Summary of Consultative Meeting

Transcription

1 HIV Preventin fr Gay Men & Men Wh Have Sex with Men: Develpment f a Cmprehensive Plicy Agenda Octber 26, 2010 Summary f Cnsultative Meeting The President released the Natinal HIV/AIDS Strategy (Natinal Strategy) in July 2010 with an aim t reduce new HIV infectins, increase access t care fr peple living with HIV and t reduce HIV-related health disparities in the United States. Althugh the Natinal Strategy identified several pririty ppulatins, the dcument specifically cited CDC surveillance data that reprted that gay and bisexual men are the nly ppulatin in the U.S. amng whm new cases f HIV are rising. In respnse, amfar, the Fundatin fr AIDS Research and the Trust fr America s Health (TFAH), supprted by funding frm the M A C AIDS Fund, cnvened a meeting f experts n Octber 26, 2010, t: Develp a cmprehensive public plicy agenda t mre effectively prevent HIV transmissin amng gay men and ther men wh have sex with men (MSM). Engage HIV/AIDS and gay health advcates t re-think and imprve current methds f preventin. Prvide guidance t decisin-makers n hw t frmulate the mst effective HIV preventin strategy. The cnvening fcused n ppulatin-level activities and cntext in an attempt t reach the abve gals. While effrts t mdify individual risk behavirs remain valuable, there was cnsensus that fcusing slely upn individual behaviral interventins is insufficient. Envirnments that present risk f facilitating HIV transmissin and ways t re-structure thse settings t impede viral expsure must be the fcus f new plicy initiatives. Indeed, an verarching message frm the cnvening was n the need t mve away frm just HIV-specific interventins, t structural interventins (including harm reductin), health systems interventins, and plicy strategies t prmte HIV risk reductin within the brader cntext f prmting healthy lives fr gay men. Framewrk fr HIV Preventin amng Gay Men The meeting was framed by a backgrund dcument, which emphasized this larger pprtunity fr changing the risk envirnment and creating healthier lives fr MSM. There was general agreement that there is nt ne magic bullet that wuld create this healthier envirnment, but a cmbinatin f appraches that wuld address many factrs including: Cmmunity viral lad By understanding the level f viral lad in gegraphic areas and within sexual netwrks, it may be pssible t intervene t lwer transmissin risks assciated with episdes f unprtected sex. HIV Status and Treatment Access Different behavir patterns are apparent fr men wh are HIVdiagnsed, have tested negative fr HIV, r have unknwn serstatus. These differences underscre the ptential fr imprved serstatus targeting f preventin prgrams. Capturing the preventin benefits f 1

2 antiretrviral therapy depends n timely diagnsis f HIV, swift and sure linkage t high-quality care, timely administratin f effective antiretrviral regimens, cntinuity f care, and strng treatment adherence. Relatinship Status Few preventin prgrams are targeted based n the relatinship status f gay and bisexual men. Data indicate that primary partnerships may be respnsible fr tw-thirds r mre new HIV infectins. Althugh many cuples aim t reduce their HIV risks thrugh negtiated safety, this apprach is ften imperfectly implemented. Syndemics A ntable minrity f gay men experience multiple, inter-related medical and psychscial issues that bth reflect and increase their vulnerability t infectin. Key issues include drug and alchl abuse, depressin and ther mental health issues, prir experience f sexual abuse, and victimizatin by vilence. Addressing syndemics requires nt nly prviding services, but als tackling the structural causes assciated with the risk-related issues including racism, cnstructs arund masculinity, and hmphbia. These strategies must als take int accunt culturally specific cntexts fr Black and Hispanic gay men. Emplyment f nn-discriminatin and zer tlerance fr anti-gay bullying in schls are examples f the kinds f plicy refrms needed t address scial factrs in vulnerability. Situatinal Factrs The Internet, bathhuses, and sex clubs may facilitate multiple sex partners but the degree t which they encurage sexual behavir that increases the risks fr HIV transmissin (e.g., unprtected sex between serdiscrdant partners) is nt always clear. Althugh they present pprtunities t prvide testing and preventin services, the Internet and GPS-related technlgy which a significant number f gay men are using t find sex partners are currently beynd the reach f cnventinal preventin services. Harm Reductin Althugh preventin prgrams tend t treat the universe f sexual behavir as cnsisting f safe r risky cmpnents, sexual behavirs fr gay and bisexual men exist alng a cntinuum f risk. Many gay men are experimenting with strategies t reduce their risk, but ften ding s withut sund evidence r the guidance f public health fficials r cmmunity-based preventin prgrams. Cmmunity Issues Preventin prgrams have generally failed t capitalize n the well-dcumented resiliency f gay men. Overwhelmingly fcused n individual behavir change, preventin effrts in recent years have seldm targeted brader cmmunity nrms r institutins. Preventin campaigns shuld be created with the input f the targeted cmmunity t assure cultural apprpriateness and t avid pathlgizing in the name f addressing nrms. Bimedical Appraches Existing r ptential ptins can reduce the physilgical likelihd that an episde f unprtected anal intercurse will lead t infectin. These ptins include pre-expsure prphylaxis (fr HIV-negative MSM), pst-expsure prphylaxis (fr HIV-negative MSM), test-and-treat appraches (fr undiagnsed HIV-psitive MSM), and treatment f STDs (fr MSM generally). Recent research demnstrating the efficacy f PrEP in gay men (when used in cmbinatin with ther interventins) raises significant hpe, tempered by questins related t adherence, the ptential fr increased risk taking, lng term safety, and hw t peratinalize a PrEP prgram. The discussin f these issues was primarily fcused n federal plicy and with the recgnitin that the federal gvernment des nt have unlimited resurces t implement these new appraches. That said, there was general agreement amng the nn-federal representatives that bth new resurces and realignment f existing resurces wuld be needed t achieve this new apprach t HIV preventin amng gay men. Changing the Risk Envirnment thrugh Reduced Cmmunity Viral Lad While there was a general view that addressing cmmunity viral lad is a prmising apprach, sme key issues were identified that need t be reslved befre this culd be embraced as a natinal plicy. They include: 2

