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NationalHIV/AIDSStrategyUpdate:
HHSImplementation
TimothyP.Harrison,Ph.D.
SeniorPolicyAdvisor
U.S.DepartmentofHealth&HumanServices
ONAP Regional Listening Session: Brooklyn NY ONAPRegionalListeningSession:Brooklyn,NY
August8,2014
NationalHIV/AIDSStrategy
Reducenewinfections (25%),lower
transmissionrate(30%),andincrease
to 90% awareness of HIV+ serostatus to90%awarenessofHIV+serostatus
Improveaccesstoandoutcomesof
carebylinking80%ofPLWHtocare
w/in3moofdiagnosis,increaseto
80%RWclientsincontinuouscare,
andincreaseto86%RWclientswith
permanenthousing
ReduceHIVrelatedhealthdisparities
byincreasingby20%thenumberof
MSM,Blacks,andLatinoswith
undetectableviralload
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NHASGoalI:HIVIncidence
By2015,lowertheannualnumberofnew
infectionsby25percent
47,500newHIVinfectionsoccurredin2010comparedto48,600
in2006
Comparing2008to2010:
21%reductioninnewHIVinfectionsamongAAfemales
22%reductioninnewHIVinfectionsamongM/FIDUs g /
12% 12%increase increase innewHIVinfectionsamongMSM;22%amongyoungMSM innewHIVinfectionsamongMSM;22%amongyoungMSM
(13 (1324yrs) 24yrs)
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(ONAP:NHASProgressReport,2013)
i i Promisingprogress
insomegroups
15%decreaseamong
heterosexuals
22%decreaseamong
IDUs
For 2010 versus 2008.
21%decreaseamong
AfricanAmerican
women
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FewerPeopleHaveUndiagnosed
HIVInfectionintheU.S.
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(FromCDC,NationalHIVPreventionProgressReport,2013)
NHASGoalI:KnowledgeofSerostatus
By2015,increaseto90%thepercentageof
peoplelivingwithHIVwhoknowtheirserostatus
TotalnumberofPLWH/Aincreased9%from1,045,800in2006to
1,144,500in2010
Atthesametime,numberofpeoplewithundiagnosedHIVinfection
decreased9%(from199,748in2006to180,900in2010)
In2010,84.2%ofPLHknewtheirserostatus,upfrom80.9%in2006
In2010,serostatus awarenesswas90%orhigheramongpersons45
yrsandolderbutalmost60%ofyouthaged1324withHIVwere
unaware
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(ONAP:NHASProgressReport,2013)
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NHASGoalII:
TimelyLinkagetoMedicalCare
By2015,increaseto85%theproportionofnewly
diagnosed patients linked to clinical care w/in 3
Linkagetocarerate:79.8%in2011
LowerratesoflinkagetocareforBlacksandyoungpersons(13
24yrs)
diagnosedpatientslinkedtoclinicalcarew/in3
mos oftheirHIVdiagnosis
Completereportingoflabdataisneededinmoreareasto
providebetternationalestimates(19reportingsitesin2011)
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(ONAP:NHASProgressReport,2013)
NHASGoalIII:ReduceDisparities
By2015,increaseby20%undetectable
viralloadamongMSM,Blacks,andLatinos
IncreaseVLSamong: Current(2010) 2015Goal
MSM 41.7% 48.8%
Blacks 34.9% 39.2%
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(ONAP:NHASProgressReport,2013)
Latinos 37.2% 43.9%
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ViralSuppressionAmongBlacks*
353,653blackslivingwithHIVfrom19jurisdictionsreporting
CD4+andVL
46 2% (163 515) had an ART prescription 46.2%(163,515)hadanARTprescription
Overall35.2%hadSVLatlastvisit
Males<females(32.7%vs.39.8%)
Byage,1824yrshadlowestratesofSVL(18.3%)
Byrisk:
MaleIDU 22.2%
Toimprove
outcomes,
needtargeted
strategiesfor
different groups
MSM 37.0%
Heterofemale 41.3%
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(MMWR2014;63(5):8589)
*Aged18yearswithanHIVdx by12/31/09andaliveon12/31/10
differentgroups
PercentageofPersonswithHIVEngagedinSelected
StatesoftheContinuumofCare US,2009
(CDC,HIVintheU.S.:TheStagesofCare,July2012)
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InterventionsforImprovingHIV
CareEngagement
LinkageCaseMgmt(intense,timelimitedinteraction)
M di l C M t (l it di l l ti hi t dd t MedicalCaseMgmt(longitudinalrelationshiptoaddressunmet
needs)
IntensiveOutreach(timeandresourceintensive,requires
multiplefollowups)
PeerorParaprofessionalPatientNavigation(sharesfeatures
with health educators and case managers but no formal training withhealtheducatorsandcasemanagersbutnoformaltraining
insocialworkorhomeagency)
ClinicwideMessaging(posters,brochures,briefmessaginglow
costwithmodestimprovements)
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(Mugavero etal.Clin InfectDis 201357(8):11641171)
DisparitiesinEngagementinCareand
ViralSuppressionamongPersonswithHIV
862SanFranciscoresidents
diagnosed with HIV between
Twomarkersofsocial
diagnosedwithHIVbetween
20092010
Usingsurveillancedata:
87%(750)enteredcarewithin6mos
ofdx
72%(540)hada2ndvisitinthenext
3 6 mos
marginalizationand
decreasedresources
healthinsuranceand
housingstatusemerged
asfactorsassociated
withpoorutilizationof
36mos
50%(431)oftotalpopulationhad
suppressedVLin12mos
76%ofthoseretainedfor3visits
hadsuppressedVL
careandnotachieving
viralsuppression.
