HIV/AIDS Bureau Update Ryan White HIV/AIDS Program Clinical Conference New Orleans, LA December 15, 2015 Laura Cheever, MD, ScM Associate Administrator Department of Health and Human Services Health Resources and Services Administration HIV/AIDS Bureau

HAB Vision and Mission Vision 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

2016 Priorities Continue to integrate Ryan White HIV/AIDS Program (RWHAP) with the new health care landscape Implement National HIV/AIDS Strategy: Updated to 2020 (NHAS 2020) Focus on greatest health disparities and care continuum Augment partnerships Advance data utilization to improve health outcomes Enhance national and international leadership Improve HIV/AIDS Bureau (HAB) operations

2016 Priorities Continue to integrate RWHAP with the new health care landscape Documenting what the RWHAP is and does Understanding the dynamic intersections of the Affordable Care Act (ACA) and the RWHAP and beyond Considering how the program should change, to respond to an evolving population of people living with HIV (PLWH)

Ryan White HIV/AIDS Program Moving Forward Framework

Special Study-Emerging Issues Related to ACA Implementation: The Future of Ryan White Services: A Snapshot of Outpatient Ambulatory Medical Care Final Project Report Briefing September 29, 2015

Abt Associates | pg 8 Service Visit Length Clinic visits can vary in length from 15 minutes to four hours, the median times reported ranged from 41 minutes to 145 minutes. Interview Data

Abt Associates | pg 9 Drivers of OAMC Visit Length The activities most often associated with longer OAMC times are primary care treatment and screening and patient education. Interview Data

Conclusions Outpatient Ambulatory Care Visits (OAMC) are complex and more than just “reimburable services ” First category: services that insurers typically cover e.g., diagnostic testing, preventive care and screening, practitioner examination, medical history taking, diagnosis and treatment Second category: intensive OAMC activities that are critical for improved outcomes but may not be reimbursed Education and counseling around prescribing and managing of ARVs, education and counseling on prevention, adherence, and other health issues, care management of chronic HIV-related conditions and referral/provision of specialty care (e.g., behavioral health and support needs)

Overview  Two recent papers illustrate Ryan White HIV/AIDS Program impact using Medical Monitoring Project (MMP) data  Service delivery and patient outcomes in Ryan White HIV/AIDS program-funded and non-funded healthcare facilities (Weiser et al., JAMA Internal Medicine, 2015)  Ryan White HIV/AIDS program assistance and HIV treatment outcomes (Bradley et al., Clinical Infectious Diseases, 2015)  CDC and HRSA collaboration

 Service delivery and patient outcomes in Ryan White HIV/AIDS program-funded and non-funded healthcare facilities (Weiser et al., JAMA Internal Medicine, 2015)  2009 and 2011 MMP data show:  34% of facilities received Ryan White HIV/AIDS Program (RWHAP) funding  73% of patients received care at RWHAP-funded facilities Weiser (paper #1): Main Findings

Services provided by RWHAP-funded and non- RWHAP-funded outpatient facilities

ART prescription and viral suppression RWHAP-funded (%) Non-RWHAP funded (%) P-value Prescribed ART* Viral suppression § *Documentation in the medical record of prescription of antiretroviral therapy §Documentation in the medical record of most recent viral load undetectable or <200 copies /mL

Viral suppression * among low-income § patients % (95% CI)Adjusted prevalence ratio (95% CI) P-value RWHAP73 (70 – 75)1.09 (1.02 – 1.16)0.01 Non-RWHAP67 (62 – 71)Reference *Most recent viral load undetectable or <200 copies /mL § Living at or below the federal poverty level

 Ryan White HIV/AIDS Program Assistance and HIV Treatment Outcomes (Bradley et al., Clinical Infectious Diseases, 2015)  2009 – 2012 MMP data show:  41% of patients received RWHAP assistance  25% received RWHAP assistance as a supplement to another healthcare payer type  15% relied solely on RWHAP assistance for HIV care Bradley (paper #2): Main Findings

Adjusted * prevalence of viral suppression by healthcare payer type and RWHAP assistance *Results from logistic regression model adjusted for age, race, place of birth, poverty, education, homelessness, and HIV disease stage

 Uninsured and underinsured HIV-infected patients receiving RWHAP assistance were more likely to be prescribed ART and to be virally suppressed than those with other healthcare payer types. Bradley (paper #2): Primary Conclusion

Preliminary Analysis of Ryan White Services Report Data from 2014 How is the Affordable Care Act affecting Ryan White HIV/AIDS Program clients, services, and clinical outcomes?

Years of Analysis Prior to the Affordable Care Act After the Affordable Care Act 2014 PRELIMINARY DATA

Health Care Coverage Among HIV-Positive RWHAP Clients, 2012–2014 PRELIMINARY DATA

Health Care Coverage, by Medicaid Expansion Status, 2012–2014 PRELIMINARY DATA

How the RWHAP Needs to Change in Response to Projected Workforce Shortage Gap in understanding of best models of care to support improved outcomes Regional AIDS Education and Training Centers (AETC) program revamped in 2015 Focus on multidisciplinary teams, workforce pipeline, low-volume providers, practice transformation Shift to national curriculum, National Clinical Conference and National Clinical Consultation Center to support more experienced clinicians

2016 Priorities Continue to integrate RWHAP with the new health care landscape Implement NHAS 2020 Focus on greatest health disparities and care continuum Augment partnerships Advance data utilization to improve health outcomes Enhance national and international leadership Improve HAB operations

National HIV/AIDS Strategy: Updated to 2020

National HIV/AIDS Strategy Updated to 2020

Integrated HIV Prevention and Care Plan Guidance, including the Statewide Coordinated Statement of Need, CY Health Resources and Services Administration, HIV/AIDS Bureau/Centers for Disease Control and Prevention, Division of HIV/AIDS Prevention

2016 Priorities Continue to integrate RWHAP with the new health care landscape Implement NHAS 2020 Focus on greatest health disparities and care continuum Augment partnerships Advance data utilization to improve health outcomes Enhance national and international leadership Improve HAB operations

Retained in care: >= 1 OAMC visit before Sept. 1 of the measurement year and at least 2 visits 90 or more days apart Viral suppression: Percent with last viral load test in year < 200 copies Source: 2014 Ryan White Services Report Retention and Viral Suppression

Viral Suppression by State Viral suppression: had at least one OAMC visit, at least one viral load count, and last viral load test <200 Source: 2014 Ryan White Services Report

Retention and Viral Suppression Race/Ethnicity, RSR

RSR 2013 Viral Suppression - Age Viral suppression: had at least one OAMC visit, at least one viral load count, and last viral load test <200

Reducing Viral Load Suppression Rate Disparities for Young People in the RWHAP, RSR VL suppression rate disparity has decreased by ~20% in only 3 years Growth rate in viral suppression is 8.8%, compared to only 4.0% in rest of population

Ongoing Efforts All-Grantee Meeting in 2016 Tentative dates: August 23-26, 2016 in Washington, DC New Webpage: Clinical Conference it will return! Stay tuned for details

Thank You! Dr. Laura Cheever HIV/AIDS Bureau