Defining Our Goal

DC has a goal: Fewer than 130 new HIV diagnoses a year by 2030.

DC’s first plan to end the HIV epidemic, known as the 90/90/90/50 Plan, had four goals: 90% of people with HIV knowing their status; 90% of people diagnosed with HIV being in treatment; 90% of people with HIV on treatment achieving viral suppression; and a 50% reduction in new diagnoses by the year 2020.

For this updated plan, DC Health has made the 90/90/90 a floor rather than the ceiling. By 2030, we are aiming for a new ceiling with 95% of people knowing their HIV status, 95% of those diagnosed being in treatment, and 95% of those in treatment reaching viral suppression.

Instead of a percentage decrease in new diagnoses, we want to give DC a solid number: an ambitious but achievable number that represents ending the epidemic — a number that means we have maximized all the tools we have in order to end the epidemic. It is not zero, because we do not yet have a cure or vaccine. However, the number means we are making new HIV diagnoses as rare as possible in DC.

That number is 130 or fewer new diagnoses by 2030.

To precisely assess progress toward the goal of fewer than 130 new HIV diagnoses a year by 2030, DC Health developed a predictive model for estimating the planned impact of scale-up of plan strategies. DC Health needed to determine starting points, or baseline values, for several parameters: people living with HIV; of those living with HIV, the number who are diagnosed; of those diagnosed, the number who are “in treatment” — defined here to mean on using antiretrovial therapy (ART); and of those in treatment, the number who have reached viral suppression. Those parameters are known as the HIV care continuum.

DC Health attributes most of the goal of fewer than 130 new diagnoses by the year 2030 to increasing the numbers of the care continuum. However, to reach the goal will also require expansion of PrEP. Given gaps in certain data, establishing baseline model inputs required the estimation of several parameters.

Undiagnosed model estimates

DC Health used the Fellows model¹, which produced the estimate that 11% to 17.7% of HIV cases were undiagnosed within the District.DC Health used the more conservative (base bound) estimate (11%) for its reported estimates of total HIV infection (see Figure 1).

Care continuum estimates

To measure the progress of the DC Ends HIV plan and to achieve its goal by 2030, DC Health calculated its baseline for several parameters. DC Health used a data-driven model¹ that uses local surveillance data to project care continuum targets for each year. The model calibrated predicted incidence estimates from HAHSTA’s Annual Epidemiology & Surveillance Report ² for the years 2015–2019 by scaling predicted values using the following formula:

— where n is the number of years and x is the year in question. To bring the latest surveillance estimates to the year 2020, the model assumed that care continuum parameters of percentage diagnosed, in treatment, and virally suppressed continued to improve at a linear rate since last observed; after 2020, these parameters formed the basis of intervention scenarios. The denominator remained n-1 for the years after 2020.

DC Health changed the model and assumed the mortality rate continued at the 0.97% annual decline observed during 2015-2019. After 2019, the model projected the end epidemic goal by achieving 95% of people diagnosed, 95% in treatment, and 95% virally suppressed by 2030 with 20% of new diagnoses averted by PrEP. The 20% of diagnoses averted by PrEP scenario approximately corresponds to the AIDSVu estimate of PrEP use for DC³.

As of November 2020, the number of people diagnosed and residing in DC was 12,408 (89%). Retention to care, which is based on laboratory visits reported to DC Health, was 9,745 (78.5%) in 2019. The number of people virally suppressed retained in HIV care at the end of 2019 was 8,495 (87.2%). The model estimated 12,202 (95%) diagnosed, 11,592 (95%) retained, and 11,012 (95%) virally suppressed (Figures 1 and 2) in 2030. DC Health used the model to estimate the number of new diagnoses of 130 by 2030. The number of death estimates includes all deaths and is not restricted to only HIV-related deaths.

As additional data and information become available, the model will be updated to reflect the evolving knowledge of the characteristics of the HIV epidemic within the District and the efficacy of intervention strategies within the local population.

Figure 1.

Figure 2.

Development of Local PrEP Utilization Targets

Effectively monitoring progress in maximizing the benefits of pre-exposure prophylaxis (PrEP)in the prevention of HIV at the population level is in part dependent on an accurate assessment of optimal targets for utilization coverage. Such information is essential for not only understanding the total number of individuals who can potentially benefit from PrEP use, but it is also integral in defining the key populations for PrEP awareness, linkage, and adherence support programs.Modeled after a previous analysis done by the CDC Centers for Disease Control and Prevention, a multiplier method was applied to local demographic and HIV surveillance data to ascertain estimates of the number of individuals living in the District with indications for PrEP use. To facilitate a focused assessment of local PrEP coverage needs, estimates were stratified by four key categories: men who have sex with men (MSM),heterosexually active men, heterosexually active women, and people who inject drugs.

