The Challenges of the HIV Continuum of Care in the U.S.
The Challenges of the HIV Continuum of Care in the U.S.
For illustrative purposes, we provide an overview of some of the recent activities implemented by the CDC in response to the NHAS and particularly the CCI.
For HIV prevention, CDC directly funds all state health departments in the United States, 8 large city health departments, and a handful of territorial or other special health departments. The CDC also directly funds over 100 community-based organizations and provides indirect support to even more community-based organizations through health department funding. This funding covers basic public health activities such as HIV surveillance (health departments only) and HIV programs such as HIV testing, linkage to care, and behavioral interventions to reduce risk, enhance linkage to and engagement in care, and improve adherence to HIV treatment. One important shift in HIV prevention since 2010 is that surveillance and programmatic activities, once very separate domains, are increasingly becoming linked and interdependent, as surveillance data are being used for programmatic purposes at both the individual level (for patient tracking through the care continuum) and the jurisdictional level (for monitoring of outcomes along the care continuum). Recent funding announcements have supported this linkage and have also directed grantees to focus on highest impact activities, learn how to bill for services now covered by the Affordable Care Act such as HIV testing, implement systems that allow complete reporting of surveillance data including HIV care indicators, and explore how to share those data safely for program use.
Immediately after NHAS was announced, CDC began, with support from numerous federal partners, the first of 3 demonstration projects with health departments to design and implement programs to best meet NHAS goals and accelerate progress along the continuum of care. The first project, Enhanced Comprehensive HIV Prevention Planning (ECHPP), involved the implementation of a wide range of high-impact HIV prevention activities in the 12 cities with the most cases of AIDS. As described below, NIH also provided funding to researchers in most of the ECHPP cities to conduct research in conjunction with health departments to support the goals of ECHPP and NHAS. In 2012, the second project, Care and Prevention in the United States (CAPUS) was implemented in 8 states including 6 southern states. This project focuses on improving outcomes across the continuum of care and addressing the social determinants of health that most directly affect continuum outcomes in each jurisdiction. In 2014, the third project, Partnerships for Care (P4C) was implemented with funding going to 4 health departments from CDC and to up to 6 community health centers in each jurisdiction [funded by Health Resources and Services Administration's (HRSA) Bureau of Primary Health Care]. There are over 100 service sites involved in P4C, and the goal is to increase provision of routine HIV screening and HIV prevention and care services in health centers in areas adversely affected by HIV.
In addition to the high-visibility demonstration projects, CDC has research, programmatic, and surveillance efforts to improve outcomes along the continuum of care. CDC launched a Web site on the "data to care" or D2C strategy of using surveillance data for programmatic purposes to follow-up on individuals shown to be out of care. This tool is one of many identified by federal agencies that support NHAS and the CCI. In 2014, CDC funded the Cooperative Re-Engagement Controlled Trial (CoRECT) to test the data to care strategy of using surveillance and clinic data to identify and reengage people out of HIV care. CDC HIV surveillance staff and grantees have worked on improving completeness of laboratory data reporting (key for monitoring continuum of care outcomes) and provided technical assistance on how to calculate the continuum of care using CDC guidance for local analyses. CDC has also required that funding for some activities is contingent on state collection and submission of data necessary to calculate the care continuum. In September 2014, CDC released the first "State HIV Prevention Progress Report," which provides data, where available, across all states and the District of Columbia for 6 indicators that measure outcomes across the continuum of care. This report showed that no state was in the bottom or top quartile on all indicators, and it highlights the fact that national goals cannot be met without closing the gaps between states. CDC launched 2 communication campaigns in 2014. "HIV Treatment Works" targets HIV-positive persons to try to improve outcomes along the continuum of care, whereas "Start Talking, Stop HIV" is a campaign targeted to all gay and bisexual men urging communication with partners and understanding of the many new prevention options available today. Finally, CDC expanded its Compendium of Evidence-Based Interventions and Best Practices for HIV Prevention to include interventions to improve adherence to care (2012) and interventions to improve linkage to and retention in care (2014). The activities covered here highlight the focus on continuum of care activities at just 1 agency, but they mirror what has occurred at many federal agencies to respond to the groundbreaking NHAS and the CCI.
