Introduction to AID Education and Training Centers

1. Introduction to AID Education and Training Centers

2. Big Picture

3. Overall Directives • Millennium Development HIV/AIDS Goal • Healthy People 2020 • National AIDS Strategy for the United States • Health Resources and Services Administration • The AIDS Education and Training Centers Program • The Pacific AIDS Education and Training Regional Center

4. Millennium Development HIV/AIDS Goal • GOAL 6: COMBAT HIV/AIDS, MALARIA AND OTHER DISEASES • Target 6.A: Have halted by 2015 and begun to reverse the spread of HIV/AIDS • Target 6.B: Achieve, by 2010, universal access to treatment for HIV/AIDS for all those who need it

5. Healthy People 2020 • Healthy People 2020 established the goal of preventing human immunodeficiency virus (HIV) infection and its related illness and death. • The Office of National AIDS Policy created a National HIV/AIDS Strategy with three primary goals: • Reducing the number of people who become infected with HIV • Increasing access to care and improving health outcomes for people living with HIV • Reducing HIV-related health disparities

6. National AIDS Strategy for the United States • To accomplish these goals, the directive includes an order to undertake a more coordinated national response to the epidemic

7. National AIDS Strategy for the United States • Funding for HIV services is spread across multiple departments, including: • Health and Human Services (HHS), Housing and Urban Development (HUD), Justice, Veterans Affairs (VA), and Defense. Within HHS, in particular, responsibility for HIV programs is spread across multiple agencies including the Centers for Medicare & Medicaid Services (CMS), the Health Resources and Services Administration (HRSA), CDC (including alignment with the Healthy People 2020 goals), the Indian Health Service (IHS), the Food and Drug Administration, the Office of HIV/AIDS Policy, the Office of Minority Health, and others. Responsibility for HIV research is primarily carried by NIH, but CDC, VA, Department of Defense, and USAID also support research initiatives.

8. Health Resources and Services Administration • Vision: Optimal HIV/AIDS care and treatment for all • Mission: Provide leadership and resources to assure access to and retention in high quality, integrated care and treatment services for vulnerable people living with HIV/AIDS and their families

9. The AIDS Education and Training Centers Program • Supports a network of 11 regional centers (and more than 130 local affiliated sites) that conduct targeted, multidisciplinary education and training programs for health-care providers treating people with HIV/AIDS • Increases the number of health-care providers who are educated and motivated to counsel, diagnose, treat, and medically manage people with HIV disease and to help prevent high-risk behaviors that lead to HIV transmission • Training focuses on providers who serve minority populations, the homeless, rural communities, incarcerated persons, and sites funded under other components of the Ryan White HIV/ AIDS Program. AETCs focus on training primary health-care clinicians

10. The Pacific AIDS Education and Training Regional Center • PAETC Mission: • To provide health care professionals with the knowledge and skills necessary to care for HIV-infected patients in underserved and vulnerable populations • To increase the numbers of trained health care professionals working with HIV-infected patients • To respond to the needs of high-risk populations and the changing face of the epidemic

11. University of Southern California PAETC Local Performance Site • Description • The Pacific AIDS Education and Training Center (PAETC) at the Keck School of Medicine of the University of Southern California in Los Angeles is one of 15 local performance sites located throughout the states of California, Arizona, Nevada, and Hawaii. The PAETC offers HIV and AIDS education and training to healthcare professionals to keep busy providers up-to-date with the latest in HIV/AIDS treatment.

12. University of Southern California PAETC Local Performance Site • Mission • To prepare health care professionals with the knowledge and skills necessary to diagnose and manage HIV-infected patients in underserved and vulnerable populations • To increase the numbers of trained health care professionals caring for patients living with HIV • To prepare health care professionals with the skills to educate and counsel their patients to prevent the transmission of HIV • To respond to the needs of emerging populations and the changing face of the epidemic

13. Service Area Los Angeles County Ventura County

14. Organization

15. University of Southern California, Keck School of Medicine, Department of Family Medicine, Pacific AIDS Education and Training Center

