Based on the results of this pilot, NASTAD will provide the EPHI with recommendations for HIV case-based surveillance sy
2014 Annual Report 2014-2015 NASTAD Executive Committee OFFICERS Maria Courogen, Washington, Chair DeAnn Gruber, Louisiana, Vice-Chair Aimee Shipman, Idaho, Secretary-Treasurer Andrew Gans, New Mexico, Chair-Elect EXECUTIVE COMMITTEE MEMBERS Susan Jones, Alaska Karen Mark, California Melanie Mattson, Colorado William Lyons, Georgia Peter Whiticar, Hawaii Mildred Williamson, Illinois Randy Mayer, Iowa Dan O’Connell, New York Jacquelyn Clymore, North Carolina Paul Loberti, Rhode Island Janet Tapp, South Carolina Shanell McGoy, Tennessee Shelley Lucas, Texas Diana Jordan, Virginia Jim Vergeront, Wisconsin EX-OFFICIO/NASTAD PAST CHAIR Dawn Fukuda, Massachusetts EXECUTIVE DIRECTOR Julie Scofield
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OPENING STATEMENT As I began my tenure as NASTAD’s chair in May 2014, I knew a key objective of continuing the great work my predecessors began would need to involve creating more opportunities for meaningful community engagement to further advance our shared mission of raising the bars of the HIV and hepatitis care continuums in all jurisdictions, for all populations. To further this conversation, we developed and released a policy statement on Strategic Community Engagement to End the HIV and Hepatitis Epidemics to promote innovative health department community engagement strategies. We firmly believe that community engagement is an essential process in the implementation of high-impact HIV prevention as changes in the health care landscape and sexual health service ecosystems take shape. In particular, the statement is a call for health departments to scaleup opportunities for community engagement and re-tool the community engagement process. In addition to our focus on meaningfully engaging communities, we addressed other barriers to effectively responding to the HIV and hepatitis epidemics in our jurisdictions, including increased reporting burden. To spur action on this issue by our federal partners, we released an updated Federal Reporting Requirements Table and Chart and accompanying report to document how federal reporting requirements undermine the domestic response to the HIV and hepatitis epidemic. While some progress has been made to streamline federal reporting requirements, health departments have yet to experience any significant reduction in the overall administrative effort. In fact, in some instances, we have seen the introduction of new or expanded reporting requirements associated with existing funding streams. As states continued to confront the challenges of our nation’s changing health care landscape, NASTAD played a critical role in supporting HIV and hepatitis programs in navigating these shifts. NASTAD convened the Ryan White and Affordable Care Act Regional Meetings in four cities to assist health department staff with transition planning and implementation for programs such as the AIDS Drug Assistance Program (ADAP). NASTAD also published data demonstrating the essential role the Ryan White Program, specifically ADAP, plays for people living with HIV. NASTAD was also successful in its application for two cooperative agreements to expand and intensify the high quality technical assistance it provides to states. The first one is a partnership with the Centers for Disease Control and Prevention (CDC) on the Modernizing HIV Prevention Project to provide health departments with state-of-the-art information, training and technical assistance to strengthen their capacity to deliver High-Impact Prevention strategies. The second cooperative agreement is a partnership with the Health Services and Resources Administration (HRSA) to build the Center for Engaging Black MSM Across the Care Continuum (CEBACC). CEBACC continues NASTAD’s long history of addressing the HIV epidemic among gay men/ MSM. The goal of this new national center is to identify, compile, and disseminate best practices and effective models for HIV care and treatment across the HIV care continuum in order to increase the capacity, quality, and effectiveness of healthcare providers to link and retain Black gay men/MSM in HIV clinical care. It is vital that as a collective team of AIDS Directors and community partners and members that we work together and understand that we are responsible for building out an innovative service system that connects across all sectors of the medical care and public health environment that works effectively to eliminate HIV and hepatitis. My time as NASTAD chair was both challenging and enjoyable during this phase of our fight to end HIV and hepatitis. After working more closely with our Executive Committee and NASTAD staff over the last year, I am more than confident that our strong leadership in the U.S. and around the world will continue to play a pivotal role in helping us achieve a generation free of HIV and hepatitis.