3 Surveillance capacity: D states r lcalities have the capacity t cllect and/r analyze the data? What are the mst imprtant data t have fr best targeting interventins? What evaluatin measures shuld be used t determine the success f a cmmunity viral lad interventin? Are there dangers in targeting neighbrhds t narrwly given differences between where peple live and where they have sexual encunters? States and lcalities wuld need technical assistance in bth creating the plitical supprt fr viral lad surveillance and adpting the health infrmatin technlgies that are assciated with effective implementatin f this apprach. Expanded HIV testing, linkage t care, and adherence t care are essential t the success f a cmmunity viral lad apprach. Indeed, measurement f cmmunity viral lad has a fundamental gap it nly reflects data n peple wh are already identified as HIV infected and have sme linkage t the care system. Bringing the missing 21 percent f peple with HIV wh dn t knw their status int the system and keeping them there will require a separate, but related, set f initiatives. Higher rates f undiagnsed and untreated HIV infectin amng particular grups at elevated risk, including Black gay men, pint t the need t design, fund and evaluate prgrams that can be mre successful at reaching these grups with testing, linkage, care and preventin services. Rutine HIV testing becmes part f the standard f care amng public prviders and thrugh public financing prgrams. This includes: Making rutine HIV screening part f the standard f care at Cmmunity Health Centers. Making rutine HIV screening part f the standard f care at all SAMHSA funded sites prviding substance abuse and/r mental health services. Making rutine HIV screening a high prfile plicy within the Medicaid prgram, including an emphasis n emergency department encunters. T assure apprpriate linkage t care and adherence t care several steps culd be taken, all f which recgnize the fact that preventin and treatment are part f a single cntinuum. Amng the plicy changes cnsidered were: Integratin f the HIV preventin and HIV care services planning prcesses at the state and lcal levels. Permit blending f CDC, HRSA, and SAMHSA funding streams either literally r thrugh a virtual blending (by simplifying reprting requirements and adpting cmmn eligibility criteria, amng ther things). The CDC, in implementing the cmmunity health wrkers prgram authrized in the Affrdable Care Act and likely t be initiated in FY 2011, culd include an initiative that fcuses n linking peple at risk t testing and care and assuring adherence fr thse already in care. Adequate cverage f HIV care and drugs. The best testing, linkage, and adherence appraches will nly wrk if peple with HIV truly have ready access t HIV treatment. The shrtfalls in ADAP are the mst visible threat t successful implementatin f the strategies described abve. Addressing the Scial and Behaviral Determinants f Risky Behavir by Gay/Bisexual Men Effrts t reduce the risk envirnment (such as reducing cmmunity viral lad) must be cmplemented by effrts at reducing risk taking by the individual. Public health has a respnsibility t prvide the best pssible infrmatin t individuals abut risk, s they can make infrmed chices. This is particularly true with regard t behavirs such as sersrting and specific sexual practices. Hwever, a fcus strictly n HIV risk r sexual health r risk taking amng MSM des nt fully address the behaviral determinants f risk taking, the ften deeply embedded factrs that are usually nn-sexual in rigin that result in higher risk taking. The literature suggests that these range frm experience f bullying and ther frms f stigma in adlescence and beynd, experience f sexual vilence, dmestic vilence, depressin and 3

