National HIV/AIDS Strategy 2020 and the Federal Action Plan:

Implications for ASOs, CBOs, and Health Centers

Sean Cahill, PhDDirector, Curriculum and Policy, National Center for Innovation in HIV Care

December 14, 2015

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Outline Intro: Changed context with new HIV diagnosis data NHAS 2020 (July 2015) and Federal Action Plan

(December 2015): Key Goals and Action Items Implications for AIDS Service Organizations (ASOs),

Community-based Organizations (CBOs), and Health Centers (HCs)

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Caveat I am only highlighting some points from NHAS 2020

and the Federal Action Plan, not every point Access these documents at www.aids.gov/nhas

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New HIV diagnosis data released December 6 at CDC conference Number of new diagnoses down 19% from 2005 to

2014, from 48,795 to 39,718 per year Improvements with some populations

Diagnoses down for Black women 42% Diagnoses down for People Who Inject Drugs (PWID) by 65% Diagnoses down for heterosexuals by 35% Diagnoses down for White gay/bi men by 18%

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New HIV diagnosis data 2005-2014 Still getting worse for others

Diagnoses up for gay and bisexual men by 6% Diagnoses up for Black gay and bisexual men by 22%,

stabilized in recent years Diagnoses up for Latino gay and bisexual men by 24%, still

getting worse in recent years (up by 13%) Black gay and bisexual males age 13-24: 87% increase in

new HIV diagnoses over last decade, 2% decline in recent years

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Key findings HIV diagnoses becoming even more concentrated

among gay and bisexual men Racial/ethnic and age disparities becoming even more

pronounced among gay and bisexual men Improvements among Black women, heterosexual

women and men, PWID

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Current Status of State Medicaid Expansion Decisions

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Goals of NHAS 2020 Goal 1: Reduce New HIV Infections Goal 2: Increase Access to Care and Improving Health

Outcomes for People living with HIV Goal 3: Reduce HIV-Related Disparities and Health

Inequalities Goal 4: Achieve a More Coordinated National

Response to the HIV Epidemic

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Indicators at a Glance

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Federal Action Plan (Dec. 2015) Four Key Foci of NHAS 2020:

Widespread testing, linkage to care Support for engagement in care/treatment

adherence Universal viral suppression Full access to comprehensive pre-exposure

prophylaxis (PrEP) services

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Goal 1 (NHAS 2020): Reducing New HIV InfectionsOverview of steps:

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Goal 1 Step 1.B (NHAS 2020) Recommended Actions Support and strengthen integrated, patient-centered HIV and

related screening (STIs, behavioral health, Intimate Partner Violence, Hep C) and linkage to basic services

Action Items 2016-2020 (Federal Action Plan): Promote HIV screening among homeless, in job training programs HIV screening within context of IPV, Family Planning Clinics HRSA/CDC pilot system level interventions to increase HIV testing

among health center patients diagnosed with acute STIs (2018) Add lifetime HIV test to Uniform Data System for Health Centers,

aligned with Meaningful Use, for all 15- to 65-year-olds (HRSA, 2018)

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Goal 1 Step 1.B (NHAS 2020) Recommended Actions Support and strengthen integrated, patient-centered

HIV and related screening (STIs, behavioral health, Intimate Partner Violence, Hep C) and linkage to basic services

Action Items 2016-2020 (Federal Action Plan): Support provision of wrap-around services (vocational,

educational, housing, nutrition, transportation services) within behavioral health treatment programs (SAMHSA, ED 2018-20)

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Goal 1 Step 1.B (NHAS 2020) Recommended Actions Expand access to effective HIV prevention services,

including PrEP and PEP Action items:

HRSA TA/trainings on PrEP, PEP implementation strategies for HRSA programs (2016-20)

SAMHSA training for grantees re: linking patients in behavioral health programs to PrEP, PEP (‘16-20)

SAMHSA provide medication-assisted treatment (MAT) services with pharmacotherapies for treatment of opioid use disorders, support integrated care addressing HIV infection as part of substance use treatment (2018)

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Goal 1 Step 1.B (NHAS 2020) Recommended Actions Expanded prevention with people living with HIV

(PLWH) Action items:

Promote Treatment as Prevention at Ryan White Part C clinics, Health Centers

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Goal 1: Reducing New HIV InfectionsOverview of steps:

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Goal 1 Step 1.C (NHAS 2020) Recommended Actions “All health and wellness practitioners (peer counselors,

intake specialists, doctors, nurses, and other health professionals) must be…equipped to deliver education that is culturally appropriate and inclusive of LGBT people.” (p.24)

I.e. they must be trained and be culturally competent.

