Michael Horberg, MD MAS FIDSAExecutive Director Research and Community BenefitMid-Atlantic Permanente Medical GroupDirector HIV/AIDS, Kaiser PermanenteChair, Board of Director, HIV Medicine Association

October 2, 2013

Success and Challenges

Disclosures

Employee of Kaiser Permanente Ongoing research grants from:

– Pfizer– Merck

• Organizational• Chair, HIV Medicine Association• Member and committee chair, Presidential Advisory Council on HIV/AIDS

Please note that the opinions expressed in this presentation represent those of the presenter and do not necessarily reflect the view of Mid-Atlantic Permanente Medical Group or Kaiser Permanente.

3 April 9, 2023

Success is Possible

The 5 STDs: GC/Chlamydia, HBV, HCV, Syphilis

Males andFemales

Females Males0

20

40

60

80

100

55.252.2

61.5

43.1 44.840.8

49.7 50.6 48.5

55.2 54.057.357.7 56.4

59.9

Patients with Any of 5 STDs also tested for HIV: all regions

2007* 2008 2009 2010 2011

Percent

*for 2007 data from GA, NC, NW, SC only and Hep B/C pos required prior neg

4 April 9, 2023

Even Better:

Gonorrhea, Chlamydia, Syphilis

Males andFemales

Females Males Males andFemales

Females Males0

20

40

60

80

100

55.452.4

61.859.3

55.3

68.0

61.757.6

70.3

63.358.6

72.9

64.960.5

74.1

Patients with Any of 3 STDs also tested for HIV: all regions

2007 2008 2009 2010 2011

Percent

5 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.April 9, 2023

Improved KP HIV Care Cascade (compared to US)

Reasons for success:• Multidisciplinary Care

Team • Electronic Health

Record• Quality Measurement

and Quality Improvement

• Continued Provider Education

KP Performance on Chlamydia Testing

• Committed to it • (KP Georgia #1 nationally 2011—not just within KP)

• US 90th Percentile performance: 53.4% (age 16-24)• KP Program wide performance: 65.8%*

• All KP regions are above US 90th percentile• Also, all regions and KP nationally above US 90th percentile for ages 16-20 or 21-24

age groups

• KP performance demonstrates that with commitment at multiple levels this is achievable

• But even we can improve

*--Commercial plans; similar results for Medicaid only patients2011 data; probably has gotten better

No evidence that we are capturing all STDs– But at least we are testing them for HIV

These are not rates:– STDs are increasing, not decreasing

– So are we really doing the job?

Doesn’t reflect patient education And are all doctors talking to their patients about

prevention, sexual health, domestic violence?

But What That is NOT:

7| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.April 9, 2023

HIV Disparities among Black MSM vs. White MSM, Black Community, and U.S. Population

vs. White MSM vs. Black community vs. U.S. population0

10

20

30

40

50

60

70

80

90

HIV

Pre

vela

nce

Sum

mar

y O

dds

Ratio

(Millett et. al, The Lancet, 2012)

3X

22X

72X

Undiagnosed HIVOR, 6.38 (4.33-9.39)

>200 CD4 cells/mm3 before

ART initiation OR, 0.40 (0.26-0.62)

ART adherenceOR, 0.50 (0.33-0.76)

HIV suppressionOR, 0.51 (0.31-0.83)

Healthcare visitsOR, 0.61 (0.42-0.90)

HIV Detection

Viral Suppression

Health insurance

OR, 0.47 (0.29-0.77)

Lower income (<$20k)

OR, 3.42 (1.94-6.01)

(Millett, 2012)

Diagnosed HIV+OR, 3.00 (2.06-4.40)

Disparities persist between black and other MSM throughout treatment cascade

(24 comparative studies)

ART utilization/ accessOR, 0.56 (0.41-0.76)

“To eliminate difference in viral suppression, an estimated additional 38,920 black MSM and 17,043 Latino MSM would need to be on treatment to raise viral suppression to levels on

par with white MSM aware of their infection (56%).” (Hall, 2013)

Physicians and Diagnosing Positives 1208 MSM (597 black, 611 Latino) not

previously diagnosed with HIV– 105 black, 33 Latino MSM HIV-positive

unaware

Black MSM who were HIV-positive unaware

– 3x more likely than HIV- black MSM to have health insurance

– 3x more likely to have disclosed sexuality their healthcare provider

– 94% less likely to have more than 3 lifetime HIV test

Of 44 undiagnosed HIV+ black MSM who disclosed sexuality to provider

– UIAI with 9 HIV- partners past 3 mos– URAI with 14 HIV- partners past 3 mos

11 April 9, 2023

US Preventive Services Guidelines for HIV Testing

Release Date: April 2013 The USPSTF recommends that clinicians screen for HIV infection

in adolescents and adults ages 15 to 65 years. Younger adolescents and older adults who are at increased risk should also be screened.Grade: “A” Recommendation.

