Federal funding is evolving in ways that will enhance TLC-Plus: The new Ryan White Part A application for 2011 focuses on coordination and clustering of services with an emphasis on quality, standards of care, and health outcomes. Furthermore, coverage expansions planned for 2014 under health care reform could allow a re-allocation of resources (e.g., ADAP and Ryan White) to expand coverage of care and treatment. Three of the four cities profiled here (Washington, D.C., Los Angeles, and San Francisco) are recipients of nearly $1 million each from the CDC as part of the Enhanced Comprehensive HIV Prevention Planning (ECHPP) and Implementation for Metropolitan Areas Most Affected by HIV/AIDS. These 12 jurisdictions represent 44% of the HIV epidemic. The goal of ECHPP is to align resources and jurisdictions' prevention activities with the prevention goals of the National HIV/AIDS Strategy. ECHPP funds many strategies associated with TLC-Plus, including routine opt-out screening for HIV in medical settings, HIV testing in non-clinical settings, and efforts to change existing structures, policies, and regulations that are barriers to prevention, care, and treatment. Funding began in September 2010.
The President's 2012 proposed budget, if approved, includes expanded funding for programs in line with TLC-Plus.
While targeted testing in high prevalence communities is more effective than widespread testing, the cost-effectiveness of routine HIV testing in health care settings is similar to those of commonly accepted interventions. A study by Sanders et al. found that screening costs less than $50,000 per quality-adjusted-life-year if HIV prevalence exceeds just 0.05%.14 Recurrent screening became more cost-effective in communities or populations with higher HIV incidence.
According to the same study, even a one-time screening program leads to a lifetime reduction of 44% in transmissions for a person with HIV, as compared with the natural history of the disease had the person gone undiagnosed, and a reduction in the annual transmission rate of approximately 21% with the use of a screening program, as compared with the absence of screening.14
The Louisiana State University Health System Health Care Services Division (LSU HCSD) and the Louisiana Department of Health and Hospitals Office of Public Health (DHH OPH) have successfully implemented an electronic information exchange between the two organizations with the purpose of improving timeliness of disease reporting and access to care and treatment for persons with HIV, syphilis, or tuberculosis. The OPH HIV/AIDS Program estimates that 45% of the more than 17,500 persons living with HIV in Louisiana are not in care. As many as 1,100 persons who were previously diagnosed by OPH but who did not receive their HIV test results or were not in HIV care, presented at HCSD facilities for other medical reasons. With electronically shared medical information, OPH is able to alert clinicians in the LSU HCSD system of patients who need to be informed of their diagnosis or linked/re-linked to care. The system allows for "electronic outreach" for those lost to OPH and the care system and increases opportunities to intervene with patients earlier in the course of disease.
A fundamental question in a project such as this is whether consumers would accept the sharing of confidential medical information between two health agencies. In order to understand consumer opinion before moving forward with the plan, the two Louisiana agencies conducted 16 focus groups of 149 persons in eight rural and eight urban locations followed by more in-depth interviews with selected participants. These focus groups and interviews revealed that consumers expect protection of their records but that control of content and access to those records, not privacy per se, was the main concern. Consumers were more comfortable with those closest to treatment having the most access and having a tracking system in place so that records are kept of who has viewed medical records.
As of May 2010, there were 282 matches from the system and a 65% response rate. Of 216 LSU patients tracked for follow-up, 118 had received follow-up HIV care, and 111 had current CD4 and viral load counts.
The strategies discussed here begin to demonstrate the feasibility of implementing components of TLC-Plus in various settings -- from large urban metropolitan areas such as Los Angeles to smaller geographical areas such as San Francisco and Washington, D.C., to less urban settings such as Alabama. HIV testing in medical settings and targeted testing strategies among hard-to-reach populations in which testing yields a high positivity rate (generally >= 1%) are the cornerstones of TLC-Plus. With a higher percentage of those infected with HIV knowing their status, HIV transmission can be lowered significantly through behavioral change and through care and treatment.
Linkage to care includes a number of strategies to simplify entry (and re-entry) into care. These include financial incentives, streamlining of appointments, co-location of testing and care services, physical escort to services, and other means to track patients missing from care. Strategies to link newly diagnosed patients into care often work effectively to assist patients in re-entry in care, particularly when coupled with surveillance data or when coupled with shared electronic medical records so that patients seeking care for non-HIV or non-STD-related medical conditions can be re-linked into care, as has been done in Louisiana.
As the several aforementioned studies released this year and last indicate, TLC-Plus strategies, in which a greater percentage of those infected receive ARV treatment and more people with undetected HIV are diagnosed and entered into care, can curb the domestic HIV epidemic in ways thought unimaginable just a few years ago.
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