HIV Care Continuum and Ryan White HIV/AIDS Program Services · engagement in care will pose to test...

HIV Care Continuum and Ryan White HIV/AIDS Program Services

U.S. Conference on AIDS 2014

Laura Cheever, Associate Administrator, HIV/AIDS Bureau

Harold Phillips, Deputy Director, Division of State HIV/AIDS Programs Steven Young, Director, Division of Metropolitan HIV/AIDS Programs

HIV/AIDS Bureau

Health Resources and Services Administration U.S. Department of Health and Human Services

October 4, 2014

Workshop Agenda

• The HIV Care Continuum

• Ryan White Services Report (RSR) Data and the Care Continuum

• Programmatic Emphasis and What Grantees and Planning Councils can do to Strengthen Stages Along the Continuum

• Examples of Service Models

• Questions and Answers/Discussion

HIV Care Continuum Development & Timeline

• Dr. Laura Cheever, HRSA’s Associate Administrator for the HIV/AIDS Bureau, uses the phrase continuum of engagement in care in a 2007 editorial “to describe the fluid nature of HIV health-care delivery and patient experience”

(Cheever LW. Engaging HIV-Infected Patients in Care: Their Lives Depend on It. [Editorial]. Clinical Infectious Diseases, 2007; 44 (June 1): 1501-2.)

• Gardner, et al., release “Spectrum of Engagement in HIV Care” article in

2011, “to help understand the magnitude of the challenges that poor engagement in care will pose to test-and-treat strategies for HIV prevention” (Gardner, et al., The Spectrum of Engagement in HIV Care and its Relevance to Test-and-Treat Strategies for Prevention of HIV Infection. Clinical Infectious Diseases, 2011: 52 (March 15): 793-800.)

HIV Care Continuum Development & Timeline (cont.)

• CDC releases its first “Stages of Care” in 2012 and its comprehensive

analysis shows that only one-quarter of the 1.1 million Americans living with HIV have their virus under control — and that African Americans and young people are least likely to receive ongoing care and effective treatment

• HIV Care Continuum Executive Order, July 2013, “It is the policy of my Administration that agencies implementing the Strategy prioritize addressing the continuum of HIV care, including by accelerating efforts to increase HIV testing, services, and treatment along the continuum. This acceleration will enable us to meet the goals of the Strategy and move closer to an AIDS-free generation”

What is the HIV Care Continuum?

• HIV Diagnosis —The HIV Care Continuum begins with a diagnosis of HIV infection. The only way to know for sure that you are infected with the HIV virus is to get an HIV test. People who don't know they are infected are not accessing the care and treatment they need to stay healthy. They can also unknowingly pass the virus on to others

• Getting linked to care—Once you know you are infected with the HIV virus, it is important to be connected to an HIV health care provider who can offer you treatment and counseling to help you stay as healthy as possible and to prevent passing HIV on to others

• Staying in care—Because there is no cure for HIV at this time, treatment is a lifelong process. To stay healthy, you need to receive regular HIV medical care

• Getting antiretroviral therapy— Antiretrovirals are drugs that are used to prevent a retrovirus, such as HIV, from making more copies of itself. Antiretroviral therapy (ART) is the recommended treatment for HIV infection. It involves using a combination of three or more antiretroviral drugs from at least two different HIV drug classes every day to control the virus

• Achieving a low amount of HIV virus in your body—By taking ART regularly, you can achieve viral suppression, meaning a very low level of HIV in your blood. You aren’t cured. There is still some HIV in your body. But lowering the amount of virus in your body with medicines can keep you healthy, help you live longer, and greatly reduce your chances of passing HIV on to others

CDC Stages of Care – 2009 National HIV Surveillance System & Medical Monitoring Project

CDC. HIV in the United States: Stages of Care. July 2012. Hall HI, Frazier EL, Rhodes P, et al. JAMA Internal Medicine. Jun 17 2013:1-7.

Limitations of the Treatment Cascade

• The Bars before the Cascade and other issues o Prevention should not be forgotten o Social and Structural Determinants of Health o Large overlap in the stages of engagement in care o Achieving consensus on the standards of care and practice

• Mortality as the “ultimate indicator” of success and failure

• The Human Factor o Progress along the HIV Care Continuum may not be linear o Achieving viral suppression does not end the work

• Data collection and reporting o Access limitations o Data quality

Why is the HIV Care Continuum Important?

