HIV Prevention in the Biomedical Era, presented by Brett Palmer
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Brett Palmer's presentation on HIV prevention in the biomedical era, as provided to the Philadelphia HIV Planning Group in August 2014
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HIV Prevention in the Biomedical Era, presented by Brett Palmer
- 1. Regional Resource Network Program U.S. Department of Health & Human Services HIV Prevention in the Biomedical Era Thursday, August 27, 2014 Brett J. Palmer, MEd Regional Resource Coordinator HIV/AIDS U.S. Department of Health and Human Services Office of the Assistant Secretary for Health Region III – DE, DC, MD, PA, VA, WV
- 2. Regional Resource Network Program Goals • Educate and promote to regional HIV/AIDS stakeholders, both governmental and non-governmental, the: • National HIV/AIDS Strategy (NHAS) • Affordable Care Act • Viral Hepatitis • HIV/AIDS Treatment Cascade Model • Foster or facilitate increased opportunities among regional stakeholders for better local coordination in HIV/AIDS prevention, planning, and service delivery consistent with the NHAS’s priorities and principles. Regional Resource Network Program U.S. Department of Health & Human Services
- 3. Presentation Overview HIV Prevention in the Biomedical Era 1. What has changed in federal prevention funding? 2. What is biomedical HIV prevention? 3. Why a shift to biomedical prevention? 4. Three major policies impacting biomedical prevention. Regional Resource Network Program U.S. Department of Health & Human Services
- 4. Presentation Overview HIV Prevention in the Biomedical Era 1. What has changed in federal prevention funding? 2. What is biomedical HIV prevention? 3. Why a shift to biomedical prevention? 4. Three major policies impacting biomedical prevention. Regional Resource Network Program U.S. Department of Health & Human Services
- 5. Regional Resource Network Program U.S. Department of Health & Human Services
- 6. Regional Resource Network Program U.S. Department of Health & Human Services
- 7. Kaiser Family Foundation - U.S. Federal Funding for HIV/AIDS: The President’s FY 2015 Budget Request http://kff.org/global-health-policy/fact-sheet/u-s-federal-funding-for-hivaids-the-presidents-fy-2015-budget-request/ Regional Resource Network Program U.S. Department of Health & Human Services
- 8. Presentation Overview HIV Prevention in the Biomedical Era 1. What has changed in federal prevention funding? 2. What is biomedical HIV prevention? 3. Why a shift to biomedical prevention? 4. Three major policies impacting biomedical prevention. Regional Resource Network Program U.S. Department of Health & Human Services
- 9. Biomedical Prevention: Male Circumcision For men, lowers the risk of: • Acquiring HIV from female partner • STDs • Penile cancer • Infant urinary tract infection For women, lowers the risk of: • HPV and cervical cancer • Genital ulceration • Bacterial vaginosis • Trichomoniasis Centers for Disease Control and Prevention: http://www.cdc.gov/hiv/prevention/research/malecircumcision/index.html Regional Resource Network Program U.S. Department of Health & Human Services
- 10. Biomedical Prevention: Pre-Exposure Prophylaxis (PrEP) Medication to reduce risk for non-positive people: • Daily pill Used consistently: • Effective in MSM, MSW, WSM Centers for Disease Control and Prevention: http://www.cdc.gov/hiv/prevention/research/prep/index.html Regional Resource Network Program U.S. Department of Health & Human Services
- 11. Biomedical Prevention: Treatment as Prevention Full prevention benefit of treating HIV infection, four tenets: • HIV testing is foundation for both prevention and care efforts • Early identification of infection empowers individuals to take action • Early treatment reduces risk of transmitting HIV to others • Prevention benefit of treatment can only be realized with the continuum of care ART as prevention may be promising if: 1. Widespread testing and early identification of infected persons 2. Ongoing counseling to support maintenance of safer sexual behaviors 3. Adequate clinical follow-up to monitor for adverse effects of ART 4. Geographic and financial accessibility of treatment for affected persons Centers for Disease Control and Prevention: http://www.cdc.gov/hiv/prevention/research/tap/index.html Centers for Disease Control and Prevention: http://www.cdc.gov/hiv/prevention/research/art/index.html Regional Resource Network Program U.S. Department of Health & Human Services
