1. HIV Prevention and Care
101
Patricia Young and Holly Hanson
Bureau of HIV, STD, and Hepatitis
Iowa Department of Public Health
Monday, March 5, 2012

3. U.S. Dept. of Health and
Human Services
CDC HRSA
Prevention Care
CPG
HIV Comprehensive Plan

4. Background of HIV/AIDS Funding in
Iowa
CDC HRSA
Prevention Ryan White
 Counseling, Testing, and  Part B
Referral (CTR) ADAP
 Partner Services (PS) Case Management
 Health Education/Risk Support Services
Reduction (HE/RR) Planning
 Planning  Part C
 Primary Health Care
Surveillance
 MATEC

5. Prevention-Care-Prevention Continuum
Enter Utilize Full
High Risk Learn HIV Quality Array of Adhere to
Individual Status Care and Care and Prescribed
s Treatment Therapies
Prevention Services
Unknown Services
Status
Negative
Positive
Utilize Full Array of
Existing Prevention
Programs and Services
Utilize Quality Prevention Services
Adopt and Maintain
HIV Risk Reduction

6. HIV Prevention Funding
for Health Departments
CDC provided HIV prevention funding to 65 health
departments in the form of cooperative
agreements:
All 50 states
The District of Columbia
Six directly funded cities and counties
Puerto Rico, the U.S. Virgin Islands, and six U.S.-
affiliated Pacific Islands

7. Comprehensive HIV Prevention
Program Components
HIV Community Planning
 Target populations will be prioritized and interventions
selected based on data;
 The CPG will review the health department application to
CDC; and
 The allocation of CDC-awarded funds will be consistent with
the plan.

8. High Risk and Disproportionately
Impacted Populations
 HIV-positive persons who engage in unprotected sex and needle
sharing behaviors and partners of HIV-positive persons
 Men who have unprotected sex with men
 Racial and Ethnic Minorities –African American/Black and Hispanic/
Latino/a
 Heterosexuals who:
 have been diagnosed with an STD within the last year; or
 exchange sex for money, drugs, or things they need; or
 have unprotected sex with bisexual males, injecting drug users, or
someone who exchanges sex for money, drugs, or things they need
 Injection Drug Users - Individuals who have ever shared injection
equipment

9. Comprehensive HIV Prevention
Program Components
Counseling Testing and Referral (CTR) Services
 Targeted testing consistent with the comprehensive plan.
 Confidential testing at 13 CTR sites.
 Demonstrate 80% HR and/or from disproportionately impacted populations.
 Integration of hepatitis and STD services.
 Referral and linkage into medical care
Partner Services (PS)
 Provide PS for HIV-infected persons
 Referral Services with strong linkages to prevention and care services
 Referral for STD screening, HCV screening, and Hepatitis A and B vaccinations
 Health Education and Risk Reduction (HE/RR)
Evidence-based interventions
 DEBIs
 CDC Compendium of Effective Interventions
 Contracted with local health departments and community based organizations

10. Comprehensive HIV Prevention
Program Components
 Prevention for HIV- Infected Persons
 Integration of HIV Prevention Services into Care and Treatment Services
 Quality Assurance/Evaluation of Major Program Activities
 XPEMS- Luther Consulting LLC - EvaluationWeb
 Standardization
 Data Quality Assurance
Public Information
 Clearinghouse
 MSM Modernization Project
 Capacity Building Activities
 Fundamentals of HIV Prevention Counseling
 Training on Evidence-Based Interventions
 Data Collection and Reporting
 Bi-annual IDPH, IDE, CPG - Sponsored Conference

11. HIV Prevention Activities
Sexually Transmitted Disease (STD) Prevention
Activities
Collaboration and Coordination with Other
Related Programs
Laboratory Support
MSM Supplemental – development of an MSM
Strategic Plan

12. Perinatal Transmission Prevention
All pregnant women must be tested for HIV
infection as part of the routine panel of prenatal
tests.
If she declines the test, the decision must be
documented in her medical record.
Iowa’s Requirements and Guidelines for HIV
Testing during Pregnancy can be found at http://
www.idph.state.ia.us/HivStdHep/HIV-AIDS.aspx?prog=H

13. Obtaining Consent
Adults
 General consent: All persons who are able must give
consent for an HIV test, but written consent is not required
for adult HIV testing
Minors
 Before undergoing an HIV test, a minor must be informed
that the legal guardian will be notified by the testing
facility if the test is confirmed as positive. Minors must
give written consent for HIV testing and treatment
services.

