4
Using the Clinical Setting

The majority of HIV prevention efforts have focused primarily on preventing HIV acquisition by uninfected persons. Several factors conspired to preclude a focus on infected persons, These factors include racism, and homophobia, and the stigma surrounding HIV/AIDS (see Chapter 7 for a more detailed description of these factors). However, given that every new infection begins with someone who already is infected, omitting persons with HIV from prevention efforts represents an important missed opportunity for averting new infections. This failure is made even more glaring by the fact that advances in antiretroviral therapy have considerably increased the number of people living with and receiving care for HIV/AIDS.

It is estimated that 350,000 to 528,000 persons with HIV now make use of the clinical care delivery system and receive regular HIV care (Bozzette et al., 1998). If prevention programs are to more effectively reach those already diagnosed with HIV, then linking clinical care and prevention is a logical next step. Forging this linkage will require that clinical care agencies and providers recognize and act upon their responsibility to provide HIV prevention services, that providers be trained accordingly, and that prevention agencies improve their ties to clinical care.

In this chapter, the Committee describes how existing clinical settings might better integrate HIV prevention activities into their care activities. We also discuss several programmatic and funding changes that may be required to better integrate HIV prevention activities in the clinical care setting.



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No Time to Lose: Getting More from HIV Prevention 4 Using the Clinical Setting The majority of HIV prevention efforts have focused primarily on preventing HIV acquisition by uninfected persons. Several factors conspired to preclude a focus on infected persons, These factors include racism, and homophobia, and the stigma surrounding HIV/AIDS (see Chapter 7 for a more detailed description of these factors). However, given that every new infection begins with someone who already is infected, omitting persons with HIV from prevention efforts represents an important missed opportunity for averting new infections. This failure is made even more glaring by the fact that advances in antiretroviral therapy have considerably increased the number of people living with and receiving care for HIV/AIDS. It is estimated that 350,000 to 528,000 persons with HIV now make use of the clinical care delivery system and receive regular HIV care (Bozzette et al., 1998). If prevention programs are to more effectively reach those already diagnosed with HIV, then linking clinical care and prevention is a logical next step. Forging this linkage will require that clinical care agencies and providers recognize and act upon their responsibility to provide HIV prevention services, that providers be trained accordingly, and that prevention agencies improve their ties to clinical care. In this chapter, the Committee describes how existing clinical settings might better integrate HIV prevention activities into their care activities. We also discuss several programmatic and funding changes that may be required to better integrate HIV prevention activities in the clinical care setting.

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No Time to Lose: Getting More from HIV Prevention CLINICAL CARE-BASED PREVENTION Some guidance on how to integrate HIV prevention into clinical care is available from the U.S. Preventive Services Task Force Guide to Clinical Preventive Services (U.S. Preventive Services Task Force, 1996), which provides a careful review of scientific evidence and indicates which preventive services are most effective. First, the guide recommends that all adolescents and adult patients should be advised about risk factors for HIV and other sexually transmitted diseases (STDs), and counseled about effective measures to reduce the risk of infection. Clinicians are further recommended to assess risk factors for HIV infection by obtaining a careful sexual and drug use history for all patients, and to periodically screen for infection among all persons at increased HIV risk. Providers who care for injection drug users (IDUs) are recommended to advise them about measures to reduce their risk of infection and to refer them to appropriate drug treatment facilities. These basic HIV prevention recommendations become even more critical for clinicians that provide care to patients known to be HIV-infected. The Committee believes that, in all clinical care settings serving HIV-infected persons and those at high risk of infection, the standard of care should include the taking of sexual and drug-using histories to help determine each patient’s risk and the appropriate level of HIV prevention intervention. If an HIV-infected individual is found to have another STD, this in itself should trigger the delivery of some type of HIV prevention counseling, as STD infection is a marker for risky sexual behavior. This is particularly important because studies have shown that STDs in an HIV-infected individual may facilitate HIV transmission by increasing the concentration of the virus in genital secretions (Moss and Kreiss, 1990; Cohen et al., 1997). Even HIV-infected persons receiving antiretroviral therapy can still spread infection. Some studies have shown that antiretroviral therapy can reduce a person’s viral load, which has been associated with a decrease in infectiousness of the person’s blood or genital secretions (Musicco et al., 1994; Royce et al., 1997; Ragni et al., 1998). These findings suggest the potential use of antiretroviral therapy in HIV prevention. However, a recent study shows that treated individuals may continue to shed HIV even after 6 months of therapy, and thus may continue to pose at least some risk for transmitting the virus to sex partners (Barroso et al., 2000). In addition, recent statistics showing a rise in HIV infections among San Francisco’s gay male population (San Francisco Department of Public Health et al., 20001), a community that has high levels of access to antiretroviral therapy, heightens the need to focus prevention interventions on HIV-infected persons and to develop multifaceted approaches to

