National HIV/AIDS Strategy 2020 and the
Federal Action Plan: Implications for ASOs,
CBOs, and Health Centers
Sean Cahill, PhD
Director, Curriculum and Policy, National Center for Innovation in HIV Care
December 14, 2015
Outline
 Intro: Changed context with new HIV diagnosis data
 NHAS 2020 (July 2015) and Federal Action Plan
(December 2015): Key Goals and Action Items
 Implications for AIDS Service Organizations (ASOs),
Community-based Organizations (CBOs), and Health
Centers (HCs)
2
Caveat
 I am only highlighting some points from NHAS 2020
and the Federal Action Plan, not every point
 Access these documents at www.aids.gov/nhas
3
New HIV diagnosis data released
December 6 at CDC conference
 Number of new diagnoses down 19% from 2005 to
2014, from 48,795 to 39,718 per year
 Improvements with some populations




Diagnoses down for Black women 42%
Diagnoses down for People Who Inject Drugs (PWID) by 65%
Diagnoses down for heterosexuals by 35%
Diagnoses down for White gay/bi men by 18%
4
New HIV diagnosis data 20052014
 Still getting worse for others
 Diagnoses up for gay and bisexual men by 6%
 Diagnoses up for Black gay and bisexual men by 22%,
stabilized in recent years
 Diagnoses up for Latino gay and bisexual men by 24%, still
getting worse in recent years (up by 13%)
 Black gay and bisexual males age 13-24: 87% increase in
new HIV diagnoses over last decade, 2% decline in recent
years
5
Key findings
 HIV diagnoses becoming even more concentrated
among gay and bisexual men
 Racial/ethnic and age disparities becoming even more
pronounced among gay and bisexual men
 Improvements among Black women, heterosexual
women and men, PWID
6
Current Status of State Medicaid
Expansion Decisions
7
Goals of NHAS 2020
 Goal 1: Reduce New HIV Infections
 Goal 2: Increase Access to Care and Improving Health
Outcomes for People living with HIV
 Goal 3: Reduce HIV-Related Disparities and Health
Inequalities
 Goal 4: Achieve a More Coordinated National
Response to the HIV Epidemic
8
9
Federal Action Plan (Dec. 2015)
 Four Key Foci of NHAS 2020:
 Widespread testing, linkage to care
 Support for engagement in care/treatment
adherence
 Universal viral suppression
 Full access to comprehensive pre-exposure
prophylaxis (PrEP) services
10
Goal 1 (NHAS 2020): Reducing
New HIV Infections
Overview of steps:
11
Goal 1 Step 1.B (NHAS 2020)
Recommended Actions
 Support and strengthen integrated, patient-centered HIV and
related screening (STIs, behavioral health, Intimate Partner
Violence, Hep C) and linkage to basic services
 Action Items 2016-2020 (Federal Action Plan):
 Promote HIV screening among homeless, in job training programs
 HIV screening within context of IPV, Family Planning Clinics
 HRSA/CDC pilot system level interventions to increase HIV testing
among health center patients diagnosed with acute STIs (2018)
 Add lifetime HIV test to Uniform Data System for Health Centers,
aligned with Meaningful Use, for all 15- to 65-year-olds (HRSA, 2018)
12
Goal 1 Step 1.B (NHAS 2020)
Recommended Actions
 Support and strengthen integrated, patient-centered
HIV and related screening (STIs, behavioral health,
Intimate Partner Violence, Hep C) and linkage to basic
services
 Action Items 2016-2020 (Federal Action Plan):
 Support provision of wrap-around services (vocational,
educational, housing, nutrition, transportation services)
within behavioral health treatment programs (SAMHSA, ED
2018-20)
13
Goal 1 Step 1.B (NHAS 2020)
Recommended Actions
 Expand access to effective HIV prevention services,
including PrEP and PEP
 Action items:
 HRSA TA/trainings on PrEP, PEP implementation strategies
for HRSA programs (2016-20)
 SAMHSA training for grantees re: linking patients in
behavioral health programs to PrEP, PEP (‘16-20)
 SAMHSA provide medication-assisted treatment (MAT)
services with pharmacotherapies for treatment of opioid
use disorders, support integrated care addressing HIV
infection as part of substance use treatment (2018)
14
Goal 1 Step 1.B (NHAS 2020)
Recommended Actions
 Expanded prevention with people living with HIV
(PLWH)
 Action items:
 Promote Treatment as Prevention at Ryan White Part C
clinics, Health Centers
15
Goal 1: Reducing New HIV
Infections
Overview of steps:
16
Goal 1 Step 1.C (NHAS 2020)
Recommended Actions
 “All health and wellness practitioners (peer counselors,
intake specialists, doctors, nurses, and other health
professionals) must be…equipped to deliver
education that is culturally appropriate and inclusive
of LGBT people.” (p.24)
 I.e. they must be trained and be culturally competent.
