Ongoing Implementation of the National HIV/AIDS Strategy to Improve HIV Prevention and Care

Grant Colfax, MDOffice of National AIDS Policy

International AIDS ConferenceJuly 22, 2012

As part of the NHAS, President Obama and his Administration have…

• Supported and increased investment in domestic HIV prevention and care.– Over $22 billion budgeted for HIV efforts– $2.5 billion increase during administration

• Directed resources to populations at greatest risk for HIV infection.– Focus on gay men, communities of color

• Implemented the Affordable Care Act.– Medical coverage extended to tens of thousand of persons living with HIV – Prevention services extended to millions of Americans

• Provided robust Federal funding to ADAP ($933 million, with $1 billion in 2013).– Waitlists have dropped by 80%– Federal share of funding sufficient to end waitlists with States doing their share

• Addressed HIV-related stigma and discrimination.– Lifted the HIV entry ban– Affordable Care Act prohibits denial of coverage based on pre-existing conditions, including HIV

• Supported groundbreaking NIH research in HIV prevention and care.– Breakthroughs include: treatment as prevention, pre-exposure prophylaxis, vaccines,

microbicides, cure research

Addressing Stigma and Discrimination:President Obama Supports Same-Sex

Marriage

Ongoing Challenges to Implementing the National HIV/AIDS Strategy

• Fiscal – Ensuring wise investments– Linking investments to health

outcomes

• Coordination among agencies– Metrics– FOAs– Traditional siloed approach

• Coordination across Federal, State, and local levels

– Higher you go, less understanding of issues on the ground

– Inadequate funding or staffing at some levels

• Ability of organizations to adapt to a changing environment

– Capacity– Technical assistance needs– Creating new models of prevention and care

delivery

• Will to allocate funds for interventions that are

– Achievable– Sustainable – Effective

• Educating providers about HIV prevention and care

– # of HIV care providers decreasing– Reluctance to care for HIV+ patients– Reimbursement

Implementation Questions at the Ground Level

• Are resources being used by the populations at greatest risk?• Are these populations being engaged in all components of the

implementation process?• Are the interventions evidence-based, scaleable, sustainable,

and effective?• What is the optimal combination of interventions?• How do we tailor interventions at the local level, while also

maintaining the integrity of “evidence-based”?• Do we have and use metrics to measure local program success?• How long do we take to declare success or failure of a program?

Aligning Resources with the Epidemic

(Prejean et al., 2011)

New HIV Infections in the U.S., 2009

Racial minority populations in the U.S. less likely to have access to care, ART, adhere to ART or be virally suppressed.

Diagnosed HIV+OR, 2.59 (1.82-3.69)

Undiagnosed HIVOR, 6.38 (4.33-9.39)

Health insurancecoverage

OR,0.47 (0.29-0.77)

>200 CD4 cells/mm3 before

ART initiation OR, 0.40 (0.26-0.62)

ART adherenceOR, 0.50 (0.33-0.76)

HIV suppressionOR, 0.51 (0.31-0.83)

ART utilization/ accessOR, 0.56 (0.41-0.76)

HIV Detection

Viral Suppression

Healthcare visits

OR, 0.61 (0.42-0.90)

Lower income (<$20k)

OR, 3.42 (1.94-6.01)

(Millett, 2012)

Reducing HIV incidence via combination prevention

29 September 2011 – SW regional conference Treatment as Prevention

Effi cacy in prevention trials

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Toward Health Equity: The Affordable Care Act

• Expands coverage to over 30 million Americans– Tens of thousands with HIV– Millions of Blacks and Latinos

• Prohibits denials of coverage based on HIV status

• Already– Millions have increased

prevention service coverage– Millions of young adults

covered on parents’ plans

Source: Office of the Assistant Secretary for Planning and Evaluation, 2012

0 2 4 6 8 10

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% W

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AIDS

0 2 4 6 8 10

Death

Silverberg, et. al., J Gen Intern Med. 2009;24(9):1065-72.

HR (95% CI)

P

White 1Black 1.2 (0.9-1.5) 0.2

5Hispanic

0.8 (0.6-1.1) 0.17

HR (95% CI)

P

White 1Black 1.1 (0.9-1.4) 0.2

7Hispanic

0.7 (0.5-0.9) 0.01

Kaiser: Time to AIDS-Related Events or Death

Measuring HIV-related Outcomes: Towards a National Consensus

• Parsimony• Harmony• Achievable• Sustainable• Usable

Table 2. National and Facility Rates for 10 National Quality Forum Measures for HIV/AIDS Care

73 Facilities With 100 HIV Caseload

Measure Eligible, No. National Rate, %Minimum Facility

Rate, %Maximum Facility

Rate, %Medical Visit 21564 83 73 96

HBV Screening 17904 97 88 100

HCV Screening 17904 98 92 100

HBV vaccination 16606 81 53 98

TB screening 16526 65 30 94

Syphilis screening 17904 54 8 97

CD4 lymphocyte count 17904 93 81 100

Potent ART 14508 91 75 99

HIV RNA control 15537 73 28 91

PCP prophylaxis 2709 72 20 93

Abbreviations: ART, antiretroviral therapy; HBV, hepatitis B virus; HCV, hepatitis C virus; HIV, human immunodeficiency virus; PCP, Pneumocystis pneumonia; TB, tuberculosis

Backus, L., Boothroyd, D., Phillips, B., Belperio, P., Halloran, J., Valdiserri, R., Mole, L. (2010). National Quality Forum Performance Measures for HIV/AIDS Care: The Department of Veterans Affairs’ Experience. Archives of Internal Medicine , 170(14), 1239-1246

Measuring outcomes: VA System

Cascade Research: Federal Coordination

Convene interagency consultation to discuss and identify all cascade research being conducted within each Federal agency, e.g. NIH, CDC, HRSA, SAMHSA

Create and maintain an inventory of all Federal “linkage-to-care”

research, organized by the population targeted & timelines for scaled-up implementation

Create an online database of Federal, evidence-based, population-specific “linkage-to-care” strategies to help local communities

Ongoing Implementation Needs

• Continued collaboration among Federal, State, local government and private partners

• Flexibility at local level regarding implementation while maintaining alignment with NHAS principles

• Technical assistance to prepare HIV workforce for ongoing changes in environment

• Support for shift from process-oriented to outcome-oriented metrics

• Adherence studies along the cascade • Research to determine best ways to move forward among

multiple options

Acknowledgements

• HHS: Ron Valdiserri, Howard Koh, Greg Millet

• ONAP team: James Albino, Aaron Lopata, Helen Pajcic