Using NASTAD’s National HIV Prevention Blueprint to Guide HIV Prevention Community Planning Processes

1. Using NASTAD’s National HIV Prevention Blueprint to Guide HIV Prevention Community Planning Processes

2. Session overview • NASTAD overview • Learning objectives • Rationale for developing a national HIV Prevention Blueprint • Epidemiological overview of the domestic HIV/AIDS epidemic • Blueprint overview • In-depth discussion about using the principles outlined in the Blueprint to help guide Community Planning • CPG strategy development

3. Represents the nation’s chief health agency HIV/AIDS and viral hepatitis staff in all 50 states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands and the U.S. Pacific Islands Responsible for protecting and guaranteeing the health of constituents within jurisdictions’ borders Responsible for more than half of CDC’s domestic HIV prevention budget and a third of CDC’s domestic viral hepatitis prevention budget Responsible for significant HIV/AIDS and viral hepatitis funding from jurisdictional governments Responsible for implementing a comprehensive HIV/AIDS and viral hepatitis response in every jurisdiction in the U.S. Provides national leadership on HIV/AIDS and viral hepatitis policy and programs Educates about and advocates for necessary federal funding Who is NASTAD?

4. Learning Objectives • Learn the current epidemiological profile of HIV/AIDS in the U.S. • Learn key questions to ask about epidemiology • Learn deeper level issues that underlie the current state of HIV/AIDS in the U.S. • Learn the specific principles that must be considered and, where possible, operationalized in order to mount a successful prevention response to HIV/AIDS in the U.S. • Learn specific strategies for engaging community planning groups in discussion and engagement of the identified principles

5. Why develop a Prevention Blueprint and Policy Agenda (BP/PA)? • Assert expertise and role of health department HIV/AIDS programs and their communities to reclaim “core” public health to meet our mandate to protect the public’s health • Enter the perspective of HIV/AIDS directors, their staff, and their communities into the national discourse • Capitalize on the timing • Not in the intense throes of Ryan White reauthorization • Dr. Fenton’s leadership at NCHHSTP • Upcoming election (Congress and Administration) • Release of the revised incidence estimates • Remind the nation: HIV INFECTION IS PREVENTABLE!

6. What are the overarching goals of the BP/PA? • BP/PA represents the collective wisdom of health departments and their communities. • BP/PA is a concise, yet comprehensive plan for ending the epidemic in the U.S. • BP/PA speaks to all communities, not just health departments. • BP/PA recommendations seek to meet the needs of all populations at risk for or living with HIV/AIDS. • BP/PA is a living document.

7. Epidemiological overview Source: www.cdc.gov

8. Epidemiological overview Source: www.cdc.gov

9. Where are we now? Why are we here? Where do we need to be? How do we get there? HIV Prevention Blueprint Overview

10. Where are we now? • Increasing annual HIV/AIDS prevalence • Decreasing AIDS morbidity • Unknown HIV incidence • Politicization of HIV prevention • Erosion of HIV prevention funding

11. Where we are now—HIV Incidence and CDC’s HIV Prevention Budget (in 1983 Dollars), US, 1978-2006 2007: + $47M for expanded HIV testing HIV incidence $500,000,000 CDC HIV prevention budget HIV incidence CDC HIV prevention budget 180,000 $500,000,000 $450,000,000 $450,000,000 160,000 $400,000,000 $400,000,000 140,000 $350,000,000 $350,000,000 120,000 $300,000,000 $300,000,000 100,000 $250,000,000 $250,000,000 80,000 $200,000,000 $200,000,000 60,000 $150,000,000 $150,000,000 40,000 $100,000,000 $100,000,000 20,000 $50,000,000 $50,000,000 000 $- $- 1979 1981 2006 1991 1978 1986 1997 1989 1980 2002 1982 1983 1984 1985 1987 1988 1990 1992 1993 1994 1995 1996 1998 1999 2000 2001 2002 2003 2004 2005 Adapted from David Holtgrave Year

