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Use geospatial and demographic data to increase targeted testing, and require providers receiving testing grants to use evidence-based programs that target social networks where new infections are most likely to occur.
Since 2006, to increase the number of tests administered, the DC Department of Health (DOH) has promoted routine, opt-out testing when residents visit their medical providers. Other innovative initiatives to reach more people include testing offered in hospital emergency rooms and at the Department of Motor Vehicles offices. Comparing two studies of District residents in 2006 and 2013 showed a promising improvement in testing rates.
While the general testing approach has been successful, the number of persons diagnosed in many of the nonmedical settings has decreased. For example, in 2015, while more than 3,000 people were tested at the Department of Motor Vehicle offices, there was not one person diagnosed as HIV-positive. A recent study from researchers at the George Washington University (GWU) has shown that testing directed to populations at higher risk of HIV infection is much more likely to identify new cases of HIV. The study also shows that focused testing is much more cost-effective than broad efforts directed at the general population.
To ensure that testing connects the largest possible number of HIV-positive District residents to care, DOH will encourage a mix of testing strategies: The most successful current testing programs — those with positivity rates of 1% or more, such as testing in hospital emergency departments — will continue, while some funding will be redirected to new, more targeted testing programs.
This recommendation will build on DOH’s traditional practice of using geospatial data — that is, examining where HIV infections are occurring to document the geographic distribution of newly diagnosed cases of HIV. DOH will identify “hot spots” in which to focus care and prevention efforts, including expanded testing. While routine, opt-out testing is necessary to truly reach 90% of all District residents living with HIV, DOH will direct its limited resources toward networks at the highest risk.
Continue media campaigns and medical provider education to ensure new and ongoing HIV testing approaches.
DOH’s successful media and medical provider education campaigns will continue to bean important part of ensuring that routine testing is sustained and that future testing programs are effective. Surveys show increased knowledge about HIV in general and testing in particular: 50% of respondents “said the campaigns provided them with new knowledge about HIV and testing.” Further, demographic groups at higher risk were successfully targeted for outreach. For example, 46%of African American District residents — who are at higher risk of contracting HIV — recalled seeing advertisements for testing, compared with 37% of white residents.
DOH will maintain its medical provider education program on routine HIV screening. DOH has contracted with an academic detailing organization to deliver education on HIV testing and prevention approaches. (This is the same approach that pharmaceutical companies use to make in-person educational visits to medical providers.) The program has demonstrated effectiveness. In 2014, the nurse educators visited more than 565 physicians in the District. Of the 357 who completed the education sessions, 68.6% reported they had fully implemented the HIV testing recommendations for all patients. Another 23.5% reported partial implementation of the guidelines. In 2006, study participants said that only 40% of their medical providers offered an HIV test. In 2013, participants reported that 71.3% of their medical providers offered an HIV test. Continued outreach to individual providers and institutional medical providers, like hospitals and primary care clinics, is essential to ensure that current routine testing numbers do not fall.
Identify those who test negative but are at elevated risk and engage counseling for prevention strategies—including counseling for Pre-Exposure Prophylaxis (PrEP).
While a positive test requires engagement with treatment, a negative test often does not lead to any particular action. This can be a missed opportunity to identify individuals at risk for HIV infection and to avert future infections. Elevated risk factors can include past positive sexually transmitted infection (STI) tests, STI nongenital diagnosis (particularly anal gonorrhea infection), frequent testing, self-reported unprotected sex, or a relationship with an HIV-positive partner. Those who fit these categories should be counseled on prevention. For example, someone in a relationship with an HIV-positive partner may be an ideal candidate for PrEP initiation. For providers using an electronic medical record, prompts could identify individuals at risk and suggest possible prevention counseling.
DOH will collect only aggregate data on negative tests. DOH will not collect the individualized data that grantees will use for follow-up. However, having data on the number of District residents who test negative will give DOH a better picture of the epidemic in the District and inform strategy going forward.
Adopt and implement HIV-testing performance measures and thresholds for managed care organizations (MCOs).
The Healthcare Effectiveness Data and Information Set (HEDIS) is a tool used by more than 90% of America’s health plans, including Medicare and Medicaid, to measure performance on important dimensions of care and service. There are 81 measures across preventive health, clinical care, and standards. The Department of Health Care Finance (DHCF) uses HEDIS measures to assess the performance of the managed care organizations. However, there are no current measures related to HIV.
DOH will model efforts on other jurisdictions, particularly Louisiana, to develop and implement a performance measure on HIV testing for the DC Medicaid program. The HIV branch of the Louisiana Department of Health was able to negotiate with the Medicaid branch to include HIV performance measures in the state’s managed care contracts. This measure will help increase the number of District residents who receive annual testing as part of their healthcare.
Reduce the time from initial diagnosis to initiation of anti-retroviral therapy (ART) through a relaunch of the Red Carpet Entry Program. Demonstration project: Rapid ART
Before 2012, HIV clinical treatment guidelines published by the U.S. Department of Health and Human Services (DHHS Guidelines) strongly recommended ART only for patients with CD4 counts below 350, because this threshold was generally associated with the onset of Stage 3 or AIDS-defining illnesses and other morbidities. This “wait to treat” approach reflected uncertainty about the clinical benefits of starting ART in asymptomatic patients with relatively high CD4 counts, coupled with concerns about adverse side effects and reduced quality of life under available ART regimens.
However, two large clinical studies published in 2015, the Strategic Timing of Antiretroviral Treatment (START) and TEMPRANO studies, offered clear and definitive evidence that early initiation of HIV therapy reduces mortality and morbidity in HIV-positive individuals. As a result, Centers for Disease Control and Prevention (CDC) guidance has been updated to recommend immediate initiation of ART.
With this new understanding, the Red Carpet program in DC will be revamped to expand on previous success by implementing intensive linkage and navigation efforts to “anchor” the patient into care with a medical home. A medical home or patient-centered medical home is a redesign of primary healthcare where persons receive comprehensive and continuous medical care with the goal of obtaining maximized health outcomes. A project manager will provide oversight for case managers or other peer navigators who can help establish and maintain linkage with care.
