1. Ryan White HIV/AIDS Program Update
Laura W. Cheever, MD, ScM
Associate Administrator
HIV/AIDS Bureau (HAB)
Health Resources and Services Administration (HRSA)
San Antonio, Texas: August 21-23, 2017

2. Secretary Price’s Principles and Priorities
Patient-Centered Health Care System: 6 Principles
Affordability
Accessibility
Quality
Choices
Innovation
Responsiveness
Clinical Priorities
Severe mental illness
Opioid epidemic
Childhood obesity
Talk about the importance of remembering who we serve, getting input from the community

3. HIV/AIDS Bureau Vision and Mission
Optimal HIV/AIDS care and treatment for all.
Mission
Provide leadership and resources to assure access to and retention in high quality, integrated care, and treatment services for vulnerable people living with HIV/AIDS and their families.

4. Program Legislation
The Ryan White HIV/AIDS Treatment Extension Act is a legislative program:
Public Health Law under Title XXVI
Enacted into law in 1990
Reauthorized 1996, 2000, 2006, and 2009
The authorization of appropriation for the Ryan White HIV/AIDS Program (RWHAP) expired on September 30, The Program will not sunset and can continue to operate through Congressional appropriations
Mention reauthorization in the FY 18 President’s budget

5. HIV/AIDS Bureau Priorities
Leadership
Partnerships
Integration
Data Utilization
National Goals to End the HIV Epidemic/President’s Emergency Plan For AIDS Relief (PEPFAR) 3.0
Operations
In pursuit of the mission and vision, HAB has identified 5 priorities to guide the work of the Bureau.
In developing these priorities, HAB recognized that making progress in each of these areas benefits the entirety of the RWHAP.
Recipients may struggle with building and maintain partnerships, or better integrating programs to provide seamless services to their clients.
Data utilization is essential to program management. The client-level data demonstrate progress in achieving positive health outcomes at all levels of the RWHAP. Improving utilization of data throughout the program, facilitates recipients and subrecipients identification of successful interventions promoting improved rates of viral suppression as well as the identification of disparities where more or new work needs to be done.

6. Ryan White HIV/AIDS Program Appropriations History FY 1991-FY 2017

7. Ryan White HIV/AIDS Program FY 2017 Full-Year Appropriation- $2,318,781
Dollars in thousands

8. Ryan White HIV/AIDS Program
People Living with HIV Served by the Program

9. Clients Served by the Ryan White HIV/AIDS Program by Race/Ethnicity, 2015—United States and 3 Territories*
Source: HRSA. Ryan White HIV/AIDS Program Services Report (RSR) Does not include AIDS Drug Assistance Program data
Note: HAB added this slide because these populations have the greatest health disparities and are served by the program
*Puerto Rico, Guam, U.S. Virgin Islands
**Hispanics/Latinos can be of any race
Source: HRSA. Ryan White HIV/AIDS Program Services Report (RSR) Does not include AIDS Drug Assistance Program data.

10. Clients Served by the Ryan White HIV/AIDS Program by Poverty Level, 2015—United States and 3 Territoriesa
In 2015, 65.4% of the 510,218 clients with income information were living at or below 100% of the federal poverty level (FPL).
The three territories include Guam, Puerto Rico, and the U.S. Virgin Islands.
FPL, federal poverty level.
a Guam, Puerto Rico, and the U.S. Virgin Islands.
Source: HRSA. Ryan White HIV/AIDS Program Services Report (RSR) Does not include AIDS Drug Assistance Program data.

11. Clients Served by the Ryan White HIV/AIDS Program by Age Group, 2010 and 2015—United States and 3 Territoriesa
The RWHAP client population is aging. Here we can see clients served by the Ryan White HIV/AIDS Program by age group – in 2011 and Notably, clients aged 55 and older accounted for 27.5% of all clients, which is an increase from 18.1% of clients in 2011.
aGuam, Puerto Rico, and the U.S. Virgin Islands.
Source: HRSA. Ryan White HIV/AIDS Program Services Report (RSR) Does not include AIDS Drug Assistance Program data.

