Improving Medication Adherence through Walgreens HIV-Specialized Pharmacies

By: Glen Pietrandoni, R.Ph., AAHIVP, senior manager, virology, Walgreens

What would it take for an HIV patient to achieve their best health and an improved quality of life? Could we…perhaps, realize an AIDS-free world? Walgreens studies show some of the ways in which better outcomes can be achieved.

Medication adherence is vital to maintaining optimal health for patients with the HIV virus and could contribute to suppressed viral loads which make the virus less likely to be transmittable. Walgreens HIV-specialized pharmacies are committed to keeping patients adherent and being a part of the solution to end AIDS.

A recent Walgreens study[1]  of more than 15,000 HIV patients showed that those who received care through one of its HIV-specialized pharmacies were significantly more adherent to their medication (74 percent) than those receiving care through a traditional, non-specialized Walgreens pharmacy (69 percent).

In examining the differences in medication adherence for HIV patients with a comorbid condition using Walgreens HIV-specialized pharmacies and those using other Walgreens retail pharmacies[2], researchers confirmed that HIV patients utilizing the specialized pharmacies were more adherent to their anti-retroviral and comorbid therapies.

This includes the nearly 30 percent of patients living with HIV and serious mental illness, a population which often experiences challenges associated with willingness and ability to take medication as prescribed such.  Of the HIV patients with serious mental illness who exclusively used HIV-specialized pharmacies, 33 percent were adherent to their anti-retroviral therapy versus 19 percent for HIV patients with serious mental illness using other Walgreens retail pharmacies.

Patients with other comorbid conditions, including hypertension and high cholesterol, also demonstrate increased adherence when using Walgreens HIV-specialized pharmacies.

So what’s our secret? It’s no secret at all. Since the beginning of the epidemic, more than 30 years ago, our pharmacists have been focused on education, counseling, testing and treatment. In the more than 700 U.S. communities impacted by HIV, our pharmacists have established deep relationships with local patients. Beyond dispensing medication, our HIV-specialized pharmacists are trained to provide confidential wellness consultations, coordinate care and benefits with physicians and insurance providers, and to help patients access financial support programs to reduce medication costs. Above all, medication adherence remains our primary objective because we know that taking the right medication at the right time is key to improving health outcomes.

Walgreens recently announced we’re leveraging the expertise of our pharmacists to collaborate with the Centers for Disease Control and Prevention (CDC) and University of North Texas (UNT) College of Pharmacy to develop and evaluate a model of HIV patient-centered care through a national project aimed at advancing clinical integration and medication therapy management.

According to the CDC, only 25 percent of Americans with HIV have the virus under control. Our more than 2,000 HIV-specialized pharmacists can plan an important role in working with patients and providers to help improve the population’s health and help make an AIDS-free world a reality.

________________


1.  Murphy P, Cocohoba J, Tang M, et al. Impact of HIV-specialized pharmacies on adherence and persistence with antiretroviral therapy. AIDS PatientCare and STDs, Volume 26, Number 9, 2012.
 2. Dr Janeen DuChane PhD,Michael Taitel PhD,Leonard Fensterheim MPH,Bobby Clark PhD,John Hou PhD,Julia Zhu MPH,Jenny Jiang MS,Adam Cannon MPH,Glen Pietrandoni RPh
The Lancet - 3 November 2013 ( Vol. 382, Page S3 )
DOI: 10.1016/S0140-6736(13)62251-5

Is the RWCA dead?

By: 

Eddie Hamilton

Director

ADAP Educational Initiative

There has been a lot of chatter and disputes in the HIV/AIDS advocacy world regarding the Ryan White Program Care Act (RWCA) expiration on September 30, 2013. Granted, there are numerous valid arguments for and against Ryan White Program RWCA reauthorization and for reprioritization. There are inherent dangers by acting now and also waiting until 2015 until the numerous impacts of the ACA are known. With the ACA enrollment issues, it may be even longer than 2015 before all of the impacts are fully understood.

However, I truly believe that there are two bigger and dangerous elephants in the room that needs to be addressed by all nationwide advocacy groups.

The first is sequestration where organizations are already feeling tremendous negative impacts in service delivery and those impacts will only get worse. There is not much being said publically about Sequestration 2.0.

The second and more immediate issue is a much bigger problem. Upon further research from credible government sources, I have found that it is very possible that the Ryan White Program no longer legally exists due to sloppy appropriations writing and Washington gridlock.

Many HIV/ AIDS organizations are relying on the argument that “Even though there is not a 'sunset' provision, the RWCA program is just fine because there is money being appropriated for the program.”

I had to question that argument because it was too easy of an answer to such an important question.

Question: Is the RWCA dead? Short Answer: In other words, Maybe no but most likely so.

Long Answer: There are a few different sources of information regarding “Unauthorized Appropriations” primarily from the U. S. Government Accountability Office (GAO).  An “Unauthorized Appropriation” is where Congress has allocated money for a program whose primary authorization has since expired that could be subject to a point of order within either chamber that could possibly kill the bill.

In this toxic political atmosphere, anything can happen as it only takes one representative from either chamber to raise a point of order. In the case of the Ryan White program, the authorization had expired on 9/30/2013. The Program has already hit the list for Unauthorized Appropriations.

An authorization bill is known as an enabling statute or a program’s “organic’ authority that articulates a program parameters and an agencies’ mission within in a program. In usual course, no funds can be expended until an actual separate dedicated appropriation authority with specific language directing programs goals and requirements has been initiated.

However, when an appropriations authorization has expired, the language within a continuing resolution or appropriations bill is critical when making the determination of whether the appropriation has the force of a continuing reauthorization of its’ “organic “ authority.