• Provides answers to some questions about care delivery at critical stages

• Policymakers and service providers can identify gaps that require additional or special attention

• Intensifies focus on barriers to care and needed solutions

• Serious implications for our test and treat programs, treatment as prevention prospects, reducing community viral load and ultimately and AIDS-free generation

Ryan White Services Report, 2010-2012 Retention in Care & Viral Suppression

Retained in care: had at least 1 OAMC visit before September 1, 2012, of the measurement year and had at least 2 visits 90 days or more apart Viral suppression: had at least one OAMC visit, at least one viral load count, and last viral load test <200

MSM and IDU Retained in Care and Virally Suppressed

82% 75.10%

82.05% 76.39% 79.6%

67.8% 74.4%

52.9%

81.30%

74.50%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Retained in care Virally suppressed

All RSR clients

MSM

Black MSM

Young (13-24) MSM

IDU

Retained in care: had at least one OAMC visit before September 1, 2012, and had at least 2 visits 90 days or more apart Viral suppression: had at least one OAMC visit, at least one viral load count, and last viral load test <200

Source: 2012 RSR data (preliminary)

Women HIV Outcomes Data, 2012 RSR

• Women: 29% of all RSR clients o Represent 1.8% of the women ages 13-18 (youth) o Represent 4.7% of the women ages 19-24 (young

adult)

• Approximately 75.1% of women are at 100% or below federal poverty level (FPL) o 32.6% of these women are Black

• More than one-third (38.9%) of women receive Medicaid at some time during the year

Women Retained in Care and Virally Suppressed

87.8%

62.3%

78.8%

50.0%

80.9% 77.5% 83.3%

70.8%

86.10%

76.8% 82.0%

69.8%

83.5%

73.2%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Retention in Care Viral Load Suppression

age 13-18age 19-24White non-HispanicBlack non-HispanicHispanicMedicaid

All females

Summary of the Ryan White HIV/AIDS Program 2012 RSR

• RWHAP data remains relatively stable and consistent over the past 3 cycles (2010-2012)

• Approximately 60% of all RSR clients receive outpatient ambulatory medical care and about 54% receive medical case management

• Black MSM: 32.4% of all MSM o Retention in care: Young MSM (13-24) are less likely to be retained (74%) o Viral Load Suppression: Black MSM and Young MSM (13-24) are less likely

to be suppressed (68%/53%) • Women: 29% of all RSR clients

o Retention in care: 19-24 year olds are less likely to be retained (79%) o Viral load suppression: 13-18 and 19-24 year olds are less likely to be

suppressed (62%/50%) along with those on Medicaid (70%) • HIV in the South

o Lower retention in care and viral suppression rates compared to the rest of the U.S.

o Viral Load Suppression: Blacks are less likely to be virally suppressed (68%)

Programmatic Emphasis

The Ryan White HIV/AIDS Program

• Works with cities, states, and local community-based organizations to deliver a comprehensive system of HIV care and treatment aimed at achieving optimal health outcomes for PLWH

• By design, the program provides access to a

wide-range of core medical and support services aimed at early diagnosis of HIV, linkage to care, retention in care, medically appropriate treatment, and sustained viral load suppression…a trajectory formally referred to as the HIV/AIDS Care Continuum

Expanded Insurance Coverage & Ryan White HIV/AIDS Program

• The Affordable Care Act (ACA) provides expanded reimbursement for a discrete set of essential health benefits

• Ryan White HIV/AIDS Program supports a community-based, comprehensive “system” of care with a public health focus that addresses the issues faced by diverse populations of individuals with HIV

• Funding supports a myriad of core medical and supportive services under the Ryan White HIV/AIDS Program

• And, grantees, particularly Part A and B jurisdictions, are uniquely positioned and legislatively charged to address the system of care and prevention/care continuum. With the ACA, grantees have that opportunity for significant impact utilizing RWHAP grant funding applied to the new treatment and Care Continuum paradigms

Social Determinants, Interdisciplinary Approach and Complex Needs

Provision and success of HIV care and treatment extends beyond an individual’s insurance status. Facilitating progress along the HIV Care Continuum requires an interdisciplinary approach to addressing the complex health needs of PLWH in the context of their staggering socio-economic constraints

Part A - New Emphasis Related to the Care Continuum

• EMA/TGA graphs, which depict the RWHAP Part A HIV Care Continuum

• Using available baseline data and numerators/denominators clearly defined

• Five main stages of the HIV Care Continuum in the graph: o Diagnosed - Number and percentage of people living with HIV/AIDS in the

