Planning and Priority Setting to Address the HIV Epidemic

in Broward County:Data Presentation

June 2008

Julia Hidalgo, ScD, MSW, MPH

Positive Outcomes, Inc. &

George Washington University

We acknowledge the efforts of HIV program staff in Broward County,

as well as the

Part A Grantee William Green, Leonard Jones, Lorene Maddox, Spencer Lieb,

Patricia Callahan, Regine Lefevre Michele Rosiere and Devlon Jackson

in preparing the information presented

What are questions we must address to plan and set priorities for Part A funds?

What is the scope of the HIV/AIDS epidemic in Broward County?

What population groups have unique service needs that must be addressed?

Which funders pay for HIV care, how much do they allocate for core medical and support services, and are those funds sufficient to meet demand for HIV services?

In the Broward County Part A Program, what services are funded, how many people are served, and what are their service utilization characteristics?

Are high quality services being provided by Part A-funded agencies?

What are the unmet need for HIV services and service gaps in Broward County?

What factors must we consider in setting priorities for Part A funds?

What is the scope of the HIV/AIDS epidemic in

Broward County?

Data from the Florida Department of Health (DOH)

What is the scope of the HIV/AIDS epidemic in Florida as of 2007?

Population: 18.8 million4th in the US in population size

Cumulative AIDS cases: 109,3643rd in nation

Cumulative pediatric AIDS cases: 1,5232nd in nation

Cumulative HIV (not AIDS) cases as of 1997: 40,642Persons living w/ HIV/AIDS (PLWHAs): 87,500 reported

casesHIV prevalence estimate: 125,000

What is the scope of the HIV/AIDS epidemic in Broward County as of 2007?

Population: 1.8 millionAIDS case rate through 2006: 43.0 per 100,000

population Broward ranked 2nd in the U.S. for 2005 and 2006, behind Miami

Cumulative pediatric AIDS cases through 2006: 262 per 100,000 population

4th in the U.S., excluding Puerto Rico and DC

Cumulative AIDS through 2007: 17,184 through 2007Cumulative HIV (not AIDS) through 2007: 7,073Persons living with HIV/AIDS (PLWHAs): 14,131

Estimated prevalence: 20,507

One in 125 Broward County residents is living with HIV/ AIDS, compared to one in 218 FL residents

Another Way of Looking at HIV Prevalence Estimates and 2007 HIV and AIDS Cases in Broward County

Total Alive %

+ 17,184 7,680 45%

+ 7,073 6,677 94%

Grand Total Total Alive %

HIV/AIDS Cases = 24,257 14,357 59%

20,507

HIV Prevalence Estimate =

Cumulative AIDS Cases (through 12/07)

Cumulative HIV Cases (not AIDS) (through 12/07)

Alive #

Alive #

What has been the impact of the new FL HIV / AIDS reporting statue that went into effect on 11/20/06? A positive Western blot is reportable by labs and physicians

and is considered diagnostic of HIV (i.e., confirmatory) The reporting requirement was implemented in November

1997

NEW: A detectable viral load (VL) (or equivalent viral test) is

reportable, and is considered evidence of HIV Other reportable virologic tests considered to be evidence

of HIV are: p24 antigen, Nucleic Acid Test (NAT/NAAT), viral culture

CD4 counts/percents are reportable, but follow-up is conducted only if it is <200 or <14%

Changes in FL HIV reporting have seriously and negatively impacted Broward and other FL counties The increase of new HIV cases observed in 2007 was

primarily due to the change in the law which requires viral load reporting

This increase may not level off until 2009 Persons with undetectable viral tests results are NOT reportable

In 2007, many labs (including Labcorp) switched from paper to electronic lab reporting (ELR)

Due to technical difficulties, 2007 tests were un-retrievable from ELR in 2007

In January 2008, surveillance staff performed retroactive review of Western Blot data received through ELR, thus leading to an unexpected increase of new HIV cases in 2008

