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BEHAVIORAL HEALTH: CHALLENGES AND OPPORTUNITIES IN HELPING TO

END THE HIV/AIDS EPIDEMIC

Pamela S. Hyde, J.D.SAMHSA Administrator

National Minority AIDS Council 16th Annual United States Conference on AIDS

Las Vegas, NV • September 30, 2012

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WHY DOES BEHAVIORAL HEALTH MATTER?

CDC estimates: half of all Americans will meet criteria for mental illness at some point in their lives; half of us know someone in recovery from substance abuse

7 percent of the adult population (34 million people), have co-morbid mental/physical conditions w/in a given year

People with M/SUDs are nearly 2x as likely as general population to die prematurely, (8.2 years younger) often of preventable/treatable medical causes (95.4 percent)

Violence and trauma are significantly associated with ↑ risk for health, BH & HIV• Lifetime history of sexual abuse among women: ~ 15 to 25 percent• 30 to 57 percent of female substance abusers meet criteria for PTSD, with

elevated risk related to higher incidence of childhood physical and sexual abuse – 2 or 3 times ↑ than males

• Almost all women in M/SUD treatment settings have history of trauma

Untreated M/SUDs among top 5 predictors of poor adherence to HIV/AIDS treatment

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M/SUDs ↑ RISK

Physical health problems & chronic diseaseHIV/AIDS, STDs, HepatitisLost productivity/job loss

Parenting deficiencies & involvement in CW systemAdult & Juvenile incarceration & recidivism

HomelessnessSuicide attempts and completions

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SUBSTANCE USE AND HIV/AIDS

Behaviors associated w/substance abuse fuel HIV transmission

9 percent of all new HIV infections occur among injection drug users; 3 percent among MSM/IDU

Effects of drugs/alcohol alters judgment; people engage in impulsive and unsafe sexual behaviors contributing to spread of HIV as well as lowering adherence to treatment

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MENTAL HEALTH AND HIV/AIDS

~50 percent of those in HIV care have a co-morbid mental illness • Mental illness can arise independently of HIV infection; can

predispose to HIV (through risk-related behaviors); can be a psychological consequence of HIV (e.g., depression)

Regardless of etiology, co-morbidity of MI-HIV poses special challenges for care• Clinical depression is the most commonly observed MH

disorder among HIV-infected patients, affecting up to 22 percent of patients; prevalence may be even greater among substance users

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NATIONAL LOOK: SUBSTANCE DEPENDENCE OR ABUSE

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2011 RATE OF SUBSTANCE DEPENDENCE OR ABUSE 12 AND ↑: RACE/ETHNICITY

SAMHSA, CBHSQ, 2011 NSDUH

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PAST MONTH ILLICIT DRUG USE: 12 OR ↑, BY RACE/ETHNICITY, 2002-2011

Percent Using in Past Month

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CHANGING LANDSCAPE: REPORTED AIDS CASES

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NATIONAL HIV/AIDS STRATEGY: REDUCING DISPARITIES/PROMOTING EQUITY

Reduce HIV-related mortality in communities at high risk for HIV infection

Adopt community-level approaches to reduce HIV infection in high-risk communities

Reduce prejudice and discrimination against people living with HIV

http://www.aids.gov

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NATIONAL HIV/AIDS STRATEGY: 4 KEY GOALS

1) ↓ # of people who become infected w/ HIV

2) ↑ access to care and optimize health outcomes for people living w/ HIV

3) ↓ HIV-related health disparities

4) Achieve a more coordinated national response to HIV epidemic in U.S.

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GOAL 4: ACHIEVE A MORE COORDINATED NATIONAL RESPONSE TO HIV EPIDEMIC IN U.S.

Central to goal: 2 related directives• Develop improved mechanisms to monitor, evaluate, and report on progress

toward achieving national goals

• Simplify grant administration activities by standardizing data collection and reducing undue grantee reporting requirements for federal HIV programs

Secretary Sebelius to OPDIVs: Finalize common, core HIV/AIDS indicators consistent w/ IOM recommendations

RFI: Data Streamlining /Reducing Undue Reporting Burden• For HHS-funded HIV prevention, treatment, and care services grantees• Issued in Federal Register 8/22/12; public comment period closed 9/21/12

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COMMON CORE INDICATORS(SAMHSA Reducing Burden 20-25%)• HIV Positivity

• Late HIV Diagnosis

• Linkage to HIV Medical Care

• Retention in HIV Medical Care

• Antiretroviral Therapy (ART) Among Persons in HIV Medical Care

• Viral Load Suppression Among Persons in HIV Medical Care

• Housing Status

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SAMHSA’S ROLE IN NHAS IMPLEMENTATION – Funding (# in millions)

CENTER/PROGRAM FY 2013 CR

Center for MH Services (CMHS) Minority Aids Initiative (MAI

$9.3

CMHS S-to-S $.773

Center for SA Prevention (CSAP) MAI $41.3

Center for SA Treatment (CSAT) MAI $65.9

SA Prevention & Treatment Block Grant (SABG) (HIV Early Intervention Services 5% set aside)

$60.1

Total $177.4

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SAMHSA’S ROLE IN FEDERAL IMPLEMENTATION PLAN – NHAS TARGETS

Simplifying grant administration activities: Work on development of core indicators

