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H H S Department of Health and Human Services
Health Resources and Services Administration
Primary Care: The Health Center Program

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HIV/AIDS Care & Treatment in Health Centers

Program Assistance Letter 2011-06

I. Purpose

This Health Center Program Assistance Letter (PAL) provides information and resources regarding the treatment and care of people living with HIV/AIDS (PLWHA). In alignment with the National HIV/AIDS Strategy (NHAS) (http://www.aids.gov/federal-resources/policies/national-hiv-aids-strategy/), the Health Resources and Services Administration (HRSA) and the Bureau of Primary Health Care (BPHC) will continue to support efforts to prevent new HIV infections, provide access to high quality care for PLWHA, and reduce HIV-related health disparities.

II. Background

In the United States, more than 1.1 million individuals are living with HIV/AIDS and roughly 21% of them do not know their HIV status (CDC, 2008). According to the Uniform Data System (UDS), in 2009 Health Centers provided HIV testing to more than 700,000 people and provided HIV/AIDS care and treatment to nearly 95,000 patients, approximately 9% of Americans with HIV.

Recent advances in pharmacologic therapies for HIV have improved the safety, tolerability, and efficacy of treatments, leading to adherence and improved health outcomes. These same advances enable more primary care practices, including health centers, to actively manage the care and treatment needs of PLWHA. To reduce AIDS-related mortality, guidelines recommend routine HIV testing and the provision of antiretroviral treatments soon after infection. This recommendation requires substantial increases in the availability, accessibility, and quality of HIV/AIDS services. Health centers are well positioned to help meet this demand.

BPHC strongly encourages and supports health centers to improve the quality of care and treatment services for PLWHA by adopting electronic health records (EHR), collecting and meaningfully using HIV/AIDS related data, and becoming patient-centered medical homes for patients living with HIV or at increased risk for HIV infection. Patient access to HIV/AIDS health and social support services can be achieved through on-site service delivery and the establishment of formal referral networks. Furthermore, health centers can improve the coordination and quality of their services through the inclusion of HIV/AIDS-related performance measures in BPHC’s Clinical Performance Measures Forms and HIV/AIDS-related protocols in Quality Assurance/Quality Improvement (QA/QI) plans (for examples of performance measures, see http://hab.hrsa.gov/deliverhivaidscare/habperformmeasures.html). These and related activities will support the Health Center Program’s efforts to improve access to care, ensure the provision of care in accordance with evidence-based clinical guidelines, and reduce disparities in health outcomes for vulnerable and underserved communities impacted by HIV/AIDS.

Early detection and treatment of HIV/AIDS integrated with culturally-appropriate support services, increases longevity and quality of life for people living with and affected by HIV/AIDS. As the HIV/AIDS epidemic in the United States moves toward 30-plus year history, Health Centers remain an essential part of the public health safety net. BPHC remains committed partners in your efforts to care for PLWHA, their families, and communities. In close collaboration with the HRSA HIV/AIDS Bureau, administrator of the Ryan White HIV/AIDS Program, BPHC is striving to increase the availability and quality of resources available to support health centers in this important work.

III. Guidelines and Protocols for HIV/AIDS Care and Treatment 

Health Centers can access a broad array of guidelines and protocols regarding the provision of care and treatment to PLWHA and the prevention of new infections among those at risk for HIV infection. The AIDSinfo website is a primary vehicle for disseminating current information about treatment regimens and clinical trials for HIV infection and AIDS-related illnesses (see Clinical Guidelines Portal at http://www.aidsinfo.nih.gov/). AIDSinfo is entirely federally-funded and does not allow any company or product advertising or endorsements. The HRSA HIV/AIDS Bureau (HAB) and the Centers for Disease Control and Prevention (CDC) are other key and reliable sources of HIV/AIDS care and treatment information. BPHC encourages health centers to comply with federally-approved, evidence-based, and/or consensus-driven guidelines and protocols for HIV/AIDS care and treatment, some of which are outlined below.

Antiretroviral Treatment

The provision of antiretroviral treatment (ART) to HIV-infected persons substantially reduces the risk of HIV transmission. Recent federal guidelines support initiation of ART for all patients with CD4 lymphocyte counts less than 500 cells/ml. In addition, the National HIV/AIDS Strategy highlights the use of ART for HIV prevention. Adherence to ART among PLWHA is critical for treatment success and is highly associated with beneficial health outcomes, including reduced mortality. Sub-optimal adherence may lead to viral resistance and fewer and more complex treatment options for patients. Efficacious adherence strategies should be incorporated into HIV clinical care. 

Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents DHHS (January 2011) http://www.aidsinfo.nih.gov/Guidelines/GuidelineDetail.aspx?MenuItem=Guidelines&Search=Off&GuidelineID=7&ClassID=1

Testing, Referral, Linkage, and Retention

Research demonstrates that early initiation of HIV treatment optimizes health outcomes for PLWHA. In addition, assessing the immediate needs of PLWHA and identifying appropriate referrals for psychosocial and support services is essential to the adequate treatment of HIV infection. Both clinical guidelines and the NHAS highlight that PLWHA must both receive needed services and be retained in care to ensure optimal health outcomes.

Mother to Child Transmission

Nearly all HIV infections in children are acquired from their HIV-infected mothers. HIV treatment guidelines support the following interventions: prenatal and perinatal HIV testing, antiretroviral treatment and prophylaxis, scheduled cesarean delivery, and avoidance of breastfeeding. ART should be initiated for HIV-infected women who are planning on becoming or are already pregnant regardless of CD4 count.

Partner Services

Partner services include a broad array of services that should be offered to HIV-infected persons and their partners. Research demonstrates that partner services, including its critical component of partner notification by a public health professional, increases identification of a individuals at high risk for HIV-infection and the identification of HIV-positive individuals who did not know their status.

Prevention Services

The CDC has launched a national campaign to inform health care providers of the importance of providing prevention services to PLWHA as a new “standard of care.” The guidelines, protocols, and other resources listed below can support health center efforts to integrate HIV prevention into the care and treatment services they provide to PLWHA.

IV. Key Resources for HIV/AIDS Training and Technical Assistance

Health Centers are encouraged to seek training and technical assistance from the following programs funded by HRSA and our Federal partners.

AIDS Education and Training Centers (AETC) Program

The Ryan White HIV/AIDS Program administers the AETCs, which supports 11 regional centers (and more than 130 local performance sites) that conduct targeted, multi-disciplinary education and training programs for healthcare providers treating persons with HIV/AIDS. The AETCs serve all 50 States, the District of Columbia, the Virgin Islands, Puerto Rico, and the six U.S.-affiliated Pacific Jurisdictions. The mission of the AETCs is to improve the quality of life of patients living with HIV/AIDS through the provision of high quality professional education and training. Regional and national AETCs endeavor to  maintain and increase the number of health care providers who are competent and willing to counsel, diagnose, treat, and medically manage individuals with HIV infection and to help prevent high risk behaviors that lead to HIV transmission.

  • National Center for HIV Care in Minority Communities (NCHCMC)—Provides in-depth and long-term support to help Federally Qualified Health Centers NOT directly funded by Ryan White build or improve their organizational capacity to provide primary medical care and treatment. The NCHCMC is led by HealthHIV in collaboration with the National Association of Community Health Centers (NACHC). HealthHIV provides technical assistance, capacity building, and medical education services to advance effective prevention, care and treatment, and support for racial/ethnic minorities living with HIV or at risk for HIV infection. NACHC provides education, training, technical assistance, and leadership development to health centers to promote excellence and cost-effectiveness in primary care. http://www.nchcmc.org/
  • National HIV/AIDS Clinicians’ Consultation Center—Provides health care providers with timely, expert and appropriate responses to clinical questions regarding the prevention and treatment of HIV/AIDS. All consultations provided through the services listed below are free and confidential. http://www.nccc.ucsf.edu/
    • The National HIV Telephone Consultation Service (Warmline) offers physicians and other health care practitioners up-to-the-minute HIV clinical information, and individualized expert case consultation across the broad range of clinical HIV/AIDS problems. The Warmline is staffed by physicians, clinical pharmacists and nurse practitioners every Monday through Friday, from 5:00 AM to 5:00 PM (Pacific Time). Voice mail is available 24 hours a day. Phone 800-933-3413.
    • The National Clinicians' Post-Exposure Prophylaxis Hotline (PEPline) offers treating clinicians up-to-the-minute advice on managing occupational exposures (i.e., needle sticks, splashes, etc.) to HIV, hepatitis and other blood-borne pathogens. PEPline clinicians will respond to your call 24 hours a day, 7 days a week. Phone 888-448-4911.
    •  The National Perinatal HIV Consultation and Referral Service (Perinatal HIV Hotline) offers clinical consultation and advice regarding the management of HIV in pregnant women, HIV testing in pregnancy, and the care of HIV-exposed infants. Clinical consultations are available 24 hours a day, 7 days a week. Phone 888-448-4911.
  • National Resource Center—Offers a virtual library of on-line training resources for adaptation to meet local training needs; timely, high quality, state-of-the-art clinical information; training materials on new and emerging issues important to HIV care providers; and listservs providing information about updates in clinical treatment guidelines, availability of new training resources and newly available government documents. Links to regional, national, and international AETCs also are provided. http://www.aidsetc.org/
  • National Multicultural Center—Provides quality standardized training and technical assistance in Cultural Competency (knowledge and practice) for HIV/AIDS care and treatment, and serves as a resource for the improvement of multicultural health care. http://www.aetcnmc.org/