The number of HIV cases reported in 2008 is expected to increase significantly over 2007, due to the results of the review

It is expected that these trends should level back off in 2009

The impact of delayed investigation and processing of HIV/AIDS case reports may result in potential losses of federal care and housing funds

Over 1,300 Broward HIV and AIDS cases reported in 2007 were not investigated or processed by local DOH HIV/AIDS surveillance staff before the CDC submission deadline and therefore, these cases were not credited to Broward County for the upcoming FY 2009 Part A formula award

The impact of the delayed reporting was offset for the FY 2008 Part A award by the “hold harmless” clause of the Ryan White HIV/AIDS Treatment Modernization Act

It is unclear what impact this delayed reporting may have in relation to making the case for FY 2009 Part A supplemental or MAI funding

Due to this delayed reporting, 2007 HIV and AIDS case data are unreliable and should be considered with caution, making planning for services more challenging than ever before

What advise is offered to local planning bodies from the FL DOH HIV/AIDS surveillance staff?

“So…. With the increase in HIV cases and the drop in AIDS cases, how should you use these data for program planning?Forget using % change for the next two years!!”

FL HIV Cases, by Year of Report (1998-2007) and

Year of Diagnosis (1998-2006)

4,000

4,500

5,000

5,500

6,000

6,500

7,000

98 99 00 01 02 03 04 05 06 07

Num

ber o

f Cas

es

VL & WBYear of Report

Year of DiagnosisWB

Note: Y-axis begins at 4,000 to magnify trends for discussion.

TestingInitiatives

Where does Broward County rank in the percentage changes in HIV and AIDS cases reporting among FL counties for 2006 versus 2007?

Note: 27 counties included with 20+ HIV cases and 20+ AIDS cases in 2006

SELECTED COUNTY 2006 - 2007 HIV

% CHANGE

2006 - 2007

AIDS % CHANGE

SELECTED COUNTY

2006 - 2007 HIV

% CHANGE

2006 - 2007

AIDS % CHANGE

ALACHUA 50% -38% MIAMI-DADE 24% -30%BAY -30% -59% MONROE 28% -37%BREVARD 39% -13% ORANGE 42% -9%BROWARD -5% -16% OSCEOLA 63% -13%COLLIER -6% -49% PALM BEACH 16% -23%DUVAL 20% -3% PASCO 86% -35%ESCAMBIA 36% 2% PINELLAS 44% -19%GADSDEN -23% -33% POLK 10% -19%HILLSBOROUGH 35% -21% ST LUCIE 13% -28%LAKE 44% 7% SARASOTA 2% -36%LEE 1% -8% SEMINOLE 143% 0%LEON 42% -17% VOLUSIA 12% -38%MANATEE 33% -40% INSTIT./DOC -10% -39%MARION 63% -19% FLORIDA 21% -21%MARTIN -24% -58%

Is this a true decrease, or the result of delayed HIV/AIDS reporting in Broward County?

What are the trends in AIDS cases and annual AIDS case rates per 100,000 population for Broward County between 1998 and 2007?

642

761803

933

629676609

741

835770

0100200300400500600700800900

1000

98 99 00 01 02 03 04 05 06 07

Year of Report

Nu

mb

er o

f C

ases

Note: The advent of HAART was associated with decreases in AIDS cases in the late 1990s. Generally, AIDS cases fluctuated in the early 2000s, with an increase in 2004 due to increased CD4 testing statewide. Increasingly, an AIDS diagnosis reflects late diagnosis of HIV and limited access to treatment.

2007Year Rate98 5399 55.900 48.901 36.802 40.103 37.104 53.605 45.206 42.907 36.3

What are the trends in HIV cases and annual HIV case rates per 100,000 population for Broward County between 1998 and 2007?