Although inadequate information regarding risk behavior patterns within the HIV-negative population limits the ability to conduct a direct assessment of PrEP need, an estimation can be derived through extrapolating information from national and local survey and disease surveillance data. According to information available from the 2019 American Community Survey (ACS) 5-Year Estimate Data Profile, the documents an adult (i.e., people 18 or older) male population in the District is 266,022. With this number as a base, there are around 40,701 MSM living in the District, assuming previous estimates (15.3% of adult male population) derived from the ACS and National Health and Nutrition Examination Survey (NHANES).⁶ Based on local surveillance data, there were 6,081 MSM diagnosed with HIV living in the District in 2019. Subtracting the number of MSM diagnosed with HIV from the total MSM population produces a local HIV-negative MSM population estimate of 34,620. Nationally, it is estimated that 24.7% of HIV-negative MSM have indications for PrEP based on an assessment of NHANES data documenting the number of individuals reporting sex with two or more men and any sex without condoms or sexually transmitted infections within 12 months.⁴ Applying this percentage to the local HIV-negative MSM population produces an estimate of 8,551 MSM in the District with indications for PrEP.

Consistent with previous analysis,⁵ there is a similar assumption of the ratio of the number of people in other focus populations (heterosexual men, heterosexual women, and people who inject drugs) with indications for PrEP relative to the proportion of new HIV diagnoses attributable to their populations based on the MSM calculation above. By multiplying the latter ratios by the number of MSM in the District with indications for PrEP, estimates for the number of individuals with PrEP indications can be derived for each of the additional focus populations. Of the 1,766 new HIV diagnoses documented in the District between 2015 and 2019, 53% were accounted for by MSM, 17% heterosexual women, 11% heterosexual men, and 2% people who inject drugs. Using these percentages, the ratio of the proportion of new HIV diagnoses attributable to focus populations relative to the proportion of new HIV diagnoses attributable to the MSM population is 0.32 (i.e., ratio = 17/53) for heterosexual women, 0.21 (i.e., ratio = 11/53) for heterosexual men, and 0.04 (i.e., ratio = 2/53) for the people who inject drugs. Based on applying these ratios to the estimated number of MSM (n = 8,551) with indications for PrEP, there are around 2,743 heterosexual women, 1,775 heterosexual men, and 323 people who inject drugs with indications for PrEP in the District.

Similar to previously published assessments,⁴ ⁵ DC Health estimates that 13,392 individuals have indications for PrEP in the District, based on analysis using the most current demographic and HIV surveillance data.

As additional data and information are available, the model will be updated to reflect the evolving knowledge of the characteristics of the HIV epidemic within the District and the efficacy of intervention strategies within the local population.

References

1. Bradley H, Rosenberg ES, Holtgrave DR. data-driven goals for curbing the U.S. HIV epidemic by 2030. AIDS and Behavior. 2019;23(0123456789):557-563. doi:10.1007/s10461-019-02442-7.

2. HAHSTA. Annual epidemiology & surveillance report; 2019.

3. AIDSVu. All states PrEP data Sets. Retrieved from https://aidsvu.org/resources/#/.

4.    Smith DK, Van Handel M, Wolitski RJ, Stryker JE, Hall HI, Prejean J, et al. Vital Signs: Estimated percentages and numbers of adults with indications for pre-exposure prophylaxis to prevent HIV acquisition-United States, 2015. MMWR Morb Mortal Wkly Rep 2015;64(46):1291-5.

5.    Smith DK, Van Handel M, Grey J. Estimates of adults with indications for HIV pre-exposure prophylaxis by jurisdiction, transmission risk group, and race/ethnicity, United States, 2015. Annuals of Epidemiology 2018; 28:850-857.

6.    Grey JA, Bernstein KT, Sullivan PS, Purcell DW, Chesson HW, Gift TI, et al. Estimating the population sizes of men who have sex with men in US states and counties using data from the American Community Survey. JIMR Public Health Surveill 2016; 2(1):e14.

First Challenge: Social Threats

First, there are fundamental social threats: structural racism, stigma, and inequity. The negative impact of racism on health is widely recognized, and ongoing systemic, structural change is needed to improve health outcomes in historically marginalized communities. Improving health and well-being in these communities is no small task — meaningful change requires respect and cultural humility while addressing ways to undo the systems that hold damaging policies in place. As part of this plan and for all future actions, DC Health acknowledges and will address the impact of structural racism on sexual health and HIV outcomes.We will begin by developing a framework for promoting social justice in our work, centering the voices and lives of Black and Latino/a/x people and creating our principles and dedicating resources to erode racism and inequity. Internally, DC Health will intentionally look at race and racism, working mindfully and fully taking into account the diversity of the populations it serves, the diversity of its workforce, and the larger context in which DC Health delivers programs and develops policies.