Summary of Current CDC Programs on the HIV Continuum of Care
For illustrative purposes, we provide an overview of some of the recent activities implemented by the CDC in response to the NHAS and particularly the CCI.
For HIV prevention, CDC directly funds all state health departments in the United States, 8 large city health departments, and a handful of territorial or other special health departments. The CDC also directly funds over 100 community-based organizations and provides indirect support to even more community-based organizations through health department funding. This funding covers basic public health activities such as HIV surveillance (health departments only) and HIV programs such as HIV testing, linkage to care, and behavioral interventions to reduce risk, enhance linkage to and engagement in care, and improve adherence to HIV treatment. One important shift in HIV prevention since 2010 is that surveillance and programmatic activities, once very separate domains, are increasingly becoming linked and interdependent, as surveillance data are being used for programmatic purposes at both the individual level (for patient tracking through the care continuum) and the jurisdictional level (for monitoring of outcomes along the care continuum). Recent funding announcements have supported this linkage and have also directed grantees to focus on highest impact activities, learn how to bill for services now covered by the Affordable Care Act such as HIV testing, implement systems that allow complete reporting of surveillance data including HIV care indicators, and explore how to share those data safely for program use.
Immediately after NHAS was announced, CDC began, with support from numerous federal partners, the first of 3 demonstration projects with health departments to design and implement programs to best meet NHAS goals and accelerate progress along the continuum of care. The first project, Enhanced Comprehensive HIV Prevention Planning (ECHPP), involved the implementation of a wide range of high-impact HIV prevention activities in the 12 cities with the most cases of AIDS. As described below, NIH also provided funding to researchers in most of the ECHPP cities to conduct research in conjunction with health departments to support the goals of ECHPP and NHAS. In 2012, the second project, Care and Prevention in the United States (CAPUS) was implemented in 8 states including 6 southern states. This project focuses on improving outcomes across the continuum of care and addressing the social determinants of health that most directly affect continuum outcomes in each jurisdiction. In 2014, the third project, Partnerships for Care (P4C) was implemented with funding going to 4 health departments from CDC and to up to 6 community health centers in each jurisdiction [funded by Health Resources and Services Administration's (HRSA) Bureau of Primary Health Care]. There are over 100 service sites involved in P4C, and the goal is to increase provision of routine HIV screening and HIV prevention and care services in health centers in areas adversely affected by HIV.
In addition to the high-visibility demonstration projects, CDC has research, programmatic, and surveillance efforts to improve outcomes along the continuum of care. CDC launched a Web site on the "data to care" or D2C strategy of using surveillance data for programmatic purposes to follow-up on individuals shown to be out of care. This tool is one of many identified by federal agencies that support NHAS and the CCI. In 2014, CDC funded the Cooperative Re-Engagement Controlled Trial (CoRECT) to test the data to care strategy of using surveillance and clinic data to identify and reengage people out of HIV care. CDC HIV surveillance staff and grantees have worked on improving completeness of laboratory data reporting (key for monitoring continuum of care outcomes) and provided technical assistance on how to calculate the continuum of care using CDC guidance for local analyses. CDC has also required that funding for some activities is contingent on state collection and submission of data necessary to calculate the care continuum. In September 2014, CDC released the first "State HIV Prevention Progress Report," which provides data, where available, across all states and the District of Columbia for 6 indicators that measure outcomes across the continuum of care. This report showed that no state was in the bottom or top quartile on all indicators, and it highlights the fact that national goals cannot be met without closing the gaps between states. CDC launched 2 communication campaigns in 2014. "HIV Treatment Works" targets HIV-positive persons to try to improve outcomes along the continuum of care, whereas "Start Talking, Stop HIV" is a campaign targeted to all gay and bisexual men urging communication with partners and understanding of the many new prevention options available today. Finally, CDC expanded its Compendium of Evidence-Based Interventions and Best Practices for HIV Prevention to include interventions to improve adherence to care (2012) and interventions to improve linkage to and retention in care (2014). The activities covered here highlight the focus on continuum of care activities at just 1 agency, but they mirror what has occurred at many federal agencies to respond to the groundbreaking NHAS and the CCI.
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