HIV/AIDS Bureau Update Ryan White HIV/AIDS Program Clinical Conference New Orleans, LA December 15, 2015 Laura Cheever, MD, ScM Associate Administrator Department of Health and Human Services Health Resources and Services Administration HIV/AIDS Bureau HAB Vision and Mission Vision Optimal HIV/AIDS care and treatment for all Mission Provide leadership and resources to assure access to and retention in high quality, integrated care and treatment services for vulnerable people living with HIV/AIDS and their families 1
2016 Priorities Continue to integrate Ryan White HIV/AIDS Program (RWHAP) with the new health care landscape Implement National HIV/AIDS Strategy: Updated to 2020 (NHAS 2020) Focus on greatest health disparities and care continuum Augment partnerships Advance data utilization to improve health outcomes Enhance national and international leadership Improve HIV/AIDS Bureau (HAB) operations 2016 Priorities Continue to integrate RWHAP with the new health care landscape Documenting what the RWHAP is and does Understanding the dynamic intersections of the Affordable Care Act (ACA) and the RWHAP 2014 and beyond Considering how the program should change, to respond to an evolving population of people living with HIV (PLWH) Ryan White HIV/AIDS Program Moving Forward Framework 2
Special Study-Emerging Issues Related to ACA Implementation: The Future of Ryan White Services: A Snapshot of Outpatient Ambulatory Medical Care Final Project Report Briefing September 29, 2015 Service Visit Length Clinic visits can vary in length from 15 minutes to four hours, the median times reported ranged from 41 minutes to 145 minutes. Interview Data Abt Associates pg 9 Drivers of OAMC Visit Length The activities most often associated with longer OAMC times are primary care treatment and screening and patient education. Interview Data Abt Associates pg 10 3
Conclusions Outpatient Ambulatory Care Visits (OAMC) are complex and more than just reimburable services First category: services that insurers typically cover e.g., diagnostic testing, preventive care and screening, practitioner examination, medical history taking, diagnosis and treatment Second category: intensive OAMC activities that are critical for improved outcomes but may not be reimbursed Education and counseling around prescribing and managing of ARVs, education and counseling on prevention, adherence, and other health issues, care management of chronic HIV related conditions and referral/provision of specialty care (e.g., behavioral health and support needs) Overview Two recent papers illustrate Ryan White HIV/AIDS Program impact using Medical Monitoring Project (MMP) data Service delivery and patient outcomes in Ryan White HIV/AIDS program-funded and non-funded healthcare facilities (Weiser et al., JAMA Internal Medicine, 2015) Ryan White HIV/AIDS program assistance and HIV treatment outcomes (Bradley et al., Clinical Infectious Diseases, 2015) CDC and HRSA collaboration Weiser (paper #1): Main Findings Service delivery and patient outcomes in Ryan White HIV/AIDS program-funded and non-funded healthcare facilities (Weiser et al., JAMA Internal Medicine, 2015) 2009 and 2011 MMP data show: 34% of facilities received Ryan White HIV/AIDS Program (RWHAP) funding 73% of patients received care at RWHAP-funded facilities 4
Services provided by RWHAP-funded and non- RWHAP-funded outpatient facilities ART prescription and viral suppression RWHAP-funded (%) Non-RWHAP funded (%) P-value Prescribed ART* 90 91 0.53 Viral suppression 74 79 0.02 *Documentation in the medical record of prescription of antiretroviral therapy Documentation in the medical record of most recent viral load undetectable or <200 copies /ml Viral suppression * among low-income patients % (95% CI) Adjusted prevalence ratio (95% CI) P-value RWHAP 73 (70 75) 1.09 (1.02 1.16) 0.01 Non-RWHAP 67 (62 71) Reference *Most recent viral load undetectable or <200 copies /ml Living at or below the federal poverty level 5
Bradley (paper #2): Main Findings Ryan White HIV/AIDS Program Assistance and HIV Treatment Outcomes (Bradley et al., Clinical Infectious Diseases, 2015) 2009 2012 MMP data show: 41% of patients received RWHAP assistance 25% received RWHAP assistance as a supplement to another healthcare payer type 15% relied solely on RWHAP assistance for HIV care Adjusted * prevalence of viral suppression by healthcare payer type and RWHAP assistance *Results from logistic regression model adjusted for age, race, place of birth, poverty, education, homelessness, and HIV disease stage Bradley (paper #2): Primary Conclusion Uninsured and underinsured HIV-infected patients receiving RWHAP assistance were more likely to be prescribed ART and to be virally suppressed than those with other healthcare payer types. 6