DEMONSTRATION PROJECT: Rapid ART
While the CDC recommendations promote early initiation of ART, the period between diagnosis and starting medication can be weeks or sometimes months while patients wait for certain laboratory tests, appointments, prescriptions, and other factors related to readiness for treatment. DOH will develop a demonstration project on a new approach called Rapid ART, which starts medication within 24 hours of diagnosis. DOH will start at its new Health and Wellness Center (formerly known as the STD and TB clinics). It will also engage one or two clinical partners to ensure a diverse population cohort and range of settings (e.g., primary care and hospital) to gauge effectiveness. The DC Health and Wellness Center is in the process of acquiring new laboratory capacity to run routine select tests before administering an HIV medication regimen. DOH will provide initial 30-day starter packs of a frontline ART regimen upon HIV diagnosis. The demonstration project will measure the effectiveness of uptake, adherence, time to viral load suppression, need to change regimen based on genotype testing results, and patient self-efficacy. This demonstration will be informed by the profile of genotypes among the thousands of persons in the DC Cohort study (the joint longitudinal HIV study between GWU and DOH). Genotypes are the genetic differences among strains of HIV; this is important as some variations of HIV are resistant to certain medications. By understanding the overall types of HIV in the District, medical providers can select the best medications for persons to start treatment.
Examine the feasibility of requiring all providers in DC to report treatment of a new patient with HIV and when a patient begins ART to DC Health. Public call to action: Providers should voluntarily report (a) when they begin treating a new patient with HIV who is not a new diagnosis and (b) when patients begin ART.
Currently, all new HIV infections in DC must be reported to DOH, and some government-funded programs report on ART uptake as part of their grant requirements. But this leaves DOH with an incomplete picture of the epidemic. It also makes it difficult to help providers determine which of their patients may be actively engaged in care and treatment elsewhere and which are truly lapsing in treatment. Since 2008, DOH has regularly undertaken “recapture or retention blitzes,” where providers who had not seen a patient for a period of time can find out whether that patient is in treatment somewhere else. In interviews with providers in DC, these retention blitzes were universally praised as huge timesavers for staff who did not have to spend hours attempting to locate and contact a client thought to be out of care.
DC Appleseed and DOH will examine appropriate language for amended regulations that require providers to report when they begin treating a new patient who was previously diagnosed with HIV, and when patients under a provider’s care initiate ART. This will allow for better data-sharing with District providers — through, for example, retention blitzes — and more accurate tracking of progress toward the goals set in this plan.
Expand access to treatment and related services, targeting demographics and geographic areas where populations are at higher risk.
As noted in the discussion of targeted testing, DOH is already working to identify hot spots where new transmissions are geographically concentrated in order to identify where resources are most needed. Understanding where in the District the burden of HIV is concentrated is an important tool for maximizing the impact of public health resources. DOH will utilize hot spot statistical analysis to assess the geographic clustering of HIV and sexually transmitted infections (STI), as well as identifying where there are lower rates of retention in care and viral suppression. Through this analysis, DOH will be able to better target HIV prevention and care efforts in those regions of the District where it will have the largest impact. Additionally, the analysis will increase understanding of the potential influence of social determinants of health (e.g., education, employment, income, transportation, child care, nutrition services, and housing) in addition to clinical outcomes.
Develop a standard consent form for HIV care that allows the DC Department of Health (DOH) and providers to share information that could improve treatment while respecting patient confidentiality. Demonstration project: Black Box Program
Providers typically ask patients to complete a form that allows the provider to conduct various medical actions such as screenings, examinations, laboratory tests, and procedures specific to the provider. A patient needs to provide separate consent to allow sharing of information with another provider. During a retention blitz, for example, DOH can only share whether a patient is in treatment with another provider — not which provider is currently seeing a patient. If patients have given prior consent, DOH could share additional information, which could allow providers to share treatment information that would improve care or help in reengaging patients who have fallen out of care, while also respecting patients’ privacy.
DC Appleseed and its pro bono partners at Hogan Lovells US LLP will identify best practices in this area and draft a consent form that DOH can distribute to providers. This form will allow patients to consent to share information that could improve care. DOH and DC Appleseed will engage providers and community members to identify the most useful information and potential privacy concerns.
Demonstration project: Black Box Program
In 2012, Georgetown University invited the DC, Maryland, and Virginia health departments to discuss the barriers and challenges to sharing data across the three jurisdictions. This initial conversation led to Georgetown developing a prototype technological solution that would provide more efficient and timely matching of data among the three state-level HIV data sources.
Georgetown pioneered the creation and application of a novel computerized algorithm and privacy device that would receive data from the Enhanced HIV/AIDS Reporting System (eHARS) database and detect matches of identifiable information. The algorithm, housed on a secure computer, would report the matches back to the jurisdiction and then destroy the data internally to ensure security and confidentiality.
Georgetown tested a proof of concept and prototype device with the health departments, and it demonstrated that the technology could quickly and routinely identify people who were diagnosed in one jurisdiction and had subsequently moved to another.
The demonstration will test whether this technology can improve the timeliness, accuracy, and completeness of HIV care continuum data and improve the health of people living with HIV in the region.
Expand the use of community health workers as a component of HIV care and treatment.
In 2010, the Washington AIDS Partnership led a public-private initiative to pilot a project that provides peer HIV community health workers (CHWs) for low-income African Americans living in Washington, DC, and Prince George’s County, Md. The project, called Positive Pathways, was managed by the Institute for Public Health Innovation. Positive Pathways employed CHWs at several local organizations to identify out-of-care HIV-positive individuals and provide personalized assistance to help them navigate the healthcare system and reengage in HIV care.
Between 2011 and 2015, Positive Pathways reached more than 1,600 individuals and linked almost 1,300 individuals to medical care. Positive Pathways participated in a national evaluation for the AIDS United Access to Care initiative, which was conducted by the Johns Hopkins Bloomberg School of Public Health. Preliminary evaluation results show that 86% of enrolled Positive Pathways clients were linked to care—defined as visiting a medical provider within 30 days of first contact. For any person with HIV in need of this support, there should be sufficient funding to increase the availability of CHWs.
Given the potential value both for people living with HIV and for the District’s healthcare system, DOH will work with government partners such as DHCF, the University of the District of Columbia, and community partners on aspects related to training, certification, credentialing, and integration of CHWs into healthcare and non-healthcare settings. The result will be an optimal and sustainable Districtwide CHW program.