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No Time to Lose: Getting More from HIV Prevention prevention for this population. Furthermore, risky behavior can also compromise the health of the infected person through secondary infections (Blazquez et al., 1995; Cleghorn and Blattner, 1992; Knox and Carrigan, 1995; Phair et al., 1992; Wiley et al., 1993), re-infection with drug-resistant HIV, and such opportunistic infections as tuberculosis (Japour et al., 1995; Johnson, 1995; Larder, 1995).1 To build on this initial assessment, clinicians should provide modest but recurring counseling about HIV prevention (including precautions for sexual activity, drug use, and partner notification), in order to reinforce preventive behaviors and assess whether a patient needs more intensive intervention (Francis et al., 1989; Francis, 1996). This type of routine activity within the clinical care setting is perhaps the only means that the public health system has for regularly “checking in” with infected persons about their risk behavior. Clinicians can also utilize prevention case management techniques to assess risk behavior and reinforce risk reduction among HIV-infected patients. Prevention case management, which is a client-centered, more intensive counseling and risk-management approach to delivering prevention services, has seven essential components: client recruitment and engagement; screening and assessment (comprehensive screening of HIV/STD risks and medical psychosocial service needs); development of a client-centered prevention plan; multiple sessions of HIV risk-reduction counseling; active coordination of services with follow-up; monitoring and reassessment of clients’ needs, risks, and progress; and discharge from prevention case management upon attainment and maintenance of risk-reduction goals (CDC, 1997).2 Prevention case management should also include attention to adherence to HIV antiretroviral therapies to improve and lengthen the lives of those with HIV infection. Although prevention case management techniques have not been fully evaluated for efficacy and more research is clearly needed, limited results show that these techniques hold promise. For example, the Centers of Disease Control and Prevention and the Health Resources Services Administration sponsored a study of community health centers providing HIV prevention and early intervention services within primary care 1   Recent studies have found that some new cases of HIV infection in untreated patients in which the HIV strain that was transmitted was already resistant to protease inhibitors (Hecht et al., 1998; Dietrich et al., 1999) and reverse transcriptase inhibitors (Fontaine et al., 1998; Brodine et al., 1999). Although the research does not provide conclusive evidence, other data also suggest that reinfection of an already infected individual with other strains of HIV could accelerate HIV disease progression (Angel et al., 2000). 2   Prevention case management can also be utilized with uninfected, high-risk populations.

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No Time to Lose: Getting More from HIV Prevention programs. Results of this study indicate that HIV-infected persons who received ongoing HIV prevention case management adopted and sustained selected safer sexual practices during the 6 month follow-up period (CDC, 1990). Other studies have found that ongoing counseling can be effective at preventing further transmission, as documented from studying discordant couples3 (van der Straten et al., 1998, 2000; Sweat et al., 2000; Padian et al., 1993) and in decreasing mother-to-child transmission of HIV (Havens et al., 1997). In addition to prevention case management, two clinician-delivered HIV prevention interventions are in development for HIV outpatient settings. The “Partnership for Health” study tests three different behavioral interventions for HIV-infected persons (Richardson et al., 2000). Two of the interventions are designed to increase safer sexual behaviors and disclosure of HIV status to sex partners among persons living with HIV using positively versus negatively framed prevention messages about safer sex and disclosure. The third intervention aims to increase antiretroviral treatment adherence; because this intervention does not address sexual behavior, it serves as the comparison (or “control”) condition for the safer sex interventions. Six HIV outpatient clinics in California are participating in this study and, upon its completion, health care providers in these clinics will have delivered one or more behavioral interventions to approximately 10,000 HIV-infected persons coming in for care. Preliminary results are expected in 2001 (G. Marks, personal communication). In another study, “Physician Delivered Intervention for HIV+ Individuals,” Fisher and colleagues (cited in University of California at San Francisco, 2000) are conducting pilot research for an intervention targeted to clinicians and their HIV-infected clients. The intervention is based on the assumption that many clinicians who provide HIV care are not sufficiently skilled to provide HIV prevention services to their clients. The goal is to develop a physician-directed HIV prevention intervention that can be delivered over time, adapted to meet clients’ changing prevention needs, and easily integrated into the context of continuing HIV outpatient care. Preliminary results from this study are expected in 2002 (W. Fisher, personal communication). Both studies emphasize the role that care providers can play in encouraging adherence to antiretroviral medications and in assessing HIV risk and encouraging safe behaviors. Several studies indicate that a personalized approach by health care providers can optimize patient adherence to antiretroviral therapy by providing careful drug selection in addi- 3   Discordant couples have one HIV-infected partner and one non HIV-infected partner.