—Maria Courogen Director, Office of Infectious Disease Washington State Department of Health NASTAD Chair
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PROGRAM HIGHLIGHTS
Supporting Drug-User Health In recent years, health departments have seen an alarming increase in new hepatitis C (HCV) cases among people under the age of 30 in a number of states across the country. Unlike historical trends of HCV infections in most jurisdictions (i.e., concentration in larger, urban city centers), new HCV infections are increasingly found in suburban and rural settings, especially in Appalachia. However, new infections continue to occur in urban areas, as well. In addition, the updated Viral Hepatitis Action Plan, identifies “Reducing Viral Hepatitis Caused by Drug Use Behaviors” as a priority area. Many health departments are working to incorporate a broadened focus to continue the identification of existing cases of chronic HCV among the baby boomer cohort, while being attentive to new, rising HCV infections, especially among young people who inject drugs. Through the support of the MAC AIDS Fund, NASTAD convened “HIV, Hepatitis and Overdose among Drug Users: The Health Department Role in an Effective Response” to provide an opportunity for health department HIV and hepatitis staff to examine their efforts to reduce HIV and HCV transmission and overdose among persons who inject drugs, and to develop plans to expand their efforts through the framework of drug user health and enhanced primary prevention efforts. To call attention to rising rates of HCV among young people and urge increased action, NASTAD and the Harm Reduction Coalition co-hosted the Congressional briefing, An Emerging Epidemic: The Public Health Response to Hepatitis C Infection among Young People who Inject Drugs. The briefing included expert perspectives from the White House White House Office of Drug Control Policy (ONDCP), National Institutes of Health (NIH), National Institute on Drug Abuse (NIDA), University of Kentucky and the Wisconsin Division of Public Health. Additionally, to continue to advance the organization’s Statement of Commitment: Promoting Drug User Health, NASTAD published a series of blog posts discussing the importance of adopting a harm reduction model to improve the health of people who use drugs. Harm reduction programs have had limited access to consistent funding. As such, by necessity, these programs have continued to be innovative and creative in their approach to funding, particularly in light of expanded insurance access through the Affordable Care Act (ACA). This means translating public health and harm reduction speak into the language of insurance in order to expand the universe of covered and reimbursable services.
Supporting Public Health’s Response to Hepatitis NASTAD has supported the work of the Centers for Disease Control and Prevention (CDC)funded Viral Hepatitis Prevention Coordinators (VHPC) and the integration of hepatitis services into existing programs for 15 years. CDC currently provides no funding to NASTAD to support
VIRAL HEPATITIS
PREVENTION:
IS $1 ENOUGH?
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Health department Viral Hepatitis Prevention Coordinators receive less than $1 in federal funding for every person living with viral hepatitis.
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$1
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this important work, though NASTAD’s commitment remains strong and hepatitis is fully integrated into all program and policy initiatives as well as the organization’s mission and vision. As more curative HCV therapies become available, there is more incentive for the 75% of individuals who are unaware of their status to be tested and diagnosed. NASTAD’s work with health departments has continued to support the implementation of HCV testing recommendations and integrating HCV testing into existing infrastructure and programs. The work of health departments is central to identifying existing and new cases of HCV, though this continues to be challenging as health department VHPCs remain chronically underfunded and underprioritized by the federal government.
Because of this great work, in July of 2014, Julie Scofield, NASTAD’s Executive Director, was recognized by the White House Office of Drug Control Policy and Office of National AIDS Policy for her leadership in the prevention and treatment of viral hepatitis. The event was held at the White House in observance World Hepatitis Day.
Addressing the Epidemic among Gay Men of All Races and Ethnicities NASTAD continued to place high importance on a comprehensive HIV, STD and hepatitis disease response among gay men/men who have sex with men (MSM). In cooperation with the National Coalition of STD Directors (NCSD), we released Addressing Stigma: A Blueprint for HIV/ STD Prevention and Care Outcomes for Black and Latino Gay Men. The blueprint contains 17 recommendations for reducing public health stigma that prevents Black and Latino gay men/MSM from receiving optimal health care.
Overall: Of all Americans diagnosed with HIV, only 25% are virally suppressed.
