ENHANCED COMPREHENSIVE HIV PREVENTION PLAN for MARYLAND International AIDS Conference Satellite...

ENHANCED COMPREHENSIVE HIV PREVENTION PLAN for MARYLAND

International AIDS Conference Satellite Session

July 22, 2012

Heather L. Hauck, Director

Prevention and Health Promotion Administration

Maryland Department of Health and Mental Hygiene

Prevention and Health Promotion Administration July 2012

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Objectives

Describe the Baltimore-Towson Metropolitan Statistical Area (MSA) Enhanced Comprehensive HIV Prevention Plan (ECHPP) Process

Describe the resource optimization model for the Baltimore-Towson Metropolitan Statistical Area (MSA) Enhanced Comprehensive HIV Prevention Plan (ECHPP)

Identify utilization opportunities for the resource optimization model in the Baltimore – DC corridor


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ECHPP DEFINED


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ECHPP Objectives

Develop an enhanced plan that aligns the jurisdiction’s prevention activities with the National HIVAIDS Strategy

− Using resources so that they have the biggest impact on HIV incidence− Identifying and addressing gaps in scope and reach of prevention

activities among priority populations− Enhancing coordination between prevention, care, and treatment

Identifying/implementing the optimal combination of prevention, care, and treatment activities to maximally reduce new infections

− Assuring that the most effective biomedical, behavioral and community/structural interventions are prioritized

− Assuring that interventions are going to populations/communities in such a way that the level of investment matches the level of risk


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Maryland ECHPP Scope

Viewed ECHPP as an opportunity to: – Step back from “business as usual” and look at HIV

prevention strategies with “fresh eyes”– Begin to develop our state NHAS implementation plans– Enhance collaboration, coordination and integration

Assessed and planned for the entire Baltimore-Towson MSA (7 jurisdictions)

Decided to implement strategies statewide


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Maryland ECHPP Process

Assessment of existing programming– Current level of implementation, including data on program

funding, activities, reach and outcomes

Collaborative planning with key public health and community stakeholders– Presentations/meetings with seven local heath departments

and five HIV/AIDS community planning bodies– Workgroup composed of HIV and STI prevention,

care/treatment, and surveillance staff from IDEHA and the Baltimore City Health Department


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Maryland Modeling Process

Health Department/Academic Partnership– Worked with Dr. David Holtgrave from the Johns Hopkins

University Bloomberg School of Public Health

Modeling Activities– Estimated key HIV transmission rates for the MSA– Analyzed the cost effectiveness of various HIV testing approaches– Developed a resource optimization model to inform the allocation

of current resources– Quantified additional resources needed to reach the prevention

goals of the NHAS


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Maryland Modeling Process

Modeling scope based on rapid ECHPP timeline, local resource allocation questions, and data availability– Limited scope to HIV prevention funds and a subset of

HIV prevention interventions– Built upon previous modeling work– Modified model components to reflect “ideal” local

implementation of interventions– Customized parameter values to reflect local costs and

outcomes (when data available)


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SECTION 3: ATTEMPTING TO MEET NATIONAL HIV/AIDS STRATEGY GOALS IN THE BALTIMORE-TOWSON MSA WITH CURRENT RESOURCES

ECHPP Mathematical Modeling for the Baltimore-Towson MSA


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Interventions Included in the Baltimore-Towson MSA Modeling

HIV Counseling and Testing – hybrid reflective of Baltimore-Towson experiences and best practices in the field

(assuming rapid testing model; 1.5% seropositivity rate; and 0.9% new diagnosis rate);

– includes post-test counseling for at-risk HIV- persons

Prevention Services with Persons Living with HIV– intensive behavioral risk-reduction intervention services (and reinforcement of

linkage to other needed services)

Partner Services and Intensive Linkage to Care– calculated as a core service for all new diagnoses and previously diagnosed PLWH

who are retested

Prevention Services for HIV- Persons at High Risk of Infection– intensive behavioral interventions above and beyond post-test counseling

Total Size of Funding Pool: $6 million


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Modeled “Best Performance”: Costs by Category

Year 0 Year 1 Year 2 Year 3 Year 4 Total Y1-4

Total Costs $6,002,859 $6,002,844 $5,724,757 $6,007,416 $6,276,419 $24,011,436

Counseling and Testing $3,260,500 $3,807,730 $2,293,361 $2,411,791 $2,521,157 $11,034,039

