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Linkages between Family Planning
and HIV/AIDS Medical Care
HIV Prevention Project Annual Technical Support
Meeting
December 5, 2013
Laura W. Cheever, MD
Associate Administrator
Department of Health and Human Services
Health Resources and Services Administration
HIV/AIDS Bureau
Disclosure The following people have no relevant financial, professional or personal
relationships to disclose:
Faculty:
Laura W. Cheever, MD
CNE Program Planner(s):
Melanie Steilen, RN, BSN, ACRN
Iris Stendig-Raskin, MSN, CRNP, WHNP-BC
CNE Program Reviewer:
Iris Stendig-Raskin, MSN, CRNP, WHNP-BC
There are no commercial supporters of this activity.
Learning Objectives By the end of the presentation participants will be able to:
1. Explain the impact of the Ryan White HIV/AIDS Program
(RWHAP) on outcomes for people living with HIV
2. Describe key features of the transition of the RWHAP
into the new healthcare environment
3. Delineate several key challenges in the care of women
living with HIV today in the United States.
Ryan White HIV/AIDS Program - Intent
• Increase access to care for people living with HIV disease domestically
• Safety net for uninsured and low-income individuals living with HIV/AIDS
• Funding for: – Primary health care including medications and
support services
– Provider training, technical assistance, demonstration projects (SPNS)
4
Basic Tenets of Ryan White • Local planning and prioritization of funding
based on needs assessment
• Involvement of people living with HIV/AIDS in the planning process
• Funding of both primary care and support services to improve access to care – Support of a multidisciplinary team
– Building of a medical home
• Quality of care
5
Ryan White HIV/AIDS Program Structure
• Cities (Part A)
• States and Territories (Part B)
– AIDS Drug Assistance Program (ADAP)
• Health Care Agencies
– Early Intervention Services and Capacity Development (Part C)
– Women, Infants, Children and Youth (Part D)
• Other programs (Part F)
– Dental, Education/Training, Planning, Capacity Development and Demonstrations, Minority AIDS Initiative
6
Ryan White HIV/AIDS Program – Part D
• Part D program funds family-centered outpatient or ambulatory
care (directly or through MOUs and contracts) for women, infants,
children, and youth (WICY) living with HIV/AIDS
• Funding may also be used to provide support services to PLWH
and their affected family members
• Currently fund 114 WICY programs in 38 states and Puerto Rico
• All funds are awarded competitively
Ryan White HIV/AIDS Program - Part F/Training
• AIDS Education and Training Center (AETC) Program: • Supports a network of 11 regional centers (and more than 130 local
associated sites) that conduct targeted, multidisciplinary education and training programs for health care providers treating PLWH
• The AETCs provide training in all states, territories, DC, Puerto Rico and Virgin Islands
• Also fund three National Centers:
o National Clinicians Consultation Center
o National Resource Center
o National Evaluation Center
Ryan White HIV/AIDS Program –
Part F/Special Projects of National
Significance (SPNS)
Part F SPNS funds:
• Innovative models of care and supports the
development of effective delivery systems for HIV care
• Dissemination of successful models for replication and
integration by Ryan White HIV/AIDS Program funded
grantees
• Development of a standard client-level data system
(which began in 2007)
Part F: Minority AIDS Initiative
Minority AIDS Initiative (MAI):
• Provides funding to evaluate and address the disproportionate
impact of HIV/AIDS on racial and ethnic minorities
o Addresses disparities in access, treatment, care, and outcomes
• MAI funding provided for Parts A, B, C, D, and F/AETCs
Key Provisions of Ryan White
• Payer of last resort
– Can “wrap around” other insurance
• 75% core services/ 25% support services
– Core: outpt care, labs, meds, case management, mental
health tx, substance abuse tx, oral health
– Support: transportation, emergency housing, child care, food
assistance
– Can apply for Waiver if: no ADAP waiting list and core
services available to all eligible patients
• Funding based on living HIV/AIDS cases in the most
recent year of data
11
Core Medical Services for Parts A, B, and C
(N=13)*
• Outpatient and ambulatory health services
• AIDS Drug Assistance Program treatments
• AIDS pharmaceutical assistance
• Oral health care
• Early intervention services
• Health insurance premium and cost sharing assistance for low-income individuals
• Home health care
• Medical nutrition therapy
• Hospice services
• Home and community-based health services
• Mental health services
• Substance abuse outpatient care
• Medical case management, including treatment adherence services
* 75% of funds for Parts A, B, and C must be spent on Core Medical Services
13
Ryan White HIV/AIDS Program – Examples of
Support Services Funded
Support Services:
• Outreach
• Transportation
• Emergency housing assistance
• Health insurance continuation
• Legal services
• Child care
• Respite services
• Psychosocial support services
2013 Ryan White HIV/AIDS Appropriations $2.248 Billion
$624.3
$401.2 $886.3
$194.4
$72.4
$32.4 $12.6 $25.0 Part A 28%
Part B 18%
Part B ADAP 39%
Part C 9%
Part D 3%
AETC 1%.