Use peer navigators to engage with African American and Latino men who have sex with men and transgender people of color.
DOH received a four-year grant from CDC to fund demonstration projects that provide culturally competent services for men who have sex with men of color and transgender people of color, particularly African American and Latino, living with or at risk of acquiring HIV. DOH designed the demonstration, called Improve Measurable Participation and Access to Care and Treatment in the District, Maryland, and Virginia (IMPACT DMV) in collaboration with the Maryland and Virginia health departments and community partners to create a regional system of care for both HIV-negative and HIV-positive men who have sex with men and transgender individuals of color.
The project aims to address the circumstances that relate to success, such as education, employment, housing, and overall wellness to enhance self-efficacy. The demonstration project will develop additional measures to evaluate this comprehensive approach to be shared with CDC and the community. In an initial approach to integrate economic opportunity and health engagement in the health system, DOH will create new peer-counseling positions, called Health IMPACT Specialists, who will help with outreach to persons at risk of HIV and living with HIV, and assist in connecting people to community resources and services.
DOH will seek to expand this opportunity for more participants, assess its effectiveness, and determine whether this model can be used to engage other focus populations in care.
Reconsider the six-month in-person re-registration for the DC Healthcare Alliance.
The DC Healthcare Alliance is a locally funded program that offers public insurance coverage to low-income District residents who have no other insurance options, including those who do not qualify for Medicaid or Medicare. This includes insurance for undocumented immigrants. In 2012, DHCF began to require reregistration every six months — previously this was required every 12 months — to help ensure that only District residents benefit from this unique program.
Many providers that DC Appleseed interviewed noted that requiring clients to re-register in person every six months is an overwhelming burden and causes people to fall out of care. Anecdotally, advocates believe the recertification process itself discourages some beneficiaries from recertifying. The recertification process requires Alliance beneficiaries to go to one of five service centers for an in-person interview. Advocates describe long lines, and DHCF data show that the average wait time in 2015 for re-registration was more than an hour and a half.
It is reasonable for DHCF to limit the program to District residents as a program entirely funded by District dollars, but the process should be reconsidered so that District residents who most need the benefits have reasonable access. This will be a major investment for the District government; DHCF estimates that it could cost as much as $14 million to move from a six-month to 12-month recertification. This increase can be attributed to the fact that more people eligible for coverage will remain enrolled at any point, but it could also potentially be the result of non-District residents utilizing the program.
Identify opportunities to enhance culturally competent HIV treatment. Public call to action: Healthcare providers in DC should increase their own understanding of culturally competent HIV treatment practices.
The DC Council recently approved legislation that would require medical professionals in the District to take continuing medical education (CME) courses on culturally competent practices for LGBTQ patients. As DOH Director Dr. LaQuandra Nesbitt noted in a response to questions about the legislation from Council member David Grosso, implementation of the regulations is pending, but DOH anticipates the requirements will become applicable at the beginning of each license renewal cycle. Before promulgating regulations, DOH should examine whether existing requirements for HIV-specific education can be part of this or other CME requirements. Additionally, providers in DC should independently seek out opportunities to improve their ability to provide care that is respectful of various patients’ backgrounds and needs, including sexual orientation, gender identity, age, race/ethnicity, language, nationality, history of substance use and mental health, and returning citizen status within the context of HIV treatment.
Examine the feasibility of leveraging a Health Information Exchange to improve HIV care and treatment.
The District currently has multiple platforms for electronic health information exchange (HIE) among healthcare providers, hospitals, and agencies that select and implement their own systems. However, there is not a consistent mechanism for information to be shared among the systems. The District government formed an HIE policy board in 2012 to solve the communication challenges or adopt anew platform. A more robust DC-wide HIE system would allow providers to query regularly to find out whether a particular patient is in care elsewhere. This would, in effect, replace the successful retention blitzes, which providers interviewed for this plan would welcome. DOH is currently working with Ryan White HIV/AIDS Program providers to share these data through CAREWare—software that manages and monitors HIV clinical and supportive care. The results of the work with Ryan White providers will inform a Districtwide plan.
Provide more accessible healthcare services by hours, locations, and providers. Demonstration project: Retention in HIV Care and Treatment
Most persons living with HIV maintain routine visits with medical providers. But for some, there are barriers to accessing care. According to a study conducted by GWU, individuals cited multiple reasons: transportation, forgetting appointments, and competing priorities. The study participants shared approaches that would improve their access: flexible appointments, appointment reminders, providers co-located in sites, and transportation assistance.
DOH will work with medical providers and community-based organizations (CBOs) to develop strategies that will address barriers and facilitate access to healthcare services. One critical area would be shifting available times for appointments, particularly to evenings and weekends. Flexible hours would improve access, for example, for people who cannot leave work during business hours for a medical appointment without lost wages.
Other approaches to increase access include: co-locating providers at CBOs, creating opportunities for lab testing at more convenient times outside of a medical visit through engagement with community partners, lab specimen self-collection approaches, and directly observed therapy (DOT) for initial HIV treatment.
DEMONSTRATION PROJECT: Retention in HIV Care and Treatment
In 2015, the Washington AIDS Partnership and DOH launched a new public-private partnership aimed at reaching DC residents living with HIV/AIDS who struggle with engagement in HIV care provided through the traditional medical services. The Mobile Outreach Retention and Engagement (MORE) initiative is a new, mobile medical team approach in Washington, DC, with medical and supportive services provided in the home and at pop-up community clinics. MORE will address common and persistent barriers associated with engagement in HIV care, including transportation challenges, inability to attend daytime medical appointments, and disengagement with the medical system.
Through a grant to Whitman-Walker Health, the MORE team is deployed in the community to find out-of-care individuals and provide medical evaluations, blood draws for lab tests, and counseling either in the home or at pop-up community clinics, with the ultimate goal of supporting effective engagement in care.
An evaluation of the project by an independent firm will review effectiveness and cost. These results will inform DOH and DHCF on developing a sustainability plan that could include dedicated Ryan White CARE Act funding and a Medicaid state plan amendment to cover clinical care in non-clinical settings.
Partner with other DC government agencies to address the social support needs of clients that may influence treatment-seeking and adherence.
