burden, little is known about the actual care received by those treated for EGWs. Patient management of this chronic and frequently recurrent condition involves a variety of options including office-based procedures (cryotherapy, trichloroacetic acid, podophyllin resin) and home therapies (podophyllotoxin gel/solution, imiquimod cream). There is significant treatment-specific variation in number of visits, resources required and recurrence rate (which may exceed 50%). In many cases, patients failing initial therapy will require switching to a second treatment, concomitant use of two treatments or referral for more invasive therapy. Although total cost estimates for EGW management are unavailable, US spending could exceed $300 million annually.

Objectives: To describe the treatment patterns and cost of care for patients with EGWs in seven countries (US, Canada, UK, Holland, Denmark, Italy, Finland and Australia) and six different treatment settings (STD and family planning clinics, student health services, and Ob/Gyn, dermatology and general practices); and To present current and proposed US and European Union (EU) EGW practice guidelines.

Content: After an opening presentation describing the results of the multi-national research project on care provided to patients with EGWs, investigators will discuss the determinants and outcomes of different treatments and combinations of treatments with emphasis on resource utilization and total cost of care. A comparison and critique of US and EU consensus guidelines will be presented. Recent recommendations to eliminate the use of podophyllin (one of the most common treatments available in US STD clinics) and to promote home-based therapies will be discussed in the context of evidence-based medicine and public health STD priorities.

Implications for Programs: This presentation will assist STD and family planning clinics and other health care providers: 1) determine the most appropriate and cost effective approach to EGW management for their setting, patient population, and public health priorities; and 2) assess their current EGW management in the context of national and international guidelines.

Implications for Research: Future research and evaluation activities should address the extent to which local and state STD and family planning programs, managed care organizations, and private practice settings achieve successful treatment outcomes. Further examination of the determinants of cost and future cost-effectiveness studies will help address the challenge facing programs with limited budgets and high demand for EGW-related care.

Learning Objectives:

1) Participants will be able to describe the determinants of services and costs associated with EGW management in public and personal health cares settings in the US and other countries.

2) Participants will be able to describe current and proposed EGW clinical practice guidelines and key EGW-related clinical and public health issues that remain unaddressed at this time.

Contact information: Gary A. Richwald / Ph.310-396-2200 / drgary1@mediaone.net

“Sex in the City: An Inside View”—A Group Intervention to Help HIV Prevention Providers Understand the STD-HIV Connection

K Berkhoudt, P McGrath, M Urban, M Scahill, P Coury-Doniger

Center for Health & Behavioral Training, University of Rochester School of Medicine, Rochester, NY

Background: It is known that the presence of STDs facilitates both HIV acquisition and transmission. HIV prevention interventions have traditionally been provided by CBOs which serve hard-to-reach populations. These CBO providers often lack knowledge and awareness of the connection between STDs and HIV and may not see the need to incorporate STD/HIV interactions in their HIV prevention interventions. Teaching CBO providers about STD/HIV interactions and their significance for HIV prevention is a priority. The Center for Health and Behavioral Training (CHBT) in Rochester, NY is part of the NYS STD/HIV Prevention Training Center. The CHBT uses a variety of educational methodologies to provide training on STD/HIV interactions to both STD and HIV prevention providers from CBO, clinic, and criminal justice settings. Didactic (lecture) presentations are often effective for health care providers with professional training; however experiential methods may be more effective to meet the learning needs of CBO providers with varying educational backgrounds.

Purpose: To teach STD prevention providers how to use an experiential group intervention to teach CBO providers about HIV/STD inter-relationships and how to incorporate these concepts into their prevention interventions and services.

Methods: CHBT adapted an educational theatre technique to develop a group intervention to increase knowledge and awareness of STD/HIV interactions. Workshop attendees will be given a written group intervention module, participate in the group intervention, and then learn how to conduct similar groups with CBO providers.

Learning Objectives:

1. To increase participants’ knowledge of how the presence of an STD increases a person’s chances of becoming infected with HIV and/or transmitting HIV to a sexual partner.

2. To increase participants’ skill in using a group intervention to teach CBO providers how and why treating STDs is an important HIV prevention intervention.