Linking people to continuous and coordinated quality care: Rapid HIV testing supplements to CSAP grantees

Promoting a more holistic approach to health: Funding Targeted Capacity Enhancement (TCE) grantees to provide viral hepatitis (B and C) testing and referral to care that addresses prevention of HIV related co-morbidities; integrates activities from the National Vial Hepatitis Action Plan

Preventing HIV among substance users: Identifying people w/SUDs via SABG funded HIV programs; also SABG HIV Early Intervention Services 5 percent set-aside

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SAMHSA’S ROLE IN 12 CITIES PROJECT

2011: HHS initiated steps to strengthen coordination of responses to HIV/AIDS of CDC, HRSA, IHS, NIH, SAMHSA, CMS, and OASH

12 Cities Project central to effort - Houston, Tallahassee, San Juan, Philadelphia, San Francisco, New York, Chicago, Los Angeles, Baltimore, Washington, Atlanta and Dallas

• SAMHSA was able to fund 11 of 12 cities

Local level collaboration w/ housing, veterans services, and other HIV-related programs in jurisdictions w/ highest AIDS burden

Anchor: CDC’s Enhanced Comprehensive HIV Prevention Planning initiative – SAMHSA provides joint project officers

Cross-agency and cross-departmental communications at federal/local levels• Data sharing discussions• Development of common core indicators• Mapping of Ryan White Program service locations• Exploration of data streamlining• Coordinated funding opportunities

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SAMHSA’S MINORITY AIDS INITIATIVE TCE: INTEGRATED BH/PC NETWORK GRANTS

Purpose: Develop and expand culturally competent/effective integrated behavioral health and primary care networks, including HIV services and medical treatment, w/in racial and ethnic minority communities in Metropolitan Statistical Areas and Metropolitan Divisions most impacted by HIV/AIDS

Eligible Grantees: Public Health Departments funded under CDC’s Enhanced Comprehensive HIV Prevention Planning and Implementation of Metropolitan Statistical Areas Most Affected by HIV/AIDS grant program

Priority Populations: Minority MSM, WomenGrant awards in FY 2011: 11 awards at ~ $1.3 million each; 3-year

grant program funded from FY 2011-FY 2013

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SAMHSA’S SA TREATMENT FOR RACIAL/ETHNIC MINORITY POPULATIONS AT HIGH-RISK FOR HIV/AIDS GRANTS

Purpose: Develop and expand culturally competent and effective community-based treatment systems for SUDs and co-occurring M/SUDs w/in racial and ethnic minority communities in states w/ highest HIV prevalence rates (at or above 270 per 100,000)

Eligible Grantees: Community Based Organizations

Priority Populations: Young MSM, Women

Grant awards in FY 2012: Up to 52 awards at ~ $500K each; 5-year

New grant awards expected in FY 2013: Expected funding for treatment based grants under FY 2013 CR

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SAMHSA’S PREVENTION OF SUBSTANCE ABUSE AND HIV FOR AT-RISK RACIAL/ETHNIC MINORITY POPULATIONS GRANTS

Purpose: Deliver and sustain quality/accessible SA and HIV prevention services aimed at preventing and reducing onset of SA and transmission of HIV/AIDS among at-risk racial/ethnic minority subpopulations

Eligible Grantees: Community-level domestic public and private nonprofit entities

Priority Populations: Minority MSM, Women, Injection Drug Users, Re-Entry Populations

Grant awards in FY 2008/09: 51 awards at ~ $400k each; 5-year

New grant awards expected in FY 2013: Expected funding for prevention based grants under the FY 2013 CR

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ACA: TRANSFORMATIVE POSITIVE EFFECT FOR THOSE LIVING W/BH PROBLEMS AND/OR HIV

People w/ BH problems and/or HIV are more likely to be uninsured, to face barriers in accessing medical care, and to experience higher rates of prejudice and discrimination than other groups

ACA ↓ disparities that currently exist between availability of services for M/SUDs compared w/availability of services for other medical conditions – parity applies

ACA supports integrated, coordinated care, especially for people w/ BH and co-occurring health conditions, such as HIV/AIDs

Expands Medicaid for the lowest income people; strengthens and improves Medicare; and makes private insurance work better for all Americans

Increases access to critical prevention services, including SBIRT and HIV testing

Prohibits discrimination on basis of M/SUDs and HIV status as pre-existing conditions; bans lifetime limits on insurance coverage; and is phasing out annual limits in coverage

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SAMHSA’S HEALTH REFORM PRIORITIES – FY 2012 AND FY 2013

Uniform Block Grant Application for FY2014 & FY2015 Enrollment PreparationExchanges and Qualified Health Plans CapacityParity in Medicaid Benchmark Plans and Essential Health

BenefitsProvider Capacity Development (Including Workforce)Work with States and Medicaid• Health homes, rules/regs, service definitions and evidence,

screening, prevention, duals, PBHCI, payment issues• Parity – MHPAEA/ACA Implementation & Communication

Quality (NBHQF) and Data (including HIT)

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BEHAVIORAL HEALTH IS COMMUNITY HEATLH