Download HIV Care Continuum and Ryan White HIV/AIDS

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
100%
90%
80%
82%
82.05%
79.6%
74.4%
70%
60%
81.30%
75.10%
76.39%
67.8%
74.50%
All RSR clients
52.9%
50%
MSM
40%
Black MSM
30%
Young (13-24) MSM
IDU
20%
10%
0%
Retained in care
Virally suppressed
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)
MSM and IDU Retained in Care
and Virally Suppressed
100%
90%
80%
82%
82.05%
79.6%
74.4%
70%
60%
81.30%
75.10%
76.39%
67.8%
74.50%
All RSR clients
52.9%
50%
MSM
40%
Black MSM
30%
Young (13-24) MSM
20%
IDU
10%
0%
Retained in care
Virally suppressed
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
100%
90%
80%
70%
87.8%
86.10%
83.5%
83.3%
82.0%
80.9%
77.5%
78.8%
76.8%
70.8%
69.8%
73.2%
62.3%
60%
50.0%
50%
age 13-18
age 19-24
White non-Hispanic
Black non-Hispanic
Hispanic
40%
Medicaid
30%
20%
All females
10%
0%
Retention in Care
Viral Load Suppression
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 communitybased 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 communitybased, 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
Attachment 9
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:
Service Category Priority Number:
1. Objectives:
List quantifiable time-limited objectives
related to the service priorities listed above
Total Service Category Allocation:
Part A Core Medical ☐
2. Service Unit
Definition:
Define the service unit to
be provided
Part A Support ☐
3. Quantity
3b) Total
3a) Number
Number of
service units
of people to
be served
to be
provided
MAI Core Medical ☐
MAI Support ☐
5. Funds:
Provide the approximate amount of funds
to be used to provide this service.
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 ☐
Sample Part A Implementation
Plan
SAMPLE FORM
Ryan White Part A Implementation Plan: Service Category
Grantee Name:
Big City EMA
Fiscal Year:
2013
Page
Service Category Name: Medical Transportation Services
Part A Core Medical ☐
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
management service providers will have bus passes available
for distribution to clients requiring assistance with
transportation to medical appointments
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
of
15
Pages
Total Service Category Allocation: $35,000
Service Category Priority Number : 9
a: By March 1, 2014, 100% of RW funded medical case
7
Part A Support ☒
3. Quantity
3b) Total
3a) Number
Number of
of people to
service
be served
units to be
provided
MAI Core Medical ☐ MAI
5. Funds:
Provide the approximate amount of
funds to be used to provide this
service.
1-day pass
7-day pass
30-day pass
50
240
150
70
440
600
$280
$3,520
$16,200
Total: $20,000
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
Attachment 9
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
I. Diagnosed
Goal
HIV Positivity*
Late HIV Diagnosis*
Baseline: Numerator/Dominator, %
II. Linked to Care
Target: Numerator/Dominator, %
Antiretroviral Therapy (ART) Among Persons in HIV
Medical Care*
Prescription of HIV Antiretroviral Therapy **
Baseline: Numerator/Dominator, %
V. Virally Suppressed
Target: Numerator/Dominator, %
Retention in HIV Medical Care*
HIV Medical Visit Frequency**
Baseline: Numerator/Dominator, %
IV. Prescribed ART
Target: Numerator/Dominator, %
Linkage to HIV Medical Care*
Baseline: Numerator/Dominator, %
III. Retained in Care
Service Category (One or
more may apply)
Outcome
Target: Numerator/Dominator, %
Viral Load Suppression Among Persons in HIV Medical
Care*
HIV Viral Load Suppression**
Baseline: Numerator/Dominator, %
Target: Numerator/Dominator, %
* 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
Sample Part A Implementation
Plan – HIV Care Continuum
Attachment 9
SAMPLE FORM
Ryan White Part A Implementation Plan: HIV Care Continuum Table
Grantee Name:
Big City EMA
Stages of the HIV Care
Continuum
I. Diagnosed
II. Linked to Care
Fiscal Year:
HIV Care Continuum
Goal
Increase in the percentage of
clients who are aware of their
HIV Status
Increase in the percentage of
clients linked to care
2015
Outcome
Service Category (One
or more may apply)
HIV Positivity*
Late HIV Diagnosis*
Early Intervention Services
Baseline: Numerator/Dominator, %
7/10
70%
67/100
Increase in the percentage of
clients retained in care
67%
58/100
Increase in the percentage of
clients with access to prescribed
HIV/AIDS medications consistent
with PHS Treatment Guidelines
Increase in the percentage of
clients with a viral load of <200
Target: Numerator/Dominator, %
87/100
87%
58%
Outpatient Medical Care
Medical Case Management
Medical Transportation
Target: Numerator/Dominator, %
72/100
72%
Antiretroviral Therapy (ART) Among Persons in HIV Medical Care*
Prescription of HIV Antiretroviral Therapy **
Baseline: Numerator/Dominator, %
76/100
V. Virally Suppressed
Outpatient Medical Care
Medical Case Management
Medical Transportation
Retention in HIV Medical Care*
HIV Medical Visit Frequency**
Baseline: Numerator/Dominator, %
IV. Prescribed ART
9/10 90%
Linkage to HIV Medical Care*
Baseline: Numerator/Dominator, %
III. Retained in Care
Target: Numerator/Dominator, %
76%
Target: Numerator/Dominator, %
92/100 92%
Viral Load Suppression Among Persons in HIV Medical Care*
HIV Viral Load Suppression**
Baseline%:
45/100
45%
Outpatient Medical Care
Medical Case Management
Medical Transportation
Target: Numerator/Dominator, %
80/100
80%
* 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
Outpatient Medical Care
Medical Case Management
Medical Transportation
Treatment Adherence
Counseling
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; evidencebased 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) colocated 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)
Progress Along the Continuum –
Select Examples
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
Progress Along the Continuum –
Select Examples
•
•
•
•
•
Massachusetts and Colorado – Expanded coverage options and increased cost saving
through the 340B rebate program and cost avoidance by linking and retaining more HIVpositive 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 copayments. 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-toreach 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
o
o
o
appropriate structures in place
experience in data-driven, community-based needs assessment
responsive procurement of a variety of direct medical and supportive services
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