- 12. Presentation Overview HIV Prevention in the Biomedical Era 1. What has changed in federal prevention funding? 2. What is biomedical HIV prevention? 3. Why a shift to biomedical prevention? 4. Three major policies impacting biomedical prevention. Regional Resource Network Program U.S. Department of Health & Human Services
- 13. Why a Biomedical Approach: HIV Cost-Effectiveness HIV testing cost per new diagnosis • In health care settings: $1,900 – $10,000 • In non-health care settings: $10,334 – $20,413 Cost of HIV treatment • Annual: $23,000 • Lifetime: $379,668 Centers for Disease Control and Prevention: http://www.cdc.gov/hiv/prevention/ongoing/costeffectiveness/index.html Regional Resource Network Program U.S. Department of Health & Human Services
- 14. Annual HIV-related healthcare costs Acute HIV 10–500 Asymptomatic HIV – Untreated 3,000–6,000 Symptomatic HIV – Untreated 5,000–9,000 Symptomatic HIV – Treated with ART (excludes ART costs) 5,000–7,000 AIDS – Untreated 15,000–26,000 AIDS – Treated with ART (excludes ART costs) 6,000–17,000 Annual non-HIV-related healthcare costs for uninfected and infected individuals 3,000–6,000 Annual cost of ART 12,500–19,000 Cost of PrEP TDF/FTC (30-day supply) 300–1,118 STI testing 25–75 Blood urea nitrogen and serum creatinine testing 10–40 Physician visit 10–200 Cost of HIV testing and counseling – Antibody test Uninfected 5–25 HIV-infected 50–100 Pre-test counseling 0–100 Post-test counseling for HIV-negative persons 0–50 Post-test linkage/counseling for HIV-positive persons 0–100 Cost of HIV diagnosis 125–1,200 The Cost-Effectiveness of Preexposure Prophylaxis for HIV Prevention in Men Who Have Sex with Men in the United States; Jessie L. Juusola, Margaret L. Brandeau, Douglas K. Owens, Eran Bendavid; Ann Intern Med. 2012 April 17; 156(8): 541–550. doi: 10.1059/0003-4819-156-8-201204170-00001; PMCID: PMC3690921 Regional Resource Network Program U.S. Department of Health & Human Services
- 15. Presentation Overview HIV Prevention in the Biomedical Era 1. What has changed in federal prevention funding? 2. What is biomedical HIV prevention? 3. Why a shift to biomedical prevention? 4. Three major policies impacting biomedical prevention. 1. Routine HIV Testing 2. Affordable Care Act 3. Continuum of Care Regional Resource Network Program U.S. Department of Health & Human Services
- 16. Routine HIV Testing in Medical Settings: The U.S. Preventive Services Task Force Rationale: • Identification and treatment of HIV infection means reduced risk of: • HIV progression to AIDS • AIDS-related events • Death in individuals with immunologically advanced disease • Earlier ART means reduced risk for AIDS-related events or death • ART decreases risk for transmission from HIV-positive persons • Identification and treatment of HIV-positive pregnant women reduces rates of mother-to-child transmission • “The overall benefits of screening for HIV infection in adolescents, adults, and pregnant women are substantial” U.S. Preventive Service Task Force: Screening for HIV: http://www.uspreventiveservicestaskforce.org/uspstf13/hiv/hivfinalrs.htm Regional Resource Network Program U.S. Department of Health & Human Services
- 17. Routine HIV Testing in Medical Settings: The U.S. Preventive Services Task Force Recommendations: • Clinicians screen for HIV infection in adolescents and adults ages 15 to 65 • Younger adolescents and older adults who are at increased risk should also be screened • Clinicians screen all pregnant women for HIV U.S. Preventive Service Task Force: Screening for HIV: http://www.uspreventiveservicestaskforce.org/uspstf13/hiv/hivfinalrs.htm Regional Resource Network Program U.S. Department of Health & Human Services
- 18. Routine HIV Testing in Medical Settings: The U.S. Preventive Services Task Force Screening intervals: • One-time screening of adolescent and adult patients • Repeated screening: • “At lease annually” for those who are very high risk: • Men who have sex with men • Active injection drug users • “Somewhat longer intervals” (3–5 years) for those at increased risk based on behavioral risk factors: • Having unprotected vaginal or anal intercourse • Having sexual partners who are HIV-infected, bisexual, or injection drug users • Exchanging sex for drugs or money U.S. Preventive Service Task Force: Screening for HIV: http://www.uspreventiveservicestaskforce.org/uspstf13/hiv/hivfinalrs.htm Regional Resource Network Program U.S. Department of Health & Human Services