1,044 972906 900

1,097 1,057951 992

875833

0

200

400

600

800

1000

1200

98 99 00 01 02 03 04 05 06 07

Year of Report

Nu

mb

er o

f C

ases

Note: Generally, HIV cases remained fairly stable with an increase in 2002 due to increased HIV testing statewide as part of the “Get to Know Your Status” campaign. Since that time, newly reported HIV cases have decreased each year, however, in 2006 there was an increase in reported cases.

2007Year Rate98 71.999 65.100 59.801 54.302 65.003 62.304 54.705 55.906 49.4

In the absence of accurate and reliable HIV/AIDS

epidemiologic data, it is important to hope for the best

and plan for the worst

What are the trends in adult AIDS cases among men and women in Broward County between 1998 and 2007?

0

20

40

60

80

98 99 00 01 02 03 04 05 06 07

Year of Report

Per

cen

t o

f C

ases Females

MalesM:F Ratio*

1997 2.4:1

2007 1.7:1

Adult HIV Cases by Sex and Year of ReportPartnership 10, 1998-2007

0

20

40

60

80

98 99 00 01 02 03 04 05 06 07

Year of Report

Perc

en

t o

f C

ases

FemalesFemales

MalesMales

M:F Ratio*

1998 1.5:1

2007 2.4:1

Comment: The trend for HIV cases by sex is the opposite of that for AIDS cases. Recent trends in HIV transmission are best described by the HIV case data. The relative increases in male HIV cases might be attributed to proportional increases in HIV transmission among men who have sex with men (MSM), which may influence future AIDS trends.

What are the trends in adult HIV cases among men and women in Broward County between 1998 and 2007?

Adult HIV Casesby Race/Ethnicity and Year of Report

Partnership 10, 1998-2007

0

10

20

30

40

50

60

70

80

98 99 00 01 02 03 04 05 06 07

Year of Report

Per

cen

t o

f C

ases

Black, non-HispanicBlack, non-Hispanic

HispanicHispanic

White, non-HispanicWhite, non-Hispanic

Comment: In absolute numbers, from 2001-2006, HIV cases among blacks decreased by 17%, while increasing by 27% among whites. The decreases among blacks may correspond to some extent with recent targeted prevention, while the increases among whites may be associated with recent increases in HIV transmission among white MSM.

What are the trends in adult HIV cases among racial and ethnic groups in Broward County between 1998 and 2007?

Among adult males, what are the trends in HIV cases by race and ethnicity for 1998 through 2007?

0

10

20

30

40

50

60

98 99 00 01 02 03 04 05 06 07Year of Report

Per

cen

t o

f C

ases

Hispanic

White, non- Hispanic

Black, non- Hispanic

What are the trends among Broward County adult female HIV cases when race, ethnicity, and year of report are considered?

0

30

60

90

98 99 00 01 02 03 04 05 06 07

Year of Report

Perc

en

t o

f C

ases

Black, non- Hispanic

HispanicWhite, non- Hispanic

3%

53%

21%

23%

Significant disproportionate impact among adolescent and adult HIV and AIDS racial and ethnic minorities are identified when comparing the rates to the Broward County population in 2007

59%

2%12%

27%

2%

46%

34%

18%

AIDS (N=641)2007 Broward County Population Estimates*

(N=1,473,035)

HIV (N=823)

White Black Hispanic Other

Note: In this snapshot of 2007, blacks are over-represented among the AIDS cases, accounting for 59% of adult cases, but only 23% of the adult population. A group is disproportionately impacted to the extent that the percentage of cases exceeds the percentage of population.*Other includes Asian/Pacific Islanders and Native Alaskans/American Indians.