The USPSTF recommends that clinicians screen all pregnant women for HIV, including those who present in labor who are untested and whose HIV status is unknown.Grade: “A” Recommendation.

Now covered by Affordable Care Act (ACA). Encourage all healthcare professionals to test their patients.

htp://www.uspreventiveservicestaskforce.org/uspstf/uspshivi.htm

12 April 9, 2023

US Preventive Services Guidelines for HIV Testing

Release Date: April 2013 The USPSTF recommends that clinicians screen for HIV infection

in adolescents and adults ages 15 to 65 years. Younger adolescents and older adults who are at increased risk should also be screened.Grade: “A” Recommendation.

The USPSTF recommends that clinicians screen all pregnant women for HIV, including those who present in labor who are untested and whose HIV status is unknown.Grade: “A” Recommendation.

Now covered by Affordable Care Act (ACA). Encourage all healthcare professionals to test their patients.

htp://www.uspreventiveservicestaskforce.org/uspstf/uspshivi.htm

This is an important innovation.

13 April 9, 2023

However, next steps for the change:

1. Get eligible patients enrolled in the marketplace or enlarged Medicaid.

2. Get them to see their doctor.3. Get the patient educated to ask the right questions.4. Need to think of sub-populations:

1. Not just men/women, younger/older, gay/straight2. Need to think about as young Black MSM, etc.

1. Each of these sub-groups may need a different strategy

Your doctor or nurse

Federal agencies

State agencies

Your local pharmacist

An employer

Your local church or place of worship

Non-profit or community organization

Friends and family

A health insurance company

The news media*

Social networking sites

44%

34%

33%

30%

21%

21%

20%

18%

15%

8%

3%

NA = Item not asked for this question.*The news media includes cable TV news, national or local TV news, radio news or talk radio, online news sources, and newspapers/magazines.NOTE: Wording for some items abbreviated; item wording between questions varies. For full question wording see topline: http://www.kff.org/health-reform/poll-finding/kaiser-health-tracking-poll-august-2013/ SOURCE: Kaiser Family Foundation Health Tracking Poll (conducted August 13-19, 2013)

Most Trusted on ACA: Doctors and Nurses, Federal and State Agencies, Pharmacists

22%

16%

14%

19%

12%

49%

15%

81%

23%

NA

NA

Percent who say they have heard something about the law from each of the following in the past 30 days:

Percent who say they would trust information about the health care law from each of the following ‘a lot’:

Healthcare professionals are the most trusted. We must inform.

States Health Insurance Marketplace Decisions, May 10, 2013

Partnership Marketplace (7 states)

State-based Marketplace (16 states and DC)

Federally-facilitated Marketplace (27 states)

WA

OR

WY

UT*

TX

SD

OK

ND

NM

NV NE

MT

LA

KS

ID

HI

CO CA

ARAZ

AK

WI

WV VA

TN SC

OH

NCMO

MS

MN

MI

KY

IA

IN IL

GA

FL

AL

VT

PA

NY

NJ

NH

MA

ME

CT

DE

RI

MD

DC

• In Utah, the federal government will run the marketplace for individuals while the state will run the small business, or SHOP, marketplace.

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17 April 9, 2023

This will need promotion.We’ll need your help.

18 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.

April 9, 2023

Other Innovations Pre-Exposure Prophylaxis (PrEP) to Prevent HIV Post-Exposure Prophylaxis (PEP)

– Likely Underutilized

STD testing as quality measures– This is what worked in Kaiser Permanente– Shouldn’t just be chlamydia screening of younger women

Making it a practice priority NOT just the job of urgent care or primary care

– It should be part of every healthcare worker’s evaluation and care of each patient.

19 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.

April 9, 2023

Other Considerations

Testing needs resources.– Costs of labs– Costs of personnel– Need time to contact patients, get the right treatment, etc.– Partner notification, etc.

Testing is only one part of sexual health– Empowerment!– Safety!– Pride in one’s self

Homophobia is a health hazard.

Program Sustainability-Access to Care

-Ryan White -Public & Private

Coverage-Provider

Reimbursement

Patients-Adherence to Rx

-Adherence to Care-Enhanced Quality

of Life-Improved Immune

Status-Risk/Harm Reduction

-Virologic Control

Healthcare Team-HIV/Primary Care

Provider-Specialty Medical

Care-Clinical Pharmacist-Care Coordinator

-Oral Health-Nursing

Support Services-Alcohol and Drug

Tx-Drug Assistance

-Housing-Legal Services

-Secondary Prevention Counseling-Nutrition

Counseling-Pharmacy

-Psychosocial -Mental Health

-ElectronicHealth

Records

Quality Improvement-Performance

Standards-Practice

Guidelines

-HIV Testing-Linkage to Care-Engagement & Retention in Care

-Access to Rx-Medication

Adherence Support-Medical Case Management-Co-located

Social Services-Public Health &

Community Agencies

Service Delivery & Integration

All that’s (ideally)needed to provide HIV (STD) care

Gallant, CID, 2012