14. The National HIV/AIDS Strategy
2010

15. National HIV/AIDS Strategy
 Launch of National HIV/AIDS Strategy (2010)
An opportunity to:
Realign CDC funded prevention activities.
Address misalignment of HIV prevention resource allocation.
 Focus on high impact HIV prevention
Requires strengthening of targeted prevention with positives and high risk
negatives.
Move beyond combination prevention by focusing on improved
implementation, coverage, scale and impact.
Increase monitoring and accountability.
 New cooperative agreement started: January 1, 2012

16. Health Department FOA Categories

17. Category A: Eligible Jurisdictions
 Applicants eligible for Category A of this FOA are limited to state, local
and territorial health departments. This includes:
 50 states
 10 cities: Atlanta, Baltimore, Chicago, Fort Lauderdale, Houston, Los Angeles,
Miami, New York, Philadelphia, and San Francisco
 District of Columbia
 Puerto Rico
 Virgin Islands
 6 Pacific Island jurisdictions: American Samoa, Commonwealth of the Northern
Mariana Islands, Federated States of Micronesia, Guam, Republic of the Marshall
Islands, and Republic of Palau

18. CATEGORY A:
HIV PREVENTION PROGRAMS FOR HEALTH
DEPARTMENTS
• Purpose is to support and enhance the ability of health
departments to design, implement, and evaluate
comprehensive HIV prevention programs that are
effective, scalable, and intended to yield maximum impact
on reducing new HIV infections.
• Applicants are expected to allocate programmatic and
financial resources to local areas based on the burden of
disease.
• Category A is required for all applicants applying for
funding.

19. Category A –Required Core Components
 Category A includes required core program components and activities.
 Applicants must implement all four of the core components; however,
the distribution of resources and implementation of the elements under
each core component should be based on scalability and balance of
resources, epidemiologic data, local need, and at-risk and priority
populations, including racial and ethnic groups.
 Applicants must also implement the three required activities to support
the core components.
 Approximately 75% of funding must be allocated to the required
components and activities.

20. Category A –Required Core
Components
Program Monitoring and QA also includes epi/surveillance,
objectives/targets, program monitoring , data collection and submission,
QA plan, etc.

21. HIV Testing Performance Standards
 CDC expects each funded jurisdiction to achieve the
following performance standards, when the program is
fully implemented:
 For targeted HIV testing in non-healthcare settings or venues, achieve at
least a 1.0% rate of newly identified HIV-positive tests annually.
 At least 85% of persons who test positive for HIV receive their test
results.
 At least 80% of persons who receive their HIV positive test results are
linked to medical care and attend their first appointment.
 At least 75% of persons who receive their HIV positive test results are
referred and linked to Partner Services.

22. Comprehensive Prevention with
Positives
 Linkage to HIV care, treatment, and prevention services for those persons testing HIV
positive or currently living with HIV/AIDS.
 Retention or re-engagement in care for HIV-positive persons.
 Referral and linkage to other medical and social services as needed for HIV-positive
persons.
 Ongoing Partner Services for HIV-positive persons and their partners.
 Behavioral, structural, and/or biomedical interventions (including interventions focused
on treatment adherence) for HIV infected persons.
 Integrated hepatitis, TB, and STD screening, and Partner Services for HIV infected
persons, according to existing guidelines.
 Provision of antiretroviral therapy (ART) in accordance with current treatment
guidelines. CDC funds may not be used to purchase antiretroviral therapy.

23. Condom Distribution
Conduct condom distribution targeting
HIV-positive persons and persons at highest
risk of acquiring HIV infection.

24. Policy Initiatives
Support efforts to align structures, policies, and
regulations in the jurisdiction with optimal HIV
prevention, care, and treatment and to create an
enabling environment for HIV prevention efforts.
Policy efforts should aim to improve efficiency of
HIV prevention efforts where applicable, and are
subject to lobbying restrictions under federal law.

25. Jurisdictional HIV Planning
All funded jurisdictions are required to have in place a
planning process to include:

26. Capacity Building and Technical
Assistance
 Capacity-building needs assessment of the health department, HIV
prevention service providers, and other prevention agencies/partners,
including CBOs capacity to provide HIV prevention services.
 Provide or coordinate training and technical assistance (e.g.,
interventions, organizational infrastructure, HIV testing efforts,
policies for data security and confidentiality, data sharing across
programs and data reporting to surveillance) for providers and staff of
participating healthcare facilities and CBOs or other service
organizations.

27. Program Planning, Monitoring &
Evaluation (M&E), and Quality Assurance

28. Comprehensive HIV Program Plan
• Develop and submit to CDC a detailed comprehensive
program, monitoring and evaluation (M&E), and quality
assurance (QA) plan, referred to as the Comprehensive
Program Plan.
• The jurisdictional HIV prevention plan should be used as a
reference for the development of the Comprehensive
Program Plan.
• The final version of this comprehensive program plan must
be submitted to CDC within six months after start of the
project period.

29. Category A –Recommended Program
Components
 In addition to the core program components, the following program
components are recommended for health department jurisdictions (based on
resources, capacity, and local need) applying for funding under Category A:

31. Ryan White HIV/AIDS
Treatment
Extension Act of 2009
Part B in the State of Iowa

32. So…Who was Ryan White?
 Ryan White was a 13-year-old
hemophiliac who contracted AIDS from
factor VIII, which was used to control
this disorder.
 This courageous teen found it in his
heart to struggle and proved to the
world that people live with AIDS, and
are not dying from it.
He died in 1990 and the CARE Act was
named after him.