In interviews with key stakeholders, DC Appleseed found that access to supportive services like substance use or mental health treatment were barriers to remaining in care and ART adherence — both of which are necessary to reach viral suppression. DOH will continue to strengthen coordination with substance use and mental health systems to mitigate the extent to which these co-morbidities affect a person’s ability to adhere to HIV treatment. Key players involved in responding to the broad range of needs include the DC departments of Behavioral Health and Health Care Finance, as well as the Office of Victim Services and Justice Grants.
In 2011, DOH and the Department of Behavioral Health collaborated to develop a short universal screening tool for initial assessments of people entering HIV, substance use, or mental health services. The screening tool is used by providers among the three funded service networks to identify needs and connect people with further services. DOH will continue the collaboration.
Under the Affordable Care Act (ACA), states are allowed to design “health homes” for care coordination and chronic disease management for certain populations with multiple conditions, such as mental health and HIV. Effective January 2016, DHCF launched a Medicaid Health Home for people with serious mental illness. DHCF is working on a second Health Home for persons with chronic conditions. DOH will collaborate with DHCF on the design of the chronic condition Health Home that would enhance health outcomes for persons living with HIV.
Assume direct responsibility for improving clinical quality and health data among all providers in the District.
DOH will examine the success of medical providers in retaining patients in treatment and creating good health outcomes for persons living with HIV. DOH will establish a clinical quality management team as an ongoing resource to all clinical providers in the District. The team will establish a learning collaborative to define clinical excellence standards, particularly in addressing co-morbidities associated with HIV. For instance, the District has an aging cohort of people living with HIV. As HIV is known to accelerate the aging process, there is greater probability that certain conditions, such as diabetes, cardiovascular conditions, or cancer could affect this population. The management team will help care providers improve their knowledge of and capacity to address these conditions.
DOH will also collaborate with the DC Cohort — the joint longitudinal HIV study between GWU and DOH — to develop baselines and goals for other health conditions among persons living with HIV, such as those mentioned above. DOH will then be able to assess how all individual providers are meeting goals for the overall health of persons living with HIV.
Implement a data-to-care program to increase levels of engagement in care.
DOH proposes implementing a “data-to-care” strategy for the District. Data-to-care is a CDC-endorsed public health strategy that seeks to use HIV surveillance data to identify HIV-diagnosed individuals not in care and link them to care that will help lead to viral suppression.
The foundation of the proposed data-to-care strategy is the effective integration and use of the various surveillance, monitoring and evaluation, and administrative data systems already maintained by DOH and other governmental agencies that collect information on care and treatment utilization. The linkage of case information across multiple data sources will help to identify whether an individual HIV-positive person is actively engaged with a provider, what treatment regimen the person is using, and health outcomes, including viral suppression rates. This will help DOH notify providers of patients who have gaps in care and treatment. DOH can also contact people with whom providers have lost contact.
In addition to housing the District’s eHARS, AIDS Drug Assistance Program (ADAP), and RyanWhite CAREWare database, DOH currently has a data use and security agreement with DHCF for the Medicaid program. DOH plans to determine which patients have reached viral suppression by incorporating service utilization and prescription information collected through these ancillary data systems, ratherthan relying only on HIV laboratory data in eHARS. The goal is not to be intrusive to patients or providers, but to engage with providers and deliver support to people living with HIV.
Work with pharmacies and Pharmacy Benefits Managers to increase access to prescriptions and better track medication adherence.
Relationships with medical providers, regular health visits, and laboratory testing are all essential components of a care and treatment plan for a person living with HIV. However, getting and taking medication is the key to ensuring that a person succeeds in achieving viral load suppression and maintaining a healthy immune system. There is currently no established process by which to report and track ART initiation. Similarly, there is no current data collection on medication utilization. The proxy for measuring medication adherence is the dispensing and refilling of medication.
In the healthcare system, a pharmacy benefits management system (PBM) is a third-party administrator of prescription drug programs, primarily responsible for processing and paying prescription drug claims. Every health insurance plan contracts with a PBM for its medication benefits, including Medicaid and ADAP. DOH manages ADAP, and its PBM provides regular reporting on prescription dispensing and refills. Through a data-sharing agreement with the DC Medicaid program, DOH can obtain equivalent Medicaid PBM reports. DOH calculates that these two sources account for approximately half of all persons living with HIV in the District. The other half are under private health insurance plans. DOH has initiated a collaboration with the major health insurance plans in the District to obtain aggregate data on medication adherence. These sources, combined with providers’ reporting on ART initiation, will provide a critical marker on the progress the District is making to achieve Goals 2 and 3.
Promote policies to enable and encourage pharmacists to assist in ART adherence.
Working with PBMs will track medication utilization at a population level. The next step is to provide support to maintain treatment adherence. Pharmacies have the role of dispensing medications. The District has several specialty pharmacies, including medical provider-based pharmacies, which provide medication management and counseling. DOH has established an HIV pharmacy network for ADAP beneficiaries.
DOH will work with the DC Board of Pharmacy and select pharmacies to expand medication therapy reviews and pharmacotherapy consults to address actual or potential medication ART adherence problems, such as drug interactions with other medications that could result in side effects. Including clinical pharmacists in a comprehensive medication management model can help manage patient problems and formulate treatment goals. The DC boards of Pharmacy and Medicine will be considering regulations to allow pharmacists to enter into collaborative practice agreements with physicians. This new agreement will enhance the medication management model.
DOH will start a pilot program to track medication utilization with ADAP and DC Medicaid. This will help to identify people with HIV who experience interruptions in their medication utilization and could benefit from an approach that includes engagement with a pharmacist.
Promote telemedicine approaches for adherence support. Demonstration project: Treatment Adherence Technology
Slightly over 20% of HIV-positive individuals who we reengaged in care in the District — though not necessarily prescribed ART — failed to reach or remain virally suppressed. Among patients in the Ryan White program and the DC Cohort study, for whom DOH has more complete data, over 10% of even those who are prescribed treatment still are not virally suppressed. This is primarily because those patients do not consistently take their medication. Innovative approaches are needed to increase access and adherence especially among hard-to-reach populations. DOH proposes to promote multiple strategies to support adherence and compliance, including telemedicine-based interventions.