EMA/TGA diagnosed with HIV/AIDS o Linked to Care - Number and percentage of PLWH in the EMA/TGA connected

to an HIV health care provider o Retained in Care - Number and percentage of PLWH in the EMA/TGA,

receiving regular HIV medical care o Prescribed Antiretroviral Therapy (ART) - Number and percentage of PLWH in

the EMA/TGA, prescribed a combination of three or more antiretroviral drugs from at least two different HIV drug classes every day to control the virus

o Virally Suppressed - Number and percentage of people living with HIV/AIDS in the EMA/TGA with a viral load below 200

HIV Care Cascade in Seattle/King County

§Hall, IAS 2012 *King County surveillance (green) and population-based chart review (yellow) data; % undiagnosed estimates from local modeling data

HIV Care Cascade in Los Angeles County

Paint a Picture – Tell the Story

• Utilization of the HIV Care Continuum in planning, prioritizing, targeting and monitoring available resources in response to needs of PLWH in the jurisdiction and in improving engagement at each stage in the continuum

• Successes/improvements in supporting PLWH as they move from one stage in the continuum to the next

• Gaps, barriers or unique challenges that exist in developing and utilizing the HIV Care Continuum model in the Part A program. Describe how the Part A program addresses these gaps, barriers or unique challenges

• How will the FY 2015 award be used to address gaps/barriers and improve the HIV Care Continuum?

• Any significant health disparities brought to light related to race, gender, sexual orientation and age among populations within your jurisdiction’s HIV Care Continuum and activities targeted current or planned to address these disparities

Part A Implementation Plan – Service Categories

Ryan White Part A Implementation Plan: Service Category

Grantee Name:_________________________ Fiscal Year________________ Page ________of _____ pages Budget Period: 03/01/2015 thru 02/28/2016

Service Category Name: Total Service Category Allocation:

Service Category Priority Number: Part A Core Medical ☐ Part A Support ☐ MAI Core Medical ☐ MAI Support ☐

1. Objectives: List quantifiable time-limited objectives related to the service priorities listed above

2. Service Unit Definition: Define the service unit to be provided

3. Quantity

5. Funds: Provide the approximate amount of funds to be used to provide this service.

3a) Number of people to be served

3b) Total Number of service units to be provided

a: b: c: d: e. 6. Stage of the HIV Care Continuum related to this service category: More than one Stage may be applicable. I. Diagnosed ☐ II. Linked to Care ☐ III. Retained in Care ☐ IV. Prescribed Antiretroviral Therapy ☐ V. Virally Suppressed ☐ 7. HHS/ HAB Performance Measure related to the above Stage of the HIV Care Continuum related to this service category: HIV Positivity ☐ Late HIV Diagnosis ☐ Linkage ☐ Frequency /Retention ☐ Prescribing ART ☐ Viral Load Suppression ☐

Attachment 9

Sample Part A Implementation Plan

SAMPLE FORM

Ryan White Part A Implementation Plan: Service Category

Grantee Name: Big City EMA Fiscal Year: 2013 Page 7 of 15 Pages

Service Category Name: Medical Transportation Services Total Service Category Allocation: $35,000

Service Category Priority Number : 9 Part A Core Medical ☐ Part A Support ☒ MAI Core Medical ☐ MAI Support ☐

1. Objectives: List quantifiable time-limited objectives related to the service priorities listed above

2. Service Unit Definition: Define the service unit to be provided

3. Quantity 5. Funds: Provide the approximate amount of funds to be used to provide this service.

3a) Number of people to be served

3b) Total Number of service units to be provided

a: By March 1, 2014, 100% of RW funded medical case management service providers will have bus passes available for distribution to clients requiring assistance with transportation to medical appointments

1-day pass 7-day pass

30-day pass

50 240 150

70 440 600

$280 $3,520 $16,200

Total: $20,000 b:By May 1, 2014, 100% of medical case management service providers will have taxi vouchers available for distribution to clients requiring assistance with transportation to medical appointments

One-way trip 75 600 $15,000

6. Stage of the HIV Care Continuum related to this service category: More than one Stage may be applicable. I. Diagnosed ☐ II. Linked to Care ☒ III. Retained in Care ☒ IV. Prescribed Antiretroviral Therapy ☐ V. Virally Suppressed ☒ 7. HHS/ HAB Performance Measure related to the above Stage of the HIV Care Continuum related to this service category: HIV Positivity ☐ Late HIV Diagnosis ☐ Linkage ☒ Frequency /Retention ☒ Prescribing ART ☐ Viral Load Suppression ☒

Part A Implementation Plan – HIV Care Continuum

* HHS Measures can be found at http://www.aids.gov/pdf/hhs-common-hiv-indicators.pdf ** HAB Core performance measures can be found at: http://hab.hrsa.gov/deliverhivaidscare/coremeasures.pdf

