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STOP HIV/AIDS Pilot: Program Science and Systems
TransformationChris BuchnerRegional Director, PreventionVancouver Coastal HealthApril 30th, 2015
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New Infections in BC
BC CfE Q3 2014
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A provincial initiative to enhance early diagnosis and treatment of HIV with the goal of changing the course of
the epidemic
•3 year, $48 million pilot project •Two pilot sites: Vancouver & Prince George•Evaluation:
• Was diagnosis improved?• Are more people on treatment?• Did we change the course of the epidemic?
Seek & Treat to Optimally Prevent (STOP) HIV/AIDS
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STOP HIV/AIDS Project Goals • Reduce HIV/AIDS cases in Prince George &
Vancouver Inner City• Improve early detection of HIV• Ensure timely access to high-quality & safe
HIV/AIDS care & treatment• Improve client experience in every step of
HIV/AIDS journey• Demonstrate system & cost-optimization
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“If you always do what you’ve always done, you’ll always get
what you’ve always got.”- Henry Ford
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Data as a transformative tool
• Population-level monitoring• Establish current system / program
performance and identify gaps• Set common goals, outcome measures, targets• Program-level evaluation• Establish a common culture and articulate
expectations
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Percent & proportion of new HIV diagnoses with ≥ 1 prior Outpatient, Lab, ER or Inpatient encounter, by CD4 count
* Only 57.5% (291/506) of new HIV Dx had a CD4 count on * Only 57.5% (291/506) of new HIV Dx had a CD4 count on record at time of Dx
CD4 Count* ≥ 1 prior encounter< 200 58% (30/52)< 350 60% (64/107)< 500 55% (97/177)
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Innovation in HIV Prevention
• Health Promotion Case Managers for HIV- people
• NP for HIV- Gay men
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Innovation in HIV Testing
• Routine offer of an HIV test in acute and primary care
• Routine offer of HIV test in key settings (abortion clinics, MH&A programs)
• Peers POC testers• Dental and pharmacy POC• First Nations wellness approach
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Innovation in HIV Treatment & Support
• Clinical outreach pods• Dear Dr. letters• Monitoring retention in care
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Rapid Cycle Monitoring and Adjustment
• Quarterly population level reports– Volumes of HIV tests performed by setting– Contacts elicited and tested– % positivity– CD4 count at diagnosis– Sustained viral suppression
• 6 month evaluation reports by individual initiative
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Mean Monthly HIV Lab Tests per 10,000 Population by LHA
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Proportion of Patients’ CD4 Cell Count and Disease Stage at Diagnosis by Year of Diagnosis
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Number of Contacts Notified and Tested for HIV and Percent Positivity due to Contact Tracing
Integrated Service Delivery System
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Primary & Secondary Health Care
7. TESTING
9. ‘Cultural’ Competency; Monitoring, Surveillance & Evaluation; Information Systems; Policy & Clinical Practice Guidelines; Social Determinants of Health; Education; Community Engagement; Regional Governance
10. References: Expanded Chronic Care Model – Hospital Quarterly Volume 7 (2003); *BC’s Guiding Framework for Public Health Principles with the exception of ‘Proportionate Universality’; Cascade of Prevention & Care – BC Ministry of Health – Hope to Health; Prevention Model – adapted from the UN AIDS HIV Highly Active HIV Prevention Model; Testing Triangle – VCH/PHC STOP HIV/AIDS & IMPACT- HIV
Highly active HIV prevention
Biomedical
Behavioural
Structural
Highly active HIV preventionHighly active
HIV prevention· Primary Care· Mental Health &
Addiction Services· Chronic Disease
Management· School based
prevention· Communicable
Disease Control· Other Public
Health Initiatives
Connection to other settings, related
interventions including:
Self Management
Community Case Management
Complex CM
ARV Support
Disengaged
SM
SM
SM
NEE
D
1. E
xpan
ded
Ch
ron
ic C
are
Mo
del
8. CARE & TREATMENT
2. C
asca
de
of
Pre
ven
tio
n &
Car
e
6. PREVENTION
4. Hope to Health - Goals: 1. Reduce the number of new HIV infections in British Columbia.2. Improve the quality, effectiveness, and reach of HIV prevention services.3. Diagnose those living with HIV as early as possible in the course of their infection.4. Improve quality and reach of HIV support services for those living and vulnerable
to HIV.5. Reduce the burden of advanced HIV infection on the health system.
5. Hope to Health – Milestones for achievement: 1. By 2016, rates of HIV testing in each health service delivery area (HSDA) will be
at or above 3,500 per 100,000 people, each HSDA will have increased HIV testing by at least 50 percent.
2. By 2016, the proportion of people diagnosed early in the course of their infection will meet or exceed 50 percent in each health authority.
3. By 2016, of those diagnosed early in the course of their infection, there will be zero case reports of progression to AIDS.
4. By 2016, at least 90 percent of those medically eligible to access HIV treatment in each health authority will be on treatment.