In other words, unless an appropriations bill contains the explicit language reauthorizing the Ryan White Program, the “organic” authority laying out the priorities is still expired and therefore, dead. A catch-all sloppy appropriation to an agency (i.e. HRSA) on January 13th (the new appropriation date) is and will be insufficient without the adequate instructions for the Ryan White Program because there is no valid authorization on the books. The last CR that was passed to stop the shutdown does not explicitly lay out any new authority for the RWCA.

Therefore, in my opinion, the RWCA is legally dead!

Do we have a Plan B in the event the states cannot issue new operating rules (based on ACA or Medicaid expansion) based on the fact that the RWCA is dead?

I also argue at a bare minimum that the any state law and rules, Request for Proposals, bids and contracts constructed and awarded listing the RWCA 2009 as their source of authority, immediately become inoperative when the entity spends the last dollar authorized in their budgets (prior to 9/30/2013) for FY 2013 because they refer to RWCA 2009 as their source of authority. Rebate monies will not count towards this authority as this money comes from the pharmaceutical companies and not the Federal Government.

As a result, I would highly encourage that the entire HIV advocacy community do some appropriate research before coming out with blanket statements on such a vital program.

Various national HIV advocacy groups who are making assumptions that the status quo will be maintained are not viable options. It is imperative that both of these issues be addressed as our lives depend on it!   Hollow words of advocacy no longer cut it anymore.

References:

• GAO-04-2618P Principles of Appropriations Law, U.S. Government Accountability Office (2004), p.69-71, http://www.gao.gov/assets/210/202437.pdf
• CBO Testimony (Douglas Holtz Eakin) , Unauthorized Resolutions and Senate Resolution 173, Congressional Budget Office, http://www.cbo.gov/sites/default/files/cbofiles/ftpdocs/44xx/doc4400/07-09-uaea.pdf
• GAO-06-382SP Principles of Appropriations Law, U.S. Government Accountability Office (2006), p.32-36, http://www.gao.gov/assets/210/202819.pdf
• Unauthorized Appropriations and Expiring Resolutions, Congressional Budget Office (Jan. 15, 2013) Page 24.
• Analysis H. R. 2775 Continuing Resolution for 2014, http://www.gop.gov/bill/113/1/hr2775-senateamendment

Survey Reveals Sequestration Impacting AIDS Care while Number of Patients Increase

By: 
Carl Schmid
Deputy Executive Director
The AIDS Institute

A survey conducted by The AIDS Institute found that HIV care in the United States is suffering as a result of sequestration and cuts in the Budget Control Act, while the number of AIDS patients is increasing. One hundred and thirty-one AIDS organizations in 29 states and the District of Columbia took the survey on the impact of these cuts, and the findings were troublesome.

In the last year, domestic HIV/AIDS programs have been cut nearly $380 million. As a result of these and other cuts 85% of the organizations surveyed experienced funding reductions. At the same time, 79% experienced an increase in clients.

As a result of cuts, 52% of survey respondents who detailed the impact of their lost funding indicated they have had to reduce staff, while 38% had to cut prevention education programs, and 22% cut back on HIV testing.  At least one organization had to close down completely.

Staff reductions impacted case management, administrative and clinical staff the hardest, and researchers, educators, and peer advocates were also cut from organizations. The majority of responding organizations had to lay off three to five staff members due to these cuts.

According to survey respondents, the funding reductions have resulted in cuts to patient services, including longer times between appointments and increased wait times at the clinic.  Some have even stopped seeing certain patients.

During the same period , the number of clients was increasing. The average increase in clients since January 1, 2012 was 18% according to surveyed organizations, compared to the average reported reduction in funding of 17%.

This survey demonstrates that the severe cuts enacted by the Budget Control Act are having real, negative consequences on HIV/AIDS organizations and their patients across the nation.  These budget cuts, coupled with an increasing number of HIV patients, have impacted their ability to provide timely, quality care and prevent future HIV infections.  If these cuts continue, they will certainly lead to increased infections, more deaths, and higher healthcare costs.

At a time when we know how to reduce an infectious disease such as HIV through prevention and treatment, and we have a National HIV/AIDS Strategy grounded in science, now is not the time to reverse the substantial progress that has been made.

There are nearly 50,000 new infections each year in the U.S. and only one third of the nearly 1.2 million people with HIV in the US have been prescribed antiretroviral treatment.

We have a long way to go before we can realize the dream of an AIDS-free generation.  We urge the Congress and the President to reverse the cuts caused by sequestration and adequately fund critical public health programs, including those that prevent HIV and provide for care and treatment for people living with HIV.

Negotiations going on right now in the Congress on the budget will directly impact if these cuts continue in the future.  The AIDS Institute hopes that these survey results, which have been forwarded to all members of congress, will help convince budget conferees that these cuts to domestic HIV programs must end.

The full survey results can be found at: http://bit.ly/1hwV52p.

The Affordable Care Act Crystal Ball

The Patient Protection and Affordable Care Act (PPACA), or the Affordable Care Act (ACA) – also known as "Obamacare" – is supposed to see most of the law’s major provisions phased in by January 2014, with other provisions phased in by 2020. The ACA will have numerous implications generally on the United State’s health care delivery system, but more specifically on the supports and services afforded to people living with HIV-infection, or viral Hepatitis. What’s more, ongoing Medicaid expansion and the implementation of insurance exchanges will also impact nearly all healthcare providers, as well as their patients.

President Obama signs the Affordable Care Act into law on March 23, 2010.