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No Time to Lose: Getting More from HIV Prevention tion to routine follow-up and the provision of information, feedback, and reminder systems (Ostrop et al., 2000; Chesney, 2000; Roberts, 2000). Thus, health care providers play an important role in HIV prevention. Indeed, physicians have been cited by the public as the most trusted source of health information (David and Boldt, 1980), and they are teenagers’ preferred source of health information (Manning and Balson, 1989). However, physicians and other providers are often faced with significant barriers to integrating prevention into their standard of care practice. Many clinicians (particularly physicians) may feel that prevention counseling is not within their role of delivering treatment and care, and that these services are best done by other types of health care professionals, such as social workers or counselors (Makadon and Silin, 1995). Although providers’ HIV/AIDS knowledge is generally high (Gemson et al., 1991), they may be uncomfortable delivering prevention messages that they feel are ambiguous or confusing (e.g., levels of risk for different types of sexual practices) (Makadon and Silin, 1995). Perhaps the most significant barrier for providers is the lack of comfort or perceived skill in discussing sensitive issues such as substance abuse, sexual behavior, or psychological well-being with patients. To facilitate the integration of HIV prevention in the care setting, several tools and guides for conducting HIV risk assessments and encouraging safe behaviors have been developed for use by clinical care providers (e.g., Hearst, 1994; American Medical Association, 1996). Also available are predesigned risk assessment algorithms that can guide providers when asking risk-related questions, as well as facilitate discussions about particular aspects of prevention that are most relevant to the patient’s risk reduction needs (Cohen, 1995). Such tools and guidelines could be incorporated into current HIV treatment guidelines to ensure that prevention becomes a standard component of clinical care for HIV-infected persons. Integrating HIV prevention early in health professionals’ training and in subsequent continuing education opportunities is another strategy that may improve the skill and comfort level of providers in conducting HIV prevention (Yedidia and Berry, 1999). Such courses could offer training on obtaining sexual and substance use histories, how to deliver clear, effective prevention messages, and how to assist patients in developing realistic risk reduction goals (Makadon and Silin, 1995; Taylor and Moore, 1994; McCance et al., 1991). HIV testing offers another option for the integration of prevention into the clinical care context. Testing plays multiple roles, including identifying people with HIV and those at risk of infection who can receive prevention services, identifying pregnant women with HIV so they can be offered pharmacological interventions to prevent perinatal transmission, and identifying HIV-infected persons so they can receive more intensive

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No Time to Lose: Getting More from HIV Prevention clinical care services (ranging from closer monitoring of immune status to intervention with antiretroviral therapies or prophylaxis for opportunistic infections). The CDC has long maintained the importance of HIV testing as a prevention tool, and recent studies have shown that counseling and testing can be a cost-effective prevention intervention (e.g., Kamb et al., 1998; Weinhardt et al., 1999; The Voluntary HIV-1 Counseling and Testing Efficacy Study Group, 2000). The CDC also has supported an anonymous HIV counseling and testing infrastructure that is separate from the clinical care setting. Originally created to keep high risk people from using blood banks to learn their HIV status, these alternative testing sites funded by the CDC have often been considered an important part of prevention interventions and a valuable resource for individuals who fear the stigma of HIV testing and want to learn their status in an anonymous setting. The CDC estimates that 24.6 million people were tested in the United States in 1996. Of these, an estimated 2.6 million tests (not individuals) were performed at CDC publicly funded test sites (CDC, 1998),4 meaning that the overwhelming majority of HIV tests in 1996 occurred in clinical care settings. If one of the objectives of testing is to identify individuals with HIV and get them into appropriate care (both clinical care and prevention services), the integration of HIV testing services into existing clinical care settings would accomplish several important goals, including assuring that those identified as HIV-infected would have immediate access to clinical care, destigmatizing HIV testing and making it a routine part of care, and promoting the linkage of clinical care and prevention services. PROGRAMS THAT PROVIDE CLINICAL CARE TO HIV-INFECTED PERSONS If the clinical care setting is to become a venue for prevention, then it is important to understand where people with HIV are served and how clinical care programs can be better adapted to address prevention needs. 4   The CDC defines its publicly funded sites as those receiving CDC funds; the majority of these sites are clinical care settings but about 26 percent are freestanding counseling and testing sites (CDC, 1990). The CDC definition may exclude HRSA-funded testing sites where a significant number of HIV tests are performed. Community Health Centers (CHCs) alone report performing 218,742 tests in 1998 (National Summary Data, 1999), whereas Title III grantees report performing 315,234 tests in 1997 (HRSA, 1997). This may overlap significantly with the CHC data, since many Title III grantees are CHCs and report to both programs. In addition, many Title III grantees also receive CDC counseling and testing money, and some of these tests might be included in the CDC’s data.

