Executive Perspective While older paradigms of HIV prevention and care focused exclusively on the biologic determinants of health, newer and more challenging models recognize the importance of addressing social determinants. In this Executive Perspective, Ronald Valdiserri, Deputy Assistant Secretary for Health, Infectious Diseases and Director of the Office of HIV/AIDS and Infectious Disease Policy, explains the various social factors that influence outcomes of HIV care and discusses federal initiatives to promote improvements along the HIV care continuum. Robert DeMartino, MD CAPT, U.S. Public Health Service Acting Editor
Improving Outcomes Along the HIV Care Continuum: Paying Careful Attention to the NonBiologic Determinants of Health Ronald O. Valdiserri, MD, MPH
More and more, we realize that behavioral, social, economic, and environmental factors interact with biologic conditions and life circumstances to substantially influence health outcomes for individuals, families, and communities.1 But recognizing the fact that health is much more than the mere absence of disease is not a new concept. In fact, the preamble to the constitution of the World Health Organization, adopted in 1946, states this premise explicitly.2 In our own time, this notion of health as a complete and holistic state of well-being is most readily evident in the increasingly urgent calls to address the social determinants of health, especially as they relate to health disparities and inequities. The current focus on health disparities and inequities across the continuum of human immunodeficiency virus (HIV) care—from timely diagnosis through regular receipt of optimal treatment resulting in viral suppression—is once again forcing us to confront the many factors beyond biology that affect health outcomes. Scientists from the U.S. Centers for Disease Control and Prevention (CDC) used national HIV surveillance data from 19 jurisdictions with complete reporting of CD4+ and viral load (VL) test results to assess statelevel differences in HIV diagnosis, retention in care, and viral suppression. They found that while 80% of people who were diagnosed with HIV were linked to care within three months, in all 19 jurisdictions, a large percentage of people living with HIV (PLWH) were not receiving ongoing care; by jurisdiction, the percentage
of people with a suppressed VL ranged from 14.3% to 55.7%, with an average of 43.4%.3 Although this analysis did not allow for the investigation of specific factors associated with disparities across the care continuum, the investigators noted that social and economic barriers, as well as behaviors, likely explain many of these differences. An earlier analysis conducted by CDC used data from both the National HIV Surveillance System and the Medical Monitoring Project to estimate nationally, for various subpopulations, the percentages of PLWH who were aware of their HIV diagnosis, retained in care, prescribed antiretroviral therapy, and had achieved viral suppression. Their analysis found that the estimated percentages of black and Hispanic or Latino people who were aware of their HIV infection were lower than that of white people, and also revealed significant age disparities at each step of the HIV care continuum, with younger people less likely than older people to have received an HIV diagnosis or to have a suppressed VL.4 We know that a variety of factors can influence outcomes at each stage of the HIV care continuum, including poverty and lack of health insurance,5 homelessness,6 food insecurity,7 substance use,8 mental health problems and accumulated lifetime trauma,9 deficits in health literacy (e.g., not understanding the importance of adherence to antiretroviral medication),10 and stigma related to HIV and/or the behaviors placing one at risk for infection.11 Recognizing that a single strategy or approach cannot address all of these barriers is a major reason why President Obama issued Executive Order 13649 on July 15, 2013, calling for the establishment of an HIV Care Continuum Initiative to “identify potential impediments to improving outcomes along the HIV care continuum” and “recommend ways to integrate (federal) efforts to improve outcomes.”12 In response to the Executive Order, leaders from
Public Health Reports / July–August 2014 / Volume 129
319
320 Executive Perspective