As the full implementation of the law fast approaches, it seems to be raising more questions than providing answers. The roll-out hasn't been without its share of bumps, either. Nonetheless, many public health advocates see a lot of "positive" (no pun intended) changes coming with respect to the delivery of health care supports and services for individuals living with HIV/AIDS, as well as Viral Hepatitis.

With so many changes forthcoming under the ACA, there is no crystal ball that will show what is in store for the nation's health care system. For starters, at least pre-existing conditions will no longer prevent people from gaining access to insurance, and thus access to care. Of particular interest to stakeholders advocating for a robust AIDS Drug Assistance Program (ADAP), an ACA provision allows ADAP to count toward the true-out-of-pocket expenses (TrOOP) under the Medicare Part D program is also welcome news.

Antonio J. Carrion, PharmD, MPH, who is an Assistant Professor of Pharmacy Practice at Florida A&M University's College of Pharmacy and Pharmaceutical Services (COPPS), has outlined some of these changes in his recent blog. In fact, Carrion's analysis dispels the myth that the Ryan White CARE Act -- including ADAP -- is going away under the ACA.

The blog reads, in part: "Because of the new health care law, ADAP benefits will be considered as contributions toward Medicare Part D’s True Out of Pocket Spending Limit (TrOOP). What does that mean? ADAP clients who are Medicare Part D enrollees will be able to move more quickly through the “donut hole.” Before the ACA, this transition was very difficult for ADAP enrollees to complete" (Florida/Caribbean AETC, 10/30/13).

Another excellent resource on this topic was made available by the National Alliance of State & Territorial AIDS Directors (NASTAD), which can be downloaded here.

TheBodyPro also recently published an excellent interview with Dr. Michael Saag and Dr. Michael Wong, whereby they each shared their perspective about the upcoming ACA implementation. The article can be viewed online, here.

In the interview when asked if the law was a good or bad thing for HIV patient care, Dr. Saag pretty much summed-up the advocacy community's sentiment: "I think, overall, it's a good thing. Number one, it will put, generally speaking, more people into insurance plans, be it Medicaid or some other kind of plan. And it creates more options. In essence, there's more money flowing to clinics and flowing to cover the costs of medications, so it will give some relief to the Ryan White CARE Plan -- and we'll get back to that, I'm sure, later. But the bottom line is, it's a good thing" (TheBodyPro, 08/22/13).

Unfortunately, one other area that also tends to draw a common theme is the concern over the ACA's uneven implementation nationwide. Whereas some states, like California, Massachusetts, and New York will accept the Medicaid expansion provisions included under the law, other states, such as Alabama -- which has the largest ADAP waiting list creeping up on nearly 200 patients statewide -- plans to decline the Medicaid expansion. The South appears to be disproportionately impacted, again.

Patients, advocates, providers and healthcare professionals alike would be well-advised to obtain the latest information about the ACA, its implementation, and how it might affect the healthcare delivery for individuals living with HIV/AIDS, and/or Viral Hepatitis. One thing is for certain, it remains very fluid.

To that end, the ADAP Advocacy Association (aaa+) -- in partnership with the Community Access National Network (CANN) Great Lakes ADA Center, and HealthHIV -- is hosting an educational webinar on Wednesday, November 6th, 2013. The webinar, themed "Impact of the Affordable Care Act, Medicaid Expansion & Insurance Exchanges on HIV/AIDS and Viral Hepatitis Services," will be open to all HIV/AIDS and Virtal Hepatitis stakeholders nationwide. It is free, so there is no excuse not to participate and learn more about what changes are coming...

Learn More about the Impact of the Affordable Care Act, Medicaid Expansion & Insurance Exchanges on HIV/AIDS and Viral Hepatitis Services

SANDBOX STANDOFF: Day 11

It has now been 11 DAYS since the government closed its doors on the American people because the politicians in Washington, DC are more concerned with scoring political points and posturing on the cable news programs rather than collectively doing their job; in the meantime, people living with HIV/AIDS -- and many other underserved populations -- scramble to make ends meet, including how the shutdown is impacting their daily lives. Some political pundits have described the current partisan rancor on Capitol Hill as nothing less than a bunch of cranky children fighting over a sandbox. The ADAP Advocacy Association (aaa+) agrees.

The negative consequences of the current political stalemate between the President, House Republicans (especially the Tea Party element of the GOP) and Senate Democrats cannot be under-estimated, or maybe even truly comprehended without digging deeper. But recent new reports provide ample evidence that the budget debacle is already raging havoc on the nation's public health system.

The Washington Blade reported that the shutdown will prevent the Health Resources & Services Administration (HRSA) from properly monitoring grants administered under the Ryan White CARE Act -- including the AIDS Drug Assistance Programs. And after the debacle with the Florida ADAP several years ago, there is plenty of reason for advocates to be concerned over the loss of federal oversight. The impasse also will halt the seasonal influenza program. It even means potential delays in Food and Drug Administration (FDA) approvals of new drugs, as well as delays in clinical trials at the National Institutes of Health.

The online publication, Medical Economics, has made available a listing of healthcare agencies being affected by the shutdown.

With so much of the blame being placed at the feet of the Tea Party, it is rather ironic that one of the nation's leading coffee retailers has entered the fray. On October 10th, Starbucks launched its "Come Together" campaign designed "to harness the sentiment many of us are feeling — a growing concern about the lack of progress from our Congressional leadership to work together to resolve the business of the American people." The company is encouraging people to sign an online petition at www.ComeTogetherPetition.com.

All ADAP stakeholders -- especially people living with HIV-infection -- are encouraged to contact their elected federal lawmakers in Washington and urge them to end the government shutdown. Lives are at stake!