12. Why are we here? • Bottom Line: The nation’s HIV prevention response cannot keep pace with increasing prevalence in the current environment. • The obvious reasons: • Lifesaving advancements in HIV/AIDS care and treatment = increasing prevalence • Inadequate funding and restrictive policies = unrealized potential of prevention

13. Why are we here?The Complex Reasons • America’s prevention response suffers from a legacy of indifference. • While America’s support for our work is broad, it is very shallow. • Oppression and stigma are at the root of America’s social problems, including HIV/AIDS. • The nation’s response to HIV/AIDS is fragmented. • Scientific fact does little to confront ideological concerns.

14. Why are we here?The Complex Reasons • America’s prevention response suffers from a legacy of indifference. • Historically inadequate funding for HIV prevention • Historical distance by policy makers from the issues that drive the epidemic • Treatment approach favored over a prevention approach

15. Why are we here?The Complex Reasons • While America’s support for our work is broad, it is very shallow. • Perception that HIV/AIDS is a problem faced by “others” • Divide between value for personal wellbeing and the collective wellbeing of society

16. Why are we here?The Complex Reasons • Oppression and stigma are at the root of America’s social problems, including HIV/AIDS. • Overt and covert oppression of the “others” reinforces the divide between those with power and those without it • Poverty and discrimination, especially racism, homophobia, sexism and prejudice associated with immigration status, undermine every attempt we make to keep people healthy. • “HIV points to everything that’s wrong with society.” (Thomas Coates, 2007 NHPC)

17. Why are we here?The Complex Reasons • The nation’s response to HIV/AIDS is fragmented. • Shifting patchwork of strategies and approaches • Compromises the success of our programs through ongoing change in emphasis and imposition of unfunded mandates

18. Why are we here?The Complex Reasons • Scientific fact does little to confront ideological concerns. • Our arguments have relied on research and scientific fact • N/SEP have been proven to prevent new HIV infections • Correct and consistent condom use has been proven to prevent new HIV and STD infections • Opponents arguments have relied on ideological concerns • N/SEP tacitly endorses illegal drug use • Condoms are not 100% effective against STDs including HIV • Other areas: • Abstinence-until-marriage • PEPFAR—anti-prostitution pledge • Must reframe our arguments to be have more broadly-acceptable value and meaning to society

19. Where do we need to be? • Providing full coverage of services and tools that prevent infections. • Ever expanding the HIV prevention arsenal. • Encouraging all people living with HIV/AIDS to know their status. • Linking people living with HIV/AIDS to quality care and treatment. • Working to eliminate disparities based on race, ethnicity, gender, sexual identity, prejudice associated with immigration status and class. • Addressing the complexity of individuals’ lives. • Continuously educating the mass public. • Using structural-level interventions to effect change.

20. Where do we need to be—Providing full coverage of services and tools that prevent infections • HIV INFECTION IS PREVENTABLE! • Tools that prevent infection directly • Condoms • Clean needles and syringes • STD treatment • Prevention of mother-to-child transmission • Tools that prevent infection indirectly • Behavioral interventions • Comprehensive sexuality education • HIV counseling and testing • Partner services

21. Where do we need to be—Ever-expanding the HIV prevention arsenal • New behavioral interventions • Developed for specific high-risk populations • Derived from academic research and locally-driven empirical studies • Fast-tracked process for broad diffusion • Effective services that are not widely practiced • Non-occupational post-exposure prophylaxis • Potentially effective services • Pre-exposure prophylaxis • Circumcision • Not-yet-realized options • Microbicides • Vaccine

22. Where do we need to be—Encouraging all people living with HIV/AIDS to know their status and linking them to quality care and treatment services • HIV testing as part of a comprehensive portfolio • Targeted HIV counseling and testing to high-risk populations • HIV screening in health care settings • As appropriate in a given jurisdiction • Financed appropriately through public and private payers • Early diagnosis and actualized linkage to care and treatment • Knowledge of status can impact decision-making • Adherence to treatment lowers viral load