37.1

8.1

120.4

103.8

44.8

7.5

0

20

40

60

80

100

120

140

Male Female

Rat

e p

er 1

00,0

00

White Black Hispanic

Another approach to demonstrating disproportionate impact on Broward County men and women of color is to calculate reported AIDS case rates per 100,000 population in 2007

MALES Rate ratios Blacks: Whites, 3.2:1 Hispanics: Whites, 1.2:1

FEMALES Rate ratios Black: Whites, 12.8:1 Hispanics: Whites, 0.9:1

66.9

7.0

121.6

104.9

83.5

13.1

0

20

40

60

80

100

120

140

Male Female

Rate

per

100,0

00

White Black Hispanic

A similar disproportionate impact is seen in HIV population adjusted HIV cases among women and men of color in Broward County in 2007

MALES Rate ratios Blacks: Whites, 1.8:1 Hispanics: Whites, 1.2:1

FEMALES Rate ratios Black: Whites, 14.9:1 Hispanics: Whites, 1.9:1

The disproportionate impact of the HIV/AIDS epidemic is also seen in population adjusted HIV/AIDS case rates among men and women of color living with HIV/AIDS in 2007

2298.4

1835.5

117.6

1175.1

186.0

973.2957.4

368.8

0.0

500.0

1000.0

1500.0

2000.0

2500.0

Males Females

Ra

te p

er

10

0,0

00

WhiteBlackHispanicOther**

MALES Rate ratios Blacks: Whites, 2:1 Hispanics: Whites, 1:0

FEMALES Rate ratios Black: Whites, 16:1 Hispanics: Whites, 2:1

How did the distribution of HIV/AIDS cases among racial/ ethnic minorities compare to other FL counties in 2006?

White Black Hispanic White Black HispanicMiami-Dade 13% 49% 37% 16% 20% 62%Broward 35% 51% 12% 51% 24% 21%Palm Beach 24% 64% 11% 66% 16% 16%Orange 37% 43% 19% 50% 21% 24%Hillsborough 39% 44% 16% 58% 16% 22%Florida 30% 50% 18% 62% 16% 20%Data Source: FL Department of Health HIV/AIDS Reporting System. Data as of 04/2007Population data based on 2006 population estimates

Proportion of Living HIV/AIDS Cases Proportion of County PopulationCounty

The one-in statement is an expression of the impact (or rate) of disease on the community

County One in… County One in… County One in…Monroe 115 Saint Lucie 42 Miami-Dade 185Miami-Dade 138 Miami-Dade 45 Monroe 190Broward 192 Palm Beach 46 Broward 227Orange 266 Collier 61 Orange 262Hillsborough 369 Broward 62 Palm Beach 267

Whites Blacks: Hispanics:

Another way to consider geographic and racial/ethnic differences among the five counties with the largest rates of HIV/AIDS in FL in 2006 is to use “one in” statements

Let’s shift gears and consider the relationship between age and HIV cases among Broward County adults

Note: The percentage of newly reported cases has shown increases among the 20-29 age group over the past several years.

0

5

10

15

20

25

30

35

40

45

98 99 00 01 02 03 04 05 06 07Year of Report

Per

cen

t of

Ca

ses

13-19 20-29 30-39 40-49 50+

The emerging HIV epidemic among young adults is reflected in adult HIV cases rates among Broward County residents in 2007, particularly among young females

Males (N=580)

3

30 30

16

21

0

5

10

15

20

25

30

35

13-19 20-29 30-39 40-49 50+

Percent Percent

4

2624

16

30

0

5

10

15

20

25

30

35

13-19 20-29 30-39 40-49 50+

Females (N=243)

Now let’s address the role of exposure category on trends in Broward County HIV case rates among adults

0

100

200

300

400

500

600

98 99 00 01 02 03 04 05 06 07

Year of Report

Cas

es

MSM IDU MSM/IDU Hetero

Note: NIRs redistributed

Note: From 2001 – 2006, MSM HIV cases increased by 23%, while heterosexual male cases decreased by 5% and IDU male cases decreased 53%.