• Find Your Senators & Representative: CLICK HERE

Medicaid Reform and a (New) New York State of Mind: Housing Is Healthcare!

By:

Christine Rodriguez, Program Associate

National Advocacy & Organizing

Housing Works

A few short days from the October 1 marketplace openings, and uncertainty and confusion linger in discussions around healthcare and implementation of the Affordable Care Act (ACA). Policy experts, providers, and consumers alike speculate, and it seems there will be more questions than answers until we at last see how reforms play out across the country.

The HIV/AIDS community knows that health reform, both affectionately and derisively referred to as “Obamacare,” certainly benefits people living with HIV/AIDS (PLWHA) and those at risk; we absolutely need to spread the word far and wide. But let us also be sure to remember the existing tools in our arsenal that can maximize those benefits. One such tool, often detrimentally omitted from conversations about health care, is unequivocally an effective, cost-saving intervention – HOUSING.

Housing is Healthcare!, Housing is Prevention!, or Housing Saves Lives!, aren’t rallying cries that Housing Works advocates causally toss into articles and testimony or banners and protest signs simply out of habit after nearly 25 years of advocacy and activism. The health and cost-related benefits conferred by access to safe, affordable housing are well demonstrated by research, both for PLWHA and to prevent transmission among HIV-negative homeless populations.

Housing Works' Housing is Healthcare Rally

For marginalized communities – whether HIV-positive, living with mental illness or substance abuse issues, or others unstably housed – having housing means better holistic health. Even without the research this is common sense, right? Housing means having a place to store medications and healthy food, get a full night’s sleep, and often relief from the fear of violence. It means an address for job applications, avoiding hypothermia in the winter, and a safe space to engage with family, friends, and lovers. It means treatment adherence, safer sex, and everything taken for granted by many of us every day.

New York State, leading by example, is not taking housing for granted in its current efforts to improve the healthcare system. Governor Cuomo is proving to be a national leader in the effort to effectively utilize the Medicaid program and underscore that housing IS healthcare. New York’s Medicaid Redesign Team (MRT) was initiated in 2011, and early on an Affordable Housing work group was deemed critical and included in the process. Gov. Cuomo, thanks to MRT’s efforts, recently announced a $4.6 billion savings over the past year alone. From those savings, the Supportive Housing Initiative will be allocated $36.4 million in capital funds, $30.6 million in rental/service subsidies, and $24 million for critical new pilot programs – a total of $91 million.

New opportunities require new ways of thinking; innovation is necessary to address the complex and diverse health concerns of PLWHA, especially as the population ages. The MRT allocation for pilot housing programs begins to address this – one of several critical projects being the “Health Home HIV+ Rental Assistance Project.” Much to our collective chagrin, it is not uncommon for official policy to be somewhat disconnected from lived reality. Under current HIV/AIDS Services Administration regulations in New York City, instead of providing housing to prevent exacerbating illness, one must already have an AIDS diagnosis or advanced HIV-illness to even qualify for such services. This pilot project creates access to housing for HIV-positive individuals otherwise medically ineligible for existing programs, finally prioritizing true preventive care PLWHA.

Jason Helgerson, New York’s Medicaid Director, explained it plain and simple – that finally “[t]here is a growing national recognition that addressing the social determinants of health is critical for improving health while reducing health care costs. This is most evident in the matter of housing.” This recognition, coupled with financial commitment, is essential for homeless communities and PLWHA. States seeking to maximize Medicaid dollars – whether or not they opt for expansion – should consider adopting or (dare I say) expanding upon this model of redesign, reinvestment, and innovation. The historic opportunities created by ACA reforms present a crucial time to take full advantage of evidence-based interventions, like housing, to truly commit to realizing the end of AIDS.

Combatting HIV/HCV Co-Infection

Earlier this year on March 19th when the ADAP Advocacy Association and Community Access National Network (CANN) announced that they were co-hosting an HIV/HCV Co-Infection ADAP Summit, Bill Arnold said, "CANN has long been recognized for its commitment to promoting patient access to timely care and treatment, and we need to educate consumers, community partners, as well as congressional staff here in Washington, DC about the fastest growing public health epidemic since AIDS: Viral Hepatitis C infection. We have learned many valuable lessons from the HIV/AIDS advocacy community over the last three decades, and CANN will now apply those lessons to ensuring access to effective HCV treatments."

The Summit convened in Las Vegas, NV on April 25th-26th and various stakeholder groups participated in the conversation (only the federal government agencies were not represented because Sequestration restricted agency travel budgets). By all accounts the Summit achieved the objective laid out in Arnold's statement, but unfortunately there are some very sobering statistics behind the need for the event being held in the first place, among them:

• About 25% of people infected with HIV in the U.S. are also infected with HCV.
• About 80% of injection drug users (IDUs) with HIV infection also have HCV.
• HIV/HCV co-infection more than triples the risk for liver disease, liver failure, and liver-related death from HCV.
• Compared with other age groups, a greater proportion (about 1 in 33) of people aged 46–64 years are infected with HCV.
• Chronic HCV is often "silent," and many people can have the infection for 20 to 30 years without having symptoms or feeling sick.
• In the U.S., HCV is twice as prevalent among blacks as among whites.
• New data suggest that sexual transmission of HCV between MSM living with HIV occurs more commonly than previously believed and that sexual transmission can occur undetected between HIV-infected MSM in the absence of injection drug use.[1]

Some public health experts predict that the HIV/AIDS epidemic of the 1980s will pale in comparison to what is likely to happen with the onslaught of new HCV infections. Fortunately, there is a cure for HCV infection.