33. So, What is the Ryan White HIV/AIDS
Treatment Extension Act?
Until December 2006, it was known as
the Comprehensive AIDS Resources
Emergency (CARE) Act of 1990. It
provides funding to States, cities, and
nonprofit entities to deliver essential
health care and support services to
medically under-served individuals and
families affected by HIV disease.

34. Ryan White HIV/AIDS Treatment
Extension act of 2009
 Enacted August 18, 1990
 Reauthorized: May, 1996
October, 2000
December, 2006
October, 2009
 Purpose: To improve the quality and
availability of care for
individuals and families with
HIV disease.

35. Revised Purpose of the Ryan White Legislation
 No longer “emergency relief” for overburdened health care
systems
 Now “Revise and extend the program for providing life-saving
care for those with HIV/AIDS”
 “Address the unmet care and treatment needs of persons living
with HIV/AIDS by funding primary health care and support
services that enhance access to and retention in care”

36. Ryan White has four “Parts”
Part A: Provides emergency relief to
metropolitan areas that are
disproportionately affected by HIV/AIDS

37. Part B
Assists States and territories in improving the
quality, availability, and organization of health
care and support services for individuals and
families with HIV disease, and provides access
to needed pharmaceuticals through the AIDS
Drug Assistance Program (ADAP)

38. Ryan White Part B
 Total of 59 Part B Grantees
 Part B funds are awarded to all 50 states plus
 The District of Columbia
 Puerto Rico
 Virgin Islands
 Pacific Islands: American Samoa, Federated States of
Micronesia, Guam, Marshall Islands, Northern Marianas,
Republic Of Palau

39. Part C
Provides support for early intervention and
primary care services for people with HIV/AIDS

40. Part D
Enhances access to comprehensive care for
children, youth, women and their families
with/at risk for HIV, and access to research
of potential clinical benefit

41. Ryan White Appropriations
FY 1991- 2009

42. HIV/AIDS Bureau Expectations:
Four Critical priorities

43. Priority Issue #1:
Access to Care and Treatment
Early Identification of Individuals with
HIV
Addressing Unmet Need
Access and retention in care for special
populations
Revising and Revamping Systems of Care

44. Priority Issue #2:
Access to Medication Therapy
Understanding the structure, function, and
enrollment issues of ADAP
Collaborating with HRSA, Pharmacy, NASTAD,
and contractors to enhance cost containment
and cost saving strategies

45. Priority Issue #3:
Changes in the economics of health care
 Learn the Affordable Care Act and begin to explore the
role of the Ryan White Programs
 Medicaid
 Continued opportunities
 Challenges
 Strategic and necessary changes
 Strengthening of partnerships

46. Priority Issue #4:
Accountability
 Administrative Accountability
 National Monitoring Standards (program and fiscal accountability)
 Subgrantee monitoring systems
 OIG/GAO Audits
 How do we act as good stewards of federal funds?
 Data Collection and Reporting
 Client level data
 Reporting to Congress
 Who our programs serve and what we do?
 Clinical Quality Management Programs
 Quantitative information on impact and our continued efforts to
improve
 What difference do our programs make?
 Reauthorization

47. Part B in Iowa
The State of Iowa, Department of
Public Health is the state grantee for
Part B.
The program is run by the HIV/AIDS
Program, located within the Bureau of
HIV, STD & Hepatitis within the Division
of Behavioral Health.

48. Bureau of
Division of HIV, STD
Behavioral Health & Hepatitis S
U
Randy Mayer
P Valerie
Kathy Stone
P Emberton
O
HIV/AIDS Program R
T
SURVEILLANCE P CARE
R
E
V Danie Coulter,
E Interim ADAP
Coordinator
N Pat Young Holly Hanson
Jerry Harms
T
I
O
Karen Quinn
N
Amy Wadlington
Al Jatta Patresa Hartman

49. Flow of Part B Funds and Decision Making
Federal Government
Governor/CEO of State/Territory
State
Advisory Administrative Agent or “Grantee”
Body (Usually the State/Territory’s Health Department)
State Managed Services One or more HIV Care Consortia
(Optional)
ADAP
Health Home-/ Service Service Service
Direct
Insurance Community Providers Providers Providers
Services
Continuation Based Care
Multiple Service Providers
Services are provided to low-income &
uninsured people living with HIV/AIDS Note: Funds do NOT go directly to
service providers.
.

50. 2011 Part B Funding
$4,173,109
Base Award ADAP
$2,902,350 (Total)
$1,258,207 $1,555,860
$119,807
$17,986
$709,751
$498,946

51. Core Medical Services by Part B
Case Management - Medical
Medical/Oral Health
Substance Abuse
Mental Health
Medical Nutrition Therapy

52. Supportive Services
Case management-Nonmedical
Transportation
Referral
Psychosocial Support
Food/Nutrition
Linguistic

53. Iowa ADAP
The Iowa ADAP Program serves over
600 people per year.
 Single, contract pharmacy,
mostly mail order
ADAP is the payer of “Last Resort”.

54. Key things to remember
“Payer of Last Resort”
Discretionary vs. Entitlement
All Services must support clients
getting in to or staying in medical
care