Preliminary Analysis of Ryan White Services Report Data from 2014 How is the Affordable Care Act affecting Ryan White HIV/AIDS Program clients, services, and clinical outcomes? Years of Analysis Prior to the Affordable Care Act 2012 2013 After the Affordable Care Act 2014 PRELIMINARY DATA Health Care Coverage Among HIV Positive RWHAP Clients, 2012 2014 50 Health care coverage, % 40 30 20 10 0 33.3 33.1 33.0 27.9 28.0 25.4 2012 2013 2014 Medicaid/Other Public Uninsured PRELIMINARY DATA 7
Health Care Coverage, by Medicaid Expansion Status, 2012 2014 Health care coverage, % 50 45 40 35 30 25 20 15 10 5 0 Medicaid Expansion States 50 45 42.7 39.3 39.5 40 35 30 25 22.2 21.4 20 16.7 15 10 5 0 2012 2013 2014 Medicaid/Other Public Non Medicaid Expansion States 35.2 36.6 36.1 25.6 24.8 21.1 2012 2013 2014 Uninsured PRELIMINARY DATA How the RWHAP Needs to Change Gap in understanding of best models of care to support improved outcomes Regional AIDS Education and Training Centers (AETC) program revamped in 2015 Focus on multidisciplinary teams, workforce pipeline, low volume providers, practice transformation Shift to national curriculum, National Clinical Conference and National Clinical Consultation Center to support more experienced clinicians 2016 Priorities Continue to integrate RWHAP with the new health care landscape Implement NHAS 2020 Focus on greatest health disparities and care continuum Augment partnerships Advance data utilization to improve health outcomes Enhance national and international leadership Improve HAB operations 8
National HIV/AIDS Strategy: Updated to 2020 National HIV/AIDS Strategy Updated to 2020 Integrated HIV Prevention and Care Plan Guidance, including the Statewide Coordinated Statement of Need, CY 2017 2021 Health Resources and Services Administration, HIV/AIDS Bureau/Centers for Disease Control and Prevention, Division of HIV/AIDS Prevention 9
2016 Priorities Continue to integrate RWHAP with the new health care landscape Implement NHAS 2020 Focus on greatest health disparities and care continuum Augment partnerships Advance data utilization to improve health outcomes Enhance national and international leadership Improve HAB operations Retention and Viral Suppression 100.0 80.0 Retention (%) 82.1 82.1 82.0 81.0 100.0 80.0 Viral Load Suppression (%) 69.5 72.6 75.1 78.6 81.4 60.0 60.0 40.0 40.0 20.0 20.0 0.0 2010 2011 2012 2013 0.0 2010 2011 2012 2013 2014 Retained in care: >= 1 OAMC visit before Sept. 1 of the measurement year and at least 2 visits 90 or more days apart Viral suppression: Percent with last viral load test in year < 200 copies Source: 2014 Ryan White Services Report Viral Suppression by State Viral suppression: had at least one OAMC visit, at least one viral load count, and last viral load test <200 Source: 2014 Ryan White Services Report 10
Retention and Viral Suppression Race/Ethnicity, RSR 2010 2013 90% 85% White Asian Retention Black Native Hawaiian White Black Asian Native Hawaiian American Indian Hispanic Multi racial Viral Suppression 90% 85% 80% 80% 75% 75% 70% 65% 70% 2010 2011 2012 2013 60% 2010 2011 2012 2013 RSR 2013 Viral Suppression Age 100% 80% 60% 40% 20% 0% 80.2% 65.7% 59.3% 70.4% 77.6% 81.9% 86.4% 90.6% RWHAP 78.6% <13 13 18 19 24 25 34 35 44 45 54 55 64 65+ National Viral suppression: had at least one OAMC visit, at least one viral load count, and last viral load test <200 Reducing Viral Load Suppression Rate Disparities for Young People in the RWHAP, RSR 2010 2013 Growth rate in viral suppression is 8.8%, compared to only 4.0% in rest of population 90 80 70 60 50 40 2010 2011 2012 2013 Rest of RSR clients Youth (13 24) 25 20 15 10 5 0 VL suppression rate disparity has decreased by ~20% in only 3 years 2010 2011 2012 2013 Disparity Trend 11
Ongoing Efforts All Grantee Meeting in 2016 Tentative dates: August 23 26, 2016 in Washington, DC New Webpage: http://ryanwhite2016.org/ Clinical Conference 2016 it will return! Stay tuned for details Thank You! Dr. Laura Cheever HIV/AIDS Bureau lcheever@hrsa.gov 12