Supporting California's HIV Care Needs

1. Supporting California's HIV Care Needs An Initial Meeting of Training, Consultation and Professional Organization Partners October 16, 2008

2. Agenda 10:00 – 10:30 Introductions & Agenda Review 10:30 – 11:00 Overview of Office of AIDS 11:00 – 12:00 Overview of Partner Programs 12:00 – 12:45 Lunch 12:45 – 1:00 Clarifying questions from AM 1:00 – 2:45 Discussion 2:45 – 3:00 Wrap-Up and Next Steps

3. Partner Presentations: Training, Professional Organizations, Care and Public Health Networks • PAETC Pacific AIDS Education and Training Center • PTC California STD/HIV Prevention Training Center • IAS-USA International AIDS Society • AAHIVM The American Academy of HIV Medicine • HIVMA HIV Medicine Association • ANAC Association of Nurses in AIDS Care • CMA California Medical Association • CDCR California Department of Corrections and Rehabilitation • VA Veterans Affairs Administration • KP Kaiser Permanente • CCLAD California Conferenceof Local AIDS Directors Unable to attend: NMA, UCD Telemedicine

4. Afternoon Discussion Our vision is for every person in California with HIV infection to receive high quality medical care. • How can OA facilitate and support increased coordination and collaboration among partner groups, to maximize the impact of our work to provide high quality care and support to people with HIV throughout the state. • Creating an Emergency Response Network for HIV care and support. • Are there other professional organizations with a focus on HIV care and/or clinical training and consultation in California • e.g., professional organizations representing HIV clinical pharmacists, Family Medicine, Internal Medicine, Physician's Assistants, etc

6. OA’s Primary Functions • Surveillance • Epidemiology • Education and Prevention • Care, Treatment and Support • Program Evaluation • Policy Approximately 150 staff positions

7. HIV/AIDS Core Surveillance • Confidential case registry of demographic and clinical information on all reported California HIV and AIDS cases • OA collects data from local health jurisdictions • records forwarded to CDC to monitor the epidemic nationally • Data are also used to: • determine federal Ryan White allocations • provide current information on HIV/AIDS epidemiology to HIV/AIDS programs and planning councils

8. HIV Incidence Surveillance (HIS)

9. What Is STARHS? • Antibody-based laboratory testing method that allows CDC to identify, with reasonable probability, how many newly reported HIV infections in any given population are recent • i.e., within the previous 6 -12 months

10. Requirements for HIV Incidence Surveillance Remnant HIV+ Serum Supplemental Data STARHS Testing using BED Assay Testing and Treatment History HIV Incidence Estimation

11. Key Non-Health Department Partners in HIS • Providers: • Ensure new patient records include testing and treatment history (TTH) • First positive HIV Test • Last negative HIV test • Exposure to antiretroviral medication • Facilitate completion of HIV/AIDS case report form when new case is ascertained • Labs: • Ship remnant serum samples to central facility for STARHS testing

12. Key Health Department Partners in HIS • Local Health Departments • Collect core surveillance variables and TTH data through receipt from providers and active surveillance • Office of AIDS • Raise awareness and interest • Guidance, technical support and monitoring • Data management and transfer to CDC • Complete California incidence estimation

13. Select Epidemiologic Studies • Medical Monitoring Project (MMP) • Secondary surveillance of people in care • Linkage of HIV/AIDS and STD and TB registries • HIV/AIDS Border Epidemiologic Profile • Influence of SB1159 (pharmacy-based syringe disposal) on Unsafe Syringe Discard • Evaluation of Sexual Barrier Device Distribution in State Prison Setting (with CDCR)

14. Surveillance Stakeholder Meetings 1st: April 9-10, 2008 • Purpose: Provide opportunity for consensus-building discussion regarding current and future HIV reporting policies and regulations • Attendees: • LHDs (incl. CCLAD, CCLHO) • Surveillance coordinators • Laboratory directors • Health care providers • Service organizations serving HIV-positive patients • Advocates

15. Meeting Agenda Day 1 • What’s Working at the State and Local Levels • Data Transmission: Encryption, Faxing and Mailing • HIV and AIDS Reporting Consistency Day 2 • Centralized Laboratory Reporting • Uses of HIV/AIDS Data for Public Health Purposes • Policy and Funding Implications of including HIV/AIDS Reporting in Other Communicable Disease Reporting Regulations

16. Outcomes and Next Steps • Workgroup #1: Data Transmission Issues • Workgroup #2: Centralized Laboratory Reporting • Workgroup #3: Considerations Regarding Possible Uses of HIV/AIDS Data for Public Health Purposes • eg Partner Services, case management Next Meeting December 3, 2008

17. HIV Counseling & Testing Program • Approximately 125,000 HIV tests a year • Anonymous and/or confidential HIV counseling and testing services sites • Client-focused prevention counseling and assessment of client needs • Risk-reduction planning and referral to other services • Linkages to HIV care and treatment

18. Opportunities to increase HIV screening in California CDPH/Office of AIDS Considerations: What role can we play? October 2008

19. Reduce Barriers to HIV screening • Expand in new and existing venues • Take full advantage of • CDC guidelines (2006) • Legislation (AB682) eliminating written consent requirement for performing an HIV test (2008) • Legislation (AB1894) requiring reimbursement by private insurers for HIV screening (2009) • Recent incidence and prevalence reports from CDC (2008)