- 19. Presentation Overview HIV Prevention in the Biomedical Era 1. What has changed in federal prevention funding? 2. What is biomedical HIV prevention? 3. Why a shift to biomedical prevention? 4. Three major policies impacting biomedical prevention. 1. Routine HIV Testing 2. Affordable Care Act 3. Continuum of Care Regional Resource Network Program U.S. Department of Health & Human Services
- 20. http://kff.org/report-section/assessing-the-impact-of-the-affordable-care-act-on-health-insurance-coverage-of-people-with-hiv-issue-brief/ Regional Resource Network Program U.S. Department of Health & Human Services
- 21. http://kff.org/report-section/assessing-the-impact-of-the-affordable-care-act-on-health-insurance-coverage-of-people-with-hiv-issue-brief/ Regional Resource Network Program U.S. Department of Health & Human Services
- 22. The Affordable Care Act: Improving Access to Coverage Insurers can no longer: • Deny coverage to anyone based on pre-existing conditions • Impose annual limits on coverage or lifetime caps on insurance benefits Tax subsidies available: • Based on financial need • Only through the Health Insurance Marketplaces Medicaid expansion: • Not available in all states Prescription benefits: • Closing the Medicare Part D prescription drug benefit “donut hole” • AIDS Drug Assistance Program AIDS.GOV: http://aids.gov/federal-resources/policies/health-care-reform/ Regional Resource Network Program U.S. Department of Health & Human Services
- 23. http://kff.org/report-section/assessing-the-impact-of-the-affordable-care-act-on-health-insurance-coverage-of-people-with-hiv-issue-brief/ Regional Resource Network Program U.S. Department of Health & Human Services
- 24. The Affordable Care Act: Ensuring Quality Coverage Better information • Plans must provide user-friendly information Quality, comprehensive care • 10 essential health benefits Preventive care • HIV screening Coordinated care • Patient-centered medical home model of care AIDS.GOV: http://aids.gov/federal-resources/policies/health-care-reform/ Regional Resource Network Program U.S. Department of Health & Human Services
- 25. The Affordable Care Act: Preventive Health Services Free Preventive health services for adults • HIV screening for everyone ages 15 to 65, and other ages at increased risk Free Preventive health services for women • HIV screening and counseling for sexually active women Free Preventive health services for children • HIV screening for adolescents at higher risk AIDS.GOV: http://aids.gov/federal-resources/policies/health-care-reform/ Regional Resource Network Program U.S. Department of Health & Human Services
- 26. The Affordable Care Act: Enhancing the Capacity of the Health Care System Major investments • Community health centers to provide more opportunities for HIV care delivery Technical assistance • Help those not providing HIV care to develop the capacity to do so • Especially in minority communities Expand capacity • To deliver culturally competent care to populations heavily impacted by HIV • National LGBT Health Education Center funded by HRSA AIDS.GOV: http://aids.gov/federal-resources/policies/health-care-reform/ Regional Resource Network Program U.S. Department of Health & Human Services
- 27. The Affordable Care Act: Increasing Opportunities for Health and Well-Being Prevention and wellness • Investments in prevention, wellness, and public health activities • Improve public health surveillance, community-based programs, and outreach efforts • Increase coverage for HIV testing Diversity and cultural competency • Expand cultural competency training for health care providers • Ensure all populations are treated equitably Health care providers for underserved communities • Expand the health care workforce • Increase funding for community health centers AIDS.GOV: http://aids.gov/federal-resources/policies/health-care-reform/ Regional Resource Network Program U.S. Department of Health & Human Services