Contact Information: Kimberly Berkhoudt / Phone 716-530-4382 / Fax 716-530-4378 / kberkhou@mcls.rochester.lib.ny.us

L10

Communicating Syphilis Elimination: Stories from the Field

S Hornston, H Shepeard, D Anderson

Centers for Disease Control and Prevention, Atlanta, GA

Background and Rationale: The National Plan to Eliminate Syphilis from the U.S. was launched on October 7, 1999. To support that effort locally, many state and local health departments recognize the need for communicating syphilis testing, treatment, and prevention messages, to their communities and at-risk populations. As a result, many programs developed innovative health communication campaigns with various approaches and materials. This roundtable will give program areas involved in syphilis elimination activities the opportunity to discuss their health communications efforts, and share information and resources.

Implication for Programs: Identifying successful communication strategies and materials is paramount to continued progress of syphilis elimination. Lessons learned from not-so-successful attempts will be just as valuable as sharing success stories.

Contact Information: Sureyya E. Hornston / 404-639-8532 / soh6@cdc.gov

L11

STD Program Infrastructure: Do We Have What it Takes? Key Findings from the National Needs Assessment

B Meyerson, T Raphael, H Jenkins

Policy Research Group, LLC

Background and Rationale: Our nation’s response to the threat of sexually transmitted disease depends in large part upon crumbling state and local public health infrastructures. In 2000, the National Coalition of STD Directors (NCSD) commissioned a study of the STD program infrastructure needs. Measures of program infrastructure closely resembled research from public health research, and were enhanced for the appropriateness of STD program contexts. This roundtable will discuss key findings from this needs assessment, and will provide time for participants to discuss issues associated with STD program infrastructure, policy implications of the findings, and time to identify key action steps to enhance STD programs in their communities. It is hoped that the audience for this roundtable will include STD program staff from local, state and federal programs, community organizations in partnership with STD programs, local and state policy makers, and persons engaged in community level planning for HIV and STD prevention programs.

Method: The roundtable will consist of a brief overview of key findings from the STD program infrastructure needs assessment, followed by guided discussion focused on the following: 1) general feedback: do these findings reflect what you believe about STD program infrastructure? 2) What are the STD infrastructure needs in your area? 3) What are the policy implications of these findings? 4) What action steps can be taken in your communities to strengthen STD program infrastructure? A written executive summary will be available for participants, and didactic information will be presented using projection of PowerPoint files.

Learning Objectives By the end of this session, participants will be able to:

1) Describe 3 key findings from the STD program infrastructure needs assessment

2) Discuss STD infrastructure needs in their communities 3) Identify 2 policy action steps related to strengthening STD infrastructure in their communities

Presenting Author Contact Information:

Beth Meyerson / Phone 636-456-5100 / Bmeyerson@policyresourcegroup.com.

L12

Reframing the Picture: Incorporating Youth Development Principles into STD Prevention

K Compoc; A Shankar

Health Initiatives for Youth, San Francisco, California

Come discuss how to incorporate youth development principles into your STD prevention program! Most young people know the facts of STD prevention (“what to do”), but not enough programs address the complexities that young people face in integrating information into the reality of their lives (“why to do it”). HIFY’s holistic approach to health education views youth as high potential persons rather than a high-risk category. Our fun, interactive workshops create safe spaces for people to share information and build skills. In this roundtable, we will present some of our lessons from the road, facilitate small group discussions and exchange best strategies. By the end of the discussion, you will be able to define the principles of youth development, challenge deficit-based perspectives in our communities & curricula and identify how youth development can be incorporated into STD prevention programs.

Presenting Author Contact Information: Anita Shankar, shankar@hify.org

L13

Effective Methods for Involving African-American Men Who Have Sex with Men in the Planning, Implementation, and Evaluation of HIV Prevention Programs

R Swayzer, T Franklin, D Evans

Brotherhood, Incorporated

Background: Among African-American men with AIDS, men who have sex with men (MSM) represent the largest proportion (37%) of reported cases since the epidemic began. In a sample of young men who have sex with men (ages 15–22) in seven urban areas, researchers found that, overall, 7% were infected with HIV (range, 2–12%). A significantly higher percentage of African-American MSM (14%) than white MSM (3%) were infected. Interventions that successfully engage African-American MSM in the planning, implementation, and evaluation have proven to be more effective in reducing the spread of HIV among this at risk aggregate.

Purpose: To examine innovative and effective methods for involving African-American MSM in the planning, implementation, and evaluation of HIV prevention programs.

Methods: In this workshop, we will describe effective methods for mobilizing and engaging the African-American MSM community in the planning of HIV prevention programs. This workshop emphasizes various elements of community organization as a major educational approach to community dynamics, social change, and community participation in addressing health problems. Presenters will describe how to “work with communities from the inside out.” Specific methods for identifying gatekeepers, community leaders, and mapping existing community assets will be presented. Participants in the workshop will have an opportunity to respond to and propose additional strategies or lessons learned in the process of engaging African-American MSM in program planning, implementation, and evaluation

Learning Objectives:

1. Describe successful methods for engaging African-American MSM in the planning, implementation, and evaluation of HIV prevention programs.

