HIV Care in the Washington metropolitan area: A mosaic of clinical care models David Wheeler, MD Medical Director, Inova Juniper Program Springfield, VA

HIV Care in many high-prevalence cities worldwide is provided by one or two centrally coordinated entities Ministry of Health and/or Government-sponsored health insurance (Social Security)

Centrally-funded, dedicated HIV services make up only a fraction of the HIV care available in most American cities The result is a “mosaic” of concurrently administered and occasionally coordinated systems of care

I offer the Washington, DC metropolitan area as an example

Sources of data for this presentation Washington DC EMA Comprehensive HIV Care Plan Washington DC Health Department (HAHSTA) Virginia State Health Department – Northern Virginia Regional Commission Maryland State Health Department – Montgomery County Health Department – Prince Georges County Health Department Direct queries to non-federally funded clinicians – Self reports of patient volume, based on data bases or best estimates

Geographic Makeup of Washington, D.C. EMA The Washington, D.C. EMA consists of: The District of Columbia Northern and Northwestern Virginia (17 counties/areas) Suburban Maryland (five counties) West Virginia (two counties) Overall prevalence: 0.6% 6

Scale of the HIV epidemic 34,000 reported to be infected with HIV in the expanded metropolitan area – 17,200 in Washington DC – 9,200 in suburban Maryland – 7,200 in suburban Virginia – 330 in corresponding West Virginia 05/2010Data as of Dec 20087

Maryland Infectious Disease and Environmental Health Administration June 11, HIV Statistics Adult/Adolescent Cases Washington MSA (Maryland) Reported HIV Diagnoses during 2010 Living HIV Cases on 12/31/2010 Washington MSA (MD) 5119,257 Calvert 5 99 Charles Frederick Montgomery 1443,051 Prince George’s 3245,534 Using data as reported through 12/31/2011

Warren Loudoun Clarke Fauquier Culpeper Spotsylvania King George Stafford Prince William FairfaxAlexandria Fairfax City Arlington Falls Church Manassas Manassas Park City Fredericksburg

10 Prevalence of HIV in the District of Columbia % 1.9% 2.7% 2.1% 2.6% 3.1% 2.6% Prevalence 0-1.4% 1.5%-2.4% 2.5%-3.4% Proportion of persons living with HIV, by Ward, 2010 For 6.3% of cases, ward information was not available

Washington, DC and the inner suburbs # of individuals living with HIV

Sources of funding of HIV care Private insurance Medicaid (medical care for poor people) Medicare (medical care for elderly and disabled) Ryan White Care Act (emergency funding for those without coverage) – Part A, B, C, D, Minority AIDS Initiative Other sources (military, veterans, clinical trials) 05/2010Data as of Dec

Standards of HIV Care National HIV/AIDS Strategy for the United States (July 2010) Department of Health and Human Services HIV Treatment Guidelines Committees Specialty Society Guidelines (HIVMA, AAHIVM) Ryan White Standards of Care – Monitoring of RW funded sites 05/2010Data as of Dec

Ryan White funded sites in DC and numbers of patients served (2011) Clincal facility providing primary HIV medical care# of patients AIDS Healthcare Foundation31 Andromeda Transcultural Center112 Carl Vogel Center182 Children’s National Medical Center367 Christ House28 Family and Medical Counseling818 Howard University Medical Center430 La Clinica del Pueblo201 Regional Addiction Prevention109 Unity Health Care1735 Whitman Walker Clinic2449 Washington Hospital Center580 DC Health Department, 2011 (RW Part C)

Ryan White funded sites in inner suburbs and numbers of patients served (2011) Clinical facility providing primary HIV medical care# of patients Greater Baden Medical Services (MD)312 Montgomery County Health Department (MD)265 Prince Georges County Health Department (MD)723 Alexandria City Health Department (VA)188 Inova Juniper Program (VA)1024 Loudon County Health Department (VA)47 Total individuals in HIV Care in 2011 with Ryan White funding9,601 DC Health Department