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No Time to Lose: Getting More from HIV Prevention HIV/AIDS care is best described as a patchwork of public and private programs. Although little detailed information exists on where HIV-infected persons obtain their health care, two large studies—the AIDS Cost and Services Utilization Survey (ACSUS) (Mohr, 1994) and the HIV Cost and Services Utilization Study (HCSUS) (Frankel et al., 1999)—shed some light on how individuals who know they are HIV-infected use health care services. ACSUS has found that these individuals use health care services in ways similar to the pattern found in the general population in that HIV-infected minorities, females, male IDUs, persons in the lowest income category, and the unemployed are more likely to report a hospital stay or a hospital emergency room visit. In contrast, HIV-infected white persons and those in the highest income category are more likely to visit a private physician’s office, use psychological counseling, and use dental care services (Mohr, 1994). The HCSUS notes that most HIV care is provided by a relatively small number of providers. Providers include predominately publicly and privately funded hospitals and clinics, staff or group model HMOs, and private physician or medical groups. Many people who are HIV-infected but do not know their status seek care from a wide variety of health care settings. For example, young people typically utilize community health centers, drop-in centers, emergency and ambulatory care departments, family planning clinics, and doctors’ offices (Steiner and Gest, 1996; Ryan et al., 1996; Hedberg et al., 1996). Women and children with or at risk for HIV/AIDS also rely on a broad array of services from public and private providers. The poor or nearly poor are more likely to use public and nonprofit hospitals, community health centers, family planning clinics, and public health clinics, such as STD clinics (Lyons et al., 1996; Brackbill et al., 1999). In addition, individuals with HIV and those at high risk often have co-occurring substance abuse and mental disorders, and thus receive care from providers in drug treatment centers and mental health clinics. Some segments of the population receive care in specific health care settings, such as the Department of Veterans Affairs Health Care System (VA),5 the Department of Defense Health Care Systems, and from clinical settings associated with the Department of Justice and state correctional facilities. Financing of HIV Care Resources to pay for health care services delivered to HIV-infected persons and those at high risk can also be described as a patchwork of 5   The VA system is the largest single provider of HIV care in the U.S. In 1999, HIV care was provided to 18,000 veterans.