DRAFT 2013-Jul-24VCH/PHC – Overview of HIV Service Delivery Models
Inp
uts
Inp
uts
(S
urve
illan
ce; e
pide
mio
logy
cu
rren
t & g
ranu
lar;
pro
gram
ev
alua
tion
curr
ent,
gran
ular
&
ongo
ing)
Ou
tco
mes
(Mon
itorin
g &
E
valu
atio
n R
esul
ts)
POPULATIONSETTING
Key populationsPartners of cases
Individuals seeking an HIV test
Key populationsOther clients of
health services forhigh prevalence
population
Entire population
HIV/STI ClinicPartner notification
Community outreachGeneral Health Care Settings
Health services for high prevalence__
populations___
HospitalsFamily Practice__
Health Clinics____
REAC
H
COST
& D
IAG
NO
STIC
YIE
LD
Routine TestingHigh Prevalence Settings
Routine Testing General Health Care Settings
Risk BasedTesting
3. BC’s Guiding Framework for Public Health Principles:· Health Surveillance· Evidence, Evaluation & Innovation· Equity· Working Together· Across the Lifespan· Multiple Settings & Supportive Environments· Proportionate Universality*
Combination HIV Prevention SDM
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Highly active HIV prevention
· Primary Care· Mental Health & Addiction
Services· Chronic Disease
Management· School based prevention· Communicable Disease
Control· Other Public Health
Initiatives
Structural Interventions
Activities designed to alter environmental features so as to create a more enabling environment for HIV prevention, treatment and care and support.
· Community Development/Capacity Building
· Social Mobilization· Service Access Assessment (i.e. Supply
& Availability)· Policy, Legislation & Regulation· Advocacy· Social Supports (e.g. Employment,
Income Supports, Food Security)
Biomedical Interventions
Focus on biological and medical approaches to reducing HIV infection and disease progression.
· Harm reduction supplies (e.g. syringe services & condoms)
· HIV Testing· ART Treatment as prevention· STI Testing/Treatment· PEP/PrEP· Prevention of Mother to Child
Transmission· Partner notification
Behavioural Interventions
Attempt to motivate change, increase targeted positive behaviours, and reduce non-adaptive behaviours at an individual, group, and community level through addressing beliefs, motivations, and skill-building approaches.
· Health Promotion & Skills building
· Education· Social marketing· Intensive HIV Prevention Case
Management
*Examples of Prevention Interventions: Not exhaustive list
Biomedical
Behavioural
4. Combination HIV Prevention Model VCH/PHC
4.1 Connection to other settings, related Prevention
interventions such as:
Inputs (Surveillance; epidemiology current & granular; program evaluation current, granular
& ongoing)
1. Reduce the number of HIV infections in British Columbia.Evidence-informed health promotion, HIV prevention, testing and care will be implemented.
2. Improve the quality, effectiveness, and reach of HIV prevention services.British Columbians vulnerable to infections will be better engaged to avoid HIC exposure and transmission.
2. Hope to Health Prevention related Goals
Health Surveillance
3. BC’s Guiding Framework for Public Health Principles
Structural
Highly active HIV preventionHighly active
HIV prevention
1. Expanded Chronic Care Model
Evidence, Evaluation & Innovation
Equity
Working Together
Across the Lifespan
Multiple Settings & Supportive Environments
Proportionate Universality*
* Proportionate Universality is not included in BC’s Guiding Framework for Public Health Principles, it is defined as actions must be proportionate to the degree of disadvantage, and hence applied in some degree to all people, rather than applied solely to the most disadvantaged. - Michael Marmont – University College of London
Outcomes (Monitoring & Evaluation
Results)
HIV Testing Service Delivery Model
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• Routine testing means offering routinely, diagnostic testing when symptomatic or identified risk
• There is an assumption to provide risk based testing across all population and settings
HIV Care & Treatment Service Delivery Model
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1. BC’s Expanded Chronic Care Model
* Supports available to care providers/teams include:
· Preceptorship· PG guidelines· Collaborative· BCCfE – data linkage· Continued Medical Education· Health care provider in-service· Pharmacy· HIV test course/STI practice certification/
PCRS/POC· Reach line· MH and Addictions Teams· Nutritionists· ID Specialists· Registry· CD Nurses· CDC
3. Hope to Health Engaging & Retaining People in Care:
· By 2015, this proportion of clients on HIV therapy receiving standard of care laboratory monitoring will increase by 50%.
· By 2016, the proportion of all clients on HIV therapy who are currently virally suppressed (i.e. viral load is less than 200 copies/ml) will increase by 50%.
· By 2016, all health authorities will have initiated and evaluated client engagement and client satisfaction activities.
*
DRAFT – DO NOT DISTRIBUTE 2013-Jul-25VCH & PHC – HIV Care & Treatment Service Delivery Model
Health Surveillance
2. BC’s Guiding Framework for Public Health Principles
Evidence, Evaluation & Innovation
Equity
Working Together
Across the Lifespan
Multiple Settings & Supportive Environments
Supports Proportionate Universality**
** Supports Proportionate Universality is not included in BC’s Guiding Framework for Public Health Principles, it is defined as actions must be proportionate to the degree of disadvantage, and hence applied in some degree to all people, rather than applied solely to the most disadvantaged. - Michael Marmont – University College of London
Inputs (Surveillance; epidemiology current & granular; program evaluation current, granular
& ongoing)
Outcomes (Monitoring & Evaluation
Results)
Primary & Secondary Health Care*
Self Management
Community Case Management
Complex Case Management
ARV Support
Disengaged
Self Mgmt
SelfMgmt
SM
Kania, Kramer: Stanford Social Innovation Review, 2011
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Key Lessons in Systems Transformation
• Resources, outcomes and accountability must be seen from a population level
• Data and performance measurement are critical tools for identifying, motivating and quantifying system transformation
• Don’t be afraid to be messy or wrong – everything can be cleaned up later
