Update on PDPH Strategic Plan – Sexual Health

Ryan White Planning Council February 12, 2015

Objective: Reduce new HIV infections and improve linkage to timely, high-quality HIV care

Key Measures 2011 2013

New HIV diagnoses per 10,000 residents 4.5 4.4

HIV incidence in adults and adolescents 872 761 (2012)

Linkage to HIV care within 90 days 82% 78%

Retention in HIV care within last year 44% 45%

Viral suppression 42% 45%

Majority of HIV Transmissions From People Unaware of Their HIV Status

Unaware Estimate• National (2012)

• 168,300 persons with undiagnosed HIV infection• 14.0% of the 1.2 million estimated PLWHA• Greater unaware among males (14.8%), ages 13-24 (51.3%), ages 25-34

(26.0%), blacks (15.0%), Latinos (15.0%), MSM (16.0%), male heterosexuals (19.1%)

• Philadelphia EMA• 5,959 persons with undiagnosed HIV infection• 18.0% of the 27,830 estimated PLWHA• New estimates soon based on CDC and Washington State methods

Treatment = Prevention• HPTN 052: 96% reduction in HIV transmission in serodiscordant

couples• PARTNER Study: No transmissions in serodifferent couples

where the infected partner had an undetectable viral load• Systematic review of 11 other studies of serodiscordant

couples: 0.0% transmission rate when HIV+ partner had a viral load <400

• Summary: No studies have documented a proven case of sexual transmission of HIV where the HIV+ partner had an undetectable viral load.

Estimated HIV Incidence Rates - 2012

Population Population in 2010 (13 +)ESTIMATED

Incidence Estimate, 2012

EstimatedCase Rate per 100,000

95% CI lower bound

95% CI upper bound

MSM 29,737 357 1,200 652 1,749IDU 37,378 58 139 0 318HET 294,682* 346 117 51 185

*Includes persons >13 living in poverty

Data Source: PDPH/AACO HIV Incidence Surveillance Program

HIV in MSM in Philadelphia

HIV Incidence Estimates

• Estimated that 1.2% of MSM in Philadelphia became infected with HIV in 2012.– 54.5% estimated increase in HIV

incidence in MSM between 2006 and 2012 (driven by new infections in 13-24 AA MSM).

– 19.0% increase in the number of MSM newly diagnosed with HIV between 2006 and 2012.

– Suggests an increasing number of MSM are unaware they are infected.

HIV Prevalence (aware) among MSM, 12/31/2013

Pop size >age 13

MSM estimate

MSM LWHA

% HIV infected

Black 229,698 11,485 3,706 32.3%

White 244,551 12,228 2,094 17.1%

Latino 69,252 3,463 680 19.6%

Data Source: PDPH/AACO HIV Incidence Surveillance Program and Philadelphia eHARS data

Philadelphia Engagement in Care, 2011-2013Surveillance Method

HIV-Diagnosed In Care Suppressed viral load

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%100%

42% 40%

100%

44% 44%

100%

45% 45% 201120122013

Strategies1. Policy – promote routine HIV screening in healthcare settings2. Health promotion – offer community-based HIV screening

and education3. Health promotion – offer prison-based HIV screening and

education4. Health promotion – support syringe access services5. Clinical care – improve linkage to care6. Clinical care – improve retention in care and quality of care7. Clinical care – offer timely screening and linkage to care for

sexual partners8. Clinical care – coordinate citywide provision of PrEP

Promote routine HIV screening in healthcare settings

• In 2013 95,817 tests were funded in clinical settings• Transition from a parallel system that employs HIV testers to

funding HIV coordinators – integration into medical care• Move from point-of-care rapid tests to laboratory based testing

- early diagnosis• Develop capacity for third party billing – sustainability• Develop model programs and tools for implementation –

replication• Implement performance measure for routine testing –

evaluation

Offer community-based HIV screening• Use of new testing technology for earlier diagnosis –

phlebotomy training for community providers• Revue of all venues for community-based testing based on part

performance at site, coordination with other providers, and demographics/ethnography

• Capacity building for quality management/continuous quality improvement

• Capacity building for MSM-focused and minority-focused CBOs

Testing in Non-Healthcare Settings

Tests All Positive

Self Report

New

% New Case to

Surveillance

%

All 11,546 202 181 1.57% 46 0.40%

MSM 3,519 117 108 3.07% 30 0.85%

HET 5,862 44 38 0.65% 8 0.14%

IDU 990 35 30 3.03% 5 0.51%

January – June 2014 HIV Testing Data

Offer prison-based HIV screening and education

• Routine screening implemented in Philadelphia Prison System: 92.5% of persons admitted Jan – Jun 2014 screened for HIV

• Ongoing education• Linkage programs• Condom distribution at discharge

Support syringe access services• Can only be supported with City of Philadelphia funds• AACO increase allocation in 2014• Expanded hours• In 2014 distributes 98,000 syringes to more than 750 clients

each month

Improve linkage to care• Quality improvement projects for all funded HIV testing

programs for improving linkage to care• Implementation and ongoing support of ARTAS programs• Focus groups held to develop linkage best practices and

template for clinics to use to develop clinic-specific linkage protocols

• Very different linkage rates depending on the test setting – overall 78% linkage in 90 days based on surveillance data