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No Time to Lose: Getting More from HIV Prevention public and private funding streams. Estimates from a nationally representative sample of HIV-infected persons receiving ongoing care found that one-third were covered by private insurance, 29 percent by Medicaid, and 20 percent by Medicare (Bozzette et al., 1998).6 These estimates varied by race, with a larger percentage of African Americans and Hispanics covered by Medicaid (Bozzette et al, 1998). Many uninsured or underinsured individuals living with HIV also obtain services through the Ryan White CARE Act and Community and Migrant Health Center (CHC) programs, which are administered by HRSA. Policy initiatives designed to increase the level of prevention offered in clinical care settings can be targeted to private as well as public programs. According to the Health Care Financing Administration (HCFA), Medicaid covers over half of people living with AIDS (HCFA, 2000).7 Many of these individuals, however, are also eligible for Medicare. CARE Act programs are “payers of last resort” and, therefore, serve primarily low income and indigent populations. Nonetheless, the CARE Act represents the third largest public program paying for care for people living with AIDS, and makes funds available through four titles to states, metropolitan areas, and nonprofit entities. Title I of the Act provides emergency assistance funds to metropolitan areas disproportionately affected by AIDS. Title II provides funds to states to improve the quality, availability, and organization of health care and support services for people with HIV. Title III provides grants to community-based clinics for early intervention services. Title IV provides funds for pediatric AIDS programs (see Appendix C for a more detailed description of CARE Act programs). In fiscal year 2000, CARE Act spending totaled $1.6 billion, compared with an estimated $4.1 billion of federal and state Medicaid HIV/AIDS spending and an estimated $1.7 billion of federal HIV/AIDS Medicare spending (HCFA, 2000). Although the precise number of people served by CARE Act programs is unknown, there may be significant overlap among individuals served by the CARE Act, Medicaid, Medicare, and private insurers. The Community and Migrant Health Center (CHCs) program is another source of care for people living with HIV. While many CHCs are also HRSA-funded CARE Act grantees, CHCs without CARE Act support are significant providers of federally financed HIV-related primary care to low income populations. In 1998, CHCs conducted over 218,000 HIV 6   Most (80 percent) of the people eligible for Medicare also qualify for Medicaid. 7   HCFA’s estimate is of those with AIDS diagnoses. HCFA has not developed estimates for persons with HIV but not AIDS.

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No Time to Lose: Getting More from HIV Prevention tests, and had over 220,000 HIV-related encounters with infected clients (National Summary Data, 1999). While these are not unduplicated from HIV testing and services that are part of the CARE Act, this remains an impressive number. In parts of the country where there is high HIV incidence and relatively low CARE Act presence (e.g., the rural Southeast), CHCs may be a principal means of reaching and serving those with HIV. Finally, many HIV-infected persons and those at increased risk receive services from substance abuse treatment and mental health centers. Integrating HIV prevention interventions with the provision of substance abuse and mental health services also can play a critical role in averting new infections. The Substance Abuse Prevention and Treatment Block Grant set-aside for HIV-related services was designed to integrate these services. Although efforts are under way to examine outcomes of these programs, little information is available about how these funds are used or the exact services they provide (GAO, 2000). CHANGES NEEDED TO ENCOURAGE HIV PREVENTION: MEDICAID AND RYAN WHITE CARE ACT PROGRAMS If HIV prevention is to be more fully integrated into publicly supported clinical care settings, financing changes are needed to ensure that preventive services are a covered benefit and that these services are adequately reimbursed (Guglielmo, 1999; Makadon and Silin, 1995). This section outlines possible changes to the Medicaid and CARE Act programs that could facilitate the integration of prevention in the clinical care setting. Financing Options for Medicaid Coverage There is no mandatory or optional Medicaid service category that specifically covers the components of prevention case management described earlier. However, under the Early and Periodic Screening, Diagnostic, and Treatment program, Medicaid has a mandatory preventive service benefit for children and adolescents under age 21. Additionally, there are two optional service categories that could be used for preventive services for adults with or at high risk for HIV; one of the categories is for screening and preventive services, while the other is for targeted case management services (Committee on Ways and Means, 1998). In order for a benefit to be covered on a fee-for-service basis or through a managed care organization, it must be covered under a state’s Medicaid plan and approved by HCFA for federal matching funds. While the majority (32) of states cover screening and preventive ser-

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No Time to Lose: Getting More from HIV Prevention vices (Westmoreland, 1999),8 only 9 state Medicaid programs have opted to cover targeted case management services or counseling for persons with HIV (Jefferys, in press). The targeted case management benefit would permit Medicaid beneficiaries to obtain prevention case management services. Although case management services are applicable to most populations served by Medicaid, states have the option to limit or “target” this benefit to particular subpopulations such as individuals with HIV or AIDS (Schneider and Garfield, 2000). In addition, a state could also choose to target persons considered at high risk for HIV infection, such as persons with sexually transmitted diseases or persons who are addicted to drugs. This benefit can cover services that will assist beneficiaries in gaining access to medical, social, educational, and other services. It is up to the state to establish minimum qualifications for providers offering prevention case management services, which conceivably could include community-based organizations as well as clinical providers. In order for prevention case management services to be a meaningful service option, HCFA and the CDC need to consider taking a number of steps. HCFA must make clear to state Medicaid agencies that it encourages them to embrace prevention services as part of an HIV-related continuum of care, and that community-based prevention case management, supported through a targeted case management benefit, is one vehicle for achieving this continuum of care. The CDC should work with HCFA and state Medicaid agencies to better define what should be included in this benefit and to assist states in defining the credentials of providers who should be eligible under this benefit. HCFA has issued a number of policy guidances to state Medicaid programs relating to treatment of beneficiaries with HIV and could use this approach to clarify issues regarding prevention services.9 States have the option of offering covered services on a fee-for-service basis, through managed care plans, or both. Benefits packages are shaped, in part, by the basis on which they are paid and thus can create financial incentives for the scope and accessibility of these services. Payment systems, therefore, should be considered for the broad implications they might have on whether and how often a covered service is provided. 8   HCFA has by regulation defined “preventive services” as “services provided by a physician or other licensed practitioner … under state law to (1) prevent disease, disability and other health conditions or their progression, (2) prolong life; and (3) promote physical and mental health and efficiency.” C.F.R. 440.130 (c ). 9   See HCFA’s website: HtmlResAnchor www.hcfa.gov/medicaid/hiv/hivltrs.htm.