Several pharmaceutical companies -- including AbbVie, Boehringer-Ingelheim, Bristol-Myers Squibb, Genentech, Gilead Sciences, GlaxoSmithKline, Janssen Therapeutics, Merck, and Vertex -- have numerous new HCV treatments on the market, or in the pipeline, which are much improved over the initial treatments that won approval by the U.S. Food & Drug Administration (FDA). The marvels of modern medicine means that many of these new treatments come with far fewer side effects, better resistance profiles, and in some cases, patients will be on the treatments for less time before achieving optimal results. But at what cost?

According to the Fair Pricing Coalition (FPC), FDA-approved HCV treatments have been extremely expensive, coupled with double digit price increases accompanying some of these drugs since 2011. The FPC has released statements on the cost of the new drugs. The debate over drug pricing will surely continue to ignite emotions once the newer treatments gain FDA approval, and at a much higher cost. In all fairness to the pharmaceutical companies, they have also expanded access...or plan to expand access...to their patient assistance and co-payment assistance programs.

The aforementioned discussion led to what amounted to be the most interesting idea accepted at the Summit: A Pharmaceutical Industry Access to Care Report Card. The "report card" idea was among the recommendations included in the HIV/HCV Co-Infection ADAP Summit Final Report, which was released last week and included both short-term and long-term recommendations.

The short-term recommendations included:

1. Identify national coalitions (i.e., Federal AIDS Policy Partnership, National ADAP Working Group, HCV Coalition for the Cure) and their respective partners, and develop strategic objectives to advance the treatment of HIV/HCV Co-Infection, as well as access to them.
2. Develop universal messaging campaign surrounding access to care under the AIDS Drug Assistance Programs, using “success stories” from co-infected patients. (Editor’s Note: Some of this is already being done by the Campaign to End AIDS).
3. Analyze existing ADAPs covering HCV treatments to determine the pros/cons of recommending other ADAPs covering HCV treatments for co-infected patients. Using a mathematical model, establish guidelines and tiers for co-infected treatment options.
4. Determine feasibility of ADAPs purchasing insurance continuation plans that cover HCV treatments.
5. Ensure that ACA Essential Health Benefits include benchmarks for treatment guidelines, as well as sufficient appeals process.
6. Establish emerging treatment guidelines using existing medical data and consumer experience. It is premature to evaluate “gold standard” for treatment because too many HCV treatments are in the development pipeline, including some already being evaluated by the Food & Drug Administration (FDA).
7. Develop “Fact Sheets” on existing plans for treatment for co-infected patients, including “navigator” information and resources.
8. Expand testing.

The long-term recommendations included:

1. Commission study to identify the potential treatment gaps for HIV/HCV Co-Infection.
2. Develop pharmaceutical industry “Report Card” to evaluate access to timely and appropriate care of people living with HIV/HCV Co-Infection; grading new should take into consideration drug pricing, patient assistance programs, drug rebates (if available), community education/participation initiatives, and accessibility of user-friendly product information (aside from what is legally required by the FDA).
3. Implement “Common Portal” for ADAP.
4. Evaluate adding a new Part under the Ryan White CARE Act, specifically addressing HIV/HCV Co-Infection modeling after the Minority AIDS Initiative.

Whereas the Summit's Final Report is not necessary endorsed by the HIV/HCV Co-Infection ADAP Summit’s sponsors, panelists or participating organizations, it does represent a significant step in ensuring that the effort to combat HCV infections learns from the ongoing struggle against HIV infections.

CLICK HERE to download the HIV/HCV Co-Infection ADAP Summit Final Report.

---

[1] Centers for Disease Control & Prevention, HIV and Viral Hepatitis Fact Sheet, November 2011.

Better Linkages to Healthcare Needed for Ex-Offenders

For the past few decades, the direction and focus of corrections policy has been impacted by scholarly research, evidence-based practices, and a focus on improved outcomes in public safety and reduced recidivism.

On the correctional healthcare front, better linkages to community care for ex-offenders to improve continuity of care and personal and public health outcomes have grown considerably.  Costs associated with providing constitutionally mandated healthcare for an increasingly aging inmate population with prevalence rates of chronic diseases often 3 or 4 times the rate seen in the general public reach as high as $10 billion a year.

The national economic slump and sluggish recovery caused state and local governments to adapt to cuts in funding and resources. As a result, elected officials, voters and of course corrections professionals also had to adapt by setting their priorities, identifying efficiencies, improving outcomes and reducing duplication and redundancy of services.  This trend in reductions in correctional budgets has offered a unique opportunity to rethink how we “do” corrections and correctional healthcare.  This has opened a door of opportunity to re-imagine how to better serve inmate populations living with HIV/AIDS.

More than 2.5 million individuals are correctional inmates in the United States.  1 out of 100 adults are behind bars in our country. Over 700,000 prisoners return to the community every year.

Each year, an estimated 1 in 7 persons living with HIV pass through a correctional facility. A reported 20,093 inmates with HIV/AIDS were in custody in state or federal prison at year end 2010. These figures do not include numbers from local/county jail facilities.

On any given day, one-third of America’s inmates are in jails, but nine million individuals pass through jails in any given year. A jail is a facility in which the inmate is held for a shorter period of time, serving a sentence that is usually less than 1 year, or awaiting transfer to other facilities after conviction.  Inmates remain in jails for much shorter stays than in prisons, which results in significantly greater turnover in jail populations.

