Supporting California's HIV Care Needs

Supporting California's HIV Care Needs

An Initial Meeting of Training, Consultation and Professional

Organization Partners

October 16, 2008

AgendaAgenda

10:00 – 10:30 Introductions & Agenda Review

10:30 – 11:00 Overview of Office of AIDS

11:00 – 12:00 Overview of Partner Programs

12:00 – 12:45 Lunch

12:45 – 1:00 Clarifying questions from AM

1:00 – 2:45 Discussion

2:45 – 3:00 Wrap-Up and Next Steps

Partner Presentations: Training, Professional Organizations,

Care and Public Health Networks

Partner Presentations: Training, Professional Organizations,

Care and Public Health Networks

1. PAETC Pacific AIDS Education and Training Center

2. PTC California STD/HIV Prevention Training Center

3. IAS-USA International AIDS Society

4. AAHIVM The American Academy of HIV Medicine

5. HIVMA HIV Medicine Association

6. ANAC Association of Nurses in AIDS Care

7. CMA California Medical Association

8. CDCR California Department of Corrections and Rehabilitation

9. VA Veterans Affairs Administration

10.KP Kaiser Permanente

11.CCLAD California Conference of Local AIDS Directors

Unable to attend: NMA, UCD Telemedicine

Afternoon DiscussionAfternoon Discussion

Our vision is for every person in California with HIV infection to receive high quality medical care.

1. How can OA facilitate and support increased coordination and collaboration among partner groups, to maximize the impact of our work to provide high quality care and support to people with HIV throughout the state.

2. Creating an Emergency Response Network for HIV care and support.

3. Are there other professional organizations with a focus on HIV care and/or clinical training and consultation in California • e.g., professional organizations representing HIV clinical pharmacists,

Family Medicine, Internal Medicine, Physician's Assistants, etc

OA’s Primary FunctionsOA’s Primary Functions

1. Surveillance

2. Epidemiology

3. Education and Prevention

4. Care, Treatment and Support

5. Program Evaluation

6. Policy

Approximately 150 staff positions

HIV/AIDS Core SurveillanceHIV/AIDS Core Surveillance

• Confidential case registry of demographic and clinical information on all reported California HIV and AIDS cases

– OA collects data from local health jurisdictions – records forwarded to CDC to monitor the

epidemic nationally

• Data are also used to:– determine federal Ryan White allocations– provide current information on HIV/AIDS

epidemiology to HIV/AIDS programs and planning councils

HIV Incidence Surveillance (HIS)HIV Incidence Surveillance (HIS)Core Surveillance HIS

Measures New diagnoses

HIV Prevalence• Existing cases

New infections

HIV Incidence

• New cases

Data collected • Demographic information

• HIV risk

• HIV test result

• AIDS Indicators

Also:

• Past HIV testing history

• Medications to treat or prevent HIV (ART)

• STARHS test result from remnant blood specimen

Uses of data Both important to guiding prevention and care;

resource allocation.

Changes in burden of disease.

Where infection is spreading

What Is STARHS?What Is STARHS?

• Antibody-based laboratory testing method that allows CDC to identify, with reasonable probability, how many newly reported HIV infections in any given population are recent – i.e., within the previous 6 -12 months

Requirements for HIV Incidence Surveillance

Requirements for HIV Incidence Surveillance

Remnant HIV+ Serum Supplemental Data

HIV Incidence Estimation

STARHS Testing using BED Assay

Testing and Treatment History

Key Non-Health Department Partners in HIS

Key Non-Health Department Partners in HIS

• Providers: – Ensure new patient records include testing

and treatment history (TTH)• First positive HIV Test• Last negative HIV test• Exposure to antiretroviral medication

– Facilitate completion of HIV/AIDS case report form when new case is ascertained

• Labs:– Ship remnant serum samples to central

facility for STARHS testing

Key Health Department Partners in HIS

Key Health Department Partners in HIS

• Local Health Departments– Collect core surveillance variables and TTH

data through receipt from providers and active surveillance

• Office of AIDS– Raise awareness and interest– Guidance, technical support and monitoring– Data management and transfer to CDC– Complete California incidence estimation

