Linkages between Family Planning

and HIV/AIDS Medical Care

HIV Prevention Project Annual Technical Support

Meeting

December 5, 2013

Laura W. Cheever, MD

Associate Administrator

Department of Health and Human Services

Health Resources and Services Administration

HIV/AIDS Bureau

Disclosure The following people have no relevant financial, professional or personal

relationships to disclose:

Faculty:

Laura W. Cheever, MD

CNE Program Planner(s):

Melanie Steilen, RN, BSN, ACRN

Iris Stendig-Raskin, MSN, CRNP, WHNP-BC

CNE Program Reviewer:

Iris Stendig-Raskin, MSN, CRNP, WHNP-BC

There are no commercial supporters of this activity.

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

1. Explain the impact of the Ryan White HIV/AIDS Program

(RWHAP) on outcomes for people living with HIV

2. Describe key features of the transition of the RWHAP

into the new healthcare environment

3. Delineate several key challenges in the care of women

living with HIV today in the United States.

Ryan White HIV/AIDS Program - Intent

• Increase access to care for people living with HIV disease domestically

• Safety net for uninsured and low-income individuals living with HIV/AIDS

• Funding for: – Primary health care including medications and

support services

– Provider training, technical assistance, demonstration projects (SPNS)

4

Basic Tenets of Ryan White • Local planning and prioritization of funding

based on needs assessment

• Involvement of people living with HIV/AIDS in the planning process

• Funding of both primary care and support services to improve access to care – Support of a multidisciplinary team

– Building of a medical home

• Quality of care

5

Ryan White HIV/AIDS Program Structure

• Cities (Part A)

• States and Territories (Part B)

– AIDS Drug Assistance Program (ADAP)

• Health Care Agencies

– Early Intervention Services and Capacity Development (Part C)

– Women, Infants, Children and Youth (Part D)

• Other programs (Part F)

– Dental, Education/Training, Planning, Capacity Development and Demonstrations, Minority AIDS Initiative

6

Ryan White HIV/AIDS Program – Part D

• Part D program funds family-centered outpatient or ambulatory

care (directly or through MOUs and contracts) for women, infants,

children, and youth (WICY) living with HIV/AIDS

• Funding may also be used to provide support services to PLWH

and their affected family members

• Currently fund 114 WICY programs in 38 states and Puerto Rico

• All funds are awarded competitively

Ryan White HIV/AIDS Program - Part F/Training

• AIDS Education and Training Center (AETC) Program: • Supports a network of 11 regional centers (and more than 130 local

associated sites) that conduct targeted, multidisciplinary education and training programs for health care providers treating PLWH

• The AETCs provide training in all states, territories, DC, Puerto Rico and Virgin Islands

• Also fund three National Centers:

o National Clinicians Consultation Center

o National Resource Center

o National Evaluation Center

Ryan White HIV/AIDS Program –

Part F/Special Projects of National

Significance (SPNS)

Part F SPNS funds:

• Innovative models of care and supports the

development of effective delivery systems for HIV care

• Dissemination of successful models for replication and

integration by Ryan White HIV/AIDS Program funded

grantees

• Development of a standard client-level data system

(which began in 2007)

Part F: Minority AIDS Initiative

Minority AIDS Initiative (MAI):

• Provides funding to evaluate and address the disproportionate

impact of HIV/AIDS on racial and ethnic minorities

o Addresses disparities in access, treatment, care, and outcomes

• MAI funding provided for Parts A, B, C, D, and F/AETCs

Key Provisions of Ryan White

• Payer of last resort

– Can “wrap around” other insurance

• 75% core services/ 25% support services

– Core: outpt care, labs, meds, case management, mental

health tx, substance abuse tx, oral health

– Support: transportation, emergency housing, child care, food

assistance

– Can apply for Waiver if: no ADAP waiting list and core

services available to all eligible patients

• Funding based on living HIV/AIDS cases in the most

recent year of data

11

Core Medical Services for Parts A, B, and C

(N=13)*

• Outpatient and ambulatory health services

• AIDS Drug Assistance Program treatments

• AIDS pharmaceutical assistance

• Oral health care

• Early intervention services

• Health insurance premium and cost sharing assistance for low-income individuals

• Home health care

• Medical nutrition therapy

• Hospice services

• Home and community-based health services

• Mental health services

• Substance abuse outpatient care

• Medical case management, including treatment adherence services

* 75% of funds for Parts A, B, and C must be spent on Core Medical Services

13

Ryan White HIV/AIDS Program – Examples of

Support Services Funded

Support Services:

• Outreach

• Transportation

• Emergency housing assistance

• Health insurance continuation

• Legal services

• Child care

• Respite services

• Psychosocial support services

2013 Ryan White HIV/AIDS Appropriations $2.248 Billion

$624.3

$401.2 $886.3

$194.4

$72.4

$32.4 $12.6 $25.0 Part A 28%

Part B 18%

Part B ADAP 39%

Part C 9%

Part D 3%

AETC 1%.