• The publically funded system does not perform as well – difficulties in linking from ED, community settings, prisons etc

Linkage to Care

Setting New Positive

Linked to Care in 90 days (Test Form)

%

All Testing 363 200 55%

Medical Care 42 28 67%

Inpatient Unit 5 5 100%

Emergency Department

24 20 83%

STD Clinic 44 22 50%

Correctional Facility 67 37 55%

Non-Healthcare 181 88 49%

January – June 2014 HIV Testing Data

Role of RW Clinics in Linkage• Need for increased coordination and collaboration between

RW clinics and funded testing programs• Well-defined MOUs• Rapid appointments for newly diagosed

Improve retention in care and quality of care

• The biggest drop off in the continuum of care is retention• Major focus of Ryan White programs – MCM is focused on

retention; major indicator for OAMC; SAMHSA BHC program• Anonymous callers to assess barriers to linkage and re-

engagement• Standard re-engagement protocols developed for use by RW

providers• Protocols developed and beginning to be implemented for

surveillance assisted re-engagement• Various demonstration health navigators programs• AACO funded for CoRECT – a 5-year re-engagement study

Behavioral Health Consultants• Integrated model of provision of behavioral health services• Population level approach• Implemented with SAMHSA funds in six largest RW clinics –

three year project• 49.5% of 6568 patients have had BHC services• Significant improvements in retention and ART• Reviewing “dose” effect• Project ends 9/29/15 – CBH/MA funding will partially sustain• Would need ~$350,000 from RW and other funding to sustain

CoRECT• Implementation of standard of care for follow up on out-of-care

patients• Surveillance assisted review of out-of-care patient lists from

clinics• Randomization to standard of care or HD-delivered

intervention• HD Delivered- intervention – modified ARTAS by DIS• Clinics – 4 RW, VA, and one private• Goals: durable VL suppression; determination if this is scalable

Ryan White Baseline Performance on Key Continuum Measures

Performance Measure As of 6/30/14 As of 10/31/14HAB Core01 HIV Viral Load Suppression 77% 78%

HAB Core03 HIV Medical Visit Frequency(24 months)

70% 68%

HAB Core04 Gap in HIV Medical Visits(6 months)

17% 16%

Care Patterns of PLWHA with No Care in 2013

42%

21%

37%

Never LinkedSporadic CareLost to Care

Offer timely screening and linkage to care for sexual partners

• In April 2013, AACO and STD Control consolidated all Partner

Services under STD Control; additional resources added in 2014

• AACO and STD Control began matching all reported GC and syphilis

cases to eHARS

• Partner Services initiated for cases found to be coinfected

• Partner services provided to all new HIV morbidity

• QI process in place to improve referrals from HIV test sites

HIV Partner Services

2009 2010 2011 2012 2013 2014*# HIV Cases Referred 78 134 254 509 626 945# Interviewed 64 124 221 439 553 730# Contacts Initiated & Tested 20 76 74 170 177 235

# of Contacts with new HIV diagnosis 6 13 5 21 24 29

* Data through 3rd Quarter, 2014

17 of the newly positive contacts were named by newly diagnosed HIV cases!

Coordinate citywide provision of PrEP• Increase numbers of referral sites by training and

supporting medical providers interested in providing PrEP• Increase understanding of PrEP in Prevention workforce

and increase referrals to PrEP• Increase community awareness of PrEP• Develop evaluation plan for PrEP implementation (uptake,

breakthrough infections, resistance, increased STDs)• Provide support for PrEP adherence (future)

PrEP Referrals• Aggregate data reports from AACO funded prevention

providers show between January and September 2014:

• 67 MSM were Referred to PrEP

• 29 MSM Initiated PrEP Therapy

• ~400 on PreP in the AACO funded system

Condom Distribution• Included as a required

component of Ryan White funded services for HIV+

• Adolescent STD/HIV Prevention Project (ASHPP)

• Increasing condom availability citywide through MSM-focused service providers

NHBS –

MSM:% of Black MSM who

received free condoms in

past 12 months increas

ed from

44% to 70%

between 2011

and 2014

Preventing perinatal HIV transmission• No reported cases in 2013 or 2014 to date• Perinatal case management • Perinatal marketing project – promotes universal HIV screening

for all of their pregnant patients early in prenatal care as well as repeat HIV testing during the third trimester and rapid HIV testing during labor as clinically indicated

• FIMR/HIV• Case Review Team – reviews transmissions and missed opportunities:

chart review and interviews• Community Action Team – initiates systems changes based on findings

and recommendations of Casr Review team

Emerging issues• Coordination of HIV Treatment and Prevention systems

(planning, linkage and re-engagement, etc)• Coordination with ACA; billing and reimbursement• Increased focus on continuum services vs. EBIs• Rapidly changing technology for HIV testing• PrEP

Questions?