Select Epidemiologic Studies Select Epidemiologic Studies

• Medical Monitoring Project (MMP)• Secondary surveillance of people in care

• Linkage of HIV/AIDS and STD and TB registries• HIV/AIDS Border Epidemiologic Profile

• Influence of SB1159 (pharmacy-based syringe disposal) on Unsafe Syringe Discard

• Evaluation of Sexual Barrier Device Distribution in State Prison Setting (with CDCR)

Surveillance Stakeholder Meetings

Surveillance Stakeholder Meetings

1st: April 9-10, 2008• Purpose: Provide opportunity for consensus-

building discussion regarding current and future HIV reporting policies and regulations

• Attendees: – LHDs (incl. CCLAD, CCLHO)– Surveillance coordinators– Laboratory directors– Health care providers– Service organizations serving HIV-positive patients– Advocates

Meeting AgendaMeeting Agenda

Day 1– What’s Working at the State and Local Levels

– Data Transmission: Encryption, Faxing and Mailing

– HIV and AIDS Reporting Consistency

Day 2– Centralized Laboratory Reporting

– Uses of HIV/AIDS Data for Public Health Purposes

– Policy and Funding Implications of including HIV/AIDS Reporting in Other Communicable Disease Reporting Regulations

Outcomes and Next Steps Outcomes and Next Steps

• Workgroup #1: Data Transmission Issues

• Workgroup #2: Centralized Laboratory Reporting

• Workgroup #3: Considerations Regarding Possible Uses of HIV/AIDS Data for Public Health Purposes

– eg Partner Services, case management

Next Meeting December 3, 2008

HIV Counseling & Testing ProgramHIV Counseling & Testing Program

• Approximately 125,000 HIV tests a year

• Anonymous and/or confidential HIV counseling and testing services sites

• Client-focused prevention counseling and assessment of client needs

– Risk-reduction planning and referral to other services

• Linkages to HIV care and treatment

Opportunities to increase HIV screening in CaliforniaOpportunities to increase

HIV screening in California

CDPH/Office of AIDS Considerations:

What role can we play?

October 2008

Reduce Barriers to HIV screening

Reduce Barriers to HIV screening

• Expand in new and existing venues• Take full advantage of

– CDC guidelines (2006) – Legislation (AB682) eliminating written consent

requirement for performing an HIV test (2008)– Legislation (AB1894) requiring reimbursement

by private insurers for HIV screening (2009)– Recent incidence and prevalence reports from

CDC (2008)

Needs that OA could address to facilitate increased HIV screening by venue

Needs that OA could address to facilitate increased HIV screening by venue

• Identify appropriate test method(s) and associated training and support needs

• Consider reimbursement sources/existing billing infrastructure and associated training and support needs

– identify remaining areas in need of financial support

• Consider ‘enhanced’ data needs and associated financial, training and support

Venue considerationsVenue considerations

• * Outpatient settings – Providing continuity care– Providing as-needed care

• * Inpatient settings

• Corrections (prison, jail, juvenile)

• Substance use treatment

• Other non-clinical settings (e.g., CBOs, mobile testing programs, health fairs)

* Current focus for this discussion

Outpatient settingsOutpatient settings

• Providing continuity care– TB clinics– Primary care co-located with HIV care clinics– Other primary care (e.g., Family Practice,

General Int. Med, Women’s Health)

• Providing as-needed care– STD clinics– Emergency Departments– Urgent Care clinics– Family Planning clinics

Inpatient settingsInpatient settings

• Medical wards

• Psychiatric wards

• Surgical wards, e.g., – Trauma– Services caring for infectious processes

Consider venue-specific purpose of HIV screening/testing

Consider venue-specific purpose of HIV screening/testing

• Screen only (with minimal education)

• Screen + provide expanded education

• Test + provide prevention interventions

No matter the venue…No matter the venue…

• All are provided with basic information on the HIV test, voluntary nature of testing, and educational materials on how to remain negative

• All HIV-positive clients – receive appropriate results disclosure – are given accurate HIV care/treatment linkages as

well as appropriate assistance in accessing referrals

• Minimum data elements

OA role in all venuesOA role in all venues

• Consider venue-specific training and technical assistance needs related to:

