Care Cascade Presentation Ryan White Part A Boston EMA HIV Health Services Planning Council. Sophie Lewis MDPH Office of HIV/AIDS January 9, 2014

Transcription

1 Care Cascade Presentation Ryan White Part A Boston EMA HIV Health Services Planning Council Sophie Lewis MDPH Office of HIV/AIDS January 9,

2 Federal and State Goals National HIV/AIDS Strategy: Reduce HIV incidence Increase access to care and optimize health outcomes Reduce HIV-related health disparities Office of HIV/AIDS State Plan Reduce new HIV and HCV infections Improve health outcomes Reduce disparities in HIV and HCV incidence and in health outcomes National Trends: Test and treat, treatment as prevention, Prevention with Positives The Care Continuum Public health obligation to use available data, e.g., lab reports 2

3 Continuum Of Care Not in Care Fully Engaged Unaware Aware of May be Entered In & out of Fully of HIV HIV Status receiving HIV care care or engaged Status (wasn t medical but infrequent (never referred to care but dropped user tested or care or not HIV out (lost never didn t care to care) received keep results) appt.) 3

4 Massachusetts Consumer Survey Survey of over 1,000 PLWHA in Massachusetts 59% in medical care within 30 days of HIV diagnosis 95% had a medical visit in the last 6 months 91% currently on HIV medications 72% virally suppressed (<400 copies) 57% above 350 CD4 T-cell count 2/3 of the sample living with HIV 10+ years 4

5 MA Consumer Care Experience (Self-Report; N = 1,004) In medical care Taking HIV medications Virally suppressed Health good to excellent Source: Massachusetts and Southern New Hampshire HIV/AIDS Consumer Study Final Report, December 2011, JSI Research and Training,Inc. 5

6 The CDC Cascade for HIV in the United States Source: Cohen et al. MMWR 2011;60:

7 Another Way to Look at This. Source: Today s HIV/AIDS Epidemic May CDC. 7

8 Out of every 100 Americans living with HIV ~80 know their status ~62 are linked to care ~41 stay in care ~36 are prescribed antiretroviral therapy ~28 are able to adhere to their treatment and sustain undetectable viral loads 8

9 Why do only 82% of PLWHA know their status? People may not know they are at risk, or may be in denial about their risk People may be concerned that they will lose their job, housing, insurance, their partner, their children, their family People not born in the US may be concerned that HIV will effect their immigration Some people may not know where to go to get tested, or may think they can t afford a test People may have domestic violence concerns 9

10 Why are only 66% of PLWHA linked to care? Access to care Inconvenient office hours Lack of transportation or resources Uninsured or under insured Insurance co-pays No child care Office is too far away Stigma In small communities everyone knows everyone Undiagnosed or untreated mental illness Active drug and alcohol addiction This may directly impact access to care, or clients may feel judged by providers 10

11 Why do only 37% of PLWHA stay in care? Feeling well Feeling disrespected or misunderstood by health care providers Being uninsured or underinsured With busy and sometimes chaotic lives, health care is often low on the list of priorities Lack of access (office hours, transportation, child care, etc) Active drug and alcohol addiction Undiagnosed and/or untreated mental health issues 11

12 Recent study looking at linkage and retention Reasons given by patients who were re-engaged after being lost to follow up (2013 article from NY DOH)¹ Felt good 41% Lack of trust in health care system 16% Day to day responsibilities 16% Side-effects of HIV meds 12% Felt depressed 11% No medical insurance 10% Did not want to think about being HIV+ - 9% Only 1% - 6% reported being lost to follow up because of difficulty accessing health care or social services 12

13 Why are only 33% of PLWHA on ART? Intentional Reasons Doctor doesn t recommend treatment Client chooses not to go on treatment Treatment is not a priority Unintentional Reasons Lack of information about the importance of treatment Barriers to care, including access and language Uninsured or underinsured 13

14 Why are only 25% of PLWHA virally suppressed? 95% adherence required to maintain viral suppression² Most studies show that 40-60% of patients are less than 90% adherent and that adherence decreases over time² Partial adherence can lead to uneven levels of medication in the system, which can lead to drug resistance Some people will never have an undetectable VL Virus may be resistant to one or more of the patient s medications 14

15 What are we doing to support testing and linkage to care? Routine and targeted testing Counseling Testing and Referral programs expected to actively support linkage to care for newly diagnosed (more than a referral) 4 th Generation HIV testing (allows for identification of acute HIV cases) Public Information Campaigns Access and linkage to care is primary objective of BPHC and DPH Medical Case Management system 15

16 What are we doing to support engagement and retention in care? BPHC and DPH Medical Case Management providers are expected to assess and address barriers to linkage, engagement, and retention in care BPHC and DPH enhanced and expanded peer support services with the last procurement; primary activity of peer services is to support retention in care 16

17 What else are we doing? SPECTRuM project Peer/Nurse teams support linkage, engagement, and retention Monthly line lists from DPH Surveillance of patients without recent HIV labs and/or with detectable VL Massachusetts State HIV Plan Goals and objectives are ultimately about linkage, engagement, and retention in care Implementation plan to be released soon; activities and timeline are related to improving the care continuum 17

18 What are we doing to increase the number of PLWHA on ART? Massachusetts has a very generous HIV drug assistance program (HDAP) Individual income can be up to 500% of federal poverty (~$53,000 in MA) HDAP pays for insurance premiums and prescription co-pays Only requirements are proof of HIV status, proof of income, and proof of MA residency (part of twice yearly reapplication) Supported by BPHC and DPH 18

19 What are we doing to increase the number of virally suppressed PLWHA? BPHC/DPH Medical Case Management System Core expectation of MCM is adherence support, including information about HIV medications and treatment education MCM providers expected to provide or facilitate home-based services which can increase adherence through DOT, adherence strategies, etc BPHC/DPH Peer Support Services Core expectations of peer services include adherence support and treatment education HIV drug resistance testing is covered by insurance, including HDAP 19

20 In the future Looking at service interventions and innovative uses of data in other states Hope to provide data (aggregate surveillance data, lab data, client service data) to agencies and regions to support local identification of trends, areas that need attention, etc 20

21 What else can we do? It always seems impossible until it s done -Nelson Mandela 21

22 Thank You! 22