- 28. Presentation Overview HIV Prevention in the Biomedical Era 1. What has changed in federal prevention funding? 2. What is biomedical HIV prevention? 3. Why a shift to biomedical prevention? 4. Three major policies impacting biomedical prevention. 1. Routine HIV Testing 2. Affordable Care Act 3. Continuum of Care Regional Resource Network Program U.S. Department of Health & Human Services
- 29. What is the HIV/AIDS Care Continuum Model used to identify issues related to improving services for people living with HIV: • HIV Diagnosis • Linked to Care • Retained in Care • Prescribed ART • Virally Suppressed AIDS.gov: http://aids.gov/federal-resources/policies/care-continuum/ Regional Resource Network Program U.S. Department of Health & Human Services
- 30. HIV/AIDS Care Continuum Uses How is the HIV care continuum being used? • Federal level: • Inform how best to prioritize and target available resources • Monitor national progress • State and local levels: • Assess where resources are needed • Target resources accordingly AIDS.gov: http://aids.gov/federal-resources/policies/care-continuum/ Regional Resource Network Program U.S. Department of Health & Human Services
- 31. Importance of the HIV/AIDS Care Continuum Why is the HIV Care Continuum important? • Pinpoint where gaps exist • Better health for people living with HIV/AIDS • Helps achieve goals of the NHAS AIDS.gov: http://aids.gov/federal-resources/policies/care-continuum/ Regional Resource Network Program U.S. Department of Health & Human Services
- 32. Challenges of the HIV/AIDS Care Continuum Challenges Developing an HIV/AIDS Care Continuum • Collection of data • Lack of resources at the state and local level AIDS.gov: http://aids.gov/federal-resources/policies/care-continuum/ Regional Resource Network Program U.S. Department of Health & Human Services
- 33. HIV/AIDS Care Continuum Example Hivcontinuum.org: http://hivcontinuum.org/city-complete.html?city=Philadelphia,%20PA&cd=phl Regional Resource Network Program U.S. Department of Health & Human Services
- 34. Presentation Overview HIV Prevention in the Biomedical Era 1. What has changed in federal prevention funding? • HIV funding has increased for care and remained steady for prevention. However, as the epidemic expands, the limited resources available are being distributed to more locations. 2. What is biomedical HIV prevention? • PrEP • Treatment as Prevention • Male Circumcision • Testing in Clinical Settings Regional Resource Network Program U.S. Department of Health & Human Services
- 35. Presentation Overview HIV Prevention in the Biomedical Era, Continued 3. Why a shift to biomedical prevention? • Many cost effectiveness analysis indicate that prevention in a clinical setting is less expensive than prevention at CBO/ASOs 4. Three major policies impacting biomedical prevention. • Routine HIV Testing • Affordable Care Act • Continuum of Care Regional Resource Network Program U.S. Department of Health & Human Services
Notes de l'éditeur
- a high-prevalence setting is a geographic location or community with an HIV seroprevalence of at least 1%. These settings include sexually transmitted disease (STD) clinics, correctional facilities, homeless shelters, tuberculosis clinics, clinics serving men who have sex with men, and adolescent health clinics with a high prevalence of STDs
- Starting in 2014, states will have the option, which is fully Federally funded for the first three years, to generally include individuals with income below 133% of the Federal poverty line ($14,400 for an individual and $29,300 for a family of 4), including single adults without children who were previously not generally eligible for Medicaid. As a result, in many states, a person living with HIV who meets this income threshold will no longer have to wait for an AIDS diagnosis in order to become eligible for Medicaid. giving Medicare enrollees living with HIV and AIDS the peace of mind that they will be better able to afford their medications. Beneficiaries receive a 50% discount on covered brand-name drugs while they are in the “donut hole,” a considerable savings for people taking costly HIV/AIDS drugs. And in the years to come, they can expect additional savings on their prescription drugs while they are in the coverage gap until it is closed in 2020. This is a huge relief for ADAP clients who are Medicare Part D enrollees, since they will now be able to move through the donut hole more quickly, which was difficult, if not impossible, for ADAP clients to do before this change.