across the federal government engaged in a process to actively review current programs, policies, and research findings. Based on this assessment, they developed an initial set of 21 specific federal actions to promote improvements along the HIV care continuum.13 These actions, which were released on World AIDS Day 2013, can be broadly summarized as follows: • Develop and assess innovative models of HIV care, especially for vulnerable populations; • Tackle misconceptions and stigma that act as barriers to HIV care; • Strengthen the collection and use of data to improve HIV health outcomes; • Prioritize research to address gaps in knowledge along the HIV care continuum; and • Provide information, training, and technical assistance to strengthen comprehensive HIV services at state and local levels. Truly, the many issues hindering the receipt of timely and comprehensive HIV care among vulnerable populations will not be easily resolved, but the previously outlined actions are already beginning to influence our public health priorities. For example, the Health Resources and Services Administration recently announced funding to support the identification and dissemination of best practices and effective models of HIV care for black men who have sex with men—a group disproportionately impacted by HIV disease.14 Additionally, in early spring 2014, CDC announced available funding for health departments to work collaboratively with community health centers to use state HIV surveillance data and health center electronic health record data to improve HIV health outcomes for PLWH, by expanding HIV linkage, retention, and reengagement services.15 These are two examples among many signifying an ongoing shift from older paradigms of HIV prevention and care that focused exclusively on the biologic determinants of health to newer—and admittedly more challenging—models that recognize the importance of addressing various social determinants that influence our collective ability to achieve healthy outcomes for individuals, families, and communities. As observed by other public health leaders, commenting on the increasing influence of social determinants of health, this paradigm shift does not minimize the need for high-quality biomedical services, but it will require that public health develop and sustain “strong governmental and intersectoral leadership and collaboration.”16 In short, if we want to improve outcomes along the HIV care continuum in the United States, we must be will-
ing to embrace and reckon with all of the factors that contribute to health status, not just biology. The contents of this article represent the views of the author and do not necessarily represent the views of the U.S. Department of Health and Human Services. Ronald Valdiserri is Deputy Assistant Secretary for Health, Infectious Diseases and Director of the Office of HIV/AIDS and Infectious Disease Policy, U.S. Department of Health and Human Services in Washington, D.C. Address correspondence to: Ronald O. Valdiserri, MD, MPH, U.S. Department of Health and Human Services, Office of HIV/ AIDS and Infectious Disease Policy, 200 Independence Ave. SW, HHH Building, Room 443-H, Washington, DC 20201; tel. 202-6905560; fax 202-690-7560; e-mail .
References 1. Sadana R, Blas E. What can public health programs do to improve health equity? Public Health Rep 2013;128 Suppl 3:12-20. 2. World Health Organization. The preamble of the constitution of the World Health Organization as adopted by the International Health Conference, New York, 1946 Jun 19–22; signed by the representatives of 61 states. Official records of the World Health Organization, no. 2, p. 100. 3. Gray KM, Cohen SM, Hu X, Li J, Mermin J, Hall HI. Jurisdiction level differences in HIV diagnosis, retention in care, and viral suppression in the United States. J Acquir Immune Defic Syndr 2014;65:129-32. 4. Hall HI, Frazier EL, Rhodes P, Holtgrave DR, Furlow-Parmley C, Tant T, et al. Differences in human immunodeficiency virus care and treatment among subpopulations in the United States. JAMA Intern Med 2013;173:1337-44. 5. Rothman RE, Kelen GD, Harvey L, Shahan JB, Hairston H, Burah A, et al. Factors sssociated with no or delayed linkage to care in newly diagnosed human immunodeficiency virus (HIV)-1-infected patients identified by emergency department-based rapid HIV screening programs in two urban EDs. Acad Emerg Med 2012;19:497-503. 6. Kidder DP, Wolitski RJ, Campsmith ML, Nakamura GV. Health status, health care use, medication use, and medication adherence among homeless and housed people living with HIV/AIDS. Am J Public Health 2007;97:2238-45. 7. Weiser SD, Frongillo EA, Ragland K, Hogg RS, Riley ED, Bangsberg DR. Food insecurity is associated with incomplete HIV RNA suppression among homeless and marginally housed HIV-infected individuals in San Francisco. J Gen Intern Med 2008;24:14-20. 