The TARGET Center

The TARGET Center (Technical Assistance Resources, Guidance, Education, & Training) offers clinical information, resources, technical assistance, and training to support HIV/AIDS service delivery and programs. The TARGET Center is funded by the Ryan White HIV/AIDS program to support Ryan White agencies, planning bodies, and Federal staff; however, it also serves as a valuable resource for consumers in search of services, health and support service providers, and the general public. Key features of the TARGET Center include a TA Library, a map-based listing of Ryan White agencies, sources of technical assistance organized by topic, and a Help Desk for on-line and phone-based support. http://careacttarget.org/

Diffusion of Evidence Based Interventions (DEBI) Project

High quality training and on-going technical assistance regarding selected evidence-based HIV, STD, and Viral Hepatitis prevention interventions are available to States and community programs through the DEBI Project. The dissemination of effective interventions related to effective HIV prevention is a critical part of building capacity among organizations that implement prevention programs for populations at risk for HIV. Funding for DEBI training and technical assistance is provided by the CDC. http://www.effectiveinterventions.org/en/home.aspx

V. Partnership Opportunities and Other Information Resources

When working to build or expand HIV/AIDS capacity in response to the NHAS, health centers are encouraged to pursue new collaborations and strengthen existing partnerships with other health and support service providers, professional associations, Tribal entities and providers, and other government agencies. Health centers can pursue partnerships and obtain additional HIV/AIDS related resources and information from the following Federal agencies and national associations.

Health Resources and Services Administration

Centers for Disease Control and Prevention (CDC)

  • ECHPP Grant Program (Enhanced Comprehensive HIV Prevention Planning and Implementation for Metropolitan Statistical Areas Most Affected by HIV/AIDS)—A new grant program established to: 1) improve responsiveness to the NHAS and 2) improve access to an optimal combination of HIV prevention, care, and treatment services in areas highly impacted by HIV/AIDS (see http://www.cdc.gov/hiv/nhas/echpp/). The 12 highly impacted jurisdictions funded under ECHPP represent 44% of the AIDS epidemic. In these jurisdictions, the CDC-funded health departments listed below will work to enhance their existing HIV prevention plans and implement corresponding activities in collaboration with local, state, and national partners.
    • New York City Department of Health & Mental Hygiene, Bureau of HIV/AIDS Prevention & Control
    • Los Angeles County Department of Public Health, Office of AIDS Programs & Policy
    • District of Columbia Department of Health, HIV/AIDS, Hepatitis, STD, & TB Administration
    • Chicago Department of Public Health, Division of STD/HIV/AIDS Public Policy & Programs
    • Georgia Department of Community Health, Public Health Division, HIV Unit
    • Florida Department of Health, Bureau of HIV/AIDS
    • Philadelphia Department of Public Health, AIDS Activities Coordinating Office
    • Houston Department of Health & Human Services, Bureau of HIV/STD & Viral Hepatitis Prevention
    • San Francisco Department of Public Health, HIV Prevention Section
    • Maryland Department of Health & Mental Hygiene, Infectious Disease & Environmental Health Administration
    • Texas Department of State Health Services, HIV/STD Prevention & Care Branch
    • Puerto Rico Department of Health, Division of HIV & STD Prevention
  • Division of HIV/AIDS Prevention (DHAP), National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP)—Statistics and surveillance information, fact sheets, brochures, slide sets, podcasts, and other resources, available at http://www.cdc.gov/hiv/aboutDHAP.htm.

Indian Health Service (IHS)

Substance Abuse and Mental Health Services Administration (SAMHSA)

  • National Survey on Drug Use & Health (NSDUH)—Primary source of information on the prevalence, patterns, and consequences of drug and alcohol use and abuse in the general U.S. civilian non institutionalized population, age 12 and older (formerly called the National Household Survey on Drug Abuse), available at https://nsduhweb.rti.org/. December 2010 national report, available at http://www.oas.samhsa.gov/2k10/210/HIV-AIDS.htm.  

National Institutes of Health (NIH)

Office of Minority Health (OMH)

White House Office of National AIDS Policy

Non-Federal Partners

VI. References

Centers for Disease Control and Prevention (CDC). Estimates of new HIV infection in the United States. 2008. Available at http://www.cdc.gov/nchhstp/Newsroom/docs/Fact-Sheet-on-HIV-Estimates.pdf.

Health Resources and Services Administration (HRSA). Uniform Data System. National Report. 2009.

Horberg MA, Aberg JA, Cheever LW, Renner P, O'Brien Kaleba E, Asch SM. Development of national and multiagency HIV care quality measures. Clin Infect Dis 2010;51(6):732-8. Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20715924

Sincerely,

James Macrae
Associate Administrator for Primary Health Care

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