DOH will partner with clinical providers to use either an existing telemedicine platform or develop one to promote treatment adherence. The approaches could include mobile phone-based approaches, such as connecting DOH healthcare providers and patients via FaceTime. Another approach could be medication reminder messages. The World Health Organization has endorsed text messaging as an effective model for promoting ART adherence. A meta-analysis of text-messaging based reminder services in other areas shows that providing reminders for medications, lab, and administrative appointments improved HIV-related health outcomes. DOH will identify and explore multiple telecommunication technologies.
DEMONSTRATION PROJECT: Treatment Adherence Technology
Programs that allow alternative access points to health records — electronic health (eHealth) and related mobile health programs (mHealth) — have been a part of the healthcare system for more than 15 years. With the scale-up of electronic medical records (EMR), those systems have added patient portal features to enable individuals to access health records on the internet and through mobile applications. This demonstration project will explore the use of technology to advance treatment adherence, particularly among people with a history of inconsistent medication use.
DOH will allocate funding to initiate the demonstrations with an evaluation component. These ideas were developed by first-year medical students at The George Washington University School of Medicine and Health Sciences through its 2015 intersession program called “How Physicians Can Help Create an AIDS-Free Generation.”
Examine adding performance measures to future contracts with MCOs to enhance treatment adherence, viral load suppression, and funding for support services — especially housing.
As discussed under Task 1.4, while there are 81 Healthcare Effectiveness Data and Information Set (HEDIS) measures related to a range of health conditions, there are no HEDIS measures related to HIV care and services. Therefore, DHCF in partnership with DOH, DC Appleseed, and other relevant partners will develop aset of performance measures related to HIV clinical care and health outcomes,such as medical visits, laboratory testing, medication adherence, and viral load suppression. These performance measures will be used to determine funding for managed care organizations (MCOs) and included in future contracts.
Creative models tested in other parts of the US have demonstrated the promise of channeling MCO funds into social support services to affect health outcomes. For example, MCOs in the Chicago area fund the AIDS Foundation of Chicago (AFC) to provide supportive services similar to those envisioned in DOH’s Housing First pilot program described below. AFC was able to demonstrate to the MCOs that it could generate cost savings by improving health outcomes for clients with HIV, in this case by ensuring stable supportive housing for clients who accounted for a disproportionately large percentage of expenditures. Patient needs are better met and the MCOs save money by moving their investment “upstream.”
Retool the Ryan White HIV/AIDS Program to improve District and regional healthcare and supportive services.
For more than 25 years, the Ryan White Program has supported a system of clinical care, medication access, and support services for people living with HIV. The program design offers a dynamic range of care and support, which has consistently provided high rates of service utilization, care retention, and viral load suppression when compared with the general population of persons with HIV.
With the adoption of the ACA, the landscape of health insurance coverage changed extensively. The ACA ensures that people do not lose their health insurance because of changes in their condition, expands publicly funded insurance coverage through Medicaid, and provides more affordable options for people to purchase insurance. As the Ryan White Program is a payer of last resort — funds are available only for services not otherwise covered by any health insurance — these provisions of the ACA mean that fewer people have to rely on the program for basic coverage.This can free up resources to meet other healthcare needs.
The Ryan White CARE Act generally requires that a minimum of 75% of funds must be allocated for core medical services and no more than 25% for nonclinical services. DOH will apply for a waiver of this rule — which is typically granted — so that Ryan White funds no longer needed for medical services can be redistributed for services just as crucial for people living with HIV, such as housing, transportation, child care, nutrition support, emergency financial assistance, and assistance with insurance, benefits, and other health and nonmedical related needs.
Redesign the Housing Opportunities for Persons With AIDS (HOPWA) program to support persons toward self-sufficiency. Demonstration project: Housing and Employment Demonstration project: Housing for Victims of Violence
DOH will work with the District government and other stakeholders to redesign the Housing Opportunities for Persons With AIDS (HOPWA) housing program in the District and metropolitan area to better align with other housing programs and provide services depending on where each person is along the housing continuum:emergency shelter for the homeless, supportive housing for people with special needs, rental housing with or without assistance, home ownership, and senior housing. As people with HIV live longer, healthier lives, they will need access to all of these types of housing.
Going forward, the HOPWA program will be driven by specific goals, including helping District residents living with HIV achieve independence from ongoing HOPWA support when possible. This can include helping individuals find and maintain employment that will allow them to generate income. It might also include a housing setting that has more supports — for example, senior housing for people living with HIV who are older than 55. Future recipients of HOPWA funding will develop goals and a plan to achieve that goal. HOPWA voucher agreements will provide supportive services related to the client’s goal, including peer supports when necessary, and specify times at which the agreement will be reviewed.
The underlying idea of the revamped HOPWA program will be the nationally accepted “housing first” concept. Under a housing first model, those who need housing support are placed immediately in permanent housing without spending time in a transitional housing program. This approach can be effective for people on a housing self-sufficiency track and for people in need of supportive housing.
As those HOPWA clients who are able to become self-sufficient no longer need a HOPWA voucher, more people living with HIV who are currently locked out of the HOPWA program because of limited federal funding will be able to access stable housing. And for those who need continued support, HOPWA will work with other DC agencies, when possible, to identify other programs that can help clients achieve their housing goals.
DEMONSTRATION PROJECT: Housing and Employment
In several parts of the country, jurisdictions have started testing new approaches to support housing success, particularly among the population of people living with HIV that needs temporary assistance to get to self-sufficiency. This is the framework for the housing and employment demonstration project.
There is evidence that housing stability improves HIV health outcomes. There are also studies that show that employment benefits HIV health outcomes. Employed people were 39% more likely to have achieved optimal adherence to antiretroviral medications (reaching better than 95% adherence). Employment increased self-care (49%), CD4 count (37%), and medication adherence (21%).
The focus will be on single adults with low incomes who are homeless or at risk of homelessness, and who are living with HIV/AIDS. Support services will include case management, housing search assistance, and employment assistance; financial services will include money for security deposits, utilities assistance, and ongoing rental assistance for 24 months.