8. Spire B, Lucas GM, Carrieri MP. Adherence to HIV treatment among IDUs and the role of opioid substitution treatment (OST). Int J Drug Policy 2007;18:262-70. 9. Mugavero M, Ostermann J, Whetten K, Leserman J, Swartz M, Stangl D, et al. Barriers to antiretroviral adherence: the importance of depression, abuse, and other traumatic events. AIDS Patient Care STDS 2006;20:418-28. 10. Rao KC, Enriquez M, Gantt TC, Gerkovich MM, Bonham AJ, Griffin RG, et al. Nonengagement in HIV care: a descriptive and qualitative study in hospitalized patients and community-based analysis. J Int Assoc Provid AIDS Care 2013;12:178-84. 11. Sumari-de Boer IM, Sprangers MA, Prins JM, Nieuwkerk PT. HIV stigma and depressive symptoms are related to adherence and virological response to antiretroviral treatment among immigrant and indigenous HIV infected patients. AIDS Behav 2012;16:1681-9. 12. Government Printing Office (US). Executive Order 13649. Accelerating improvements in HIV prevention and care in the United States through the HIV care continuum initiative. Fed Reg 2013;78:43057-9. Also available from: URL: http://www.gpo.gov /fdsys/pkg/FR-2013-07-18/pdf/2013-17478.pdf [cited 2014 Apr 4]. 13. Koh HK, Valdiserri RO. New federal actions aim to improve outcomes along the HIV care continuum: World AIDS Day update. 2013 Dec 8 [cited 2014 Apr 4]. Available from: URL: http://blog. aids.gov/2013/12/new-federal-actions-aim-to-improve-outcomes
Public Health Reports / July–August 2014 / Volume 129
Executive Perspective 321
14. Health Resources and Services Administration (US). Resource and technical assistance center for HIV prevention and care for black men who have sex with men (black MSM) cooperative agreement. HRSA14-106. CFDA No. 93.145. Washington: HRSA; 2014. 15. Centers for Disease Control and Prevention (US). Secretary’s Minority AIDS Initiative funding to increase HIV prevention and care
service delivery among health centers serving high HIV prevalence jurisdictions. FOA: PS14-1410 [cited 2014 Apr 4]. Available from: URL: http://www.cdc.gov/hiv/policies/funding/announcements /PS14-1410 16. Fielding JE, Teutsch S, Breslow L. A framework for public health in the United States. Public Health Rev 2010;32:174-89.
Public Health Reports / July–August 2014 / Volume 129
Improving Outcomes Along the HIV Care Continuum: Paying Careful Attention to the NonBiologic Determinants of Health Ronald O. Valdiserri, MD, MPH
More and more, we realize that behavioral, social, economic, and environmental factors interact with biologic conditions and life circumstances to substantially influence health outcomes for individuals, families, and communities.1 But recognizing the fact that health is much more than the mere absence of disease is not a new concept. In fact, the preamble to the constitution of the World Health Organization, adopted in 1946, states this premise explicitly.2 In our own time, this notion of health as a complete and holistic state of well-being is most readily evident in the increasingly urgent calls to address the social determinants of health, especially as they relate to health disparities and inequities. The current focus on health disparities and inequities across the continuum of human immunodeficiency virus (HIV) care—from timely diagnosis through regular receipt of optimal treatment resulting in viral suppression—is once again forcing us to confront the many factors beyond biology that affect health outcomes. Scientists from the U.S. Centers for Disease Control and Prevention (CDC) used national HIV surveillance data from 19 jurisdictions with complete reporting of CD4+ and viral load (VL) test results to assess statelevel differences in HIV diagnosis, retention in care, and viral suppression. They found that while 80% of people who were diagnosed with HIV were linked to care within three months, in all 19 jurisdictions, a large percentage of people living with HIV (PLWH) were not receiving ongoing care; by jurisdiction, the percentage
