This Health Center Program Assistance Letter (PAL) provides information and resources regarding the treatment and care of people living with HIV/AIDS (PLWHA). In alignment with the National HIV/AIDS Strategy (NHAS) (http://www.aids.gov/federal-resources/policies/national-hiv-aids-strategy/), the Health Resources and Services Administration (HRSA) and the Bureau of Primary Health Care (BPHC) will continue to support efforts to prevent new HIV infections, provide access to high quality care for PLWHA, and reduce HIV-related health disparities.
In the United States, more than 1.1 million individuals are living with HIV/AIDS and roughly 21% of them do not know their HIV status (CDC, 2008). According to the Uniform Data System (UDS), in 2009 Health Centers provided HIV testing to more than 700,000 people and provided HIV/AIDS care and treatment to nearly 95,000 patients, approximately 9% of Americans with HIV.
Recent advances in pharmacologic therapies for HIV have improved the safety, tolerability, and efficacy of treatments, leading to adherence and improved health outcomes. These same advances enable more primary care practices, including health centers, to actively manage the care and treatment needs of PLWHA. To reduce AIDS-related mortality, guidelines recommend routine HIV testing and the provision of antiretroviral treatments soon after infection. This recommendation requires substantial increases in the availability, accessibility, and quality of HIV/AIDS services. Health centers are well positioned to help meet this demand.
BPHC strongly encourages and supports health centers to improve the quality of care and treatment services for PLWHA by adopting electronic health records (EHR), collecting and meaningfully using HIV/AIDS related data, and becoming patient-centered medical homes for patients living with HIV or at increased risk for HIV infection. Patient access to HIV/AIDS health and social support services can be achieved through on-site service delivery and the establishment of formal referral networks. Furthermore, health centers can improve the coordination and quality of their services through the inclusion of HIV/AIDS-related performance measures in BPHC’s Clinical Performance Measures Forms and HIV/AIDS-related protocols in Quality Assurance/Quality Improvement (QA/QI) plans (for examples of performance measures, see http://hab.hrsa.gov/deliverhivaidscare/habperformmeasures.html). These and related activities will support the Health Center Program’s efforts to improve access to care, ensure the provision of care in accordance with evidence-based clinical guidelines, and reduce disparities in health outcomes for vulnerable and underserved communities impacted by HIV/AIDS.
Early detection and treatment of HIV/AIDS integrated with culturally-appropriate support services, increases longevity and quality of life for people living with and affected by HIV/AIDS. As the HIV/AIDS epidemic in the United States moves toward 30-plus year history, Health Centers remain an essential part of the public health safety net. BPHC remains committed partners in your efforts to care for PLWHA, their families, and communities. In close collaboration with the HRSA HIV/AIDS Bureau, administrator of the Ryan White HIV/AIDS Program, BPHC is striving to increase the availability and quality of resources available to support health centers in this important work.
III. Guidelines and Protocols for HIV/AIDS Care and Treatment
Health Centers can access a broad array of guidelines and protocols regarding the provision of care and treatment to PLWHA and the prevention of new infections among those at risk for HIV infection. The AIDSinfo website is a primary vehicle for disseminating current information about treatment regimens and clinical trials for HIV infection and AIDS-related illnesses (see Clinical Guidelines Portal at http://www.aidsinfo.nih.gov/). AIDSinfo is entirely federally-funded and does not allow any company or product advertising or endorsements. The HRSA HIV/AIDS Bureau (HAB) and the Centers for Disease Control and Prevention (CDC) are other key and reliable sources of HIV/AIDS care and treatment information. BPHC encourages health centers to comply with federally-approved, evidence-based, and/or consensus-driven guidelines and protocols for HIV/AIDS care and treatment, some of which are outlined below.
The provision of antiretroviral treatment (ART) to HIV-infected persons substantially reduces the risk of HIV transmission. Recent federal guidelines support initiation of ART for all patients with CD4 lymphocyte counts less than 500 cells/ml. In addition, the National HIV/AIDS Strategy highlights the use of ART for HIV prevention. Adherence to ART among PLWHA is critical for treatment success and is highly associated with beneficial health outcomes, including reduced mortality. Sub-optimal adherence may lead to viral resistance and fewer and more complex treatment options for patients. Efficacious adherence strategies should be incorporated into HIV clinical care.
Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents DHHS (January 2011) http://www.aidsinfo.nih.gov/Guidelines/GuidelineDetail.aspx?MenuItem=Guidelines&Search=Off&GuidelineID=7&ClassID=1
Testing, Referral, Linkage, and Retention
Research demonstrates that early initiation of HIV treatment optimizes health outcomes for PLWHA. In addition, assessing the immediate needs of PLWHA and identifying appropriate referrals for psychosocial and support services is essential to the adequate treatment of HIV infection. Both clinical guidelines and the NHAS highlight that PLWHA must both receive needed services and be retained in care to ensure optimal health outcomes.
Mother to Child Transmission
Nearly all HIV infections in children are acquired from their HIV-infected mothers. HIV treatment guidelines support the following interventions: prenatal and perinatal HIV testing, antiretroviral treatment and prophylaxis, scheduled cesarean delivery, and avoidance of breastfeeding. ART should be initiated for HIV-infected women who are planning on becoming or are already pregnant regardless of CD4 count.
Partner services include a broad array of services that should be offered to HIV-infected persons and their partners. Research demonstrates that partner services, including its critical component of partner notification by a public health professional, increases identification of a individuals at high risk for HIV-infection and the identification of HIV-positive individuals who did not know their status.
The CDC has launched a national campaign to inform health care providers of the importance of providing prevention services to PLWHA as a new “standard of care.” The guidelines, protocols, and other resources listed below can support health center efforts to integrate HIV prevention into the care and treatment services they provide to PLWHA.
IV. Key Resources for HIV/AIDS Training and Technical Assistance
Health Centers are encouraged to seek training and technical assistance from the following programs funded by HRSA and our Federal partners.
AIDS Education and Training Centers (AETC) Program
The Ryan White HIV/AIDS Program administers the AETCs, which supports 11 regional centers (and more than 130 local performance sites) that conduct targeted, multi-disciplinary education and training programs for healthcare providers treating persons with HIV/AIDS. The AETCs serve all 50 States, the District of Columbia, the Virgin Islands, Puerto Rico, and the six U.S.-affiliated Pacific Jurisdictions. The mission of the AETCs is to improve the quality of life of patients living with HIV/AIDS through the provision of high quality professional education and training. Regional and national AETCs endeavor to maintain and increase the number of health care providers who are competent and willing to counsel, diagnose, treat, and medically manage individuals with HIV infection and to help prevent high risk behaviors that lead to HIV transmission.
The TARGET Center
The TARGET Center (Technical Assistance Resources, Guidance, Education, & Training) offers clinical information, resources, technical assistance, and training to support HIV/AIDS service delivery and programs. The TARGET Center is funded by the Ryan White HIV/AIDS program to support Ryan White agencies, planning bodies, and Federal staff; however, it also serves as a valuable resource for consumers in search of services, health and support service providers, and the general public. Key features of the TARGET Center include a TA Library, a map-based listing of Ryan White agencies, sources of technical assistance organized by topic, and a Help Desk for on-line and phone-based support. http://careacttarget.org/
Diffusion of Evidence Based Interventions (DEBI) Project
High quality training and on-going technical assistance regarding selected evidence-based HIV, STD, and Viral Hepatitis prevention interventions are available to States and community programs through the DEBI Project. The dissemination of effective interventions related to effective HIV prevention is a critical part of building capacity among organizations that implement prevention programs for populations at risk for HIV. Funding for DEBI training and technical assistance is provided by the CDC. http://www.effectiveinterventions.org/en/home.aspx
V. Partnership Opportunities and Other Information Resources
When working to build or expand HIV/AIDS capacity in response to the NHAS, health centers are encouraged to pursue new collaborations and strengthen existing partnerships with other health and support service providers, professional associations, Tribal entities and providers, and other government agencies. Health centers can pursue partnerships and obtain additional HIV/AIDS related resources and information from the following Federal agencies and national associations.
Health Resources and Services Administration
Centers for Disease Control and Prevention (CDC)
Indian Health Service (IHS)
Substance Abuse and Mental Health Services Administration (SAMHSA)
National Institutes of Health (NIH)
Office of Minority Health (OMH)
White House Office of National AIDS Policy
Centers for Disease Control and Prevention (CDC). Estimates of new HIV infection in the United States. 2008. Available at http://www.cdc.gov/nchhstp/Newsroom/docs/Fact-Sheet-on-HIV-Estimates.pdf.
Health Resources and Services Administration (HRSA). Uniform Data System. National Report. 2009.
Horberg MA, Aberg JA, Cheever LW, Renner P, O'Brien Kaleba E, Asch SM. Development of national and multiagency HIV care quality measures. Clin Infect Dis 2010;51(6):732-8. Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20715924
Associate Administrator for Primary Health Care
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