17
Goal 1 Step 1.C (NHAS 2020)
Recommended Actions
 Utilize evidence-based social marketing and education
campaigns, and leverage digital tools and new
technologies
 Action items:
 Digital tools aimed at adolescents, women and girls, persons
receiving substance use/mental health services (2016-2020)
 Incorporate digital technology to support MH/SU disorder
treatment, adherence to ARVs and PrEP (2020)
 Compile lessons learned from HRSA-funded interventions to
engage, retain young Black MSM, women of color in care
with optimal health outcomes (2018)
18
Goal 1 Step 1.C (NHAS 2020)
Recommended Actions
 Utilize evidence-based social marketing and education
campaigns, and leverage digital tools and new
technologies
 Action item:
 Promote Trauma-Informed Care Guidance with all federal
HIV prevention and care grantees (SAMHSA, 2016-2020)
19
Goal 1 Progress Indicators
 Indicator 1: 90% of PLWH know their serostatus (2012
87.2%; on track)
 Source: NHAS 2020 Indicator Supplement, August 2015
 Indicator 2: Reduce number of new diagnoses by at
least 25% (e.g. from 43,806/yr at baseline to 32,855/yr
by 2020; 2014 goal was 41,068, actual # was 39,718)
 Source: NHAS 2020 Indicator Supplement, August 2015
 Indicator 3: Reduce the percentage of young gay and
bisexual men who have engaged in HIV-risk behaviors
by at least 10%, from baseline of 34.1%
20
Goal 2: Increasing Access to
Care and Improving Health
Outcomes for People living with
HIV
Overview of steps:
21
Goal 2 Step 2.A (NHAS 2020)
Recommended Actions
 Integration, colocation of substance abuse and mental
health services with HIV care
 Clinical decision support tools to identify persons out
of care
 Support and strengthen capacity to implement
innovative and culturally appropriate models to deliver
care more effectively—implementation research
 Develop new care delivery models to provide culturally
appropriate services for populations like gay/bi men, trans
women, older adults, youth, racial and ethnic minorities
22
Goal 2 Step 2.A (NHAS 2020)
Recommended Actions
 Re-entry programs to link formerly incarcerated to
health homes, supportive services, disability benefits
or Medicaid
 Facilitate initial appointments post-release,
comprehensive case management
23
Goal 2 Step 2.A (NHAS 2020)
Recommended Actions
 Action items from Federal Action Plan:
 Disseminate lessons learned from safety net providers about how
to extend health care coverage enrollment to key populations
(HRSA, 2016)
 TA to grantees to help them maximize payment systems, access
third party reimbursement for behavioral health, HIV services
(SAMHSA, 2016-20)
 Guidance to grantees to enable them to receive third party
reimbursement for HIV/STI/HCV/TB testing (CDC, 2016-2020)
 Increase health centers’ capacity to integrate HIV continuum into
primary care; use HIT to improve linkage to care, care
coordination (HRSA, ‘16-20)
24
Goal 2: Increasing Access to
Care and Improving Health
Outcomes for People living with
HIV
Overview of steps:
25
Goal 2 Step 2.B Recommended
Actions
 Increase number of providers of HIV care
 “Federally-supported programs should encourage h.c.