Dental 1%
SPNS 1%
Zero New Infections
The Ryan White HIV/AIDS Program (RWHAP) supports the goals of the National HIV/AIDS Strategy by: Funding a comprehensive care systems for low-income people
living with HIV (PLWH) that: Reduces new HIV infections Improves health outcomes and increases quality of life for PLWH Decreases HIV-related health disparities
Including PLWH in the planning of services Employing a public health approach to care and treatment
Ryan White HIV/AIDS Program
Accomplishments Ryan White HIV/AIDS Program:
• Provides care, treatment, and support services to approximately half of the PLWH in the U.S.
• Specifically, of an estimated 1.1 million PLWH in U.S., Ryan White HIV/AIDS Program served 553,986 uninsured and underinsured in 2011
• Built networks and systems of care with and between public and private providers for a comprehensive response to the epidemic
• Extended knowledge base and expertise to improve the quality of HIV/AIDS care and treatment across the health care system
Who the Ryan White HIV/AIDS Program
Serves • Females: 30%
• Age:
– 13-24 years (6.4%)
– 25-29 years (6.8%)
– 30-39 years (18.3%)
– 40-49 years (32.9%)
• Race/Ethnicity:
– Black non-Hispanic (47.3%)
– White non-Hispanic (27.8%)
– Hispanic/Latino (21.9%)
Women Who Received RWHAP-funded
HIV Medical Care 2011 (preliminary)
• 56% of females received RWHAP-funded HIV
medical care
– 48% of which were in childbearing years (15-44)
• 4% of females who received RWHAP-funded
HIV medical care were pregnant in 2011
Who the Ryan White HIV/AIDS Program
Serves
• 553,999 clients served in 2011
• Uninsured:
– 28% uninsured for non-ADAP services (approximately
128,000) (HRSA CLD 2011)
– 65% uninsured in ADAP 2012 (NASTAD Request For
Information)
• Income of the uninsured:
– 69% <100% FPL
– 21% 101-200% FPL
Who the Ryan White HIV/AIDS Program
Serves
• Conclusion
– Most RWHAP patients for non-ADAP services
have coverage
– Most uninsured will qualify for Medicaid in
states where it is expanding
HIV Medical Care Ryan White Services Report 2011 (preliminary)
57.3% of non-ADAP clients
received RWHAP-funded HIV
medical care in 2011.
Retention in HIV Medical Care
Ryan White Services Report 2011 (preliminary)
Retained in HIV medical care: At least 2 HIV medical visits that were at least 90 days apart
75.5% of non-ADAP clients who received
RWHAP-funded HIV medical care in 2011
were retained in HIV medical care.
Viral Suppression
Ryan White Services Report 2011 (preliminary)
Viral suppression: Most recent HIV-1 RNA <200 copies/ml
72.6% of non-ADAP clients who received
RWHAP-funded HIV medical care in 2011
were virally suppressed.
Retention and Viral Suppression by Age Category
Ryan White Services Report 2011 (preliminary)
Health Coverage Options for PLWH
BEFORE the Affordable Care Act
Note: Data only reflective of Ryan White HIV/AIDS Program clients, not of entire HIV/AIDS
population; Source: 2011 Preliminary Ryan White Services Report Data (RSR)
Health Coverage Options for PLWH AFTER
the Affordable Care Act
Medicaid Medicare
Employer-Based
Insurance
Health Insurance
Marketplace
Other Public
Other Private
Ryan White
HIV/AIDS Program
Cover comprehensive HIV
medical and support services
not covered, or partially
covered, by public programs
or private insurance
Cover comprehensive HIV
medical and support services
not covered, or partially
covered, by public programs or
private insurance
PLWH eligible for health
coverage
PLWH who remain uninsured
Payer of Last Resort Requirements
within the Context of ACA
• By statute, RWHAP funds may not be used “for any item or service
to the extent that payment has been made, or can reasonably be
expected to be made…” by another payment source
• Grantees and their contractors are expected to vigorously pursue
enrollment in other relevant funding sources (e.g., Medicaid, CHIP,
Medicare, state-funded HIV/AIDS programs, employer-sponsored
health insurance coverage, and/or other private health insurance)
• RWHAP grantees must make every effort to ensure that individual
clients who are not eligible for public programs (Medicaid, CHIP,
Medicare, etc.) and not exempt from the Affordable Care Act’s
requirement to enroll in health coverage, are assessed for eligibility
for private health insurance
• RWHAP will continue to pay for items or services received by
individuals who remain uninsured or underinsured
How is HRSA Preparing Grantees for ACA?