of people with a suppressed VL ranged from 14.3% to 55.7%, with an average of 43.4%.3 Although this analysis did not allow for the investigation of specific factors associated with disparities across the care continuum, the investigators noted that social and economic barriers, as well as behaviors, likely explain many of these differences. An earlier analysis conducted by CDC used data from both the National HIV Surveillance System and the Medical Monitoring Project to estimate nationally, for various subpopulations, the percentages of PLWH who were aware of their HIV diagnosis, retained in care, prescribed antiretroviral therapy, and had achieved viral suppression. Their analysis found that the estimated percentages of black and Hispanic or Latino people who were aware of their HIV infection were lower than that of white people, and also revealed significant age disparities at each step of the HIV care continuum, with younger people less likely than older people to have received an HIV diagnosis or to have a suppressed VL.4 We know that a variety of factors can influence outcomes at each stage of the HIV care continuum, including poverty and lack of health insurance,5 homelessness,6 food insecurity,7 substance use,8 mental health problems and accumulated lifetime trauma,9 deficits in health literacy (e.g., not understanding the importance of adherence to antiretroviral medication),10 and stigma related to HIV and/or the behaviors placing one at risk for infection.11 Recognizing that a single strategy or approach cannot address all of these barriers is a major reason why President Obama issued Executive Order 13649 on July 15, 2013, calling for the establishment of an HIV Care Continuum Initiative to “identify potential impediments to improving outcomes along the HIV care continuum” and “recommend ways to integrate (federal) efforts to improve outcomes.”12 In response to the Executive Order, leaders from
Public Health Reports / July–August 2014 / Volume 129
319
320 Executive Perspective
across the federal government engaged in a process to actively review current programs, policies, and research findings. Based on this assessment, they developed an initial set of 21 specific federal actions to promote improvements along the HIV care continuum.13 These actions, which were released on World AIDS Day 2013, can be broadly summarized as follows: • Develop and assess innovative models of HIV care, especially for vulnerable populations; • Tackle misconceptions and stigma that act as barriers to HIV care; • Strengthen the collection and use of data to improve HIV health outcomes; • Prioritize research to address gaps in knowledge along the HIV care continuum; and • Provide information, training, and technical assistance to strengthen comprehensive HIV services at state and local levels. Truly, the many issues hindering the receipt of timely and comprehensive HIV care among vulnerable populations will not be easily resolved, but the previously outlined actions are already beginning to influence our public health priorities. For example, the Health Resources and Services Administration recently announced funding to support the identification and dissemination of best practices and effective models of HIV care for black men who have sex with men—a group disproportionately impacted by HIV disease.14 Additionally, in early spring 2014, CDC announced available funding for health departments to work collaboratively with community health centers to use state HIV surveillance data and health center electronic health record data to improve HIV health outcomes for PLWH, by expanding HIV linkage, retention, and reengagement services.15 These are two examples among many signifying an ongoing shift from older paradigms of HIV prevention and care that focused exclusively on the biologic determinants of health to newer—and admittedly more challenging—models that recognize the importance of addressing various social determinants that influence our collective ability to achieve healthy outcomes for individuals, families, and communities. As observed by other public health leaders, commenting on the increasing influence of social determinants of health, this paradigm shift does not minimize the need for high-quality biomedical services, but it will require that public health develop and sustain “strong governmental and intersectoral leadership and collaboration.”16 In short, if we want to improve outcomes along the HIV care continuum in the United States, we must be will-
ing to embrace and reckon with all of the factors that contribute to health status, not just biology. The contents of this article represent the views of the author and do not necessarily represent the views of the U.S. Department of Health and Human Services. Ronald Valdiserri is Deputy Assistant Secretary for Health, Infectious Diseases and Director of the Office of HIV/AIDS and Infectious Disease Policy, U.S. Department of Health and Human Services in Washington, D.C. Address correspondence to: Ronald O. Valdiserri, MD, MPH, U.S. Department of Health and Human Services, Office of HIV/ AIDS and Infectious Disease Policy, 200 Independence Ave. SW, HHH Building, Room 443-H, Washington, DC 20201; tel. 202-6905560; fax 202-690-7560; e-mail .