- Starting in 2014, states will have the option, which is fully Federally funded for the first three years, to generally include individuals with income below 133% of the Federal poverty line ($14,400 for an individual and $29,300 for a family of 4), including single adults without children who were previously not generally eligible for Medicaid. As a result, in many states, a person living with HIV who meets this income threshold will no longer have to wait for an AIDS diagnosis in order to become eligible for Medicaid. giving Medicare enrollees living with HIV and AIDS the peace of mind that they will be better able to afford their medications. Beneficiaries receive a 50% discount on covered brand-name drugs while they are in the “donut hole,” a considerable savings for people taking costly HIV/AIDS drugs. And in the years to come, they can expect additional savings on their prescription drugs while they are in the coverage gap until it is closed in 2020. This is a huge relief for ADAP clients who are Medicare Part D enrollees, since they will now be able to move through the donut hole more quickly, which was difficult, if not impossible, for ADAP clients to do before this change.
- Starting in 2014, states will have the option, which is fully Federally funded for the first three years, to generally include individuals with income below 133% of the Federal poverty line ($14,400 for an individual and $29,300 for a family of 4), including single adults without children who were previously not generally eligible for Medicaid. As a result, in many states, a person living with HIV who meets this income threshold will no longer have to wait for an AIDS diagnosis in order to become eligible for Medicaid. giving Medicare enrollees living with HIV and AIDS the peace of mind that they will be better able to afford their medications. Beneficiaries receive a 50% discount on covered brand-name drugs while they are in the “donut hole,” a considerable savings for people taking costly HIV/AIDS drugs. And in the years to come, they can expect additional savings on their prescription drugs while they are in the coverage gap until it is closed in 2020. This is a huge relief for ADAP clients who are Medicare Part D enrollees, since they will now be able to move through the donut hole more quickly, which was difficult, if not impossible, for ADAP clients to do before this change.
- Starting in 2014, states will have the option, which is fully Federally funded for the first three years, to generally include individuals with income below 133% of the Federal poverty line ($14,400 for an individual and $29,300 for a family of 4), including single adults without children who were previously not generally eligible for Medicaid. As a result, in many states, a person living with HIV who meets this income threshold will no longer have to wait for an AIDS diagnosis in order to become eligible for Medicaid. giving Medicare enrollees living with HIV and AIDS the peace of mind that they will be better able to afford their medications. Beneficiaries receive a 50% discount on covered brand-name drugs while they are in the “donut hole,” a considerable savings for people taking costly HIV/AIDS drugs. And in the years to come, they can expect additional savings on their prescription drugs while they are in the coverage gap until it is closed in 2020. This is a huge relief for ADAP clients who are Medicare Part D enrollees, since they will now be able to move through the donut hole more quickly, which was difficult, if not impossible, for ADAP clients to do before this change.
- Starting in 2014, states will have the option, which is fully Federally funded for the first three years, to generally include individuals with income below 133% of the Federal poverty line ($14,400 for an individual and $29,300 for a family of 4), including single adults without children who were previously not generally eligible for Medicaid. As a result, in many states, a person living with HIV who meets this income threshold will no longer have to wait for an AIDS diagnosis in order to become eligible for Medicaid. giving Medicare enrollees living with HIV and AIDS the peace of mind that they will be better able to afford their medications. Beneficiaries receive a 50% discount on covered brand-name drugs while they are in the “donut hole,” a considerable savings for people taking costly HIV/AIDS drugs. And in the years to come, they can expect additional savings on their prescription drugs while they are in the coverage gap until it is closed in 2020. This is a huge relief for ADAP clients who are Medicare Part D enrollees, since they will now be able to move through the donut hole more quickly, which was difficult, if not impossible, for ADAP clients to do before this change.