16. The HIV Epidemic

17. Overview • Worldwide • United States • California • Los Angeles County

18. Worldwide • Since the beginning of the HIV/AIDS epidemic, 60 million people have contracted HIV and 25 million have died of AIDS-related causes. • In 2008, an estimated 2 million adults and children died from AIDS, a 10% reduction from the peak number of AIDS-related deaths in 2004. • As of 2008, 33.4 million people were living with HIV/AIDS worldwide. • The annual number of new HIV infections declined from 3.2 million in 2001 to 2.7 million in 2008. Still, more than 7,000 people contract HIV every day. • More than ½ of new infections are among those under 25 yrs of age. • Though not at the astronomical prevalence levels seen in Africa 4.4-4.8, The Americas, are still the second highest contributors (0.5) to the global prevalence rate of 0.8%.

19. United States • Since the AIDS epidemic began in 1981, 1.7 million Americans have been infected with HIV and 583,298 have died of AIDS-related causes through 2007 • 1.1 million Americans are living with HIV (including more than 468,000 with AIDS) • An estimated 21% of people living with HIV are undiagnosed • Every 9.5 minutes, someone in the U.S. is infected with HIV • Gay and bisexual men continue to bear the greatest burden of HIV infection, accounting for an estimated 53% of new HIV infections • African-Americans and Latinos are disproportionately affected by HIV and AIDS. Blacks accounted for 45% of new HIV infections in 2006 and 47% of those living with the disease, yet they make up only 12% of the U.S. population. Latinos account for 17% of new infections yet comprise 15% of the U.S. population, while whites represent 35% of new infections and account for 66% of the total population. • The AIDS case rate for African Americans is more than 9 times that of whites, and the HIV rate is 7 times greater among blacks than whites. Survival after an AIDS diagnosis is lower for blacks than any other racial/ethnic group. • Young adults and teens between 13 and 29 represent 34% of new HIV infections, the largest share of any age group. Black teens are disproportionately affected, representing 68% of reported AIDS cases among 13 to 19-year-olds in 2007.

20. United States • New infections due to injection drug use have declined by about 80% since the mid-to-late 1990s, accounting for 12% of new infections in 2006. • Women now account for 27% of HIV infections, with 280,000 women living with HIV and AIDS. Black women accounted for 65% of new AIDS cases among women in 2007 and the largest share of new HIV infections (61%). • 71% of all AIDS cases reported since the beginning of the epidemic are concentrated in 10 states or territories. While the District of Columbia has the highest AIDS case rate (148.1 per 100,000 in 2007), the states of New York (17.6%), California (14.4%) and Florida (10.6%) have the most cumulative AIDS case • 1,148,200 persons aged 13 years and older are living with HIV infections, including 207,600 (18.1%) that are unaware of their infection. • In 2010, there were an estimated 47,500 new HIV infections.  • Estimated 872,990 people in the US were living HIV in 2010

21. United States • In 2011, the estimated number ofdiagnoses of HIV infection in the United States was 49,273 • In 2011, the estimated number of persons diagnosed with AIDS in the United States was 32,052 • At the end of 2010, an estimated 487,692 persons in the United States were living with AIDS • The cumulative estimated number of AIDS through 2010 in the United States was 1,155,792 • Blacks/African Americans continue to experience the most severe burden of HIV, compared with other races and ethnicities • Blacks represent approximately 12% of the U.S. population, but accounted for an estimated 44% of new HIV infections in 2010. They also accounted for 44% of people living with HIV infection in 2009 • Since the epidemic began, more than 260,800 blacks with an AIDS diagnosis have died, including an estimated 7,678 in 2010 • Estimated 1 in 16 black men and 1 in 32 black women will be diagnosed with HIV infection • Hispanics/Latinos are also disproportionately affected by HIV. • Hispanics/Latinos represented 16% of the population but accounted for 21% of new HIV infections in 2010 • Hispanics/Latinos accounted for 19% of people living with HIV infection in 2009 • Disparities persist in the estimated rate of new HIV infections in Hispanics/Latinos. In 2010, the rate of new HIV infections for Latino males was 2.9 times that for white males, and the rate of new infections for Latinas was 4.2 times that for white females • Since the epidemic began, more than 96,200 Hispanics/Latinos with an AIDS diagnosis have died, including 2,370 in 2010