Among Broward County adult female HIV cases, the predominance of heterosexual exposure has been consistent in the past ten years, with the number of cases related to injecting drug use dropping slightly

0

50

100

150

200

250

300

350

400

98 99 00 01 02 03 04 05 06 07

Year of Report

Ca

se

s

IDU Hetero

Note: NIRs redistributed

The transition in the HIV/AIDS epidemic among adult males is illustrated when you compare AIDS and HIV cases identified in 2007 by mode of exposure

AIDS (N=407) HIV (N=580)

56%

28%

2%

8%

6%

MSM

IDU

MSM / IDU

Hetero

Other

73%

17%

6%

4%

Note: NIRs redistributed

Striking differences among Broward County living adult male HIV/AIDS cases can be seen in 2007 when adjusting for race and ethnicity

88%

3% 5%4%0%

White, non-HispanicN=(4,429)

30%

10%4%

56%0%

MSM IDU MSM/IDU Hetero Other**

Black, non-HispanicN=(3,666)

76%

8%4% 12%

0%

HispanicN=(1,457)

Heterosexual

MSM

IDU

Among Broward County adult female HIV/AIDS cases, the distribution of risk among whites differs from that among blacks and Hispanics, although heterosexual contact is the major risk for all races

33%

66%

1%

White, non-HispanicN=(467)

9%

90%

1%

IDU Hetero Other**

Black, non-HispanicN=(3,324)

15%

1%

84%

HispanicN=(299)

Heterosexual

IDU

Let’s move on to consider the relationship between area of residence and presumed living female and male HIV/AIDS cases. We will explore the story that ZIP code mapping provides.

Adult males and females living with HIV/AIDS tend to reside in highly concentrated locales in the central eastern areas of Broward County

It should be noted, however, that HIV/AIDS cases reside throughout Broward County

Thus, it is important to ensure geographically accessible core medical and support services

Let’s move from our focus on living HIV/AIDS cases to consider Broward County residents that had deaths related to HIV/AIDS in the last decade*

274210 215

282 265 294 308 285 294 314

459

677

0

200

400

600

800

95 96 97 98 99* 00 01 02 03 04 05 06

Year

Nu

mb

er o

f D

eath

s

Source: Office of Vital Statistics, Death Certificates*A change in coding of HIV/AIDS deaths from ICD-9 to ICD-10, effective in 1999, has resulted in an estimated increase of approximately 14% in the annual number of HIV/AIDS deaths.

Race/EthnicityNo. rate

White Male 64 14.5White Female 10 2.2Black Male 114 56.2Black Female 98 44.0Hispanic Male 16 8.9Hispanic Female 2 1.1Other*** 10 16.9TOTAL 314 17.9

2006

What population groups have unique service needs that must be addressed?

What HIV special populations’ needs are currently addressed with Part A funds?

MSM, including racial/ethnic minority MSM

Women, infants, children, and youth (WICY)

Recently incarcerated

PLWHAs also diagnosed with Hepatitis C, mental illness, and/or addictions

Including crystal meth users

Immigrants (including long term and recent)

Why are these populations specifically highlighted for Part A-funded services?

Group Rationale MSM, including

racial/ethnic minority Large portion of the HIV/AIDS epidemic in Broward County Recent studies indicate growing rates of HIV infection, especially

among adolescents and young adults

Women, infants, children, and youth (WICY)

Large portion of the HIV/AIDS epidemic in Broward County Effective treatment available to avoid perinatal transmission HIV+ youth likely to have multiple sexual partners

Recently incarcerated PLWHA

Growing rate of HIV+ detainees and prisoners infected while incarcerated

200 PLWHA released to Broward County in 2006

PLWHA also diagnosed with mental illness, and/or addictions (including crystal meth users)

Large portion of PLWHA have multiple morbid conditions that contribute to poor adherence to medications and appointment keeping, complicate the treatment regimen, are likely to contribute to loss to follow-up, and contribute to secondary HIV infections

Crystal meth use continues to grow and presents unique addictions treatment needs

PLWHA also diagnosed with STDs

Growing rates of STDs among PLWHA indicative of unprotected sexual contact, with multiple STDs over time

PLWHA infected with Hepatitis C

Complicates HIV treatment regimens, treatment for Hep C is highly expensive

Immigrant PLWHA Rapidly growing segment of the Broward County population, with unique linguistic, cultural, and social environmental challenges

What have we learned from Part A-sponsored special population studies?