4 ther mental health issues, and substance use. Withut a syndemic apprach, we are nt ging t address the fundamental behaviral determinants f HIV-related risk taking amng gay men. One particular pprtunity t address this brader apprach t healthier lives fr gay men is thrugh the newlycreated Cmmunity Transfrmatin Grants, expected t start in FY These grants are designed t address plicy and structural changes that can prmte healthier lives, with an emphasis n addressing disparities. CDC has an pprtunity t develp a package f interventins that cmmunities (state r lcal health departments r cmmunity based rganizatins) culd adpt t change the risk envirnment fr gay men. It shuld be nted that prgrams and plicies need t reflect the many aspects f diversity in the gay cmmunity: race/ethnicity (including the fact that the experience f gay men f clr is nt unifrm cmmunity and scial factrs affecting Hispanic gay men are ften quite different frm thse affecting African-American gay men); age (differing supprts and experiences run the lifespan, frm gay yuth t gay elders); class; and relatinship status. In sme cases, Institutinal Review Bard plicies place limits n inclusin f yung gay men in health research, cmplicating effrts t develp apprpriate interventins fr this grup. The respnsibility and pprtunities fr creating a healthier envirnment fr gay men is nt limited t health agencies. The Department f Educatin s recent initiative arund enfrcement f anti-bullying plicies is an example f plicy change that can enhance the scial supprt fr gays that addresses sme f the factrs assciated with risk taking later in life. Other examples f plicy and risk envirnment change identified include: The existence f stigma and discriminatin surrunding HIV infectin; the stigma arund being gay in sme cmmunities; and the rle shame plays in the brader gay and general cmmunity; Limited access t cmprehensive and early sexual educatin; Inadequate prgrams and supprt systems fr MSM individuals and their families particularly thse f clr; Persisting mistrust and differing perspectives f the medical prfessin (particularly in cmmunities f clr); Lack f primary care services t prvide culturally apprpriate and effective care fr gay men; Cmmunity resilience as a fundatin fr HIV preventin remains largely unexplred by well-designed studies; and Preventin research effrts need t examine brader cultural issues (e.g. the deleterius effects f antigay ballt measures n mental health, the rle f shame in the lives and sexual decisin-making f gay and bisexual men, and the cntributin f prir sexual abuse t increased sexual risk-taking). Maximizing the Ptential f the Affrdable Care Act t Enhance Preventin and Treatment f HIV Several key elements assciated with implementatin f the Affrdable Care Act were identified as prviding pprtunities t enhance access t apprpriate services fr gay men at risk fr HIV. These include: Assuring apprpriate cverage f preventive services. Wrk is needed t harmnize recmmendatins by the CDC and the US Preventive Services Task Frce (USPSTF), either thrugh adptin f the CDC s recmmendatins by the USPSTF r by inclusin f CDC recmmendatins as part f the Essential Health Benefits package defined by the Secretary f Health and Human Services. Assuring access t cmprehensive care and supprt services thrugh inclusin f the HHS HIV/AIDS treatment guidelines as part f the Essential Health Benefits package; and using the Ryan White mdel f hlistic HIV/AIDS service delivery as a standard fr the newly-created Accuntable Care Organizatins, medical hme mdels, and the Medicaid health hme. Steps shuld be taken t assure that Ryan White prviders are part f these initiatives. In additin, HIV-experienced prviders shuld be required t be part f 4

5 any netwrk included in any private plan included in a Health Insurance Exchange, alng with public health departments that prvide HIV services (including HIV testing) and apprpriate Ryan White prviders. Assure that the new Health Infrmatin Technlgy (HIT) system has the capacity t prvide critically imprtant infrmatin abut the HIV epidemic and the prvisin f services. Assure that immediate changes under the Affrdable Care Act are used t imprve access t and quality f care including maximizing use f the new Pre-existing Cnditin Insurance Plan and using the new wrkfrce initiatives t expand the number f HIV prviders and imprve the LGBT-related cultural cmpetence f health prviders in general. December 9,