delivery strategies that extend the capacity of the existing
workforce of HIV specialists.” (p. 34)
 Strengthen current provider workforce
 “…integration of HIV services into health centers and other
primary care settings…” (p. 35)
 Support screening and referral for substance
use/mental health services for people living with HIV
26
Goal 2: Increasing Access to
Care and Improving Health
Outcomes for People living with
HIV
Overview of steps:
27
Goal 2 Step 2.C Recommended
Actions
 Address policies to promote access to housing, other
basic need/supportive services for people living with
HIV
 Support for case management programs, partnerships
between housing programs and HIV service organizations
 Improve outcomes for women in HIV care by
addressing factors that increase risk of violence for
women living with HIV
 Also address trauma experienced by young gay, bisexual
men, transgender women
28
Goal 2 Step 2.B & C
Recommended Actions
 Action items from Federal Action Plan:
 Improve, expand substance use services—with focus on
opioid use disorders—at health centers (HRSA, SAMHSA
2020)
 Research, share IPV screening, interventions with HRSA
grantees to improve health outcomes for women and girls,
gay and bisexual men (HRSA, NIH, 2018)
 Promote, support health centers to implement IPV services
in primary care settings, including health centers serving
PLWH (HRSA, ACF 2020)
29
Goal 2 Progress Indicators
 Indicator 4: Increase % of newly diagnosed persons linked
to HIV medical care within one month of their diagnosis to
at least 85% (2013 72.6%; on track)
 Indicator 5: Increase percentage of persons with diagnosed
HIV infection who are retained in HIV medical care to at
least 90% (2012 53.8%; not on track)
 Indicator 6: Increase the percentage of persons with
diagnosed HIV infection who are virally suppressed to at
least 80% (2012 50.1%; on track)
 Indicator 8: Reduce the death rate among persons with
diagnosed HIV infection by at least 33% (2012; on track)
30
Goal 3: Reducing HIV-Related
Disparities and Health
Inequalities
Overview of steps:
31
Goal 3 Step 3.A Recommended
Actions
 Expand services to reduce HIV-related disparities
experienced by gay, bisexual men (especially young
Black gay, bisexual men), Black women, people living in
South
 Support engagement in care for groups with low levels
of viral suppression, including youth and PWID
32
Goal 3 Step 3.A Recommended
Actions
 Action items from Federal Action Plan:
 Behavioral health programs serving groups
disproportionately affected by HIV offer HIV testing
 Test positive  case management
 Test negative  linkage to PrEP, prevention services (SAMHSA 2018)
33
Goal 3: Reducing HIV-Related
Disparities and Health
Inequalities
Overview of steps:
34
Goal 3 Step 3.B Recommended
Actions
 Scale up effective programs that address social
determinants of health
 Employ biopsychosocial prevention approach
 Address poverty, poor education, homelessness,
unemployment
 Particular need for young, Black gay and bisexual men
 Support research to better understand intersection of
HIV and violence against women, develop
interventions
35
Goal 3 Step 3.B Recommended
Actions
 Action items from Federal Action Plan :
 Expand capacity of CBOs, faith-based orgs. to address social,
structural barriers to HIV prevention, diagnosis, care (Office
of HIV/AIDS and Infectious Disease Programs, CDC, HRSA,
NIH, SAMHSA 2016)
36
Goal 3: Reducing HIV-Related
Disparities and Health
Inequalities
Overview of steps:
37
Goal 3 Step 3.C Recommended
Actions
 Promote evidence-based public health approaches to
HIV prevention and care
 Challenge stigma re substance use/mh, HCV, STIs
 Strengthen enforcement of civil rights laws, assist
states in protecting people living with HIV from
violence, discrimination
 Mobilize communities to reduce HIV stigma
 Promote public leadership of people living with HIV
38
Goal 3 Step 3.C: Reduce stigma,
end discrimination
 Action items from Federal Action Plan:
 DOJ, HHS Office of Civil Rights will conduct impact litigation
against HIV discrimination in health care treatment,
insurance coverage (2016-2020)