12. Services Provided by RWHAP-Funded and Non-RWHAP-Funded Outpatient Facilities: Medical Monitoring Project (MMP)
Treatment alone is not sufficient to meet the needs of PLWH. And the RWHAP provides more than just treatment for PLWH.
The Medical Monitoring Project compares PLWH who receive their care from RWHAP providers and those PLWH who do not receive RWHAP care.
Access to HIV treatment is seldom the only service PLWH need to achieve viral suppression. There are often co-morbid conditions that need to be addressed to ensure the RWHAP client is able to access the care and treatment in the first place and then to stay in care. The RWHAP provides 13 core medical services and 17 support services that combine to help create that comprehensive system of care. Different RWHAP clients have different needs, the RWHAP can address many needs of PLWH.
Here is a comparison of RWHAP providers/facilities (DARK GREEN) and non-RWHAP funded providers/facilities (LIGHT GREEN). This chart shows some of the services provided by the RWHAP. Case management and adherence counseling are two very important services provided by many RWHAP funded facilities. These services are often not covered by other payers, but are essential in ensuring PLWH receive quality HIV care and treatment. Risk reduction counseling helps PLWH understand how they can improve their health and well-being as well as reduce risk of transmission to others.
Source: Weiser J, Beer L, Frazier EL, Patel R, Dempsey A, Hauck H, Skarbinski J. Service delivery and patient outcomes in Ryan White HIV/AIDS Program-funded and -nonfunded health care facilities in the Unites States. JAMA Intern Med 2015:4095.

13. Health Outcomes Data Guide Program and Innovation
Using Client-Level Data to Identify Opportunities for Improving Health Outcomes for PLWH

14. Continuum of Care Among People Diagnosed* with HIV in the United States**
Denominator
In 2015, the RWHAP served just over 533,000 clients, 97% of whom were living with HIV. Our client population accounts for more than half of all people living with diagnosed HIV infection in the US, according to HIV Surveillance data.
*Denominator is 615,836 persons diagnosed with HIV by the end of 2012 and alive through 2013.
**Data from 33 jurisdictions that reported complete CD4 and viral load data. Data from these 33 jurisdictions represent 69.5% of all persons aged ≥13 years living with diagnosed HIV infection at year-end 2013
Source: Centers for Disease Control and Prevention. Monitoring selected national HIV prevention and care objectives by using HIV surveillance data—United States and 6 dependent areas—2014. HIV Surveillance Supplemental Report 2016;21 (No. 4)

15. Viral Suppression among Clients Served by the Ryan White HIV/AIDS Program 2010–2015—United States and 3 Territories a
The Centers for Disease Control and Prevention estimates that in the U.S., 54.7% of people diagnosed with HIV are virally suppressed.
(Source: Centers for Disease Control and Prevention. Monitoring selected national HIV prevention and care objectives by using HIV surveillance data—United States and 6 dependent areas—2014. HIV Surveillance Supplemental)
First, we can take a look at the proportion of clients with viral suppression from 2010 to Here we can see that overall, viral suppression has increased steadily from 69.5% in 2010 to 83.4% in 2015.
The Centers for Disease Control and Prevention estimates that in the United States, 54.7% of people diagnosed with HIV are virally suppressed.
Viral suppression outcomes lower among:
Younger age groups (13–24 years)
Specific minority populations
Clients with unstable housing
Viral suppression: ≥1 OAMC visit during the calendar year and ≥1 viral load reported, with the last viral load result <200 copies/mL.
a Guam, Puerto Rico, and the U.S. Virgin Islands. a
Source: HRSA. Ryan White HIV/AIDS Program Services Report (RSR) Does not include AIDS Drug Assistance Program data. .