The costs, both in terms of human suffering and quality of life as well as in impact on strained public resources, is immense:

• Future treatment for the 40,000 people infected with HIV in the United States every year will cost $12.1 billion annually.
• The drug mix that an HIV patient must take can cost between $15,000 to $30,000 a year. The average price is about $20,000.
• Discontinuation of antiretroviral therapy (ART) that is often associated with poor linkages to care for formerly incarcerated individuals returning home to their communities may result in viral rebound, immune decompensation, and clinical progression, resulting in higher costs of care and treatment

These circumstances pose important opportunities and challenges for arranging for HIV testing in jails and linking inmates living with HIV/AIDS with services both while they are incarcerated and after release.

Assisting more individuals in these high-risk jail populations represents an important public health opportunity; learning their HIV status, assuring that they are linked to any needed care, and tracking and reporting outcomes are key factors to success.

Recent demonstration projects funded by the Centers for Disease Control and Prevention (CDC) establish the feasibility of rapid HIV testing in jail settings and its acceptability to inmates and jail administrators.  Models for linking HIV-positive jail inmates to HIV care while incarcerated and upon release to the community have been cropping up all over the country, and important issues for crafting the models have become apparent:

• Linkage procedures vary across different jail systems and jurisdictions;
• Coordination among project partners (e.g., jails, community medical providers) is essential to any success;
• Secure and innovative technology and mechanisms for linkage need to be in place;
• Scopes of services need to be well defined;
• Understanding inmate characteristics, eligibility for public services and holistic needs (not just medical diagnoses, lab results, CD4 count, but also criminogenic needs profile based on validated needs assessment tools);
• Secure, HIPAA-compliant and appropriate information sharing needs have to be well-defined; and 
• Administration and implementation issues need to be addressed

A critically important benefit of focusing on not only linkages to care for HIV/AIDS treatment and services, but the holistic needs of offenders and ex-offender is improved public safety and fewer individuals returning to incarceration.  Closely following evidence-based practices and providing coordinated linkages to appropriate levels and types of care and services has a proven impact on reducing recidivism. The extent to which these principles are followed and treatment integrity is practiced correlates highly with client outcomes as measured by recidivism.

The National Council on Crime and Delinquency in 2006 stated, “Offenders returning to their communities bring with them a host of problems including physical and mental health and substance abuse issues, literacy, few job skills, and minimal work history. These deficits contribute directly to continuing patterns of crime, and unless they are addressed in a comprehensive and consistent fashion-both in the institutions and in the community-parolees will continue to fail.”

Underscoring the nexus of public health, public safety and taxpayer value benefits of improved linkages to care is a vital component of “selling” this approach to elected officials, voters and critical decision makers.

States across the country like Texas, North Carolina, Ohio and California are taking the lead in addressing the decades-long problems they have struggled with in corrections.  Applying evidence-based approaches, connecting offenders with appropriate levels of service and supervision, and being able to monitor, measure and report on outcomes in a timely fashion using secure, cutting edge technology is the future of Corrections.

RECOMMENDATIONS:
Linkage programs need to be tailored to fit the characteristics, culture and policies/practices of particular jails and jurisdictions including their inmate populations. Linkage models vary. Linkage to care may take place within the jail, from jail to prison or, upon release, from jail to the community. Successful strategies for linking HIV-infected inmates to outside services may include:

• Face-to-Face discharge planning (Correctional Healthcare Physicians, Nurses, or dedicated Discharge Case Planners);
• Making every effort to obtain accurate information on release dates;
• Making appointments for releasees with community-based service providers; and
• Meeting releasees at the gate (“warm hand-off”) and transporting them to their initial critical   service appointments.

Some considerations for what types and levels of services should linkage models offer:

• Should programs focus on just the diagnosis and the initial linkage to post-release care and treatment (i.e., making the linkage and getting people to their first appointments)?
• Should programs have the broader goal of making and maintaining the linkage to care and treatment for an extended period after release?
• Should programs be ambitious and comprehensive, addressing a wider range of needs such as housing, employment and family stability?
• Should programs provide full-scale case management or just focus on referrals?

Author:

David Manson

David Manson is Product Manager for Ramsell Correctional Application (RCA) at Ramsell Corporation (www.ramsellcorp.com). RCA is a web based system that solves the problem of coordination of care and benefits for ex-offenders who are in need of any of a number of different paths of assistance to successful reentry into society from state and city/county correctional facilities with the available programs and resources within a community.

David presented at the ADAP Advocacy Association's 2012 and 2013 Annual Conferences in Washington, DC. This year's presentation is available online.

Is it time to Reauthorize the Ryan White CARE Act?

On September 30th, some HIV/AIDS advocates have pontificated that the world will end with respect to supports and services afforded to people living with HIV/AIDS...but that simply isn't true. That is the date when the current Ryan White CARE Act -- which was reauthorized by Congress in 2009 as the "Ryan White HIV/AIDS Treatment Extension Act" -- is set to expire. Maybe federal lawmakers anticipated four years ago that the partisan gridlock would only worsen by today, but interestingly enough the law doesn't include language that is fairly common in reauthorizing legislation: a sunset provision.

What does that mean? In legislative terms, it means that the current law is likely (as in, very likely) to continue under the current law's framework and structure -- including appropriation levels. Putting the hysteria aside, it is nonetheless important for Ryan White stakeholders remain engaged to ensure that the "payor of last resort" safety net that the law provides remains intact, and robust funding accompanies it. Fortunately, coalitions such as the Ryan White Work Group, ADAP Coalition and the National ADAP Working Group (all of which the ADAP Advocacy Association is a member organization), are working to monitor this situation and propose meaningful advocacy strategies.