22. United States

23. California • The rate of diagnoses of HIV among adults and adolescents in 2011 in CA was 19.2 • CA reported the highest number of HIV diagnoses in 2011 • Nearly 200,000 Californians have reportedly contracted HIV/AIDS and nearly 90,000 have died since the epidemic began in the early 1980s • CA ranks 2nd in the nation to cumulative AIDS cases at 157,719, surpassed only by NY • Appr. 109,000 Californians are HIV-positive, among whom 69,728 are living with HIV • There are up to 7,000 new HIV infections in the state every year • 75.7% of all HIV/AIDS cases occur among gay men, far exceeding the 53% nationally • Men make up 89.5%. Women account for 9.8% of cases, and transgender persons for 0.6% • Of all HIV cases, whites account for 46.7%,Hispanics 29.2% and AA at 18.9%

24. California • HIV infection and risk behaviors are high among populations who are at-risk for incarceration, currently incarcerated, or recently discharged. The rate of new AIDS cases among the incarcerated population in the U.S. is estimated to be three times higher than in the general population. Further, 20-26% of the HIV-infected U.S. population is estimated to pass through a correctional facility at some point annually. Although HIV prevalence is lower among prisoners in California than in many other parts of the country, it is disproportionately high when compared to the general population. • 0.7% of California State and Federal prisoners are known to their prison systems to be infected with HIV and the HIV seroprevalence in California state prisons is 1.4% among males, according to an unlinked seroprevalence study conducted by the State Office of AIDS in 1999. This compares to an HIV prevalence of 0.03% for military applicants and 1% for STI clinic patients in California in 2000 • More than 60% of Californians living with HIV reside in Los Angeles County or the San Francisco Bay Area.

25. California

26. Los Angeles • LA County was a recipient of a Ryan White Part A HIV Emergency Relief Grant from HRSA • The rate of diagnoses of HIV infection among adults and adolescents in 2011 in Los Angeles was 18.1 • The total # of HIV cases reported as of June, 2012 is 17,991 with 17,170 living cases and 821 deceased. The total # of AIDS cases reported as of June, 2012 is 59,955 with 26,283 living cases and 33,672 deceased • Approximately 58,000 people are living with HIV in LA in 2013. Including 45,500 reported living with HIV; 10,500 people unaware of their infection; and of 4,200 notifications pending investigation approximately 2,000 will have detectable VL or a confirmatory test

27. Santa Barbara and Ventura Santa Barbara: • 2012 Cumulative HIV/AIDS cases = 1076, Total Deaths = 523. People living with HIV/AIDS = 553 – primarily 30-39 yrs, male, MSM/BI and Latino • HIV/AIDS cases have steadily risen since 2010 Ventura: • As of December 31, 2010, 1,146 reported cases of AIDS with 599 deaths, 337 cases of HIV reported • In 2010, Ventura County Public Health’s (VCPH) HIV/AIDS Surveillance reported 61% of the new cases of HIV were white and 32% were Hispanic while 54% of the AIDS cases were white and 32% were Hispanic. White and Hispanic males continue to be the largest population of new cases. • The primary mode of HIV transmission is MSM (70%) and in women is heterosexual contact (60%). • The largest % of cases reported have been between 30-50 yrs. AAs account for barely 3% of the population but account for 4% of HIV/AIDS cases in 2010

28. Epidemiology – Los Angeles

29. Epidemiology – Los Angeles Los Angeles County’s Comprehensive HIV Plan (CHP) (2012-2014), prepared by the Los Angeles County Commission on HIV and the County of Los Angeles Public Health Department, lists Los Angeles’ most vulnerable populations as those most impacted by: • Poverty • Lack of insurance • Unemployment • Mental illness • Substance abuse • Homelessness The CHP also highlights communities of color as they are the most impacted by the epidemic and they comprise the majority of all people living with HIV/AIDS as well as those who are newly diagnosed.

30. Epidemiology – Los Angeles • African Americans/Blacks • Currently/Chronically Homeless • Incarcerated/Formerly Incarcerated • Latinos • Men of Color Who Have Sex With Men (MSM • Mentally Ill (severe, persistent mental illness • Monolingual Latinos: • American Indian/Alaska Native • People with Sensory Disabilities/Impairments • Sex Workers/People Engaged in Survival or Exchange Sex • Injection Drug Users (IDUs) • Transgender Individuals • Undocumented Latinos • Women • Youth/Adolescents To add to the list of vulnerable populations above, the 2010‐2011 Los Angeles Coordinated Needs Assessment‐Care (LACHNA‐Care) project outlines 15 “special populations of interest” with special HIV care and service needs.

