ImprovingHealthOutcomesthroughtheRyanWhiteHIV/AIDSProgram:SuccessandChallengesHaroldJ.Phillips,MRPDirectorOffice ofTrainingandCapacityDevelopmentHIV/AIDSBureau(HAB)HealthResourcesandServicesAdministration(HRSA)

November3,2017

PurposeofRyanWhiteHIV/AIDSProgram

• Publichealthapproachtoprovideacomprehensivepatient-centeredsystemofHIVcare

• Ensurelow-incomepeoplelivingwithHIV(PLWH)receiveoptimalcareandtreatment

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AlignmentofHHSPrinciplesofPatient-CenteredHealthCareSystemintheRyanWhiteHIV/AIDSProgram

•ClinicalqualitymanagementisbuiltintotheRWHAP•BetterhealthoutcomesforPLWHthanPLWHoutsideRWHAPQuality•RWHAPisanationalprogram•GeographicallydiverseproviderstomeetneedAccessibility•Clientsreceiveservicesatreducedcharges•ClientscannotbedeniedservicesforinabilitytopayAffordability•Servicesprovidedarebasedonlocally-developedneedsassessment•SupportservicesavailabletoimprovehealthoutcomesbasedonneedChoices•RWHAPprovidersidentifynewapproachestoreachPLWH•NewapproachestoimprovehealthoutcomesamongallPLWHInnovation•ProvidersrapidlyadoptadvancesinmedicineandcareforPLWH•ServiceutilizationdrivenbyclientneedResponsiveness

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ContinuumofCareAmongPeopleDiagnosed*withHIVintheUnitedStates**

100

70.9

56.5 54.7

0

20

40

60

80

100

Diagnosed InCare RegularCare ViralSuppression

Percentage

Source: Centers for Disease Control and Prevention. Monitoring selected national HIV prevention and care objectives by using HIV surveillance data—United States and 6 dependent areas—2014. HIV Surveillance Supplemental Report 2016;21 (No. 4)

*Denominator is 615,836 persons diagnosed with HIV by the end of 2012 and alive through 2013.

**Data from 33 jurisdictions that reported complete CD4 and viral load data. Data from these 33 jurisdictions represent 69.5% of all persons aged ≥13 years living with diagnosed HIV infection at year-end 2013

5Source:HRSA.RyanWhiteHIV/AIDSProgramDataReport(RSR)2015.DoesnotincludeAIDSDrugAssistanceProgramdata.

ViralSuppressionamongClientsServedbytheRyanWhiteHIV/AIDSProgram,byState,2010–2015—UnitedStatesand2Territoriesa

VIRALLY SUPPRESSED

69.5%

83.4%VIRALLY SUPPRESSED

IN 2015

IN 2010

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Viralsuppression:≥1OAMCvisitduringthecalendaryearand≥1viralloadreported,withthelastviralloadresult<200copies/mL.aPuertoRicoandtheU.S.VirginIslands.Duetolownumbers,dataforGuamarenotpresented.

Source:HRSA.RyanWhiteHIV/AIDSProgramDataReport(RSR)2015.DoesnotincludeAIDSDrugAssistanceProgramdata.

StructuralBarrierstoPLWH-CenteredHealthCareSystem

HealthDisparities

Stigma&Discrimination

SocialDeterminantsofHealth

PublicHealthInfrastructure

PUBLICHEALTHasaKEYDRIVEROFSUCCESS

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ViralSuppressionamongKeyPopulationsServedbytheRyanWhiteHIV/AIDSProgram,2010–2015—UnitedStatesand3Territoriesa

Hispanics/Latinoscanbeofanyrace.Viralsuppression:≥1OAMCvisitduringthecalendaryearand≥1viralloadreported,withthelastviralloadresult<200copies/mL.aGuam,PuertoRico,andtheU.S.VirginIslands.

RWHAPoverall,2015(83.4%)

RWHAPoverall,2010(69.5%)

UsingClient-levelDatatoMeasureOutcomes

RWHAP client-level data, along with other epidemiologic andqualitative data, can be used for:

• Planning.Prioritizing,targeting,andmonitoringavailableresourcesinresponsetoneeds.

• Addressinggaps.IdentifyinggapsinandbarrierstocareforPLWH.

• Improvingservices.IdentifyingissuesandopportunitiestoimprovethedeliveryofservicestoPLWHaswellashigh-risk,uninfectedindividuals(e.g.,HIVtesting;linkagetopreventionservices,behavioralhealth,socialservices).

• Improvingoutcomes.Improvingengagementandoutcomesateachstageofthecarecontinuum.