16. Viral Suppression among Clients Served by the Ryan White HIV/AIDS Program, by State, 2010–2015—United States and 2 Territoriesa
83.4%
IN 2015
VIRALLY SUPPRESSED
69.5%
Among clients served by the RWHAP, viral suppression has increased steadily over the past six years, from 69.5 in 2010 to 83.4% in This slide shows the variation in viral suppression by state in 2010 and in 2015, with darker red indicating lower rates of viral suppression – so the lighter the better.
Each year, we can see quite a bit of variation by state; however, we can also note from these slides the great progress that has been made from 2010 to 2015 – across all states.
IN 2010
VIRALLY SUPPRESSED
Viral suppression: ≥1 OAMC visit during the calendar year and ≥1 viral load reported, with the last viral load result <200 copies/mL. a Puerto Rico and the U.S. Virgin Islands. Due to low numbers, data for Guam are not presented.
Source: HRSA. Ryan White HIV/AIDS Program Services Report (RSR) Does not include AIDS Drug Assistance Program data.

17. Viral Suppression among Key Populations Served by the Ryan White HIV/AIDS Program, 2010–2015—United States and 3 Territoriesa
RWHAP overall, 2015 (83.4%)
RWHAP overall, 2010 (69.5%)
Improvements but slowing down, need to keep pushing…
SLIDE 8 shows that while there have been overall improvements (overall VS from 69.5% to 83.4%) you can see that among populations that were above the overall, the percentage above has decreased.
Example: Hispanic/Latino in 2010 was above the overall by 4.1%. In 2015 they are above the overall by 2.3%.
no comments on the slide; however, recommend the talking points be redone to focus on the improvements in disparities. Even though disparities remain, several populations have made trememdous improvements such as the youth and transgender clients.
you may want to look at the TPs from the HP 2020 slides for this one. If you do use the example of Hispanic, be sure to update it to say percentage points, as it is not 4.1% above (feedback we received from the HP 2020 rehearsals)
Hispanics/Latinos can be of any race.
Viral suppression: ≥1 OAMC visit during the calendar year and ≥1 viral load reported, with the last viral load result <200 copies/mL.
a Guam, Puerto Rico, and the U.S. Virgin Islands.
Source: HRSA. Ryan White HIV/AIDS Program Services Report (RSR) Does not include AIDS Drug Assistance Program data.

18. Improving Health Outcomes: Understanding the Current State
Viral Suppression among Key Populations Served by the Ryan White HIV/AIDS Program, 2010‒2015—United States and 3 Territoriesa
Models of care study (evaluation study)
Evaluate the impact of different models of HIV care
Which models of care work best for people with co-morbidities or the aging population
Assessing client factors with detectable viral load (evaluation study)
Identify differences between PLWH who are virally suppressed vs. those who are not
Identify new strategies to achieve the goals
MSM: men who have sex with men; PWID: persons who inject drugs.
Viral suppression: ≥1 OAMC visit during the calendar year and ≥1 viral load reported, with the last viral load result <200 copies/mL.
a Guam, Puerto Rico, and the U.S. Virgin Islands. .
Source: HRSA. Ryan White HIV/AIDS Program Services Report (RSR) Does not include AIDS Drug Assistance Program data.

19. Improving Health Outcomes: Disseminating Effective Interventions
Dissemination of Evidence-Informed Interventions to Improve Health Outcomes Along the HIV Care Continuum
Developing four evidence-informed Care and Treatment Interventions (CATI) for linkage and retention
Based on evidence informed interventions: SPNS Jail, SPNS Buprenorphine, SPNS Outreach, and Re-Engagement and Retention initiatives
Using Evidence Informed Interventions to Improve Health Outcomes among People Living with HIV
Improving HIV health outcomes for transgender women
Improving HIV health outcomes for black men who have sex with men (MSM)
Integrating behavioral health with primary medical care for PLWH
Identifying and addressing trauma among PLWH
DEII
Cooperative Agreement: Dissemination of Evidence-Informed Interventions (DEII) is funded to replicate four evidence-informed care and treatment interventions from previously evaluated Special Projects of National Significance (SPNS) initiatives that are cost effective; improve health outcomes along the HIV Care Continuum and easily adaptable to the changing health care environment.
E2i
This initiative funds one organization to coordinate up to twenty-four (24) Ryan White HIV/AIDS Program (RWHAP)-funded recipients/subrecipients to support the implementation of evidence-informed interventions and one organization to simultaneously evaluate the evidence based interventions identified by the coordinating organization.
The project will focus on implementing effective and culturally appropriate evidence-informed interventions that will be tailored to meet the needs of the target populations, using the framework of implementation science, assessing and adapting the interventions at interim intervals throughout the project period
The evidence-informed interventions will be in four focus areas
1) Improving HIV health outcomes for transgender women
2) Improving HIV health outcomes for black men who have sex with men
3) Integrating behavioral health with primary medical care for PLWH
4) Identifying and addressing trauma among PLWH