 Provide CBA to help CBOs use social network strategies to
reduce HIV stigma (CDC, 2016)
 Mobilize faith-based orgs. to address HIV among gay and
bisexual men, transgender women and reduce stigma
related to sexual orientation, gender identity (OHAIDP,
2018)
 Promote leadership of PLWHA in integrated prevention &
care planning (CDC, HRSA ‘16)
39
Goal 3 Progress Indicators
 Indicator 7: Reduce % of PLWH in medical care who
are homeless to 5% from baseline 7.7% (2012: jumped
to 8.3%)
 Indicator 9: Reduce disparities in the rate of new
diagnoses by at least 15% in the following groups: gay
and bisexual men, young Black gay and bisexual men,
Black females, and persons living in the Southern US
 Goals for gay/bi men, YGBM not being met
 Goals for Black women being exceeded
 Goals re: Southern disparity on track
40
Goal 3 Progress Indicators
 Indicator 10: Increase percentage of youth, PWID
diagnosed with HIV who are virally suppressed to 80%
 From 2010 baseline 29.7% for youth
 From 2010 baseline 37.6% for PWID
 Indicator for both populations is on track as of 2012
41
Goal 4: Achieving a more
coordinated national response to the
HIV epidemic
42
Goal 4: Achieving a more
coordinated national response to the
HIV epidemic
 Step 4.A.1: Streamline reporting requirements for federal
grantees
 Action item from Federal Action Plan:
 HHS Operating Divisions, Staff Offices develop specific targets for
streamlining reporting obligations for award recipients (OHAIDP 2016)
 Step 4.A.2: Coordinate data systems, use data to improve health
outcomes, monitor use of $
 Action item from Federal Action Plan:
 Identify models for electronic integration of housing and HIV care data
systems to enhance coordination of svc. delivery, pat. navigation
43
Goal 4: Achieving a more
coordinated national response to the
HIV epidemic
 Step 4.A.4: Allocate resources for greatest impact
 Action item from Federal Action Plan:
 HUD work with Congress to update funding formula for
HOPWA as follows:
 A) from being based on cumulative number of AIDS cases to
being based on number of persons living with diagnosed HIV
infection
 B) incorporate local housing costs, poverty rates into
formula
44
Goal 4: Achieving a more
coordinated national response to the
HIV epidemic
 Step 4.B.3: Enhance program accountability
 Action item from Federal Action Plan:
 Examine funding algorithms for surveillance and prevention
program FOAs to consider incorporating an incentive for
award recipients who meet key data targets or other public
health goals
45
Major Points of the NHAS 2020
 Use HIV diagnosis data instead of HIV incidence data
to monitor progress
 Incidence will vary due to changes in HIV testing technology
and variations in incidence estimation methods; in contrast,
HIV diagnosis data is published in routine and standardized
format
 Incidence data is not available in all states while HIV
diagnosis data is
46
Major Points of the NHAS 2020
 Focus on most burdened populations, including gay,
bisexual men, transgender women, Black and Latino
men and women, people living in the South
 Concentrate funding and prioritize interventions for these
populations
 Address trauma, discrimination faced by these populations
 Expand services to reduce disparities faced by these
populations
47
Major Points of the NHAS 2020
 PrEP/PEP and funding for research in other promising
biomedical interventions is central to the strategy
 Intervention science and combination prevention
 New technology (ex. injectable PrEP) holds promise, needs
to be pursued
48
Major Points of the NHAS 2020
 Ambitious goals for linkage and retention in care
 Increase % linked to care in one month to 85% from
baseline 70% (73% in 2013)
 Increase % retained in care to 90% from baseline 51% (54%
in 2012)
 Increase % virally suppressed to 80% from baseline 43%
(50% in 2012)
49
What this means for ASOs, CBOs,
& Health Centers
 In order to achieve the ambitious goals for linkage and
retention, there is a major focus on improving care
along the HIV care continuum
 Key Q: How can ASOs, CBOs, HCs
 Dramatically improve linkage, retention, viral suppression?
