Ending the HIV Epidemic: An

Overview & Update of the

National Plan

Jen Kates and Lindsey Dawson

September 18, 2019

Outline

• What is the Ending the Epidemic Initiative?

• Where are we today? (National, State, Local)

• What are the opportunities?

• What are the challenges facing Texas?

• What key questions remain unanswered?

NOTES: All data are for 2018 except for Canada (2016) and Japan (2015). U.S. estimate based on Bradley et al. “Data-Driven Goals for Curbing the U.S. HIV Epidemic by 2030,”

AIDS and Behavior, 2019. All countries defined viral suppression as having a viral load test result of < 200 copies/mL.

SOURCES: Public Health Agency of Canada, 2018; The Kirby Institute for infection and immunity in society, 2018; European Centre for Disease Prevention and Control, 2018;

Bradley H, Rosenberg ES & Holtgrave DR, “Data-Driven Goals for Curbing the U.S. HIV Epidemic by 2030,” AIDS and Behavior, 2019; Iwamoto A et al., “The HIV care cascade:

Japanese perspectives,” PLoS ONE, 2017.

HIV Viral Suppression Rate in U.S. Lowest Among

Comparable High-Income Countries

84% 84% 83%

77% 76% 74% 74% 74%70%

68%

63%

54%

59%

UnitedKingdom

Switzerland Sweden TheNetherlands

Germany France Australia Austria Japan Belgium Canada United States Texas

2010 2011 2012 2013 2014 2015 2016

HIV Incidence, 2010-2016 Among all people with HIV1:

50% live in 5 states

42% are Black/African American

45% live in the South

62% are MSM2

National HIV Incidence is no Longer Falling; Epidemic is

Concentrated

NOTES: (1) Includes those with diagnosed and undiagnosed HIV. (2) Includes MSM/IDU.

SOURCES: CDC. HIV Surveillance Supplemental Report. Vol. 24, No. 1. Estimated HIV Incidence and Prevalence in the United States 2010–2016.

$1.1

$1.9

$2.4

$3.2

$3.5

$4.2

$5.1

$6.1

$6.4$6.5

$6.8

$7.3

$7.7 $7.7

<$0.0$0.0

$0.1$0.1 $0.3

$0.6

$1.5

$2.3$2.6

$3.3

$3.9

$4.8

$5.8

$6.3$6.5 $6.7

$7.0

$7.5

$7.1 $7.3

$7.7 $7.7$7.6 $7.8

FY 1981 FY 1983 FY 1985 FY 1987 FY 1989 FY 1991 FY 1993 FY 1995 FY 1997 FY 1999 FY 2001 FY 2003 FY 2005 FY 2007 FY 2009 FY 2011 FY 2013 FY 2015 FY 2017 FY 2019

Funding in Billions

Federal Funding for Domestic Discretionary HIV Programs

Has Been Relatively Flat for Several Years

SOURCES: Kaiser Family Foundation Notes: Funding includes both domestic and global HIV analysis of data from OMB, CBJs, Congressional Appropriations Bills, and personal

communication with agency staff. The decrease in 2006 reflects methodological changes at CMS. For additional information about recent budget trends see KFF fact sheet, U.S.

Federal Funding for HIV/AIDS: Trends Over Time. https://www.kff.org/global-health-policy/fact-sheet/u-s-federal-funding-for-hivaids-trends-over-time/

• Announced in the February 2019 SOTU by President Trump

• Goals: Reduce HIV incidence in the U.S. by 75% in 5 years &

90% in 10 years

• Phase 1 focus:

• 48 counties (incl. Harris, Bexar, Dallas, Tarrant, & Travis)

• DC and San Juan, PR

• 7 States

SOURCE: HHS. What is ‘Ending the HIV Epidemic: A Plan for America’? https://www.hiv.gov/federal-response/ending-the-hiv-epidemic/overview

The Federal Ending the Epidemic Initiative (EtHE)

Indicator National Texas

(Share of national)

5 TX Jurisdictions

(Share of national)

HIV Prevalence

(Diagnosed), 2016989,222 84,802 (9%) 56,767 (6%)

HIV Diagnoses, 2017 38,182 4,358 (11%) 2,499 (7%)

Rate of PrEP Users per

100,00048 41 ---

Number of Ryan White

Grants799 36 27

Number of Health

Center Grants1,369 73 22

Poverty Rate, 2017 15% 16% 16%

Uninsured Rate, 2017 11% 19% 20%

SOURCES: CDC Atlas https://www.cdc.gov/nchhstp/atlas/index.htm; AIDSVu https://aidsvu.org/local-data/united-states/south/texas/bexar-county/; U.S. Census Bureau. American

Community Survey Data, available using the American Fact Finder. https://factfinder.census.gov

Texas in Context

EtHE Key Pillars and Federal Agencies

4 Pillars

Diagnose

Treat

Prevent

Respond

Federal Agencies

CDC

HRSA

(Ryan White + Health Center Programs)

NIH

IHS

SAMHSA

OASH

SOURCE: HHS. What is ‘Ending the HIV Epidemic: A Plan for America’? https://www.hiv.gov/federal-response/ending-the-hiv-epidemic/overview

