Documentos de Académico
Documentos de Profesional
Documentos de Cultura
2
Outline
• Status-Neutral: A New Paradigm
• Defining status-neutral
• Why do we need a status-neutral approach?
• Where are the implementation gaps?
• Embracing Status-Neutral
• Lessons Learned
3
Defining status-neutral
4
5
Status-Neutral: Principles
• Positions testing as the “gateway”
• Offer the same approach regardless of status
• Integrates prevention and care programs
• Leverages the same approaches for both prevention and care
• Fully utilizes our “new” tools
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Why do we need a status-neutral approach?
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Lifetime Risk of HIV in the US
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Hess et al., CROI 2016.
Lifetime Risk of HIV in Heterosexuals
MALES FEMALES
“One in n” 95% CI “One in n” 95% CI
MSM 6 6-6
American Indian/Alaska Native 12 11-13
Asian 14 13-14
Black 2 2-2
Latino 4 4-5
Native Hawaiian/API 7 4-7
White 11 10-11
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Ending the Epidemic:
Jurisdictional Plans
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Ending the Epidemic:
Jurisdictional Plans
EtE Plan:
1. Test
2. Treat
3. PrEP
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Viral Suppression Has Increased Dramatically
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Nance et al., Ann Int Med 2018.
PrEP Use Has Increased Dramatically
Stabilization
Rapid Growth
Slow Growth
Vancouver Study
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Gaps Exist in Sustained Viral Suppression
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Crepaz N, Dong X, Wang X, Hernandez AL, Hall HI. Racial and Ethnic Disparities in Sustained Viral Suppression and Transmission Risk Potential Among Persons Receiving HIV Care — United States, 2014.
MMWR Morb Mortal Wkly Rep 2018;67:113–118. DOI: http://dx.doi.org/10.15585/mmwr.mm6704a2
Gaps Exist in Who is Starting PrEP
PrEP Retention
DISTRUST
BARRIERSOF HEALTH
SEXISM STATIC CARE MODELS
NEGATIVE
LACK OF PAST
EXPERIENCES
AFFIRMING CARE STIGMATIZING MESSAGING
HOMELESSNESS 32
What Does This Mean?
• We have embraced our “new” tools…to an extent
• Gaps plague both HIV care and prevention
• Social and structural barriers are playing a role
• We won’t improve engagement unless we fully address these
barriers
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Can embracing a status-neutral
approach help close these gaps?
Embracing a status-neutral approach
Simplifiy eligibility/monitoring
36
for ARVs Innovate Service Delivery
Embracing a status-neutral approach
Simplifiy eligibility/monitoring
37
for ARVs Innovate Service Delivery
Patient Navigation
• An intervention originally designed to help improve poor treatment
outcomes through community health workers, peers
• Recognizes both the complexity of medical care, the difficulty of
engaging in it, and the burden of social issues
• Support for
• Developing a patient-centered care plan
• Obtaining needed social services, including accompaniment
• Coaching to become self-sufficient
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Comprehensive Navigation for HIV Care
Social Services
Care
and Benefits
Navigation
Assessment
CLIENT
Treatment
Health
Adherence
Support + DOT
Promotion
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https://www1.nyc.gov/site/doh/providers/resources/playsure-network.page
NYC PlaySure Network Model: The 1 st Yr.
From March 2017-April 2018, across 27 PSN sites focused on PrEP provision:
• 7279 anonymous engagement screens
• 4077 enrollments
• 941 prescribed PrEP
• XXX linked to care
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From NYC Health Department, unpublished data, 2018
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Embracing a status-neutral approach
Simplifiy eligibility/monitoring
45
for ARVs Innovate Service Delivery
Financial Burden of HIV Medications
Financial Burden of HIV Medications
Reducing the Financial Burden of HIV Treatment
• AIDS Drug Assistance Programs (ADAPs) have played a crucial role in
reducing socioeconomic disparities in access to HIV medications
• Financial issues, including medication cost or coverage, lead to lapses in ARVs
• Receipt of ADAP is associated with earlier treatment and viral load
suppression
• Can similar financial assistance programs reduce the cost burden of
PrEP and improve access to services?
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From NYC Health Department, unpublished data, 2018.
NYC: Training on Benefits Navigation
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Controversy:
Lowering the Price of HIV Medication
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Controversy:
Lowering the Price of HIV Medication
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Embracing a status-neutral approach
Simplifiy eligibility/monitoring
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for ARVs Innovate Service Delivery
Eligibility for Treatment Initiation
A Focus on WHO Guidelines
Typical Course of HIV Infection
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DHHS HIV Treatment Guidelines, 2018. Available at: https://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-arv/458/plasma-hiv-1-rna--viral-load--and-cd4-count-monitoring
Simplifying Monitoring for PrEP?
• Less frequent monitoring is already being implemented
• Current protocols, requiring every 3 month labs, are likely too
conservative
• Onerous monitoring schedule likely contributes to low PrEP
persistence
• Controversy: Will we miss new infections?
• It is not logical to require more intensive monitoring of HIV-negative
people than of PLWH
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Spinelli et al. Open Forum Infect Dis. 2018
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Embracing a status-neutral approach
Simplify eligibility/monitoring
63
for ARVs Innovate Service Delivery
Innovate Service Delivery
• Bypass clinical settings – avoid stigma
• Improve/increase accessibility of services – hours, location
• Streamline service delivery – more use of staff, resources
• Increase points of access into the system
• Engage different communities
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Models for Innovation in Service Delivery
(meet consumers where they are)
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67
Sexual Health Clinics
Clinic Access:
• Walk-in basis (Both MD & screening-only
visits)
• 5 days/week at 8 sites; Saturdays at 2 sites;
2 evenings at one site
• Services rendered irrespective of ability to
pay
• Confidential – no documentation needed
• Ages 12 years and up; no parental
notification
• Expand services – contraception, restore
asymptomatic screening
Sexual Health Clinics
Are the Front Line of HIV
NYC HIV Incidence Studies:
• 1 in 42 MSM attending NYC STD Clinics were diagnosed with HIV within a
year1
• 1 in 20 MSM diagnosed with P&S Syphilis in NYC were diagnosed with HIV
within a year2
73
Lessons Learned
Benefits of Status-Neutral Approach
• Reduce institutionalized stigma for people living with HIV
• Recognize that the “serodivide” is already crumbling
• Create efficiencies – improve resource utilization
• Gain insights from parallel service delivery
• People-focused – embrace the person; service delivery is secondary
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Benefits of People-Focused Approach
• Assesses our models of care through a new lens
• Supports self-esteem by normalizing conversations and strategies to
optimize health
• Focuses on sexual health and pleasure – harm reduction
• Respects the individual and their autonomy
Lessons Learned from Implementing
Status-Neutral
• Robust collaboration is needed (internal/external)
• Full integration requires a thorough, deliberate approach
• Messaging has to match programming (and vice versa)
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Promoting Health Through
A Status-Neutral Lens
Beyond Status-Neutral
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Ending the Epidemic
NYC
THANK YOU!
jmyers@health.nyc.gov
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Acknowledgements
• Oni Blackstock
• Maria Ma
• Stephanie Hubbard
• Graham Harriman
• Ben Tsoi
• Paul Kobrak
• Zoe Edelstein
• Demetre Daskalakis
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