Dental 1%

SPNS 1%

Zero New Infections

The Ryan White HIV/AIDS Program (RWHAP) supports the goals of the National HIV/AIDS Strategy by: Funding a comprehensive care systems for low-income people

living with HIV (PLWH) that: Reduces new HIV infections Improves health outcomes and increases quality of life for PLWH Decreases HIV-related health disparities

Including PLWH in the planning of services Employing a public health approach to care and treatment

Ryan White HIV/AIDS Program

Accomplishments Ryan White HIV/AIDS Program:

• Provides care, treatment, and support services to approximately half of the PLWH in the U.S.

• Specifically, of an estimated 1.1 million PLWH in U.S., Ryan White HIV/AIDS Program served 553,986 uninsured and underinsured in 2011

• Built networks and systems of care with and between public and private providers for a comprehensive response to the epidemic

• Extended knowledge base and expertise to improve the quality of HIV/AIDS care and treatment across the health care system

Who the Ryan White HIV/AIDS Program

Serves • Females: 30%

• Age:

– 13-24 years (6.4%)

– 25-29 years (6.8%)

– 30-39 years (18.3%)

– 40-49 years (32.9%)

• Race/Ethnicity:

– Black non-Hispanic (47.3%)

– White non-Hispanic (27.8%)

– Hispanic/Latino (21.9%)

Women Who Received RWHAP-funded

HIV Medical Care 2011 (preliminary)

• 56% of females received RWHAP-funded HIV

medical care

– 48% of which were in childbearing years (15-44)

• 4% of females who received RWHAP-funded

HIV medical care were pregnant in 2011

Who the Ryan White HIV/AIDS Program

Serves

• 553,999 clients served in 2011

• Uninsured:

– 28% uninsured for non-ADAP services (approximately

128,000) (HRSA CLD 2011)

– 65% uninsured in ADAP 2012 (NASTAD Request For

Information)

• Income of the uninsured:

– 69% <100% FPL

– 21% 101-200% FPL

Who the Ryan White HIV/AIDS Program

Serves

• Conclusion

– Most RWHAP patients for non-ADAP services

have coverage

– Most uninsured will qualify for Medicaid in

states where it is expanding

HIV Medical Care Ryan White Services Report 2011 (preliminary)

57.3% of non-ADAP clients

received RWHAP-funded HIV

medical care in 2011.

Retention in HIV Medical Care

Ryan White Services Report 2011 (preliminary)

Retained in HIV medical care: At least 2 HIV medical visits that were at least 90 days apart

75.5% of non-ADAP clients who received

RWHAP-funded HIV medical care in 2011

were retained in HIV medical care.

Viral Suppression

Ryan White Services Report 2011 (preliminary)

Viral suppression: Most recent HIV-1 RNA <200 copies/ml

72.6% of non-ADAP clients who received

RWHAP-funded HIV medical care in 2011

were virally suppressed.

Retention and Viral Suppression by Age Category

Ryan White Services Report 2011 (preliminary)

Health Coverage Options for PLWH

BEFORE the Affordable Care Act

Note: Data only reflective of Ryan White HIV/AIDS Program clients, not of entire HIV/AIDS

population; Source: 2011 Preliminary Ryan White Services Report Data (RSR)

Health Coverage Options for PLWH AFTER

the Affordable Care Act

Medicaid Medicare

Employer-Based

Insurance

Health Insurance

Marketplace

Other Public

Other Private

Ryan White

HIV/AIDS Program

Cover comprehensive HIV

medical and support services

not covered, or partially

covered, by public programs

or private insurance

Cover comprehensive HIV

medical and support services

not covered, or partially

covered, by public programs or

private insurance

PLWH eligible for health

coverage

PLWH who remain uninsured

Payer of Last Resort Requirements

within the Context of ACA

• By statute, RWHAP funds may not be used “for any item or service

to the extent that payment has been made, or can reasonably be

expected to be made…” by another payment source

• Grantees and their contractors are expected to vigorously pursue

enrollment in other relevant funding sources (e.g., Medicaid, CHIP,

Medicare, state-funded HIV/AIDS programs, employer-sponsored

health insurance coverage, and/or other private health insurance)

• RWHAP grantees must make every effort to ensure that individual

clients who are not eligible for public programs (Medicaid, CHIP,

Medicare, etc.) and not exempt from the Affordable Care Act’s

requirement to enroll in health coverage, are assessed for eligibility

for private health insurance

• RWHAP will continue to pay for items or services received by

individuals who remain uninsured or underinsured

How is HRSA Preparing Grantees for ACA?