How is this care delivered? What is the typical model of delivering HIV care in the Washington DC area? 05/2010Data as of Dec

Children’s National Medical Center (365 in RW funded care) 05/2010Data as of Dec

Whitman Walker Clinic (2449 in RW funded care) Originally a gay-lesbian health center One of the first organizations to address HIV epidemic in DC HIV dedicated clinic for many years – Consistently the largest HIV care facility Now a primary care system, with HIV expertise – All clinicians do HIV care – Second site in high prevalence neighborhood 05/2010Data as of Dec

Unity Health Care (1735 in RW funded care) Multi-site community health care system Focus on the poor, the under-insured, and underserved HIV specialists who travel between health centers in high prevalence neighborhoods 05/2010Data as of Dec

Family and Medical Counseling (818 in RW funded care) Community health center in the highest prevalence DC neighborhood Special focus on HIV – Staff physicians with HIV expertise 05/2010Data as of Dec

Washington Hospital Center (580 in RW funded care) Large community hospital HIV program directed by Infectious Diseases physicians 05/2010Data as of Dec

Howard University (325)/ United Medical Center (121) University Medical Center – Infectious Diseases clinic – Early intervention clinic Community Hospital – Sub-contract from Howard – Located in high prevalence neighborhood 05/2010Data as of Dec

Locations of large DC programs funded by Ryan White Whitman Walker Clinic – Elizabeth Taylor Center – Max Robinson Center Family and Medical Counseling Howard University – United Medical Center Washington Hospital Center 05/2010Data as of Dec

Unity Health Centers HIV care provided in: – 4 clinics in SE – 5 clinics in NE – 1 clinic in SW – 1 clinic in NW 05/2010 DC Health Department data 24

Prince Georges County: Ryan White funded sites PG County Health – 723 patients – 2 sites – Dedicated HIV clinics Greater Baden Medical Services – 312 patients – Federally qualified health center – 3 sites offer HIV care

Montgomery County, Ryan White funded sites Montgomery County Health Department – 265 patients – Central HIV dedicated clinic – Aggressive program to pay health insurance premiums for poor people with HIV – These individuals are seen in the private setting

Northern Virginia, Ryan White funded sites Inova Juniper Program – 1024 patients – HIV dedicated clinic(s) – Hospital administered – Community located Alexandria City Health Department – 188 patients – Clinic co-managed with community health center

The treatment “gap” 32,300 infected in DC and inner counties – 9,600 in Ryan White funded care 17,000 living with HIV in DC – 7,000 in Ryan White funded care 5,500 with HIV in PG County – 1,030 in RW funded care 3,000 with HIV in Montgomery County – 265 in RW funded care 6,800 with HIV in inner counties of NoVa – 1,250 in RW funded care 05/2010Data as of Dec

Where do the other patients receive their care? Or ARE they in care? 05/2010Data as of Dec

Ryan White funded sites also see patients who have another payer source Juniper Program (Virginia) – 1300 patients in primary medical HIV care – 1024 funded by Ryan White AIDS Healthcare Foundation (DC) – 400 patients in care (report from clinical data base) – 31 in care through Ryan White 05/2010Data as of Dec

Clinical care systems with regional coverage (and excellent data bases) Kaiser* – Virginia (400 patients in care) – Maryland/DC (1500 patients in care) Veterans Administration Medical Center* – 1,000 patients in care Military Medical Center – Numbers unavailable 05/2010 *Based on verbal report of clinical data bases 31

University Medical Centers Georgetown University Medical Center George Washington University Medical Center – Dedicated HIV clinics run by Infectious Diseases divisions – About 1800 total patients in care, based on best estimates 05/2010Data as of Dec

Private practices Five large private practices in inner Northwest DC – Infectious Diseases – Internal Medicine – Many focus on gay men’s health – About 2500 patients in care Two ID practices in NE – One private practice – One hospital based – About 600 patients in care 05/2010 Self reported estimates 33