Ryan White Part A Implementation Plan: HIV Care Continuum Table Grantee Name:_________________________ Fiscal Year________________ Budget Period: 03/01/2015 thru 02/28/2016

Stages of the HIV Care Continuum

Goal Outcome Service Category (One or more may apply)

I. Diagnosed HIV Positivity* Late HIV Diagnosis*

Baseline: Numerator/Dominator, %

Target: Numerator/Dominator, %

II. Linked to Care Linkage to HIV Medical Care*



III. Retained in Care Retention in HIV Medical Care* HIV Medical Visit Frequency**



IV. Prescribed ART Antiretroviral Therapy (ART) Among Persons in HIV Medical Care* Prescription of HIV Antiretroviral Therapy **



V. Virally Suppressed Viral Load Suppression Among Persons in HIV Medical Care* HIV Viral Load Suppression**



Attachment 9

Sample Part A Implementation Plan – HIV Care Continuum

SAMPLE FORM

Ryan White Part A Implementation Plan: HIV Care Continuum Table

Grantee Name: Big City EMA Fiscal Year: 2015

* HHS Measures can be found at http://www.aids.gov/pdf/hhs-common-hiv-indicators.pdf ** HAB Core performance measures can be found at: http://hab.hrsa.gov/deliverhivaidscare/coremeasures.pdf

Stages of the HIV Care Continuum

HIV Care Continuum Goal

Outcome Service Category (One or more may apply)

I. Diagnosed Increase in the percentage of clients who are aware of their HIV Status

HIV Positivity* Late HIV Diagnosis*

Early Intervention Services

Baseline: Numerator/Dominator, % 7/10 70%

Target: Numerator/Dominator, % 9/10 90%

II. Linked to Care Increase in the percentage of clients linked to care

Linkage to HIV Medical Care*

Outpatient Medical Care Medical Case Management Medical Transportation

Baseline: Numerator/Dominator, % 67/100 67%


III. Retained in Care Increase in the percentage of clients retained in care

Retention in HIV Medical Care* HIV Medical Visit Frequency**

Outpatient Medical Care Medical Case Management Medical Transportation Baseline: Numerator/Dominator, %

58/100 58% Target: Numerator/Dominator, % 72/100 72%

IV. Prescribed ART Increase in the percentage of clients with access to prescribed HIV/AIDS medications consistent with PHS Treatment Guidelines

Antiretroviral Therapy (ART) Among Persons in HIV Medical Care* Prescription of HIV Antiretroviral Therapy **

Outpatient Medical Care Medical Case Management Medical Transportation Baseline: Numerator/Dominator, %

76/100 76% Target: Numerator/Dominator, % 92/100 92%

V. Virally Suppressed Increase in the percentage of clients with a viral load of <200

Viral Load Suppression Among Persons in HIV Medical Care* HIV Viral Load Suppression**

Outpatient Medical Care Medical Case Management Medical Transportation Treatment Adherence Counseling

Baseline%: 45/100 45%


Attachment 9

Continuum of Services Framework

Strengthening the HIV Care Continuum

Future Role of Part A Jurisdictions • Quality collaborative will support the identification and implementation

of interventions, models, and approaches (data utilization; evidence- based or best practices) that have been documented to make improvements along the Care Continuum

• Activities include: o Consultation o Training and technical assistance o Use of tools, techniques and various approaches to implement quality

management and quality improvement initiatives across the HIV public health delivery system

o Real-time virtual engagements that facilitate assessment, planning, implementation, and evaluation of interventions that can improve outcomes in the current delivery system

Support to Part A

• Year 01 – focus on cataloging and sharing approaches to utilizing HIV data, interventions targeted toward various points along the HIV care continuum, and successes/improvements that can be attributed to such interventions

• Year 02-03 – utilize the collaborative model (more intensive

engagement and support) to identify 10 jurisdictions each year with need/interest in making significant improvements in their continuum

Improvements

• Increase in the number of individuals identified as HIV positive

• Decrease in the number of individuals with a late HIV diagnosis

• Increase in the percentage of individuals linked to HIV medical care

• Increase in the percentage of individuals retained in HIV medical care

• Increase in the percentage of individuals prescribed antiretroviral therapy

• Increase in viral load suppression among persons in HIV medical care

Progress Along the Continuum – Select Examples

• Recent study - linkage, engagement, and viral suppression rates among HIV infected persons receiving care at medical case management (MCM) co-located programs in Washington, DC highlight the importance of integrating ancillary services in a single de-stigmatizing clinic environment (Willis, 2013)