Racism Poverty
violence conventionalism
SHAME
HOMOPHOBIA
STIGMA marginalization HOMELESSNESS
CLASSISM
In 2014, NASTAD published an infographic and blog post highlighting the need for increased investment in the CDC-funded VHPC program. Additionally, NASTAD, as a part of the ADAP Crisis Task Force (Task Force), reached a pricing agreement between AbbVie and AIDS Drug Assistance Programs (ADAPs) for Viekira Pak for the treatment of HCV. AbbVie became the first company to offer a discount on the ADAP price of an HCV medication in the era of new curative HCV treatments. The agreed-upon ADAP price for Viekira Pak, negotiated between the Task Force and AbbVie, reflects voluntary discounts and rebates that are significantly lower than the wholesale acquisition cost (WAC). This agreement recognizes the importance of access to HCV medications for people living with HIV and demonstrates good faith that access at a discounted price may lead to formulary inclusion for many ADAPs.
Addressing Stigma is a follow-up to a three-year study of stigma and its impact on public health practice for Black and Latino gay men/MSM that was supported by the MAC AIDS Fund. The recommendations contained in the blueprint follow many consultations with national organizations that serve Black and Latino gay men/MSM, health departments and community stakeholders. Specifically, it looks at how stigma and other social determinants impact the HIV care continuum for Black and Latino gay men/MSM by examining “the bar before the bars” (i.e., other factors and issues facing these men prior to an HIV or STD diagnosis).
MISOGYNY
State health departments receive less than $1 dollar in federal funding for every person living with hepatitis for the VHPC program. The program is the only national program dedicated to the hepatitis epidemics and provides the only public health infrastructure for the prevention of hepatitis and linking individuals to care and treatment. In order to meet the goals established by the Viral Hepatitis Action Plan and strengthen the national response to viral hepatitis epidemic, the VHPC program must continue to be funded in all existing jurisdictions and increased resources are necessary to coordinate prevention efforts at the state and local levels.
Diagnosed Linked to Care
Retained in Care
Prescribed ART
Virally Supressed
In addition to this, NASTAD and NCSD launched an updated survey assessment to continue efforts to explore, address and monitor community- and institution-level stigma impacting Black and Latino gay men/MSM within public health practice. The information gathered from this survey will provide additional information to further health department and community efforts to reduce stigma in public health practice and in communities.
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In partnership with the Health Resources and Services Administration (HRSA) as part of a two-year cooperative agreement, NASTAD kicked off a new project to establish the Center for Engaging Black MSM Across the Care Continuum (CEBACC). The goal of the Center is to identify, compile, and disseminate best practices and models for HIV clinical care and treatment across the HIV care continuum for Black gay men/MSM. This builds on our on-going efforts to raise the bars of the HIV care continuum for Black gay men/MSM, particularly young Black gay men/MSM.
The Evolving Role of PrEP The National HIV/AIDS Strategy (NHAS) highlights that current approaches to preventing HIV must be coupled with research on new and innovative prevention methods that can have a long-term impact. Pre-exposure prophylaxis (PrEP) is one emerging strategy that demonstrates the potential to significantly decrease HIV transmission rates for people at high risk for HIV infection, including gay and bisexual men/ MSM, women, transgender women and people who inject drugs. To support health department implementation of PrEP as a prevention strategy, NASTAD published PrEP Issues for Consideration, which outlines ten areas for health departments to consider related to implementing PrEP, and released an updated Policy Statement on PrEP to reflect new findings to support the use of PrEP as prevention. We also worked with health departments in a number of ways to encourage the use of PrEP across communities, including the launch of a multi-part blog series highlighting innovative state health department PrEP education and access initiatives.