31. USC PAETC’s Response to LA County’s HIV/AIDS Epidemic and Workforce Issues

32. Overall Description • Emphasizes specialized training for medical professionals who work in correctional facilities, Community Health Centers and other Federally Qualified Health Centers, Public Health Clinics, and other clinics serving vulnerable and disproportionately affected populations • USC focuses on the incarcerated and homeless populations as well as workforce development • Intent is to focus not only on the HIV/AIDS workforce, but to consider its work in the context of broader workforce shortages in primary care and care to the underserved, and to consider a variety of health professions, including nursing, medicine, dentistry and pharmacy

33. Goals and Objectives • TRAINING: GOAL 1. The PAETC will expand the number and ability of HIV clinicians and those serving at-risk populations in Arizona, California, Hawaii, Nevada and the 6 US Pacific Jurisdictions to provide high quality HIV care, HIV testing and early diagnosis with improved knowledge and skills. • OBJECTIVE 1.1: By June 30, 2014, the USC AETC will train a minimum of 600 health care providers working at Ryan White clinics, other HIV care clinics, and primary care settings serving high risk and HIV-infected patients with needs-based training and capacity-building activities (Levels I – V) in Southern California with Basic funds • OBJECTIVE 1.2: By June 30, 2014 the USC AETC will work with other regional LPSs to plan and present a minimum of one collaborative training program with other regional Federal Training Centers (CA PTC, CHT, PS ATTC and CNTC (RTMCC)) to improve integration of HIV prevention and testing, STD prevention and treatment, reproductive health, substance abuse and mental health, and TB training

34. Goals and Objectives Cont. • CAPACITY BUILDING: GOAL 2. PAETC will expand the ability of Ryan White clinics, community health centers (CHCs) and other health care settings in Southern California to improve outcomes in HIV testing, diagnosis, linkage/engagement in care, and treatment through capacity building activities. Targeted clinics: Venice Family Clinic, Los Angeles Christian Health Center, JWCH • OBJECTIVE 2.1: By June 30, 2014, the USC AETC will provide capacity building activities (TA and training) to the following RW and/or HIV specialty clinic(s): Venice Family Clinic, LA Christian Health Center, JWCH Center for Community Health, CARES clinic • OBJECTIVE 2.2: By June 30, 2014, the USC AETC will provide capacity building activities (TA and training) to the following CHCs and/or other medical settings: and (e.g., CHCs, hospitals, correctional facilities, and/or other primary care sites). Targeted sites: Emergency Department, LAC+USC Medical Center; Center for Health Justice; Special Care Clinic, St. John's HIV clinic.

35. Goals and Objectives Cont. • QUALITY MANAGEMENT/EVALUTION: GOAL 3. PAETC will strengthen the ability of the LPSs to provide high quality training, clinical consultation and capacity building programs with quality management and program evaluation activities. • OBJECTIVE 3.1: By June 2014 USC AETC will design and implement ongoing needs assessments documenting HIV-related training and capacity building needs for HIV clinicians and care sites, and non-HIV care sites serving high-risk populations • OBJECTIVE 3.2: By June 2014 USC AETC will improve educational expertise and training capacity with at least 2 annual faculty development training/TA activities using adult learning principles and ongoing information dissemination • OBJECTIVE 3.3: Implement regional evaluation plan to demonstrate outcomes and impacts of training and capacity building activities • OBJECTIVE 3.4: By June 30, 2014USC AETC will support programmatic excellence and adherence to HRSA guidance and national priorities (NHAS) via annual quality improvement activities • OBJECTIVE 3.5: USC AETC will ensure continued operation of PAETC programs through non-competitive and competitive grant applications and HRSA-required progress reports

36. Current Program Descriptions

37. Clinical Training Program for Primary Care Providers • – The five-day mini-residency training for physicians, physician assistants and nurse practitioners provides clinical instruction in the context of direct patient care. The primary clinical training site is LAC+USC Medical Center’s Rand Schrader Clinic (5P21). The weekly program is offered year-round and includes and HIV Overview and Standardized Patient Workshops • Standardized Patient Workshops • – Interactive skills-building workshops with standardized patients (actors trained to portray real patient cases) to help practitioners build skills in: HIV risk assessment and risk reduction; HIV testing and counseling; treatment adherence; cultural competency.