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Goal 1 Step 1.C (NHAS 2020) Recommended Actions Utilize evidence-based social marketing and education

campaigns, and leverage digital tools and new technologies

Action items: Digital tools aimed at adolescents, women and girls, persons

receiving substance use/mental health services (2016-2020) Incorporate digital technology to support MH/SU disorder

treatment, adherence to ARVs and PrEP (2020) Compile lessons learned from HRSA-funded interventions to

engage, retain young Black MSM, women of color in care with optimal health outcomes (2018)

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Goal 1 Step 1.C (NHAS 2020) Recommended Actions Utilize evidence-based social marketing and education

campaigns, and leverage digital tools and new technologies

Action item: Promote Trauma-Informed Care Guidance with all federal

HIV prevention and care grantees (SAMHSA, 2016-2020)

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Goal 1 Progress Indicators Indicator 1: 90% of PLWH know their serostatus (2012

87.2%; on track) Source: NHAS 2020 Indicator Supplement, August 2015

Indicator 2: Reduce number of new diagnoses by at least 25% (e.g. from 43,806/yr at baseline to 32,855/yr by 2020; 2014 goal was 41,068, actual # was 39,718) Source: NHAS 2020 Indicator Supplement, August 2015

Indicator 3: Reduce the percentage of young gay and bisexual men who have engaged in HIV-risk behaviors by at least 10%, from baseline of 34.1%

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Goal 2: Increasing Access to Care and Improving Health Outcomes for People living with HIVOverview of steps:

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Goal 2 Step 2.A (NHAS 2020) Recommended Actions Integration, colocation of substance abuse and mental

health services with HIV care Clinical decision support tools to identify persons out

of care Support and strengthen capacity to implement

innovative and culturally appropriate models to deliver care more effectively—implementation research Develop new care delivery models to provide culturally

appropriate services for populations like gay/bi men, trans women, older adults, youth, racial and ethnic minorities

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Goal 2 Step 2.A (NHAS 2020) Recommended Actions Re-entry programs to link formerly incarcerated to

health homes, supportive services, disability benefits or Medicaid

Facilitate initial appointments post-release, comprehensive case management

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Goal 2 Step 2.A (NHAS 2020) Recommended Actions Action items from Federal Action Plan:

Disseminate lessons learned from safety net providers about how to extend health care coverage enrollment to key populations (HRSA, 2016)

TA to grantees to help them maximize payment systems, access third party reimbursement for behavioral health, HIV services (SAMHSA, 2016-20)

Guidance to grantees to enable them to receive third party reimbursement for HIV/STI/HCV/TB testing (CDC, 2016-2020)

Increase health centers’ capacity to integrate HIV continuum into primary care; use HIT to improve linkage to care, care coordination (HRSA, ‘16-20)

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Goal 2: Increasing Access to Care and Improving Health Outcomes for People living with HIVOverview of steps:

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Goal 2 Step 2.B Recommended Actions Increase number of providers of HIV care

“Federally-supported programs should encourage h.c. delivery strategies that extend the capacity of the existing workforce of HIV specialists.” (p. 34)

Strengthen current provider workforce “…integration of HIV services into health centers and other

primary care settings…” (p. 35) Support screening and referral for substance

use/mental health services for people living with HIV

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Goal 2: Increasing Access to Care and Improving Health Outcomes for People living with HIVOverview of steps:

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Goal 2 Step 2.C Recommended Actions Address policies to promote access to housing, other

basic need/supportive services for people living with HIV Support for case management programs, partnerships

between housing programs and HIV service organizations Improve outcomes for women in HIV care by

addressing factors that increase risk of violence for women living with HIV Also address trauma experienced by young gay, bisexual

men, transgender women

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Goal 2 Step 2.B & C Recommended Actions Action items from Federal Action Plan:

Improve, expand substance use services—with focus on opioid use disorders—at health centers (HRSA, SAMHSA 2020)

Research, share IPV screening, interventions with HRSA grantees to improve health outcomes for women and girls, gay and bisexual men (HRSA, NIH, 2018)

Promote, support health centers to implement IPV services in primary care settings, including health centers serving PLWH (HRSA, ACF 2020)

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Goal 2 Progress Indicators Indicator 4: Increase % of newly diagnosed persons linked

to HIV medical care within one month of their diagnosis to at least 85% (2013 72.6%; on track)

Indicator 5: Increase percentage of persons with diagnosed HIV infection who are retained in HIV medical care to at least 90% (2012 53.8%; not on track)

Indicator 6: Increase the percentage of persons with diagnosed HIV infection who are virally suppressed to at least 80% (2012 50.1%; on track)