(Muthulingam etal.JAIDS2013;63:112119)
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AffordableCareAct&PersonsLiving
withHIVInfection:KeyProvisions
Ensurescoverageforpeoplewithpreexistingconditions
E pands Medicaid co erage ExpandsMedicaidcoverage
Providesmoreaffordableprivatehealthcoverage
LowersprescriptiondrugcostsforMedicarerecipients
Ensurescoverageforpreventiveservices,includingHIV
testing
Increasescoordinatedcareforpeoplewithchronichealth
conditions
Ensurescoverageofessentialhealthbenefits
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5recommendationsreleasedDecember2,2013
1. Support, implement and assess innovative models to
ff ti l d li l th ti
RecommendationstoImproveOutcomes
AlongtheHIVCareContinuum
more effectively deliver care along the care continuum
2. Tackle misconceptions, stigma and discrimination to
break down barriers to care
3. Strengthen data collection, coordination and use of data
to improve health outcomes and monitor use of federal
resources
4 Prioritize and promote research to fill gaps in the 4. Prioritize and promote research to fill gaps in the
knowledge along the HIV care continuum
5. Provide information, resources, and TA to strengthen the
delivery of services along the care continuum, particularly
at the state and local levels
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Partnerships4Care(P4C)
PurposeofFunding
Three-year project to reduce HIV/AIDS-related morbidity
and mortality among racial /ethnic minorities by:
Strengtheningpartnershipsbetweenhealthdepartments
andhealthcenters
IdentifyingpromisingmodelsforHIVservicedelivery
ImproveidentificationofundiagnosedHIVinfection
EstablishnewaccesspointsforHIVservices
ImproveHIVoutcomesalongcontinuumofcare
P4C ThreeFundingMechanisms
CDC/DHAP
A d t 4 t t h lth d t t (HD ) ith 4 6 Awardsto4statehealthdepartments(HDs)with46
healthcenter(HC)partners(Florida,Maryland,
Massachusetts&NewYork)
HRSA/BPHC
S l t l d t t 22 HC Supplementalawardstoupto22HCs
ContractawardforanHIVtrainingandtechnical
assistancecollaborationcenter(HIVTAC)
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P4C HealthDepartmentActivities
UseHIVsurveillancedata&healthcenterpatient
data to improve health outcomes for PLWH datatoimprovehealthoutcomesforPLWH
Expandpartnernotification,linkage,retention,and
reengagementwithcareservicesforPLWH
SupporttrainingandTAactivitiesforhealthcenters
(e.g.,expandHIVtesting,preventionservicesfor
PLWH
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P4C HealthCenterActivities
WorkforceDevelopment(e.g.,establishandtrainmulti
disciplinaryHIVcareteam,trainstaffandboard)
Infrastructure Development (e g formal referral agreements HIT InfrastructureDevelopment(e.g.,formalreferralagreements,HIT,
careprotocols)
ServiceDelivery(e.g.,routineHIVtesting,basicHIVcare,
referrals)
DevelopSustainablePartnershipswithStateHealthDepartments
(e g case conferences strategic planning trainings) (e.g.,caseconferences,strategicplanning,trainings)
SupportProjectEvaluationandQualityImprovement(e.g.,
collect,report,utilizepatientdata)
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P4C AnticipatedProjectOutcomes
ImprovedidentificationofundiagnosedHIVinfection
NewsitesforHIVservicedelivery
PromisingpracticesandmodelsforHIVservice
delivery
ImproveHIVoutcomesalongcontinuumofcare
Sustainable
Replicable
Efficientuseofresources
Strengthenedpartnerships
HDsandHCs
Acrosspublichealthsafetynet
CDCandHRSA
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BMSMandHIVContinuumofCare
Webinar Takeaways!
Anumberofstudieshaveshownaconnectionbetweenemploymentand
improvementsinmentalhealth,decreasesinalcoholanddruguse,
decreasesinunprotectedsex,increasesinretentioninHIVcare,increases
inCD4counts,andincreasesinHIVmedicationadherence.
