Achieving the Goals of the National HIV/AIDS Strategy: An Update

Achieving the Goals of the National HIV/AIDS Strategy: An Update Andrew D. Forsyth, Ph.D. DHHS/OASH Office of HIV/AIDS Policy Getting to Zero: World AIDS Day 2011 Conference December 1, 2011

Presentation Outline • HIV/AIDS epidemiological update • National HIV/AIDS Strategy (NHAS) • Implementation progress • Ongoing challenges • Future directions

The State of the Global AIDS Epidemic • ~34 million people were living with HIV worldwide at the end of 2010 • New HIV infections declined 21% in 2010 to ~2.7 million from 1997 peak levels • ART coverage increased 20% in sub-Saharan Africa between 2009 – 2010 • ~2.5 million HIV-associated deaths averted since 1995 due to ART – 700,000 in 2010 • Nearly half of those eligible in low- & middle-income countries are receiving treatment Source: UNAIDS, World AIDS Day Report, 2011

President’s Emergency Plan for AIDS Relief (PEPFAR), 2010 • Supported life saving ARV for 3.2 million people, from 2.5 million in 2009 • Supported PMTCT for 600,000 women, allowing 114,000 infants to be born free of HIV • Provided nearly 11 million people with care • Supported counseling and testing for 33 million people

The State of the U.S. Epidemic:HIV Incidence, 2006 - 2009 • ~1.2 million living with HIV • HIV incidence stable (~50,000) • No overall change in incidence, however: +21% among people age 13 – 29 +34% young MSM +48% among young Black MSM • HIV continues to threaten U.S. public health, esp. among MSM, racial/ethnic minorities Sources: Prejean, PlosOne 6[8], 2011; Moore, CID 52[Suppl 2], 2011

HIV Prevention Through Care & Treatment United States, 2011 • 1.2 million people living with HIV • 9.6% of adults tested, past 12 mo. • 20% are unaware of HIV infection • After diagnosis, 77% are linked to medical care • 51% of whom remain in care • Only 28% of all PLH have suppressed viral loads • Disparities evident in ART receipt, achieving viral suppression, and prevention counseling delivery Source: Cohen et al., MMRW, 2011

Figure 3. Number and percentage of HIV-infected persons engaged in selected stages of the continuum of HIV care – United States Source: Cohen et al., MMRW, 2011

National HIV/AIDS Strategy • White House releases the NHAS & Implementation Plan – July, 2010 • Nation’s first comprehensive coordinated HIV/AIDS roadmap with clear, measurable goals for 2015 • Refocuses existing efforts to maximize available resources and make the case for new investments • Seeks a more coordinated national response to the epidemic

National HIV/AIDS Strategy:Targets for 2015 • Reduce new infections (25%), lower transmission rate (30%), and increase to 90% awareness of HIV+ serostatus • Improve access to and outcomes of care by linking 80% of PLH to care w/in 3 mo of diagnosis, increase to 80% RW clients in continuous care, and increase to 86% RW clients with permanent housing • Reduce HIV-related health disparities by increasing by 20% the number of men who have sex with men (MSM), Blacks, and Latinos with undetectable viral load

NHAS Action Steps:Reducing New Infections • Intensify HIV prevention efforts in communities where HIV is most heavily concentrated • Expand targeted efforts to prevent HIV infection using a combination of effective, evidence-based approaches • Educate all Americans about the threat of HIV and how to prevent it

NHAS Action Steps:Increasing Access to Care and Improving Health Outcomes for People Living with HIV • Establish a seamless system to immediately link people to continuous and coordinated quality care when they learn they are infected with HIV • Take deliberate steps to increase the number and diversity of available providers of clinical care and related services for people living with HIV • Support people living with HIV with co-occurring health conditions and those who have challenges meeting their basic needs, such as housing

NHAS Action Steps:Reducing HIV-Related Disparities & Health Inequities • 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 stigma and discrimination against people living with HIV

NHAS Action Steps:Achieving a More Coordinated National Response to the HIV Epidemic • Increase the coordination of HIV programs across the Federal government and between Federal agencies and state, territorial, tribal, and local governments • Develop improved mechanisms to monitor and report on progress toward achieving national goals