20. Improving Health Outcomes: Identifying and Disseminating Evidence Informed Interventions – Black Men Who Have Sex with Men
Center for Engaging Black MSM Across the Care Continuum
His Health ( and Well Versed ( websites launched fall 2016
Viral Suppression among Men who have Sex with Men (MSM) Served by the Ryan White HIV/AIDS Program, 2015
Priority: National Goals to End the HIV Epidemic/President’s Emergency Plan For AIDS Relief (PEPFAR) 3.0: Maximize HRSA HAB expertise and resources to operationalize National Goals and PEPFAR 3.0
biggest disparity among Black MSM is the new infections --- the public health imperative
In 2015, viral suppression among men who have sex with men (MSM; 84.7%) was consistent with the national RWHAP average (83.4%) – indicated by the dashed red line – and men overall (83.9%). The lowest percentage of viral suppression was among black/African American MSM (77.7%).
CEBACC – responding to these disparities.
N represents the total number of clients in the specific subpopulation.
Viral suppression is defined as ≥1 outpatient/ambulatory medical care visit during the calendar year and ≥1 viral load reported, with the last viral load result <200 copies/mL.
The three territories include Guam, Puerto Rico, and the U.S. Virgin Islands.
N represents the total number of clients in the specific subpopulation and have ≥1 outpatient/ambulatory medical care visit during the calendar year and ≥1 viral load reported
Viral suppression: ≥1 outpatient/ambulatory medical care visit during the calendar year and ≥1 viral load reported, with the last viral load result <200 copies/mL.
a Guam, Puerto Rico, and the U.S. Virgin Islands.
Source: HRSA. Ryan White HIV/AIDS Program Services Report (RSR) Does not include AIDS Drug Assistance Program data.

21. Improving Health Outcomes: Identifying and Disseminating Evidence Informed Interventions – Youth
Building Futures: Supporting Youth Living with HIV (evaluation study)
Identify barriers and best practices to support youth living with HIV accessing RWHAP funded services
Youth have lower rates of viral suppression, we need more information and data to improve those rates
PRIORITY: National Goals to End the HIV Epidemic/President’s Emergency Plan For AIDS Relief (PEPFAR) 3.0: Maximize HRSA HAB expertise and resources to operationalize National Goals and PEPFAR 3.0
Building Futures: Supporting Youth Living with HIV (evaluation study)
Identify barriers to care for youth living with HIV accessing RWHAP funded services, harvest best practices, and increase use of evidence-based strategies to maximize health outcomes along the HIV care continuum for HIV infected youth accessing RWHAP funded services
Assessing client factors with detectable viral load (evaluation study)
The study will look at clinical factors like resistance or comorbidities, health care systems-level, socioeconomic, and patient-provider relationship factors

