BEHAVIORAL HEALTH: CHALLENGES AND OPPORTUNITIES IN HELPING TO END THE HIV/AIDS EPIDEMIC

2. BEHAVIORAL HEALTH: CHALLENGES AND OPPORTUNITIES IN HELPING TO END THE HIV/AIDS EPIDEMIC Pamela S. Hyde, J.D. SAMHSA Administrator National Minority AIDS Council 16th Annual United States Conference on AIDS Las Vegas, NV • September 30, 2012

3. WHY DOES BEHAVIORAL HEALTH MATTER? • CDC estimates: half of all Americans will meet criteria for mental illness at some point in their lives; half of us know someone in recovery from substance abuse • 7 percent of the adult population (34 million people), have co-morbid mental/physical conditions w/in a given year • People with M/SUDs are nearly 2x as likely as general population to die prematurely, (8.2 years younger) often of preventable/treatable medical causes (95.4 percent) • Violence and trauma are significantly associated with ↑ risk for health, BH & HIV • Lifetime history of sexual abuse among women: ~ 15 to 25 percent • 30 to 57 percent of female substance abusers meet criteria for PTSD, with elevated risk related to higher incidence of childhood physical and sexual abuse – 2 or 3 times ↑ than males • Almost all women in M/SUD treatment settings have history of trauma • Untreated M/SUDs among top 5 predictors of poor adherence to HIV/AIDS treatment

4. M/SUDs ↑ RISK Physical health problems & chronic disease HIV/AIDS, STDs, Hepatitis Lost productivity/job loss Parenting deficiencies & involvement in CW system Adult & Juvenile incarceration & recidivism Homelessness Suicide attempts and completions

5. SUBSTANCE USE AND HIV/AIDS Behaviors associated w/substance abuse fuel HIV transmission 9 percent of all new HIV infections occur among injection drug users; 3 percent among MSM/IDU Effects of drugs/alcohol alters judgment; people engage in impulsive and unsafe sexual behaviors contributing to spread of HIV as well as lowering adherence to treatment

6. MENTAL HEALTH AND HIV/AIDS • ~50 percent of those in HIV care have a co-morbid mental illness • Mental illness can arise independently of HIV infection; can predispose to HIV (through risk-related behaviors); can be a psychological consequence of HIV (e.g., depression) • Regardless of etiology, co-morbidity of MI-HIV poses special challenges for care • Clinical depression is the most commonly observed MH disorder among HIV-infected patients, affecting up to 22 percent of patients; prevalence may be even greater among substance users

7. NATIONAL LOOK: SUBSTANCE DEPENDENCE OR ABUSE 2011 NSDUH: ~20.6 million persons (8.0 percent of the population aged 12 or ↑) were classified with substance dependence or abuse in the past year

8. 2011 RATE OF SUBSTANCE DEPENDENCE OR ABUSE 12 AND ↑: RACE/ETHNICITY SAMHSA, CBHSQ, 2011 NSDUH

9. PAST MONTH ILLICIT DRUG USE: 12 OR ↑, BY RACE/ETHNICITY, 2002-2011 Percent Using in Past Month

10. CHANGING LANDSCAPE: REPORTED AIDS CASES

11. NATIONAL HIV/AIDS STRATEGY: REDUCING DISPARITIES/PROMOTING EQUITY • Reduce HIV-related mortality in communities at high risk for HIV infection • Adopt community-level approaches to reduce HIV infection in high-risk communities • Reduce prejudice and discrimination against people living with HIV http://www.aids.gov

12. NATIONAL HIV/AIDS STRATEGY: 4 KEY GOALS ↓ # of people who become infected w/ HIV ↑ access to care and optimize health outcomes for people living w/ HIV ↓ HIV-related health disparities Achieve a more coordinated national response to HIV epidemic in U.S.

13. GOAL 4: ACHIEVE A MORE COORDINATED NATIONAL RESPONSE TO HIV EPIDEMIC IN U.S. • Central to goal: 2 related directives • Develop improved mechanisms to monitor, evaluate, and report on progress toward achieving national goals • Simplify grant administration activities by standardizing data collection and reducing undue grantee reporting requirements for federal HIV programs • Secretary Sebelius to OPDIVs: Finalize common, core HIV/AIDS indicators consistent w/ IOM recommendations • RFI: Data Streamlining /Reducing Undue Reporting Burden • For HHS-funded HIV prevention, treatment, and care services grantees • Issued in Federal Register 8/22/12; public comment period closed 9/21/12

14. COMMON CORE INDICATORS(SAMHSA Reducing Burden 20-25%) • HIV Positivity • Late HIV Diagnosis • Linkage to HIV Medical Care • Retention in HIV Medical Care • Antiretroviral Therapy (ART) Among Persons in HIV Medical Care • Viral Load Suppression Among Persons in HIV Medical Care • Housing Status

