Ryan White 2016: Innovations in HIV Care
This plenary session, featuring CDC and RWHAP grant recipients, focused on innovation in HIV care, specifically the integration of HIV prevention and care and treatment systems and interventions, and RWHAP innovative approaches to program and service delivery.
Harold Phillips, Director of the HRSA HAB Office of Training and Capacity Development, presented context for the panel by summarizing HRSA HAB priorities to operationalize NHAS 2020 and PEPFAR 3.0 such as building leadership and partnerships; integrating care/prevention; and focusing on key hard-hit populations. Examples of operationalizing these priorities include new cooperative agreements, enhanced collaborations with federal partners (e.g., HUD/HOPWA), and new data collaborative efforts.
CDC High-Impact HIV Prevention
Jonathan Mermin, Director of the CDC National Center on HIV, Viral Hepatitis, STD, and Tuberculosis Prevention, discussed the CDC’s High-Impact HIV Prevention efforts, putting these initiatives into the context of our nation being “at a better time in HIV prevention than we have ever been before, with fewer new HIV infections” and many new interventions.
Mermin highlighted select CDC high-impact prevention projects, which focus on targeting this key data point: 9 of 10 new infections are attributable to those who are undiagnosed or not in medical care. Mermin outlined several initiatives: the Care and Prevention in the United States (CAPUS) project; the Young Men Who Have Sex With Men (YMSM) and Young Transgender Persons of Color projects; and Partnerships for Care (P4C), the latter being a collaborative effort with HRSA.
Overall, CDC reports a number of positive outcomes from high-impact and other prevention work. For example, almost all states require reporting of CD4 and viral load; 87% of infected individuals know their HIV status, a figure higher than ever; new HIV diagnoses have decreased by 9%, including a 2% decrease in young black MSM following a 114% increase in the prior 5 years; and a 9% reduction in mortality.
Mermin wrapped up with looking ahead to High-Impact Prevention 2.0 (e.g., merge the goals of clinical medicine, community and public health; broaden the HIV risk-reduction toolbox of multiple interventions, including PrEP; use molecular epidemiology to, for example, prescribe in relation to viral resistance patterns and help identify and manage rapid outbreaks of HIV. Mermin concluded that the National HIV/AIDS Strategy initiatives will avert tens of thousands of new cases and save billions and that “we have turned the corner on HIV, but are far from achieving success.” See Mermin's slides.
Using Data to Identify and Improve Health Outcomes
Diana Jordan of the Virginia Department of Health talked about the department's data system integration efforts and how they are being used to improve health outcomes for individuals living with HIV and to direct public health action. Jordan noted that NIH’s Anthony Fauci had said we have many tools to end AIDS, adding that, “I believe data integration is one such important tool.”
Jordan summarized efforts to bring an integrated data system to fruition, from data collaboration across silo-focused agencies, securing of additional funding from SPNS and other sources to support development work, use of the HIV care continuum to guide efforts, and development of a set of care markers around which to frame data integration.
Jordan said that getting data into one place is a challenge, one that is being tackled through a project called Black Box, and that the state is envisioning a future for data under what they call e2Virginia, that combines parts, prevention, patient navigation, and out-of-care lists. See the slides from Jordan's talk.
Peer Navigation to Improve Retention
Kimberly Butler Willis, of Roper St. Francis Healthcare in Charleston, SC, described development of their peer navigation program, its positive impact on client health outcomes along the continuum, and the need for continued attention to gaps among young African American men attributable to stigma, fear, poor transportation, and the absence of PLWH on staff.
This peer navigation program was developed under an RWHAP Part C capacity development grant. Implementation efforts included development of new policies/procedures (e.g., hiring, supervision, being responsive to clients who may have limited to no interest in such services). The program has seen viral suppression increase by 18%, along with improved retention in care and less loss to care. Patients also report positive interactions with peers, including an increased willingness to share information (e.g., one patient confided having difficulty swallowing large pills, which was addressed, and that person’s viral suppression improved within 3 months). Some patients also felt more supported and empowered to disclose their HIV status to family and friends, and even felt less isolated and more comfortable coming into the clinic, knowing that they were not alone in being infected and living well with HIV.
Among the lessons learned: When recruiting peers, use a formal process; don’t expect an instant program as it will take time and will work best if done collaboratively within the clinic; make sure peers are included and visible in the clinic team; use team building; provide mental health services for your peer navigators to help them manage the emotional toll peers will face in their new jobs; and start low and go slow to adjust to what is not working.
Two L.A. County Innovations
Mario Perez from the Los Angeles County Division of HIV and STD Programs wrapped up the panel by discussing two initiatives developed for eventual rollout in L.A. County, a vast area with a population greater than 42 states and one of the most racially and ethnically diverse regions of the country.
The first program is a fee-for-service, pay-for-performance reimbursement model under which providers can get 30%+ higher payment rate if a set of performance measures are met. The additional rate is based upon achievement of a range of supplemental measures (e.g., STD and infectious disease screens).
The second project, medical care coordination, is an integrated approach that combines medical and psychosocial support services, delivered by a clinic-based, multidisciplinary team.
Over the evaluation period, about half of clients had a moderate acuity index with about a third having high acuity. More service hours were, in turn, devoted to these clients. Over 12 months, viral suppression improved by 97% while retention in care improved by 62%. Looking ahead, Perez and colleagues hope to expand into non-RWHAP sites and to scale up the project countywide. See Perez's slides.