HIV INTEGRATED PLANNING Developing a Single Planning Approach to HIV Prevention,

LOS ANGELES COUNTYCOMMISSION ON HIV Slide 1

Michael Green, PhDMichael Green, PhDChief of PlanningDivision of HIV and STD Programs (DHSP)Department of Public Health, County of Los Angeles

Craig A. Vincent-Jones, MHACraig A. Vincent-Jones, MHAExecutive Director

Los Angeles County Commission on HIV

LOS ANGELES COUNTYCOMMISSION ON HIV

I. Los Angeles County EMA

II. Impetus for Integrated Planning

III. Process for Integrated Planning

IV. The New Configuration

V. Lessons Learned

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LOS ANGELES COUNTYLOS ANGELES COUNTY Most populous county in US. Most populous county in US.

Greater population than 42 Greater population than 42 individual states.individual states.

88 incorporated cities and 88 incorporated cities and many unincorporated areas.many unincorporated areas.

One of the most racially/ One of the most racially/ ethnically diverse areas ethnically diverse areas in the US. in the US.

Urban, suburban and rural areas.Urban, suburban and rural areas.

Divided by the San Gabriel and Divided by the San Gabriel and Santa Monica mountain ranges.Santa Monica mountain ranges.


(1) Estimate that 18.1% of HIV+ in LA County are unaware of their infection; modified from CDC estimate.

(2) Of 4,853 notifications pending investigation, estimate half of 2,400 who have detectable VL or confirmatory test to be unduplicated cases.

(3) Of 4,200 notifications pending investigation, estimate about 2,000 who have detectable VL or confirmatory test to be unduplicated cases.


Announced February 2011 Organizationally realigned the former HIV

Epidemiology Program, Office of AIDS Programs and Policy and STD Prevention and Control

Efficiency and evidence-based driven Largest fully integrated local health department Controls all HIV and STD health department

programming


HIV and STD Prevention and Control HIV Testing Services

Targeted, Routine, Social Network, Mobile Unit-Based STD Screening and Treatment Support

Public Sector/Private Sector HIV Care and Treatment Services Integrated Behavioral Health in Primary Care

Settings Navigation, Linkage, Retention Initiatives Geographic-specific STD Control Effort


Syndemic Planning and Geospatial Analysis Use of Surveillance Data/Data Matching/Data

Sharing Public Health Investigation and Use of Community

Embedded Disease Intervention Specialists Biomedical Interventions (PEP) Integrated TLC+, PrEP and Social Network Testing Housing Services Coordination with HOPWA Medical Care Coordination Integrated Community Planning


Evaluate HIV/STD surveillance, program, and other data to identify areas for programmatic focus, inform planning processes, and implementation strategies by: Matching HIV/STD surveillance and program data to

evaluate testing, linkage, retention, and viral load suppression across the spectrum of engagement in care,

Use of HIV/STD surveillance data to identify geographic areas and populations most impacted by HIV/STD syndemics,

Improve accuracy and efficiency of data collection and facilitate useful reporting.


“It’s going to be messy. Whether you support it, or whether you oppose it . . . it’s going to be messy.”

David Brooks, political pundit, on health care reform

“It’s going to be messy. It’s going to be politically contentious. But it—in the end—it’s going to happen.”

EJ Robinson, political pundit, in response to David Brooks

Accepting that transformational change of any type is difficult—it creates anxiety and disquiet (even among those who support it), and will be full of unexpected events and turns—before you begin . . . is key to a process

that, eventually, finds its way to the desired result.

Accepting that transformational change of any type is difficult—it creates anxiety and disquiet (even among those who support it), and will be full of unexpected events and turns—before you begin . . . is key to a process

that, eventually, finds its way to the desired result.


Improved planning and coordination of services and resources— National HIV/AIDS Strategy (NHAS) Treatment Cascade (national “Continuum of Care”) Early Identification of Individuals with HIV/AIDS (EIIHA) Testing, Linkage to Care, Treatment Plus (TLC+) Enhanced Comprehensive/HIV Prevention Planning

(ECHPP)

Emergence of disparities/inequities/social deter-minants as a key Commission focus and priority


Implementation of the Affordable Care Act (ACA): Need to improve service delivery efficiency and reduce

duplication of effort Prospects of additional savings and resources

Need to generate more enthusiasm/momentum for HIV prevention planning after CDC changes

Consistent with the Commission’s strategic plan Possible reductions in federal and state Ryan White/federal

appropriations and other resources


1)1) Commission and PPC attempted merger in 2002: Commission approved it; PPC opposed it—unanimously PPC was concerned that care/treatment focus would

shift attention away from prevention, Commission’s relationship with DHSP concerned PPC, The planning body votes created hard feelings/

resentments for a decade.

2)2) Quarterly joint Co-Chair meetings not successful.

3)3) Joint Public Policy (JPP) Committee formed, 2008: Three separate attempts to integrate policy work, Both bodies’ single policy unit for five years.



In 2009, Commission and PPC formed a joint “Integration Task Force” to improve collaboration and exchange between the two planning bodies— The first year was spent educating members about the full

range of LA County’s HIV services and activities—and defining terminology acceptable to both groups;

Began integrating care/prevention services/interventions into a TLC+ framework; ECHPP eventually became the predominant strategic prevention approach.


Transformation depends on “change leaders” capable of ascertaining when timing and momentum are right for change (“catalysts for change”): Following International AIDS Conference (IAC), where

“treatment as prevention” was predominant; Improved relations between two planning bodies due to

joint development of Comprehensive HIV Plan; Diminished enthusiasm for HIV prevention planning due to

limited role in CDC’s new HIV Planning Guidance; In preparation for ACA roll-out, HIV service delivery will be

re-organized/re-structured on a broader scale.