• HRSA is working on administrative flexibility and

guidance to grantees necessary to assure a

smooth transition of the program with ACA

• HRSA’s accomplishments to date:

oCommunication with Grantees

oDevelopment of Policies

oTraining

oDevelopment of technical assistance tools

Collaborating Across Federal Government

• RWHAP legislation specifically references

coordination across DHHS

• National HIV/AIDS Strategy

• Collaborate and coordinate to:

– Align across Federal programs to reduce reporting

burden on grantees

– Partner to advance evidence base and develop

interventions to improve care and treatment across the

HIV Care Continuum

– Share resources and expertise to build capacity at the

grantee level

Perinatal Care for HIV-infected Pregnant

Women

Health care providers considering the use of ARV

agents for HIV-infected women during pregnancy

must take into account two separate but related

issues:

• ARV treatment of maternal HIV infection

and

• ARV chemoprophylaxis to reduce the risk of

perinatal transmission of HIV

MTCT: From Epidemic to Elimination Lynne Mofenson (NIH)

• The reasons for U.S. success include focus on family planning, prenatal care, universal HIV testing, antiretroviral therapy as prevention, and treatment adherence.

• These lessons are being applied in the resource limited settings with success.

– South Africa: MTCT rate decreased from 3.5% to 2.7% from 2010 to 2012

– Malawi: Option B+, rates 2-6% related to breastfeeding

• How can we apply these best practices to eliminate HIV infection in U.S. adults and adolescents?

Mofenson L. CROI 2013. Abstract 15.

HIV and Unintended Pregnancy in

Women: Background Context

• 17 million HIV-infected women globally

• >150 million women use a hormonal

contraceptive (HC) method

– Nearly 60% of HC users in sub-Saharan Africa

use contraceptive injectables

• Highly effective contraceptive methods prevent

unintended pregnancy, maternal/infant morbidity

and mortality, and perinatal HIV

Polis C and Heffron R. CROI 2013. Abstract 111.

Unplanned Pregnancy

• N=151 HIV+ women, completed survey on

preconception counseling and pregnancy intention

• Unplanned pregnancies among HIV+ women:

24%

• 53% of women reported discussion of pregnancy

intentions prior to pregnancy with health care

provider

Rahangdale L et al. CROI 2013. Abstract 896.

HIV Testing among Commercially Insured

Pregnant Women: US, 2009-2010

Year # Live Births HIV tested during

pregnancy, all ages

HIV tested during

pregnancy, 18-34 years

2008 73.8%

2009 173,882 74.7% 77.7%

2010 177,930 75.7% 77.5%

• Limitations: study sample not representative of U.S. population

• Highlights missed opportunities for perinatal HIV prevention

Taylor et al. CROI 2013. Abstract 904.

Real Time Decision Support

• Perinatal HIV Hotline

1-888-448-8765 • Free 24-hour clinical

consultation and advice on:

o Management of HIV in pregnant women

o HIV testing in pregnancy

o Care of HIV-exposed infants

o Perinatal HIV Network:

Callers can be linked with local perinatal HIV specialists

• Public Health Service Guidelines

• Panel on Treatment of HIV-

Infected Pregnant Women and Prevention of Perinatal Transmission.

• Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Available at http://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf

HIV/AIDS Bureau’s Affordable Care Act

Resources • HIV/AIDS Bureau’s Affordable Care Act webpage: “Ryan

White Program & the Affordable Care Act: What You Need to Know”: http://www.hab.hrsa.gov/affordablecareact/index.html

• On this page you may:

Sign up for updates

View and download slides from the HIV/AIDS Bureau’s recent webcasts

Review FAQs, a glossary of terms, and view policies

• Email Ryan White HIV/AIDS Program/Affordable Care Act questions to: RWP-ACAQuestions@hrsa.gov

Contact Information

Laura Cheever, MD

Associate Administrator

Department of Health and Human Services

Health Resources and Services Administration

HIV/AIDS Bureau

301-443-1993

lcheever@hrsa.gov