Prev. with PLWH and Engaged in Risk Behav

$290,663 $608,014 $2,475,500 $2,590,367 $2,704,418 $ 8,378,299

Prev. for HIV- Persons

$1,162,653 $ -

$ -

$ -

$ -

$ -

Partner Services $789,043 $1,587,100 $955,896 $1,005,259 $1,050,844 $4,599,098

ECHPP $ $500,000

$ - $ -

$ -

$ -


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Modeled “Best Performance”: Results

Year 0 Year 1 Year 2 Year 3 Year 4

Incidence 1,201

1,103

995

967

936

Prevalence 27,550

28,194

28,722

29,213

29,667

Transmission Rate 4.3593 3.9108 3.4628 3.3086 3.1539Unawareness of Seropositivity 21.00% 17.69% 15.45% 13.22% 10.98%

Note: HIV incidence is reduced 22.09% (vs the 25% goal in the NHAS) and HIV transmission rate is reduced 27.65% (vs the 30% goal in the NHAS). Unawareness of seropositivity does not quite reach the NHAS goal of 10%.

SECTION : WHAT RESOURCES ARE NEEDED TO MEET NATIONAL HIV/AIDS STRATEGY GOALS IN THE BALTIMORE-TOWSON MSA?

ECHPP Mathematical Modeling for the Baltimore-Towson MSA

Prevention and Health Promotion Administration Johns Hopkins Bloomberg School of Public Health July 2012

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Unmet Needs Scenarios: Baltimore-Towson MSA

Year 1 to 4 Total Resources

Total Incidence Reduction

Total TransmissionRate Reduction

HIV SeropositivityAwareness Level

Better Use of Current Resources

$24,011,436 22.09% 27.65% 89.02%

Meeting Awareness Goal

$25,769,082 23.26% 28.69%90.00%

Same as Above But Front Loaded

$25,984,400 24.04% 29.24%90.00%

Meeting All Goals $32,281,882 24.94% 30.12% 90.00%

Same as Above But Front Loaded

$32,538,589 25.73% 30.68%90.00%

NHAS Target 25.00% 30.00% 90.00%


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Some Key Findings

Transmission rates differ greatly by population noted above and suggest strategies for intervention

There is not enough money currently in the system to meet NHAS goals, therefore….

It is critical to (a) attempt to garner necessary resources and (b) to use current resources in the very best way possible


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Some Key Findings (continued)

At current resource levels:– Targeting of counseling and testing strategies is key (and

rapid testing must be ramped up in the MSA)– Prevention with persons living with HIV must be

expanded (and especially emphasize small minority of persons living with HIV engaged in risk behavior)

– DHMH has indicated a desire to provide partner services for all persons testing HIV seropositive in a given year (even if previously aware of HIV seropositivity)

A timely evaluation question is to examine the exact impact of such services on the transmission rate


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Some Key Findings (further continued)

Evidence-based prevention services for persons who are HIV- but at risk of infection are useful and needed, but current resource levels prohibit the inclusion in the model results, however….

Such services for at-risk HIV- persons could be provided if there were additional resources and maybe the final “piece of the puzzle” to fully meet all NHAS goals


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Maryland ECHPP Activities

Significant increases in:– Routine HIV screening in clinical settings– Targeted HIV testing in non-clinical settings – Initial and ongoing HIV/STI partner services – Activities to support linkage to care, retention in care,

and adherence to antiretroviral treatment– Risk reduction interventions for PLWH

Decrease and redirect resources for:– Intensive behavioral risk reduction interventions for HIV-

negative persons


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Maryland ECHPP Activities

Increase utilization of local HIV and STI surveillance data to target persons at highest risk for HIV transmission or acquisition

Enhance collaboration with local health departments to develop jurisdictional implementation plans

Increase partnerships across funding sources and with private providers to ensure effective coordination of services and leverage additional resources


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Maryland ECHPP Benefits

Assessment of current programming:– Highlighted the importance of program targeting and the

effectiveness of HIV/STI partner services

Mathematical modeling:– Quantified the additional resources needed to meet the NHAS

HIV prevention goals in the Baltimore-Towson MSA– Recommended strategic redirections of current resources– Highlighted the prevention aspects of HIV care– Expanded the local evidence base for increasing focus on HIV

testing, linkage to care and other interventions with persons living with HIV/AIDS


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Maryland ECHPP Benefits

Collaborative, Coordination and Integration

– Enhanced collaboration between HIV prevention and care– Identified priority areas to increase coordination and

integration across the HIV and STI prevention, care and treatment continuum

– Enhanced partnerships with local health departments to develop and implement HIV prevention activities based on local epidemiology, experience and capacity

– Increased national and local partnerships across funding sources

– Developed plans to enhance public/private partnerships


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Maryland ECHPP Challenges

Local Realities– Insufficient staffing, staff turnover, and hiring time/delays– Barriers in procurement process delayed implementation of

expanded HIV prevention activities– Major change takes time

Federal Barriers– Lack of data sharing and collaboration from and between

federal agencies and related grantees at the local level.– New and ongoing federally-funded activities not coordinated

across funding streams and not based on or informed by locally identified needs.