CDC’s Enhanced Comprehensive HIV Prevention Planning Project (ECHPP) • 3 year demonstration project • 12 MSAs with highest number of people living with AIDS • Seeks to maximize the impact of HIV prevention, treatment, and care • Phase I provided $11.6M enhanced planning, coordination, and implementation (2010) • Phase 2 supports ongoing planning and coordination and implementation for 2 years (2012 – 2013) • Grantees include state and territorial health departments and directly-funded local health departments Source: http://www.cdc.gov/hiv/nhas/echpp/

HHS FY 2010 HIV/AIDS Funding

12 Cities Project: Key Activities Builds on CDC’s ECHPP Initiative Engage relevant HHS agencies (CDC, CMS, HRSA, IHS, NIH, SAMHSA) Coordinate and leverage Federal activities and resources Map Federally-funded HIV/AIDS resources in each jurisdiction Promote opportunities to blend or braid services and, where appropriate, funding streams Identify opportunities to harmonize and streamline data collection and reporting requirements Develop common indicators and evaluation strategies

ECHPP & 12 Cities At-A-Glance

12 Cities Project Status • Set aside $15 million SMAI-F for effective programs • Fostered new collaborations among non-HHS agencies (e.g., HIV and housing) • Initiated a review of data collection and federal reporting requirements • Provided technical guidance on State Plan development • Identified core indicators for assessing HIV-prevention, treatment, and care services funded by HHS • Issued a 1-yr contract to define and evaluate coordination and collaboration in implementing the 12 Cities Project

12 Cities: Seven Lessons Learned • Improve Federal communication • Enhance coordination and collaboration • Map Federal resources • Enhance the provision of technical assistance • Streamline Federal reporting requirements • Encourage the effective integration of prevention, treatment, and care • Facilitate planning

DHHS NHAS Implementation Working Group Meeting – Sept 2011 • Attended by HHS/OASH, ONAP, and HHS OPDivs (e.g., CDC, HRSA, NIH) and Staff Offices (e.g., OMH, OWH). • Goal: To provide updates on progress toward achieving NHAS targets as described in the HHS Operational Plan. • Cross-cutting issues: • Opportunities to better address needs of high priority groups • Consideration of RW reauthorization in light of ACA • Policy implications of recent scientific developments (HPTN 052) • Plans for IAS 2012 • Identify new opportunities for Federal coordination and collaboration

HHS Operational Plan: HIV Testing Highlights – Sept, 2011 HHS OS Deployed FY12 Secretary’s Minority AIDS Initiative to fund new HIV testing in racial and minorities (CDC, IHS) Facilitated the enhancement of HIV testing in behavioral health clinics (SAMHSA) Developed online links to HIV testing locations, federally funded care clinics, housing, and other supports via AIDS.gov Hosted WG meetings with Faith Leaders to encourage HIV testing and fight HIV-related stigma Will finalize recommendations to HHS/OS on core indicators, data streamlining, and reducing grantee reporting requirements (Dec., 2011)

HHS Operational Plan: HIV Testing Highlights – Sept, 2011 CDC • Implemented Expanded Testing Initiative • Launched ECHPP in 12 MSAs with greatest AIDS burden, and revolutionized program planning and implementation • Launched new Health Department FOA, emphasizing high impact prevention in areas of greatest need. • Developed new HIV testing and linkage initiatives for MSM, young MSM and Transgender persons of Color • Will finalize HIV testing guidelines in non-clinical settings (with HRSA/SAMSHA) • Will launch a new social marketing campaign and test combination prevention targeted to Latino communities

HHS Operational Plan: HIV Testing Highlights – Sept, 2011 IHS • Doubled new sites for Expanded Testing Initiative, including Tribal and Tribal organizations • Increased HIV tests ~20% between 2009-2010 SAMHSA • Issued new FY12 Block Grant focuses on HIV testing • Issued an FOA to expand integrated behavioral health and HIV care for racial/ethnic minorities in 12 Cities • Will finalize a needs assessment on HIV testing capacity in substance use and mental health clinics • Will issue guidance on improving linkage to substance use treatment and mental health services for PLH