Improving Health Care Access through the Affordable Care Act and Ryan White Programs
HIV and hepatitis programs. To this end, NASTAD published numerous Health Reform Watch newsletters, fact sheets, issue briefs and other resources for health departments and the broader HIV and hepatitis policy community and convened numerous webinars across its prevention, health care access and hepatitis programs to facilitate crossprogram dialogue about implementation issues as well as share health department implementation highlights. Further, NASTAD worked to emphasize the continued importance of the Ryan White Program with the release of new data demonstrating the important role that the AIDS Drug Assistance Program (ADAP) plays in providing expanded access to care for people living with HIV. During the inaugural open enrollment period of the ACA, ADAPs transitioned over 25,000 clients to new coverage options. This represents a significant portion of the estimated 56,000 previously uninsured Ryan White clients. We also released the 2014 Online ADAP Formulary Database and accompanying User’s Guide. The database details ADAP coverage of medications both individually and by drug class, marking the first time state-by-state ADAP formulary coverage data has been made publicly available in an online searchable format. NASTAD also convened a series of regional meetings with State AIDS Directors and ADAP Coordinators to assist health departments with ongoing implementation of the ACA. The meetings were funded with support from the MAC AIDS Fund and other private contributions. To further support ADAPs, NASTAD convened the annual ADAP Technical Assistance meeting in August 2014, hosted several webinars and published issue briefs and other technical assistance documents on such topics as billing and reimbursement, linkage, retention and reengagement in care, ADAP and insurance and utilizing Pharmacy Benefits Managers (PBMs).
Capacity Building Assistance for High-Impact HIV Prevention
As state implementation of the Affordable Care Act (ACA) continued to progress and evolve in 2014, NASTAD regularly provided concise and timely analysis of the impact of health reform on health department
Through a cooperative agreement with the CDC, NASTAD expanded and intensified the high quality technical assistance it provides to state health departments to implement HIV prevention activities on the ground. Our expanded activities for capacity building assistance (CBA) are focused on providing health departments with state of-the-art information, training, and technical assistance to strengthen their capacity to deliver High-Impact Prevention strategies that reduce new HIV infections.
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NASTAD delivers CBA services in three core areas: comprehensive prevention with HIV-positive persons, HIV prevention policy and HIV testing. Health departments have identified these components as being among the highest-priority areas for capacity building needs. The hallmark of NASTAD’s CBA model is peer-to-peer technical assistance delivered by health department staff with expertise in specific areas. NASTAD staff members are also available to provide CBA services through on-site consultations and skills-building trainings with health department staff and HIV Planning Groups. NASTAD’s CBA program also compiles and disseminates best practices through toolkits, issue briefs, tip sheets, and web-based learning opportunities.
6 Challenges with Continued Health Department Reporting Burden
The fourth goal of the National HIV/AIDS Strategy (NHAS) is focused on strengthening the national response to the HIV epidemic through increased coordination of HIV programs across the federal government and between federal agencies and state, territorial, tribal and local governments. But to achieve this goal, the NHAS calls for simplification of grant administration activities, standardization of data collection and streamlining of reporting requirements.
Emerging Foci in Global Program Technical Assistance Building on more than 10 years of work funded under the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), NASTAD Global is poised to work in close alignment with PEPFAR 3.0, which prioritizes “getting the right thing to the right place at the right time.” To that end, NASTAD Global is prioritizing two areas for capacity building assistance with partner country governments. STRONG PUBLIC HEALTH SYSTEMS
Strong, sustainable and independently managed public health systems allow countries to efficiently and effectively respond to their HIV epidemic. To support strong systems, NASTAD Global builds the capacity of public health professionals, processes and structures, and provides mentoring as skills and knowledge are applied to public health system management. Supporting Sustained Success via District-led Programming in Uganda Drawing from NASTAD’s success supporting strong U.S. state and international health systems, NASTAD Global is currently leading an exciting initiative in Uganda, in partnership with CDC Uganda and Uganda’s Ministry of Health (MoH). The goal of this work is to build the capacity of local government staff to take on a greater leadership role in order to control the HIV epidemic in their jurisdiction. Successful outcomes from this project will be improved district government-led coordination and collaboration with local U.S. government-funded implementing partners, such that the district health teams are eventually planning, overseeing, and/or managing all aspects of HIV programming in their district. These efforts to promote and build district capacity to lead local evidence-based target setting and prioritization ensure a sustained improvement in the management of health systems and service delivery.