2. Describe specific methods for identifying African-American MSM gatekeepers, community leaders, and mapping existing community assets.

L14

Maximizing Impact: How to Make Your STD Prevention Programs Engaging, Memorable and Motivational

S Fallon, S Bui

Skills4 Inc., Fort Lauderdale, FL

Background and Rationale: STD-prevention professionals are often invited to provide workshops to captive audiences: students, inmates, juvenile offenders. How can educators win over indifferent or resistant populations? Can activities overcome literacy challenges, ensuring that all participants understand health messages? Do ice-breakers have to consume time from the content of a risk-sensitizing and skills-building workshop? Can information be imparted in ways to ensure participation of target group members, and even retention of the lessons learned?

Purpose: Enhance measurable impact of single-session and multi-session group level interventions facilitated in middle schools, high schools, correctional facilities, halfway houses, youth “coming out” support settings.

Methods: The presenters provide train-the-trainer and direct community education workshops throughout the nation, primarily for minority based CBOs. They have developed a compendium of “best practices” for workshops. National STD conference participants will learn these tools though an interactive workshop. Participants will learn why teaching through metaphor or analogy allows easy comprehension of important points about the continued threat of STDs, including HIV. They will appreciate how appeals to the seven types of intelligence help maintain attention during a workshop, and business principles of dynamic closing effectively motivate participants to act on the lessons learned. Through hands-on experience, they will learn how to direct role-plays that provide safe and memorable opportunities to practice negotiation skills.

Participants will try their hand at creating a new intervention, designed to convincingly illustrate a specific behavioral point about STD risk. At closing, participants will rate the likely success of such tools with their own local target populations. Guiding behavioral theories for all principles will be presented in easy-to-use fact sheets.

Learning Objectives: By the end of the session, participants will be able to

1. Re-frame deductive presentations into the more effective inductive format;

2. Utilize tools of rhetoric commonly employed by advertisers and politicians for healthier purposes;

3. Define measures of group level changes in self-efficacy, knowledge, and risk-sensitization following an intervention.

Contact Information: Stephen J. Fallon, President, Skills4, Inc.

L15

Re-evaluation of Selective

Screening for Chlamydial Infection in Women, Region X Infertility Prevention Project (IPP)

DS LaMontagne¹, KL Gudgel²

1Region X Infertility Prevention Project, Center for Health Training, Seattle, WA; 2Washington State Department of Health, Olympia, WA

Early published evaluations of the performance of selective screening for chlamydial infection in women in Region X’s IPP advocated for periodic assessment of those criteria. Since then, Region X experienced an increased use of nucleic acid amplification tests, expansion of screening efforts, declines in chlamydia prevalence, and increased resource pressures. Reassessment of selective screening criteria seemed appropriate given these changes. Using test data from 1998 to 2000 (N = 409,882), 18 different screening models for efficiency (60% screened) and sensitivity (90% of positives detected) were analyzed. Three alternatives to the current criteria that would increase screening efficiency without sacrificing disease detection were found. We propose a roundtable discussion to address program implications, guided by these questions: 1) Should testing criteria be modified for low prevalence or non-FP settings; 2) Should selective criteria for women be applied in STD clinics; and 3) What are today’s program challenges to implementing modified screening criteria?

L16

Hospital Emergency Departments: A New Frontier for Syphilis Elimination

C Moseley¹, S Keener², C McCoy²

1Guilford County Department of Public Health, Greensboro, NC; 2Mecklenburg County Health Department, Charlotte, NC

Discussion Summary: Innovative partnerships for screening and treatment are an important part of syphilis elimination. One may be with hospital emergency departments (HEDs) where many people seek primary care services. Persons seeking primary care in HEDs are less likely to access traditional STD clinic services. However, HEDs do not consider themselves primary care providers, nor is diagnosis and treatment of STDs necessarily their priority. Is the HED the last frontier in syphilis elimination? What would a screening program look like? How can public health support HEDs in providing this service?

Implications for Research: More research is needed on syphilis screening in emergency departments.

Implications for Programs: Screening protocols need to be established and implemented.

Contact Information: Caroline Moseley / Phone no. 336-641-3136 / cmosele@co.guilford.nc.us