38. HIV Corrections Fellowship • – A one-year post-residency training opportunity in HIV medicine. Fellows receive hands-on experience in the medical management of persons living with HIV infection in all stages of disease from initial diagnosis to advanced treatment. Training occurs primarily in the correctional setting. Fellows have the opportunity to participate in Pacific AETC educational endeavors and projects.

39. Clinical HIV Fellowship • - A one-year post-residency training opportunity in HIV medicine. Fellows receive hands-on experience in the medical management of persons living with HIV infection in all stages of disease from initial diagnosis to advanced treatment. Training occurs in the outpatient and inpatient medical settings. Fellows have the opportunity to participate in Pacific AETC educational endeavors and projects.

40. Education and Training Programs: Conferences, Lectures, Overviews, Seminars • – HIV disease overviews, updates or focused topic presentations; designed specifically for the identified need and group; length of presentations range from one hour to full-day programs; programs are available at USC, presented on-site, or at various community locations.

41. Barriers to Care Study • – Assessing barriers to care (linkage-to and retention-in) for patients at the Early Intervention Clinic with incarceration history

42. New Hire HIV Overview Training • – Monthly HIV Overview trainings for new staff at the Los Angeles Men’s Central Jail conducted by MDs • – AETC Fellows also conduct the LA County Jail’s New Hire HIV Overview Training

43. Nursing and HIV Care Overview Workshop Training Program • – A three-day workshop program for registered nurses provides and HIV overview and update and focuses on helping nurses develop an effective approach to caring for persons affected by HIV disease. This program is offered several times during the year.

44. Consultation Training and HIV Capacity Building – Provision of consultation training that enables clinics to expand their HIV capacity. Pacific AETC Faculty members are available for consultation and on-site training at correctional facilities, emergency departments, county health departments, and Ryan White and other federally funded clinics. Training is adapted for high, medium, or low-volume providers. Longitudinal consultation training is also provided on-site for selected clinics and agencies.

45. Web-based Learning • – One-hour online training for oral health professionals aims to increase confidence in initiating risk assessment conversations with patients using a series of modeling vignettes. A second on-hour training targeting nurses and other healthcare workers in Labor and Delivery settings aims to increase knowledge on rapid testing for HIV.

46. Lecture Series • – Fellows at the Pacific AETC conduct lectures for the Family Medicine and Internal Medicine programs at White Memorial Medical Center.

47. Nursing Contact Hours – CA Provider • – The USC PAETC is a provider of CA nursing contact hours

48. Other Funded Program Descriptions

49. International Training • – The Pacific AETC has offered hands-on experience in the medical management of persons living with HIV infection in all stages of disease from initial diagnosis to advanced treatment to medical professionals from foreign countries. Training occurs in the outpatient and inpatient medical settings. Our most recent visitors have come from Guyana and Japan.

50. LACUSC ED HIV Testing Program • 2009 HIV testing program at the LACUSC ED • Recruited a team and secured funding to begin successful implementation of a point of care routine HIV testing in February 2011 in 1 of 5 pods • Expanded to 2 pods about 6 months into the program • Expanded to a lab based HIV testing program which will expand over time to include all patients who get labs at the LACUSC ED (approximately 70% of the 170,000 visits per year) • To date this program has offered testing to 22,000 people, over 15,000 people have tested for HIV. When accounting for exclusion criteria the program has an 89% acceptance rate for HIV testing and has resulted in 57 people being newly diagnosed for HIV of which 95% have been successfully linked to care defined as a visit with a medical provider. • Because of its success, this testing program then became a cornerstone Testing and Linkage to Care (TLC+) program for further funding through California HIV Research Program (CHrP) for a multisite grant with the California Collaborative Treatment Group to emulate a model TLC+ program.