DC Health will:

  • Create spaces to discuss racism at internalized, interpersonal, institutional, and structural levels and how these different manifestations of racism affect its work.
  • Agree on a framework and strategies to address racism within DC Health, as well as in policies and programs.
  • Define internal guiding principles for addressing racism.
  • Agree on metrics to measure progress on becoming an anti-racist organization.

Acknowledging structural racism and addressing it are fundamental to ensuring equity. It is equally important to assure equitable access to resources and opportunity to all people, regardless of racial, ethnic, gender, and sexual identities. DC Health has developed programs on the health of people who use drugs, sexual pleasure, and social and emotional well-being, and initiatives that address matters such as employment, fellowship, and housing. It has also aimed to not assign risk to people based on their identities, instead defining risk in terms of behavior (for example, not wearing condoms, not knowing the status of a partner) to lessen the stigma people might feel. All recent programs and efforts have aimed for diversity, equity, and inclusion of a number of populations often left at the margins, as well as to decrease the stigma placed on some of these populations.

Additional ongoing initiatives that help increase equity and reduce stigma are:

  • Undetectable Equals Untransmittable (U=U)
    DC Health was the second health department in the nation to endorse the Undetectable Equals Untransmittable, or U=U, consensus statement as a significant message to emphasize treatment adherence, reduce stigma for people living with HIV, and prevent new HIV transmissions. DC Health expects to integrate U=U into clinical and support services by pairing U=U messaging with other sexual health education campaigns, translating messaging into Spanish, and including it as a main strategy in planning efforts.
  • Health Impact Specialists
    In 2015, DC Health received a four-year demonstration grant from the Centers for Disease Control and Prevention (CDC) focused on creating a system of care for men who ​have sex with men and for transgender people of color​. As a part of this program, DC Health hired Health Impact Specialists from communities affected by HIV to provide health and wellness information and resources to peers, thus providing an opportunity for economic growth while putting health resources into the same communities. It is a model for activating social justice and empowerment.
  • Rapid Peer Responders
    Rapid Peer Responders address the health of people who use drugs through a harm reduction approach. Similar to the Health Impact Specialists, these responders are individuals from the community they serve, and who have employment challenges such as recent incarceration experience or limited work experience in the formal economy​.
  • Status-Neutral/Regional Early Intervention Services
    DC Health has developed a status-neutral approach, responding to individuals’ sexual health needs wherever they are on the HIV prevention and treatment continuum. This status-neutral approach is delivered using the “Hi-V model” (pronounced “high-five”),  which consists of five pillars of client-centered services that promote equity and whole person health. The five pillars are find ’em, teach ’em, test ’em, link ’em, keep ’em, and the model is designed to eliminate barriers to prevention and treatment services. These services are delivered to focus populations — that is, those who are at very high risk of HIV infection, have demonstrated high HIV prevalence, have inconsistent engagement in care and treatment, or are at increased risk of falling out of care and treatment.

Second Challenge: Local Realities

Second, there are local challenges to the District’s reaching its goal, obstacles that reflect geography as well as life priorities as expressed by residents during community engagement sessions, a series of small gatherings held with a diversity of groups throughout 2020.

One challenge to ending the HIV epidemic in the District is that DC is a small jurisdiction within a large and complex metropolitan area that includes parts of three other states. People live, work, play, and access health services irrespective of jurisdictional lines. The metropolitan area covers counties in Maryland, Virginia, and West Virginia, and the District. Two jurisdictions that also received funding through the CDC’s Ending the HIV Epidemic initiative — Montgomery County and Prince George’s County — directly border the District. Baltimore City, another funded jurisdiction, is 30 miles from Washington.

Another challenge is how HIV factors into the lives of focus populations. DC Health initiated its community engagement sessions with a simple yet multilayered question: “What’s going on in the lives of (your population)?” Subsequent questions included asking about resiliency and impacts on the population, the role of sexual health, and resources that would support overall health. Across a diversity of community members, HIV health was not among the top concerns.

The following sections present findings from a needs assessment, emerging themes from community engagement sessions, and additional strategies and activities DC is including in its updated Ending the HIV Epidemic plan.