Prince Georges County Private practices – 3 solo private practitioners – Approximately 700 patients in care Dimensions Health Care – Hospital affiliated, HIV/ID clinic – Previously RW funded – About 100 patients in care 05/2010Data as of Dec

Montgomery County Four group ID practices – Several specifically partner with health department to receive patient with newly obtained health care coverage – About 1500 patients in care 05/2010Data as of Dec

Northern Virginia Four group ID practices – About 1450 patients in care Six solo ID practices – About 600 patients in care 05/2010Data as of Dec

Re-assessment of treatment gap in DC and inner suburbs Estimated number living with HIV Reported number in Ryan White funded care Estimated number receiving care outside of the Ryan White system 32,300 9,600 12,500 – Kaiser, VA: 2,900 – DC: 4,900* – PG, Montgomery: 2,300* – Northern Va: 2,400* 05/2010 *Includes self-reported estimates 37

Tracking and monitoring HIV care in the Washington, DC area Ryan White cross-part collaborative – Data base integration – Quality assurance indicators and activities – Only involves Ryan White funded sites DC cohort – Prospective observational cohort of DC-based clinics and academic centers (RW and non-RW) – NIH funded AIDS Education and Training (AETC) funding – Roundtable meetings – Encourage collaboration among HIV treating clinicians 05/2010Data as of Dec

Summary A wide range of care systems are involved in HIV care in the Washington, DC area Those that are funded by the Ryan White Care Act are closely tracked, monitored and evaluated At least as many HIV infected individuals are receiving their care outside of the Ryan White funded network 05/2010Data as of Dec

Current models of HIV care include: Dedicated, University based HIV clinics – Georgetown, GW, Howard Community hospital based HIV clinics – Washington Hospital Center, Providence, United Medical Center Community hospital administered but community located, HIV dedicated clinics – Inova Juniper Program 05/2010Data as of Dec

Current models of HIV care include: Traditional HIV-dedicated clinic, moving into primary care – Whitman Walker clinic Traditional community heath center, with a specific emphasis on HIV care – Family and Medical Counseling Clinics that target specific populations – La Clinica del Pueblo (Latin community) – Regional Addiction Prevention (IDU) 05/2010Data as of Dec

Current models of HIV care include: Multi-site community health centers (which provide all primary care services), in which HIV specialists travel to the patient – Unity, Greater Baden Medical Services Multi-site, integrated health systems, (which provide all primary care services) in which the patient travels to the HIV specialist – Kaiser, VA, military 05/2010Data as of Dec

Current models of HIV care include: County health departments with centralized, HIV-dedicated clinics – Prince Georges County County health departments with an aggressive program of purchasing access to health insurance for clients(and referring to the private setting) – Montgomery County 05/2010Data as of Dec

Current models of HIV care include: Private practitioners – Serving insured, gay men in NW DC – Serving insured patients in high prevalence, low income neighborhoods NE DC, Prince Georges County – Suburban group and solo ID practices Montgomery, Prince Georges, Northern Virginia 05/2010Data as of Dec

Mosaic of care models Working in parallel Address needs of various communities Only a fraction is centrally monitored There may be a duplication of effort Difficult to respond as a metropolitan area 05/2010Data as of Dec

Future directions Health care reform in the United States may contribute to a change in the way HIV care is funded in the DC area This may change the way in which HIV care is delivered Some of the models of care in the DC metro area may be more successful in providing high quality HIV and related primary care than others 05/2010Data as of Dec

Tracking and monitoring A more comprehensive system of tracking and monitoring of HIV care across the metropolitan area may help to address: – Availability of HIV care within neighborhoods in the metro area – Quality of care delivered in various settings – Capacity building and mentoring between experienced and novice HIV clinicians – Assessing the best HIV care models for the future 05/2010Data as of Dec

Thank you. 05/2010Data as of Dec