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No Time to Lose: Getting More from HIV Prevention Medicaid Fee for Service. When Medicaid benefits are paid for on a fee-for-service basis, providers recognize that they will be reimbursed only for services that are part of a state’s benefit package. Given that there currently is no clearly defined service benefit for some of the major components of preventive case management (e.g., ongoing counseling) that may be required in the context of HIV-related clinical care, it is unlikely that providers will integrate these services into fee-for-service settings until states elect to cover them. States might be encouraged to cover preventive case management services if there were enhanced reimbursement for these services. This would require action by Congress to raise the federal matching rate from the traditional 50 percent to, for example, 90 percent, which is the rate that currently applies in all states to family planning services.10 In the case of states that currently cover prevention services, they could establish more generous reimbursement rates to encourage practitioners to offer the services. This is action a state could take under current law, with HCFA approval. Medicaid Managed Care. A state has some flexibility in affecting the delivery of Medicaid covered prevention services through its contract with a managed care organization. The contracting process can be used to integrate covered preventive services into clinical care delivery and require the provision of these services to uninfected individuals at increased HIV risk. There are potential benefits and risks when a managed care organization (MCO) assumes financial responsibility for the care provided. On the one hand, the MCO has a financial incentive to keep patients healthy and thus may be more aggressive about integrating prevention services into clinical care delivery and/or referring clients to appropriate community-based services, using a benefit modeled after the targeted case management benefit. On the other hand, capitation payments can create a financial incentive to withhold approval of services since savings can be applied to the provision of other services. States must take care in contracting with managed care organizations to ensure that the nature of the services expected is clearly defined, that the established managed care networks have the capacity in numbers and expertise to provide these services (including prevention case management), that quality assurance measures hold managed care organizations and their providers accountable for the provision of appropriate prevention services, 10   States receive federal Medicaid matching funds for at least 50 percent and as much as 80 percent of the costs of services for eligible beneficiaries, depending on the average per capita income of the state. Family planning services and supplies are the only exception.

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No Time to Lose: Getting More from HIV Prevention and that capitation rates reflect the expectation that these additional services will be provided.11 Encouraging HIV Prevention in CARE Act Programs While the major premise of the CARE Act is to assure a continuum of services for HIV-infected persons, those services generally have focused on treatment and support services related to primary care. Yet, HIV-infected persons also need prevention services that can help them avoid transmitting the virus to others, as well as prevent their own exposure to opportunistic infections. Such prevention-related services may include HIV prevention interventions and the critically important component of mental health and substance abuse services for those who need them. Without the last element, interventions to prevent the spread of HIV may be much less successful. The CARE Act does permit grantees to support substance abuse and mental health treatment. However, the only direct mention of prevention in the current law is in the context of preventing perinatal transmission and as part of the pretest counseling offered under Title III. Only Title III is empowered to support outreach to those who have unknown HIV status. The other titles are restricted to serving those already diagnosed with HIV. Despite numerous provisions in the CARE Act regarding coordination with other service programs, there is only one mention in the current law about coordination with other government agencies involved in prevention. CARE Act grantees are asked to coordinate with the CDC in the context of using surveillance data generated by the CDC (and state and local health departments) for care-related needs assessments. There is no requirement in the legislation that Title I planning councils, Title II consortia, or statewide determinations of need address coordination with government supported prevention initiatives (P.L. 104-146). HRSA’s current regulatory guidance to grantees also minimizes the opportunity to provide prevention services or even coordinate prevention and clinical care services. HRSA has made clear to its grantees that CARE Act funds must be targeted to those who are HIV-infected, not to those who are uninfected but at risk. CARE Act Titles I and II represent the overwhelming majority of CARE Act funding, and they have the most 11   George Washington University’s Center for Health Services Research and Policy, under the auspices of CDC and HRSA, has developed Sample Purchasing Specifications for HIV Infection, AIDS, and HIV-Related Conditions (August 1999) for use by state Medicaid agencies in purchasing coverage from managed care plans.