Findings From a Needs Assessment

The Washington, DC Regional Planning Commission on Health and HIV (COHAH), which serves as the Ryan White Planning Council and HIV Prevention Planning Group, completed a needs assessment in 2017 as a part of COHAH activities to regularly evaluate Ryan White services and community needs. Data from this needs assessment show that overall, people living with HIV were:

  • Were engaged in care.
  • Received outpatient ambulatory health services on a timely basis.
  • Used antiretroviral medication at a high rate and as prescribed.

Respondents in focus groups and interviews identified mental health services, psychosocial support, and assistance with housing services in the eligible metropolitan area as important needs. When it came to linking with HIV care, the most consistently reported barriers across communities were psychosocial and emotional factors. Barriers to using and adhering to HIV care and treatment included the cost of housing, the availability of housing, and discrimination in housing, particularly in DC and Maryland.

To address some of these barriers — especially as they affect marginalized populations — DC is:

  • Working toward formal certification for community health workers and expanding the community health worker and peer navigator models. Community health workers have access to and the trust of communities, making them an integral part of linkage and retention to care efforts, particularly for those who are marginalized, have stopped receiving care, or are newly diagnosed.
  • Addressing housing by updating its navigator program to include navigation and referral services, as well as transitional, short-term, and emergency housing assistance to enable people living with HIV to gain or maintain outpatient and ambulatory health services and treatment.
  • Developing a wellness support service category with its Ryan White funds to support holistic well-being, providing additional services that complement mental health and psychosocial support services. The regional early intervention services initiative is a status-neutral approach toward prevention and care services and is described below in more detail.

COVID-19 interrupted DC’s 2020 needs assessment, so the next comprehensive needs assessment will be conducted in 2021. There will be an emphasis on reaching people who are out of care or who recently re-engaged in care. The needs assessment will also include people who are HIV negative to better understand HIV prevention needs.

Emerging Themes From Community Engagement

In October 2019, DC Health increased its efforts to engage communities, but it paused those activities in March 2020 to launch COVID-19 prevention measures. In May 2020, DC Health resumed its engagement activities, using virtual platforms.

Through these efforts, as of late 2020, DC Health has heard from approximately 740 community members from a diversity of communities, many who are not traditionally part of engagement efforts or meetings. While many unique experiences were shared during population-specific sessions, several themes arose across communities:

Cross-Community Themes Components
Stress
  • Life and work balance
  • Generational trauma
  • "Super Woman Syndrome"
  • Violence
Connection
  • Finding partners
  • Communal spaces
  • Peer/support groups
Culture
  • Stigma, shame, fear
  • Misinformation
  • Perception of risk
  • Family/gender roles
Identity
  • Gay
  • Transgender
  • Gender
  • Nationality
Structural Issues
  • Healthcare access
  • Mental Health
  • Language
Social Determinants
  • Socioeconomic status
  • Education
  • Returning citizen status

Snapshot of Activities by Pillars

DC determined the strategies for its updated plan using a health-equity and trauma-informed framework. DC’s strategies are: testing, U=U, pre-exposure prophylaxis and post-exposure prophylaxis (PrEP and PEP), rapid antiretroviral therapy (Rapid ART), molecular surveillance, Data to Care, harm reduction, and wellness services. These strategies align with the four federal pillars — Diagnose, Treat, Prevent, and Respond — and an additional, DC-specific pillar, Engage.

Resources in the form of partnerships, funding, and new approaches will support the planning and development of programs to carry out these strategies. DC Health will ensure that programs are accessible and responsive to DC’s diverse communities and their unique intersectional needs.

DC Health continues to leverage its working partnerships across jurisdictions, including community providers and consumer and stakeholder groups and entities in government, academia, and education. Funding through the Health Resources and Services Administration (HRSA) 20-078 and the CDC PS20-2010 enables DC Health to expand access to programs, supporting the availability of innovative and effective medical, support, and prevention services, to people living with HIV and people who are HIV negative. Under HRSA-20-078, the funding will also engage people who previously were not eligible to receive Ryan White services. In addition, DC Health received a supplemental Ending the Epidemic award through the National Institutes of Health-funded District of Columbia Center for AIDS Research (DC CFAR) for planning new approaches on PrEP, molecular surveillance, and Rapid ART.

DC Health has adopted a status-neutral approach through the Regional Early Intervention Services model to create innovative and culturally appropriate services, either within specific stages or along the full continuum of HIV prevention, testing, care, and treatment. The goal is to improve access to and use of high-quality, client-centered services for individuals living in the DC eligible metropolitan area most affected by the HIV epidemic.

In addition, DC Health continues its commitment to address health inequities in communities. It will build on its work with the DMV (District of Columbia, Maryland, and Virginia) Collaborative, innovative and expanded Data to Care, and the intersection of HIV and opioid use, while recognizing the impact of COVID-19 within systems of power and privilege.

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