DEMONSTRATION PROJECT: Housing for Victims of Violence Living With HIV
The District is also committed to providing the most effective and compassionate services possible to people living with HIV who are also victims of sexual assault, domestic violence, dating violence, and stalking. DOH will partner with the DC Office of Victims Services and Justice from October 2016 through September 2018. Grants and community partners to learn about the obstacles and promising projects for system alignment, service coordination, and intervention design for low-income people living with HIV who are homeless as a result of sexual assault, domestic violence, dating violence, or stalking. Activities to increase housing stability and improve engagement along the HIV care continuum, notably treatment adherence, for this project are scheduled to run
Examine opportunities to provide more housing options for persons in the metropolitan area.
Similar to the Housing Choice Voucher program, HOPWA clients pay 30% of their monthly income for housing, while funding from the U.S. Department of Housing and Urban Development (HUD) covers the rest of the unit’s total rent cost. This makes housing affordable to low-income individuals and families in the District, where the market offers fewer and fewer units affordable to those with limited income. However, HUD also caps the maximum total rent allowable for a HOPWA-subsidized unit — at, for example, $1,623 per month for a two-bedroom unit in the DC region (2016). Expanding to a regional focus, as with the Ryan White CARE Program, will make more units available for HOPWA clients. It will also offer more choices to HOPWA clients — for example, to identify different amenities that may better align with a client’s housing goals. DOH partners have indicated an interest in providing more choice for clients living in HOPWA-subsidized housing.
Examine the need for expanded funding for affordable housing for people living with HIV.
In Tasks 3.8 and 3.9, DOH will access other sources of funding for housing support for District residents living with HIV—specifically, tapping into Ryan White CARE Act funding and creating incentives for MCOs to provide funding. Because stable housing is so closely correlated to staying in sustained treatment —and, consequently, reaching viral suppression — it is important to ensure that sufficient funding is provided. Other jurisdictions have also realized the importance of supportive housing. New York state, for example, has redesigned its Medicaid funding model and offered $47 million for supportive housing in 2015–16. DOH and DC Appleseed will continue to examine additional funding opportunities to ensure that people living with HIV in DC have access to stable housing.
Promote use of HOPWA funding for capital development to create new units of affordable housing that are available for people living with HIV.
The mayor’s strategic plan to end homelessness promotes the development of more general affordable and supportive housing for persons in need of enhanced services. Due to the high cost of housing development, the District government and project sponsors have blended multiple funding sources to make projects viable. The funding sources cover both construction and services for supportive housing. This model has been successfully implemented for projects with a range of funding sources: the Housing Production Trust Fund, federal tax credits, DC Housing Authority vouchers, Department of Behavioral Health funds,and Department of Human Services’ homeless funding. The advantage of the blended funding approach is that no one agency or program has to carry the full cost. And if there is a funding source dedicated to a certain population or health condition, then the whole unit — regardless of the amount contributed —must be set aside for that eligible occupant.
DOH and the DC Department of Housing and Community Development (DHCD) will engage developers and design housing financing proposals that would include a portion of HOPWA funds to promote new housing stock and a set-aside of units specifically for people living with HIV. DOH and DHCD will also work with the Office of the Deputy Mayor for Planning and Economic Development to encourage new developments to access this funding where feasible and appropriate. This approach leverages limited HOPWA funds to increase the stock of affordable housing for persons with HIV.
Ensure that people living with HIV who access low-barrier shelters in DC receive accommodations that will allow them to manage their condition.
Access to emergency shelters is granted on a first-come, first-served basis; homeless individuals who are able to access a shelter on a given night must vacate in the morning, then return in the evening to line up for a bed for the night. In interviews with advocates over the years, DC Appleseed has learned that this can inhibit ART adherence among homeless people living with HIV in DC. People living with HIV who are experiencing homelessness and utilizing low-barrier shelters should have access to facilities and secure accommodations for their medications.
The Community Partnership for the Prevention of Homelessness (TCP), which coordinates the District’s emergency shelters, has a policy requiring shelters to provide reasonable accommodations for people living with HIV. However, DC Appleseed surveyed shelters and found that this is not a universal practice. Some shelters allow residents, for example, to return during the day under a reasonable accommodation request, including to access refrigerated diabetes medications. However, other shelters allow entry for medication only at the discretion of staffers on duty, and some shelters do not allow residents to reenter under any circumstances.
The District government through the Department of Human Services and TCP will ensure that all District residents living with HIV who access low-barrier shelters consistently receive accommodations that facilitate adherence to medical treatment, including ART.
Expand the network of prescribers of PrEP through increased knowledge and capacity of private medical providers. Demonstration project: PrEP for Women
Pre-Exposure Prophylaxis (PrEP) use begins with a prescription. To increase PrEP uptake, DOH will work to expand the network of medical professionals prescribing PrEP in DC. DOH has initiated and will expand a regular round table of clinicians willing to prescribe PrEP. This approach also will result in peer-to-peer promotion of the intervention among providers.
DOH will also develop educational materials for medical providers in the DC region. DOH will utilize contractors to deploy clinical educators to private and large-group practices. DOH will work collaboratively with community partners to recruit more prescribers to larger clinical education sessions. The sessions and materials will advise clinicians how to connect people to the network of community partners funded by DOH who can provide counseling, adherence support, and a culturally affirming setting that is integral to PrEP adherence. DOH will continue to engage and provide technical support to community organizations to focus or integrate PrEP into their programming. This also includes building the capacity of providers to offer appropriate care and information for special populations, such as transgender people of color, in culturally affirming settings to ensure PrEP uptake in these communities.
DEMONSTRATION PROJECT: PrEP for Women
African American women have the second-highest rate of HIV infection in DC, and PrEP could be an effective prevention tool for many African American and Latina women. DC Appleseed interviewed providers and advocates in DC and found that the groups at highest risk for HIV infection often are the least likely to know about PrEP or to ask their provider for more information. Recent focus groups of African American women conducted by DOH found that nearly all the participants were unaware of PrEP. Many were angry to learn that information about PrEP had not been more widely distributed.
DOH and the Washington AIDS Partnership (WAP) will employ $1 million in funding from the MAC AIDS Fund over the next two years to develop a “DC PrEP for Women” initiative. The initiative will have several aims: (1) to encourage HIV and women’s health providers to adopt and offer PrEP as an effective strategy to reduce HIV infection; (2) to educate high-risk women to increase interest in PrEP; (3) to change and expand the conversation about PrEP with women from “protecting her from him” to “taking care of yourself”; and (4) to increase the number of medical providers prescribing PrEP for women. The initiative’s dual focus — women and providers — is designed to increase requests for PrEP from women and increase the number of providers offering and prescribing it.