22. Improving Health Outcomes: Addressing Structural Barriers
Improving HIV Health Outcomes through the Coordination of Supportive Employment and Housing Services
Supports the design, implementation, and evaluation of innovative interventions that coordinate HIV care and treatment, housing and employment services to improve HIV health outcomes for low-income, uninsured, and underinsured PLWH in racial and ethnic minority communities
HIV Care & Housing – Using Data Integration to Improve Health Outcomes along HIV Care Continuum
Promotes integration and coordination of HIV and housing services using information technology to Improve entry, engagement, retention in care for HIV positive homeless & unstably housed PLWH with mental illness and substance abuse disorders
Viral Suppression among Clients Served by the Ryan White HIV/AIDS Program, by Housing Status, 2010‒2015—United States and 3 Territoriesa
We are interested and vested in coordinating and collaborating with our federal partners. Once example is our work with the Housing and Urban Development (HUD). We are both interested in addressing housing needs of people living with HIV in order to improve patient health outcomes.
From RWHAP data, you can see in this graph, PLWH who are unstably housed or homeless have worse HIV related health outcomes than those PLWH with stable housing. Knowing this data, the RWHAP issued a funding opportunity announcement “HRSA Improving HIV Health Outcomes through the Coordination of Supportive Employment and Housing Services”
SMAIF: Employment FOA – looking at improving social determinants of health and impact on health outcomes
HAB model of demonstration sites and evaluation center
Focus on impact of improving social determinants of health on PLWH health outcomes
Addressing structural factors, such as poverty, lack of education, unemployment/underemployment, homelessness and other social determinants of health 
Promote long-term health and stability for PLWH, this initiative will support organizations that can demonstrate innovative strategies for integrating HIV care, housing and employment services into a coordinated intervention. 
Support the design, implementation, and evaluation of innovative interventions that coordinate HIV care and treatment, housing, and employment services to improve HIV health outcomes PLWH
The RWHAP SPNS Program initiatives aim to develop innovative models of HIV care and treatment to respond to emerging needs of Ryan White HIV/AIDS Program clients. PLWH who are unstably housed or homeless have worse HIV related health outcomes than those PLWH with stable housing.
The Building a Medical Home for Multiply Diagnosed HIV-positive Homeless Populations initiative is a demonstration project, currently on its fourth year of implementation.
The initiative supports organizations that will put into place innovative practices to increase entry to and retention in HIV care, as well as support services for clients who are homeless or unstably housed and those who are living with mental illness or substance use disorders
HIV Care & Housing – Using Data Integration to Improve Health Outcomes along HIV Care Continuum
Promotes integration and coordination of HIV and housing services using information technology to Improve entry, engagement, retention in care for HIV positive homeless & unstably housed PLWH with mental illness and substance abuse disorders
Viral suppression: ≥1 OAMC visit during the calendar year and ≥1 viral load reported, with the last viral load result <200 copies/mL.
a Guam, Puerto Rico, and the U.S. Virgin Islands.
Source: HRSA. Ryan White HIV/AIDS Program Services Report (RSR) Does not include AIDS Drug Assistance Program data.

23. Improving Health Outcomes: Enhancing Partnerships
HIV Health Improvement Affinity Group
Support state collaborations between public health and Medicaid programs
Improve rates of viral suppression among Medicaid and CHIP enrollees living with HIV
The Affinity Group is comprised of 19 states which represent over 55% of known living HIV cases in the U.S.
PRIORITY: Partnerships: Enhance and develop strategic domestic and international partnerships internally and externally
would add to notes that the majority of state teams chose data sharing/integration for their project
32.8% of RWHAP clients had Medicaid health care coverage in This is the largest payer of HIV care in the US
Improving relationships at the state-level between RWHAP (health department) and the Medicaid program can improve the care and treatment of PLWH, improve health outcomes, and ensure there is no duplication of services
HIV Health Improvement Affinity Group
Partnership with CMS
The Affinity Group is comprised of 19 states which represent over 55% of known living HIV cases in the U.S.