Despite this focus, state health departments are experiencing significant administrative burden with as many as 238 federal reporting requirements, as of 2014. This magnitude of administrative burden undermines and slows the domestic response to the HIV epidemic at a time when HIV programs nationwide are intensifying prevention, care and treatment strategies to end the epidemic. We released an updated Federal Reporting Requirements Table and Chart and accompanying report to document the ongoing challenge of reporting burden. The table and chart illustrate the increasing administrative burden on state health departments, including reports and data collection as well as monthly conference calls and annual site visits. Over the past two years, some progress has been made to reduce reporting burden and streamline data reporting requirements on the part of federal agencies, however health departments have yet to experience any significant reduction in the overall administrative effort related to grant or cooperative agreement management as other new administrative and reporting requirements continue to be added.
DATA FOR ACTION
The availability and effective use of quality data is critical for countries to respond to their HIV epidemics. To facilitate this, NASTAD
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Global builds and improves systems (surveillance, monitoring, quality improvement, and evaluation/research) while building the capacity of people to use those systems. Linking and Uniting Data for Action in Ethiopia Many resource-poor countries outside of the United States have a strong interest in the development and use of the HIV care continuum to drive improvement in health outcomes and monitor the HIV response. However, many countries do not have accessible, centralized access to person-level data that can generate an accurate cascade at national and regional levels. Building from NASTAD’s experience in surveillance and data use in the U.S., and NASTAD Global’s successful case-based
surveillance work in Haiti, NASTAD Global is supporting the Ethiopian government to assess and pilot HIV case-based surveillance in the Addis Ababa metropolitan area. NASTAD Global is assisting Ethiopia’s Ministry of Health (MoH) and Public Health Institute (EPHI) to assess a subset of existing patient-level data and the related data collection processes to determine whether case-based surveillance of HIV is feasible in Ethiopia such that routine, health facility data are available to guide HIV programming. Based on the results of this pilot, NASTAD will provide the EPHI with recommendations for HIV case-based surveillance system and process design and staged implementation.
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National Alliance of State and Territorial AIDS Directors REVENUE & EXPENSE SUMMARY Fiscal Year Ended September 30, 2014
REVENUE Grants & Contributions $10,118,055 Membership Dues $708,150 Registration Fees $40,336 Other $3,449 Interest $5,397 Total Revenue: $10,875,386
EXPENSES Program Services $9,296,120 General & Adminstration $979,359 Overhead $469,756 Fundraising $106,372 Advocacy $33,671 Total Expenses: $10, 885,278 Change in Net Assets:
$9,892
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2014 Donors and Funders FEDERAL Centers for Disease Control and Prevention (CDC) Health Resources and Services Administration (HRSA) FOUNDATIONS Ford Foundation Henry J. Kaiser Family Foundation MAC AIDS Fund OTHER John Snow, Inc. FHI 360 CORPORATE AbbVie Achillion Pharmaceuticals Alere Bio-Rad Laboratories Bristol-Myers Squibb Gilead Sciences Merck OraSure Technologies Ramsell Public Health RX Janssen Therapeutics Salix Pharmaceuticals Trinity Biotech Vertex Pharmaceuticals ViiV Healthcare Walgreens
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NASTAD Programs
NASTAD has considerable expertise in identifying community needs and responding to the domestic and global HIV and hepatitis epidemics. Health Care Access: Provides programmatic and policy technical assistance to state and territorial HIV and hepatitis programs in a number of HIV and hepatitis care and treatment-related areas, most specifically ADAPs and implementation of the ACA. Health Equity: Builds state and local health department responses to HIV and hepatitis
among racial and ethnic minority communities and other groups disproportionately impacted by the epidemic, in particular, gay men/MSM and people who inject drugs. Global Technical Assistance: Increases capacity of resource-constrained countries to plan, implement, and manage HIV prevention and care activities as part of a unified U.S. government response to the HIV pandemic. NASTAD’s Global Program responds to identified needs and priorities of country Ministries of Health, National AIDS Control Programs and the CDC. Policy and Legislative Affairs: Employs a multi-layered strategy of communication to
effectively translate state HIV and hepatitis care, treatment and prevention program concerns into sound policy. NASTAD staff work directly with the Administration, Members of Congress and their staff to develop legislative strategies for annual appropriations and authorization legislation. NASTAD also participates in numerous coalitions to help shape HIV and hepatitis policy. Prevention and Surveillance: Focuses on technical assistance, policy and program
development for effective HIV prevention and surveillance programs. NASTAD works with health departments to support peer-exchange and networking focused on effectively managing HIV prevention programs. Viral Hepatitis: Focuses on increasing the capacity of state and local HIV and hepatitis
health department programs to effectively integrate hepatitis prevention and care services into existing programs and enhance services to populations at risk for infection. NASTAD works closely with state and local viral hepatitis prevention coordinators, providing technical assistance and advocating on their behalf. Member Services/Operations/Finance and Accounting: Ensures efficient operations and strong fiscal management and human resources and high-quality member services. Communications: Focused on developing and facilitating timely, accurate and relevant
communications that advance NASTAD’s mission and activities and support members. The National Alliance of State and Territorial AIDS Directors (NASTAD) was founded in 1992 as an alliance of state health department HIV/AIDS program directors responsible for administering HIV/AIDS and adult viral hepatitis health care, prevention, education, and supportive services programs funded by states and the federal government. Programs administered by NASTAD members serve every population affected by and infected with HIV and viral hepatitis.