To guide the initiative, DOH and WAP will form an advisory committee, comprising practitioners, stakeholders, academics, and program participants. The program will include outreach efforts to widely share information about PrEP. WAP will award funds to organizations for two purposes: 1) to assist community organizations to integrate PrEP into their services and educate women about PrEP as an option to reduce HIV risk and 2) to help Federally Qualified Health Centers develop sexual health training — including trainings on PrEP for healthcare providers and community organizations.
Make PrEP starter packs available at the DC Health and Wellness Center.
DOH will reallocate prevention funding to give resources to more community partners to promote, educate, and engage people about PrEP. First, DOH will implement a PrEP program as part of its new Health and Wellness Center (formerly the STD and TB clinics). This will serve as a low barrier entry to obtain PrEP. Before initiating PrEP, an HIV test must confirm a negative diagnosis. To facilitate quicker access to PrEP, DOH will be acquiring new laboratory equipment for the Health and Wellness Center that will be able to run the preliminary tests required for PrEP initiation and follow-up HIV testing as recommended by the U.S. Food and Drug Administration (including tests for kidney or liver conditions). DOH will provide a starter pack of either a 30-day or seven-day supply with follow-up visits and routine lab tests. DOH has designated a PrEP adherence specialist position to help participants navigate insurance coverage that will be necessary to access refills after the starter pack is completed. The adherence specialist will also provide counseling on taking the medication.
Develop PrEP-specific telemedicine program.
DOH will also develop a PrEP-specific telemedicine pilot program — similar to the broader telemedicine program outlined in Task 3.7 — to engage participants and support PrEP adherence. The DOH clinician and adherence specialist will schedule consultation sessions according to the individual's availability, including nonstandard clinical hours. DOH will also develop an agreement with a laboratory to allow participants to take lab tests in locations other than the Health and Wellness Center. DOH will evaluate the pilot program for effectiveness.
Recruit peer navigators for African American and Latino men who have sex with men and transgender people of color to promote knowledge of PrEP.
As described in Task 2.6, the CDC-funded demonstration project for African American and Latino men who have sex with men and transgender people of color will include the peer navigator Health Impact Specialist program component to educate and engage individuals about PrEP.
Work with Medicaid, MCOs, and private health plans to ensure insurance coverage of PrEP treatment and related clinically recommended laboratory monitoring.
DOH will work with DHCF and private insurance carriers to ensure coverage of as many components of the PrEP intervention as possible. While insurance coverage for the drug itself is usually sufficient, in some cases, lab testing is not covered by insurance. DOH will work with DHCF and insurance carriers to eliminate any barriers to PrEP use caused by gaps in insurance coverage.
Monitor the need for a co-payment assistance program for PrEP. Monitor and fund gaps in coverage for PrEP.
While there are drug assistance payment programs available for PrEP and navigators can help patients access those programs, other costs associated with starting and staying on PrEP can add up. PrEP is effective only when taken as directed, and financial barriers to PrEP access reduce the likelihood of increased uptake — especially among populations that are at the highest risk of infection.
The major expense for PrEP is the medication. Most insurance plans, including DC Medicaid, cover PrEP medication. The clinical costs include medical visits and laboratory tests related to screening for HIV, hepatitis, and STDs, and tests associated with the medication, including kidney and liver function. While insurance coverage for the drug itself is usually sufficient to enable utilization, in some cases, the complementary lab testing is not covered by insurance, which can be a barrier to adherence. Co-pays for office visits to get tested and review results can add up. For undocumented persons, insurance access can also be limited. DOH will work to ensure that cost is not a barrier to protection.
Expand access and availability of Post-Exposure Prophylaxis (PEP).
Post-exposure prophylaxis (PEP) treatment is a 28-day ART regimen taken after possible exposure to HIV. If treatment is started within 72 hours of exposure, it is highly effective in preventing the development of HIV infection in a patient exposed to HIV through, for example, prior unprotected sex with an HIV-positive partner or injection drug use.
PEP is effectively the “Plan B” for HIV, analogous to emergency contraception to prevent pregnancy after unprotected sex or birth control failure. Prescribing PEP also serves as an opportunity to connect a patient who has shown a risk for future infection to PrEP.
The scale-up of PEP entails some of the elements described previously for PrEP. These include:
Develop public education campaigns to raise awareness of prevention strategies, in particular PrEP and PEP.
DOH has demonstrated through evaluation that public education campaigns motivate individuals toward health-seeking behaviors. Through its contractor, Octane Public Relations, DOH conducted an evaluation of the impact of its testing and condom campaigns. The evaluation found that DC residents clearly and consistently received messages about the primary campaign messages to get tested (54%), protect yourself (44%), and practice safe sex (52%). Nearly three-quarters (74%) of all survey respondents said the campaigns made them think about the risks of HIV. More than two-thirds (71%) of survey respondents said they know about the city’s free condom services because of the campaigns.
DOH will maintain and revise public education campaigns on testing, care and treatment, and prevention (PrEP and condoms). The programs will contain several important core components: cultural competence and affirmation, practical actions, and the use of appealing media platforms.
Improve timely notice to DOH of all new HIV diagnoses. Demonstration project: Rapid HIV Surveillance and PEP-Plan B Public call to action: Providers should give more timely notice to DOH of a new HIV diagnosis.
The District has one of the shorter time frames for reporting HIV diagnoses; current regulations require medical providers and laboratories to report an HIV diagnosis within 48 hours. Unfortunately, even the current 48-hour time frame is not always followed by practitioners. Further, some providers rely on a laboratory to report to the health department, which is not always timely and does not provide relevant information on the individual.
Standard HIV testing has evolved to allow for quicker confirmation of a positive infection, and starting ART as soon as possible speeds up the process of reaching viral load suppression. For these reasons, DOH will explore the feasibility of requiring reporting of acute HIV infection (a state that occurs immediately after HIV infection; some tests are not able to confirm the virus at this stage) to identify new cases and make contact with individuals faster.
Current DC regulations require a phone call within two hours for a range of diseases, such as anthrax, botulism, and cholera, so there is precedent in DC law for very early reporting of an infectious disease. DOH will consult with practitioners and develop an appropriate time frame and mechanism for earlier reporting of acute HIV infection.