23. Where do we need to be—Actively eliminating disparities based on race, ethnicity, gender, sexual identity and class • Oppressed populations bear the greatest health concerns • Indirect contributing factors • Poverty • Racism • Immigration status • Homelessness / unstable housing • Homophobia • Gender inequality

24. Where do we need to be—Addressing the complexity of individuals • Operationalize programming that recognizes other real-life issues: • Sexually transmitted diseases • Viral hepatitis • Tuberculosis • Reproductive health • Homelessness / unstable housing • Mental health concerns • Substance use / abuse • Immigration status • Deconstruct categorical philosophies, funding, guidance and structures to address the complex realities faced by the populations we serve

25. Where do we need to be—Continuously educating the mass public • Overall, the public supports the prevention of disease and the promotion of health. A national education campaign can: • Reinforce accurate information about HIV/AIDS • Reduce stigma associated with HIV/AIDS • Inform about the economic, social and health consequences of HIV/AIDS • Promote ownership of the epidemic beyond the infected and affected

26. Where do we need to be—Using structural-level interventions to effect change. • Individual behavior change can prevent the direct actions (determinants) that lead actual HIV transmission • Partner reduction, condom / clean needle and syringe use • Structural level interventions can begin to address the direct and indirect contributing factors that influence individual behavior • Policy, media, systems / institutions

27. How do we get there? • We must ensure CDC HIV prevention programs are adequately funded. • Invest $600M more in HIV prevention for a total of $1.3B. • Invest $35M more in HIV/AIDS surveillance including national HIV behavioral surveillance and other special studies. • Support a national education campaign.

28. How do we get there? • We must invest in programs that are working on the local level. • Lift the ban on federal syringe exchange funding. • Invest in behavioral research to provide diverse populations with diverse interventions. • Invest in HIV prevention programs in correctional settings. • Abandon abstinence-only-until-marriage programming and dedicate funding to comprehensive sexuality education.

29. How do we get there? • We must invest in programs that expand the reach of core HIV prevention activities. • Invest in substance abuse prevention and treatment and mental health services. • Invest in Housing Opportunities for People with AIDS and other housing programs. • Invest in CDC’s STD prevention program. • Invest in new biomedical interventions including vaccines and microbicides.

30. How do we get there? • The federal government must provide coordination, funding and meaningful support for locally driven HIV prevention programs. • Make a national, multi-sectoral commitment to ending the HIV/AIDS epidemic in America. • Put cooperation back into health department cooperative agreements.

31. How do we get there? • Our Commitment: State and local health departments and their communities will lead the nation’s HIV prevention efforts to ensure effective and appropriate approaches are being implemented in every jurisdiction in the U.S.

32. Questions? • Initial reaction? • Anything missing? • Relevance to your current work? • Others?

33. In-depth discussion about using the principles outlined in the Blueprint to help guide Community Planning

34. Basic questions in Community Planning—Populations • WHO is being infected? (What are the characteristics of individuals who are being infected?) • WHO is transmitting? (What are the characteristics of individuals who are transmitting?) • WHERE are these individuals being infected? (In what environments, venues, spaces and/or places are individuals being infected? In what environments, venues, spaces and/or places are individuals transmitting infection?) • WHEN are these individuals being infected? (At what points in life are individuals being infected? At what points in life are individuals transmitting infection?)

35. Basic questions in Community Planning—Populations • WHY are these individuals being infected? (What are the factors, issues and/or competing priorities in an individual’s lives that contribute to behaviors that facilitate infection? What are the factors, issues and/or competing priorities in an individual’s lives that contribute to behaviors that facilitate transmission of infection?) • HOW are these individuals being infected? (What are the behaviors that lead to infection?) • WHAT can be done to address these issues?