Six studies have been completed Haitian, Hispanic, homeless, MSM, recently incarcerated, persons

out of care

Findings Increased training opportunities are needed for providers serving

these populations on culture and care seeking behaviors Training for special population groups is needed on availability and

costs of services Expand availability of multicultural and multilingual services Employ peers to access and retention in care Several service categories already employ peers More coordinated and deliberate scopes of work

Improve referrals made by case managers and primary care providers

Improve follow-up mechanisms to ensure completion of referrals Adopt better tracking, use of peers, and implement multi-

disciplinary care teams

Improve training regarding special populations by Mandatory, frequent training for providers on the culture of

these special populations Educate special population members regarding key points of

entry, increase information dissemination, train key informants/gate keepers on availability and costs of care

What else have we learned from Part A-sponsored special population studies?

Improve the HIV care continuum by Expanding multicultural and multilingual service provision,

program directives Exploring the latest strategies from the Office of Minority Health

on CLASS standards of care

Address Comprehensive Plan Goals 1- 4 Enhance Continuum of Care Ensure the availability of core services Eliminate disparities in access Develop strategies for PLWHAP who know their status and are

not in care

Are there any other lessons learned from Part A-sponsored special population studies?

Which funders pay for HIV care, how much do they pay, and are those funds

sufficient to meet demand for HIV services?

What are the sources and amounts of public funding for direct HIV services in Broward County for FY 2008?

Does not include $217,234 in Part A banked units and $932,497 in unreimbursed expenditures

How are public funds for HIV in Broward County distributed by direct service category?

25%

19%

4%2%4%1%10%3%

1%1%

1%1%

28%

Ambulatory/Outpt Medical

ADAP

Insurance Premiums & AICP

Mental Health & Subst Abuse TX

Oral Health

Other Core Medical Services

Case Management

Food Bank

Outreach

Transporation

Other Support Services

Hospital

Housing Assistance

What is the average number of core medical service “visits” received per Broward County resident receiving Ryan White Program-funded services in 2007?

Service Categories Broward County Health Department

Care Resource

CDTC North Broward Hospital District

Nova South-eastern

Univ

Poverello Center

South Broward Hospital District

Outpatient / Ambulatory Medical Care

10.3 6.8 4.2 4.1 0.0 0.0 7.9

Oral Health Care 3.2 0.0 9.1 0.0 4.0 0.0 0.0Home and Community-Based Health Services

2.6 0.0 0.0 0.0 0.0 0.0 0.0

Mental Health Services 2.7 0.0 3.3 0.0 0.0 0.0 11.6Medical Nutrition Therapy

0.0 3.9 0.0 0.0 0.0 0.0 0.0

Medical Case Management

6.1 6.8 17.2 2.7 0.0 0.0 6.7

Substance Abuse Services- Outpatient

0.0 0.0 2.1 0.0 0.0 0.0 0.0

Based on Calendar Year 2007 Ryan White Program Data Reports

In the Broward County Part A Program, what services

are funded, how many people are served, and what are their service utilization

characteristics?

What is the “inventory” of Part A-funded services?Agency Core Medical Services Non-Core Services

Ambu-latory

Medical

Pharma-ceuticals

Oral Health

Mental Health

Therapy

Substance Abuse

Treatment

Case Manage-

ment

Out-reach

Trans-portation

Legal Services

Food Bank

AIDS Healthcare Foundation                  Broward Community & Family Health Center

        Broward County Health Department          Broward House          Care Resource                Legal Aid Service of Broward County                  Minority Development & Empowerment

           

Mount Olive Development Corp                  North Broward Hospital District              Nova Southeast University                  Poverello Center                 South Broward Hospital District        Walgreens                  

Your handouts summarize: What core medical services were made

available with Ryan White HIV/AIDS Program funds in 2007?