24. Improving Health Outcomes: Curing Hepatitis C Infection in RWHAP
Estimated 20-25% of RWHAP clients are coinfected with HCV
Curing HCV among RWHAP clients is achievable
Encourage recipients to leverage RWHAP effective approach to cure HCV among their clients
Increase availability of HCV treatment and care
Increase number of clients receiving HCV treatment and care
New initiatives demonstrate commitment to curing HCV in PLWH through the infrastructure of the RWHAP
Jurisdictional approaches to screening, treatment and cure of HCV
Contract to study barriers to screening, treatment and cure of HCV
Enhancing HCV surveillance systems and treatment of HCV in conjunction with mental health and substance abuse treatment
PRIORITY: Integration: Integrate HIV prevention, care, and treatment in an evolving health care environment
Many patients have both HIV and HCV
Estimated 20-25% of PLWH in the U.S. are co-infected with HCV
Among HIV+ PWIDs: up to 80-90% co-infected with HCV
If 20-25% are coinfected with HCV, then at least 100,000 HIV/HCV coinfected individuals are served by the RWHAP annually
Having HIV accelerates liver damage in people living with HCV
PLWH are dying of liver disease
Liver disease is a leading cause of non-AIDS death among PLWH
There are effective treatments for HCV that eliminate that virus from the body. RWHAP is working to improve rates of HCV treatment among RWHAP clients who are HIV/HCV co-infected. Substance use disorder providers and RWHAP providers can work together to achieve what we hope is a shared goal of curing HCV among HIV/HCV coinfected, RWHAP eligible clients. Many of the HIV/HCV coinfected clients also have substance use disorders. Identifying and treating co-occurring substance use disorders can, in some instances, help the client to avoid re-infection with HCV.
One initiative is the models of care for HCV treatment among HIV/HCV co-infected patients. Looks at four models of care:
Primary care delivery with expert back-up
Integrated care without a designated HCV clinic (expert consultation used for severe complications)
Integrated care with a designated HCV clinic internally
Co-located care with specialist who manages treatment at RWHAP clinical site
Jurisdictional Approach to Curing HCV among PLWH
Supported through the Secretary’s Minority AIDS Initiative Fund: Focus on people of color living with HIV that have a high prevalence of coinfection with HCV particularly Blacks/African Americans, Latinos/as, American Indians/Alaska Natives people who inject drugs and MSM
Jurisdictions include 2 local health agencies and 2 state health agencies to
Increase jurisdiction-level capacity to provide comprehensive screening, care and treatment of HCV among HIV/HCV coinfected people of color
Increase numbers of HIV/HCV coinfected people of color who are diagnosed, treated, and cured of HCV infection
(SOURCE: Ragni MV and Belle SH. J Infect Dis 2001;183:1112–5. Weber et al for the D:A:D Study Group. Arch Intern Med. 2006;166: Spradling PR et al. J Acquir Immune Defic Syndr 2010;53: )

25. Improving Health Outcomes: Clinical Quality Management
Development and testing of electronic clinical quality measures (eCQMs)
National Quality Forum Endorsement of HIV measures
HIV viral suppression
Prescription of HIV antiretroviral therapy
HIV Medical visit frequency
Gap in HIV medical visits
HIV Quality Measures (HIVQM) Module
Designed to help recipients track their clinical quality performance measures
Recipients enter performance measure data in aggregate multiple times per year
Generates reports that allow an organization to compare themselves with others who submitted
42 performance measures to select from
eCQMs are important because CMS encourages the use of eCQMs in the incentive payment programs including MIPS. We are actively pursuing acceptance of HIV measures into the CMS programs.
PRIORITY: Leadership: Enhance and lead national and international HIV care and treatment through evidence-informed innovations, policy development, health workforce development, and program implementation
All recipients are required to establish clinical quality management programs.
Clinical Quality Management is the coordination of activities that are aimed at improving patient care, health outcomes, and patient satisfaction.
Specifically, the clinical quality program assesses and develops strategies to ensure that HIV services are consistent with Department of Health and Human Services guidelines.
The focus for the HIVQM Module is on the assessment of whether your services are consistent with the HHS HIV guidelines.

26. HAB Reports and Other Resources
Find the annual RSR data report and other resources online:

27. Thank You! Laura W. Cheever Associate Administrator
HIV/AIDS Bureau (HAB)
Health Resources and Services Administration (HRSA)
Web: hab.hrsa.gov
Twitter: twitter.com/HRSAgov
Facebook: facebook.com/HHS.HRSA