References 1. Sadana R, Blas E. What can public health programs do to improve health equity? Public Health Rep 2013;128 Suppl 3:12-20. 2. World Health Organization. The preamble of the constitution of the World Health Organization as adopted by the International Health Conference, New York, 1946 Jun 19–22; signed by the representatives of 61 states. Official records of the World Health Organization, no. 2, p. 100. 3. Gray KM, Cohen SM, Hu X, Li J, Mermin J, Hall HI. Jurisdiction level differences in HIV diagnosis, retention in care, and viral suppression in the United States. J Acquir Immune Defic Syndr 2014;65:129-32. 4. Hall HI, Frazier EL, Rhodes P, Holtgrave DR, Furlow-Parmley C, Tant T, et al. Differences in human immunodeficiency virus care and treatment among subpopulations in the United States. JAMA Intern Med 2013;173:1337-44. 5. Rothman RE, Kelen GD, Harvey L, Shahan JB, Hairston H, Burah A, et al. Factors sssociated with no or delayed linkage to care in newly diagnosed human immunodeficiency virus (HIV)-1-infected patients identified by emergency department-based rapid HIV screening programs in two urban EDs. Acad Emerg Med 2012;19:497-503. 6. Kidder DP, Wolitski RJ, Campsmith ML, Nakamura GV. Health status, health care use, medication use, and medication adherence among homeless and housed people living with HIV/AIDS. Am J Public Health 2007;97:2238-45. 7. Weiser SD, Frongillo EA, Ragland K, Hogg RS, Riley ED, Bangsberg DR. Food insecurity is associated with incomplete HIV RNA suppression among homeless and marginally housed HIV-infected individuals in San Francisco. J Gen Intern Med 2008;24:14-20. 8. Spire B, Lucas GM, Carrieri MP. Adherence to HIV treatment among IDUs and the role of opioid substitution treatment (OST). Int J Drug Policy 2007;18:262-70. 9. Mugavero M, Ostermann J, Whetten K, Leserman J, Swartz M, Stangl D, et al. Barriers to antiretroviral adherence: the importance of depression, abuse, and other traumatic events. AIDS Patient Care STDS 2006;20:418-28. 10. Rao KC, Enriquez M, Gantt TC, Gerkovich MM, Bonham AJ, Griffin RG, et al. Nonengagement in HIV care: a descriptive and qualitative study in hospitalized patients and community-based analysis. J Int Assoc Provid AIDS Care 2013;12:178-84. 11. Sumari-de Boer IM, Sprangers MA, Prins JM, Nieuwkerk PT. HIV stigma and depressive symptoms are related to adherence and virological response to antiretroviral treatment among immigrant and indigenous HIV infected patients. AIDS Behav 2012;16:1681-9. 12. Government Printing Office (US). Executive Order 13649. Accelerating improvements in HIV prevention and care in the United States through the HIV care continuum initiative. Fed Reg 2013;78:43057-9. Also available from: URL: http://www.gpo.gov /fdsys/pkg/FR-2013-07-18/pdf/2013-17478.pdf [cited 2014 Apr 4]. 13. Koh HK, Valdiserri RO. New federal actions aim to improve outcomes along the HIV care continuum: World AIDS Day update. 2013 Dec 8 [cited 2014 Apr 4]. Available from: URL: http://blog. aids.gov/2013/12/new-federal-actions-aim-to-improve-outcomes
Public Health Reports / July–August 2014 / Volume 129
Executive Perspective 321
14. Health Resources and Services Administration (US). Resource and technical assistance center for HIV prevention and care for black men who have sex with men (black MSM) cooperative agreement. HRSA14-106. CFDA No. 93.145. Washington: HRSA; 2014. 15. Centers for Disease Control and Prevention (US). Secretary’s Minority AIDS Initiative funding to increase HIV prevention and care
service delivery among health centers serving high HIV prevalence jurisdictions. FOA: PS14-1410 [cited 2014 Apr 4]. Available from: URL: http://www.cdc.gov/hiv/policies/funding/announcements /PS14-1410 16. Fielding JE, Teutsch S, Breslow L. A framework for public health in the United States. Public Health Rev 2010;32:174-89.
Public Health Reports / July–August 2014 / Volume 129