Indicator 8: Reduce the death rate among persons with diagnosed HIV infection by at least 33% (2012; on track)

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Goal 3: Reducing HIV-Related Disparities and Health InequalitiesOverview of steps:

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Goal 3 Step 3.A Recommended Actions Expand services to reduce HIV-related disparities

experienced by gay, bisexual men (especially young Black gay, bisexual men), Black women, people living in South

Support engagement in care for groups with low levels of viral suppression, including youth and PWID

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Goal 3 Step 3.A Recommended Actions Action items from Federal Action Plan:

Behavioral health programs serving groups disproportionately affected by HIV offer HIV testing Test positive case management Test negative linkage to PrEP, prevention services (SAMHSA 2018)

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Goal 3: Reducing HIV-Related Disparities and Health InequalitiesOverview of steps:

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Goal 3 Step 3.B Recommended Actions Scale up effective programs that address social

determinants of health Employ biopsychosocial prevention approach Address poverty, poor education, homelessness,

unemployment Particular need for young, Black gay and bisexual men

Support research to better understand intersection of HIV and violence against women, develop interventions

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Goal 3 Step 3.B Recommended Actions Action items from Federal Action Plan :

Expand capacity of CBOs, faith-based orgs. to address social, structural barriers to HIV prevention, diagnosis, care (Office of HIV/AIDS and Infectious Disease Programs, CDC, HRSA, NIH, SAMHSA 2016)

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Goal 3: Reducing HIV-Related Disparities and Health InequalitiesOverview of steps:

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Goal 3 Step 3.C Recommended Actions Promote evidence-based public health approaches to

HIV prevention and care Challenge stigma re substance use/mh, HCV, STIs

Strengthen enforcement of civil rights laws, assist states in protecting people living with HIV from violence, discrimination

Mobilize communities to reduce HIV stigma Promote public leadership of people living with HIV

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Goal 3 Step 3.C: Reduce stigma, end discrimination Action items from Federal Action Plan:

DOJ, HHS Office of Civil Rights will conduct impact litigation against HIV discrimination in health care treatment, insurance coverage (2016-2020)

Provide CBA to help CBOs use social network strategies to reduce HIV stigma (CDC, 2016)

Mobilize faith-based orgs. to address HIV among gay and bisexual men, transgender women and reduce stigma related to sexual orientation, gender identity (OHAIDP, 2018)

Promote leadership of PLWHA in integrated prevention & care planning (CDC, HRSA ‘16)

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Goal 3 Progress Indicators Indicator 7: Reduce % of PLWH in medical care who are

homeless to 5% from baseline 7.7% (2012: jumped to 8.3%)

Indicator 9: Reduce disparities in the rate of new diagnoses by at least 15% in the following groups: gay and bisexual men, young Black gay and bisexual men, Black females, and persons living in the Southern US Goals for gay/bi men, YGBM not being met Goals for Black women being exceeded Goals re: Southern disparity on track

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Goal 3 Progress Indicators Indicator 10: Increase percentage of youth, PWID

diagnosed with HIV who are virally suppressed to 80% From 2010 baseline 29.7% for youth From 2010 baseline 37.6% for PWID Indicator for both populations is on track as of 2012

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Goal 4: Achieving a more coordinated national response to the HIV epidemic

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Step 4.A.1: Streamline reporting requirements for federal grantees

Action item from Federal Action Plan: HHS Operating Divisions, Staff Offices develop specific targets for

streamlining reporting obligations for award recipients (OHAIDP 2016) Step 4.A.2: Coordinate data systems, use data to improve health

outcomes, monitor use of $ Action item from Federal Action Plan:

Identify models for electronic integration of housing and HIV care data systems to enhance coordination of svc. delivery, pat. navigation

Goal 4: Achieving a more coordinated national response to the HIV epidemic

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Step 4.A.4: Allocate resources for greatest impact Action item from Federal Action Plan:

HUD work with Congress to update funding formula for HOPWA as follows:

A) from being based on cumulative number of AIDS cases to being based on number of persons living with diagnosed HIV infection

B) incorporate local housing costs, poverty rates into formula

Goal 4: Achieving a more coordinated national response to the HIV epidemic

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Step 4.B.3: Enhance program accountability Action item from Federal Action Plan:

Examine funding algorithms for surveillance and prevention program FOAs to consider incorporating an incentive for award recipients who meet key data targets or other public health goals

Goal 4: Achieving a more coordinated national response to the HIV epidemic

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Major Points of the NHAS 2020 Use HIV diagnosis data instead of HIV incidence data

to monitor progress Incidence will vary due to changes in HIV testing technology

and variations in incidence estimation methods; in contrast, HIV diagnosis data is published in routine and standardized format