ServicesProvidedbyRWHAP-FundedandNon-RWHAP-FundedOutpatientFacilities:MedicalMonitoringProject(MMP)2009-2012

64%

34%

49%

76% 82%

59% 53%

60%

71%

18% 12% 9%

15%

30% 29%

11%

22% 22%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

MentalHealth SubstanceAbuse

Treatment

DentalCare CaseManagement

AdherenceCounseling

InterpreterServices

TransportationAssistance

Nutritionist/Dietician

RiskReductionCounseling

Percentageoffacilitie

sprovidingse

rvices

RWHAP-Funded Non-RWHAP-Funded

11Source:WeiserJ,BeerL,FrazierEL,PatelR,DempseyA,HauckH,Skarbinski J.ServicedeliveryandpatientoutcomesinRyanWhiteHIV/AIDSProgram-fundedand-nonfundedhealthcarefacilitiesintheUnitesStates.JAMAInternMed2015:4095.

PercentageofVirallySuppressedClientsbyHealthCareCoverageandRyanWhiteHIV/AIDSProgramAssistance:MMP2009-2012

76% 71%

76% 76% 81%

76% 78% 79%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Private Medicaid Medicare Medicare+Medicaid

Percentageofp

atientsw

ithvira

lsup

pressio

n

Non-RWHAPPayer Non-RWHAPPayer+RWHAP

12Source:Bradley,H,MattsonC,BeerL,HuangP,Shouse,R.Luke;fortheMedicalMonitoringProject.IncreasedantiretroviraltherapyprescriptionandHIVviralsuppressionamongpersonsreceivingclinicalcareforHIVinfection.AIDS2016;30(13):2117–24.

CommunityEngagementandImplementation

StateHealthDepartments

CommunityPartners

RSRUtilization

Data

CEBACC

CEBACC:HIVProviderFocusGroups

• Patientandproviderprioritiesareoutofsync• StigmarelatedtoHIV,sex,andsexualityisveryprevalent• BlackMSMareresilientandarebuildingtheirownsupportsystemsoutsideoftraditionalfamilystructures

• BlackMSMareseekingoutproviderswheretheycanbuildpositive,affirmingrelationships

• Mustbewillingtoeducateprovidersaswellasbeeducatedbythemandnon-providers

CEBACC:BlackMSMandProviderFocusGroups

• Patientandproviderprioritiesareoutofsync• StigmarelatedtoHIV,sex,andsexualityisveryprevalent• BlackMSMareresilientandarebuildingtheirownsupportsystemsoutsideoftraditionalfamilystructures

• BlackMSMareseekingoutproviderswheretheycanbuildingpositive,affirmingrelationships

• Mustbewillingtoeducateprovidersaswellasbeeducatedbythemandnon-providers

ImprovingHealthOutcomes:EngagingandSupportingYouth

BuildingFutures:SupportingYouthLivingwithHIV• IdentifybarriersandbestpracticestosupportyouthlivingwithHIVaccessingRWHAPfundedservices

• Youthhavelowerratesofviralsuppression,weneedmoreinformationaboutwhatworksandwhytodisseminatewidely

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ViralSuppressionamongClientsServedbytheRyanWhiteHIV/AIDSProgram,byAgeGroup,2010‒2015—UnitedStatesand3Territoriesa

Viralsuppression:≥1outpatient/ambulatorymedicalcarevisitduringthecalendaryearand≥1viralloadreported,withthelastviralloadresult<200copies/mL.aGuam,PuertoRico,andtheU.S.VirginIslands.

Source:HRSA.RyanWhiteHIV/AIDSProgramDataReport(RSR)2015.DoesnotincludeAIDSDrugAssistanceProgramdata.

OtherStepstoAddressDisparities

• Secretary’sMinorityAIDSInitiativeFund– InnovativeProjects• MinorityAIDSInitiative– addressesgapsincare• SpecialProjectsofNationalSignificance/RyanWhiteHIVAIDSProgramPartF– DemonstrationProjectsdesignedfocusedonimplementationofservicedeliveryreformstocreateefficiencies,improveeffectivenessandimprovehealthoutcomes

• LearningCollaboratives– SouthernInitiativestoaddressgeographicdisparitiesbasedonInstituteforHealthcareImprovement

• IncreasedCollaborationsandPartnershipswithHUD,SAMSHA,DOL,toaddresstheintersectionalityofillness,mentalandbehavioralhealth,poverty,employmentandhousingstatus

SoutheastAETC– SuccessandChallenges

• Challenges• Viralsuppressionrateswhilerisingstilllagbehind• LinkagetocareisstillachallengeinclinicswhichofferanHIVtest

• Needtocreatetrainingopportunitiesforlowvolumeandearlycareerproviders

• TargetedMAIactivitiestobetterserveminoritiesengageprofessionalswithmentalandbehavioralhealthandsubstanceusedisordertreatmentexperience.