– Specific test technology – Education – Disclosure and other counseling– Care and support linkages– Financial eligibility screening– Data issues

• Coordinate or contract with appropriate venue-specific training and TA partners

Progress to DateProgress to Date• CDPH/OA has identified preliminary venue

types and a process to determine how approach scale-up of HIV screening with well-managed resource assistance from CDPH/OA– Continuing internal process to refine thinking – Initiating discussions with CDPH and external

partners– Prioritize and pilot – Identify existing funding sources to support

Primary care co-located with HIV clinics

Purpose Test Method Financial Eligibility Screening

Additional Data

Training Financial Needs from OA

Partners

Screen + Educate

(Education opportunity given continuity care)

Standard Yes No Test-specific training

Disclosure

Linkages

Eligibility

Lab costs as payer of last resort

Training and TA

PAETC

PTC

(AAHIVM)

(CMA)

(CA Primary Care Association)

(CA Family Health Council)

(NMA)

(Community (Community Health Center)Health Center)

e.g., Altamed, SFGH outpatient clinics, Tom Waddell

TB ClinicsPurpose Test Method Financial Eligibility

ScreeningAdditional Data

Training Financial Needs from OA

Partners

Screen +Educate

(TB-specific education)

Active TB cases: clients seen more than once and blood is drawn. Whichever test fits best with clinic flow.  Contacts: clients seen more than once so rapid not required. If PPD, oral fluid preferred. If Quantiferon standard preferred due to cost (rapid blood is alternative). LTBI: single visit, so rapid test. Oral fluid if no phlebotomy to help make the decision about whether or not to initiate LTBI treatment with a preliminary positive result.

Bill Medi-Cal if available. Most TB clinics are set up to bill Medi-Cal.  Both Medi-Cal categories have to meet income (low) and immigration (legal) criteria.  Regular Medi-Cal pays for folks who would qualify for regular Medi-Cal (children and adults with minor children). Regular Medi-Cal would pay for LTBI treatment and contact evaluation for eligible persons.   TB Medi-Cal pays for outpatient services for people who would not qualify for regular Medi-Cal (single adults).  TB Medi-Cal is only for cases and suspects.  TB cases that are co-managed with LHD and private sector and LTBI treated in the private sector: bill private insurance.  

All others for whom LHDs cover services:

OA support

Neg: None

Pos: None beyond TB/AIDS registry match

TOT to create system

HIV-TB education

Test-specific training

Disclosure

Linkages

Eligibility Data

Test kits or lab costs as payer of last resort

In process:

Initial Training

limited on-going TA

Curry Training Center

TB Control Branch

(Targeted case management pays for some LHD case management activities that might apply to all cases. These people may be available to assist with these activities)

Implementation of HIV Screening in Acute Care Settings: A Strategic Planning Workshop for Hospitals

Implementation of HIV Screening in Acute Care Settings: A Strategic Planning Workshop for Hospitals

October 22-24, 2008• Sponsored by CDC and OA

– Attendees: Up to 17 California hospitals and clinics - administrators and staff

– Purpose: To provide hospital teams with an opportunity to hear from “early adopters” of HIV screening and problem-solve on how they can implement HIV screening in their emergency departments, urgent care, and other inpatient and outpatient departments.

Prevention Think TankPrevention Think Tank

May 13-14, 2008• Purpose: To create an opportunity for

prevention and care providers, funders, researchers, and public health officials to review current status of selected HIV prevention strategies and assess possibilities for scale-up in the future

Attendees Attendees

• LHDs• University-affiliated researchers • HIV prevention providers• CDC managers and behavioral scientists• NIMH scientist• Physicians providing direct care to clients• State partners: STD, PTC, Lab• 25 members of OA management and staff

Agenda TopicsAgenda Topics

Day One1. Post-exposure Prophylaxis (PEP)

2. Prevention with Positives

3. Acute HIV testing

4. Behavioral Interventions

Day Two5. HIV testing in Emergency Depts. and hospitals

6. HIV testing in STD and other clinics

7. Partner Counseling and Referral Services (PCRS)

Prevention Think Tank….morePrevention Think Tank….more

• “Big picture discussions:” Prioritization, Evaluation and Capacity-building

• Outcomes/Next Steps:– Report on website

– Focus groups, key informant interviews and additional focused meetings

– Convene additional stakeholders, including community partners, providers, consumers

– Discussion with CCLAD, CHPG, LAB, CAHAAC, other community partners

HIV Prevention Policy &Program Development

HIV Prevention Policy &Program Development

• Addresses emerging risks by responding to the needs of priority populations, including:

– African American– Latinos– Women of Childbearing Years– Transgendered Persons– Injection Drug Users

• Analyzes proposed legislation related to HIV prevention and provides recommendations to the CDPH administration.