More timely notification of new diagnoses could initiate the Partner Services intervention sooner and potentially with greater success. DOH will under take a demonstration project to allow for earlier identification of and intervention for possible partners of a newly diagnosed HIV patient. This could also allow for more effective use of PEP.
DEMONSTRATION PROJECT: Rapid HIV Surveillance and PEP-Plan B
DOH will develop a demonstration project of a rapid HIV surveillance protocol. The project will assess the effectiveness of a more timely deployment of Partner Services to new HIV diagnoses as a means to interrupt HIV transmissions. Preliminary parameters would include:
Establish programs to eliminate stigma and educate the community about HIV. Public call to action: DC residents and healthcare providers must work to eliminate stigma and educate themselves about HIV. Healthcare providers must educate themselves about new clinical advances to treat and prevent HIV— including PrEP.
With 18% of District residents reporting they would not tell their friends if they were diagnosed with HIV, and 11% incorrectly fearing they could contract HIV during regular household activities if living with someone who has HIV, education about HIV is still essential. DOH provided funding to Howard University to survey healthcare providers on attitudes and beliefs related to HIV and stigmatizing perspectives. The preliminary, unpublished results indicate that some healthcare providers harbor potentially negative attitudes about people living with HIV: 20% reported wearing double gloves with HIV patients, an unnecessary and potentially stigmatizing precaution; 30% heard health care workers talking badly about a person with HIV; 20% agreed or strongly agreed that people with HIV do not care if they infect other people; 38% agreed or strongly agreed that people with HIV engage in irresponsible behavior; and 25% disagreed or strongly disagreed that women with HIV should have babies.
This plan calls all District communities to ensure the city is free of fear, stigma, and discrimination against those with HIV. These negative attitudes not only harm and marginalize people living with HIV, but also perpetuate potentially harmful myths about the disease and transmission. Stigma associated with race/ethnicity, country of origin, immigration status, history of substance use and mental illness, and offender status also perpetuate barriers to accessing and providing affirming healthcare. Public messaging can help, but all District residents can seek out information to educate themselves and their peers and reduce stigma. DC Appleseed and DOH will continue to collect data on stigma and hope to see reductions in all of the unfounded negative attitudes listed above through education and other activities.
Promote model programs for persons to take control of their healthcare and improve their well-being.
DOH has supported a model called ManDate, a peer-based approach providing a nontraditional environment for African American gay men ages 18 to 60 to safely engage in conversations and develop support mechanisms to improve health and wellness, relationships, employment, compatibility with other sectors of their lives (e.g., faith, career, and family), mental wellness, character building, and a more confident identity of self. The settings are usually members’ homes, where there is a greater comfort level. DOH and community partners are developing ManDate models for Latino gay and bisexual men and African American and Latina transgender women.
Church and faith-based institutions have historically been a consistent touchstone for African American women. DOH has supported a faith-based initiative for African American women that has featured integrating prevention and wellness into health, women’s, men’s, and youth ministries. DOH will continue to develop this self-efficacy approach further, including for Latina women.
Peer self-efficacy approaches also have demonstrated effectiveness. DOH has identified and supported models among young persons and transgender persons. DOH will review and promote models for multiple population groups that support self-actualization and success strategies.
Maintain and adjust funding for syringe-exchange services (SES) to reach injection drug users in DC.
The network of syringe-exchange services (SES) providers in the District continues to demonstrate effectiveness in engaging injection drug users in a harm-reduction approach to prevent HIV infection. DOH estimates that the number of active injection drug users in the District ranges from 8,000 to 13,000 people. The SES providers served approximately 10,000 people in 2015, representing 77% of estimated active drug users in the District, using the highest estimate as a baseline. This is significant coverage of people at risk of HIV exposure. However, there are more people to be served.
Funding for SES providers has remained flat over the last several years; despite this, providers have distributed more and more clean needles. However, continuing to expand services with flat funding is no longer possible. Accordingly, DOH will adjust funding for providers to compensate for increases in expenses and to reach all residents requiring syringe exchange services. DOH will also work with providers to expand programs to reach populations harder to access through traditional syringe exchange services, such as younger people, women, and transgender people.
Promote healthy decision-making and increase the availability of sexual health information for young people.
The classroom is not the only place to engage young people, and encouraging better decision-making will help to reduce risky behavior and HIV infections. In order to provide adults that young people trust with information about STIs and HIV, as well as to share information about how to encourage healthy decision-making, DOH will partner with DCPS and DC public charter schools to identify optimal channels for engagement with and education for students’ caregivers. This could include developing an informational text-message service for caregivers, and establishing a mechanism to recruit and train champions of the trusted adult model. These efforts will dovetail with additional recommendations to create consistent, medically accurate messaging for young people in various settings.
Ensure that DC Public Schools and public charter schools provide appropriate HIV and sexually transmitted infection (STI) prevention education to all DC students and that students’ understanding is assessed regularly.
In May 2010, the DC Council passed the Healthy Schools Act (HSA), a landmark law designed to improve the health and wellness of students attending all DC schools. The law created standards and oversight in a number of areas, including school nutrition, physical education, health and wellness, and health education. The HSA was enacted with the understanding that it would help ensure better HIV education for DC schoolchildren.
To meet this goal,the health education requirements of public and public charter schools “shall meet the curricular standards adopted by the State Board of Education.” DCPS officials noted in interviews with DC Appleseed that they are planning professional development programs to ensure that teachers understand how to present the new health education standards effectively.
Charter schools use their own curriculum and generally do not coordinate with DCPS on such matters, so there is nothing outside of the HSA and framework of the education standards that would ensure consistency and excellence in HIV education in public charter schools. The Public Charter School Board should accordingly ensure that students in public charter schools receive consistent education about HIV and STI prevention and that staff are trained and empowered to deliver lessons.
Ensure that all DC schools meet their sexual health education obligations under the Healthy Schools Act.
In conversations with DCPS officials, DC Appleseed learned that most schools are not currently meeting all of the obligations of the HSA. Providing assessment data, as discussed above, for parents will create transparency about student proficiency, but it is a separate task to ensure that all students receive the level of sexual health education that the DC Council intended when passing the HSA.