• EightStateregionwith28%ofnewNationalcasesin2014

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SoutheastAETC– SuccessandChallenges

• Successes- OpportunitiestoexpandHIVtesting• 1,177hospitals• 1,688CommunityHealthCenters(CHC)• 105,343internalmedicineandprimarycarephysicians• 39,448nursepractitioners• 7,334psychiatrists

• Top5trainingsin2016Trainings(ART,Adherence,Epidemiology,Race/Culture,Co-morbidities)

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T/TAGoalandTargetPopulation- CollaborationwithBPHC

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GOAL:TotrainHIVpracticecoacheswhocandrivepatient-centered,HIVpracticetransformationinupto15non-RWHAP,healthcentersinhigh-riskmetropolitanareasfromHHSRegion4(Alabama,Florida,Georgia,Kentucky,Mississippi,NorthCarolina,SouthCarolina,andTennessee).

TARGETPOPULATION:Non-RWHAPhealthcentersinhigh-riskmetropolitanareasinHHSRegion4withPCMHrecognitionornoticeofintent(NOI).

ProposedT/TAInitiativeTimeline,OutcomesandDeliverablesTentativeTimeline:21months

• 6Months:HIVPracticeCoachtraining,readinessassessments,andtailoringofpoliciesandprocedures(e.g.,October2017– March2018)

• 15months:CoP forroutineHIVtestingandHIVlinkagetocare(e.g.,April2018– June2019)

HealthCenterOutcomes:

• Increased%ofpatientswhoreceiveanHIVtest

• Increased%ofnewlydiagnosedpatientslinkedtoHIVcare

Deliverables:

• EnhancedPrimaryCareHIVIntegrationToolkit

• Apatient-centeredHIVcarecurriculumforhealthcenterpracticetransformation

• RapidQImodelforroutineHIVtestingandHIVlinkagetocare

EnsuringGoals,Strategies,ActivitiesareResponsivetotheData

1. Assesstrends

• Moredatamaybeneededtoexplainunexpectedtrends

2. Focusonmostaffectedcommunities

3. Ensurestrategiesandactivitiesculturallyappropriate

4. Engagemostaffectedcommunitiestoinformdecisionsandassistwithimplementation

5. Engagecareproviders

HABReportsandOtherResources

• Findtheclient-leveldatareportandotherresourcesonline:https://hab.hrsa.gov/data

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Resources

• RyanWhiteHIV/AIDSProgramAnnualClient-LevelDataReporthttp://hab.hrsa.gov/data/servicesdelivered.html• National- andstate-leveldataonallclientsservedbyRWHAP,includingselectindicatorsofthecarecontinuum

§ RyanWhiteHIV/AIDSProgramresourcesfordeliveryofHIVcarehttp://hab.hrsa.gov/deliverhivaidscare/index.html

• AIDSEducationandTrainingCenters(AETC):MultidisciplinaryeducationandtrainingprogramsforhealthcareproviderstreatingPLWHhttp://hab.hrsa.gov/abouthab/partfeducation.html

• AETCNationalResourceCenterhttp://aidsetc.org/• TARGETCenter:TechnicalAssistanceresourcesforprogramstobetterservepeoplelivingwithHIVhttps://careacttarget.org/

FASTTrackingtheEndofAIDS

• MoreHIVTestingwithpromptlinkagetocareorpreventionservices• Immediateantiretroviraltherapy(ART) forallHIV-infectedpeoplefortheirhealthandtohelppreventon-goingtransmission

• Usingdatatohelpdeterminewhichpopulationsarefacingdisparitiesinhealthoutcomes

• Tailoringservicestoaddressthesocialandeconomicdeterminantsofhealth

• Pre-exposureprophylaxis(PrEP) andotherHIVpreventionservices forindividualsathighriskofHIVinfection.

ThankYou!

HaroldJ.Phillips,MRPDirectorOfficeofTrainingandCapacityDevelopmentHIV/AIDSBureau(HAB)HealthResourcesandServicesAdministration(HRSA)Email:Hphillips@hrsa.gov

Web:hab.hrsa.govTwitter:twitter.com/HRSAgovFacebook:facebook.com/HHS.HRSA

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