CARE Services ProgramCARE Services Program

• Contracts with 36 health department and community based organizations in all 58 counties

• Access to a comprehensive continuum of community-based medical care and support services

Early Intervention SectionEarly Intervention Section

EIP: 36 sites

8,655 active clients as of 7/1/06

Positive Changes: 20 sites

830 clients served in FY 07-08

Pathways: 17 sites

Bridge Project: 36 sites

1120 clients served in FY 07-08

TMP: 130 statewide provider sites

18,663 clients served in FY 06-07

Case Management ProgramsCase Management Programs

• CMP– RN- and SW-based medical case

management– 44 contractors statewide in 52 counties

• Medi-Cal Waiver– 2580 served in CY 2007

AIDS Drug AssistanceProgram

AIDS Drug AssistanceProgram

• Provides drugs for individuals who could not otherwise afford them. Drugs on the formulary slow the progression of HIV disease, prevent and treat opportunistic infections, and treat co-morbidities and the side effects of antiretroviral therapy.

• Currently 181 drugs on the ADAP formulary

• Serves approximately 32,800 clients annually

• Approximately 3,870 pharmacies in the network

• Approximately 217 enrollment sites

CARE/HIPP CARE/HIPP

Maintain private health insurance coverage and assist with Medicare Part D prescription coverage

• Pays insurance premiums• Pays Medicare Part D premiums for ADAP clients

who do not qualify for Full Low Income Subsidy. – As of July 2008, premiums were paid for approximately

865 clients.

CDPH Integration EffortsCDPH Integration Efforts• Common data elements/forms

– Evaluate co-infection and risks

• HIV screening in: – TB programs– STD programs

• Increased uptake of Partner Services• STD, hepatitis and TB screening in HIV

programs

Integration in OAIntegration in OA

• Surveillance, Epi, Program Development and Evaluation

• Prevention and Care

• Care and Treatment

• Population-specific focus

OA Organizational ChartOA Organizational ChartDIVISION CHIEFMichelle Roland

___________________ASSISTANT DIVISION CHIEF

Christine Nelson

HIV EDUCATION & PREVENTION SERVICES

BRANCHKevin Farrell

ADMINISTRATION SECTION

Dawn Munoz

HIV/AIDS EPIDEMIOLOGY

BRANCHJuan Ruiz

AIDS DRUG ASSISTANCE PROGRAM

SECTIONTherese Ploof

HIV CARE BRANCHPeg Taylor

CARE SECTIONClarissa Poole-Sims

EARLY INTERVENTION SECTION

Carol Russell

COMMUNITY BASED CARE SECTIONRichard Iniguez

EPIDEMIOLOGY STUDIES SECTION

Mark Damesyn

AIDS CASE REGISTRY SECTION

Teresa Lauchaire, Acting

CARE RESEARCH & EVALUATION SECTION

Susan Sabatier

HIV PREVENTION RESEARCH &

EVALUATION SECTIONChristopher Krawczyk

HIV COMMUNITY PREVENTION SECTION

Gail Sanabria

HIV PREVENTION POLICY & DEVELOPMENT

SECTIONBrian Lew

HIV COUNSELING, TESTING & TRAINING

SECTIONSandy Simms

CONTRACTS & GRANTS UNIT

Vacant

CLERICAL SUPPORT UNIT

Vikki Stone

AIDS DRUG ASSISTANCE PROGRAM

UNITSteve Berk, Acting

CARE/HIPP UnitCynthia Smiley

SURVEILLANCE PROCESSING UNITTheresa Lauchaire

ADMINISTRATIVE SERVICES UNIT

Sarah Hendrickson