Treatment as Prevention:Still not the magic bulletJeffrey Levi, PhDSYNChronicity ConferenceApril 20, 2012Arlington, VA
Combination prevention, not magicbullets Clinical (behavioral and biomedical; address syndemics) Community context and mobilization Structural environment (stigma, discrimination, social determinants) US preference for technology rather than addressing context of risk behavior (shared belief among public officials and in affected communities)—yet Tx as Prev. is harm reduction
For treatment as prevention towork: Change the Gardner cascade Increase testing Missed opportunities in clinical system Get people into care Siloed testing and treatment systems Keep people in care Keep people adherent to treatment
A new financing environment Our current system is siloed and loses people along the way Health reform changes the context for all programs Medicaid expansion, subsidized coverage New role for CDC and RW programs Rethink the system before rethought for us Start with the individual
HIV INTEGRATED SERVICES DELIVERY MODEL DEMONSTRATION CDC CMS HRSA/Ryan White State Medicaid CDC surveillance Agency ASO funded by funding with RW/HRSA with enhanced CMS enhanced CMS funding for QA using comm. viral load Coordinating Agency funding for high (could vary by design – Clinical group, ASO, etc.) intensity casesPublic Health Dept. Intensive Case Management and Funding according Capitated Medical Care Related Support to insurance status Program ServicesHIV Testing Services Behavioral Health ServicesHIV “Prevention for Housing Support Positives” (HUD/HOPWA)Funding SAMHSAServicesand PatientReferrals
Steps along the way… Testing integrated into clinical system Standard of care, reimbursement Mobilization of affected communities Address associated needs Sense of community, social determinants, syndemics, health literacy, adherence ASOs become community health organizations HIV community health workers Financed with RW/CDC funds freed from clinical needs
A time for hard conversations What is the role of AIDS service organizations in a reforming environment? What does “payer of last resort” mean in a reforming environment? And reform is happening regardless of the outcome of the ACA litigation/election What social/sexual norms do we promote? How do we frame harm reduction?