Integration Task Force becomes Comprehensive HIV Comprehensive HIV Plan (CHP) Task ForcePlan (CHP) Task Force, to oversee Plan development.

Final Los Angeles County Comprehensive HIV Plan 2013 – 2017 submitted to HRSA and CDC, 3/2013: Links HIV prevention, care and treatment services to NHAS

goals, treatment cascade, and ACA; Local continuum of care consistent with local/national

priorities; addresses disparities/health inequities; Goals/objectives to be monitored/updated annually.


FRAMEWORKFRAMEWORK: The term “unification” was selected carefully—to represent a union of interests, rather than one interest consuming or absorbing the other.

TIMELINETIMELINE: Commission and PPC agreed to complete the process in six months—by July 2013—because:procrastination weakens stakeholder resolve/enthusiasm;the HIV planning body could not devote more time to unification with ACA implementation advancing so rapidly;unification needed a sense of urgency to generate a timely County response (from other, necessary departments).


Following successful development of the CHP, the Commission agreed (unanimous) to “merge” in Spring 2012; PPC agrees (unanimous) in September 2012: Two (2) co-chairs from the Commission/and 2 from the PPC; Merger is formally renamed a “unification”; and CHP Task Force agrees to an expedited timeline.


CHP Task Force anticipated the following challenges: Generating/maintaining stakeholder support/enthusiasm; A continuing, relevant role for HIV community health

planning after implementation of the ACA; Integrating HIV care and prevention perspectives into a

single, jurisdictional HIV response; Presenting HIV care and prevention in a balanced manner

that gives both perspectives sufficient consideration; Synchronizing planning, priorities, allocations and standards

of HIV care and prevention; Effectively blending two distinct organizational cultures.


Los Angeles CountyLos Angeles County Prevention PlanningPrevention PlanningCommission on HIVCommission on HIV Committee (PPC)Committee (PPC)



LA County Board of Supervisors[Chief Elected Official (CEO), per Ryan White (RW)]

LA County Chief Executive Officer (CEO)

Department of Public Health(RW Grantee)

Other StakeholdersProvidersConsumers

Commission on HIV(RW Planning Council and HIV Planning

Group)

Division of HIV/STD Programs(RW Administrative Agency)

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1)1) During Fall 2012Fall 2012, the CHP Task Force recommended hiring a consul-tant to 1) facilitate unification planning, and 2) who had sufficient RWPA/CDC expertise to ensure that federal guidance/expectations would be reliably represented and properly addressed in unification.

2)2) The Task Force felt that using an outside facilitator was beneficial in a number of ways: it would enhance more orderly decision-making, and could mitigate the impact of unexpected surprises or results.

3)3) As a non-conflicted, third-party facilitator, the consultant would also be better equipped to identify and confront subjective bias or unre-solved conflict if it emerged, and to maintain greater objectivity.

4)4) In 12/2012In 12/2012, HRSA approved LA County’s request for Technical Assis-tance (TA) and assigned Emily Gantz McKay to serve as the consul-tant for the unification. Ms. Gantz McKay began her work 1/20131/2013.



MEMBERSHIPMEMBERSHIP: The formation of a unified planning body requires a new membership, and is enacted when the new members are installed:a limited number of membership seats would be added (Board of Supervisors concern);equal attention to RWPA and CDC guidance—even though RWPA “requires” and CDC only “recommends” specifics;anyone wishing to serve on the new planning body must (re-)apply—regardless of a candidate’s current planning body member status or participation on the Task Force.



Interest in joining the new Commission far exceeded the projected response, in part due to (as expressed by applicants): Unification generated community enthusiasm; HIV stakeholders got involved due to changes; Applicants felt it was a new organization; It was an opportunity to bring new issues; Applicants excited about the new direction.

Transitional Open Nominations Process Results: 46 members 46 members and 15 alternates 15 alternates appointed by the BOS—leaving only five (5) seats vacant. Complies with “reflectiveness”/

“representation” requirements from RWPA, and CDC’s Parity, Inclusion and Representation (PIR) recommendations;

Three types of members on the new Commission: returning Commission members, returning PPC members, and new members —representing educational/ orientation challenges. Still Unresolved: Still Unresolved: defining “HIV

prevention” consumer organizationally.

Membership: Membership: 79 applications submitted by first deadline.



Community Engagement Task Force


Still much work left to do before Commission can claim full HIV planning integration . . .

and, . . .some work goes on— indifferent to the time-consuming nature of integration!and, . . .some work goes on— indifferent to the

time-consuming nature of integration!


Much of the work occurs afterwardsMuch of the work occurs afterwards Stakeholder investment/buy-inStakeholder investment/buy-in Support of the grantee/CEOSupport of the grantee/CEO Right/opportune timingRight/opportune timing ““Consumer” definitionsConsumer” definitions Jurisdictional similaritiesJurisdictional similarities Aggressive timelineAggressive timeline Creating enthusiasm and momentumCreating enthusiasm and momentum

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Issue #1Issue #1: How do we define “HIV-negative or prevention consumer” [vs. “unaffiliated (HIV-positive) consumer” from HRSA]?

Issue #2Issue #2: How do we integrate very different “cultures” of the former Commission and former PPC?

Issue #3Issue #3: What is the meaning of “integration” in an organizational setting (vs. used as a programmatic reference)? For example, what are the indicators that an organization has successfully integrated, vs. successfully collaborated or partnered?

Issue #4Issue #4: How do we allocate funds for prevention activities that have already been determined?

Issue #5Issue #5: What are the decisions that must be made before two planning groups can integrate (vs. what decisions can be left to the planning body to make after it has integrated)?

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HIV INTEGRATED PLANNING Developing a Single Planning Approach to HIV Prevention,