• HRSA is working on administrative flexibility and
guidance to grantees necessary to assure a
smooth transition of the program with ACA
• HRSA’s accomplishments to date:
oCommunication with Grantees
oDevelopment of Policies
oTraining
oDevelopment of technical assistance tools
Collaborating Across Federal Government
• RWHAP legislation specifically references
coordination across DHHS
• National HIV/AIDS Strategy
• Collaborate and coordinate to:
– Align across Federal programs to reduce reporting
burden on grantees
– Partner to advance evidence base and develop
interventions to improve care and treatment across the
HIV Care Continuum
– Share resources and expertise to build capacity at the
grantee level
Perinatal Care for HIV-infected Pregnant
Women
Health care providers considering the use of ARV
agents for HIV-infected women during pregnancy
must take into account two separate but related
issues:
• ARV treatment of maternal HIV infection
and
• ARV chemoprophylaxis to reduce the risk of
perinatal transmission of HIV
MTCT: From Epidemic to Elimination Lynne Mofenson (NIH)
• The reasons for U.S. success include focus on family planning, prenatal care, universal HIV testing, antiretroviral therapy as prevention, and treatment adherence.
• These lessons are being applied in the resource limited settings with success.
– South Africa: MTCT rate decreased from 3.5% to 2.7% from 2010 to 2012
– Malawi: Option B+, rates 2-6% related to breastfeeding
• How can we apply these best practices to eliminate HIV infection in U.S. adults and adolescents?
Mofenson L. CROI 2013. Abstract 15.
HIV and Unintended Pregnancy in
Women: Background Context
• 17 million HIV-infected women globally
• >150 million women use a hormonal
contraceptive (HC) method
– Nearly 60% of HC users in sub-Saharan Africa
use contraceptive injectables
• Highly effective contraceptive methods prevent
unintended pregnancy, maternal/infant morbidity
and mortality, and perinatal HIV
Polis C and Heffron R. CROI 2013. Abstract 111.
Unplanned Pregnancy
• N=151 HIV+ women, completed survey on
preconception counseling and pregnancy intention
• Unplanned pregnancies among HIV+ women:
24%
• 53% of women reported discussion of pregnancy
intentions prior to pregnancy with health care
provider
Rahangdale L et al. CROI 2013. Abstract 896.
HIV Testing among Commercially Insured
Pregnant Women: US, 2009-2010
Year # Live Births HIV tested during
pregnancy, all ages
HIV tested during
pregnancy, 18-34 years
2008 73.8%
2009 173,882 74.7% 77.7%
2010 177,930 75.7% 77.5%
• Limitations: study sample not representative of U.S. population
• Highlights missed opportunities for perinatal HIV prevention
Taylor et al. CROI 2013. Abstract 904.
Real Time Decision Support
• Perinatal HIV Hotline
1-888-448-8765 • Free 24-hour clinical
consultation and advice on:
o Management of HIV in pregnant women
o HIV testing in pregnancy
o Care of HIV-exposed infants
o Perinatal HIV Network:
Callers can be linked with local perinatal HIV specialists
• Public Health Service Guidelines
• Panel on Treatment of HIV-
Infected Pregnant Women and Prevention of Perinatal Transmission.
• Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Available at http://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf
HIV/AIDS Bureau’s Affordable Care Act
Resources • HIV/AIDS Bureau’s Affordable Care Act webpage: “Ryan
White Program & the Affordable Care Act: What You Need to Know”: http://www.hab.hrsa.gov/affordablecareact/index.html
• On this page you may:
Sign up for updates
View and download slides from the HIV/AIDS Bureau’s recent webcasts
Review FAQs, a glossary of terms, and view policies
• Email Ryan White HIV/AIDS Program/Affordable Care Act questions to: [email protected]
Contact Information
Laura Cheever, MD
Associate Administrator
Department of Health and Human Services
Health Resources and Services Administration
HIV/AIDS Bureau
301-443-1993