HHS Operational Plan: HIV Testing Highlights – Sept, 2011 HRSA • Released a Program Assistance Letter to ensure medical providers at its 1,100 health centers comply with routine HIV testing recommendations • Hosted web-based training to National Health Service Corps clinicians on HIV testing • Will work with Federal partners to use SPNS data to improve linkage to care following an HIV diagnosis FDA • Approved ARCHITECT Ag/Ab Combo assay, a 4th generation diagnostic test that can detect both antigen and antibodies for HIV • Approved INSTI™ HIV-1 Antibody test, yields results in 60 seconds

HHS Operational Plan: HIV Testing Highlights – Sept, 2011 CMS • Expanded Medicare to cover HIV screening tests (2009) • Enhanced the Women’s Preventive Service to include HIV testing (Aug, 2011) NIH • Funded new grants on peer-driven or network-based testing (Gwadz DA34083; Latkin DA32217), increasing screening for acute HIV infection (Remien MH92187), and molecular epidemiology of HIV transmission (Chan AI96923) • Fielded HPTN 065/TLC+, a feasibility study of community-level test, linkage, and treatment strategy in the U.S.

Reducing HIV Incidence: Challenges & Opportunities • Cultural shift from risk-based to routine HIV testing • Challenges in identifying acute HIV infection • Information gap about effective combinations of interventions • Ongoing structural challenges of incorporating HIV prevention into systems of care

Access to Care: Challenges & Opportunities • Lack of precise population-based estimates of number of infected persons not in care/treatment • Disconnect between systems of care (public/private, vertical federal programs) • Lack of a unified national electronic medical record (EMR) • Need to identify resources to support organizational components for linkage/retention in care • Must prepare workforce for a larger number of newly diagnosed persons

Reducing HIV Health Disparities: Challenges & Opportunities • Inadequate surveillance capacity to routinely monitor community viral load • Ongoing HIV stigma, confounded by racism, sexism, homophobia, transgender phobia • Preparing community health workers to incorporate NHAS into their service agendas • Lack data about structural interventions to influence social determinants of health

Improving Federal Coordination: Challenges & Opportunities • Lack of common definitions, metrics, & policies in funding announcements • Multiple, often independent processes for making recommendations about testing & treatment • Federal data systems are not typically interoperable • Striking an appropriate balance between organizational centralization and decentralization: policy, practice, priority setting

NHAS Implementation • Strategy at work through federal agencies (Ops Plans) • New strategic investments (ECHPP, ADAP, MAI) • Make necessary policy changes (funding formulas, HD FOA) Next steps • Strengthen new state, city, local, and tribal partnerships • Empower communities to implement NHAS • Define common metrics to measure progress • Streamline administrative burden while maintaining accountability Source: http://aids.gov/federal-resources/policies/national-hiv-aids-strategy/hiv_aids_july_2011.pdf

“What Can I Do?” • Read the Strategy and accompanying Federal Implementation Plan available online at AIDS.gov • Follow updates on the Strategy blog (blog.aids.gov), which features posts from the Office of National AIDS Policy, HHS officials, and others. • Inform others about the Strategy and encourage their engagement in activities that help achieve its goals. • Discuss what your agency or organization can do in new or different ways to better serve your constituents and align your efforts with the Strategy • Participate in state and local discussions about how HIV prevention, care and treatment efforts can better serve vulnerable populations • Engage new partners in HIV prevention, care, treatment and stigma-reduction efforts to strengthen our collective efforts

Vision of the NHAS “The United States will become a place where new infections are rare and when they do occur, every person, regardless of age, gender, race/ethnicity, sexual orientation, gender identity or socio-economic circumstance, will have unfettered access to high quality, life extending care, free from stigma and discrimination.”

For more information about NHAS Implementation, please visit: AIDS.gov Send questions or comments to: Andrew.Forsyth@hhs.gov

Achieving the Goals of the National HIV/AIDS Strategy: An Update