36. Principle 1: Providing full coverage of services and tools that prevent infections • How can you ensure the tools that prevent infections directly are available to the populations at risk in your jurisdiction? • Condoms • Clean needles and syringes • STD treatment • How can you ensure the tools that prevent infections indirectly are available to the populations at risk in your jurisdiction? • Behavioral interventions • Comprehensive sexuality education • HIV counseling and testing • Partner services

37. Community Planning Strategies for Principle 1 • Talk about it. • EXAMPLE: Condoms • Advocate for (err…Educate about) it. • EXAMPLE: Needle / syringe access • Prioritize it. • EXAMPLE: STD screening and testing • Be innovative. • EXAMPLE: Home-grown interventions • Match the strategy to your needs. • EXAMPLE: HIV counseling and testing / PS

38. Principle 2:Ever-expanding the HIV prevention arsenal • How can you ensure behavioral interventions match the needs of your target populations? • How can you ensure nPEP is understood and available? • What can a CPG do with strategies that are not available yet? • PrEP • Circumcision • Microbicides • Vaccine

39. Community Planning Strategies for Principle 2 • Get Educated about it. • EXAMPLE: PrEP, Microbicides, Vaccine, Circumcision • Question it. • EXAMPLE: Vaccine (HBV?) • Prioritize it. • EXAMPLE: nPEP • Borrow and / or create it. • EXAMPLE: New home-grown interventions • Match the strategy to your needs. • EXAMPLE: nPEP, new home-grown interventions

40. Principles 3 and 4:Encouraging all people living with HIV/AIDS to know their status and linking them to quality care and treatment services • How can you ensure individuals living with HIV/AIDS know their status? • How can your jurisdiction ensure HIV testing is a balanced part of your comprehensive portfolio? • How can you ensure linkages to care and treatment are actualized?

41. Community Planning Strategies for Principles 3 and 4 • Question it. • EXAMPLE: HIV Screening • Balance it. • EXAMPLE: HIV Testing • Target it. • EXAMPLE: HIV Testing / community viral load • Link it. (and Understand how it works.) • EXAMPLE: HIV/AIDS C&T • Be innovative. • EXAMPLE: Treatment adherence, community-based partner services

42. Principle 5:Actively eliminating disparities based on race, ethnicity, gender, sexual identity and class • What can a CPG do with issues like poverty, racism, homelessness / unstable housing, homophobia, gender inequality and immigration status.

43. Community Planning Strategies for Principle 5 • Make the argument that it matters. • Talk about it. • Understand it. • Assess it. • EXAMPLE: Community services assessment • Learn about it. • EXAMPLE: Cultural humility training

44. Racism Homophobia Immigration Community Planning Strategies for Principle 5—A Model for Consideration

45. Community Planning Strategies for Principle 5—A Model for Consideration

46. Principle 6:Address the complexity of individuals • How can you ensure programs recognize and address other real-life issues? • Sexually transmitted diseases • Viral hepatitis • Tuberculosis • Reproductive health • Homelessness / unstable housing • Mental health concerns • Substance use / abuse

47. Community Planning Strategies for Principle 6 • Make the argument that it matters. • Prioritize it. • EXAMPLE: STD screening and testing • Integrate it. • EXAMPLE: Hepatitis prevention • Partner. • EXAMPLE: Homelessness / Unstable housing • Be innovative. • EXAMPLE: Substance abuse, research

48. Community Planning Strategies for Principle 6—A Model for Consideration

49. Community Planning Strategies for Principle 6—A Model for Consideration Syndemics: Two or more afflictions, interacting synergistically, contributing to excess burden of disease in a population.

50. Community Planning Strategies for Principle 6—Example • Special Concerns Populations • Prioritized to create HIV prevention programs for populations that: • are not / may not be adequately covered in other priority recommendations. • are marginalized. • are known to engage in high-risk behavior(s). • are known to be disproportionately represented in other categories of health disparity. • have known HIV risk co-factors. • are in need of specialized services. • There exists no other system to handle the HIV prevention needs of these populations. Courtesy of the Chicago Department of Public Health