Of particular interest to most Ryan White stakeholders is the fate of the current law's "Hold Harmless" provision, which was added during a previous reauthorization. The Hold Harmless provision initially continued the previous 95% rate for the first two fiscal years, but increased to 100% of fiscal year 2010 funding for each of the fiscal years 2011 and 2012. For fiscal year 2013, the amount will be 92.5% of the previous fiscal year’s grant. This hold harmless continues to apply to both Part A and Part B grants.[1]

On July 16th, Rep. Frank Pallone (D-NJ) introduced H.R.2699. The legislation would "extend the hold harmless provisions of the Ryan White HIV/AIDS Program pending reauthorization of the overall program." The legislation has no co-sponsors and it also reportedly doesn't have the support of the majority staff on the House Committee on Energy & Commerce, Subcommittee on Health. In other words, Rep. Pallone's legislation probably isn't going anywhere in the Congress.

According to Bill McColl of AIDS United and Co-Chair of the Ryan White Work Group, "We are aware that hold harmless will be a major issue for many people in the HIV community and will be trying to develop points of agreement as the Congress works on a continuing resolution or appropriations bill in FY 2014."

Meanwhile, ADAPs have already experienced a major systemic shock between the changes in the funding formula, and the pending cuts from Sequestration. Data from the Health Resources & Services Administration (HRSA) demonstrates the changes between this year's number with last year's totals.

(Editor's Note: The totals are calculated from the actual reduction from last year per locality after subtracting accounting adjustments and carryovers from prior years). The numbers paint a picture that should keep Ryan White stakeholders on the edge of their seats.

PART A FUNDING: (Avg. Cut  7.12%)
The Part A spreadsheet encompasses all Part A areas in the country. This section of funding had experienced a few changes, including:
1) There was a new TGA in the Part A funding stream (i.e., Columbus, Ohio) , As a result, the EMA/TGA pie had to be divided up with one more additional locality.
2) Sequester had played a varying effect per locality as reflected by the percentages.
3) Shifting trends in epidemiology and formulas towards the South; therefore the cuts were somewhat cushioned and less drastic.

PART B FUNDING: (Avg. Cut  5.61%) 
The Part B Basic Earmark spreadsheet is the bulk (90-95%) of the Federal Grant to the States for ADAPs.
1) The Part B Grant for Medical Services has not been broken out yet as that will take some time to separate and compile that data as the Part B grants are multi-layered.
2) Again, Sequester had played a big factor in the reduction but the Southern States were saved the brunt of the Sequester because of a new formula change.

Eddie Hamilton, who heads up the ADAP Educational Initiative, summarized it best: "The grassroots do need to be afraid of sequester 2.0 coming up as it looks like Congress won’t be able to change that anytime soon."

In light of the current political climate on Capitol Hill, practically everyone with an interest in protecting HIV/AIDS supports and services is taking nothing to chance. Considering that the Ryan White law -- and especially the AIDS Drug Assistance Program (ADAP) -- has long enjoyed bipartisan support, education efforts to remind lawmakers of its importance are ongoing, including a new web video released by the AIDS Healthcare Foundation.

[Photo: AHF Ryan White Video]

One thing is for certain, prematurely opening up a popular law that doesn't require reauthorization could prove disastrous in the hyper-partisan, hyper-political environment that has consumed the current Congress.  Any suggestion to the contrary simply ignores the political realities that exist today. A more cautious approach might be pursuing a legislative technical fix.

The reality of the situation is best summarized by Bill Arnold, President & CEO of the Community Access National Network (CANN): "The issue boils down to congressional staff has no appetite to enter the debate over a full reauthorization until they have data after Affordable Care Act implementation, and can assess the impacts nationally, as well as locally."

Arnold suggests that the data won’t be available until well after “opening day” on January 1, 2014, and it will likely take all of that same year to clean and sort through the data. "That argues for a serious attempt to reauthorize in 2015, especially since it will also be past congressional election," Arnold said.

The bottom line is Ryan White stakeholders must remain vigilant in their efforts to maintain the nation's oldest and only law solely dedicated to providing life-sustaining supports and services to people living with HIV/AIDS in the United States. No one could disagree that the need exists. How the "community" achieves that objective is open to interpretation.

Stay tuned.

[1] Department of Public Health, Los Angeles County, California, "SECTION-BY-SECTION DESCRIPTION OF RYAN WHITE HIV/AIDS TREATMENT EXTENSION ACT OF 2009,” December 2009.

Profiles in ADAP Leadership

The ADAP Advocacy Association hosted its 3rd Annual ADAP Leadership Awards Dinner on Monday, July 8th in Washington, DC. The event marked an opportunity for stakeholders invested in the AIDS Drug Assistance Program (ADAP) -- most notably people living with HIV-infection -- to celebrate the accomplishments achieved and leadership demonstrated by individual, community, government, media and corporate leaders who are working to improve access to care and treatment. It was headlined by the Honorable Tommy G. Thompson, former Governor of Wisconsin and former Secretary of the U.S. Department of Health & Human Services.

Thompson's keynote provided a reflective glimpse into all that the HIV/AIDS community has achieved over the last several decades, both domestically and abroad. It also showed that HIV/AIDS transcends partisan politics.

His understanding of the unique challenges facing people living with HIV-infection dated back to his tenure as Wisconsin's 42nd Governor, and it continued into his service at the federal level. While serving as the Secretary at HHS, ADAP federal appropriations increased from $571 million in 2001 to $787 million in 2005. He also oversaw the $20 million in emergency ADAP funding that was released during the first ADAP waiting list crisis nearly a decade ago. Working alongside Secretary of State Colin Powell, Thompson was instrumental in developing President George W. Bush's PEPFAR initiative and chaired the Global Fund to Fight AIDS, Tuberculosis, and Malaria, a worldwide effort that focused on the problem around the world, with annual trips to Africa. 