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No Time to Lose: Getting More from HIV Prevention flexibility in terms of implementation at the local level. However, the FY2000 guidance documents for both titles make only one mention of prevention in the context of the definition of support services. That definition refers to “health education/risk reduction,” which is described as: (1) provision of information, including information dissemination about medical and psychosocial support services and counseling, or (2) preparation/distribution of materials in the context of medical and psychosocial support services to educate clients with HIV about methods to reduce the spread of HIV (HRSA, 1999). These same guidance documents make clear that outreach has as its “principal purpose identifying people with HIV disease so they may become aware of and may be enrolled in care and treatments, not HIV counseling and testing nor HIV prevention education” (emphasis added) (HRSA, 1999). The HRSA guidance also refers to the CDC’s syphilis elimination plan, although there is no requirement for coordination. Similarly, the Title I guidance asks grantees to show how they coordinate with prevention planning groups, but there is no requirement that prevention planning groups be included in Title I planning councils, as are representatives of other federally funded programs (HRSA, 2000). The Title II guidance is similarly vague, though states are asked to show their linkages with prevention programs (HRSA, 1999). HRSA can potentially contribute to more coordinated provision of services with relatively minor modifications of its requirements for Title I and Title II grantees: HRSA can require the inclusion of a representative of the prevention planning group on Title I planning councils, on local Title II consortia, and on the group creating statewide coordinated statements of need. HRSA can encourage the inclusion of outreach activities to the range of services provided in order to facilitate referral to counseling and testing as well as longer-term prevention services. HRSA can encourage all clinical care providers supported by the CARE Act to make HIV risk assessment a standard part of their clinical care encounters in order to judge whether HIV-infected clients are in need of referral to more intensive prevention services. As part of the services provided by case managers, HRSA can permit referrals to prevention case management services funded by the CDC (or other agencies), in addition to the current practice of allowing referrals to substance abuse and mental health services. The current definition of case management does not include any reference to coordination with prevention services (HRSA, 2000).

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No Time to Lose: Getting More from HIV Prevention HRSA can require that its AIDS Education and Training Centers provide training for clinical care providers in undertaking HIV prevention-related activities. DHHS-WIDE POLICIES TO ENCOURAGE INTEGRATION OF PREVENTION INTO CLINICAL CARE If the federal government is to fully embrace the goal of integrating prevention services into the clinical care setting, then the government should move to adopt policies that would support the coordination of prevention and care activities at the federal, state, and local levels. Funding policies need particular attention; the current separate funding streams for prevention and clinical care services discourage grantees from integrating these services. The rigid distinction between entitlement and discretionary programs also creates a similar disincentive to bring services together in a “one-stop shopping” approach for people living with or at risk for HIV. Consideration should be given to creating a demonstration program in a series of communities (perhaps using different models) that would allow communities to create integrated systems of clinical care and prevention services by bringing together HIV-related funds from Medicaid, Medicare, HRSA, the CDC, and the Substance Abuse and Mental Health Services Administration (SAMHSA). The outcomes of these demonstration projects will help reveal untoward effects that are not counter-balanced by the potential for administrative efficiencies or by the opportunity to promote greater integration of clinical care and prevention services. The Committee finds that current prevention programs do not effectively target individuals who are HIV-infected and who may still engage in risky behavior. The Committee believes that all HIV-infected persons should have access to prevention services, and that the clinical care setting provides opportunities for integrating prevention into the standard of care for those who are infected or at high risk. Therefore, the Committee recommends that: Prevention services for HIV-infected persons should be a standard of care in all clinical settings (e.g., primary care settings, sexually transmitted disease clinics, drug treatment facilities, and mental health centers). Health care providers should have adequate training, time, and resources to conduct effective HIV prevention counseling. Enabling this activity may require adjustments in health care provider time allocations and/or specific financial incentives from public and private sources of health coverage.

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