 Prioritize key populations (MSM, trans women, Black and
Latino men and women?)
 Improve youth and PWID treatment outcomes?
 Reduce death rate for PLWH (for any reason)?
50
ASOs/CBOs
 Partner with behavioral health providers to provide
wrap-around services for patients receiving MH/SU
treatment (2018-20)
 Vocational, educational, housing, nutrition, transportation
 Many ASOs/CBOs have experience, cultural competency in
providing these to key populations
 All staff must be trained in providing HIV prevention
education, screening that is culturally sensitive to gay,
bi men, trans women (i.e. not homo-/bi/transphobic)
51
ASOs/CBOs
 Partner with agencies like the Fortune Society or
(other example of CBO working with ex-inmates) to
link formerly incarcerated to health care, supportive
services, benefits
 Access TA from CDC, SAMHSA to receive third party
reimbursement for HIV/STI/HCV testing, behavioral
health and HIV services (2016-)
 CBOs, faith-based orgs. address social determinants
that increase vulnerability (poverty, homelessness,
education) especially among young Black MSM
52
ASOs/CBOs
 Faith-based orgs. address HIV among gay, bi men,
transgender women
 ASOs, CBOs use social network strategies to reduce
HIV stigma
 Promote PLWH leadership in integrated prevention
and care planning
53
Health Centers
 Test patients diagnosed w/acute STIs for HIV
 Lifetime HIV test to be added to UDS in 2018 for all 15-
to 65-year-old patients
 Provide wrap-around services for patients receiving
MH/SU treatment (2018-20)
 All staff must be trained in providing HIV prevention
education, screening that is culturally sensitive to gay,
bi men, trans women (i.e. not homo-/bi-/transphobic)
54
LGBT Education and Training
The National LGBT Health Education Center offers educational programs,
resources, and consultation to health care organizations with the goal of
providing affirmative, high quality, cost-effective health care for lesbian, gay,
bisexual, and transgender (LGBT) people.
 Training and Technical
Assistance
 Grand Rounds
 On Line Learning
 Webinars and
Learning Modules
 CE, and HEI Credit
 Resources and
Publications
 lgbthealtheducation@fenwayhealth.org
 www.lgbthealtheducation.org
55
Health Centers
 HRSA 2016-2020: Increase HC’s capacity to integrate
HIV continuum into primary care
 Could address what Krakower et al. call the “purview
paradox,” whereby HIV specialists think that primary care
clinics should be the principal venue for PrEP
implementation, whereas primary care providers think PrEP
is best prescribed by HIV specialists
 Krakower D, Ware N, Mitty J, Maloney K, Mayer K, AIDS Behav 2014
 Use Health Information Technology to improve linkage
to care, care coordination
 December 3, 2015 webinar on EHR solutions for ASOs, HCs
56
Health Centers
 EHRs: Inclusion of sexual orientation and gender
identity in Uniform Data System, to be rolled out by
HRSA starting in 2016
 Should allow for better understanding and addressing
disparities along HIV continuum for gay and bisexual
men, transgender women, especially Black and Latino
 Resources:
 www.doaskdotell.org
 www.lgbthealtheducation.org
57
Health Centers
 Partner with agencies like the Fortune Society to link
formerly incarcerated to health care, supportive
services, benefits
 Access TA from CDC, SAMHSA to receive third party
reimbursement for HIV/STI/HCV testing, behavioral
health and HIV services (2016-)
 Expand substance use services, especially regarding
opioids
 Implement IPV services for women, MSM
58
Questions, discussion
59
Acknowledgements
 Ryan Kruis, MSW, The Fenway Institute
 Adrianna Sicari, MPH, The Fenway Institute
60