6 HIV Preventin fr Gay Men & Men Wh Have Sex with Men: Develpment f a Cmprehensive Plicy Agenda Octber 26, :30am 4:30pm The Renaissance Washingtn, DC DuPnt Circle Washingtn, DC Cnfirmed Participant List* Urj Arshad Assciate Directr Advcates fr Yuth Crnelius Baker Senir Cmmunicatins Advisr Center n AIDS & Cmmunity Health AED Chris Bland Mbilizatin Manager Black AIDS Institute Sean Cahill Managing Directr, Public Plicy, Research and Cmmunity Health GMHC Grant Clfax Directr f HIV Preventin & Research San Francisc Department f Public Health Kevin Cranstn Directr, Bureau f Infectius Disease Massachusetts Department f Public Health Julie Davids C-Directr Cmmunity HIV/AIDS Mbilizatin Prject (CHAMP) Diana Echevarria Executive Directr M A C AIDS Fund Tam H Directr M A C AIDS Fund Kali Lindsey Senir Directr f Federal Plicy Harlem United Cmmunity AIDS Center, Inc. Manya Magnus Stephen Massey Ken Mayer Mazdak Mazarei Assciate Prfessr, Department f Epidemilgy and Bistatistics & Assistant Prfessr, Department f Health Plicy Assciate Directr, Entertainment Media Partnerships Prfessr f Medicine and Cmmunity Health and Directr, Brwn AIDS Prgram HIV Prgram Capacity Building Specialist Gerge Washingtn University, Schl f Public Health and Health Services Kaiser Family Fundatin Brwn University Asian & Pacific Islander American Health Frum Bill McCll Plitical Directr AIDS Actin Britt Ris-Ellis Directr NCLR/CSULB Center fr Latin Cmmunity Health Rn Stall Tyler TerMeer Wakefield Patrick Wilsn Prfessr and Chair, Department f Behaviral and Cmmunity Health Sciences Preventin Prgram Manager, Gay Men s Prtfli Assciate Directr fr Cmmunity Relatins Assistant Prfessr f Scimedical Sciences Graduate Schl f Public Health, University f Pittsburgh Natinal Assciatin f State & Territrial AIDS Directrs HIV Vaccine Trials Netwrk Mailman Schl f Public Health, Clumbia University Observers Jeff Crwley Directr f the Office f Natinal AIDS Plicy and Senir Advisr n Disability Plicy The White Huse 6

7 Jhn Duglas Chief Medical Officer, Natinal Center fr HIV, Viral Hepatitis, STD, and TB Centers fr Disease Cntrl and Preventin Preventin Cynthia Grssman Prgram Officer Natinal Institute f Mental Health/NIH Debrah Parham Hpsn Assciate Administratr, HIV/AIDS Bureau Health Resurces and Services Administratin, U.S. Department f Health and Human Services Jn Mermin Directr, Divisin f HIV/AIDS Preventin Centers fr Disease Cntrl and Preventin Greg Millett Senir Plicy Advisr in the Office f The White Huse Rn Valdiserri Cnsultants Natinal AIDS Plicy Deputy Assistant Secretary fr Health, Infectius Diseases U.S. Department f Health and Human Services Abby Dilley Senir Mediatr/Meeting Facilitatr The RESOLVE Team Mike Isbell amfar & TFAH Cnsultant amfar Chris Cllins Vice President and Directr f Public Plicy amfar Jirair Ratevsian Deputy Directr amfar Kate Gertzen Research & Plicy Assistant amfar TFAH Jeff Levi Executive Directr Trust fr America's Health Karen Hendricks Directr f Plicy Develpment Trust fr America's Health Curtney Pastrfield Plicy Develpment Manager Trust fr America s Health Hannah Graff Plicy Develpment Assciate Trust fr America s Health Dara Alpert Lieberman Gvernment Relatins Manager Trust fr America s Health Jack Rayburn Gvernment Relatins Representative Trust fr America s Health Lacy Serrs Natinal Urban Fellw, GR Trust fr American s Health Rebecca St. Laurent Health Plicy Research Assciate Trust fr America s Health Albert Lang Cmmunicatins Manager Trust fr America s Health Jackie Britz Gvernment Relatins Intern Trust fr America s Health *Nte that this list is fr infrmatinal purpses nly and des nt mean t imply that these individuals r rganizatins supprt the ttality f this dcument. 7