Public Health Response to HIV/AIDS

1. Public Health Response to HIV/AIDS NASTAD Minority Leadership Program Washington, DC February 27, 2012 Humberto Cruz, Director, AIDS Institute NYS Department of Health

2. What Happened in the 1980s?HIV/AIDS Began to Emerge • Earliest cases concentrated in a few areas (e.g., LA, SF, NYC). • The epidemic unfolded in different ways around the country. • What we now refer to as HIV/AIDS was not well-understood. • The community response preceded an organized governmental response. • Public health responses at the local, state and national levels were required. Early efforts focused on understanding the epidemic and providing educational messages/materials.

3. Emergence of HIV/AIDS in the United States

4. Public Health and Civil Liberties • Protecting the privacy of those with, or at risk for, HIV/AIDS was seen as crucial to public health (e.g., to obtaining epi data, to engage those most at risk, to protect persons with the disease). • This perspective led to policy debates that persist today, for example: • Testing Policies, Including Informed Consent • Newborn HIV Screening • Name-Based Reporting

5. Public Health Approaches Evolved asMore Became Known About Modesof Transmission • Sexual Transmission • Transmission Through Needle Sharing • Perinatal Transmission • Transmission through Transfusion of Blood and Blood Products

6. Public Health HIV/AIDS Surveillance • Named Reporting Standard for Other Reportable Infectious Diseases • AIDS Surveillance Implemented at State and Local Levels • Reports Forwarded to CDC • Some Jurisdictions Used Codes Instead of Names • When HIV Diagnostics Became Available (1985) HIV Surveillance was Possible • HIV Surveillance with Identifiers Faced Political Opposition • Risks Due to Stigma and Discrimination • No Treatment or Services Available

7. Public Health HIV/AIDS Surveillance (cont’d) “Surveillance Events” Include: • Incident HIV Infection (New Infections; STAHRS) • HIV Diagnosis • AIDS Diagnosis • CD4 and T-Lymphocyte Count • Viral Load Test • Deaths due to HIV/AIDS • STD

8. Examples of Uses of HIV/AIDS Surveillance Data • Monitor the HIV/AIDS Epidemic • Identify Populations and Communities at Risk • Target Prevention and Care Services • Identify Gaps and Missed Opportunities for Interventions • Ensure Proper Treatment and Partner Services • Demonstrate Need for Funding • Allocation of Funding (e.g., Ryan White, Prevention FOA)

9. Focus on Prevention • Public Education - What to Say? To Whom? • Confronting Stigma and Discrimination • Changing Behavior Among IDUs – Drug Treatment, Sterile Syringes, “Works” • Promotion of Voluntary Testing (Anonymous, Confidential) • Target Interventions Based on Surveillance Data

10. Focus on Prevention (con’t) • Contact Tracing and Partner Notification (public health tools used in STD control) • Closing/Regulation of Facilities (e.g., bathhouses) • Compulsory Measures in Same States for Some Populations (e.g., inmate testing) • Preventing Occupational Exposure, Perinatal Transmission • Behavioral Interventions (e.g., today’s DEBIs) • Bio-medical Interventions (PREP, PEP)

11. Advent of Antiretroviral Therapy • Ryan White CARE Act • Emphasis on Testing and Referral to Care, Retention in Care • Access to Medication, ADAP • Adherence • Optimize Role of the Health Care System • Integration of Prevention and Care • Accelerated Process for FDA Approval of Medications • Reducing community viral load • Biomedical Interventions • ART Policy

12. Multi-Level Public Health Interventions for HIV/AIDS Are Employed • Individual Level - Harm Reduction/Syringe Exchange - Biomedical Interventions - Condom Availability - Behavioral Interventions - Circumcision - ART • Community Level - HIV Testing Events - Community Viral Load - Social Marketing/Media Campaigns - Faith Based Initiative - Integration of Primary Care in Substance Abuse Treatment • Systems Level - Financing – Reimbursement, Grants - Audits - Quality Monitoring - Utilization Reviews - Laws and Regulations

