HIV Care Continuum and Ryan White HIV/AIDS Program Services U.S. Conference on AIDS 2014 Laura Cheever, Associate Administrator, HIV/AIDS Bureau Harold Phillips, Deputy Director, Division of State HIV/AIDS Programs Steven Young, Director, Division of Metropolitan HIV/AIDS Programs HIV/AIDS Bureau Health Resources and Services Administration U.S. Department of Health and Human Services October 4, 2014

Workshop Agenda • The HIV Care Continuum • Ryan White Services Report (RSR) Data and the Care Continuum • Programmatic Emphasis and What Grantees and Planning Councils can do to Strengthen Stages Along the Continuum • Examples of Service Models • Questions and Answers/Discussion

HIV Care Continuum Development & Timeline • Dr. Laura Cheever, HRSA’s Associate Administrator for the HIV/AIDS Bureau, uses the phrase continuum of engagement in care in a 2007 editorial “to describe the fluid nature of HIV health-care delivery and patient experience” (Cheever LW. Engaging HIV-Infected Patients in Care: Their Lives Depend on It. [Editorial]. Clinical Infectious Diseases, 2007; 44 (June 1): 1501-2.) • Gardner, et al., release “Spectrum of Engagement in HIV Care” article in 2011, “to help understand the magnitude of the challenges that poor engagement in care will pose to test-and-treat strategies for HIV prevention” (Gardner, et al., The Spectrum of Engagement in HIV Care and its Relevance to Test-and-Treat Strategies for Prevention of HIV Infection. Clinical Infectious Diseases, 2011: 52 (March 15): 793-800.)

HIV Care Continuum Development & Timeline (cont.) • CDC releases its first “Stages of Care” in 2012 and its comprehensive analysis shows that only one-quarter of the 1.1 million Americans living with HIV have their virus under control — and that African Americans and young people are least likely to receive ongoing care and effective treatment • HIV Care Continuum Executive Order, July 2013, “It is the policy of my Administration that agencies implementing the Strategy prioritize addressing the continuum of HIV care, including by accelerating efforts to increase HIV testing, services, and treatment along the continuum. This acceleration will enable us to meet the goals of the Strategy and move closer to an AIDS-free generation”

What is the HIV Care Continuum? •

HIV Diagnosis —The HIV Care Continuum begins with a diagnosis of HIV infection. The only way to know for sure that you are infected with the HIV virus is to get an HIV test. People who don't know they are infected are not accessing the care and treatment they need to stay healthy. They can also unknowingly pass the virus on to others

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Getting linked to care—Once you know you are infected with the HIV virus, it is important to be connected to an HIV health care provider who can offer you treatment and counseling to help you stay as healthy as possible and to prevent passing HIV on to others

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Staying in care—Because there is no cure for HIV at this time, treatment is a lifelong process. To stay healthy, you need to receive regular HIV medical care

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Getting antiretroviral therapy— Antiretrovirals are drugs that are used to prevent a retrovirus, such as HIV, from making more copies of itself. Antiretroviral therapy (ART) is the recommended treatment for HIV infection. It involves using a combination of three or more antiretroviral drugs from at least two different HIV drug classes every day to control the virus

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Achieving a low amount of HIV virus in your body—By taking ART regularly, you can achieve viral suppression, meaning a very low level of HIV in your blood. You aren’t cured. There is still some HIV in your body. But lowering the amount of virus in your body with medicines can keep you healthy, help you live longer, and greatly reduce your chances of passing HIV on to others

CDC Stages of Care – 2009 National HIV Surveillance System & Medical Monitoring Project

CDC. HIV in the United States: Stages of Care. July 2012. Hall HI, Frazier EL, Rhodes P, et al. JAMA Internal Medicine. Jun 17 2013:1-7.

Limitations of the Treatment Cascade • The Bars before the Cascade and other issues

o Prevention should not be forgotten o Social and Structural Determinants of Health o Large overlap in the stages of engagement in care o Achieving consensus on the standards of care and practice

• Mortality as the “ultimate indicator” of success and failure • The Human Factor

o Progress along the HIV Care Continuum may not be linear o Achieving viral suppression does not end the work

• Data collection and reporting o Access limitations o Data quality

Why is the HIV Care Continuum Important? • Provides answers to some questions about care delivery at critical stages • Policymakers and service providers can identify gaps that require additional or special attention • Intensifies focus on barriers to care and needed solutions • Serious implications for our test and treat programs, treatment as prevention prospects, reducing community viral load and ultimately and AIDS-free generation

Ryan White Services Report, 2010-2012 Retention in Care & Viral Suppression

Retained in care: had at least 1 OAMC visit before September 1, 2012, of the measurement year and had at least 2 visits 90 days or more apart Viral suppression: had at least one OAMC visit, at least one viral load count, and last viral load test