1. Health Departments and HIV Screening Institute of Medicine Workshop 1: Screening and Access to Care April 15, 2010 Natalie Cramer, Associate Director, Prevention

2. Presentation Overview Role of Public Health Public Health and HIV Programs Public Health and HIV Testing Policies Impacting Health Departments Challenges and Barriers for HIV Testing in Health Departments Recommendations

3. Public Health and HIV Prevention Programs Since 1988, CDC has provided HIV prevention resources to 65 state, local and territorial health departments to implement comprehensive prevention programs. In FY2007 these 65 jurisdictions received approximately $581 million to conduct HIV prevention programming.

4. Domestic HIV Prevention Funding

5. Health Departments & HIV Services Services and Activities –HIV testing –Behavioral interventions –Capacity building –Program evaluation –Quality assurance –Surveillance Response –Develop and enforce policy –Provide direct services –Partner with external entities Funding Coordination CBA / TA Evaluation –Engage communities

6. Health Departments & HIV Testing Activities In FY2007 Health Department spending on Counseling and Testing was $152.1 million Targeted HIV counseling, testing, referral Routine HIV screening

7. Coordination of HIV Testing Services Direct provision Interfacing with health department funded institutions Interfacing with other entities (not financially supported by health departments) –Local health departments –Hospitals and other health care settings –Correctional institutions –Substance abuse treatment centers –Other federally funded institutions (ex. Veterans Administration)

8. Health Departments Funding for HIV Testing Cooperative Agreements with CDC CDC Funding Covers: –Development and maintenance of capacity and infrastructure –support essential complementary services (e.g. partner services, linkages to medical care, treatment and prevention services) –activities that recruit individuals into testing (e.g. social marketing, public information)

9. Federal Policies Impacting Health Departments CDC – FOA, Cooperative Agreements, Guidance, Recommendations HRSA – RW Part C – early intervention, Part A, plans, national testing goal SAMHSA – block grants CMS – Medicare, Medicaid, CLIA FDA – Testing devices, guidelines OCR - HIPAA

10. States Implementing Components of CDC’s 2006 Revised HIV Testing Recommendations *All states implement targeted HIVCTR The National HIV Prevention Inventory: The State of HIV Prevention Across the U.S., A Report by NASTAD and the Kaiser Family Foundation (KFF), July 2009

11. States Implementing Components of CDC’s 2006 Routine Testing Recommendations Since 2006, states continue to change laws and regulations –Eleven states have removed written informed consent requirements (AZ, CA, IA, IL, IN, LA, ME, MD, NH, NM, NC) –CT, HI, MA and MT have removed separate written informed consent –Eight states have proposed legislation to remove written informed consent (MA, MI, NE, NY, PA, RI, TX, WI)

12. Testing of Pregnant Women and Newborns States making changes to their laws and regulations to be in line with 2006 Recommendations –In last two years: CO, DE, MD, TX, VA, VT 27 states have opt-out testing of pregnant women 25 states have opt-in 11 states have newborn testing

13. Implementation of Opt-Out Testing in Health Care Settings by Health Departments after the ETI (as of February 2008 )  80% increase Number of Health Departments The National HIV Prevention Inventory: The State of HIV Prevention the U.S., A Report by NASTAD and the Kaiser Family Foundation (KFF), July 2009.

14. Insurance Policies Impacting Health Departments Medicare Medicaid Private insurers

15. Challenges for Health Departments – Federal Policies Restrictions: –Funding Opportunity Announcements –Cooperative Agreements Lack of coordination between federal funding agencies

16. Challenges to Health Department – State Policies Limit of scope/contradictory to federal recommendations Budgets and workforce Differing philosophies among state program partners Emergency preparedness

17. Challenges to Health Departments – Local Institution Policies Expectation of collaboration without authority or oversight Institutional resistance Philosophies and policies may be incompatible (e.g. data collection and sharing, counseling) Resistance if health department cannot ensure continued funding

18. Challenges to Health Departments – Insurance Policies Lack of resources to meaningfully scale up services Advances are often limited –Medicare policy –Medicaid coverage Limited capacity to bill insurance companies for testing

19. Other Challenges Current systems of M&E rely on limited measures ADAP waiting lists Need for adequate and sustained funding for HIV testing Policy changes alone = increased testing?

20. Summary Recommendations Resolve reimbursement issues Scale up/maintain funding Improve federal coordination Please contact Natalie Cramer at ncramer@NASTAD.org with questions.ncramer@NASTAD.org