Editor’s note: As summer winds down, we are looking back at some of the highlights of a busy summer in the HIV/AIDS field. Today we share reflections from Dr. Ron Valdiserri on a White House meeting on HIV in the southern U.S. held earlier this summer.
HIV continues to take a heavy toll in states across the American South, a fact underscored at a meeting convened by the White House Office on National AIDS Policy (ONAP) earlier this summer. The June 18 meeting explored the response to HIV in the 17 southern states, a rapidly growing region where one-third of the U.S. population resides and the region of the country where the largest proportion of people living with HIV (PLWH) resides.
Echoing the President’s observation in the National HIV/AIDS Strategy (NHAS) that the federal government cannot achieve the Strategy’s goals alone, ONAP Director Douglas Brooks, MSW, observed that the diversity of voices participating in the meeting represented many vital partners, including PLWH, community-based organizations (CBOs), health centers, AIDS service organizations (ASOs), state and local health departments, academic medical centers, and funders. Mr. Brooks observed that only by working together can we refine and pursue strategies and policies that support communities in the southern U.S. to enhance prevention efforts and improve outcomes for thousands of Americans living with HIV in the region.
The meeting opened with an overview of HIV/AIDS in the southern United States by Dr. Amy Lansky, Deputy Director for Surveillance, Epidemiology, and Laboratory Science in CDC’s Division of HIV/AIDS Prevention (DHAP). She noted that nearly half (49%) of all diagnoses of HIV infection in the U.S. in 2011 occurred in the South. Dr. Lansky observed that while the characteristics of the HIV epidemic in the South are similar to those in U.S. generally (e.g., mostly male; concentrated among gay, bisexual and other men who have sex with men (MSM) and in urban communities; and disproportionately affecting African Americans), there are some differences. These include the following: HIV in southern states affects a higher proportion of women than the national average; there is a slightly larger proportion of infections attributable to heterosexual contact; and the population affected by HIV is slightly less concentrated in urban settings. These characteristics, she observed, are important to consider when tailoring HIV prevention, care, and treatment to the needs of the region. She also pointed to another important factor: recent significant increases in the rate of HIV diagnoses among younger males in the South.
Across the several panel presentations that followed, we heard recurring accounts of a number of prevalent challenges to mounting effective responses to HIV in the southern states, including poverty; limited access to HIV prevention and care in rural areas and associated transportation concerns; and widespread homophobia, stigma, and discrimination against PLWH. While none of these factors are exclusive to the southern states, they seem to combine in unique ways in that region, requiring thoughtful regional, state, and community responses.
Another concern frequently cited by panelists was the challenge of poverty and the large number of vulnerable individuals who lack health insurance in states in the southern United States. In six southern states, Medicaid is being expanded under the Affordable Care Act and this will help overcome these challenges and improve health outcomes for many citizens, not just those at risk for or living with HIV. In the 11 southern states that have not chosen to expand Medicaid, the Ryan White HIV/AIDS Program must continue to provide a vital safety net for uninsured or marginally insured individuals.
But challenges notwithstanding, presenters also highlighted a number of innovative and successful approaches by federal and non federal stakeholders that are improving the response to HIV in communities across the South. Among these were:
Realigning HIV Prevention Funding to Match Disease Burden
Ms. Janet Cleveland, MS, DHAP’s Deputy Director for Prevention Programs, highlighted CDC’s four-year effort to re-align its programs and funding to match the burden of disease geographically and concentrate on cost-effective prevention interventions that have been shown to work at a scale that will achieve significant reductions in HIV incidence. As an example, she pointed to the fact that CDC has re-aligned its HIV prevention grants to health departments to be more reflective of the current epidemic, which significantly increased funding to many southern states. Additionally, she noted that one-third of the CBOs whose HIV prevention activities DHAP supports with grant funds are located in the southern region.
Implementing “Red Carpet” Service to Accelerate Linkage to HIV Care
Mr. Don Blanchon, Executive Director of Whitman-Walker Health, a former ASO turned health center in Washington, DC, shared that the center recognized the need to improve linkage to care for newly diagnosed individuals in the city. In response, the center piloted an on-demand protocol in which the clinic “rolls out the red carpet,” making it possible for a newly diagnosed individual to get into care the same day they are diagnosed. A similar approach has now been adopted city-wide, according to Mr. Michael Kharfen, Director of the DC Department of Health’s HIV/AIDS administration. Under this protocol, the health department guarantees an appointment for a newly diagnosed person with an HIV medical provider within 72 hours of diagnosis. Over the past year, more than 70% of DC’s newly diagnosed individuals have been engaged via that protocol and the city has achieved a linkage to care rate of 87% among those newly diagnosed.
Utilizing Telemedicine to Extending the Reach of HIV Services
Dr. DeAnn Gruber, Director of the Louisiana Department of Health and Hospitals’ STD/HIV Program, discussed a promising use of technology to enhance care transitions for people living with HIV who are leaving incarceration and returning to the community. With support from a Ryan White HIV/AIDS Program grant, Louisiana is enabling virtual case management sessions between incarcerated individuals preparing to leave the corrections system and CBOs or Ryan White clinics offering case management services. These sessions are designed to keep individuals in care by establishing relationships virtually, before their return to the community.To date, of the individuals who have participated in such virtual sessions and have been released, 75% have been linked to HIV care within 90 days of release.
Tailoring HIV Services
Ms. Tonya King of the Tennessee Department of Health shared that the state has established specialized “one-stop shops” for PLWH. These clinics offer not just medical care, but also other needed support services, including assistance with housing and utility payments. Dr. Gruber of Louisiana also pointed to the creation of the state’s six wellness centers for gay men as another example of tailoring HIV services to meet the needs of specific populations.
Harnessing the Promise of PrEP
Several participants indicated that they were supportive of the addition of pre-exposure prophylaxis (PrEP) to the HIV prevention toolbox, but likewise observed that there are barriers to its uptake in the southern states, including low provider awareness as well as stigma, shame, and homophobia. To increase PrEP uptake, Dr. Vignetta Charles of AIDS United highlighted the work of two of her organization’s grantees. One of them, Georgia Equality , is using social media to educate individuals about PrEP. Another, My Brother’s Keeper in Jackson, Mississippi, is supporting PrEP education and outreach for community health centers. Dr. Michael Kolber of the University of Miami noted the importance of work underway to enhance healthcare providers’ understanding of both PrEP and post-exposure prophylaxis (PEP) and educate providers about their merits.
This ONAP meeting was important for a number of reasons, not the least of which was bringing together some 200 diverse stakeholders to share their experiences and perspectives. The day’s dialogue also underscored the importance of using data to drill deeper and examine what is happening not just in the region or even in particular states, but at the county and community levels. As Mr. Brooks noted at the opening of the meeting, improving HIV outcomes across the southern U.S. will require concerted and focused efforts by all stakeholders—the federal government as well as state and local governments, medical academia, the faith community, the business community, the media, and affected communities. Working together, we can make a difference.