1. Ongoing Implementation of the National HIV/AIDS Strategy to Improve HIV Prevention and Care Grant Colfax, MD Office of National AIDS Policy International AIDS Conference July 22, 2012

2. As part of the NHAS, President Obama and his Administration have… Supported and increased investment in domestic HIV prevention and care. – Over $22 billion budgeted for HIV efforts – $2.5 billion increase during administration Directed resources to populations at greatest risk for HIV infection. – Focus on gay men, communities of color Implemented the Affordable Care Act. – Medical coverage extended to tens of thousand of persons living with HIV – Prevention services extended to millions of Americans Provided robust Federal funding to ADAP ($933 million, with $1 billion in 2013). – Waitlists have dropped by 80% – Federal share of funding sufficient to end waitlists with States doing their share Addressed HIV-related stigma and discrimination. – Lifted the HIV entry ban – Affordable Care Act prohibits denial of coverage based on pre-existing conditions, including HIV Supported groundbreaking NIH research in HIV prevention and care. – Breakthroughs include: treatment as prevention, pre-exposure prophylaxis, vaccines, microbicides, cure research

3. Addressing Stigma and Discrimination: President Obama Supports Same-Sex Marriage

4. Ongoing Challenges to Implementing the National HIV/AIDS Strategy Fiscal – Ensuring wise investments – Linking investments to health outcomes Coordination among agencies – Metrics – FOAs – Traditional siloed approach Coordination across Federal, State, and local levels – Higher you go, less understanding of issues on the ground – Inadequate funding or staffing at some levels Ability of organizations to adapt to a changing environment – Capacity – Technical assistance needs – Creating new models of prevention and care delivery Will to allocate funds for interventions that are – Achievable – Sustainable – Effective Educating providers about HIV prevention and care – # of HIV care providers decreasing – Reluctance to care for HIV+ patients – Reimbursement

5. Implementation Questions at the Ground Level Are resources being used by the populations at greatest risk? Are these populations being engaged in all components of the implementation process? Are the interventions evidence-based, scaleable, sustainable, and effective? What is the optimal combination of interventions? How do we tailor interventions at the local level, while also maintaining the integrity of “evidence-based”? Do we have and use metrics to measure local program success? How long do we take to declare success or failure of a program?

6. Aligning Resources with the Epidemic

7. (Prejean et al., 2011) New HIV Infections in the U.S., 2009 Racial minority populations in the U.S. less likely to have access to care, ART, adhere to ART or be virally suppressed.

8. Diagnosed HIV+ OR, 2.59 (1.82-3.69) Undiagnosed HIV OR, 6.38 (4.33-9.39) Health insurance coverage OR,0.47 (0.29-0.77) >200 CD4 cells/mm 3 before ART initiation OR, 0.40 (0.26-0.62) ART adherence OR, 0.50 (0.33-0.76) HIV suppression OR, 0.51 (0.31-0.83) ART utilization/ access OR, 0.56 (0.41-0.76) HIV Detection Viral Suppression Healthcare visits OR, 0.61 (0.42-0.90) Lower income (<$20k) OR, 3.42 (1.94-6.01) (Millett, 2012)

9. Reducing HIV incidence via combination prevention 29 September 2011 – SW regional conference Treatment as Prevention (Cairns, 2012)

10. Toward Health Equity: The Affordable Care Act Expands coverage to over 30 million Americans – Tens of thousands with HIV – Millions of Blacks and Latinos Prohibits denials of coverage based on HIV status Already – Millions have increased prevention service coverage – Millions of young adults covered on parents’ plans Source: Office of the Assistant Secretary for Planning and Evaluation, 2012

11. Silverberg, et. al., J Gen Intern Med. 2009;24(9):1065-72. HR(95% CI)P White1 Black1.2(0.9-1.5)0.25 Hispanic0.8(0.6-1.1)0.17 HR(95% CI)P White1 Black1.1(0.9-1.4)0.27 Hispanic0.7(0.5-0.9)0.01 Kaiser: Time to AIDS-Related Events or Death

12. Measuring HIV-related Outcomes: Towards a National Consensus Parsimony Harmony Achievable Sustainable Usable

13. Table 2. National and Facility Rates for 10 National Quality Forum Measures for HIV/AIDS Care 73 Facilities With  100 HIV Caseload MeasureEligible, No.National Rate, % Minimum Facility Rate, % Maximum Facility Rate, % Medical Visit21564837396 HBV Screening179049788100 HCV Screening179049892100 HBV vaccination16606815398 TB screening16526653094 Syphilis screening1790454897 CD4 lymphocyte count179049381100 Potent ART14508917599 HIV RNA control15537732891 PCP prophylaxis2709722093 Abbreviations: ART, antiretroviral therapy; HBV, hepatitis B virus; HCV, hepatitis C virus; HIV, human immunodeficiency virus; PCP, Pneumocystis pneumonia; TB, tuberculosis Backus, L., Boothroyd, D., Phillips, B., Belperio, P., Halloran, J., Valdiserri, R., Mole, L. (2010). National Quality Forum Performance Measures for HIV/AIDS Care: The Department of Veterans Affairs’ Experience. Archives of Internal Medicine, 170(14), 1239-1246 Measuring outcomes: VA System

14. Cascade Research: Federal Coordination  Convene interagency consultation to discuss and identify all cascade research being conducted within each Federal agency, e.g. NIH, CDC, HRSA, SAMHSA  Create and maintain an inventory of all Federal “linkage-to- care” research, organized by the population targeted & timelines for scaled-up implementation  Create an online database of Federal, evidence-based, population-specific “linkage-to-care” strategies to help local communities

15. 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 Adherence studies along the cascade Research to determine best ways to move forward among multiple options

16. Acknowledgements HHS: Ron Valdiserri, Howard Koh, Greg Millet ONAP team: James Albino, Aaron Lopata, Helen Pajcic