Moving Forward: Continuing Implementation of the National HIV/AIDS Strategy

1. Moving Forward:Continuing Implementation of the National HIV/AIDS Strategy

2. Strategy Overview Goals • Reduce the number of people who become infected with HIV. • Increase access to care and optimizing health outcomes for people living with HIV. • Reduce HIV-related health disparities. Facets of the Strategy • Small number of action steps. • 5-year targets. • Emphasis on evidence-based approaches. • Provides a roadmap for all public and private stakeholders responding to the domestic epidemic. • Focuses on improving coordination and efficiency across and within Federal, State, local and tribal governments. • Serves as a catalyst for all levels of government and stakeholders to develop their own implementation plans for achieving their goals.

3. Implementation • Reinvigorated Response to Domestic HIV Epidemic • Strategy has become the center of virtually all domestic HIV policy discussions • Support for HIV Funding and Strategic New Investments • President Obama’s FY 2013 budget provides $766 million increase in HIV prevention and care • Increased funding for HIV prevention at CDC and increased investment in ADAPs • ECHPP/Twelve Cities Project • New MSM programs • Expanded surveillance programs • True Government Wide Effort and Collaboration • Strong leadership from HHS, with active engagement of HUD, DOJ, DOL, SSA, and VA. • Doing the Hard Stuff at the Federal level • CDC Funding Announcement for Health Departments • HUD developing legislative plan for HOPWA funding formula • Refocusing Minority HIV/AIDS Initiative • Reducing data collection and reporting requirements • Developing parsimonious, harmonious, meaningful outcomes metrics

4. New HIV Infections in the U.S. • Estimated 50,000 new HIV infections annually in US • MSM 64% of new infections; 48% increase young black MSM • Black women most impacted among all women • Latinos disproportionately impacted compared to whites (Prejean et al., 20011)

5. Aligning Resources with the Epidemic

6. Preventing HIV Infection Using a Combination of Effective, Evidence-based Approaches Tools that work in preventing HIV • Condom availability • Comprehensive drug treatment • HIV testing (awareness of status) • Circumcision (limited effectiveness in US) • Antiretroviral therapy for diagnosed positives • Antiretroviral therapy for high risk negatives • Serosorting (among positives) • Testing pregnant women Best combination of HIV prevention approaches that will have a population-level impact for specific populations is unknown

7. Modeling Test and Treat: Annual Number of New HIV Infections Sorensen, PLoSOne, 2012

8. Ongoing Challenges to Implementing the National HIV/AIDS Strategy • Fiscal • Reductions and shifts in funding at the State and Local level • Cost for biomedical interventions • Funding for HIV prevention • Coordination among agencies • Metrics • FOAs • Traditional siloed approach • Coordination among Federal, State, and local level • Communication • Alignment • Competition • Ability of organizations to adapt to a changing environment • Political will to place funds where the epidemic is • Educating providers about HIV prevention and care • # of HIV care providers decreasing • Reluctance to care for HIV+ patients • Reimbursement

9. We Must Do Better MMWR, December 2011

11. AIDS Mortality by Race • AIDS deaths have declined least in the ART era • Among black and Latino MSM relative to white MSM (Blair et al., 2002; Hall et al., 2007) • Among black women compared to white men (44% vs. 79%, respectively; CDC 2009) • Among Latinos compared to blacks or whites (Cunningham et al., 2010) • (Levine, 2010)

12. Time to AIDS-Related Events or Death AIDS- Silverberg, et. al.,J Gen Intern Med. 2009;24(9):1065-72.

13. Structural Change: The Affordable Care Act • Meaningful Change Now • 54 million additional Americans are receiving preventive services • Hundreds of persons living with HIV now covered under Pre-existing Condition Insurance Plans • Insurers cannot rescind coverage except in cases of fraud or intentional misrepresentation • 2014 • No denial of coverage for pre-existing conditions • Expands Medicaid eligibility to 133% of Federal poverty level

14. Implementation at the Ground Level • Are resources being allocated to the populations at greatest risk? • Are these populations being reached? • Are the interventions evidence-based, scaleable, sustainable, and effective? • Do we have and use metrics to measure program success? • How long do we take to declare success or failure of a program? • Are Federal, State, and local efforts to change policies, laws, and regulations supported and aligned?

15. NHAS Implementation Dialogues • Incorporating Prevention and Care Research Into HIV Programs • Birmingham, AL • Building Capacity within the HIV Workforce so that it Delivers What We Need Today and Tomorrow • Seattle, Washington • Sustaining the Community-Based Response to HIV • Philadelphia, PA • Fostering Collaboration Between all Public and Private Stakeholders at the State and Local Level • Baton Rogue, Louisiana • Maximizing Impact in Low-Prevalence Jurisdictions • De Moines, Iowa

16. Selected Quotes: Implementation Dialogues “…Studies have shown us is that anywhere from 25-40 percent of people who come to one or two visits fall out of care in that first year… how do we, early on, keep someone coming, develop self-care skills, behaviors, system-navigation that carry forward in the long term? -Dr. Michael Mugavero (University of Alabama, Birmingham) “…I think that one of the things that we learned related to primary prevention is that we have to determine scalable and effective strategies strategies for preventing new infections in jurisdictions. If you are not talking about what a jurisdiction can do to scale with limited resources, then I think we’re missing the boat. -Tiffany West, (District of Columbia Department of Health) “Oftentimes, case managers are either nurses or social workers. The other services are those spokes on a wheel. We have substance abuse treatment, primary care, medication management, and all of those other services. However, in the center of the wheel or the hub is the social worker, the nurse, the case manager that helps the client get access to all of those services. We need to not only expand the primary care workforce, but think about other providers who work with people with HIV.” -Richard Aleshire, Washington State Department of Health

17. Ongoing Implementation Needs • Continued collaboration among Federal, State, local government and private partners • Flexibility at local level regarding implementation while maintaining alignment with NHAS principles • Technical assistance to prepare HIV workforce for ongoing changes in environment • Support for shift from process-oriented to outcome-oriented metrics

18. Measuring HIV-related Outcomes • Parsimony • Harmony • Achievable • Sustainable • Usable

19. AIDS 2012 • Target date for ONAP Implementation Update • HHS Implementation Progress Report release

20. “The success of the Strategy doesn’t lie in the hands of the Federal government alone. Success will require the commitment of governments at all levels, businesses, faith communities, philanthropy, the scientific and medical communities, educational institutions, people living with HIV, and others.”

21. Grant Nash Colfax, MD Director Office of National AIDS Policy The White House Email: Grant_N_Colfax@who.eop.gov