15. SAMHSA’S ROLE IN NHAS IMPLEMENTATION – Funding (# in millions)

16. SAMHSA’S ROLE IN FEDERAL IMPLEMENTATION PLAN – NHAS TARGETS Simplifying grant administration activities: Work on development of core indicators Linking people to continuous and coordinated quality care: Rapid HIV testing supplements to CSAP grantees Promoting a more holistic approach to health: Funding Targeted Capacity Enhancement (TCE) grantees to provide viral hepatitis (B and C) testing and referral to care that addresses prevention of HIV related co-morbidities; integrates activities from the National Vial Hepatitis Action Plan Preventing HIV among substance users: Identifying people w/SUDs via SABG funded HIV programs; also SABG HIV Early Intervention Services 5 percent set-aside

17. SAMHSA’S ROLE IN 12 CITIES PROJECT • 2011: HHS initiated steps to strengthen coordination of responses to HIV/AIDS of CDC, HRSA, IHS, NIH, SAMHSA, CMS, and OASH • 12 Cities Project central to effort - Houston, Tallahassee, San Juan, Philadelphia, San Francisco, New York, Chicago, Los Angeles, Baltimore, Washington, Atlanta and Dallas • SAMHSA was able to fund 11 of 12 cities • Local level collaboration w/ housing, veterans services, and other HIV-related programs in jurisdictions w/ highest AIDS burden • Anchor: CDC’s Enhanced Comprehensive HIV Prevention Planning initiative – SAMHSA provides joint project officers • Cross-agency and cross-departmental communications at federal/local levels • Data sharing discussions • Development of common core indicators • Mapping of Ryan White Program service locations • Exploration of data streamlining • Coordinated funding opportunities

18. SAMHSA’S MINORITY AIDS INITIATIVE TCE: INTEGRATED BH/PC NETWORK GRANTS Purpose: Develop and expand culturally competent/effective integrated behavioral health and primary care networks, including HIV services and medical treatment, w/in racial and ethnic minority communities in Metropolitan Statistical Areas and Metropolitan Divisions most impacted by HIV/AIDS Eligible Grantees: Public Health Departments funded under CDC’s Enhanced Comprehensive HIV Prevention Planning and Implementation of Metropolitan Statistical Areas Most Affected by HIV/AIDS grant program Priority Populations: Minority MSM, Women Grant awards in FY 2011: 11 awards at ~ $1.3 million each; 3-year grant program funded from FY 2011-FY 2013

19. SAMHSA’S SA TREATMENT FOR RACIAL/ETHNIC MINORITY POPULATIONS AT HIGH-RISK FOR HIV/AIDS GRANTS Purpose: Develop and expand culturally competent and effective community-based treatment systems for SUDs and co-occurring M/SUDs w/in racial and ethnic minority communities in states w/ highest HIV prevalence rates (at or above 270 per 100,000) Eligible Grantees: Community Based Organizations Priority Populations: Young MSM, Women Grant awards in FY 2012: Up to 52 awards at ~ $500K each; 5-year New grant awards expected in FY 2013: Expected funding for treatment based grants under FY 2013 CR

20. SAMHSA’S PREVENTION OF SUBSTANCE ABUSE AND HIV FOR AT-RISK RACIAL/ETHNIC MINORITY POPULATIONS GRANTS Purpose: Deliver and sustain quality/accessible SA and HIV prevention services aimed at preventing and reducing onset of SA and transmission of HIV/AIDS among at-risk racial/ethnic minority subpopulations Eligible Grantees: Community-level domestic public and private nonprofit entities Priority Populations: Minority MSM, Women, Injection Drug Users, Re-Entry Populations Grant awards in FY 2008/09: 51 awards at ~ $400k each; 5-year New grant awards expected in FY 2013: Expected funding for prevention based grants under the FY 2013 CR

21. ACA: TRANSFORMATIVE POSITIVE EFFECT FOR THOSE LIVING W/BH PROBLEMS AND/OR HIV People w/ BH problems and/or HIV are more likely to be uninsured, to face barriers in accessing medical care, and to experience higher rates of prejudice and discrimination than other groups ACA ↓ disparities that currently exist between availability of services for M/SUDs compared w/availability of services for other medical conditions – parity applies ACA supports integrated, coordinated care, especially for people w/ BH and co-occurring health conditions, such as HIV/AIDs Expands Medicaid for the lowest income people; strengthens and improves Medicare; and makes private insurance work better for all Americans Increases access to critical prevention services, including SBIRT and HIV testing Prohibits discrimination on basis of M/SUDs and HIV status as pre-existing conditions; bans lifetime limits on insurance coverage; and is phasing out annual limits in coverage

22. SAMHSA’S HEALTH REFORM PRIORITIES – FY 2012 AND FY 2013 • Uniform Block Grant Application for FY2014 & FY2015 • Enrollment Preparation • Exchanges and Qualified Health Plans Capacity • Parity in Medicaid Benchmark Plans and Essential Health Benefits • Provider Capacity Development (Including Workforce) • Work with States and Medicaid • Health homes, rules/regs, service definitions and evidence, screening, prevention, duals, PBHCI, payment issues • Parity – MHPAEA/ACA Implementation & Communication • Quality (NBHQF) and Data (including HIT)

23. BEHAVIORAL HEALTH IS COMMUNITY HEATLH