Incidence data is not available in all states while HIV diagnosis data is

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Major Points of the NHAS 2020 Focus on most burdened populations, including gay,

bisexual men, transgender women, Black and Latino men and women, people living in the South Concentrate funding and prioritize interventions for these

populations Address trauma, discrimination faced by these populations Expand services to reduce disparities faced by these

populations

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Major Points of the NHAS 2020 PrEP/PEP and funding for research in other promising

biomedical interventions is central to the strategy Intervention science and combination prevention New technology (ex. injectable PrEP) holds promise, needs

to be pursued

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Major Points of the NHAS 2020 Ambitious goals for linkage and retention in care

Increase % linked to care in one month to 85% from baseline 70% (73% in 2013)

Increase % retained in care to 90% from baseline 51% (54% in 2012)

Increase % virally suppressed to 80% from baseline 43% (50% in 2012)

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What this means for ASOs, CBOs, & Health Centers In order to achieve the ambitious goals for linkage and

retention, there is a major focus on improving care along the HIV care continuum

Key Q: How can ASOs, CBOs, HCs Dramatically improve linkage, retention, viral suppression? Prioritize key populations (MSM, trans women, Black and

Latino men and women?) Improve youth and PWID treatment outcomes? Reduce death rate for PLWH (for any reason)?

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ASOs/CBOs Partner with behavioral health providers to provide

wrap-around services for patients receiving MH/SU treatment (2018-20) Vocational, educational, housing, nutrition, transportation Many ASOs/CBOs have experience, cultural competency in

providing these to key populations All staff must be trained in providing HIV prevention

education, screening that is culturally sensitive to gay, bi men, trans women (i.e. not homo-/bi-/transphobic)

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ASOs/CBOs Partner with agencies like the Fortune Society or

(other example of CBO working with ex-inmates) to link formerly incarcerated to health care, supportive services, benefits

Access TA from CDC, SAMHSA to receive third party reimbursement for HIV/STI/HCV testing, behavioral health and HIV services (2016-)

CBOs, faith-based orgs. address social determinants that increase vulnerability (poverty, homelessness, education) especially among young Black MSM

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ASOs/CBOs Faith-based orgs. address HIV among gay, bi men,

transgender women ASOs, CBOs use social network strategies to reduce

HIV stigma Promote PLWH leadership in integrated prevention

and care planning

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Health Centers Test patients diagnosed w/acute STIs for HIV Lifetime HIV test to be added to UDS in 2018 for all 15-

to 65-year-old patients Provide wrap-around services for patients receiving

MH/SU treatment (2018-20) All staff must be trained in providing HIV prevention

education, screening that is culturally sensitive to gay, bi men, trans women (i.e. not homo-/bi-/transphobic)

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LGBT Education and TrainingThe National LGBT Health Education Center offers educational programs, resources, and consultation to health care organizations with the goal of

providing affirmative, high quality, cost-effective health care for lesbian, gay, bisexual, and transgender (LGBT) people.

Training and Technical Assistance

Grand Rounds On Line Learning

Webinars and Learning Modules

CE, and HEI Credit Resources and

Publications lgbthealtheducation@fenwayhealth.org www.lgbthealtheducation.org

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Health Centers HRSA 2016-2020: Increase HC’s capacity to integrate

HIV continuum into primary care Could address what Krakower et al. call the “purview

paradox,” whereby HIV specialists think that primary care clinics should be the principal venue for PrEP implementation, whereas primary care providers think PrEP is best prescribed by HIV specialists Krakower D, Ware N, Mitty J, Maloney K, Mayer K, AIDS Behav 2014

Use Health Information Technology to improve linkage to care, care coordination December 3, 2015 webinar on EHR solutions for ASOs, HCs

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Health Centers EHRs: Inclusion of sexual orientation and gender

identity in Uniform Data System, to be rolled out by HRSA starting in 2016

Should allow for better understanding and addressing disparities along HIV continuum for gay and bisexual men, transgender women, especially Black and Latino

Resources: www.doaskdotell.org www.lgbthealtheducation.org

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Health Centers Partner with agencies like the Fortune Society to link

formerly incarcerated to health care, supportive services, benefits

Access TA from CDC, SAMHSA to receive third party reimbursement for HIV/STI/HCV testing, behavioral health and HIV services (2016-)

Expand substance use services, especially regarding opioids

Implement IPV services for women, MSM

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Questions, discussion

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Acknowledgements Ryan Kruis, MSW, The Fenway Institute Adrianna Sicari, MPH, The Fenway Institute