• According to the study, among 5,361 prevalent cases,

57% received care at clinics providing MCM of which 76% were retained in care and 70% were virally suppressed (Willis, 2013)

• Further, those receiving care at clinics providing MCM

were significantly more likely to be retained in care than persons receiving care at clinics that did not provide MCM (Willis, 2013)


Los Angeles – County health department works with Ryan White HIV/AIDS Program-funded clinics to find PLWH who are out of care, using clinic records and the social networks of in-care clinic patients cross-matched with surveillance data to confirm that identified individuals have not transferred care elsewhere in Los Angeles San Francisco – Department of Public Health directs a reengagement program that accepts referrals from medical providers and community sites, which now includes a pilot project to explore the use of surveillance data to identify persons who are out of care New York City – Health department staff members investigate cases with no evidence of care in the past nine months to offer linkage to care and partner services. In the first 30 months of this program, the staff successfully reached 414 out-of-care persons in New York, 72% of whom subsequently relinked to care


• Massachusetts and Colorado – Expanded coverage options and increased cost saving through the 340B rebate program and cost avoidance by linking and retaining more HIV-positive individuals in care and reducing overall viral load

• Both states continue to support clinical care by funding assistance with out of pocket health care insurance premium, deductible and co-payment costs. An amount of these expenditures is subject to receipt of a rebate from drug manufactures when they have paid for all or any part of the costs of a prescription, including costs sharing or co-payments. Payments of premiums only do not allow ADAPs to access rebates on covered 340B drugs. The revenue generated by the rebates is reinvested resulting in cost savings extends its ability to impact the health outcomes of PLWH

• They continue to support direct funding to services (such as dental, case management, treatment adherence and transportation) with inadequate coverage by patients’ insurance plans and outreach and engage PLWH who are out of care

• Colorado is reinvesting a portion of its RWHAP Part B funding by revamping its model of disease intervention specialists to cover outreach, retention and treatment adherence

• Massachusetts has reported a reduction in new HIV diagnoses, very high retention in care rates, and high rates of viral suppression attributed coverage expansions, the RWHAP, the state’s network of community health centers and other factors

Interventions for Improving HIV Care Engagement

• Linkage Case Management (intense, time-limited interaction)

• Medical Case Management (longitudinal relationship to address unmet needs)

• Intensive Outreach (time and resource intensive, requires multiple follow-ups)

• Peer or Para-professional Patient Navigation (shares features with health educators and case managers but no formal training in social work or home agency)

• Clinic-wide Messaging (posters, brochures, brief messaging—low cost with modest improvements)

(Mugavero et al. Clin Infect Dis 2013 57(8): 1164-1171)

Select Examples of CAPUS Activities

• Georgia developed a legislative proposal that would allow HDs to share pertinent surveillance information with HIV providers, so as to identify PLWH out-of-care

• Louisiana is increasing access to no-cost, rapid HIV testing among uninsured by implementing opt-out HIV testing in at least two hospital ERs

• Mississippi is partnering with an academic institution and a rural community-based organization to develop a program to train PLWH to become peer navigators

• North Carolina is implementing a telehealth training for rural providers caring for PLWH

• Tennessee is employing a social networking strategy to engage hard-to-reach MSM in Memphis and Nashville and employ community “recruiters” to encourage HIV testing

• Virginia is experimenting with a housing pilot where HIV positive clients incarcerated three years or more are eligible for six months of housing support upon release

Part A…and Beyond?

• Period of significant change: o An estimated 72% of all PLWH infection reside in one

of the 52 metropolitan areas funded under Part A

o Increasingly diverse and challenging (from the perspective of service delivery) populations are impacted with an ever-changing epidemiologic profile

o Clinical paradigm has changed significantly such that ongoing and effective treatment cannot only enhance the quality and length of life but can suppress the virus and reduce further infections

o Affordable Care Act has created new opportunities for health insurance coverage (public and private) for many people living with HIV

Part A…and Beyond?

• Part A program, along with others, has a potentially new and significant public health impact on HIV incidence moving forward

• Part A jurisdictions are uniquely positioned to take on the responsibility of supporting a system of HIV care in this new environment o appropriate structures in place o experience in data-driven, community-based needs assessment o responsive procurement of a variety of direct medical and supportive services o set of providers to weave together a constellation of services

• Such an initiative will also help inform future programmatic grant efforts o increase the focus on achieving specific goals tied to each step of the HIV

Care Continuum o modify programmatic efforts and set targets tied to the use of grant funds and

improvements along the continuum

• Future policy and grant awards could also consider including metrics or performance-based bonus payments or withholds to drive improvements

Discussion/Questions

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