Upstreamapproachtoengagingblackmeninhealthcare.Thetimeto
startthinkingaboutlinkageandretentionisnotatdiagnosisbutduring
prediagnosistosupporthealthseekingbehaviorearlierandtargetBlack
MSMandothersathighestriskforHIVwithprevention
FutureResearch shouldinclude:
modelsthataddresshealthsysteminnovationsinHIVcare
antiracismandantioppressionframeworksforhealthcareenvironments
opportunitiesforcollaborativeresearchamonghealthdepartments,clinics,
communitybasedorganizationsandthefederalgovernment
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DontLoseSightofPrevention(I)
Nationallyrepresentativesampleof
DatafromCDCsMedicalMonitoringProject
4,217adults(>18yrs)incare
Reportingperiod:JanApril2009
23projectareasin16statesand
PuertoRico
71.2%Male,27.2%Femaleand1.6%
Transgender Transgender
41.4%Black,34.6%White,19%
Hispanic/Latino
(MMWR2014;63(SS#5):128)
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DontLoseSightofPrevention(II)
14%ofMSM,9%ofMSWand15%ofWSMhadunprotected
sex with a partner of negative or unknown HIV status
DatafromCDCsMedicalMonitoringProject
sexwithapartnerofnegativeorunknownHIVstatus
Fewerthan20%testedannuallyforSTDs
FewerthanhalfcounseledbyprovideraboutHIV/STD
prevention
1in5womenwithHIVnotscreenedforcervicalcancer
(MMWR2014;63(SS#5):128)
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CoreHIVPreventionActivitiesfor
State/LocalHealthDepartments
HIVTesting
IncludesoptouttestinginHCsettings(1364yrs)&targeted
testing for high risk populations testingforhighriskpopulations
ComprehensivePreventionwithHIVpositive
Individuals
Includesinterventionstoimprovelinkageto&retentionincare,
referraltosubstanceabuse&otherneededservices,PMTCT&
riskreductioninterventions
CondomDistribution
Promote correct and consistent use among PLWHA and those at PromotecorrectandconsistentuseamongPLWHAandthoseat
highrisk
PolicyInitiatives
Alignstructures,policiesandregulationstooptimizeHIV
prevention&careandfacilitatesharing/useofdatafordecision
making
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(CDC)
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CombiningPreventionStrategiesto
IncreaseEffectiveness
Modelingstudyestimating1yrand10yrHIVriskforserodiscordant
M/MandM/Fcouples
Consideredconsistentcondomuse,malecircumcision,PrEP,andART
Modesttransmissionprobabilitiestranslateintosubstantial
cumulativerisksovertime
Condomsreduceriskby80%peractbut1yrand10yrHIVriskforM/Mwas
estimatedat13%and76%
AmongM/MusingARTandcondomsconsistently1yrand10yrHIVrisk
reduced to 1% and 6% reducedto1%and6%
ForM/Fcoupleusingonlycondoms,estimatedriskover10yrwas11%with
ART,lessthan1%
ARThadthemostsubstantialprotectiveeffectofanystrategy
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(Lasry etal.AIDS2014;28(10):15211529)
GrowingEvidenceSupportingCHWs inDiabetes
Care:APotentialModelforHIVCBOs
Racial/ethnicminoritiesexperiencedisproportionateburdenof
diabetesandmorecomplications
Barrierstooptimaldiabetesmanagementinvolveindividual,
community,andhealthsystemlevelfactors
Communitybasedparticipatoryresearch(CBPR)improves
interventiondevelopmentandevaluation:
Culturallytailoredhealthylifestyletraining
CHWs troubleshoot with participants to improve adherence CHWs trouble shoot withparticipantstoimproveadherence
IntegrateCHWs intothechroniccareteam:carecoordination&support
Policyissuesincludescopeofpractice,trainingmodels,and
sustainability
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(seeShahetal.Curr DiabetesRep2013;13(2):163171)
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USDOJ:BestPracticesGuidetoReformHIVSpecific
CriminalLawstoAlignwithScientificallySupported
Factors
Providestechnicalassistance
regardingstatelawsthat
criminalizeengagingincertain
behaviorswithoutdisclosing
knownHIVpositivestatus.
Assistsstatestoensurethattheir
policiesreflectcontemporary
understandingofHIV
transmissionroutesand
associated benefits of treatment associatedbenefitsoftreatment
anddonotplaceunnecessary
burdens onindividualslivingwith
HIV/AIDS.
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DOJWeighsIn...
Whileinitiallywellintentioned,theselawsoftenruncounterto
currentscientificevidenceaboutroutesofHIVtransmission,and
mayruncountertoourbestpublichealthpracticesfor
preventionandtreatmentofHIV,saidActingAssistantAttorney
GeneralJocelynSamuelsfortheCivilRightsDivision.The
departmentiscommittedtousingallofthetoolsavailableto
addressthestigmathatactsasabarriertoeffectivelyaddressing
thisepidemic.
Source:http://www.justice.gov/opa/pr/2014/July/14crt739.html
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VisionoftheNationalHIV/AIDSStrategy
TheUnitedStateswillbecomeaplacewhere
newHIVinfectionsarerareandwhentheydo
occur,everypersonregardlessofage,gender,
race/ethnicity,sexualorientation,genderidentity
orsocioeconomiccircumstance,willhave
unfetteredaccesstohighquality,lifeextending
care,freefromstigmaanddiscrimination.
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