Thompson was presented with the ADAP Advocacy Association's first-ever "ADAP Lifetime Achievement Award" as a 'thank you' for his decades of public service commitment to people living with HIV-infection.

Following the keynote, Brandon M. Macsata, CEO of the ADAP Advocacy Association, presented the ADAP Leadership Awards.  The 2012-2013 award recipients included:

• ADAP Champion of the Year (individual): 
• President Barack Obama
• ADAP Emerging Leader of the Year (individual): 
• Julio Fonseca, HealthHIV (Wash-DC)
• ADAP Corporate Partner of the Year: 
• HarborPath
• ADAP Community Organization of the Year: 
• AIDS Foundation of Chicago
• ADAP Lawmaker of the Year: 
• The Honorable Tom Coburn, M.D., U.S. Senate (OK), The Honorable Donna Christensen, M.D., M.C. (Virgin Islands)
• ADAP Social Media Campaign of the Year: 
• My HIV Journey by Aaron Laxton
• ADAP Grassroots Campaign of the Year: 
• Syringe Decriminalization Campaign by the North Carolina Harm Reduction Coalition
• ADAP Media Story of the Year: 
• Why Some with HIV Still Can’t Access Treatment by Sarah Childress, PBS Frontline

Upon announcing the 2012-2013 awardees earlier this year, Macsata stated, “The ADAP Advocacy Association is pleased to present this year’s recipients of its annual leadership awards, as we recognize a truly distinguishable group of awardees who have demonstrated a keen interest in preserving access to care under the AIDS Drug Assistance Program...thousands of underserved people living with HIV/AIDS have gained access to care and treatment, thanks to this year’s awardees."

The significance of the combined commitment to excellence displayed by the 2012-2013 awardees cannot be understated. According to the National Alliance of State & Territorial AIDS Directors (NASTAD), there were 4,717 people in 12 states on ADAP waiting lists, as of January 12, 2012. As a result of FY2011 ADAP emergency funding, Alabama, Florida, Georgia, Idaho, Louisiana, Montana, North Carolina, Ohio, South Carolina, Utah, and Virginia were able to reduce the overall number of people on their waiting lists.  As of April 19, 2012, that number had decreased 3,079 people on ADAP waiting lists in 10 states.  By mid-year, there are 2,170 people on ADAP waiting lists in 9 states. The total number of people on waiting lists had decreased 77 percent since a high of 9,298 individuals on September 1, 2011.  The most dramatic decrease occurred in the latter part of the year when NASTAD reported only 58 people on ADAP waiting lists in four (4) states, as of December 13, 2012.

The bar this year was set very high starting with President Obama's budget including additional federal appropriations for the cash-strapped ADAPs, as well as his numerous unilateral attempts to funnel more funding into the program via intra-department transfers. The latter action, first announced on Worlds AIDS Day in late 2011, led to the dramatic decrease in the number of people living with HIV-infection languishing on ADAP waiting lists.

Additionally, Julio Fonseca's efforts at HealthHIV with its Workforce Capacity Building have led to greater awareness within the medical community and elsewhere by matching physicians, nurse practitioners, and physician assistants to HIV clinical experts who provide one-on-one coaching, education, and training. Sarah Childress' reporting at PBS Frontline showed that some in the news media not only haven't turned a blind eye to HIV/AIDS in America, but truly understand the negative consequences of restricting access to care. Her story, "Why Some with HIV Still Can’t Access Treatment," represented one of the most comprehensive analysis of the problem facing thousands of people living with HIV-infection in the United States, especially those on ADAP waiting lists.

Senator Tom Coburn (R-OK) and Rep. Donna Christensen (D-Virgin Islands) reassured ADAP stakeholders that bi-partisan, bi-cameral support for Ryan White CARE Act programs still exists in the U.S. Congress. Rep. Christensen was in attendance to accept the Lawmaker of the Year Award, sharing her past experiences as a physician in the Virgin Islands trying to treat patients with virtually no medical treatment options available on the island.

The awards also reminded ADAP stakeholders that traditional grassroots advocacy is alive and well today, and so is the emerging advocacy platform of social media. The North Carolina Harm Reduction Coalition was represented by its Executive Director, Robert Childs, who accepted the Grassroots Campaign of the Year Award for their Syringe Exchange Decriminalization Campaign. Whereas Aaron Laxton could not attend the event in person, he posted a video on his YouTube page accepting the Social Media Campaign of the Year Award for his My HIV Journey vlog.

Finally, nonprofit community organizations and corporations also proved that their contributions remain invaluable. The AIDS Foundation of Chicago's efforts in Illinois prevented a potentially devastating cut to that state's ADAP, thus keeping hundreds of patients actively in care and treatment. HarborPath's new patient assistance portal links patients, who would otherwise not be receiving care and treatment, with life-saving medications donated by pharmaceutical companies. Their combined efforts earned them the Community Organization and Corporate Partner awards, respectively.

For three years running, even if just for a few hours, ADAP stakeholders came together in celebration...and appreciation. The evening ended with countless hugs, congratulatory salutes and a renewed sense of purpose. Much work remains to be done!

[Event Photos]

Brandon M. Macsata presents Tommy G. Thompson with the ADAP Lifetime Achievement Award

Brandon M. Macsata (left), Rep. Donna Christensen (center), Bill Arnold (right)

Brandon M. Macsata (left) presents Dr. Grant Colfax with the ADAP Champion of the Year Award, which was awarded to President Barack Obama