SOURCE: FY2020 Federal budget requests

FY2020 Budget Request Funding Levels for the Ending the HIV Epidemic Initiative

(In Millions)

Agency Funding Purpose Budget Request

HRSA

Ryan White Program

Community Health Centers

HIV Care & Support Services

PrEP

$70

$50

CDC HIV Prevention $140

Indian Health Service(HIV Screening; HCV Prevention

& Treatment)$25

NIH

Centers for AIDS Research

(CFARs)/ AIDS Research

Centers (ARCs)

$6

TOTAL --- $291

EtHE FY 2020 Budget Request

$257

$656

$1,436

$2,018

$2,138

$2,337 $2,319 $2,319

$2,389

Ryan White Funding, FY1991- FY2020 Budget

Request (BR)

3% over FY19 funding

$6

$136

$378

$498

$617

$750$732

$732

$823

$787 $789

$929

18% over FY19 funding

Funding in MillionsFunding in Millions

CDC HIV Prevention Funding, FY1981-

FY2020 Budget Request (BR)

FY 2020 Budget Request Would Mark First Significant

Increase for Ryan White & CDC in Years

SOURCE: Kaiser Family Foundation analysis of data from OMB, budget request, CBJs, Congressional Appropriations Bills.

• Awarded

• FY19 MAI Fund ($29m)• HHS - Pilot Sites (3 counties & Cherokee Nation in OK)

• CDC - Strategic Partnerships & Planning to Support EtHE (32 jurisdictions; grantees not named)

• NIH - CFAR/ARC EtHE Supplemental Awards (17 CFARs & 6 ARCs, none in Texas)

• FY19 HRSA/HAB ($981,763)• 10 RW Part A jurisdictions rec’d TA funding to enhance EtHE efforts (8 in EtHE jurisdictions, incl. Bexar)

• Announced

• FY2020 HRSA/HAB NOFO Out ($60.125m)• New Part A & B funding opportunity to support EtHE activities due Oct. 15 w/ 3/20 start date

• Separate NOFOs for a TA grantee and a coordinator

SOURCES: https://www.hiv.gov/blog/hhs-awards-pilot-funds-three-jurisdictions-jumpstart-federal-initiative-end-hiv-epidemic-us; https://files.hiv.gov/s3fs-public/jumpstart-release-

dekalb.7.1.19.pdf; https://www.cdc.gov/hiv/funding/announcements/ps19-1906/index.html; https://www.hiv.gov/blog/trump-administration-awards-1-million-ryan-white-hivaids-

program-grants-counties-strengthen; https://www.hiv.gov/blog/nih-bolsters-funding-hiv-implementation-research-high-burden-us-areas;

https://www.hrsa.gov/grants/fundingopportunities/default.aspx?id=9ba1c4a1-4d18-4782-8065-0be264564d64

Awarded & Announced EtHE Funding for FY 2019 + FY2020

• Policy Priority from the White House

➢Opening to start conversations about HIV care and prevention within communities and

with local/state/federal officials

• Local Focus

➢Allows for community engagement – listening sessions/plan development

➢Plans responsive to local context

➢Encourages jurisdictions to refine/develop plans, engage with stakeholders

• Providers/workforce

➢9 PHS Corp Officers deployed to 3 EtHE sites - 3 each in Atlanta, Dallas and LA

➢Workforce development through the RWP Part F AETCs

• Planning funding for EtHE

➢HAB NOFO (Due Oct 15th)

➢Possible HRSA Health Center NOFO in the works

Opportunities for Texas

• Ryan White

➢Rapid initiation of HIV care & treatment

➢Expand re-engagement & retention for those out of care

➢Leverage data/data sharing

➢Take advantage of TA/dissemination of best practice from HAB

• Health Centers

➢Implement/increase routine and risk based HIV testing and linkage to care

➢Community outreach & engagement

➢Receive referrals from community outreach activities

➢Expand prevention education & PrEP services/leverage 340B

Opportunities, continued

No

Medicaid

Expansion

(> %

uninsured)

State Law

Prohibits

Syringe

Exchange

No State

SOGI

Protections

for Health

Insurance

Border

State/

Stigma

facing

immigrant

populations

5 TX

Counties

have

moderate to

high SVI

scores

Workforce

Capacity

Challenges

Stigma +

Discrimination

(race, SOGI,

HIV status)Funding

Opportunities

Narrow (e.g.

how to

address

housing?)

SOURCES: KFF State Health Facts, AmfAR Ending the HIV Epidemic Database: http://ehedev.amfar.org, CDC – Social Vulnerability Index https://svi.cdc.gov/map.html

• FY2020 Budget Process (delays/CR? Anomalies?)

• Funding for the future (Level? Approach?)

• Updated NHAS

• Intersection of EtHE with other Trump Administration policies:

❖1557, conscience rule, public charge proposal, legal threats to ACA,

Medicaid work requirements, non-compliant plans etc.

• How can national & local EtHE plans address stigma, discrimination, and

SDOH

• Shifting healthcare access landscape

• Evolving Rx landscape (e.g. generics, injectable, potential policy change)

• Impact of 2020 election

Outstanding Questions/Issues

Thank you.