13. HIV/AIDS Has Changed Public Health: “PIR” and Shared Decision-Making • Well-Organized, Well-Informed Advocacy Community(GMHC, ACT-UP) • PLWHA Self-Empowerment Movement (Denver Principles, 1983) • HIV Prevention Community Planning, “PIR” Required by CDC Guidance for HIV Prevention Cooperative Agreements • P = Parity, Equitable Access/Participation • I = Inclusive Process • R = Representative of Populations Affected • Ryan White Planning Councils • Community Advisory Boards • Commitment to Leadership Development • National HIV/AIDS Strategy (Community/City Consultation) • Presidential Advisory Council on HIV/AIDS (PACHA)

14. HIV/AIDS Has Changed Public Health:Enhanced Community Collaboration • “Traditional” Public Health System Lacked Access to Some Populations • Increased coordination/ collaboration with community based organizations • Diversity Requires Cultural Sensitivity and Multiple Approaches • Community-Based Organizations Have Access to Individuals at High Risk, Staff Reflective of Population Served • Faith Leaders Can Foster Trust and Access • Peer Models of Service Delivery

15. HIV/AIDS Has Changed Public Health:Transformation of STD Prevention and Control • Past Efforts – Find ‘Em, Count ‘Em, Treat ‘Em • STD Control Can Reduce New HIV Infections – Power of Prevention! • Increased Emphasis on Innovation & Evaluation • Integration of Primary and Secondary HIV Prevention Activities • Community Capacity Building, Mobilization & Engagement • Improved Sexual Health of Communities/Populations

16. HIV/AIDS Has Changed Public Health: Sociocultural Approach • Context for Public Health Initiatives and Interventions • Those at Greatest Risk are Poor and Marginalized • Considerations: - Culture - Education - Poverty - Disparities - Trauma - Socio-economic - Stigma - Discrimination • Public Health Interventions Tailored to Communities/Populations; Context for Greatest Impact

17. HIV/AIDS Has Changed Public Health: Multiple Points of Entry for Services • Co-located Services (i.e. Substance Use and HIV/AIDS) • Outreach and Testing in Family Planning, Planned Parenthood, Prenatal Care, Emergency Departments • Integration of Prevention and Care • HIV, STD, TB, Hepatitis Integration • HIV Testing in Health Care Settings • New York State HIV Testing Law requiring a mandatory offer to individuals 13-64 years old • Enhanced Collaboration Between Public Health and the Criminal Justice System • Managed Care Settings • Faith Communities • Harm Reduction Service Settings

18. System Considerations • HIV/AIDS specific reimbursement • Mandatory managed care for patients living with HIV/AIDS • Health Homes • Prevention/ Prevention for Positives • Community Health Center • Designated AIDS Centers • Insurance Continuation /ADAP • HOPWA/SAMHSA • NIH Grants • Changes in Medicaid/Medicare (donut hole) • Changes in immigration restrictions • Funding • Reprioritization

19. HIV/AIDS and Public Health:On-Going Challenges for Public Health • HIV/AIDS as a Chronic Disease • HIV/AIDS and Aging • Intersection with Other Chronic Diseases • Aging of Public Health Work Force and Community Leaders • HIV/AIDS Fatigue • Stigma

20. HIV/AIDS and Public Health: On-Going Challenges for Public Health (cont’d) • Health Care Reform • Global Epidemic • Immigration Reform • Unanswered Questions and Need for Research • Competing Priorities (e.g. military) • Resources/Financing for Prevention, Care and Supportive Services

21. The HOPE is that each of you… • Will learn from each other. • Will carry the torch. • Will take leadership roles and develop responses that bring positive change within your communities.

22. The FUTURE is TODAY!

23. Public Health Response to HIV/AIDS Thank You for Listening! Humberto Cruz, Director, AIDS Institute (212) 417-5500 NYSDOH AIDS Institute 90 Church Street; 13th Floor New York, NY 10007 E-Mail Address: HXC01@health.state.ny.us