What non-core services are made available with Ryan White HIV/AIDS Program funds in 2007?

How many HIV+ clients and affected family members received Ryan White HIV/AIDS Program-funded services in 2007?

What other Ryan White Program-funded services are provided to HIV+ Broward County residents?

The FL Part B program directly funds FL AIDS Drug Assistance Program AIDS Insurance Continuation Program

(AICP) Health insurance premium and co-payment

assistance

We are awaiting data from the Part B Program to assess trends in utilization and expenditures among Broward County HIV+ residents

Are high quality services being provided by Part A-

funded agencies?

What is the performance of Part A-funded subgrantees in achieving quality indicators?Service Category Indicator Year To

Date Report

Status of Indicator

Outpatient/Ambulatory Medical CareSlow/prevent clients disease progression (clients on HAART with a VL >400)

70% of clients decrease in viral load by at lease half a log from baseline or increase in CD4

71% Met

Maintain clients current medical condition (for clients on HAART with VL<400)

70% of clients have not greater than a confirmed half log increase in viral load or a 10% decrease in CD4 percent

93% Met

80% of clients maintain undetectable viral load or sustainable CD4 percent.

90% Met

Medical Case Management Improved ability to independently navigate and access needed services

80% of clients achieve care plan goals by designated target dates

90% Met

Increased access, retention, and adherence to primary medical care

80% of clients self-report adherence with their prescribed medication (data collection only)

95% Met

80% of new clients have outpatient medical visit scheduled to occur within 2 weeks of intake

97% Met

What is the performance of Part A-funded subgrantees in achieving quality indicators?

Service Category Indicator Year to Date

Report

Status of Indicator

AIDS Pharmaceutical AssistanceClients provided an opportunity to improve medication adherence

100% of clients accept or reject counseling as indicated by client’s signature

100% Met

Improve access to medication

80% of new prescriptions are filled and available within 24 hours or refilled and available within 48 hours

100% Met

Oral HealthSlow periodontal disease progression

50% of clients show a decrease in their PI (Plaque Index) score, bleeding index, or gingival index

50% Met

What is the performance of Part A-funded subgrantees in achieving quality indicators?

Service Category Indicator Year to Date

Report

Status of Indicator

Mental Health ServicesIncreased access, retention, and adherence to primary medical care

85% of clients referred to primary medical care kept initial appointment

95% Met

85% of clients remain enrolled in primary medical care at time of discharge (completion of initial treatment plan)

92% Met

Substance Abuse ServicesIncreased number of clients successfully completes their initial treatment plan

60% of clients complete their initial treatment plan by 2/28/08

85% Met

Increased access, retention, and adherence to primary medical care

60% of clients referred to medical care kept their initial appointment by 2/28/08

100% Met

Clients referred to medical care kept 75% of their appointments

96% Met

What is being done to continue to improve the quality of Part A-funded services?

A Part A quality management multi-year plan and annual work plan are being developed in collaboration with the Networks and the Quality Management Committee The National Quality Center supported TA to assist Part A

grantee staff in the development of its QM program and plan Supplemental data courses are being considered to enrich the

quality assessment process HAB quality measures are being considered and adopted,

starting with the Group 1 measures Quality improvement projects (QIPs) are being designed and

implemented by Networks and subgrantees to test improvements through rapid Plan-Do-Study-Act (PDSA) cycles

Feedback from consumers regarding quality of care and satisfaction with services also will be sought in the months to come

What are the unmet need for HIV services and service gaps in Broward County?

What steps are taken to prepare the data for estimating unmet need?1. Matching living HIV/AIDS cases and out of state (OOS) cases

with the following databases of active clients with HIV/AIDS services in CY 2007

a. ADAP, Medicaid, and HCMS data (new this year)

2. Access to some Electronic Lab Reporting (ELR), including Labcorp (N=15,154 cases in care in 2006, this should significantly increase for 2007)

3. Data entry of some paper labs reported to the state, including Quest and other labs (N=1,765 cases in care in 2006, similar for 2007)

4. HIV viral load and CD4 tests became reportable on 11/20/06, therefore more reportable HIV cases appear to be in care than previously

Okay, tell me more. What steps are taken to estimate unmet need?