20. Needs that OA could address to facilitate increased HIV screening by venue • Identify appropriate test method(s) and associated training and support needs • Consider reimbursement sources/existing billing infrastructure and associated training and support needs • identify remaining areas in need of financial support • Consider ‘enhanced’ data needs and associated financial, training and support

21. Venue considerations • * Outpatient settings • Providing continuity care • Providing as-needed care • * Inpatient settings • Corrections (prison, jail, juvenile) • Substance use treatment • Other non-clinical settings (e.g., CBOs, mobile testing programs, health fairs) * Current focus for this discussion

22. Outpatient settings • Providing continuity care • TB clinics • Primary care co-located with HIV care clinics • Other primary care (e.g., Family Practice, General Int. Med, Women’s Health) • Providing as-needed care • STD clinics • Emergency Departments • Urgent Care clinics • Family Planning clinics

23. Inpatient settings • Medical wards • Psychiatric wards • Surgical wards, e.g., • Trauma • Services caring for infectious processes

24. Consider venue-specific purpose of HIV screening/testing • Screen only (with minimal education) • Screen + provide expanded education • Test + provide prevention interventions

25. No matter the venue… • All are provided with basic information on the HIV test, voluntary nature of testing, and educational materials on how to remain negative • All HIV-positive clients • receive appropriate results disclosure • are given accurate HIV care/treatment linkages as well as appropriate assistance in accessing referrals • Minimum data elements

26. OA role in all venues • Consider venue-specific training and technical assistance needs related to: • Specific test technology • Education • Disclosure and other counseling • Care and support linkages • Financial eligibility screening • Data issues • Coordinate or contract with appropriate venue-specific training and TA partners

27. Progress to Date • CDPH/OA has identified preliminary venue types and a process to determine how approach scale-up of HIV screening with well-managed resource assistance from CDPH/OA • Continuing internal process to refine thinking • Initiating discussions with CDPH and external partners • Prioritize and pilot • Identify existing funding sources to support

28. Primary care co-located with HIV clinics e.g., Altamed, SFGH outpatient clinics, Tom Waddell

29. TB Clinics

30. Implementation of HIV Screening in Acute Care Settings: A Strategic Planning Workshop for Hospitals October 22-24, 2008 • Sponsored by CDC and OA • Attendees: Up to 17 California hospitals and clinics - administrators and staff • Purpose: To provide hospital teams with an opportunity to hear from “early adopters” of HIV screening and problem-solve on how they can implement HIV screening in their emergency departments, urgent care, and other inpatient and outpatient departments.

31. Prevention Think Tank May 13-14, 2008 • Purpose: To create an opportunity for prevention and care providers, funders, researchers, and public health officials to review current status of selected HIV prevention strategies and assess possibilities for scale-up in the future

32. Attendees • LHDs • University-affiliated researchers • HIV prevention providers • CDC managers and behavioral scientists • NIMH scientist • Physicians providing direct care to clients • State partners: STD, PTC, Lab • 25 members of OA management and staff

33. Agenda Topics Day One • Post-exposure Prophylaxis (PEP) • Prevention with Positives • Acute HIV testing • Behavioral Interventions Day Two • HIV testing in Emergency Depts. and hospitals • HIV testing in STD and other clinics • Partner Counseling and Referral Services (PCRS)

34. Prevention Think Tank….more • “Big picture discussions:” Prioritization, Evaluation and Capacity-building • Outcomes/Next Steps: • Report on website • Focus groups, key informant interviews and additional focused meetings • Convene additional stakeholders, including community partners, providers, consumers • Discussion with CCLAD, CHPG, LAB, CAHAAC, other community partners

35. HIV Prevention Policy &Program Development • Addresses emerging risks by responding to the needs of priority populations, including: • African American • Latinos • Women of Childbearing Years • Transgendered Persons • Injection Drug Users • Analyzes proposed legislation related to HIV prevention and provides recommendations to the CDPH administration.

36. CARE Services Program • Contracts with 36 health department and community based organizations in all 58 counties • Access to a comprehensive continuum of community-based medical care and support services

37. Early Intervention Section EIP: 36 sites 8,655 active clients as of 7/1/06 Positive Changes: 20 sites 830 clients served in FY 07-08 Pathways: 17 sites Bridge Project: 36 sites 1120 clients served in FY 07-08 TMP: 130 statewide provider sites 18,663 clients served in FY 06-07

38. Case Management Programs • CMP • RN- and SW-based medical case management • 44 contractors statewide in 52 counties • Medi-Cal Waiver • 2580 served in CY 2007

39. AIDS Drug AssistanceProgram • Provides drugs for individuals who could not otherwise afford them. Drugs on the formulary slow the progression of HIV disease, prevent and treat opportunistic infections, and treat co-morbidities and the side effects of antiretroviral therapy. • Currently 181 drugs on the ADAP formulary • Serves approximately 32,800 clients annually • Approximately 3,870 pharmacies in the network • Approximately 217 enrollment sites

40. CARE/HIPP Maintain private health insurance coverage and assist with Medicare Part D prescription coverage • Pays insurance premiums • Pays Medicare Part D premiums for ADAP clients who do not qualify for Full Low Income Subsidy. • As of July 2008, premiums were paid for approximately 865 clients.

41. CDPH Integration Efforts • Common data elements/forms • Evaluate co-infection and risks • HIV screening in: • TB programs • STD programs • Increased uptake of Partner Services • STD, hepatitis and TB screening in HIV programs

42. Integration inOA • Surveillance, Epi, Program Development and Evaluation • Prevention and Care • Care and Treatment • Population-specific focus

44. OA Organizational Chart