Julie M. Scofield, Executive Director Maria Courogen, Washington, Chair
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CLOSING STATEMENT NASTAD began 2014 with the release of “Raising the Bars: Accelerating HIV Prevention and Care in the U.S.” and an accompanying commitment to work with our health department members to develop jurisdiction and population-specific HIV care continuums if they had not already done so. We focused much of our engagement with our members on developing and implementing action steps designed to “raise the bars” in their states. These efforts were enhanced significantly due to NASTAD’s success in securing new funding from CDC and HRSA for capacity building assistance and an initiative designed to improve HIV prevention and care for Black gay men/MSM. Overall, 2014 was a year of expanded technical assistance and capacity building assistance for state health departments in the areas of implementation of the Affordable Care Act and synergy with Ryan White and AIDS Drug Assistance programs, modernizing HIV prevention policies and programs, and addressing the HIV epidemic and stigma impacting gay men/MSM, particularly young Black gay men/MSM. It was also a year of great promise for our efforts to address hepatitis with the re-release of the HHS “Action Plan for the Prevention, Care, & Treatment of Viral Hepatitis” in April and approval of additional cure treatments for hepatitis C. I was very humbled and grateful to be recognized for NASTAD’s leadership in prevention and treatment of viral hepatitis on World Hepatitis Day in July by the Office of National Drug Control Policy and the Office of National AIDS Policy. While the promise is great, the challenge is also enormous given the alarming national crisis of prescription opioid and heroine drug use and overdose. With support from the MAC AIDS Fund, NASTAD convened a meeting, “HIV, Hepatitis and Overdose among Drug Users: The Health Department Role in an Effective Response” in April. As 2015 commences, it is important to continue to sound the alarm on this issue as new HCV and HIV infections are occurring as a result. NASTAD’s global technical assistance to ministries of health continued as well with some new areas of work in Uganda and the Caribbean region. While our work in Zambia and Botswana is coming to an end, I am confident that there will continue to be a need to share public health expertise in the global HIV response among peers around the world. Here at home and based on the disturbing events in Ferguson, New York and elsewhere, the year ended with the launch of an internal initiative focused on engaging our staff in a year of exploration of issues related to racism and white privilege and their impact on the personal lives of our staff and the work of NASTAD. I’m very proud of the talent and diversity of the NASTAD staff and their willingness to be fully engaged in these critical conversations. In closing, I want to thank NASTAD members and staff for their unwavering commitment to the mission of the organization and its vision of a world free of HIV and hepatitis. I believe we have the tools to end these epidemics and I’m hopeful that working together we will continue to accelerate our progress.
Julie M. Scofield Executive Director NASTAD
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Mission and Vision NASTAD’s mission is to strengthen state and territory-based leadership, expertise and advocacy and bring them to bear in reducing the incidence of HIV and viral hepatitis infections and on providing care and support to all who live with HIV/AIDS and viral hepatitis. NASTAD’s vision is a world free of HIV/AIDS and viral hepatitis.
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