1. Document the actual number of PLWHs and PLWAs reported and alive through 2007

2. Estimate number PLWHAs aware Assumes 100% of PLWAs are aware of their HIV serostatus Assumes that 90% of PLWHs are aware of their HIV serostatus

3. Calculate number of PLWAs and PLWHs in care in Broward County by collecting lab data in HARS for 2006

4. Match HARS data with ADAP, Medicaid, HCMS, the ELR database, and the paper-lab database to determine which cases had either an office visit, HIV/AIDS prescription, and/or CD4/viral load lab (as defined by HAB) A “hit” for each of these conditions indicates a case was “in

care” in 2007

4. Further adjustments account for persons in care via “other sources” (about 15%), where the FL surveillance program may not have received a lab report due to their limited/revised reporting laws in 2006 and 2007, and the slow implementation of the ELR (e.g., private MDs, the Veterans Administration, and Medicare/not Medicaid)

Adjustments vary each year and for each area, depending on the completeness of lab reporting and the estimates of care from these sources

5. Once in care estimates are calculated, subtract estimate in care from 100% to estimate the percentage NOT in care (unmet need)

6. Based on these steps, the FL DOH estimates that approximately 6,082 Broward County residents are aware that they are HIV positive but have NOT received specific primary medical care services

The FL DOH is now updating these figures for 2008

Wow, this is interesting! What are the next steps in estimating unmet need?

What are the plans of the State Part B Program for estimating unmet need? Continue to re-evaluate and fine-tune the entire step-by-step

process of calculating the unmet need to provide the most accurate area-specific data

Evaluate the completion of HARS data for use in more steps of this process of calculating unmet need

Once they have migrated from HARS to e-HARS later in 2008 and have more complete electronic lab reporting, they hope to be closer to the gold standard for estimating unmet need

It is unclear what their plans are for getting updated information from FL Medicaid

What factors must we consider in setting

priorities for Part A funds?

What does the HIV/AIDS Bureau require that Part A programs document about their setting priorities? According to the most recent grant guidance: Describe how the priority setting and allocation process was conducted, including

how the needs of those not in care and those from historically underserved populations were considered in this process

How PLWH/A were involved in the process and how their priorities are considered How data were used in the process to increase access to core medical services

and to reduce disparities in access to the EMAs/TGAs continuum of HIV/AIDS care

How changes and trends in HIVAIDS epidemiology data were used in the process How cost data were used by the Planning Council in making funding allocation

decisions How unmet need data were used by the Planning Council in making priority and

allocation decisions How the Planning Council’s process will address a prospective funding increase

or decrease in the Part A award

What current factors must we consider in setting priorities for Part A funds?

75% of Part A funds must be used for core medical services These funds include medical case management, a service category

whose definition is broad at this time No more than 25% of funds may be used for non-core services

These services must directly support the provision of core medical services

The Ryan White HIV/AIDS Program is the payer of last resort Clients must be assessed for eligibility for other programs before Ryan

White-funded services are provided Funds for housing services are limited by the Ryan White

HIV/AIDS Program under a recent program guidance Significant changes in Part A funding priorities may result in

disruption in continuity of care for PLWHAP

What is on the horizon that we must consider in setting priorities for Part A funds?

HAB is finalizing their plans for implementation of the Part A Severity of Need (SON) Index Its potential impact on Broward County and other EMAs and

TGAs is unclear

The Ryan White HIV/AIDS Treatment Act will sunset in 2010 Planned changes in the statute are in the earliest stages of

development by Congressional staff and national advocacy groups

Continued downturns in the State and local economy are likely to continue to impact public funding available for HIV/AIDS

Questions and Discussion