– Separate CDC and HRSA planning requirements


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ECHPP as a Foundation

The directions and strategies described in the Maryland ECHPP are the foundation for our state's response to NHAS and guided the development of Maryland and Baltimore’s PS12-1201 applications.

The ECHPP process is a model for collaborative, evidence-based decision making across funding sources that is grounded in NHAS, our local goals, and the Maryland epidemic.

ECHPP AS A MODEL FOR THE BALTIMORE – DC CORRIDOR


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2010 Estimated HIV Diagnoses, Ranked by Rates

STATE/TERRITORY Cases Rate per 100,000 1. District of Columbia* 939 156.7 2. Virgin Islands 47 42.8 3. Florida 5,782 31.2 4. Maryland* 1,708 30.0 5. Louisiana 1,279 28.5 6. Puerto Rico 1,118 28.2 7. New York 5,321 27.2 8. Georgia 2,581 26.3 9. New Jersey 2,207 25.310. South Carolina 914 20.0

United States** 48,298 16.3

CDC. HIV Surveillance Report, 2010. Vol. 22. Table 19.* Maryland DHMH estimates from CDC data.** Based on 46 states and 5 territories.


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METROPOLITAN AREA Cases Rate per 100,000 1. Miami, FL 2,757 49.7 2. Baton Rouge, LA 339 43.0 3. New Orleans-Metairie-Kenner, LA 439 36.9 4. Washington, DC-VA-MD-WV* 1,995 36.4 5. Baltimore-Towson, MD* 951 35.4 6. Jackson, MS 184 34.0 7. Memphis, TN-MS-AR 440 33.7 8. Orlando, FL 686 32.9 9. New York, NY-NJ-PA 6,160 32.3 10. Columbia, SC 230 30.9

2010 Estimated HIV Diagnoses, Ranked by Rates

CDC. HIV Surveillance Report, 2010. Vol. 22. Table 24. * Maryland DHMH estimates from CDC data.** Based on 46 states and 5 territories.

United States** 47,692 16.3


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Maryland Living Adult/Adolescent HIV Cases

by Region, 12/31/10

Baltimore City44%

Suburban Washington

29%

Suburban Baltimore

15%

Corrections5%

Western2%

Eastern3%

Southern2%

N = 29,642

Using data as reported through 12/31/2011


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Maryland Reported Adult/Adolescent (age 13+ at HIV Diagnosis) HIV Diagnoses during 2010 with or without an AIDS diagnosis, per 100,000 population, by Jurisdiction of Residence at Diagnosis

50+ 25 – 49.9 15 – 24.9

10 – 14.90 – 9.9

Maryland HIV Diagnosis Rate, 12/31/10

State Rate = 29.7 per 100,000

Using data as reported through 12/31/2011


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Maryland – DC Corridor “ECHPP” Potential Benefits

Assessment of current programming:– Would focus attention on where targeting needs to occur

Mathematical modeling:– Would quantify the additional resources needed to meet

the NHAS HIV prevention goals in the Baltimore-DC corridor

– Would recommend strategic redirections of current resources

– Would expand the local evidence base for increasing focus on HIV testing, linkage to care and other interventions with persons living with HIV/AIDS


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Maryland – DC Corridor “ECHPP” Potential Benefits

Collaborative, Coordination and Integration–Would provide opportunities for regional planning

and collaboration including enhanced collaboration between HIV prevention and care

–Would identify priority areas to increase coordination and integration across the HIV and STI

prevention, care and treatment continuum

–Would maximize the regional resources


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Contact Information:

Heather Hauck, DirectorPrevention and Health Promotion Administration (PHPA)Maryland Department of Health and Mental [email protected](410) 767-5013

Claudia Gray, Acting Center ChiefCenter for HIV Prevention and Health Services, PHPA

[email protected](410) 767-5280

Hope Cassidy-Stewart, Acting Evaluation Division ChiefCenter for HIV Prevention and Health Services, [email protected](410)767-5250


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http://ideha.dhmh.maryland.gov

http://fha.dhmh.maryland.gov

Maryland Prevention and Health Promotion

Administration

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